Orthopedic Radiology

Fred Pike, DVM, DACVS

 DISCLOSURE

MWI Consultant

Securos Orthopedic Institute

F.S. Pike, DACVS

Veterinary Specialty Hospital of San Diego
 Goals
• Discuss everyday strategies to improve the
utility of radiographs in the diagnosis of
orthopedic disease

• Review radiographic features of common

orthopedic diseases

• Discuss less-common orthopedic diseases

that can be diagnosed with the aid of
radiograph
 Positioning
• Normal vs. abnormal is based off of comparison to a
mental image of a well-positioned normal radiograph

• Most likely result of a malpositioned radiograph is

overdiagnosis, but many lesions can also be missed
with a poorly-positioned radiograph

• Common causes of poor positioning

– Time constraints
– Uncooperative patients
– Not aware of criteria
– Accepting suboptimal images
 Technique
• Improper technique can lead to over-,
under-, misdiagnosis
Too Hot! Technique
Too Cold
Just Right
Orthogonal Views
Orthogonal Views
Orthogonal Views
Orthogonal Views
Orthogonal Views
Orthogonal View Radiographs
Orthogonal View Radiographs
Orthogonal View Radiographs
Orthogonal View Radiographs
Orthogonal View Radiographs

Diaphyseal Fracture
Orthogonal View Radiographs
Influence of Positioning
Influence of Positioning
 Pelvic fractures
• The pelvis is a rigid box

• Fractures or separation of one bone is usually

accompanied by 2 others
 Weight-bearing axis of the pelvis
• Typically, only injuries involving the weight-
bearing portion of the pelvis are
considered for repair
Weightbearing
 Sacroiliac luxation
• Indications for repair
– Highly (>50%) displaced
– Painful
– Unstable
– Contralateral limb injury
– Significant pelvic canal collapse
• Dogs tolerate more than cats
1
Good CranioCaudal Hip Positioning
– Stifles internally rotated
– Hips fully extended
• Can compensate by lifting patient’s upper body
– Include ilium to stifles
– Pelvis should look symmetrical
• Look at obturator foramina, SI’s, spinous
processes
 To TPO or Not To TPO
• Is this dog a TPO candidate?
– Rads cannot say that a dog IS a TPO
candidate, only if it ISN’T
– Exam (after rads that don’t exclude) defines
candidacy
• Capture
• Advanced imaging
• arthroscopy
 “Treat the patient, not the
radiographs”
• 8 year SF Lab
– Presented for right pelvic limb lameness
“Treat the patient, not the
radiographs”
 Coxofemoral Luxation
• The most common luxation in dogs and cats
• Most often secondary to trauma, also occurs
because of hip dysplasia or after acetabular
fracture repair
• Most common type is a craniodorsal luxation
because of the strong pull of gluteal musculature
– Caudoventral luxations account for < 5%
 Coxofemoral Luxation
• Anatomy:
– ball and socket joint,
allows wide range of
motion
• Stability by three
structural groups
– joint capsule is primary
stabilizer
– ligament of head of
femur
– muscle groups
 Coxofemoral Luxation
• Clinical Signs
– Animal may be partially
weight bearing or NWB
– toes mildly rotated
externally
– greater trochanter
dorsally displaced
relative to ilium, ischium
and opposite trochanter.
– Negative ‘thumb test’
– Hind limb length disparity
– Crepitus may be palpable
 Coxofemoral Luxation
• Treatment
– Closed reduction
• Contraindications to
closed reduction
– Hip dysplasia
– Closed reduction
contraindicated in
cases with
acetabular or femoral
fracture
CLOSED REDUCTION

• uncomplicated
luxation
• first attempt
• <4-5 days duration
• no other orthopedic
trauma
CLOSED REDUCTION
• Osteoarthritis
• Hip dysplasia
• Acetabular fracture
• Femoral head
fracture
CLOSED REDUCTION
 CLOSED REDUCTION
 Manipulate to evacuate capsule and granulation
tissue
 Ehmer sling or modified Ehmer sling

 Radiograph to confirm reduction

EHMER SLING

• Ehmer sling 10 days

• Bandage care

• 50% recurrence rate

• no difference in long
term outcome
compared to ORIF if
reduction maintained
 Modified Ehmer Sling

• Addition of a “belly
band” improves
internal rotation and
abduction
 Modified Ehmer Sling
• Major potential for
bandage complications

• Owner compliance is
critical

• Consider commercial
Slings
HIP LUXATION
CAUDOVENTRAL
• Closed
reduction
• Hobbles

• ORIF indicated
for greater
trochanter
fractures
 Coxofemoral Luxation
• Open reduction
• Indications
– Luxated head does not
seat well in acetabulum
– Reluxation after closed
reduction
– Hip has been chronically
luxated
– Fractures are present
– Hip dysplasia?
 Good Stifle Positioning
• Femoral condyles superimposed
• Fabellae superimposed
• Intercondylar eminences visible
• Getting the butt up and/or externally
rotating the stifle on the table tends to help
 Shoulder OCD
• Bilateral rads recommended
• Consider slight rotation on the lateral if
high index of suspicion
Normal
 Supraspinatus Mineralization
• May or may not be clinically relevant
• Differentiate from biceps
– Biceps can be treated with scope
– Supraspinatus requires open incision
 Incomplete Ossification of the
Caudal Glenoid
• May be an incidental finding
• May be a cause of lameness in the
absence of other findings
• Usually accompanied by caudal humeral
OA
Good Lateral Elbow Positioning
• Medial and lateral condyles of humerus
should be concentric
 Elbow Dysplasia
• Fragmented Medial Coronoid Process
• Humeral condylar OCD
• Ununited Anconeal Process
• Elbow incongruity
 Fragmented Medial Coronoid
(FCP, FMCP)
• Radiographic features
– Osteophytosis
• Caudal anconeal process
– Fully-flexed lateral may highlight
• Radial head
• Epicondylar region (AP)
– Indistinct MCP
– Trochlear notch sclerosis
– Fragmentation of the MCP
• Radiographs are fairly sensitive but far from
perfect
– Consider CT
scope
Elbow OCD
 Ununited Anconeal Process
UAP
• AP growth center closes by maximum of
22 weeks
– Lucency @UAP @>22 weeks = UAP
Ununited Medial Epicondyle
 Abductor Pollicus Longus
Tenosynovitis
• Similar pathogenesis to biceps
tenosynovitis
• Good differential for carpal pain and
swelling without instability
• Fairly characteristic radiographic
appearance