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Case Study: Approach to Premature Closure of the Distal Radial Physis

Overview

Gayle Jaeger, DVM, MSpVM, DACVS, an orthopedic and soft tissue surgeon at VRC, has been treating a Golden Retriever puppy named Lito after his distal radial physis closed prematurely.  As a result, his right radius was shorter than the adjacent growing ulna with subluxation of the elbow joint. If left untreated, this would progressively create lameness and complete dysfunction of the limb.

History & Diagnostics

Lito initially presented to Dr. Jaeger in early December 2016 at 5.5 months of age, with a progressive three-week history of right front limb lameness unresponsive to rest and anti-inflammatories. Radiographs at that time revealed evidence indicating premature closure of his distal radial physis with secondary elbow subluxation.

Initial Radiographs


Above are lateral radiograph projections of the front limbs. The left is the normal side and the right is the affected side. Notice the open left distal radial physis on the left compared to the closed distal radial physis 
on the right. Also, note the shorter length of the right radius compared to the ulna as well as the resultant radiohumeral (elbow) incongruity.

 

Procedures

Partial Ulnar Ostectomy

A partial ulnar ostectomy was elected in an attempt to curb the secondary effects this incongruity would create on the elbow and carpal joints. By performing this procedure, we realized that over time his right antebrachium and overall limb length would be shorter than his left side. Our first priority was to save his elbow joint from discomfort and irreversible damage as the ulna continued to push up against the humerus.

 

Above are post-operative lateral radiographs of the right antebrachium before and after the partial ulnar ostectomy. There is immediate mild improvement of the step between the height of the radius and ulna simply by releasing tension in the longer ulna. This improved further with weight bearing on the limb.

Second Partial Ulnar Ostectomy

Unfortunately, due to his young age, Lito’s ulna healed prematurely requiring a second partial ulnar ostectomy to remove more of the ulna while he continued to grow.


Note above how the step between the radius and ulna improved with weight bearing, making his elbow more comfortable and preventing deformity.

Once his growth plates started closing and we knew how long his normal leg would be as an adult, we could measure the true length deficit of his right side and start planning to lengthen his limb. The affected right radius was ultimately almost 4 cm shorter in length than the normal left side.


Above depicts the left fully-grown normal limb versus the shorter right limb. Note the persistent changes of his right elbow compared to his left.

Radial Osteotomy & Stryker Triax External Skeletal Fixator Application

We contacted Stryker for assistance in providing a special external skeletal fixator called the Triax.  This device would allow us to slowly lengthen his leg over time. The external connecting bar of the Triax frame has the ability to lengthen bone by turning a distraction bolt; separating two bone segments in small increments. Lito again went into surgery and we repeated the partial ulnar ostectomy, created a radial osteotomy, and applied the external fixator.

 


Post-operative radiographs of the radial osteotomy and application of the Stryker Triax External Skeletal Fixator.

Slowly, we distracted and lengthened the limb by having the owners turn the distraction bolt on the fixator in small increments every day.

Outcome

After a month of distraction, we can see the amount of bone length that was achieved (figure below). There is also a cone of new bone at each end of the osteotomy. When performing these distraction procedures, there is a fine balance in timing. If performed too slowly, the bone may heal before distraction is complete. If performed too quickly there is not enough time to allow the soft tissues (tendons, muscles and ligaments) to stretch with the bone, which may impede full extension of the carpus.  During his distraction, Lito has also been involved in a rigorous formal physical rehabilitation program.


Lateral radiograph after one month of distraction. Note the length of the distraction gap and the new bone forming from each fragment end.

Once Lito’s distraction program was completed and the desired radial length was achieved, the bone was permitted to consolidate. When complete healing occurred, his fixator was removed. He continues physical rehabilitation to improve his joint range of motion, build muscle mass and improve overall limb use.


Above: Lito’s radius has almost completely healed.

 

Welcome Dustin Lewis, DVM, DACVR (Radiation Oncology)!

We are thrilled to welcome our newest radiation oncologist, Dustin Lewis, DVM, DACVR (Radiation Oncology)!

 

 

The VRC team is growing! We are excited to announce that Dr. Dustin Lewis is the newest radiation oncologist at VRC! He brings with him years of experience and skill in the field of radiation oncology.

 

MORE ABOUT DR. LEWIS

Dustin Lewis, DVM, DACVR-RO grew up in Northeast Indiana and attended to Purdue University for both undergraduate studies and veterinary school.  In 2010, he graduated and began a small animal rotating internship at The Animal Medical Center in New York, NY.  In July 2011, he began a joint residency in radiation oncology at both North Carolina State University in Raleigh, NC and Colorado State University in Fort Collins, CO.  Dr. Lewis completed his radiation oncology residency in July of 2013.  Upon completion of his residency, he accepted a position as radiation oncologist at Red Bank Veterinary Hospital in Tinton Falls, NJ before he began also offering his services at VRC in 2017.


GET TO KNOW OUR TEAM

If you are a referring veterinarian and would like to schedule a Meet & Greet or Lunch & Learn with Dr. Lewis or any of our other doctors, please contact
Brian Haugen at Brian.Haugen@CompassionFirstPets.com.

To learn more about VRC and the many services that we offer, give us a call at (610) 647-2950.

Welcome Justin Guinan, DVM, DACVIM (SA-IM)!

We are thrilled to welcome our newest internist, Justin Guinan, DVM, DACVIM (SA-IM)!

The VRC team is growing! We are excited to announce that Dr. Justin Guinan is the newest internist at VRC! He brings with him years of experience and skill in the field of internal medicine.

HIS SERVICES INCLUDE:

  • Endoscopy with biopsy collection (esophagoscopy, gastroduodenoscopy, colonoscopy, rhinoscopy, nasopharyngoscopy, tracheoscopy, bronchoscopy, cystoscopy)
  • Abdominal ultrasonography (with aspiration or biopsy if indicated)
  • Diagnostic airway sampling (endotracheal wash, bronchoalveolar lavage)
  • Bone marrow collection (aspiration or biopsy)
  • Diagnostic/therapeutic fluid collection (cystocentesis, arthrocentesis, CSF tap, thoracocentesis, abdominocentesis)
  • Phone Consultations with Veterinarians
  • Available for Lunch & Learns

 

MORE ABOUT DR. Guinan

A native of Westchester County, New York; Justin Guinan, DVM, DACVIM (SA-IM) began his veterinary career in 2000 with a BS in biology from Syracuse University, followed by a DVM degree from Atlantic Veterinary College in 2005. Later that year, Dr. Guinan enrolled in a yearlong general internship program, followed by another yearlong specialty internship program in internal medicine and neurology at Long Island Veterinary Specialists. In 2009, he went on to complete his residency in small animal internal medicine at the Animal Medical Center in New York City.  With years of experience, education, and a board certification under his belt, Dr. Guinan worked at a large specialty and emergency veterinary hospital in New Jersey for several years before joining the VRC team in 2017.  His clinical interests include hematology, endocrinology, ultrasonography, and all forms of diagnostic endoscopy. Outside of work, Dr. Guinan enjoys spending time with his wife and two young sons, baseball, football, hiking, and music.


GET TO KNOW OUR TEAM

If you are a referring veterinarian and would like to schedule a Meet & Greet or Lunch & Learn with Dr. Guinan or any of our other doctors, please contact
Brian Haugen at Brian.Haugen@CompassionFirstPets.com.

To learn more about VRC and the many services that we offer, give us a call at (610) 647-2950.

Upcoming Continuing Education Lecture

jager-2It’s Lame Being Lame

 

Gayle Jaeger, DVM, MSpVM, DACVS

Wednesday, November 9, 2016
7:00pm

When working with canine orthopedics, veterinarians are no strangers to the appearance of clinical lameness in their patients. However, lameness should not be a catch-all term, as its presentation can indicate various and sometimes unexpected underlying issues.  In this lecture, we will review case presentations and discuss a variety of clinical lameness in dogs; identifying the site of lameness, possible differentials, diagnostic techniques and treatments. Join us as we unearth and review recent innovations and practical application techniques regarding a symptom that we see on an almost daily basis.
Lecture provides 1 credit of complimentary CE through RACE to veterinarians and veterinary technicians.

LOCATION
VRC
340 Lancaster Avenue
Malvern, PA 19355

PROGRAM
Complimentary meet and greet dinner starts at 7:00pm on Wednesday, November 9th. Session begins at 7:30pm followed by Q & A.

RSVP
Space is limited so please RSVP by Friday, November 4th to reserve your seat. You can RSVP to this event by clicking HERE. If you have any questions regarding this event you can give Brian Haugen a call at 267-566-6302 or send him an email at Brian.Haugen@CompassionFirstPets.com.

Sponsored by
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