fundemental orthopedic dieaseas(2 hrs).ppt...

陳冠升

Fundamentals of Orthopedic Radiology in Dogs and Cats

陳冠升 DVM, MVS, PhD, MACVS-Veterinary Radiology

國立中興大學獸醫學院

台灣獸醫外科專科醫學會

Radiography Technique

Correct/Straight positioning

knowledge of normal radiographic anatomy+

knowledge of normal radiographic anatomy

Successful interpretation!!!II


• Heavy sedation or general anaesthesia are required

• Positioning• Reduce motion• Radiation safety

• Low kVp and high mAs• Good contrast

• Proper collimation and centering• Decrease image distortion and scattering


• 2 views • Bone

• Centering is on the centre of the bone of interest• Collimation includes jointsj

• Joint• Centering on the center of the joint of interest• Collimation includes proximal and distal aspect of bones

• Additional radiographs• Flexed, stressed or oblique for complete evaluation

• Contralateral limb

Irish Vet J 60(4) 241-245

Inadequate collimation

•Include too much softInclude too much soft tissue

• Increase scattering• Decrease

definition/resolution

Same kVp and mAs

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*Inadequate collimation and radiation safety

Proper Centering and Collimation

• Minimal image distortion

• Decrease scattering• Ideal image quality

for interpretation

“Where to look….”

• Developmental orthopedic diseases often occur in very specific anatomic locations!

Bone Development

Bone Anatomy

• E – epiphysis (骨端)• P – physis (生長板)• M – Metaphysis (骨骺)

骨幹 MP

E

A

M P

D

D

• D – Diaphysis (骨幹)• A – Apophysis (骨隆起）• Joints

• Cartilage• Soft tissue opacity

D

M

M

EE

P

P

Some Normal Radiographic Feature of The Appendicular Bone

• Nutrient foreminae• Present in all long bones

• “Cut-back” zone

• Mach line• 2 cortical surfaces are superimposed

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Conditions Primarily Affecting BONES• Diaphyseal region

• Panosteitis

• Metaphyseal and Physeal regions

• Hypertrophic

• Physeal Region• Physeal trauma

• Epiphyseal Region • Congenital hypothyroidism• Mucopolysaccharidosis

osteodystrophy (HOD)

• Retained cartilage core

• Scottish Fold cat osteochondrodysplasia

• Incomplete ossification of the humeral condyle

Others*Malformation or agenesis*Trauma+/- fracture*Soft tissue injury*Foreign body(manus)

• Generalized• Nutritional secondary

hyperparathyroidism

Diaphyseal Region

• Panosteitis• Young, large breed dogs• Unknown Self-limiting disease• < 12 months of age • Shifting lameness

D D

Shifting lameness• Radiographic findings

• Lesions often originate at the diaphysis near the nutrient foramen.

• Increase medullary cavity opacity • Commonly seen in the humerus, radius, ulna

and femur. • Different stage of Panosteitis• Early: nodular opacities similar to cortical bone within the diaphysis• Late: diffusely increased opacity with continuous periosteal

reaction

PANOSTEITIS PICMetaphyseal and Physeal Regions

• Hypertrophic osteodystrophy (HOD)• Rapid growing, large/giant breed• 2-7 months• Fever, lethargy, diarrhea• Distal radius and ulna, distal tibia and fibula mostly affected

M

M

, y• Premature closure of the distal ulnar physis

• Angular limb deformity (Valgus)• Unknown cause:

• Oversupplementation of minerals and vitamins• Hypovitaminosis C• Virus (distemper)• ….

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• HOD• A transvers lucent zone within the metaphysis, parallel to the

physis. “double physes”• Irregular periosteal cuff around the metaphysis

Thrall. Text book of veterinary diagnostic radiology. 5th. Ed.

mirc.veterinaryradiology.net

Metaphyseal and Physeal Region

• Retained cartilage core• Large breed dogs• Commonly seen on distal ulna metaphysis• Disruption of the endochondral ossification

M

M

Disruption of the endochondral ossification• Retention of hypertrophic chondrocytes

• Cause angular limb deformity • DJD of the elbow and carpal joints

Normal •Radiographic findings•Triangular radiolucent region•A sclerotic rim•Slight cranial bowing of radius•Thickened caudal radial cortex

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Metaphyseal and Physeal Region• Incomplete ossification of the humeral condyles

• Should fuse by ~84 days after birth.• Spaniels and others

Metaphyseal and Physeal Region

• Scottish Fold cat osteochondrodysplasia

• Simple autosomal dominant trait

• Shorter than normal

• Stiff and swollen joints – difficult to jump or climbStiff and swollen joints difficult to jump or climb

• Predominant abnormalities seen around the distal joints

• Main radiographic feature

• Symmetrical carpal and tarsal ankylosis

Severe degenerative changes and ankylosis of tarsocural joint

Physeal Region

• Contribution of growth of the radius and ulna

• Angular deformity 35%15%

85%

65%

Angular Deformity

• Valgus or varus• Premature closure of

the distal ulnar physis (most common)• Physeal trauma

Courtesy of Dr 蔡盈庫

• May not be seen radiographically initially

• HOD• Retained cartilage

core

Physeal Trauma

• Salter-Harris types

Thrall. Text book of veterinary diagnostic radiology. 5th. ed. 2008

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LR

Courtesy of Dr 林建良

Physeal trauma

Epiphyseal region

• 1. Congenital Hypothyroidism• Disproportionate short-limb dwarfism• Epiphyseal dysplasia• Bowed limbs and long necks and trunks

E il i

EE

• Easily seen in• Proximal tibia• Humeral and femoral condyles• Cuboid bone• Carpus and tarsus• Short vertebral• Endplate dysplasia

Congenital Hypothyroidism

Normal

Thrall. Textbook of veterinary diagnostic radiology. 5th. ed. 2008

In Practice (2006) 28,188-199

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Epiphyseal region - Continued • 2. Mucopolysaccharidosis

• Abnormal of glycosaminoglycan catabolism

• Stunted, lame and visual deficit

• Disproportionate dwarfism

• Facial dysmorphia - broad maxilla, widespreadFacial dysmorphia broad maxilla, widespread eyes and short ears.

• Hyperextension of the distal extremity joints

Mucopolysaccharidosis• Epiphyseal dysplasia• Osteopenia

MUCOPOLY PIC

• Hip luxation and femoral head epiphysis remodeling

• Epiphyseal dysplasia

Generalized

• Nutritional hyperparathyroidism• Ca/P imbalance• Generalized osteomalacia

• Generalised decreased bone opacityGeneralised decreased bone opacity• Similar to soft tissue opacity• Thin cortex• Spinal deformity• Pathologic folding fracture

Disorders Affecting Growing JOINTS• 1. Osteochondrosis, osteochondritis dissecans (OCD)

• 2. Elbow dysplasia• Ununited anconeal process (UAP)• Fragmented medial coronoid process (FCP)g p ( )• OCD of the medial humeral condyle

• 3. Hip dysplasia (HD)

• 4. Legg-Calvé-Perthes

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1.Osteochondrosis and OCD

• Young, rapidly growing large-breed dogs• Common sites

• Caudal humeral head (lateral view)Caudal humeral head (lateral view)• Medial aspect of distal humeral condyle (Cr-Cd view)• Lateral condyle of femur (Cd-Cr view)• Medial and lateral trochlear ridges of talus (Cd-Cr view)

SHOULDER OCD

www.acvs.org

mirc.veterinaryradiology.netCourtesy of Dr 林建良

ELBOW OCD

www.aap.org

ELBOW OCD

L

R R

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STIFLE OCD

L R


HOCK OCDHOCK OCD

NormalL R

2.Elbow Dysplasia

• Ununited anconeal process

• Should be fused to the olecranon by 150 days

• German shepherd and other large breeds

• Extreme flexed mediolateral view is required.

Ununited Anconeal Process

http://www.michvet.com/


Fragmented medial coronoid process (FCP)• Medium- and large-breed dogs

• Male > Female

• Clinical signs: 4 - 6 months of age

• Medial coronoid process

U il t l bil t l• Unilateral or bilateral

• Cranial 25°lateral - caudomedial oblique (Cr-25°-L, Cd-M oblique)

Evans. Guide to the dissection of the dog, 7th ed

http://www.michvet.com/


• Arthritic findings• Joint incongruity• Osteophytes on anconeal process• Changes on medial coronoid process• Subtrochlear sclerosis• Lateral epicondylar osteophytes

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• Changes on medial coronoid process


UAP, FCP


FCP

(Cr 25° L Cd M oblique)

CT provides the best visualisation of FCP

(Cr-25 -L, Cd-M oblique)

Thrall. 2007

3. Hip Dysplasia

• Changes on coxofemoral joints• Perifoveal cartilage erosion• Round ligament hypertrophy Cannot be seen• Synovitis• Synovial effusion

• => joint laxity

radiographically

Technique of Caudal Extension View

• Generalised anaesthesia

• Includes lumbar vertebrae and stifle joints

• Evaluation of the quality of the image

• Dorsal spinous process of spine

• Wings of ilium

• Obturator foramens

• PatellaeThrall. Textbook of veterinary diagnostic radiology. 5th. ed. 2008

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• A : Cranial effective acetabular margin

Hip anatomy

AB

• B : Cranial acetabular edge

• C : dorsal acetabular edge

• D : caudal acetabular edge

• E : acetabular fossa

C

D E

Hip Dysplasia

Radiographic findings• Flattened cranial acetabular edge• Wedge-shaped joint space• Center of femoral head is lateral

to the dorsal acetabular edge• Norberg angle < 105 degree

• Advanced remodeling of www.vetwest.com.au

HD• Remodeling of the femoral

head and neck• Osteophytes on the femoral

head, neck and cranial effective acetabular margin

• New bone formation at the acetabular fossa

• Irregular subchondral bone

Morgan line• Enthesophyte• Parallel to the trochanteric fossa• Early sign of degenerative joint disease

Narrowed joint space

4. Legg-Calvé-Perthes Disease• Aseptic necrosis of the femoral head

• Young toy and small breed

• Early stage: a mottled or linear pattern of lucencies in the femoral head

• Progressing: flattening and irregular femoral head (remodeling), subluxated coxofemoraljoint

• Can be unilateral or bilateral

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Osteoarthritis

• Weight bearing joints• Such as hip, stifle

• Slowly progressive degenerative joint disease• Synovial effusion and cartilage degradation

• Aging change, or a result of a developmental or acquired disorder• Developmental: FCP, UAP, HD, Patellar luxation,

conformational valgus/varus• Acquired: trauma (cranial cruciate ligament rupture, joint

instability, joint malalignment )• Age-related cartilage degeneration

Radiographic signs of joint disease

•1. Increased synovial mass•2. Perichondral osteophyte•3. Enthesophyte formation•4. Erosion of the subchondralb fbone surface

•5. Joint mice/intraarticularmineralization

•6. Increased subchondral bone opacity

•7. Subchondral bone cyst formation


Osteophytes vs enthesophytes

• Osteophytes• Abnormal cartilage load => cartilage fibrilation => loss of

cartilage => synovial hyperplasia => osteophyte• Initially consist of cartilage, then mineralised => bony

outgrowths

• Enthesophytes• Enthesis: the point of insertion of a tendon, ligament, joint

capsule or fascia to bone• Enthesitis: inflammation of the site of tendon of ligament attach

to bone

• Enthesophyte, a bony spondylopathy at an enthesis

“New bone formation / degenerative change

Evans&deLahunta. Guide to the dissection of the dog. 7th ed.

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FULLY FLEX ELIncreased subchondral bone opacity

Erosion of subchondral bone

Feline arthritis

• Older than 12 years old > 90%

• Clinical signs are subtle

Fabcat.org

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Sprains/trauma

• Clinical examination• Radiographic examinations

• Documenting the presence and magnitude of the sprain and identifying avulsed osseous fragments.

• Radiographic feature• Periarticular soft tissue swelling• Avulsion fracture• Joint instability of subluxation• Spatial derangement of the osseous components

of a joint

Stressed View


Summary• Evaluation of developmental orthopedic disorders

requires high quality orthogonal radiographs • centered on the area of interest

• Remember the specific anatomical locations for developmental orthopedic diseases

B j i t• Bone or joint• Age of closure of growth plate

• ABCS• A : Alignment• B : Bone (epiphyses, physes, metaphyses, diaphyses)• C : Cartilage (joint space)• S : Soft tissue

Dog

Young

Large

S ll

1.OCD2. ED3. HD4. Panosteitis5. HOD6. Retained cartilage core7. Trauma (CCL, physeal..)8. Chondrodysplasia9. Nutritional

1. Legg-calves-Perthes2. Incomplete OHC

Common causes of lameness

g

All age

Small 2. Incomplete OHC3. Trauma4. Nutritional

1.Tenosynovitis2. Avulsion3. Trauma4. Patella luxation5. Neoplasia6. Infection7. Immune mediated8. SLE

Cause of osteoarthritis in cats• Secondary

• Congenital• Hip dysplasia• Trauma• Infectious/inflammatory• Nutritional

• Hypervitaminosis A

• Primary• SFCOD• MPS• Age-related cartilage

degeneration

• Neuropathic• Diabetes mellitus

• Immune mediated• Rheumatoid arthritis• Progressive proliferative

polyarthropathy• SLE• idiopathic polyarthritides

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Thank Youany questions?

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