Condylar Fractures of the Humerus in the Dog a Review of 133 Cases

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J Feline Med Surg. 2020 Oct; 22(10): 1008–1015.

Treatment of humeral condylar fractures and humeral intracondylar fissures in cats with patellar fracture and dental anomaly syndrome

Alexander JH Chan

¹Henlow Veterinary Centre, Henlow, UK

Natalia Andrea Reyes Rodriguez

^twoFaculty of Agricultural Sciences, University of Practical and Environmental Sciences (UDCA), Bogotá, Colombia

Steven J Bailey

³Feline Medicine, College of Veterinary Medicine, Michigan State University, East Lansing, MI, USA

Sorrel J Langley-Hobbs

⁴Langford Veterinary Services, University of Bristol, Bristol, UK

Supplementary Materials

Supplementary Material

GUID: 5F23D382-6384-42C6-B572-AE06A196886D

Knees and Teeth Syndrome (KaTS) follow-up survey

Abstract

Objectives

The aim of this study is to describe the treatment and outcome of humeral condylar fractures and humeral intracondylar fissures in cats with patellar fracture and dental anomaly syndrome (PADS) and to provide advice on how to manage these cases in practice.

Methods

Data were collated on cats with PADS that were reported to have sustained humeral fractures or had fractures or fissures of the humerus identified on radiographs. The details of the fractures were recorded in addition to any treatment and effect information.

Results

Of the 207 cases reported with PADS, xviii cats (8.7%) were institute to have humeral condylar fractures, none of which was known to have resulted from significant trauma. Where treatment occurred, it involved the placement of transcondylar positional or lag screws. In some cases additional implants, including supracondylar bone plates and screws or Kirschner wires (One thousand-wires), were used. Follow-up information revealed that simply two cats were euthanased owing to the presence of the humeral fractures, with at to the lowest degree eight achieving some degree of recovery of function.

Conclusions and relevance

These humeral fractures all have the characteristics of stress insufficiency fractures, being simple isolated fractures that are short oblique, with increased radio-density at the fracture line and occurring following minimal or no trauma. Humeral intracondylar fissures were identified in two cats and it is possible that some of the other fractures may have occurred secondary to pre-existing fissures. To our knowledge, no prior reports be of fissures in cats that exercise non meet the criteria for PADS. Surgical repair primarily consisted of the placement of transcondylar lag or positional screws with, in some cases, adjunct implants such as bone plates and screws or K-wires. Though at that place were insufficient data to make up one's mind the prognosis for these fractures in the long term, dissimilar patellar fractures, many of these fractures will heal if treated appropriately.

Keywords: Patellar fracture, stress fractures, persistent deciduous teeth, humeral condylar fracture

Introduction

A pathological disorder, 'patellar fracture and dental anomaly syndrome' (PADS), formerly known as 'knees and teeth syndrome', has been identified in cats.¹ The syndrome involves stress fractures of the patella and dental abnormalities, including persistent deciduous teeth and unerupted permanent teeth. These dental anomalies can lead to the development of osteomyelitis or abscesses.² Additionally, many of these cats develop non-traumatic fractures to another bone(southward), either preceding or subsequent to the patellar fracture(s).^1,3–5 Of these other fractures, the pelvis, tibia and humeral condyle are the sites well-nigh frequently affected. To our knowledge, at the time of writing, no reports exist of atraumatic fractures of the humeral condyle in cats that practise not meet the criteria for PADS.

The aetiology of PADS is currently unknown and information technology is hoped that by increasing the sensation of the syndrome and collecting more data nosotros may advance our agreement of the condition. The objective of this study was to describe the recommended handling options for cats with PADS that sustain humeral condylar fractures in lodge to inform the veterinary community and provide owners with more authentic information concerning the prognosis for these fractures.

Materials and methods

The cats in this study were sourced from records at the Academy of Bristol (Uk) and Exclusively Cats Veterinarian Hospital, Michigan (Us) afterwards a request was made for cases that met the criteria for PADS in the Veterinarian Record,⁶ the Veterinary Information Network and social media pages (https://www.facebook.com/felinepatellafracturestudy). These criteria included transverse patellar fracture(s) with or without dental abnormalities such equally persistent deciduous or unerupted developed teeth and atraumatic fracture(south) of other bones.

Long-term follow-up data were obtained by requesting owners and veterinarians to consummate a questionnaire (run across supplementary material) relating to the cats' progress since diagnosis or treatment. Data were sourced from radiographs, questionnaires and patient histories of cats with humeral fractures in addition to PADS. Where available, the event of the cats was noted, including the cause of expiry.

The use of this information was approved by the University of Bristol Ethical Committee.

Results

Information was obtained for 207 cats with suspected PADS. Of these cats, xviii (eight.7%) had sustained humeral condylar fractures, with 24 humeral fractures in full (12 cats with unilateral and half dozen with bilateral fractures) (Table 1). The nature of the fracture was recorded in thirteen of the cats, with 12 involving the lateral condyle, three the medial condyle and ane a Y-fracture. The fractures were mostly unproblematic, isolated and brusk oblique, with varying degrees of displacement.

Table one

Details of humeral condylar fractures in cats with patellar fracture and dental anomaly syndrome

Case	Sexual practice	Breed	Age fracture occurred	Weight (kg)	Crusade	Unilateral/bilateral	Clarification of fracture	Humeral fracture handling	Outcome
7	MN	DSH	NR	7	NR	Unilateral	NR	NR	LTFU
nine	FN	DLH	NR	NR	NR	Unilateral	NR	NR	LTFU
13	MN	DSH	5 y	NR	NR	Unilateral	NR	NR	PTS due to unrelated status
17	MN	DSH	7 y	4.vii	No known trauma	Bilateral	R: lateral condyle L: HIF	R: transcondylar plate and screws Fifty: transcondylar screw	Recovered
22	MN	Russian Blue	NR	NR	NR	Bilateral	NR	NR	LTFU
28	FN	Russian Blue	NR	4.7	NR	Bilateral	Lateral condyles	NR	LTFU
32	MN	DSH	2 y vi y 4 mo	four.6	NR	Bilateral	Medial condyles	Transcondylar screws	Died attributable to unrelated condition
36	FN	DSH	viii y 5 mo	iii.viii	No known trauma	Unilateral	Medial condyle	NR	LTFU
37	ME	DSH	NR	five.ii	NR	Unilateral	Lateral condyle	Transcondylar screw and metaphyseal spiral	PTS due to other fracture
48	FN	Siamese cross	ii y	3.9	No known trauma	Unilateral	NR	NR	PTS due to humeral fracture
68	FN	DSH	1 y half-dozen mo	NR	No known trauma	Bilateral	Chronic non-union lateral condylar fractures	Conservative	PTS due to unrelated condition
72	MN	NR	ii y	NR	No known trauma	Unilateral	Y-fracture	NR	PTS due to unrelated condition
95	FN	DSH	NR	NR	No known trauma	Unilateral	Lateral condyle	Transcondylar screw and anti-rotational wire	Recovered
98	FN	DSH	NR	NR	NR	Unilateral	Chronic healed lateral condylar fracture	NR	Recovered
126	MN	DLH	6 y	five.six	NR	Unilateral	Lateral condyle	NR	LTFU
140	MN	DSH	NR	NR	No known trauma	Unilateral	Lateral condyle, suspected secondary to HIF	NR	LTFU
147	FN	DSH	3 y 11 mo	NR	No known trauma	Bilateral	L: lateral condyle R: HIF	NR	PTS due to fractures
157	NR	DSH	NR	NR	NR	Unilateral	Lateral condyle	NR	Died due to unrelated condition

Humeral intracondylar fissures (HIFs) were diagnosed in 2 cats (Figure 1). Chronic humeral fractures were observed in ii cats.

(a) Craniocaudal and (b) mediolateral radiographic views of a suspected humeral intracondylar scissure with a radiolucent line extending from the articular surface halfway up the condyle in the left humerus of case 17 (arrow). There is moderate and well-established osteoarthritis with osteophytosis affecting the radial head and ulna notch and mineralisation in the region of the medial articulation sheathing

The age at which the first humeral fracture occurred was recorded in 9/18 cats (mean 4.2 years; range 24–101 months). Trunk weight was recorded in 8/18 cats (hateful iv.9 kg; range iii.viii–7.0 kg). Sexual practice was recorded in sixteen animals (with nine males [one entire, eight neutered] and 7 females [all neutered]). Breed was recorded in sixteen cats (xi domestic shorthairs, two domestic longhairs, two Russian Dejection and i Siamese cross).

The cause of the humeral fracture was documented in 8/eighteen cats, with none of these being reported as having occurred as a issue of external directly trauma.

Treatment

Of the 24 humeral fractures, 6 were recorded as having undergone surgical treatment: three were repaired with transcondylar lag or positional screws (Figures 2 ​ ​ ​ ​ –seven), one with a transcondylar lag screw in addition to a supracondylar dynamic compression plate and screws (Figures three and ​ 4), 1 with a transcondylar lag spiral and anti-rotational Kirschner wires (K-wires) (Figure 5), and one with a transcondylar lag screw and metaphyseal screw (Figures half-dozen and ​ 7). Two fractures were managed conservatively with analgesia and anti-inflammatory medication.

Immediate postoperative (a) craniocaudal and (b) mediolateral radiographic views demonstrating transcondylar 2.4 mm/22 mm positional spiral implantation to stabilise the left humeral intracondylar crevice in case 17

(a) Craniocaudal and (b) mediolateral radiographic views of a fracture of the lateral aspect of the right humeral condyle of case 17. There is moderate, well-established osteoarthritis with osteophytosis affecting the radial head and ulna notch and mineralisation in the region of the medial joint capsule

Immediate postoperative (a) craniocaudal and (b) mediolateral radiographic views demonstrating a combination of an supracondylar contoured five-hole two.0 mm dynamic pinch plate and screws with a transcondylar 2.4 mm/22 mm lag spiral to stabilise the fracture of the lateral aspect of the humeral condyle in instance 17. At that place is astringent and well-established osteoarthritis with osteophytosis affecting the radial head and ulna notch and mineralisation in the region of the medial articulation capsule

Immediate postoperative (a) craniocaudal and (b) mediolateral radiographic views demonstrating a combination of a transcondylar lag screw and two anti-rotational Kirschner wires to stabilise the fracture of the lateral aspect of the humeral condyle in case 95

(a) Craniocaudal and (b) mediolateral radiographic views of a displaced fracture of the lateral aspect of the humeral condyle in case 37

Immediate (a) craniocaudal and (b) mediolateral radiographic views demonstrating a combination of a transcondylar lag screw and a metaphyseal lag spiral placed to stabilise the fracture of the lateral attribute of the humeral condyle in example 37

Outcomes

Outcomes were recorded for eleven/18 cats; ii were euthanased owing to the humeral fracture(s) and 1 owing to the presence of other fractures. For the remaining eight cats, 3 recovered to be fully weightbearing on the affected limb(s) and for the other five cats, their causes of death were not attributable to having sustained the fractures (although it is not clear to what degree they recovered).

Discussion

Fractures of the humeral condyle are rare in cats, with about feline humeral fractures being diaphyseal.⁷ Feline humeral condylar fractures that have been previously reported take involved loftier-energy trauma primarily due to route traffic accidents,⁸ producing comminuted fractures every bit opposed to the oblique condylar fractures institute in cats with PADS. Nevertheless, none of the cats in this study were reported to have developed these fractures as a result of external direct trauma. Furthermore, the fact that many of these cases involve indoor-but cats renders a loftier-energy traumatic cause of the fractures unlikely. Therefore, these cases are more than likely to represent stress insufficiency fractures. These occur following minimal or no trauma, when normal or physiological stresses are placed on aberrant bones,^9,10 producing unproblematic isolated fractures, transverse or brusque oblique, and oftentimes with increased radio-opacity at the fracture line, as demonstrated on radiographs (Figures 3a and ​ 6a). This contrasts with stress fatigue fractures that occur when repetitive forces act upon normal os.^11,12

One of the major risk factors for condylar fractures in dogs is the presence of HIFs, which are areas of weakness in the bone.¹³ Recently, the aetiopathogenesis of HIFs has been disputed. The by and large accustomed theory was that HIFs develop secondarily to incomplete ossification of the humeral condyle.^fourteen,15 The humeral condyle develops from two ossification centres: the medial heart comprising the medial attribute and trochlea, and the lateral involving the capitulum and lateral aspect of the condyle. In the cat, these 2 ossification centres should fuse past 14 weeks of age.¹⁶ Still, it has been discovered that HIFs can develop after ossification has successfully occurred, as observed with CT¹⁷ and MRI¹⁸ studies carried out pre- and post-fissure germination. Accordingly, some contend for an alternative hypothesis involving a previously ossified condyle undergoing remodelling and stress fatigue, leading to fissure germination. HIFs take merely been reported in cats with PADS and their presence would support the theory of stress fractures.

The bulk of the fractures in this study involved the lateral aspect of the condyle, as is generally the case with canine humeral condylar fractures. In dogs, these fractures are over-represented in certain breeds, such every bit English Springer Spaniels and French Bulldogs.^19,20 The two groups most ordinarily afflicted are skeletally immature dogs around 4 months of age and older, skeletally mature patients.²⁰ In skeletally immature dogs, the fracture is a Salter–Harris Blazon IV nomenclature, involving the growth plate, metaphysis and epiphysis. These are usually associated with minor trauma, with a possible history of low-grade lameness prior to the consequence.²¹ In older dogs, HIFs are believed to render this part of the os more than vulnerable to fracture, thus explaining why fifty-fifty minor forces acting on the limb are capable of producing fractures.^22,23

To our knowledge, HIFs have not previously been described in cats non afflicted by PADS, still HIFs were observed in 2 of the cases in this study and suspected in others. In this report, the information indicate that these fractures occurred in skeletally mature cats of at least 2 years of age; however, it is possible that fissures could have been present before the other fractures were sustained.

The pathophysiology of the fracture in dogs is that a forcefulness applied to the foot (via a fall or jump) results in impact of the radial head across the humeral condyle, producing an indirect shear fracture. The lateral attribute of the humeral condyle is thought to fracture more normally than the medial aspect owing to its articulation with the radius resulting in these forces acting laterally. Additionally, the smaller lateral supracondylar ridge is weaker than the medial ridge.²⁴

Several anatomical factors explicate why cats sustain fewer condylar fractures than dogs.²¹ Cats have a supracondyloid foramen at the level of the distal humerus as opposed to the perforate supratrochlear foramen in dogs; additionally, feline supracondylar ridges are relatively straight and wide in comparing to their canine counterparts (Effigy 8).^nineteen,24 These differences render the feline humerus less vulnerable to fracture than its canine counterpart.

Cranial aspect of canine (left) and feline (right) humeri of the right limb. Annotation the presence of (left) the perforate supratrochlear foramen in the canine humerus and (right) the supracondyloid foramen in the feline humerus

Every bit fractures of the humeral condyle are rare in cats, information technology is possible that they may exist overlooked with any accompanying elbow pain treated every bit arthritis if imaging is not performed. In 4/207 cases with PADS, sudden-onset elbow hurting was observed; however, no radiographs were taken and it is conceivable that these cats sustained undiagnosed condylar fractures. Indeed, of the cats in the present study, ane (instance 68) was treated for elbow arthritis for several years and chronic displaced condylar fractures (Figure 9) were only discovered on radiographs after the cat sustained a tibial fracture.

(a,b) Craniocaudal and (c,d) mediolateral radiographic views of a chronic healed displaced fracture of the lateral attribute of the humeral condyle in case 68

In a cat with suspected PADS, a history of forelimb lameness localising to the elbow and associated with minimal trauma should heighten suspicions of a humeral condylar stress insufficiency fracture. The lameness may be variable in severity, particularly if the fracture is incomplete or if an HIF is present. Crepitus and swelling may not be readily observable in the early stages, although elbow pain is likely to be elicited on manipulation. Although diagnosis of these cases was carried out radiographically, CT is the most sensitive diagnostic method and considered the gold standard imaging modality for these fractures, particularly in cases where HIFs are suspected, given the challenge of identifying these on obviously radiographs. Should radiographs be taken, orthogonal views are essential. MRI or arthroscopy could too be considered.

Where treatment occurred, this by and large involved the placement of transcondylar positional or lag screws to accomplish interfragmentary compression in the mode used conventionally to treat condylar fractures in dogs.⁷ Repair may be carried out with open reduction and internal fixation, or by airtight reduction with fluoroscopic guidance and a minimally invasive technique.²⁵ Boosted implants such equally supracondylar os plates and screws, anti-rotational Thousand-wires, Steinmann pins or additional supracondylar screws may be used to limit rotation and increase the stability of the fracture fragments. In cats, care should be taken during surgical repair to avoid the brachial artery and median nerve that pass through the supracondyloid foramen and ensure appropriate placement of implants to preclude farther damage.¹⁴

Condom surgical repair is indicated in dogs where an HIF is suspected given the high rates of condylar fracture associated with these fissures.⁸ In feline cases, it seems prudent to follow this recommendation equally there was a suspicion in some of these cases that fractures also occurred secondary to HIFs. Transcondylar screws in addition to a bone plate applied to the lateral supracondylar crest may exist advisable in such cases.^seven In dogs, it is suggested that these fissures exercise not heal even later on surgical repair.²⁶ As such, the aim of the fissure repair is rather to resolve lameness and lower the chance of progression to a complete condylar fracture.

Should conservative direction of fractures be attempted, this is likely to result in chronic, possibly severe, lameness that will require long-term analgesia and anti-inflammatory medication. Conservative management of HIFs in dogs, and conceivably cats, is associated with a loftier take chances of progression to complete fracture of the humeral condyle.⁸

Of the 11 cats in this written report where upshot data are present, in only two cases was the humeral fracture listed as the reason for euthanasia. It is non possible to conclude that all the remaining cases recovered to reach total office based on the information bachelor. However, a good level of recovery was recorded in three of the cases and for the other six cats the humeral fractures were non impairing the animals' quality of life enough to be a master motivation for euthanasia.

One of the cats (case 98) was found to have a chronic healed humeral condylar fracture as an incidental finding. This implies that even without surgical intervention, some humeral condylar fractures may be capable of repair. Similarly, in another cat (case 68), acceptable weightbearing was achieved with medical direction alone, despite chronic bilateral humeral condylar fractures (Effigy ix). This contrasts with patellar fractures in cats with PADS where in one written report,³ even with surgical treatment, 33/34 cats demonstrated not-unions in radiographs taken up to 2 years postoperatively. Different these patellar fractures, humeral condylar fractures appear to be capable of healing. Following appropriate treatment, the cats should regain apply of the affected limb(s) thus offering a less guarded prognosis. Withal, given that 14/xviii of these cats sustained fractures in other basic aside from the humerus and patella, it is important to warn owners that regardless of the prognosis for the humeral fractures, the risk of other frac-tures occurring in cats with a diagnosis of PADS is relatively loftier.⁵

The limitations of this report were that radiographs, treatment information and follow-up data were not bachelor for all animals. Nevertheless, despite these limitations, we experience that this study provides useful information relating to the existence and treatment of other fractures occurring in cats with PADS that are likely to be disregarded and misdiagnosed owing to a current lack of awareness of the condition. Information technology is hoped that this information will exist useful for discussion on treatment options and the prognosis of affected animals, while alerting veterinarians to the possibility that cats can be affected by this syndrome.

Conclusions

These humeral condylar fractures accept all the characteristics of stress insufficiency fractures, being simple isolated fractures, short oblique, with increased radio-opacity at the fracture line and occurring following minimal or no trauma. HIFs were present in two cats and it is possible that other cases developed complete fractures subsequent to a crack. Surgical repair primarily consists of transcondylar lag or positional screw placement with adjunct implants such every bit os plates and screws or G-wires. Although the prognosis for these fractures cannot be stated with certainty, unlike patellar fractures in cats with PADS, these fractures have the potential to heal if treated accordingly.

Supplemental Material

Supplementary Material:

Knees and Teeth Syndrome (KaTS) follow-up survey

Acknowledgments

The authors would like to give thanks Mark Longley for his assistance in the drove of data on the cats, and all the owners and veterinarians who both treated and provided details concerning these cases.

Footnotes

Accepted: 10 January 2020

Supplementary material: The following file is bachelor online: Knees and Teeth Syndrome (KaTS) follow-up survey: https://svs.onlinesurveys.ac.uk/knees-and-teeth-syndrome-kats-follow-up-survey.

Disharmonize of interest: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding: The authors received no financial support for the enquiry, authorship, and/or publication of this commodity.

Upstanding approval: This work involved the utilise of not-experimental animals only (owned or unowned), and followed established internationally recognised high standards ('best practice') of individual veterinary clinical patient care. Ethical approval from a committee was therefore non necessarily required.

Informed consent: Informed consent (either verbal or written) was obtained from the owner or legal custodian of all animal(s) described in this work for the procedure(southward) undertaken. No animals or humans are identifiable within this publication, and therefore additional informed consent for publication was not required.

ORCID iD: Natalia Andrea Reyes Rodriguez https://orcid.org/0000-0002-9939-2870

Sorrel J Langley-Hobbs https://orcid.org/0000-0003-4397-5150

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