Radiographs for CCL Injuries and TPLO Surgery

When it comes to cranial cruciate ligament (CCL) injuries in your patients, x-rays play a key role in your diagnosis, treatment, and follow-up.

So whether you’re the surgeon performing the procedure or a GP referring your patient to a specialist, having a good understanding of what to look for on your radiographic images can help you provide great patient care.

It all starts when the patient first comes in to see you…

The initial visit

More than likely, you’ll be seeing a middle-aged, medium or large breed dog who suddenly started limping on one of their hind limbs.

During the exam, you determine that the pain is in the stifle. Then, using sedation, you perform more thorough palpation, followed by radiographs.

Your detailed exam of the knee reveals some swelling and a positive drawer sign, and you take x-rays to confirm your suspicion of a CCL tear.

Considering this is one of the most common orthopedic injuries in dogs, you’re probably correct. However, occasionally there may be a surprise—such as a fracture near the stifle, or even an osteosarcoma lesion for older patients.

Radiographs will help you correctly diagnose and document the problem, and rule out concurrent conditions.

With a recent CCL injury, you might not see a lot of obvious evidence on your views—that’s because it can take more time for radiographic evidence of a CCL problem to show up.

However, you will likely see compression of the infrapatellar fat pad—which indicates joint effusion.

If the condition is chronic, you may notice arthritis and other signs of long-term inflammation.

Planning for a TPLO surgery

If your patient is a good candidate for surgery, then it’s time to discuss options with the owner. A tibial plateau leveling osteotomy is a good option for many otherwise-healthy dogs, but of course, the recommendation may vary for each individual pet.

Now’s the time when pre-op radiographs come in, by helping you to measure the tibial plateau angle and determine the saw blade size and position of the bone plate and screws.

The importance of post-op radiographs

After a surgery such as a TPLO, it’s important to document that everything went well—that all implants are in place, the tibial plateau has been repositioned as planned, and that there were no complications such as bone splintering.

This will be very reassuring to a worried pet parent, and will also be a valuable part of your medical record.

These post-op radiographs can also provide more information if a problem or complication comes up later, by using these initial images as a frame of reference for comparison.

Radiographs are useful if complications arise

More than likely, your patient is doing great. In that case, follow-up x-rays will help you confirm and document that the bone has healed as expected.

However, if they do run into any problems—such as an infection or a fracture—an additional set of radiographs can help you diagnose the issue and treat it ASAP. And follow-up rads will allow you to monitor the patient’s healing progress and their response to treatment.

Basically, radiographs give you an “inside view” throughout the whole process of diagnosing and treating a CCL injury, and are useful for common surgical options such as a TPLO.

Digital radiographs are especially helpful in terms of sensitivity for soft tissues such as a joint space, and also for providing rapid results within seconds.

But no matter which radiology equipment you choose, your X-ray images will provide valuable information for diagnosis and treatment of CCL—for happy patients and clients.

Disclaimer: This article is for general informational purposes only, and not intended as a guide to the medical treatment of any specific animal.

Written by: Dr. Tammy Powell, DVM

Identifying Trauma in X-Rays of Hit-By-Car Patients

It’s been a slow day, and you just got back from lunch. Your first-afternoon appointment is waiting, and you look through their chart, preparing to go into the room… 

All of a sudden, the clinic doors burst open. You hear a big commotion upfront…

You walk up to see what happened and discover a distraught pair of pet owners holding carrying their Border Collie, who’s just been hit by a car.

How to avoid further surprises…

Of course, as a veterinarian, you’re probably used to something like this happening from time to time—panicked pet parents arriving at your clinic with a dog or cat in need. And you’re probably well-prepared to triage and decide what to do next…

However, you’ll want to avoid unpleasant surprises down the line—liked missed diagnoses—by ensuring that you find and plan for unexpected injuries.

For example, maybe that Border Collie has an obviously broken leg and some nasty road rash.

You’ll address those injuries, but first, you’ll explain to the owners that there are other conditions you need to check if their fur kid has just been hit by a car—conditions that could be life-threatening.

What to look for on the x-rays

Your physical exam will help direct you on what to look for. For example, if you feel a painful joint with crepitus, or hear crackles or decreased lung sounds when you auscult the chest, those will be areas you want to explore with radiographs. 

But, even if the lungs sound fine and you don’t find any other obvious abnormalities, it’s always good to evaluate the thorax and abdomen radiographically.

Sometimes, x-rays will need to wait…

For example, if the pet is in critical condition, they need stabilization first. And, you’ll use your judgment on whether sedation is needed and safe, for clearer and more diagnostic x-ray images, as well as for relief from pain and stress.

Then, when you read the radiographs, it’s important to evaluate EVERYTHING on your set of x-ray images. 

The impact of being hit by a car can cause trauma to many different parts of the body all at once, including serious internal injuries.

Here are a few things to check for on your radiographs…

• Pulmonary contusions. A strong trauma to the thorax can cause dangerous bleeding in the lungs, often visible on radiographs as alveolar or interstitial opacities.

• A ruptured bladder and uroabdomen. Look for signs of fluid in the abdomen, especially if you notice bloody urine. Try to visualize the bladder.

• Internal bleeding or damaged organs. If an organ such as the spleen has been injured, you may notice a hemoabdomen (although radiographically, this would be difficult to distinguish from a uroabdomen). In the case of ruptured intestines, you may notice spots of free air in the abdominal cavity.

• Broken bones, including the ribs and vertebrae. Visually trace along the bones one-by-one to be sure no lesions are missed. 

• Dislocations, such as a dislocated hip. Also, check for tail-pull injuries, especially in cats who may get their tail caught under a car’s wheels.

• Diaphragmatic hernia. Look for evidence of intestines or other abdominal organs in the thorax.

• Air or fluid in the pleural space. Seen as gas opacity, or fluid opacity.

• Skull and jaw radiographs if needed—in case of suspected head trauma.

Of course, other abnormalities are possible, too. As you know, pets don’t always “read the book” and clinical practice can be full of surprises! If you’re unsure of something on the films or digital images, it may be good to recheck it down the line to be sure no problems are brewing internally.

The number of views you take will vary depending on the size of the pet.

For emergency situations such as this, it may be worth having digital radiographs, for faster results without waiting for films to develop.

Also, it’s important to take orthogonal views. That way, you get the full pictures and lesions are less likely to be missed.

Re-evaluate and repeat radiographs as needed

This will depend on what you see on the first set of images, in addition to how the pet is doing in real life. Use your best clinical judgment to determine if and when repeat radiographs are needed, and keep the pet under close observation.

If there’s any doubt, consider using contrast studies to obtain more information, too.

By developing a plan for radiographs—and remembering to check everything on the images—you’ll increase the chances of finding unexpected injuries and addressing them earlier. Or, in case the radiographs are normal, you may be able to give more peace of mind to the worried pet owners.

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Disclaimer: This article is for general informational purposes only, and not intended as a guide to the medical treatment of any specific animal.

Written by: Dr. Tammy Powell, DVM