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The distal limb

image of The distal limb
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Abstract

This chapter covers anatomy, diagnosis and treatment of conditions of the distal limb, including surgical preparation, external coaptation, metacarpophalangeal and metatarsophalangeal joint injury, conditions of the palmar and volar sesamoid bones, the proximal and distal interphalangeal joint, tendon injuries, conditions of the digital pads and integument of the paw, infection of the paw. Includes . : The application of a digital external skeletal fixator; Amputation of the digit; Ungual crest ostectomy (permanent nail removal); Distal digit (phalanx 3) ostectomy; Incisional and excisional separation podoplasty; Corn excision; Sesamoidectomy.

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Figures

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21.1 Anatomical diagram of the distal limb showing the positions of the bones, main ligaments and tendons. The annular ligaments are shown cut in the illustration, so that the superficial and deep superficial digital flexor tendons can be better seen. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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21.2 Illustration of the plantar aspect of metatarsophalangeal joint 5 showing the relationship of the sesamoidean ligaments to the joint. The large intersesamoidean sagittal ridge lies under the intersesamoidean ligament. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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21.3 Illustration of the lateral aspect of metatarsophalangeal joint 5 showing the relationship of the ligaments to the bones. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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21.4 A dorsoplantar radiograph of the pelvic limb paw of a Greyhound showing axial rotational deformity of digit 5. Torsion of the metatarsophalangeal joint is evident from the axial rotation of the sesamoids (arrowed). Diagnosis of concomitant instability is made by palpation, but cannot be made from this radiograph. Abaxial soft tissue swelling is apparent.
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21.5 A stressed dorsoplantar radiograph of the pelvic limb paw of a Greyhound showing abaxial rotational instability of digit 2 causing abaxial displacement of the digit. Note the abaxial subluxation of both sesamoid bones (arrowed).
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21.6 A dorsoplantar radiograph of a pelvic limb paw of a Greyhound showing abaxial luxation of the metatarsophalangeal joint and sesamoid bones of digit 5.
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21.7 A dorsoplantar radiograph of the pelvic foot of a Greyhound. There is an old healing fracture of the distal second metatarsal bone (arrowed) and rotational subluxations of MTP joints 3, 4 and 5 resulting from a subsequent dog fight.
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21.8 A dorsoplantar radiograph of the dog in Figure 21.7 following the application of transarticular external skeletal fixators across the reduced joints. 1.4 mm pins in a 2:2 configuration were applied to the metatarsal and first phalangeal joints.
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21.9 A dorsopalmar radiograph of the foot of a Labrador Retriever showing osteoarthritis of the MCP joints 3 and 4. There is also marked irregular periosteal new bone on the distal metacarpal and proximal first phalangeal bones.
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21.10 A dorsopalmar radiograph of the metacarpophalangeal joint of a Greyhound showing a fracture of the sesamoid bone. Note the distraction of the proximal fragment and the sharp fracture margins.
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21.11 A dorsopalmar radiograph of a thoracic limb paw of a Rottweiler. Sesamoid bones 2 and 7 are fragmented (arrowed). This was a coincidental finding and not the cause of lameness.
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21.12 A dorsopalmar radiograph of the thoracic limb paw of a Greyhound. Sesamoid bone 2 is bipartite (arrowed).
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21.13 A stressed dorsopalmar radiograph of the thoracic limb paw of a Greyhound. The distal interphalangeal joint is luxated and unstable.
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21.14 Open subluxation of the distal interphalangeal joint in a pet Greyhound.
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21.15 Rupture of both the superficial and deep digital flexor tendons in a central digit. Note the extended ‘dropped’ PIP joint resulting from rupture of the superficial tendon, as well as the cranial positioning of the nail compared with digit 4, and the ‘knocked-up’ DIP joint with elevated nail resulting from rupture of the deep tendon rupture.
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21.16 Contracture of the superficial digital flexor tendons as a sequel to failed tarsal fracture surgery and ischaemia from an overtight dressing over the attachment of the common calcaneal tendon to the calcaneus.
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21.18 A hyperplastic digital pad (arrowed) that has developed from abnormal weight-bearing on the distal digit.
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21.19 A hyperplastic fifth digital pad (a ‘false’ pad) in a Dobermann with skin fold pedal dermatitis. Resection of the hyperplastic pad combined with incisional separation podoplasty of the adjacent interdigital webbing resolved the lameness.
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21.20 A corn (arrowed) on the digital pad of a Greyhound. This is a circumscribed area of hyperkeratosis that protrudes above the surface of the pad.
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21.21 An excised corn showing thickened pad tissue and a cylindrical ‘root’ extending into the subdermis.
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21.22 A mediolateral radiograph of a digital pad containing a glass foreign body.
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21.23 Chronic fibrosing interdigital pyoderma after antibiotic treatment but prior to excisional separation podoplasty.
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21.24 A split foot in a racing Greyhound. There is a full thickness split of the dermis overlying the flexor tendons to digit 3 or digit 4 in the pelvic limb paw.
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21.25 Incisional separation podoplasty being used to treat a split foot in a racing Greyhound.
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21.26 Musladin–Leuke syndrome in a Beagle. Note the ballerina-type stance.
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21.27 Patient positioning for a mediolateral view of the manus. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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21.28 Patient positioning for a dorsopalmar view of the manus. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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21.29 Patient positioning for a plantarodorsal view of the pes. Note the use of wedges or sandbags to elevate the contralateral limb to facilitate positioning. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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21.30 Patient positioning for a splayed toe mediolateral view of the digits; note the use of tape to separate the toes. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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21.31 Multiplanar CT reconstruction images: (a) sagittal plane, (b) dorsal plane and (c) transverse plane. These reconstructions show a medial sagittal fracture of (medial) palmar sesamoid 1 of the MCP/MTP joint of digit 2 (arrowed). This 5-year-old Labrador Retriever had exercise-induced acute onset thoracic limb lameness clinically localized to this joint, but radiographs were inconclusive. (Courtesy of Gordon Brown)
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21.32 A dorsoplantar radiograph of a pelvic limb paw of a Greyhound with a transarticular external skeletal fixator placed for treatment of PIP joint instability. The acrylic putty was applied after the joint was aligned.
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21.33 A transarticular external skeletal fixator . It is important that the acrylic putty is not too close to the skin.
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21.34 Illustration showing the dorsal skin incisions for amputation of an abaxial digit 2 or 5. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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21.35 A dorsopalmar radiograph of the metacarpus. The diagonal white lines show the positions of the osteotomies for amputation of digits 2 and 5. Digits 3 and 4 are amputated through the MCP/MTP joints.
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21.36 Ungual crest ostectomy showing the skin incision circumscribing the nail (arrowed). Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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21.37 Ungual crest ostectomy. The skin has been retracted from the ungual Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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21.38 Ungual crest ostectomy. The remnants of the nail and ungual crest are removed with rongeurs. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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21.39 Distal digital ostectomy. An eliptical area of skin is excised proximal/dorsal to the digital pad. The defect is closed using simple interrupted sutures so that the pad is pulled over the bone stump. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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21.40 Incisional separation podoplasty. Illustration showing the position of the incision. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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21.41 Corn excision. With the pad held between the thumb and forefinger by an assistant, the corn is excised and the wound closed with simple interrupted sutures. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
Image of 21.42
21.42 (a) Surgical approach to the left fore sesamoid 2. (b) Surgical approach to palmar sesamoid 7. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission. Designed and drawn by Vicki Martin Design and printed with their permission. (b, Courtesy of JEF Houlton)

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