Carpal (wrist) injuries in Dogs and Cats

Article Written by Dr. Daniel A. Degner, Board-certified Veterinary Surgeon (DACVS)

Key Points

This surgical procedure is used to alleviate pain in a joint that has end-stage arthritis or other severe debilitating disease of a joint

The joint is permanently fused by removing the cartilage of the joint surfaces and placing bone graft in the joint; the joint is stabilized using metal implants so that the bone can heal together

Most dogs do well following surgery


Introduction

  • Hyperextension (joint extends well beyond what is normal) can tear the ligaments that support the carpus (wrist) and result in a devastating instability of the joint that in almost all cases will not heal unless the injury is minor.
  • The palmar fibrocartilage is the main supporting structure of the carpus in dogs and cats. If this structure is torn the pet will walk with the paw dropped down (hyperextended).
  • The cause of hyperextension injury is typically a single traumatic event or repeated hyperextension of the carpus. Jumping off an elevated surface (out windows, off a roof, out of a pick-up truck, off a deck etc) or hitting the wrist against a solid surface (such as in fly ball) are the primary causes of this injury.

Diagnosis

  • The diagnosis of joint instability typically should include stress radiographs. This is performed by applying a stress to the joint and seeing where the damage has occurred. This is very important when evaluating damage to the carpus (wrist) or the tarsus (hind paw) in order for the veterinarian to determine which joints need to be fused. Place your cursor over the image; the two arrows show the separation of the back part of the joint indicating that the lower joint of the carpus is damaged, hence only a partial fusion of the joint is needed.

Treatment options

  • A conservative approach usually is not successful in most cases as ligaments usually do not heal very well. In addition, if the behavior of the pet is not modified (i.e. the dog continues to jump off the deck onto the ground) reinjury is common. Conservative treatment includes supporting the affected limb in a splint for two months and restricting activity for three months.
  • Surgery is generally the best option for a carpal hyperextension injury. The surgeon must first determine which which joint(s) of the carpus are unstable (see diagnostics above), then the surgeon can determine whether a partial or a complete fusion of the wrist joint is needed. Fusion of the unstable joints takes over the function of the torn fibrocartilage: to limit hyperextension of the wrist. More over, the fusion surgery will stop the pain that the dog has in the carpal joint.
  • Partial fusion of the carpus results in normal to near normal function of the wrist. Complete fusion of the carpus will result in a wrist that has no movement at all. This still has a good outcome and many dogs actually can walk very well in spite of the loss of movement of the carpus.

Surgical principles

  • Joint must be free of infection
  • All cartilage surfaces of the joint are removed
  • Bone graft harvested from the patient is packed into the joints to stimulate healing
  • Joint is positioned in a functional angle and stabilized with rigid fixation devices such as
    • plates and screws
    • screws
    • pins and wires
    • external skeletal fixator
    • we prefer the use of plates and screws as this results in our best outcomes; we usually use an arthrodesis plate specifically made for this purpose
  • The plates and screws usually are not removed.
  • Right is an example of a partial carpal arthrodesis in a dog.  After healing had taken place the dog was able to walk once again without pain.  Take note of the plate and screws that are holding and joints in a fixed position. 
  • Because a partial arthrodesis is performed the patient will have excellent function of the carpus with minimal function deficits.

Postop care

  • Pain management
  • The limb is supported in a cast or splint during the healing phase which is about 6 weeks
  • The padding of the cast or splint is changed every 2 weeks
  • Limited leash walks for urination/bowel movements until arthrodesis has been confirmed to be healed on radiographs
  • Radiographs are taken 6 weeks after surgery
  • After the cast has been removed, exercise is gradually increased on a leash over the next 6 weeks; during the first week a 5 minute walk twice daily is permitted; the walks can be increased by 5 minute increments each week until a normal amount of walking has been achieved

Potential complications

  • Anesthetic death is very uncommon with our sophisticated monitoring devices and advanced anesthesia protocols
  • Infection is possible but very uncommon
  • Cold sensitivity requiring removal of the plate and screws after a year
  • Failure of healing, necessitating regrafting of the joints
  • Breakage of the plate or screws
  • Pressure sores from the cast or splint

Frequently Asked Questions After Surgery

When should my dog have the first bowel movement after surgery?

  • Many dogs will not have a bowel movement for the first 4 to 5 days after surgery
  • Reasons that a dog will not have regular bowel movements after surgery include:
    • The dog has been fasted prior to surgery
    • Dogs do not eat well during the hospital stay
    • They frequently do not eat well when the go home
    • They are fed highly digestible food that produces little stool
    • Pain medication that contain narcotics (such as tylenol with codeine, tylenol 3, tylenol 4, morphine) can be constipating
  • If a pet does not have a bowel movement on the 5th day of being home a stool softener such as metamucil can be fed
    • Dose of metamucil 1 tsp per 25 Kg mixed in with each meal (canned dog food)

My pet had surgery and will not eat.  What can be done?

  • Dogs
    • Most pets will not eat their regular dog food after surgery, especially if it is kibble.
    • Offer a cooked diet having a 1:1 ratio of a protein source and carbohydrate source.  The protein source can be any meat (example: chicken breast, turkey breast, lean hamburger) that is low fat and should be cooked and any residual fat skimmed off.   The carbohydrate can be pasta, potato or white rice.
    • Try canned dog food; to enhance the flavor sprinkle a very small amount of garlic powder or chicken or beef broth (Chicken-in-a- MugTM or Beef-in-a-MugTM products)
    • Try Gerber strained meats for babies such as the chicken, beef, turkey, or veal
    • Try Hill's A/D diet available at most veterinary hospitals
    • Hand feeding;  place a small amount of food in the mouth so that they get the flavor
    • Warm the food slightly in a microwave as the food will be more aromatic; remember to stir the food before feeding and test the temperature on the bottom side of your wrist; it should only be luke warm.
    • Remember that most pets will not eat the first day or two after they get home from surgery
  • Cats
    • Offer smelly foods that contain fish such as tuna or smelly cat foods
    • Try Gerber strained meats for babies such as the chicken, beef, turkey or veal
    • Hand feeding;  place a small amount of food in the mouth so that they get the flavor
    • Warm the food slightly in a microwave as the food will be more aromatic; remember to stir the food before feeding and test the temperature with your finger; it should  be only luke-warm.
    • Some cats will only eat dry food, try kibble if your cat normally has been fed that food
    • Petting and stroking your cat frequently will help to stimulate appetite
    • Remember that most pets will not eat the first day or two after they get home from surgery
    • Appetite stimulants such as cyproheptadine may be helpful
    • If your cat refuses to eat anything for 7 days a stomach tube should be placed to provide nutrition so that a serious liver problem (hepatic lipidosis) does not develop

My pet is vomiting now that he/she is at home.  What can be done?

  • The first thing for you to discern is whether your pet is vomiting or regurgitating.  Both will result in fluid or food being brought up.  Vomiting always will have heaving or retching of the abdomen prior to expulsion of the vomitus.  Regurgitation is not associated with heaving and the dog usually just opens the mouth and fluid or food will be expelled.  Usually the regurgitant will be clear or brown colored fluid. 
  • Next is to identify the cause of the vomiting or regurgitation.
  • Causes and treatment of vomiting after surgery
    • When some pets return home after a stay in the hospital they may drink excessive amounts of water at one time and then vomit; if this appears to be happening the water should be limited to frequent smaller amounts.
    • Medications such as antibiotics or tylenol/codeine are are common cause of vomiting after surgery.  In order to see which medication is causing the problem the administration of each drug should be separated 2 hours apart.  Usually the pet will vomit or appear nauseated (drooling and sick look) within 1 hour of administration of the medication that they are sensitive to.  The antibiotic in some cases may be changed to a different one, or may be discontinued.  The tylenol/codeine should be discontinued and another type of pain medication tried to help minimize vomiting.
    • Stomach upset from anesthesia is a potential cause of vomiting and will pass within a couple of days. 
    • Unusual cause of vomiting after surgery is internal organ failure.  Blood testing will confirm this problem. For this reason vomiting should not be ignored if it persists for more than 24 hours.
    • If your pet had surgery of the bowels or stomach, vomiting is always a concern, as it may indicate that infection of the abdominal cavity, called peritonitis, is present.  Do not ignore this sign.
    • Symptomatic treatment of vomiting involves with holding food for 12 to 24 hours, then introducing small amounts of bland food such as rice and lean cooked hamburger, if your pet does not vomit after that then.  In order to decrease the acidity of the stomach Pepcid AC 0.5 mg/kg given by mouth twice daily for 5 days can sooth an upset stomach.  Metoclopramide is a good anti-vomiting medication for dogs and cats.  You should always consult a veterinary healthcare professional before administering medication.
  • Causes and treatment of regurgitation after surgery
    • The most common cause of regurgitation is reflux of acid from the stomach into the esophagus while your pet is under anesthesia.  Acidic fluid from the stomach can cause a chemical burn of the esophagus and result in a bad case of heart burn, which is called esophagitis.  This results in poor motility of the esophagus so water and food will accumulate in this structure.  In most cases esophagitis is self-eliminating and will resolve within two or three days. 
    • Regurgitation also can be caused by a neuromuscular degeneration of the esophagus and this problem will persist.  It is not associated with surgery, rather other underlying diseases.
    • If the esophagitis is severe the esophagus may develop one or more strictures.  A stricture is a narrowing or stenosis of the esophagus, does not allow passage of food down the esophagus, thus the pet has persistent regurgitation.  This problem should be brought to the attention of your doctor within the first two weeks so that it can be treated by ballooning the stricture (minimally invasive procedure as it is done with the aide of an endoscope).  If an esophageal stricture is chronic surgery is needed.
    • Symptomatic treatment of regurgitation caused by esophagitis includes feeding bland food, and administering a coating agent such as sucralfate.  You should consult a veterinary health care professional if the regurgitation continues for more than a couple of days.

How do I know that my dog is in pain following surgery?

  • Signs of pain include
    • crying
    • biting if you get near the surgical site
    • grimacing (lips are pulled back and the the dog looks anxious)
    • tragic look of the face
    • restlessness and not wanting to sleep; pacing
    • if abdominal surgery was done the pet will not lie down on the incision, or will continually sit up in spite of appearing very tired
    • the worst pain will be for the first 2 to 3 days after surgery

What can be done for pain at home for my dog?

  • Pain medication such as tylenol with codeine, butorphanol, Duragesic (fentanyl patch) anti-inflammatories such as Deramaxx, Rimadyl, or Etogesic; in some cases a sedative such as acepromazine will augment the effect of pain medication and allow your pet to sleep
  • If an orthopedic surgery has been done cold packing the surgical site may be helpful
    • A cold pack may be a pack of frozen peas, crushed ice in a Ziploc bag, or a cold gel pack; place a thin barrier between the skin and the cold pack.  An alternative to a cold pack is to freeze water in a styrofoam cup; after frozen cut the bottom of the styrofoam cup out and in circular motions (directly on skin) cool the surgical site around the incision.  Cooling the surgical site helps to numb the area

How do I know that my cat is in pain following surgery?

  • Pain is more difficult to assess in cats versus dogs as signs can be more subtle and they usually do not vocalize
  • Signs of pain in a cat include the following:
    • biting if you get near the surgical site
    • growling or deep cry
    • not wanting to eat
    • hiding and not wanting to be near owner (remember that this could also be caused by the cat just being upset about leaving home and coming back)

What can be done for pain at home for my cat?

  • Pain medication such as buprenorphine or a Duragesic (fentanyl) patch
  • Tylenol will kill a cat as they lack abundant glutathione enzyme in the liver
  • Anti-inflammatories can be used, but the dose is much less than dogs and they should be given only for a few days

Is it okay for my pet to lick the incision?

  • If a dog licks his incision it will actually delay the healing process because they usually lick too much and traumatize the area.
  • Licking can remove stitches and cause the incision to open
  • Licking can become a severe habit that is difficult to break
  • Licking can cause infection as the mouth has many bacteria
  • Dogs will frequently lick the incision when the owner is not watching such as at night time; if the skin looks red or excoriated the most common cause is from licking.
  • To stop your pet from licking the following can be tried:
    • Elizabethan collar can be placed on the neck; this will not help stop your pet from scratching at the region
    • Cervical collar (bite not collar) is a less awkward device and can be effective at stopping a pet from licking the surgical site
    • If the incision is over the chest a tee shirt can be put on your pet and the waist of the shirt fastened in place with an ace bandage or duct tape.
    • If the incision is over the paw or lower limb a bandage or sock could be put on and kept up with tape.
    • Bitter apple can be applied around the incision; many dogs will continue to lick  after application of this topical
    • Bitter Apple and Liquid HeetTM (obtain this from a drugstore...it is used for sore muscles) mixed in a 2:1 ratio can be applied around the skin incision
    • Antipsychotic medication in some cases is needed

Board-certification by the American College of Veterinary Surgeons

What does it mean?

  • Four years of advanced training in surgery beyond the Doctor of Veterinary Medicine Degree

  • Experience in the development of new surgical treatments

  • Rigorous examination by the American College of Veterinary Surgeons to ensure competency in advanced surgical techniques

  • Assurance that a veterinarian is a surgical specialist

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