HISTORY / CLINICAL SIGNS: 3 day Hx of sudden and progressive lameness, shifting between the forelimbs with reluctance to walk and play. Decreased appetite. No known trauma. UTD vaccines. On flea/tick/heartworm prevention.
PHYSICAL EXAM FINDINGS: QAR, depressed. BCS 4.5/9. T 103.1ยฐF (39.5ยฐC), P 110 bpm, R 30/min. mm pk/moist, CRT <2 sec. Heart & lung sounds unremarkable. Abdominal palpation unremarkable. EENT unremarkable. Slow, stiff gait; weight-bearing, but shifts posture between forelimbs. No obvious soft tissue or joint abnormalities (no swelling, crepitus, etc.). No abnormalities palpated along long bones or spine, but patient yelps upon deep palpation of right antebrachium. Abbreviated neuro exam unremarkable.
What is on your differential diagnosis list? What diagnostic tests would you order? Any other questions?
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DIFFERENTIALS: Osteochondritis dissecans (OCD). Panosteitis. Hypertrophic osteodystrophy (HOD). Fracture. Osteomyelitis. Nutritional secondary hyperparathyroidism.
DIAGNOSTIC TESTS & RESULTS:
โผ๏ธBloodwork: unremarkable
โผ๏ธSNAP 4Dx: neg.
โผ๏ธRadiographs of the right forelimb: unremarkable
Based on this patientโs signalment, clinical signs, physical exam findings, and test results, can a diagnosis be reached?
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DIAGNOSIS: Panosteitis
Despite an initial lack of radiographic findings to support the diagnosis of panosteitis of the right forelimb, a diagnosis was made due to the signalment and clinical signs of this puppy as well as other differential diagnoses having been ruled out by X-rays and bloodwork. Panosteitis (bone inflammation) is a painful condition typically affecting large or giant breed dogs between the ages of 5-18 months. Synonyms include eosinophilic osteomyelitis and enostosis. Males are more commonly affected. The exact cause of this condition is not entirely known, yet it results in a temporary replacement of the fatty adipose tissue inside bone marrow by fibrous tissue; bony growth of the endosteum and periosteum also occur. However, changes on radiographs are not usually visible until 7-10 days following clinical signs. The forelimbs are most commonly affected, especially the ulna followed by the radius and humerus; the femur and tibia of the hind limbs can also be affected, though less commonly. Puppies exhibit acute clinical signs, most notably shifting limb lameness that becomes more severe over the first few days. Panosteitis is self-limiting and its prognosis is excellent, meaning it will eventually result in a natural cure with the bone marrow and bony changes returning to normal. This healing process typically takes 2-3 months to fully occur (longer in some patients), yet pain and lameness typically only last for 2-14 days. During this time, pain management to minimize bone inflammation as well as exercise restriction is key to keep the patient comfortable.
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TREATMENT & PROGNOSIS: This patient was treated with carprofen, a non-steroidal anti-inflammatory drug (NSAID), to control pain and inflammation. His owners were also instructed to keep him quiet for several weeks to minimize inflammation of his right forelimb. On day 14, he was re-checked, and was much brighter and more comfortable, having returned to eating well and enjoying some light activity. Radiographs of the right forelimb were repeated, now displaying patchy areas of increased bone opacity of periosteum and endosteum of proximal ulna โ classic features of panosteitis. Carprofen was discontinued on day 14, and the patient recovered fully.
Any other questions, comments, or suggestions?
Unless otherwise stated, these clinical cases are real-life cases that I have managed as a veterinarian in general small animal veterinary practice or else assisted with as a student in vet school. These cases are a great real-world learning tool for vet students and other veterinary professionals. They shall be used for learning purposes and collaboration of knowledge only. These cases are not intended to diagnose or treat any disease by pet owners. – Maranda Elswick, DVM
