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Elbow Dysplasia
Elbow Dysplasia
Fractured coronoid processes
Elbow Dysplasia syndrome possible
Elbow Dysplasia
Bilateral Elbow Dysplasia
Elbow dysplasia or injury
Elbow damage - part 2
also see Arthritis
also see Hip Dysplasia
also see Orthopedic
also see Medication
Elbow dysplasia is the term for an elbow joint that is malformed on X-rays. The mechanism of the malformation is unclear but it may be due to differences in the growth rates of the three bones that make up the elbow joint, particularly the humerus and ulna. In mildly affected dogs the only consequence may be arthritis. In more severely affected dogs, osteochondritis dissecans (OCD), fragmented medial coronoid processes and united anconeal processes can result from the stress in the joint. Some vets think that these problems may not be secondary but may actually be the primary problems and that the bone changes occur as a result of them. It is difficult to be sure but there does appear to be measurable differences in bone growth in dogs that have elbow dysplasia. There are a number of changes visible on X-rays and the OFA does evaluate X-rays for evidence of elbow dysplasia.
Due to the number of possible complications, it is hard to make predictions about how elbow dysplasia will affect a dog. If it can be identified at a young age before changes are severe, surgical correction has a reasonably good success rate. Once severe changes set in, it is much harder to prevent subsequent arthritic changes. Most dogs with this condition eventually become lame and the lameness can be very severe in some dogs, even to the point of disuse of one leg or severe difficult getting up and walking even short distances.
Treatment consists of surgical correction of whatever complications are present, if possible. Medical management using aspirin or other anti-inflammatory medications is helpful. Weight control is very important over the long term for success of either surgical or medical management of this condition.
Mike Richards, DVM
Fractured coronoid processes -injury associated with Elbow dyplasia
Question: We have a 9 month old Labrador Retriever. In March he started limping-
right front leg. He showed no signs of pain - he still wanted to play. Being
concerned we took him to the vet in March. They found nothing on range of
motion/manipulation. Therefore no x-rays were done. They assumed he
sprained/strained it. They gave him Rimadyl and a Vetalog injection. He
seemed to improve for a couple of weeks then he was limping again. In May
we took him back to a different the vet and again nothing was found on
range of motion/manipulation. No x-ray was done. They suggested to try and keep him
confined and calm and see what happens. There seemed to be no
improvement.
Again in May we took him back to the vet and a x-ray of the right front leg
was done. It was negative. Again the plan was to keep him calm and
confined. To me he seemed improve if we exercised him. When he is lying
down and gets up the limp is worse. In July we took him to the vet again
and decided to refer him to a surgery specialist. He noticed that he had
developed some muscle atrophy. We took him to the specialist in July and
x-rays of the right and left front leg were done. The vet said the x-rays showed early degenerative joint
disease, increased radiohumoral joint space and probable fragmented medial coronoid
process (elbow dysplasia) involving the right elbow. Tx. for now he said until we
decide what path to take is moderate activity with as needed NSAID's. My
vet does not believe in Rimadyl in a 9 month old puppy so he suggested starting
him on Synovicre for a month and see how he does. What is next? Another
opinion from a Orthopedic specialist instead of a surgery specialist?
CT/MRI to confirm a fragmented medial coronoid process? I would prefer for him to
have a Arthroscopy instead of open - for recovery reasons- if they could remove the loose body. The surgery
specialist mentioned corrective osteotomy surgery, but said the surgery was still new
and is not sure of the results. I want to do whatever I can so my dog can
lead a active and pain free life. It hurts to know that he is only 9 months old and already
has early degenerative joint disease. I know my dog's parents had no
genetic/heredity disorders. If you could please provide any
information/help.Thank you, Faith
Answer: Faith-
In the Jan 1, 1999 issue of the AVMA Journal there was a report on X-ray
technique for diagnosing fractured coronoid processes and they found that a
craniolateral-caudomedial oblique X-ray (not part of the standard views
taken at most practices) was the best way to see a fractured coronoid
process. Your vet might be able to find this paper and get an idea of the
technique. It might help to resolve some of the question about what is
going on if it works to allow a better view of the coronoid process.A report in the December 1997 Journal of Veterinary Research, a comparison
of X-rays, surgery and MRI for evaluation of the elbow joint. In dogs with
fractured coronoid processes, this injury could only be seen on X-rays in
about 1/3 of the cases. It was visible on MRI exam about 95% of the time.
So if an MRI is an option where you are, it will allow much more precise
detection of a fractured coronoid process.Exploratory surgery of the joint is an acceptable way to establish a
diagnosis, as well. Arthroscopic surgery has been reviewed and works for
vets experienced in the technique, based on the literature. I think that
arthroscopy is probably used more as a diagnostic technique than as a
surgical repair technique in dogs at this time but as orthopedic surgeons
become more experienced with this option, that may change.I see mixed reports on all of the techniques for repairing fractured medial
coronoid processes and other lesions associated with elbow dysplasia. I
honestly think that at this point in the "state of the art" the best thing
you can do is find a bone surgeon that you and your vet feel comfortable
with and let him or her do what they think is best after evaluating the
joint surgically. I know that is scary. The best second choice is probably
to live with the problem and treat it medically to the best of your ability.If you do elect to treat this medically, let me know and I will try to
research the various pain relief options for a young dog. Personally, I do
use carprofen (Rimadyl Rx) and etodolac (Etogesic Rx) in puppies but your
vet may know something I don't.Hope this helps some.
Mike Richards, DVM
8/5/2000
Syndrome of elbow dysplasia possible
Q: Hi, we were attracted to your site as a useful reference on dog problems
and it's solution. We are convinced that you represent a honest medical
opinion, that's why we are asking for your help. We just suscribed to your VetInfo
digest on Friday.We live in Mexico and have a 7 months old, 66 lb neapolitan mastiff
bitch, and two kids (7 & 6) that always go with us.We start taking her with us for bicycle mountain rides, first time we
did 4 miles, then we went for 6 miles and last week we did a long ride of 10
miles with a lot of ups and downs.14 hours after we finished de ride (Sunday 6 AM) she started complaining
from her left forearm, it started gradually, but soon she was under a lot of
pain.
She didn't want to walk or eat, the local veterinary (as we were out of
town) injected her buscapine. She show some relief. Later on our vet ask us to
use an adult Neomelubrine suppository every 8 hours, she started eating few
amounts as the pain was fading out, we use Neomelubrine till tuesday.We X-ray her from her elbows, the x-rays shows the growing plates are
not close yet, with the left one a little bit more open that the right one. She
got her left elbow very inflamed, the vet didn't use an anti-inflammatory as she is
coming out of a demodex mange, so we are using homeopathy, Arnica
(anti-inflammatory), Symphitum (bone reconstruction) and Barita Carb. (Helps calcify).
Latter on the vet call us saying that he has an anti-inflammatory
without cortisone, but she is doing ok with homeopathy, so we have not use it yet.She is currently only under the homeopathy treatment. She is not taking
any other medicine, and she is eating very well, is very active, but she
limps of her left elbow as she can not fully extend it. (if we force it to full
extension she shows some pain)Our vet sent the X-rays to an orthopedist that says we need to perform
surgery and remove the growing plates from both elbows, he said that probability
of success is 85%We would like to know if this is right, as she has the problem in only
one leg, and she has not finish growing yet.Would you also provide us with some insights of what would be an
adequate treatment and diagnosis.We will try sending you copies of the X-rays via e-mail, as soon as we
recover them.Thanks in advance.
Hector and Lucia.
A: Dear Lucia and Hector-
There are three different problems that seem likely based on the history
that you have included in your note. I'll just give you information on all
of them. All three may be part of the syndrome of elbow dysplasia.The most likely problem that fits the description you have included is a
condition usually referred to as a fragmented medial coronoid process.
Sometimes it is also referred to as elbow dysplasia. The coronoid process
is a small portion of the bone on the end of the ulna where it meets the
elbow joint. In large breeds of dogs it is prone to fragmenting, probably
due to stress on the area from the dog's size and anatomical configuration
of the elbow. This is supposed to be the most common elbow injury in dogs
according to Olmstead's "Small Animal Orthopedics". When the coronoid
process fragments it leads to degeneration of the joint (arthritis). The
first signs of problems from this disorder usually occur between five
months and nine months of age. Most dogs with this condition are obviously
lame but they may not have any really obvious signs of elbow problems such
as swelling or heat in the joint. The usually do dislike having the elbow
pressed on or flexed completely. Rotating the elbow from side to side while
holding it flexed may produce a stronger pain response. Sometimes swelling
is present and that can aid in making a diagnosis. X-rays may show the
fragment but often there are no clear signs of this problem visible on
X-rays. In these cases exploratory surgery may be the only way to make a
diagnosis.The second most likely problem in a young large breed dog is
osteochronditis dissecans (OCD) affecting the elbow. The signs are very
similar. In some cases OCD and fragmented coronoid processes occur
simultaneously in the same dog. This disorder occurs when the cartilage
within the joint develops a flap. This exposes the underlying bone and
leads to a painful elbow. The flap may be visible on X-rays but sometimes
the diagnosis has to be made based on changes in the bone around the defect
which are often visible on X-rays, too.Another possible problem which is less common than the first two is an
united anconeal process. This disorder seems to be associated most commonly
with German shepherds but has been seen in other large breed dogs. The
anconeal process is another portion of the ulna that forms part of the
elbow joint. It fits the description of a growth plate that hasn't closed
better than the first two problems but it is comparitively rare so I still
think it is the least likely of the three problems in your dog. This
disorder usually causes a much more subtle lameness than you are describing
but the lameness may be worse than usual due to exercising hard without a
lot of training time. Ununited anconeal processes show up much better on
X-rays than OCD or fragmented coronoid processes and there is usually more
swelling around the joint, too.Osteochronditis lesions are surgically repaired by finding and removing the
cartilage flap. Fragments of the coronoid process are usually removed when
possible during surgery. It is important when either of these conditions is
present to look for the other one during surgery. Ununited anconeal
processes are sometimes treated by attempting to stabilize the anconeal
process but more frequently the loose portion is either surgically removed
if surgery is attempted. This condition is not always best to treat with
surgery, especially if there are already significant degenerative changes
at the time X-rays are taken.All three of these conditions have similar surgical outcomes. Most
orthopedic surgeons feel that surgical repair is helpful in limiting the
damage done by these disorders but acknowledge that degeneration of the
joint will usually continue even if surgery is preformed. With that in
mind, I think you have to consider the following guidelines when making a
decision to proceed with surgery or to proceed with medical treatment instead.1) The goal of surgery is not to cure the condition. The goal of surgery is
to alleviate some of the immediate pain and to try to make the long term
arthritic process less severe.2) The surgeon has to be experienced in caring for these types of
conditions. It is very important to pick a good orthopedic surgeon if
surgery is going to be attempted. There may be some advantage to
arthroscopic surgery for these conditions due to the ability to make
smaller joint incisions but the availability of veterinary surgeons with
experience working on elbow joints with arthroscopic instruments is very
limited.3) The earlier a decision is made to attempt surgical repair, the more
likely it is to help. If there is already significant degenerative change
in the elbow surgery is less likely to work and long-term medical treatment
may work just as well.4) You have to be prepared to follow the directions for after care and you
have to ask what those directions are in advance of surgery to make sure
that you have the ability to follow them.5) These conditions are often bilateral. There is a strong possibility that
the other elbow may already be affected or may develop problems later. It
is a good idea to check the other elbow prior to considering surgical
repair so that you and your vet can discuss surgical repair options for
that elbow as well, if necessary.I know an orthopedic surgeon who I would trust to operate on a dog of mine
with this condition and I would consider the possibility of improvement
without a cure acceptable. I encourage my clients to consider surgery if
cost is not a major problem and if they really seem to understand that they
are not going to get a cure, just a good chance that the long term
arthritic changes will be less severe.In the meantime, using a glucosamine product or Cosequin (TM) may be
helpful. I personally like to use anti-inflammatory medications such as
aspirin or carprofen (Rimadyl Rx). I am not sure they make a lot of
difference in the amount of arthritis that eventually develops but they do
seem to provide pain relief. Some orthopedic surgeons do advise against the
use of pain relief medications, though. I didn't recognize the names of the
medications prescribed so far, so I can't provide information on them.I hope this helps. It is a tough decision to have to make.
Mike Richards, DVM
Q: Dear Mike:
I have a Labrador Retriever that has been diagnosed with elbow dysplasia. He is currently 11 month old. At the time of the diagnosis (8 months old), the surgeon that we visited said that he was grossly over-weight. At that time he was 88lbs. At that time, he was showing signs of favoring his right front leg, and would get tired on very short walks, and started to limp on his front legs.Since this diagnosis, we have reduced his weight significantly, down to 72lbs., and have him taking vitamin C, vitamin E, and a Glucosamine/Chondroitin compound. He has shown some very good improvement. We can now take him on strenuous walks, and he is very actively, but he still has a definite limp with his front legs. This situation seems to get better with rest, but seems that this is not
going to go away.My question to you is, do we have to correct this problem with surgery? Can he live a relatively pain free life without surgery to correct this problem? Is all elbow dysplasia the same? Will elbow dysplasia get worse as he gets older? Is there any medical proof that elbow dysplasia can be treated without the need for surgery?
We really do not have the means for surgery, nor do we want to keep him caged up after the surgery, so I am looking for some answer on the subject of elbow dysplasia and the various forms of treatment. I have looked at many articles on the Internet, but there is not much on the treatment of elbow dysplasia.
I hope you can provide some input.
Sincerely Yours,
Brian
A: Brian-
Most veterinary orthopedic surgeons truly seem to believe that surgery is beneficial if it can be done under the following circumstances: in a young dog, when the diagnosis is reasonably certain, by an experienced surgeon, with as little disturbance of the normal anatomy as possible.
(arthroscopic surgery, for instance) and with good aftercare by a committed owner.There is not much evidence to support their beliefs in the journals, though. The presently available information seems to indicate that surgery is only slightly more likely to produce a good outcome than medical treatment of the condition, which mostly consists of using non-steroidal anti-inflammatory medications and other treatments for arthritis that occurs secondary to the elbow dysplasia. Weight control is an excellent aid in the treatment of most degenerative joint diseases and is often considered to be more important than medications in the control of pain and maintenance of function so you have probably already helped a lot.
This may be a situation similar to that which occurred with colic surgery in horses, though. When
it was first being attempted it rarely worked because it was done pretty much as a last ditch effort. The few successes eventually led to horses being considered to be surgical candidates before
it was reasonably certain they were going to die imminently. After that happened, the success rates of surgery dramatically improved. After that happened it was possible to come up with a better idea of which horses really would respond to surgery. Now it is an accepted treatment option
when the circumstances seem to warrant it. Elbow dypslasia surgery is often being done after there is significant degeneration of the joint at the current time. This is less likely to help than earlier intervention but it will take a little time to see how much more effective doing surgery earlier can be. We just have to wait and see right now.If surgery is not a good option financially it is comforting to know that even with surgery there is usually still arthritis and that often it is still necessary to treat medically. You can help a great deal by doing the things you are already doing and the outcome may be very close to that obtainable with surgery. On the other hand, if surgery by an experienced orthopedic surgeon with good equipment is an option you can afford it may lessen the long term severity of the joint degeneration and is probably a good choice. I don't think this is a situation in which I would skimp on the surgery and still have it done. I'd either find a very good orthopedic surgeon and pay what he or she wanted for the surgery or I'd skip it.
Mike Richards, DVM
Q: Hope you can advise us about our two year old Labrador. He has bilateral elbow dysplasia going on about 6 months. He limps more after running or even prolonged rest. What is the natural prognosis with medical management and what is the natural course after surgery.
A: I am under the impression that surgery for elbow dysplasia is pretty unlikely to help unless it is done in the very early stages of the disease and there is a contributing cause like an united anconeal process. I have some information on this at the office and will double check on that for you.
The only alternative is chronic use of anti-inflammatory medications. It is best to use non-steroidal anti-inflammatory medications (NSAIDS). It may be helpful to use one of the "nutriceuticals" like Cosequin (Rx) or Arthroflex (Rx). I think that it is still debatable whether these medications are of significant help but they appear to be pretty harmless so it seems reasonable to try them. An alternative is injection with Adequan (Rx) which is not approved for dogs but is felt by many veterinarians to be useful in the treatment of degenerative joint diseases. My favorite NSAIDS are aspirin and carprofen (Rimadyl Rx). There is a new aspirin product for dogs, Arthricare Rx, which has aspirin and nutriceutical ingredients as well.
Most dogs with elbow dysplasia probably also have hip dysplasia. If the hip dysplasia is also severe it might help to do surgery for hip dysplasia to allow your dog to bear more weight on the rear limbs and take some of the pressure off the front legs. I don't know if anyone has explored that theory - it is just something I wonder about.
Mike Richards, DVM
Q: Dear Dr. Mike, I have a question which so far I have been unable to find an answer to. I hope you can help! I am a breeder of German Shepherd dogs. Not a backyard breeder, either; I spent five intense years studying canine genetics in general and the genetics of the GSD in general. Last year I had a young male--four months old--which I had decided to keep for a while myself. He was playing too rambunctiously with my adult male, bounced off the older dog's shoulder and landed hard on his elbow in the driveway. He was in obvious pain, crying and refusing to use the leg. A week later he was still lame in the (left front) leg and quite sore, so I took him in for x-rays. My usual vet was booked so I took him to another. The x-ray showed an ununited anconeal process, which this vet told me was elbow dysplasia, and without doubt genetic in origin. He went on to say that neither of our dogs should be be bred from again, and advised prospective puppy buyers not to buy our pups because "if one had it they would all have it".
Everything I can dig up on UAP, or elbow dysplasia in general, suggests that it is governed by three dominant genes. Both sire and dam are free of elbow dysplasia--the sire is OFA Excellent for hips, in fact, and the dam received her German "a" stamp at over three years of age. No littermates have any orthopedic abnormalities. His other elbow is completely normal, and he has no other joint problems whatsoever. In fact, the lameness had disappeared by six months of age, and allthough that elbow joint does appear very slightly different to my very critical eye, he evidences no pain even after prolonged and vigorous exercise, and is not affected in the least by very cold weather. Do you have any specific information on the genetics of UAP, or can you tell me where I can find it? Should I scrap my breeding program or, as I believe, is this a case of accidental injury? And very importantly, how likely is this joint to deteriorate? There is an older couple who desperately wants this dog--he is the best-looking and best-tempered Shepherd I''ve ever bred--but I cannot in good conscience sell a dog which will go lame later on (he is thirteen months old now). Any and all information you can give me will be greatly appreciated.
A: I believe that I have some information on the genetics of elbow dysplasia at the office, although I am uncertain that it will be detailed enough to suit your needs. I'll try to remember to check on this tomorrow when I go in.
I would have to think that it is possible that the elbow problems are from trauma based on the history you sent.
In our practice it seems that elbow disorders are very likely to be a source of chronic discomfort. It is isn't possible for me to say if this will happen with your dog but our overall experience makes me suspicious it is likely, if degenerative changes can be seen on new X-rays taken now.
I would tend to disagree with your assessment of the situation concerning selling this dog. To me, temperament is a crucial issue and outweighs the possibility of orthopedic problems that are likely to be restricted to one leg. I feel that if you fully inform these people that they may very well be making a good decision to take on this dog despite the existing problem.
I also would be suspicious of a diagnosis of an ununited anconeal process that was made at four months of age. I don't know about other vets, but I can be confused by the growth plates in dogs in this age range and do not always feel competent to read the X-rays. I would strongly suggest X-raying this elbow again and submitting them for review by a radiologist if necessary. It may be worth sending them to the OFA since they look at a great number of elbows and probably charge less than a referral radiologist to review the films. This would certainly be a good idea prior to scrapping your breeding program -- the small investment in X-rays could be far less costly than finding new dogs to serve as the foundation for your breeding efforts! You might even consider asking for copies of the original X-rays for re-evaluation but it is probably more meaningful to retake them at this age.
Mike Richards, DVM
Elbow damage - German Shepherd pup - part 2
Continued: Thank you for your advice concerning the UAP. I am planning on having Arrow re-X-rayed (I'll submit hip prelims at the same time) and see what the OFA thinks. If the elbow shows degeneration I'll consider it genetic and have him neutered (I probably will anyway to be on the safe side) and submit the findings with his pedigree to an open genetic registry. Evidently not enough is known about the specific genetics of this disorder, so hopefully this information may help. Anyway--concerning the GSD puppy with a floppy ear, maybe I can help you! If the puppy is under 8 months of age, especially if it is a big-boned male, and if the ear stands on its own occasionally, it will more than likely remain erect on its own in time. The ears of a GSD can be taped by a vet (7-8 mos of age) in the same manner as a cropped Dobe's--I do not have this >done myself, but it is not an uncommon practice. My mentor in Germany, who has been breeding GSDs for 60+ years, recommends a calcium injection. Above all, do not fondle, rub, or play with the baby's ears as this can soften and damage the forming cartilage. Hope this helps!
A: The book I have at work with the best information on the etiology of diseases (Slatter's book "Small Animal Surgery") says that in the German Shepherd there is one ( I think it said one) study purporting to show that the disorder is passed through a dominant gene, as you stated. It said there are other studies that support other causes including trauma, nutritional problems and stress from other orthopedic conditions. It did say that any diagnosis of this made before 5 months of age should be confirmed due to difficulty in identifying the disorder when growth plates are not normally closed. Unquestionably, there is a strong feeling that there is at least a partial causative effect related to inheritance in some manner. Your plan sounds about right.
I appreciate the information on the ear standing up. We haven't had any luck with calcium injections and I have to admit I'm suspicious that taping the ears has not been too helpful but have no real proof of that. I freely admit that my own experience is limited! It is good to see your experiences with the ears standing up at later dates.
Mike Richards, DVM
Last edited 08/30/02
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