Case Report 231

© 2007 Schattauer GmbH

Ulnocarpal arthrodesis for the treatment of

radial agenesis in a dog
B. E. Hildreth III, K. A. Johnson
The Ohio State University, College of Veterinary Medicine, Columbus, Ohio, USA

In humans afflicted with radial agenesis,

Summary Introduction treatment by ulnocarpal arthrodesis, alone
Forelimb deformity caused by radial agenesis was
diagnosed in a one-year-old Shih Tzu dog. In contrast or subsequent to ulnar lengthening, results
to most of the previously reported cases of radial agen- Radial agenesis, or congenital absence of in restoration of forearm function (10). In
esis, the humeroulnar joint was inherently stable. The the radius, is one of the more common dogs, carpal arthrodesis generally facilitates
deformity was treated by means of a one-stage ulno- single bone dysostoses of dogs (1, 2). It has restoration of forelimb function because it
carpal arthrodesis with the application of an eight hole been hypothesized that radial agenesis is eliminates joint pain, instability, sub-
dorsolateral arthrodesis bone plate and autogenous due to a defect in the medial limb ray, which luxation, and malalignment (11, 12). A dor-
corticocancellous bone graft from the ilial wing. Radio- is one of the three rays of the thoracic limb sal bone plate application is most commonly
graphic evaluation at the eighth and sixteenth post-op- bud that gives rise to the forelimb during used for pancarpal arthrodesis stabilization
erative week showed evidence of union of the arthrode- embryonal development (3–5). However, in dogs (11–13). This report describes the
sis. At sixteen weeks post-operatively, the dog had the precise aetiology of radial agenesis is successful treatment of radial agenesis in a
much improved limb function. In humans afflicted with
unknown. Maternal and environmental fac- dog by means of a one-stage ulnocarpal
radial agenesis, ulnocarpal arthrodesis is used to re-
store forearm function by minimizing pain and decreas-
tors have been suggested, and an autosomal arthrodesis using a dorsolateral arthrodesis
ing the magnitude of angular deformity and instability dominant and recessive inheritance has also bone plate.
at the level of the ulnocarpal joint. However, to our been implicated (4, 6).
knowledge, this is the first report of treatment of radial Radial agenesis manifests clinically as
agenesis in the dog by means of a one-stage, ulnocar- forelimb shortening with disuse muscle
pal arthrodesis. atrophy and flexural contracture (1, 3, 5, 7). Case report
Incomplete development of the medial com-
Keywords partment of the carpus results in varus de- A one-year-old, 9.0 kg, male Shih Tzu dog
Radial agenesis, ulnocarpal arthrodesis formity at the level of the ulnocarpal joint. was referred because it had angular deform-
Complete agenesis of the radial head can ity and shortening of the left forelimb that
Vet Comp Orthop Traumatol 2007; 20: 231–235 also result in humeroulnar joint subluxation had been evident since birth. According to
(3, 7). Pain is an inconsistent finding, unless the owner, the birth of the dog was uncom-
Prepublished online July 26, 2007
there is concurrent injury (5, 7). Radio- plicated. It had been using the limb since the
doi:10.1160/VCOT-06–08–0067
graphs typically reveal complete or partial owner acquired it at two months of age, and
absence of the radius, ulnar shortening, and the only incident of lameness occurred one
ulnocarpal varus, with ulnar recurvatum month prior to referral, when the dog be-
and humeroulnar joint subluxation in some came acutely non-weight bearing after
cases (1, 3). being struck by a bicycle. Diagnostic im-
The early reports of the treatment of radi- aging was not performed at that time and the
al agenesis in dogs and cats described fore- lameness resolved within three days after
limb amputation in cases of functional loss administration of one dose of corticosteroid
and potential self-trauma (3, 5, 7). Treat- by the referring veterinarian. On examin-
ment by radial reconstruction with a rib ation we observed a moderate weight bear-
autograft and Kirschner wire fixation (8), ing left forelimb lameness when the dog was
forelimb lengthening by distraction osteo- walked on a leash. Examination revealed a
genesis (1), and by a combination of simul- marked varus deviation of the left manus
taneous humeroulnar and dorsal ulnocarpal centered at the ulnocarpal joint and antebra-
arthrodesis (9) have been described. How- chial shortening when compared to the
ever, recovery of limb function was compro- contralateral, unaffected forelimb. There
mised in the two latter cases by the need for was not any pain on antebrachial palpation
additional surgeries to stabilize the ulnocar- nor on manipulation of any joint; however,
pal joint (1, 9). there was a decrease in range of motion of
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232
Hildreth, Johnson

mg/kg IM), anaesthesia was induced with

propofolc (3.125 mg/kg IV) and maintained
with isofluraned in oxygen, and a continu-
ous rate infusion of a solution of 0.0048%
morphinee, 0.06% lidocainef, and 0.012%
ketamineg in lactated Ringer’sh at 5 ml/kg/
hr. Cefazolin sodiumi (25 mg/kg) was given
at induction and additionally two hours
later.
The patient was positioned in right lat-
eral recumbancy for surgery and a dorsal
surgical approach to the left carpus was per-
formed (14). Articular cartilage was de-
brided to the level of subchondral bone with
a saline-cooled pneumatic burrj from all of
the carpal and carpometacarpal joints, ex-
cept for the accessorioulnar and carpometa-
carpal I and II joints. The styloid process of
the ulna was exposed and ostectomized per-
pendicular to the long axis with an oscillat-
ing sawk to permit correction of the axial
malalignment. The distal radial remnant
was left in situ. Temporary stabilization of
Fig. 1 Analogue, orthogonal radiographs of the left antebrachium taken at the time of initial examination from which a the carpus was achieved by retrograde inser-
radiographic diagnosis of radial agenesis was made. tion of a Kirschner wire through metacarpal
bone V, the ulnar carpal bone, and the ulna.
An eight-hole 2.0/2.7-mm arthrodesis bone
the humeroulnar joint. There was disuse 45% down the ulnar length, was present. In platel was contoured and secured to the dor-
muscle atrophy of the entire left forelimb. addition, varus deformity was noted on the solateral aspect of the distal ulna, the ulnar
Neurological examination and the re- craniocaudal radiographic view (Fig. 1). carpal bone, and metacarpal bone V. In-
mainder of the physical examination were Marked ulnocarpal varus (70°) was associ- itially, a 2.0-mm cortical bone screwm was
within normal limits. The patient was se- ated with ulnocarpal joint subluxation. In inserted in the neutral position into the ulnar
dated with acepromazinea (0.05 mg/kg IV) addition, there was 13° of metacarpal valgus carpal bone through the fourth hole in the
and hydromorphoneb (0.05 mg/kg IV) and due to curvature of the metacarpal bones. plate. A 2.0-mm cortical bone screw was
orthogonal radiographs of the left antebra- The left humerus measured 78 mm from the then inserted in the load position through
chium and humerus were taken. A radio- proximal aspect of the greater tubercle to
graphic diagnosis of radial agenesis was the caudal border of the medial epicondyle, c
Propoflo, Abbott Laboratories, North Chicago,
made (Fig. 1). The ulnar notch was deeper and the left ulna measured 71 mm from the IL, USA.
than normal due to the presence of promi- most proximal aspect of the olecranon to the d
Isoflo, Abbott Laboratories, North Chicago, IL,
nent coronoid processes that might have distal aspect of the styloid process. The USA.
e Morphine sulfate, Baxter Healthcare Corp., Deer-
arisen from fusion of a remnant of the radi- growth plates of these two bones were com-
al head to the ulna, or from hypertrophy of pletely closed. The owners elected not to field, IL, USA.
f
Lidoject, IVX Animal Health, Inc., St. Joseph,
the ulna. The humeral condyle was located proceed with surgical intervention at this MO, USA.
in the ulnar notch with mild humeroulnar time. g
Ketaset, Fort Dodge Animal Health, Fort Dodge,
joint subluxation. A distal radial remnant The dog was re-examined five months IA, USA.
h
was present and the ulnar diaphysis was hy- later, at which time it was approximately Lactated Ringer’s Injection, Baxter Healthcare
Corp., Deerfield, IL, USA.
pertrophied. On the mediolateral radio- one-and-a-half-years-old and it weighed 9.6 i
Cefazolin sodium, Sandoz, Inc., Broomfield, CO,
graphic view, approximately 22° of ulnar re- kg. In the interim, there had not been any ap- USA.
curvatum, which was maximal at a point preciable change in limb function. Physical j Surgairtome Two, Hall Surgical, Linvatec
examination revealed a greater magnitude Corp., Largo, FL, USA.
k Stryker System 5, Stryker Instruments, Inc., Kala-
a
of ulnocarpal varus and muscle atrophy. Ul-
Acepromazine maleate, Vedco, Inc., St. Joseph, mazoo, MI, USA.
MO, USA. nocarpal arthrodesis was recommended. l 2.0/2.7 mm DCP Carpal Arthrodesis Plate, Vet-
b
Hydromorphone HCl, Baxter Healthcare Corp., After pre-medication with acepromazinea erinary Instrumentation, Sheffield, UK.
Deerfield, IL, USA. (0.1 mg/kg IM) and hydromorphoneb (0.2 m Synthes Ltd., Paoli, PA, USA.

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 233
Ulnocarpal arthrodesis in radial agenesis

the fifth plate hole into the base of metacar-

pal bone V. Three 2.7-mm cortical bone
screwsm were then inserted proximally into
the distal end of the ulna after removal of the
Kirschner wire. The screw in the third plate
hole was in the load position. Three 2.0-mm
cortical bone screws were then inserted dis-
tally in the neutral position into the diaphy-
sis of metacarpal bone V. Autogenous cor-
ticocancellous bone graft, harvested from
the ilial wing using an acetabular reamern,
was inserted juxta-articularly (15). Post-op-
eratively, orthogonal radiographs of the left
antebrachium confirmed that the arthrode-
sis bone plate was attached to the distal end
of the ulna, the ulnar carpal bone, and the
metacarpal bone V (Fig. 2). The bone plate
covered approximately 87% of the length of
metacarpal bone V. Although alignment of
the antebrachium was much improved, there
was residual ulnocarpal varus and external
rotation of the manus at the level of the ul-
nocarpal joint. Dorsally, articular surfaces
that were debrided with the pneumatic burrj
were less distinct. Bone graft extended from
the distal end of the ulna to the base of the Fig. 2 Digital, orthogonal radiographs of the left antebrachium taken post-operatively.
metacarpal bones.

Post-operative care and re-evalu-

ation
After extubation, naloxoneo (0.004 mg/kg
IV) was administered. External coaptation,
consisting of a cylindrical soft padded ban-
dage was applied to the left forelimb during
the recovery period. Cephalexinp (25 mg/kg
PO q 12 h) and deracoxibq (2.5 mg/kg PO q
24 h) were administered for two weeks. The
bandage was changed daily during the first
three days post-operatively and then
changed weekly for the following eight
weeks. A fiberglass splintr was incorporated
into the bandage at the second post-oper-

n
22 mm BFX acetabular reamer, Biomedtrix, LLC,
Boonton, NJ, USA.
o
Naloxone HCl, Hospira, Inc., Lake Forest, IL,
USA.
p
Cephalexin, Ivax Pharmaceuticals, Inc., Miami,
FL, USA.
q
Deramaxx, Novartis Animal Health US, Inc.,
Greensboro, NC, USA.
r Scotchcast Plus, 3M Health Care, St. Paul, MN, Fig. 3 Digital, orthogonal radiographs of the left antebrachium taken at the time of sixteen week post-operative re-evalu-
USA. ation from which a diagnosis of radiographic union of the ulnocarpal arthrodesis was made.

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Vet Comp Orthop Traumatol 3/2007
234
Hildreth, Johnson

ative week. During this period, the dog was implants were unchanged in appearance. on the dorsolateral aspect of the carpus.
cage confined and restricted to short walks The final ulnocarpal arthrodesis angle was Dorsal application may have resulted in
on a leash. 0°. Assessment of angular deformity reveal- problems with the screws being oversized,
On examination eight weeks post-oper- ed 29° of residual ulnocarpal varus and 13° as well as other complications associated
atively, we observed a mild intermittent of metacarpal valgus, resulting in 16° of with both dorsal pancarpal and ulnocarpal
weight bearing lameness when the dog was varus deformity distal to the humeroulnar arthrodesis (9, 17). The risk of metacarpal
walked on a leash. There was decreased joint. Radiographs of the contralateral, un- bone fracture with dorsal and medial bone
humeroulnar joint range of motion, most affected humerus and ulna were taken for plate application is lower if there is at least
notably in flexion, however, the range of the purpose of forelimb length and angular 53 and 40% metacarpal bone coverage by
motion was not quantified. There was not deformity comparison. When compared to the bone plate, respectively (13, 19). In our
any pain on antebrachial palpation. Moder- the right humerus (86 mm) and ulna (85 case we achieved coverage of the entire dia-
ate diffuse muscle atrophy was present. mm), the left humerus (78 mm) and ulna (71 physis of metacarpal boneV. It has been pro-
Radiographs of the left antebrachium mm) had a 9.3 and 16.5 % length deficit, re- posed that this is advantageous since the dis-
showed signs of bridging callus at the level spectively. The contralateral, unaffected tal metaphysis is more apt to absorb con-
of the ulnocarpal, middle carpal, and carpo- forelimb had 19° of varus deformity distal struct stiffness changes and evenly dis-
metacarpal joints, together with bone graft to the elbow joint. tribute forces through the screws, minimiz-
incorporation. Scant bridging callus was ing the risk of implant loosening and frac-
noted at the level of the medial ulnocarpal ture (13, 19). This may be of specific im-
joint. The accessorioulnar and carpometa- portance with radial agenesis due to altered
carpal I and II joint spaces were appreciable, Discussion load transmission from the lack of an intact
probably because the articular cartilage of paired bone system. Treatment of radial
these joints had not been debrided. Scant We selected ulnocarpal arthrodesis in this agenesis in a dog by ulnocarpal arthrodesis
bridging callus was noted between the ulnar case in an attempt to achieve acute, rigid fix- with a dorsal bone plate application, in com-
carpal bone and metacarpal bone V on the ation of the carpus with potentially more bination with humeroulnar arthrodesis, has
palmar aspect of the joint. The implants rapid healing and return to function, when been recently reported (9). In that report,
were unchanged in appearance. A radio- compared to prior treatment methods. One complications similar to those reported with
graphic diagnosis of progressive healing of of the problems of attempting ulnar leng- dorsal pancarpal arthrodesis were experi-
the arthrodesis was made. thening is that residual shortening or angu- enced. These complications included screw
At the sixteen week re-evaluation, the lar discrepancies may require additional loosening and wound formation over the
owners reported that the dog had become oprtations, and also ankylosis may develop bone plate, which necessitated implant re-
progressively more weight bearing on the despite attempts to preserve the ulnocarpal moval and stabilization with an acrylic ex-
limb and had resumed a full level of activity. joint (1). Therefore, we believe that unless ternal fixator (9).
On examination, we observed a mild, inter- lengthening is being considered, then one- The residual lameness observed in this
mittent weight bearing lameness when the stage ulnocarpal arthrodesis should be per- case was likely due to humeroulnar joint
dog was walked on a leash, which was im- formed. However, ulnocarpal arthrodesis subluxation, ulnar shortening and the ulnoc-
proved from the eight week re-evaluation. with a bone plate requires precise intra-op- arpal arthrodesis, since the latter can result
The left humeroulnar joint range of motion erative correction and it does not allow for in mechanical lameness (20, 21). Approxi-
(78° of flexion and 137° of extension) was progressive correction of shortening or mately 50 to 60% of people afflicted with
less than that of the contralateral, unaffected angular deformity, as with circular external radial agenesis also have ulnar shortening,
forelimb (48° of flexion and 155° of exten- fixation (16). but the mechanism for this is unknown (10).
sion). There was not any pain on antebra- The arthrodesis bone plate used in this One explanation is that the absence of the
chial palpation. The muscle mass of the case has been specifically designed with re- radius from the paired bone system predis-
forelimbs was bilaterally symmetrical. gard to screw hole size and orientation, and poses to distal ulnar physeal damage with
Radiographs of the left antebrachium re- also plate width and thickness, to address subsequent ulnar shortening and recur-
vealed complete union of the ulnocarpal, concerns of metacarpal bone implant over- vatum. Despite different times of radio-
middle carpal, and carpometacarpal joints sizing and soft tissue closure (17). Although graphic evaluation, our comparison should
(Fig. 3). The distal radial remnant was dorsal, palmar, and medial bone plate appli- be valid because the dog was skeletally ma-
united with the radial carpal bone. The pre- cations have been described for pancarpal ture with closed growth plates at the time of
viously noted bridging callus between the arthrodesis, there are not any previous re- initial examination.
ulnar carpal bone and metacarpal bone V on ports of dorsolateral bone plate application Pancarpal arthrodesis angles of less than
the palmar aspect of the joint had resorbed. for carpal arthrodesis (12, 13, 18, 19). Due 10° are preferred due to the fact that hyper-
The accessorioulnar and carpometacarpal I to the inherent morphology of the distal extension results in limb circumduction and
and II joint spaces were unchanged in com- antebrachium and manus, in this case we stress riser formation at the distal aspect of
parison to the eight week re-evaluation. The elected to apply the arthrodesis bone plate the bone plate (13). The arthrodesis bone
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 235
Ulnocarpal arthrodesis in radial agenesis

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