Orthopedic Diagnostic

Im ag i n g i n Ex o ti c P ets
Federico Vilaplana Grosso, DVM, DECVDI

KEYWORDS
 Radiography  CT  Ultrasound  MRI  Trauma  Fracture
 Metabolic bone disease  Osteomyelitis

KEY POINTS
 Orthopedic disorders in exotic pets are common due to trauma, infection, and metabolic
bone disease.
 Knowledge regarding the anatomic, physiologic, and pathophysiologic characteristics of
the exotic pet species is crucial when interpreting diagnostic imaging examinations.
 Computed tomography is increasingly used in exotic pet medicine due to public aware-
ness, higher standards of care demand, and the increased availability in small animal
practice.

INTRODUCTION

Orthopedic disorders are a common problem in exotic pets. Nevertheless, there are
many different species kept as pets, each with a variety of orthopedic conditions
with different implications in their health, diagnosis, and treatment options. Therefore,
knowledge regarding the anatomic, physiologic, and pathophysiologic characteristics
of these exotic pet species is crucial when interpreting diagnostic imaging
examinations.
Exotic animals are acquiring popularity, and the number of exotic pets presented to
the veterinary practices has significantly increased in recent times, becoming a large
percentage of the clientele in many veterinary hospitals and clinics.
On the other hand, nowadays there are diagnostic and therapeutic options available
that were not accessible few years ago. Public awareness has translated into an
increased expectation of targeted and competent diagnostic testing for pet animals.
An increasing number of clients are willing to provide higher standards of medical
care regardless of the cost involved on diagnostics and treatment.
There are many species of exotic pet birds, small mammals, and reptiles with major
differences in anatomy. In interpreting diagnostic imaging studies in exotic pets,

Disclosure Statement: The author has nothing to disclose.

Department of Small Animal Clinical Sciences, College of Veterinary Medicine, University of
Florida, 2015 Southwest 16th Avenue, PO Box 100116, Gainesville, FL 32610-0116, USA
E-mail address: [email protected]

Vet Clin Exot Anim 22 (2019) 149–173

https://doi.org/10.1016/j.cvex.2019.01.003 vetexotic.theclinics.com
1094-9194/19/ª 2019 Elsevier Inc. All rights reserved.
150 Vilaplana Grosso

thorough knowledge of the different species anatomy is paramount, but the literature
about it is scarce. Fortunately, the number of publications describing the radiographic,
tomographic, or MRI anatomy of different exotic pet species and breeds is increasing
over the last years.1–17 The bilateral and symmetric musculoskeletal anatomy may be
used for interpreting an imaging examination by means of comparing with the contra-
lateral part of the body or producing contralateral limb radiographs.

DIAGNOSTIC IMAGING MODALITIES

Radiography has been traditionally used as the first diagnostic imaging modality in
veterinary care. However, over the past years, other imaging modalities, such as ultra-
sonography (US) and advanced cross-sectional techniques (eg, computed tomogra-
phy [CT] and MRI), are becoming more available and accessible. The use of
advanced imaging techniques is increasingly used in exotic animal patients as the
availability of the advanced imaging equipment becomes readily available in small
and exotic animal practice. Radiography and CT are frequently used for the diagnosis
of orthopedic diseases as well as for surgical planning and follow-up. US and MRI can
be used for assessment of orthopedic diseases affecting soft tissue structures, such
as muscles, ligaments, tendons, and joints. For the evaluation of the central nervous
system in traumatized or neurologic patients, MRI is the modality of choice. Nuclear
scintigraphy (NS) is less frequently used and scarcely available. In musculoskeletal
diseases, NS provides information about regions of increased bone metabolism and
may be used to determine decreased perfusion of soft tissues after an injury.

Radiography
Radiography is the most common imaging modality used because of its availability
and low cost. Similarly, radiography is a very good modality for assessment of bony
structures, making it ideal for the evaluation of skeletal diseases. In small exotic
pets, this modality allows fast and whole-body radiographic assessment using one
single exposure. Quick and whole-body evaluations are an advantage for patients
who may present severely ill or in shock after a traumatic incident. In these cases,
the use of whole-body radiography is a valuable tool for a rapid health assessment,
and for investigation of the underlying cause and extent of the disease. Therefore, a
quick diagnosis, prognosis, and detection of life-threatening conditions may be pro-
vided, allowing a prompt action in cases that require lifesaving treatment. After stabi-
lization of the patient, collimated orthogonal radiographs of the affected area should
be performed for an optimal assessment.
Nowadays, most practices are using digital radiography (DR) instead of conven-
tional radiography. The advantages of DR over analog radiography are numerous.
The main advantage of DR as compared with analog radiography is that it provides
a wide range of exposures for an acceptable image quality, which means that even
being less accurate with the specific exposure technique of the radiograph, the image
quality will probably be acceptable and will allow greater flexibility than in the case of
analog radiography. Therefore, this will help to reduce the number of retakes because
of overexposure and underexposure. DR also permits image postprocessing, such as
modification of the brightness and contrast of the image (window width and leveling)
and consequently allows an optimal examination of all anatomic areas.18 Other post-
processing manipulations include image sharpening, edge enhancement and smooth-
ing, image subtraction, and contrast inversion, among others.
In many occasions, the small size of the patients may be a compromising factor
because of the limited spatial resolution of the DR systems. These patients may
 Orthopedic Diagnostic Imaging 151

benefit from being examined with analog radiography (eg, high-detail radiographic film
or mammography) because of the increased spatial resolution. However, a very pre-
cise exposure technique is required.
Horizontal beam radiography is frequently used in exotic pets because it allows
easier positioning and sometimes decreases or eliminates the need of restraint.
Decreased restraint and manipulation is especially important in patients affected
with metabolic bone disease (MBD), where restraint and manipulation may induce
pathologic fractures. In addition, horizontally directed radiographic beams are useful
when assessing gravity-dependent (fluid, sediment, and mineral) and non-gravity-
dependent (gas) structures (Fig. 1).

Ultrasonography
US is a noninvasive imaging modality that allows a good evaluation of soft tissues and
fluid-filled structures and does not produce any ionizing radiation. In exotic pets
affected with orthopedic disorders, US is useful for the assessment of soft tissue
swellings, muscles, tendons, and joints.
Another advantage of US is that it provides guidance during the aspiration of fluids
or masses, and US-guided biopsies (Fig. 2). Fine needle aspirates (FNA) can be very
helpful to distinguish between infectious, inflammatory, and neoplastic causes. US
can also be used to guide locoregional anesthesia (ie, nerve blocks) or therapy deliv-
ering (eg, ethanol ablation), among others.
The use of color and power Doppler US is useful when assessing blood flow of a
certain organ or a lesion, ischemia, or the degree of vascularization of a mass. At
the same time, use of color and power Doppler US can be used to assess the amount
of hemorrhage after performing FNAs or biopsies.

Computed Tomography
CT has become more available and economically affordable, and consequently, its
use in exotic pets is exponentially increasing over the last several years. On some oc-
casions, general anesthesia may be required; however, modern multidetector CT ma-
chines allow the scanning of large anatomic areas in a very short time. Because of this
increased scanning velocity, many patients can be scanned under sedation or

Fig. 1. Horizontal beam radiograph of a tortoise that was attacked by a dog, demonstrating
the presence of free gas in the celomic cavity. (Courtesy of Federico Vilaplana Grosso and the
Diagnostic Imaging Service, College of Veterinary Medicine, University of Florida.)
152 Vilaplana Grosso

Fig. 2. Transverse ultrasonographic image of the humerus of a marmoset with a pathologic

fracture. Multiple small bone fragments are seen as well as a collection of hypoechoic fluid.
The examination was performed to obtain FNAs. (Courtesy of Federico Vilaplana Grosso and
the Diagnostic Imaging Service, College of Veterinary Medicine, University of Florida.)

conscious with the help of commercial physical restraint devices (eg, VetMouseTrap)
or self-made restraint devices.19
CT has many advantages compared with radiography. The major advantage over DR
is the ability to visualize the internal anatomy without superimposition of the adjacent or
external structures. This lack of superimposition is very advantageous when evaluating
exotic pets, especially for the skull, or in chelonians, where the superimposition of the
shell may mask underlying lesions. One study revealed a higher sensitivity of CT when
compared with radiography in the detection of fractures and luxations in chelonians.20
CT has a higher contrast resolution than radiography, distinguishing between
different types of soft tissues and fluids. In addition, the great spatial resolution of CT
can help detect subtle fractures that may not be seen with other imaging modalities.
Multiplanar reconstructions (eg, dorsal and sagittal) can be reformatted after
acquiring the transverse scan of the patient. Multiplanar reconstructions allow
the clinician to appreciate the disease, because it is oriented relative to the sur-
rounding anatomy. Three-dimensional (3D) renderings can also be performed. 3D
reconstructions can be very helpful for surgical planning, especially in compli-
cated fractures (Fig. 3).
Intravenous iodinated contrast media can be administered during the examination
to enhance tissues and vessel visualization. Soft tissue structures with abnormal
vascularization or increased vessel permeability due to disease manifest abnormal
patterns of enhancement, allowing their differentiation from normal tissues.
Similarly to US, CT-guided FNAs and biopsies can be performed.21 Some of the dis-
advantages of CT are the use of ionizing radiation, the higher cost, the lesser availabil-
ity, and the potential requirement of general anesthesia.
Microcomputed tomography (m-CT) is becoming more popular in exotic animal prac-
tice. Originally, this type of CT was designed for laboratory animals (eg, small rodents),
but due to the very high resolution, it may be used in small exotic species.22 Scanning
and operation principles of m-CT are similar to those of standard CT. Some advantages
of m-CT over standard CT are the much smaller size and the lack of need of lead shield-
ing of the CT room (ie, m-CT units are configured within a leaded shield structure). The
main disadvantage of m-CT is the limited range of species that can fit in the gantry.
Depending on the manufacturer, m-CT can accommodate patients up to 15 kg.23
 Orthopedic Diagnostic Imaging 153

Fig. 3. Craniocaudal 3D rendering of a humeral intercondylar fracture of an eclectus parrot.

(Courtesy of Federico Vilaplana Grosso and the Diagnostic Imaging Service, College of Vet-
erinary Medicine, University of Florida.)
154 Vilaplana Grosso

MRI
MRI is an excellent imaging modality for the investigation of the musculoskeletal and
central nervous systems. This modality is considered noninvasive because it does not
use ionizing radiation for generating images. MRI has a superior contrast resolution
when compared with CT, allowing a better depiction of soft tissue structures.
Same as CT, MRI has the advantage of avoiding the superimposition of structures.
However, unlike CT, the different scan planes need to be acquired separately and
cannot be reconstructed, therefore increasing the time of the examination. Other fac-
tors that may increase the time of the examination are the type of sequence used, the
sequence planes, and the overall number of sequences.
The major disadvantages of MRI are the lower availability, the higher cost, and the
long scan times that often require the use of general anesthesia. General anesthesia is
the main limiting factor. In very small patients, inhalational general anesthesia cannot
be performed for MRI examinations due to limiting factors, such as the anesthetic cir-
cuit dead spaces and the fact that a ventilator cannot be used inside the MRI room.
Nuclear Scintigraphy
NS is rarely used in exotic animal orthopedic disorders. The main reason is the lack of
availability when compared with other imaging modalities. In NS, a radioactive sub-
stance, such as 99m technetium methylene diphosphonate, is injected intravenously
in the patient. Then, the radiopharmaceutical is localized in areas of increased bone
metabolism, where it will emit radiation that can be measured and imaged with a
gamma camera. Bone scintigraphy allows whole-body examination but requires
heavy sedation or anesthesia to avoid motion while the images are being acquired.
Some indications of musculoskeletal NS in exotic pets are the evaluation of frac-
tures that may not be seen with radiography, polyostotic infectious osteomyelitis,
occult lameness, bone and soft tissue viability after a traumatic injury, and neoplastic
bone disease (Fig. 4).
NS has been previously used to assess ischemia and necrosis of the extremities of a
ferret and for evaluation of multifocal infections and plastron necrosis in a Horsfield
tortoise.24,25

RESTRAINT OF EXOTIC PETS FOR IMAGING

Manual, physical, and chemical restraint can be used in exotic pets. The use of re-
straints will depend on the species and size of the patient, the behavior, the degree
of illness, and the elected imaging modality.
Manual Restraint
Manual restraint may be used in radiography and US in relatively calm birds, small
mammals, and reptiles. It is important to take into consideration the human exposure
to ionizing radiation during manual restraint in radiographic examinations.
Physical Restraint
Physical restraint with acrylic devices or devices made of other radiolucent material,
such as plastic, or cardboard can also be used in radiography and sometimes in
CT, especially in critical patients, where the use of sedation or anesthesia might be
discouraged. Acrylic tubes, boxes, and plates are routinely used for immobilization
of exotic animals for radiography. Ancillary devices for physical restraint and posi-
tioning include rope, roll gauze, adhesive tape, towels, sand bags, wedge foam,
and Velcro, among others. A large number of specialized radiographic positioning
 Orthopedic Diagnostic Imaging 155

Fig. 4. Ventrodorsal (A) and laterolateral (B) scintigraphic images of an African gray parrot
with a transverse middiaphyseal fracture of the right tibiotarsal bone after being attacked
by a cat. NS was performed to investigate soft tissue and bone viability. Decreased radio-
pharmaceutical uptake is noted, suggestive of ischemia. (Courtesy of Federico Vilaplana
Grosso and the Diagnostic Imaging Service, College of Veterinary Medicine, University of
Florida.)

aids are also commercially available for the use in small animals (eg, VetMouseTrap,
Bird Board).19,26

Chemical Restraint
Chemical restraint is generally required in large, powerful, highly stressed or fractious
animals, in venomous animals, or in individuals with injuries that can be exacerbated
with struggling. Sedation may be achieved with injectable drugs or intranasal drugs,
and general anesthesia with injectable or inhalational drugs. Patient monitoring is
required whenever a patient is under sedation or anesthesia. Oxygen should be sup-
plied during the examination in critically ill, traumatized, sedated, or anesthetized
patients.
For radiographic studies, rabbits and ferrets can be physically restrained with tech-
niques similar to those used with cats. Physical or chemical restraint will be required
for small-sized mammals and fractious or stressed individuals.27 Birds can be physi-
cally restrained with tape or commercial restraint devices. Otherwise, chemical re-
straint is used. Most lizards, tortoises, and turtles can be examined without any
restraint or with the help of positioning aids, such as foam rubber block, where the pa-
tient can be placed on top. The restraint of a snake can be challenging. Manual re-
straint or placement of the snake in an acrylic tube is the most common form of
restraint. Snakes may be alternatively placed in a bag during radiographic examina-
tion, but they tend to curl, making the image difficult to interpret. In such cases, the
use of external metallic markers placed on the snake at the level of the potential ab-
normality may be helpful.
When using CT and MRI, the use of general anesthesia is most of the time required
to avoid motion artifacts that will degrade the image quality and make the examination
suboptimal. The use of general anesthesia is even more important in the case of MRI
because longer examination times are often needed. However, in exceptional cases,
CT examinations can be performed with no or light sedation, especially in critical
patients.28
156 Vilaplana Grosso

FRACTURES OF THE APPENDICULAR SKELETON IN EXOTIC PETS

Fracture Classification
Fractures are defined as a disruption in the continuity of the bone. In exotic pets, frac-
tures are classified in the same way as in other species. Fractures may be classified
according to the following: 1. Anatomic location; 2. possible communication with
the skin (ie, open or closed); 3. fracture configuration (ie, simple, double, multiple,
comminuted, or segmental); 4. direction of the fracture line (ie, transverse, oblique,
spiral, longitudinal, or irregular); 5. extent of the bone damage (ie, complete or incom-
plete, such as greenstick fractures and fissures); 6. relative displacement of the bone
fragments (ie, avulsion fracture, impacted fracture, compression fracture, and depres-
sion fracture); 7. communication with the joint (ie, articular or not articular); 8. fractures
of healthy or diseased bone (ie, traumatic or pathologic); 9. age of the fracture (ie,
acute or chronic) (Fig. 5); and 10. involvement of the physis (ie, Salter Harris fractures
types I to VI) (Fig. 6).
When the fracture segments are displaced, the distal fracture segment is used to
describe the displacement relative to the proximal fracture segment.

Fracture and Bone Healing in Exotic Species

Numerous factors affect the time taken for a fracture to heal (eg, species, nutritional
status, presence of underlying MBD, type of bone, fracture configuration, stability of
the fracture, age of the patient, vascular supply, method of treatment, presence of sys-
temic diseases, if the fracture was traumatic or pathologic, and presence of complica-
tions such as osteomyelitis).
As compared with mammal species, birds have a different bone-healing response in
fracture repair.29–31 For further reading about bone healing in exotic species, please
see Mikel Sabater González’s article, “Skeletal bone structure and repair in small
mammals, birds and reptiles,” in this issue.
Avian bones may clinically heal faster than mammalian bones.30 A simple closed
fracture in a healthy individual may clinically heal and be stable by 3 weeks. Radio-
graphic union often lags behind clinical union, requiring approximately 4 to 6 weeks
for the development of the radiographically visible osseous callus.
Reptile species are considered slow bone healers. Between the different species of
reptiles, snakes often produce a more prominent periosteal reaction than chelonians
and lizards.
In reptile and avian species, fracture fibrous union may occur; this means that
during the healing process, fibrous tissue would be present at the level of the frac-
ture leading to visualization of a persistent radiolucent line in later follow-ups.
Therefore, because of the particular bone-healing process in these species, radio-
graphic evidence of complete bone healing is expected at a later time than in small
mammals, being frequently up to 12 to 16 weeks after the injury.32 In small mam-
mals, fracture healing is generally expected by 4 weeks in young individuals, 6 to
8 weeks in young adults, and around 12 weeks in aged adults. However, specific
healing times will also depend on the previously described factors. If complications
are suspected or the patient presents clinical complaints related to the fracture,
radiographic examination is indicated before the anticipated time of clinical union.
When the expected time of clinical union exceeds 6 to 8 weeks, radiographic ex-
amination at a halfway stage can be recommended to give assurance of a correct
healing. In birds and reptiles, radiographic assessment can be made first at
3 weeks after surgery and then every 2 to 3 weeks until radiographic evidence of
union is present.
 Orthopedic Diagnostic Imaging 157

Fig. 5. Mediolateral (A) and caudocranial (B) radiographs of an Amazon parrot with an
acute oblique distal diaphyseal tibiotarsal fracture. Mediolateral (C) and caudocranial (D) ra-
diographs of a lovebird with a chronic middiaphyseal tibiotarsal fracture. Note the sharp
and well-defined fracture margins in (A) and (B), as compared with the smooth and ill-
defined margins in (C) and (D). (Courtesy of Federico Vilaplana Grosso and the Diagnostic
Imaging Service, College of Veterinary Medicine, University of Florida.)

Complications
The most common complications in fracture healing are infection (ie, osteomyelitis),
sequestration, delayed union, nonunion, and malunion.

Osteomyelitis
Osteomyelitis associated with a fracture may be the result of contamination occurring
at the time of the fracture, such as in an open fracture (Fig. 7), or due to intraoperative
contamination. Fractures may be related to traumatic injuries, such as bites or nail
158 Vilaplana Grosso

Fig. 6. Ventrodorsal radiograph of a raccoon with a Salter Harris type I fracture of the right
femoral head, after falling from a closet. (Courtesy of Federico Vilaplana Grosso and the
Diagnostic Imaging Service, College of Veterinary Medicine, University of Florida.)

punctures provoked by other animals. In these cases, osteomyelitis might be ex-

pected. Severe soft tissue injury may also create an adequate environment for path-
ogen growing and predisposed bone infection.33 Although all ballistic fractures are
open, the likelihood of osteomyelitis to occur is reduced, because of the heat related
to this type of trauma.
In birds, fractures that involve the pneumatic bones are at a greater risk of osteo-
myelitis, and in very rare cases, secondary extension into the air sacs and, conse-
quently, inducing air sacculitis. As the avian species does not generate much
periosteal reaction during fracture healing, the same happens with osteomyelitis,
and osteolysis together with soft tissue swelling will be the predominant radiographic
abnormality.

Fig. 7. Ventrodorsal radiograph of a bat with an open middiaphyseal fracture of the right
humerus (A). An external fixator was placed but removed 2 months later due to osteomye-
litis (B). Note the heterogeneous bone opacity with mixed pattern of osteolysis and the ill-
defined and irregular periosteal reaction. (Courtesy of Federico Vilaplana Grosso and the
Diagnostic Imaging Service, College of Veterinary Medicine, University of Florida.)
 Orthopedic Diagnostic Imaging 159

In reptiles, osteomyelitis also yields a predominant lytic reaction with little periosteal
proliferation.
In small mammals, from approximately 7 to 10 days after infection of a fracture, a
small and ill-defined periosteal proliferation may be detected. If the infection pro-
gresses, signs of an aggressive bone lesion will be noted, including extensive lysis
and marked irregular periosteal reaction. If surgical implants were used, ill-defined
radiolucency around the implants and endosteal sclerosis can be noted as a sign of
osteomyelitis.
Radiography is very useful in the detection of osteomyelitis, although radiographic
changes will be noted at least 1 to 2 weeks after infection and even later in birds and
reptiles. In cases of suspected of early infection, US may show changes, such as fluid
collections, before the patient develops radiographic changes. US also allows sam-
pling for cytologic analysis and culture.

Sequestration
Sequestration can occur in combination with osteomyelitis. A sequestrum is an avas-
cular, nonviable fragment of bone that may serve as a focus of infection that will not be
eliminated without removing this fragment. A sequestrum is recognized radiographi-
cally as a sharply marginated sclerotic bone fragment surrounded by, or separated
from, the rest of the bone by a radiolucent region called involucrum. If a draining tract
originates from the involucrum and communicates with the skin, it means that a cloaca
is present. Sequestration is particularly relevant in birds that have comminuted frac-
tures, in which the bone fragments may lose the blood supply. For the assessment
of draining tracts, radiographic or CT contrast studies (ie, sinusograms and fistulo-
grams) can be performed. Administration of nonionic iodinated contrast media
through the draining tract is done with a catheter or a cannula. This procedure may
confirm or rule out communication between the draining tract with and osseous or
articular structures.

Delayed union and nonunion

Delayed union and nonunion are common in exotic pets. With delayed union, a sub-
jectively longer than expected time to heal for the type and location of the fracture oc-
curs, although little evidence of bone healing is present. Some reasons for delayed
union are limb disuse, instability, poor fracture reduction, poor vascular irrigation,
poor nutrition, MBD, old age, infection, presence of a sequestrum, or undetected un-
derlying pathologic condition, such as a tumor. Usually given enough time and in the
absence of instability or other complications, a delayed union fracture should heal. If
not, the fracture will progress to nonunion, at which point it is considered that com-
plete healing will not occur. Nonunion is defined as a fracture that has not healed
and has no evidence of progression on later follow-ups. Determination of nonunion
is also subjective, and no specific time is strictly defined. In avian and reptile species,
nonunion may be considered after 16 weeks, and after 12 weeks in small mammals,
especially when there is no evidence of radiographic healing in sequential
radiographs.
In nonunion cases, intervention to improve the stabilization and application of bone
grafting may be used to increase the chance of a successful union. Otherwise, ampu-
tation of the limb may be required.

Malunion fractures
Malunion fractures are healed but have abnormal anatomic alignment. In exotic pets,
especially in small-sized animals, malunion fractures are mainly related to lack of initial
reduction and stabilization or because of poor reduction or instability, which is more
160 Vilaplana Grosso

frequent when external coaptation is applied. This type of complication can produce
bone shortening, angulation or rotation of the limb, development of joint pain, or
cosmetic deformity (Fig. 8). Severe malunion fractures may require surgical correc-
tion34 (Fig. 9).

ORTHOPEDIC DISEASES IN EXOTIC PETS

Traumatic Injuries of the Appendicular and Axial Skeleton
Orthopedic trauma is very frequent in exotic pet species. In small mammals, it often
results from household accidents such as falls, injury from a falling object, a closing
door, or a human stepping on the pet. Other types of traumatic injuries may happen
in the cage, in which fractures most frequently occur when a limb becomes entrapped
in a rodent wheel or a wire cage or toy. In cities with tall buildings, high-rise syndrome
can occur, especially in ferrets, with injuries similar to those described in cats. Injuries
are also the result of the attack by other animals.
After a traumatic event, whole-body radiographs are indicated to detect life-
threatening conditions, as well as fractures of the axial and appendicular skeleton,
in a fast manner. After stabilization of the patient, collimated radiographs of the
affected area should be acquired.
Most of the traumatic fractures in small mammals occur in the long bones. When
fractures occur distal to the elbow and stifle, they are usually open because of the
small amount of soft tissues covering the bone. The femur is the most commonly frac-
tured bone in ferrets.35 In rabbits, fractures of the limbs occur more frequently in the
femur, tibia, radius, and ulna17 (Fig. 10). The most common fractured bone in Guinea
pigs is the femur.17
The most common traumatic fracture in chinchillas is the tibial fracture, presumably
because their tibia is longer than the femur and because of their very thin fibula.36 A
frequent reason for this type of fracture includes catching their limb in its cage or grab-
bing the animal by its hind limb.37 Tibial fractures tend to be short spiral or transverse.
Nonunion can result with tibial fractures in chinchillas because of their thin and fragile
bone structures as well as their active behavior. Bones in rabbits and chinchillas are
thin and fragile. For this reason, surgical repair can be difficult, and complications

Fig. 8. Mediolateral radiograph of a rabbit with a chronic distal diaphyseal radioulnar frac-
ture with malalignment and extensive osseous callus (A). If this fracture was not corrected, it
would progress into a malunion fracture. Ventrodorsal radiograph of an aracari with a mal-
union fracture of the left tibiotarsal bone (B). (Courtesy of Federico Vilaplana Grosso and
the Diagnostic Imaging Service, College of Veterinary Medicine, University of Florida.)
 Orthopedic Diagnostic Imaging 161

Fig. 9. Ventrodorsal radiograph of a blue and gold macaw with proximal diaphyseal radio-
ulnar malunion fracture and carpal fractures (A). Ventrodorsal radiograph of the same ma-
caw after surgical correction of the radioulnar malunion and carpal arthrodesis (B).
(Courtesy of Federico Vilaplana Grosso and the Diagnostic Imaging Service, College of Vet-
erinary Medicine, University of Florida.)

are common. These complications include bone-pin loosening, infection, nonunion,

necrosis of the distal limb, and self-mutilation.
In captive birds, diaphyseal fractures to the pelvic limbs are the most common trau-
matic injury.29 However, in wild birds, thoracic limb and thoracic girdle fractures are
more common. Fractures of the shoulder girdle may be difficult to assess radiograph-
ically because of superimposition. Consequently, fractures of the scapula, coracoids,
and clavicle are often underdiagnosed. A specific oblique radiographic view has been
recently reported for the assessment of fractures of the thoracic girdle in raptors.38
This radiographic view can also be used in other bird species. Thoracic girdle fractures
are easily assessable with CT.

Fig. 10. Mediolateral radiograph of a rabbit with a comminuted distal diaphyseal tibial frac-
ture (A). Immediate postoperative mediolateral radiograph after reduction of the fracture
with internal osteosynthesis (B). (Courtesy of Federico Vilaplana Grosso and the Diagnostic
Imaging Service, College of Veterinary Medicine, University of Florida.)
162 Vilaplana Grosso

In adult reptiles, fractures are most commonly traumatic, whereas in young reptiles,
fractures are usually pathologic secondary to fibrous osteodystrophy (Fig. 11).
Assessment of fractures in chelonians is very limited because of the external shell
and their propensity to retract their head, tail, and appendages into the shell. Shell
fractures usually occur because of a fall, dog bite, or vehicular accident. If external
trauma to the shell is seen, radiography, and, even better, CT, are indicated to deter-
mine the extent of the internal damage, fractures, and luxations. 3D reconstructions
are very useful for surgical planning of shell fractures (Fig. 12).
In chelonians, the vertebral column is closely connected to the shell, which means
that in case of shell trauma, the vertebral column may also be affected. Vertebral frac-
tures carry a very bad prognosis in chelonians, and for this reason, their detection with
CT is very important (Fig. 13).
Vertebral fractures are also regularly diagnosed in lizards and snakes, generally
pathologic secondary to fibrous osteodystrophy or osteomyelitis. However, traumatic
fractures may occur, especially if attacked by another animal (Fig. 14).
Traumatic spinal fractures in small mammals are generally due to crush injuries
(Fig. 15). In rabbits, the most common reason of acute posterior paralysis is vertebral
fracture or luxation.39 Fractures are more common than luxations, and the most
frequent site for them to occur is the lumbosacral junction (L7).39 This type of traumatic
injury often results from improper handling or restraint (eg, a startled rabbit that jumps
from a table or chair), but can also happen in caged rabbits that are frightened.39,40
The spinal injury generally occurs when the muscled hind limbs are hyperextended
and causes hyperextension of the vertebral column, which may result in disc damage,
luxations, and fractures with subsequent spinal cord compression, paresis, or
paralysis.39
In birds, cranial impact against a window is frequent. This type of trauma can pro-
duce vertebral fractures that usually happen cranial to the fused synsacrum (ie, be-
tween the notarium and synsacrum, usually at the level of L3 but varies among the
species).29 For that reason, thorough examination of the vertebral region immediately
cranial to the synsacrum should be performed in avian patients with suspected verte-
bral trauma. These fractures will be easier to recognize with CT because it avoids the
superimposition of structures.
For evaluation of spinal fractures and luxations, radiography is an excellent imaging
modality; however, for less clearly visible lesions, such as subluxations or small non-
displaced fractures, CT is a better modality. When assessing for compressive myelop-
athy, myelography, CT-myelography, and MRI are indicated. With MRI, no need of
intrathecal injection of nonionic iodinated contrast media is required, being therefore

Fig. 11. Laterolateral radiograph of a gecko with a pathologic bilateral mandibular frac-
ture. Note the severe generalized osteopenia because of nutritional secondary hyperpara-
thyroidism and fibrous osteodystrophy. (Courtesy of Federico Vilaplana Grosso and the
Diagnostic Imaging Service, College of Veterinary Medicine, University of Florida.)
 Orthopedic Diagnostic Imaging 163

Fig. 12. Dorsal (A), lateral (B), and ventral (C) 3D reconstructions of a tortoise with multiple
carapacial and plastral fractures after being hit by a car. (Courtesy of Federico Vilaplana
Grosso and the Diagnostic Imaging Service, College of Veterinary Medicine, University of
Florida.)

less invasive. Also, it may aid in the detection of spinal cord disorders, such as spinal
contusions, edema, myelomalacia, or hemorrhage.
Skull fractures generally occur secondary to severe trauma. This type of fractures is
difficult to assess in exotic pets because of their reduced size. In birds, cranial frac-
tures are frequently a diagnostic challenge because of the fine cortical bone, the
numerous air sac extensions, and the complexity of the avian jaw apparatus.2 For
additional information about avian skull orthopedics, please refer Minh Huynh and col-
leagues’ article, “Avian skull orthopedics”, in this issue. In general, CT can be per-
formed to fully assess the severity of the injury. Mandibular and maxillary fractures
can occur in association with dental disease.17
Elbow luxations are a common condition in ferrets and can occur spontaneously or
secondary to a traumatic insult.35 Elbow luxations are also frequent in rabbits and trau-
matic in nature.41,42 Craniodorsal coxofemoral luxation is also a common orthopedic
condition in rabbits and may be iatrogenic, traumatic, or congenital.
164 Vilaplana Grosso

Fig. 13. Sagittal CT image of a tortoise with a carapacial and vertebral fracture. Note the
presence of gas in the epidural space. Several mineralized eggs are also noted. (Courtesy
of Federico Vilaplana Grosso and the Diagnostic Imaging Service, College of Veterinary Med-
icine, University of Florida.)

In birds, luxations seem to be more prevalent in the coxofemoral joints, in the stifles,
and involving the digits; however, luxations of other joints have been reported.29,43,44
Luxations are uncommon in reptiles and mainly affect the coxofemoral joint of lizards.

Pathologic Fractures
Pathologic fractures are spontaneous fractures that occur without evident trauma,
because of weakening of the bone by an underlying disease. In exotic pets, this
type of fracture is usually due to underlying MBD or osteomyelitis. Bone neoplasia
is a less frequent cause of pathologic fractures. In cage birds, pathologic fractures
secondary to MBD have been described to be more common than traumatic fractures
or infection.29

Metabolic Bone Disease

One of the most common osseous diseases in exotic pets is fibrous osteodystrophy.
Exotic species seem to be quite susceptible to nutritional secondary hyperparathy-
roidism. Nutritional deficiencies (eg, calcium or vitamin D3) due to feeding an improper

Fig. 14. Dorsoventral (A) and laterolateral (B) radiographs of a pet snake with a luxated
vertebral fracture after being attacked by a dog. (Courtesy of Federico Vilaplana Grosso
and the Diagnostic Imaging Service, College of Veterinary Medicine, University of Florida.)
 Orthopedic Diagnostic Imaging 165

Fig. 15. Laterolateral whole-body radiograph of a squirrel with hind limb paraparesis. A
chronic compressive thoracic vertebral fracture with dorsal subluxation is noted (A). Colli-
mated view of the vertebral fracture (B). (Courtesy of Federico Vilaplana Grosso and the
Diagnostic Imaging Service, College of Veterinary Medicine, University of Florida.)

diet will cause calcium/phosphorus imbalances that result in secondary hyperparathy-

roidism and fibrous osteodystrophy.
Renal secondary hyperparathyroidism can also occur because of chronic kidney
disease or renal dysplasia. In small mammals, it happens more frequently in older rab-
bits that are infected with Encephalitozoon cuniculi.17 In reptiles, renal secondary hy-
perparathyroidism may occur secondary to visceral gout. Animals affected with renal
secondary hyperparathyroidism may present pathologic mandibular fractures,
although the opacity of the long bones may appear normal.32
The most obvious radiographic feature of this disease is osteopenia. Radiographi-
cally, osteopenia is characterized by a severe decrease in bone opacity compared
with the soft tissues, thinning of the cortices, and coarse bone trabeculation. Radiog-
raphy is relatively insensitive for bone loss, because approximately 30% to 60% of the
bone must be lost before being radiographically evident.45 Frequently, the pattern of
demineralization is irregular and may mimic aggressive bone lesions with a patchy
pattern of demineralization, especially in the long bones (Fig. 16).
The bones of animals diagnosed with MBD are very fragile and predisposed to path-
ologic, folding, and incomplete fractures. The handling, restraint, and positioning of
these patients has to be very careful because of their fragile body condition (Fig. 17).
Guinea pigs are the only small mammal that is genetically susceptible to vitamin C
deficiency. Hypovitaminosis C in Guinea pigs will present clinical complaints, such as
poor wound healing, weakness, or diarrhea, and can show radiographic evidence of
bone and/or joint disease. Radiographic changes include enlargement of the epiphy-
ses of long bones and costochondral junctions of the ribs, and there may be an in-
crease in soft tissue opacity in the joints. Pathologic fractures may occur.37
Articular gout is a common cause of lameness in reptiles and birds, such as para-
keets and small psittacines. Gout in birds is thought to result from chronic kidney dis-
ease or high dietary levels of proteins.43 In reptiles, gout develops secondary to renal
disease and hyperuricemia. Radiographic findings of gout are subchondral bone lysis
and periarticular new bone formation.46

Orthopedic Diseases Secondary to Infection

Osteomyelitis and septic arthritis may result from open fractures, penetrating wounds,
hematogenous spread, extension from a soft tissue infection (eg, pododermatitis,
cellulitis, or abscess), or may be iatrogenic. In birds, it can also happen because of
extension of an air sac infection to the pneumatized bones.
In early stages of osteomyelitis, radiographic changes may not be readily apparent.
Later in the course of the disease, soft tissue swelling, osteolysis, and aggressive peri-
osteal reactions are often seen. Fungal osteomyelitis may cause a marked periosteal
166 Vilaplana Grosso

Fig. 16. Mediolateral radiograph of a capuchin monkey with severe osteopenia secondary
to fibrous osteodystrophy with multiple pathologic fractures. This was confirmed with his-
topathology. (Courtesy of Federico Vilaplana Grosso and the Diagnostic Imaging Service,
College of Veterinary Medicine, University of Florida.)

reaction and increased opacity of the medullary cavity of the bone due to granuloma
formation (Fig. 18). In the case of acute septic arthritis, the only radiographic finding
may be soft tissue swelling. As the infection progresses, lytic changes to the cartilage
and subchondral bone (ie, erosive arthritis) as well as ill-defined periarticular new bone
formation may be seen.
Posttraumatic osteomyelitis is a potential complication of fractures in ferrets, rab-
bits, and small rodents and occurs secondary to inciting trauma to the joint and/or
bones, bone avascularity, or wound contamination with secondary postoperative
infection.35,47
Radiographic examination is indicated in ulcerative pododermatitis (ie, bumblefoot),
because in chronic or severe cases, osteomyelitis may be present. Septic arthritis is
most commonly seen in the intertarsal joints of cage birds.
Avian tuberculosis (Mycobacterium spp) may result in focal areas of increased med-
ullary opacity and periosteal proliferation, affecting principally the long bones and
causing lameness.29,43

Degenerative Diseases
Degenerative joint disease
Degenerative joint disease may occur because of prior trauma or age-related degen-
eration (Fig. 19). Age-related osteoarthritis is commonly seen in exotic pets, affecting
 Orthopedic Diagnostic Imaging 167

Fig. 17. Laterolateral radiograph of a rabbit with renal secondary hyperparathyroidism and
pathologic fracture of the left femur (A). Ventrodorsal view of the same rabbit showing an
additional pathologic fracture of the right femur that occurred during the examination (B).
(Courtesy of Federico Vilaplana Grosso and the Diagnostic Imaging Service, College of Vet-
erinary Medicine, University of Florida.)

principally the stifle, coxofemoral, and shoulder joints, and is usually bilateral. Degen-
erative joint disease is often underdiagnosed in certain exotic pet species, such as ro-
dents, and it is frequently an incidental finding. Spontaneous cartilage degeneration
has been reported in Guinea pigs, resulting in degenerative changes and arthritis of
the stifle joint37 (Fig. 20). Radiographic findings include periarticular osteophytes,
enthesophytes, subchondral bone sclerosis and lysis, joint space narrowing, and peri-
articular dystrophic mineralization. Periarticular mineralized bodies and linear dystro-
phic mineralization of entheses and muscles are commonly seen in rodents and
usually lack of clinical significance.48

Fig. 18. Ventrodorsal radiograph of a macaw with fungal osteomyelitis of the right humer-
us. Note the patchy multifocal intramedullary increased opacity and distal periosteal reac-
tion. (Courtesy of Federico Vilaplana Grosso and the Diagnostic Imaging Service, College
of Veterinary Medicine, University of Florida.)
168 Vilaplana Grosso

Fig. 19. Craniocaudal (A) and mediolateral (B) radiographs of a rabbit with trauma-induced
marked coxofemoral and stifle degenerative joint disease. (Courtesy of Federico Vilaplana
Grosso and the Diagnostic Imaging Service, College of Veterinary Medicine, University of
Florida.)

Degenerative intervertebral disc disease

Degenerative intervertebral disc disease has been reported in hedgehogs.49 In a se-
ries of 4 cases, radiographic findings included spondylosis deformans, intervertebral
disc space narrowing, and intervertebral disc mineralization.50 Degenerative interver-
tebral disc disease is common in older pet rabbits (Fig. 21). Radiographic findings are
similar to those encountered in other species (eg, dog), such as spur-shaped or
bridging new bone formation ventrally to adjacent endplates, endplate sclerosis, or
intervertebral disc space narrowing.

Neoplasia Osteosarcomas have been diagnosed in small mammals, reptiles, and

birds affecting the appendicular and axial skeleton, but overall, bone tumors are
rare in exotic pets.29,51–53 In rabbits, it seems that osteosarcomas more commonly
affect the skull. Bone neoplasia in exotic pets is usually characterized by osteolysis
with minimal periosteal change; however, osteoblastic neoplasia with marked perios-
teal reaction may occur. Soft tissue neoplasia may involve the bone and be a cause of
lameness. The most frequent radiographic findings are bone lysis and reactive perios-
teal reaction.

Fig. 20. Ventrodorsal radiograph of a Guinea pig with severe bilateral stifle degenerative
joint disease. (Courtesy of Federico Vilaplana Grosso and the Diagnostic Imaging Service,
College of Veterinary Medicine, University of Florida.)
 Orthopedic Diagnostic Imaging 169

Fig. 21. Laterolateral radiograph of a rabbit with degenerative intervertebral disc disease.
Note the narrowing of the intervertebral disc spaces L1-L3 with associated endplate sclerosis
and mild spondylosis deformans. (Courtesy of Federico Vilaplana Grosso and the Diagnostic
Imaging Service, College of Veterinary Medicine, University of Florida.)

Chordomas are the most common type of musculoskeletal neoplasia reported in

ferrets. Cervical chordomas may induce osteolytic reaction of the vertebrae and can
develop compressive myelopathy and compression of the adjacent tissues54 (Fig. 22).
Also, in ferrets, lymphoma, invasive histiocytic sarcoma, and plasma cell neoplasia
can cause osteolytic lesions with associated spinal cord compression.55,56 Metastatic
bone disease is rare in exotic species.

Miscellaneous Polyostotic hyperostosis is seen seasonally in reproductively active fe-

male birds because of the storage of calcium salts before the beginning of the egg
laying and usually happens in the ulna and tibia. Radiographically, polyostotic hyper-
ostosis is characterized by a diffuse, uniform, or patchy increase in the opacity of the
medullary cavity of nonpneumatic bones, such as the femur, tibiotarsus, radius, and
ulna.43 Polyostotic hyperostosis can also occur in female birds with oviductal
neoplasia or male birds with Sertoli cell tumors.57
Spine curvature disorders (eg, scoliosis, lordosis, and kyphosis) and angular limb
deformities (eg, tibiotarsal valgus or splayed legs) are commonly seen exotic species,
probably secondary to MBD (with concomitant folding fractures) and malunion

Fig. 22. Laterolateral radiograph of a ferret with a cervical chordomas. A large soft tissue
opaque mass with associated amorphous dystrophic mineralization is seen. (Courtesy of Fed-
erico Vilaplana Grosso and the Diagnostic Imaging Service, College of Veterinary Medicine,
University of Florida.)
170 Vilaplana Grosso

Fig. 23. Dorsal CT reconstruction of a rabbit showing scoliosis. (Courtesy of Federico Vila-
plana Grosso and the Diagnostic Imaging Service, College of Veterinary Medicine, University
of Florida.)

fractures. Scoliosis is the most usual spine curvature malformation and in most cases
is difficult to determine the underlying cause (Fig. 23). Congenital causes are also
possible but less frequent. In reptiles, improper incubation temperatures during
embryogenesis may lead to these abnormalities.46

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