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Avian luxations: occurrence, diagnosis and treatment

a

Panagiotis N. Azmanis , Morena B. Wernick & Jean-Michel Hatt

a

Clinic for Zoo Animals, Exotic Pets and Wildlife, Vetsuisse Faculty, University of Zurich,
Zurich, Switzerland.
Accepted author version posted online: 18 Mar 2014.Published online: 02 May 2014.

To cite this article: Panagiotis N. Azmanis, Morena B. Wernick & Jean-Michel Hatt (2014): Avian luxations: occurrence,
diagnosis and treatment, Veterinary Quarterly, DOI: 10.1080/01652176.2014.905731
To link to this article: http://dx.doi.org/10.1080/01652176.2014.905731

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Veterinary Quarterly, 2014

http://dx.doi.org/10.1080/01652176.2014.905731

REVIEW ARTICLE
Avian luxations: occurrence, diagnosis and treatment
Panagiotis N. Azmanis*, Morena B. Wernick and Jean-Michel Hatt
Clinic for Zoo Animals, Exotic Pets and Wildlife, Vetsuisse Faculty, University of Zurich, Zurich, Switzerland.

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(Received 5 February 2014; accepted 14 March 2014)

Whereas the treatment of fractures in birds has been a matter of multiple studies and reviews, comparatively little
information is available for the treatment of luxations in birds. In this article, we review the current knowledge regarding
the frequency, etiology, clinical presentation, diagnosis, and treatment of luxations in birds, aiming to guide the clinician in
private practice as well as future research. The type, the localization, and the frequency of luxation do not follow a
concrete pattern. In general, pet and aviary birds are more susceptible to leg and spinal luxations while in wild birds wing
luxations are more frequently observed. Diagnosis is made on the basis of detailed orthopedic and radiographic
examinations. Conservative management and coaptation has been successfully used in carpal, minor elbow,
shoulder, coracoid, and metatarsophalangeal luxations. Surgical management is recommended in palatine bone,
metacarpophalangeal, severe elbow, coxofemoral, stifle, and intertarsal joint luxations. The techniques, which have been
applied, include arthrodesis, femoral head osteotomy, polymer rods, bone plates, and internal and external fixation in
various combinations. Currently, there are no controlled studies, which underline the advantages and disadvantages of each
technique.
Keywords: bird; avian; luxation; joint; surgical treatment; prognosis; review

1. Background
The word luxation derives from the Latin word luxare
which means to dislocate. Luxation or dislocation is the
abnormal displacement of a bone from a joint. A partial
dislocation is called a subluxation.
In most avian species luxations occur infrequently
compared to other orthopedic conditions (Martin &
Ritchie 1994). A study revealed that 1 in 10 birds, presented with wing or shoulder girdle fracture, was also
accompanied by a respective luxation (Schuster &
Krautwald-Junghanns 1996). The most commonly
affected avian taxonomic groups are psittacines, small
cage birds, raptors, pigeons, and waterfowl. These are presented to the avian practitioner as companion birds, wildlife casualties, falconry birds, or residents of a zoological
collection. Additionally, luxations are a frequent problem
in commercial broiler farms due to excessive weight gain
over a short period (Duff 1985). Although diagnosis of a
luxation typically does not pose a big challenge, the prognosis in many types of luxation remains poor to guarded.
The aim of this article is to review current knowledge
of avian luxation, its diagnosis and treatment, with a view
to understanding why the prognosis remains poor. The
review concludes with recommendations to optimize
future research.

2. Methods
The literature review was conducted using the keywords
avian, bird, luxation, dislocation, articulation, joint,
palatine bone, spinal, cervical, thoracolumbar,
*Corresponding author. Email: azmanis.vet@gmail.com
2014 Taylor & Francis

scapulohumeral, shoulder, coracoid bone, metacarpal

bone, alula, metacarpophalangeal, elbow, hip, coxofemoral, stifle, femorotibial, intertarsal, hock, metatarsophalangeal, phalangeal, etiology, pathogenesis, diagnosis,
radiography, diagnostic imaging, computed tomography,
magnetic resonance tomography, fixation, bandage,
extracapsular, internal, external, bone plate, screw, tension band, prognosis, complication, and reposition. These
keywords were used in every appropriate combination
(i.e. avian femorotibial joint luxation) via Google Scholar,
PubMed, Medline, CABNET, Science Direct, and the
University of Zurich Open Repository and Archive
(ZORA). Additional searches were conducted by examining the reference list of the articles found in the initial
searches and by using the Related Articles and Cited
by function. The focus was the period of 1976 until 2013.
Eligible studies were required to be full articles.
Because the aim of the literature review was to have an
extensive result, the kind of publication, e.g. peerreviewed article, report of a congress, publication in
books, publication in journals, etc., was no exclusion criterion. There was no restriction applied on language.
Information in major avian medicine textbooks, conference proceedings (Association of Avian Veterinarians,
Association of Zoo and Wildlife Veterinarians, Colleges
of Zoological Medicine), and thesis received a meta-survey (i.e. to trace the original reference or used as such if it
was anecdotal data of the author). The focus of the paper
analysis was on etiology, clinical signs, diagnosis, prognosis, and evaluation of treatment. In addition, a review
of the avian cases presented to the Clinic of Zoo Animals,
Exotic Pets and Wildlife of the University of Zurich

P.N. Azmanis et al.

(UZH), Switzerland from 2001 until 2011, was performed,

regarding the occurrence of luxations in relation to the
species.

The majority were Falconiformes (30%) and Psittaciformes (25%) followed by the order of Apodiformes
(swifts, swallows, 16%). Columbiformes were not
present (Figure 3).

3. Results

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3.1.

Data quality, frequency, and the affected avian

orders
Most data was retrieved by peer-reviewed journals (67%),
followed by book chapters dealing with avian orthopedic
disease management (21%), conference proceedings
(12%), and finally thesis (3%). Data quality refers to the
scientific gravity and overall input of the data as far as the
focus of the each author (e.g. experiment focused on luxations, case report, case series, or just incorporation of data
by other authors). The quality of the retrieved data is presented in Figure 1. In most chapters on orthopedic disease
management, the main focus was on fracture management. Usually only a small paragraph was dedicated on
luxation management and their content was rather generalized and only some luxation types (i.e. elbow, femorotibial, coracoid/shoulder) were discussed. Specific luxation
information was available in case reports, followed by retrospective studies (Figure 1). Experimental studies and
reviews on luxations were rare (n 3). The most commonly reported luxations were equally the scapulohumeral and femorotibial (Figure 2). This may, though, not
reflect the actual frequency, since there were two experimental studies focused on femorotibial luxation management using pigeons (n 23). This might also have been
the case with the avian order frequency, which is affected
by luxation (Figure 3). Columbiformes (i.e. pigeons) are
overrepresented due to two experimental studies, followed
by Falconiformes (i.e. diurnal raptors) and Psittaciformes
(i.e. parrots), which also are the two commonest orders
presented in an avian practice. In the evaluation of the
cases presented to the Clinic of Zoo Animals, Exotic Pets
and Wildlife (UZH) 67 cases of luxations were found.

Figure 1. Data quality (n 57 data sources).

3.2.

Etiology, diagnosis, and symptoms of specific

luxations
An overview of the etiology and clinical signs of the various reported luxations is summarized in Table 1. Luxation
is normally suspected by the history and clinical signs and
diagnosis is made following an orthopedic and neurologic
examination and radiography. Computed tomography and
magnetic resonance tomography have been applied in
some cases (Ward & Gartrell 2009; Gumpenberger &
Scope 2012; Fraga-Manteiga et al. 2013) and may be useful in specific luxations (e.g. coracoid subluxation, coxofemoral, spinal, palatine bone). Below some anatomical
and statistical notes on specific luxations are given.
3.2.1.

Proximal coracoid bone luxation

Two cases of caudoventral luxation of the left coracoid,

affecting both its distal and proximal articulation, were
recently described in a bald eagle (Haliaeetus leucocephalus) (Guzman Migallon-Sanchez et al. 2007) while
another case had been reported in a white-tailed sea eagle
(Haliaeetus albicilla) (Muller et al. 2007). A difficult-todiagnose coracoid subluxation has been described in a
New Zealand falcon (Ward & Gartrell 2009).
3.2.2. Shoulder luxation
The scapulohumeral joint is generally described as a stable joint due to the supporting musculature and the coracohumeral ligaments (Coles 1997). Luxation rarely
occurs (Roush 1980), but when it happens prognosis is
grave (Howard & Redig 1994). In a study focused on

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Veterinary Quarterly

Figure 2. Overview of published luxation data (19762013) (n 151 luxations).

Figure 3. Avian orders and luxation incidents as represented in the published literature (19762013) (n 105 incidents) and in UZH
(20012011) (n 67 cases).

P.N. Azmanis et al.

Table 1. Overview of the etiology and clinical manifestation of luxations as referred in the literature.
Articulation

Etiology

Metacarpophalangeal Trauma

Floppy wingtip

Carpal

Extended carpus with external

rotation
Floppy wingtip

Release effort of an entangled foot

Viscous mud around nest ground

Elbow

Severe blunt trauma

Proximal coracoid

Collision

Scapulohumeral

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Clinical manifestation

Palatine bone
Spine

Coxofemoral

Femorotibial

Intertarsal

Metatarsometatarsal

Wing extension and droop

Rotation up 90o
Soft tissue swelling
Crepitus
Wing droop

Flight inability
Inability to gain height
Crepitus
Rupture of the tendon of the supra- None referred
coracoideus muscle, leading to
upward subluxation of the
humeral head.
Acute head trauma
Hyperextended rhamphotheca
Simultaneous act of a dorsal force
with maxillary hyperextension
Trauma (gunshot, collision)
Poor flight performance
Improper handling (falconry)
Unilateral or bilateral leg paresis
Paralysis
Brainstem compression due to
Balance equilibrium, hard landing
trauma
Release effort of an entangled foot Fixed extension of the leg
Improper handling
Instability
Trauma
Crepitus
Contorted position of the affected
leg. Unable to stand
Lateral torsion of the leg. Unable to
stand
Stretching leg backwards
Developmental abnormality
Joint hyperextension
Spotaneous orthopedic disease
Positive withdrawal sign
Trauma (gunshot, collision,
Medial or lateral instability
inadequate leash in falcons)
Improper training (falconry)
Absence of palpable fracture
Landing inexperience (falconry)
Lack of crepitus
Non-weight-bearing lameness
Firm swelling
Ability to partially reduce the
tibiotarsus into its normal
position
Trauma
Tarsometatarsal rotation
Developmental rupture of tibial
Persistent ligamentous laxity
cartilage
Avulsion of M. flexor hallucis
Joint swelling
longus tendon
Entangled in net sealing, tendon
Palpation of the tendon of M. flexor
rupture
hallucis longus
None referred
No ligamentous damage

avian fractures, 15 shoulder luxations out of 49 fractured

shoulder girdle cases were identified (Schuster & Krautwald-Junghanns 1996). Re-luxation after treatment is not
an uncommon complication (Bennett & Altman 1997).
Luxations of the shoulder have so far been reported for
snow (Anser caerulescens) and Ross geese (Chen rossii)
(Wobeser et al. 1981), in ostrich (Struthio camelus)
(Zonghuan 1997), in raptors (Martin & Ritchie 1994;
Souza et al. 2004; M
uller et al. 2007), in one crow

Reference
van Wettere and Redig (2004)
M
uller et al. (2007)
Bennett and Altman (1997)
Hatt (1999)
Roush (1980)
Rajchard and Rachac (2003)
Ackermann and Redig (1997)
Martin et al. (1993b)
Guzman Migallon-Sanchez et al.
(2007), Ward and Gartrell (2009)
M
uller et al. (2007)
Hatt (1999)
Holz (2003)
Martin and Ritchie (1994)

Martin and Ritchie (1994)

Foerster et al. (2000)
M
uller et al. (2007)
Harcourt-Brown (2000)
Naldo and Samour (2004)
Fraga-Manteiga et al. (2013)
Hatt (1999)
Martin et al. (1994)
Campbell (1987)
Gumpenberger and Scope (2012)

Bennett (1998)
Clipsham (1991a)
Harcourt-Brown (2000)
Fukui et al. (2005)
Bowles and Zantop (2002)
Naldo and Samour (2002)

Harcourt-Brown (2002)
Roush (1980)
Demirkan and Kilic (2003)
Zsivanovits (2011)
Harcourt-Brown (2002)

(Corvus corone), as well as pigeons (Columba livia

domestica) and gulls (Coles 1997). A wing luxation has
been also reported in a Canada goose (Branta canadensis)
(Bullier 1949).
3.2.3.

Elbow luxation

The avian elbow joint is a shallow joint which lacks a

trochlear notch, annular, collateral, and olecranon

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Veterinary Quarterly
ligaments (Ackermann & Redig 1997). The supporting
structures of the joint is a weak capsular membrane common to humerus, radius, and ulna two transverse radioulnar ligaments and the extensor and flexor muscles
(Ackermann & Redig 1997). Additionally, it contains a
cartilaginous meniscus (Roush 1980). Because of the
above-mentioned anatomy, the most common type of luxation is caudodorsal (75%) (Ackermann & Redig 1997)
followed by the caudal (37%) (Martin et al. 1993b). Ventral luxation occurs when a radial fracture is present (Bennett 1998). Special attention should be directed at open
wounds and soft-tissue injuries as they could affect the
release prognosis (Martin et al. 1993b). Elbow luxations
are common in wild birds, but infrequent to rare in companion birds (Bennett & Altman 1997; Hatt 1999). In various raptor species it represented a percentage of 2 and 12
of the caseload in two busy raptor centers (Martin et al.
1993b; Ackermann & Redig 1997). Moreover, in a report
of seven cases of elbow luxation in raptors, only three
returned to the wild (Souza et al. 2004). Additionally,
elbow luxations were reported in two white-tailed sea
eagles (M
uller et al. 2007). A permanent left elbow luxation has also been recorded in a rare Mauritian pink
pigeon (Columba mayeri) (Flach & Cooper 1991).
Another study reported 18 elbow luxations (with mostly
radius involved) in 239 wing fracture cases (Schuster &
Krautwald-Junghanns 1996).
3.2.4. Carpometacarpal joint luxation
An interesting case of carpal joint luxation was reported in
free-living, juvenile black-headed gulls (Larus ridibundus) (Rajchard & Rachac 2003). Many birds were presented with rotation of the metacarpal bones, but without
any fracture suspicion or active traumatic event. The luxation was attributed to the mudded soil compacting the
joints. Schuster has also reported few cases in wild and
pet birds (Schuster & Krautwald-Junghanns 1996) while
M
uller reported two cases of ulnocarpal luxation in whitetailed sea eagles (M
uller et al. 2007).
A condition which affects the carpometacarpal region
is the angel or slipped wing. It is commonly described in
waterfowl bred in captivity, although appearing in semiwild waterfowl too (Kreeger 1984; Olsen 1994), as well
as in psittacines, bustard chicks, and a Northern Goshawk
(Accipiter gentilis) (Zsivanovits et al. 2006). The birds are
presented with deformed primary feathers and rotation of
the metacarpal bones. The left wing is mainly affected
and the males are more susceptible (Olsen 1994). Nutrition (excessive energy and/or deficiency in vitamin E and
D), limited exercise, genetic factors, and management
practices have been implicated as etiologies of this condition (Olsen 1994).
3.2.5.

Coxofemoral joint luxation

According to McCoy the coxofemoral joint is diarthroidal

with a round ligament and collateral ligaments (MacCoy
1989). In some species, a prominent antitrochanter exists
as an extension of the pelvis, dorsal of the coxofemoral

joint. Ventral collateral and round ligaments play major

roles for the proper position of the femoral head in the
acetabulum, especially in non-cursorial species such as
psittacines, hawks, falcons, owls, and pigeons (MacCoy
1989). In contrast, cursorial species (e.g. ratites) have a
ball-socket type joint (Martin & Ritchie 1994). Hip luxations have been reported in different small birds (Martin
& Ritchie 1994), psittacines (MacCoy 1989; Martin et al.
1994), a Toco toucan (Ramphastos toco toco) (Campbell
1987), a red-shouldered hawk (Buteo lineatus) (Ackermann & Porter 1995), a peregrine falcon (Falco peregrinus) (Stauber et al. 2008), two cormorants
(Phalacrocorax carbo) (Risi et al. 2005) and five mute
swans (Cygnus olor) (Gumpenberger & Scope 2012).
Based on the aforementioned cases, coxofemoral joint
luxation is more common in birds weighing up to 1 kg.
3.2.6.

Femorotibial joint luxation

Luxations of the femorotibial joint are quite common in

birds. The luxation occurs craniolaterally, craniomedially,
caudolaterally, and caudomedially with concomitant damage to the collateral and cruciate ligament (Duff 1985;
Clipsham 1991a; Fukui et al. 2005) while meniscal damage is rarely diagnosed (Harcourt-Brown 2000). The
muscles that flex and extend the joint may contract significantly after luxation making re-positioning of the initial
trauma and luxation difficult. Muscle and nerve damage
may cause paresis or paralysis of the pelvic limb, resulting
in ambulatory difficulty or inability to grip or perch
(Flammer & Clubb 1994; Martin & Ritchie 1994). Several
cases of femorotibial joint luxation have been published
including mainly psittacines, but also other captive and
wild species (Holz 1992; Rosenthal et al. 1994; Donato
2000; Jaffe et al. 2000; Alievi et al. 2001; Bowles & Zantop 2002; Harris et al. 2007) and birds of prey (David
1976; Rosenthal et al. 1994; Schuster & Krautwald-Junghanns 1996; Naldo & Samour 2002; Fukui et al. 2005;
Chinnadurai et al. 2009).
3.2.7.

Intertarsal joint luxation

This luxation is occasionally observed usually due to

trauma. Damaged tendons, ligaments, and integument
accompany the dislocations frequently. The tibial cartilage can be damaged on its own: growing birds can easily
dislocate many of the structures within or attached to the
tibial cartilage. The most frequent dislocations involve the
tendon of M. flexor hallucis longus. The tendon bursts out
of position and lies to the lateral aspect of the tibial cartilage as a consequence of trauma. The bird is unable to use
the affected leg, there is an obvious thickening of the joint
and if recently displaced the tendon can be easily palpated. The foot is rotated away from the body (HarcourtBrown 2002), with persistent ligamentous laxity (Roush
1980). Amputation is a feasible option only in small avian
species (e.g. canaries, budgerigars) because in larger species it frequently results in severe pododermatitis (bumblefoot) of the contralateral foot. Surgical options for the
treatment of intertarsal joint luxations have been

P.N. Azmanis et al.

described for larger avian species (Demirkan & Kilic

2003; Zsivanovits 2011).
3.2.8. Metatarsal joint luxation
The metatarsophalangeal joints appear to be less susceptible to luxations (Roush 1980) and may be dislocated without ligamentous damage (Harcourt-Brown 2002).

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3.2.9.

within the functional limits of each joint. For each joint, a

specified physical therapy should be planned including
massage, and both passive and active exercises. Physical
therapy is of great importance in wild birds undergoing
rehabilitation (Chaplin 1989; Chaplin et al. 1993; Martin
et al. 1993a).
In Table 2, an overview is given on the applied techniques as well as the prognosis while a summary on each
technique is attempted in the following.

Various reported luxations

Other less common luxations include an atlanto-occipital

subluxation and cranial cervical block vertebrae in a
golden eagle (Aquila chrysaetos) (Fraga-Manteiga et al.
2013), a (sub)luxation between notarium and synsacrum
on the sixth thoracic vertebra in raptors (Harcourt-Brown
2000; Naldo & Samour 2004; M
uller et al. 2007),
metacarpophalangeal luxations in a juvenile prairie falcon (Falco mexicanus), a great horned owl (Bubo virginianus) (van Wettere & Redig 2004) and a white-tailed sea
eagle (Haliaeetus albicilla) (M
uller et al. 2007) and a
palatine bone luxation in two blue and gold macaw (Ara
ararauna) (Martin & Ritchie 1994; Foerster et al. 2000).
In spinal luxations, birds typically show poor flight performance, unilateral or bilateral lameness or paralysis. The
metacarpophalangeal luxations are rare, representing
0.13% (2/1579 cases) over a two-year period in the Raptor
Center-University of Minnesota (van Wettere & Redig
2004). The palatine bone luxation has only been recorded
twice. The affected blue and gold macaws presented
hyperextended maxillary beak and a history of acute head
trauma. Luxation results from the simultaneous act of a
dorsal force with maxillary hyperextension.
3.3. Luxation treatment methods and prognosis
Many techniques have been developed to facilitate luxation management and treatment in birds. Previously, it
was thought that a luxation of an avian joint was unlikely
to be successfully treated with full or at least functional
recovery. Today a luxation is not per se considered a lost
case, if early diagnosis is made and proper management
technique selection is applied. Periarticular fibrosis may
develop within three days (Bennett 1998), inhibiting the
full recovery of the luxation and predisposing to joint
ankylosis (Bennett & Altman 1997). Additionally, a
proper technique should be correctly applied to avoid permanent ligamentous laxity caused by false anatomical
reposition and regular re-luxation. The stabilization before
joint stiffness and the necessity of physical therapy appear
to be of equal importance (Roush 1980). Evidently, a variation in prognosis also exists, depending on the luxation
site, the intervention time, and the accompanying findings
(open luxation, soft-tissue damage, ruptured tendons, ligaments, periarticular fractures, muscle contraction). In the
latter cases the prognosis is poor to guarded.
Physical therapy following stabilization may have a
positive influence to achieve the maximum range of
motion of the joint or at least achieve a range of motion

3.3.1. External coaptation and cage rest

External coaptation is a simple, fast, and cost-effective
method for fracture and luxation fixation. Nevertheless,
in most cases it is unrewarding, has a high percentage
of fracture disease, a condition characterized by inappropriate pain, soft tissue swelling, patchy bone loss,
and joint stiffness (Anderson 1991; Bennett & Kuzma
1992) and the return to function is typically prolonged
due to incomplete immobilization. Therefore, it should
only be considered as an emergency method, until surgery can be performed (Martin & Ritchie 1994; Harcourt-Brown 2002). Only certain types of luxations (e.g.
phalangeal, coracoid/shoulder, metacarpal, metarsophalangeal) following reposition of the joint, can fully
recover with cage rest and a simple bandage only and
regain their full range of motion. Many authors propose
that coaptation should only be considered when the full
return to function is not required, the bones are too
great, the patient is too small for internal fixation and
when accompanied by pathologic fractures as result of
metabolic bone disease (Martin & Ritchie 1994; Bennett
& Altman 1997; Helmer 2006). The phalangeal joint
dislocations were easily corrected, without even the
need of external support, which could additionally cause
loss of function. Damaged collateral ligaments were
repaired with 3-0 or 4-0 polygalactin sutures (HarcourtBrown 1996; Helmer 2006). The figure of eight wrap
has been successfully applied to reduce elbow luxations in two cases of diurnal raptor, but with no postrelease follow-up; the animals were assumed to have little ligamentous damage and minor instability (Martin
et al. 1993b). According to Bennett, carpal luxations
can also be conservatively managed with the figure of
eight bandage for 712 days, but if laxity is present,
an open reduction with external skeletal fixation (ESF)
should be preferred (Bennett & Altman 1997). Additionally, this bandage could act as a supportive measure
after elbow open reduction techniques (Ackermann &
Redig 1997). Spica splints, slings, and casts have in the
past been proposed for closed management of
coxofemoral luxations (Roush 1980; Altman 1982;
MacCoy 1989; Martin et al. 1994). For the open reduction femoral head osteotomy has been described (Martin
& Ritchie 1994; Bennett & Altman 1997). Experiments
to fixate a stifle luxation using a splint applied from
the femur to the metatarsal bones, including digits I and
III and wrapped with elastic tape have been carried out
(Villaverde et al. 2005).

Arthrodesis
Functional clinical outcome. Partial loss of ROM. Intra-articular histological changes.
Functional outcome. Good prognosis in recent luxations.

Triangular transarticular Type I ESF

Extracapsular technique and Type I HLTEF
Cerclage or suture in figure of eight pattern
through tibia.
Type I HLTEF

Just tendonraphy. No support needed

Intertarsal

Metatarsophalangeal

Note: ESF external skeletal fixator; HLTEF hinged linear transarticular external fixator; ROM range of motion; IM intramedullary.

Good

Normal grip and perch in a Cockatoo 10 weeks post-operation Gait and swim in 2
goslings 6 weeks post-operation with deficits

Arthrodesis. 50% deficit of ROM. Functional outcome. Healing after 5 weeks

Type I ESF (transarticular) and Type I and II

combination

Poor prognosis Euthanasia. Death

Poor anatomic stabilization and prognosis despite ambulation after 23 days
Functional outcome. Arthrodesis. Possible complications.

Safer technique. Full ROM of hip joint

Possible re-luxation
Possible kidney injury
Salvage technique. Some return to normal ROM (pseudarthrosis)

Poor. Euthanasia.

Successful

Good

Good (full flight capacity). No flight deficits after 17 weeks

Good in cases with minor damage
If instability persists after bandaging
Duck able to burst and fly long distance (4 km) after 17 days
Good but only in cases with minor ligamentous damage
95% functional restoration
For closed dislocation with minor soft-tissue damage. Normal or 25% deficit in ROM
after 6 months rehabilitation.
95% ROM after 43 days
Flight capacity after 43 days. Release.

Outcome and prognosis

90% normal function after 14 months (Jaffe et al), weight bearing 14 days after
surgery (Fukui et al), functional outcome (Villaverde et al), near-normal range and
normal use 35 days post-operation (Chinnadurai et al)

Splint, sling
Transfixation (IM) pin
Excision arthroplasty with femoral head
osteotomy
Femoral head stabilization with
polypropylene sutures
None
Full leg splint
Intramedullary pins conjoined externally

Transverse intramedullary pin stabilized in

suborbital arch and jugal bones
None

Figure of eight bandage around the body for

815 days

Type II ESF
Bone plate

Arthrodesis with Type I ESF

Figure of eight bandage (712 days)
Open reduction and Type I ESF
Natural healing
Figure of eight bandage
Type I ESF
Triangular transarticular type I ESF

Treatment method

Extracapsular techniques (cortical screw,

tension band, cerclage)

Femorotibial

Coxofemoral

Spine

Coracoid
Palatine bone

Scapulohumeral

Proximal coracoid

Elbow

Metacarpophalangeal
Carpal

Articulation

Table 2. Overview of the therapy and prognosis of each luxation as referred in the literature.

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Roush (1980), Demirkan and Kilic

(2003), Zsivanovits (2011)
Ferraz et al. (2010)
Harcourt-Brown (2002)
Helmer (2006)
Harcourt-Brown (1996)

Martin et al. (1994), Risi et al.

(2005)
Gumpenberger and Scope (2012)
Villaverde et al. (2005)
Zantop (2000), Bowles and Zantop
(2002), Harris et al. (2007)
Holz (1992), Jaffe et al. (2000),
Villaverde et al. (2005), Fukui
et al. (2005), Chinnadurai et al.
(2009)
Rosenthal et al. (1994), Donato
(2000), Alievi et al. (2001),
Villaverde et al. (2005)
Olsen et al. (2000)
Azmanis (2011)
Harcourt-Brown (1996)

Martin and Ritchie (1994), Bennett

and Altman (1997)
Olsen et al. (2000)
Foerster et al. (2000)
Martin and Ritchie (1994)
Harcourt-Brown (2000)
Naldo and Samour (2004)
Fraga-Manteiga et al. (2013)
Roush (1980), Altman (1982)
Roush (1980)
Campbell (1987), MacCoy (1989)

Martin et al. (1993b)

Guzman Migallon-Sanchez et al.
(2007)

Doty (1979)
Martin et al. (1993a)
Martin et al. (1993a)
Ackermann and Redig (1997)

van Wettere and Redig (2004)

Bennett and Altman 1997

Reference

Veterinary Quarterly
7

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3.3.2.

P.N. Azmanis et al.

Internal fixation

Many authors have reviewed the advantages and disadvantages of each method in fracture repair (Roush 1980;
Bennett & Kuzma 1992; Martin & Ritchie 1994; Bennett
1998; Harcourt-Brown 2002) but only few commented on
their use in luxation management (Roush 1980; Martin &
Ritchie 1994; Bennett 1998).
Intramedullary (IM) pinning: The transfixation of
shoulder and coxofemoral luxations with a smooth
unthreaded Steinmann pin has been proposed (Roush
1980). The pin is inserted through the trochanter into the
head of femur and across the acetabulum. The use of intramedullary pins has been described as well for stifle luxation (Zantop 2000; Bowles & Zantop 2002). A
craniolateral and a medial luxation in two monk parakeets
(Myiopsitta monachus) and an umbrella cockatoo (Cacatua alba) was reduced by inserting two IM pins normograde (Zantop 2000; Bowles & Zantop 2002). A 0.045-inch
diameter Kirschner wire was normograded into the tibiotarsal bone medially to the patellar ligament while a similar second wire entered the femoral cavity from the
greater trochanter. The exposed portion of each pin was
cut 2 cm from the joint, in a way that the end of each pin
was bent 90 cranial to its insertion. Afterwards, acrylic,
formed in a ball, was placed over the pins to provide stability. This technique was followed in experimental stifle
luxation in pigeons to compare it with other stifle fixation
techniques (Villaverde et al. 2005). A craniolateral luxation of the femur was fixed similarly, with the modification of conjoined edges of the intramedullary pins bended
in 90 towards each other (Harris et al. 2007). Finally,
two cases of palatine bone luxation have been treated
with a transverse intramedullary pin crossing the infraorbital sinus to displace the palatine bones ventrally. Then
the IM pin was removed and the reduced palatines were
bilaterally stabilized around the suborbital arch and jugal
bones with 3-0 polydioxanone absorbable sutures
(Foerster et al. 2000).
Extra-capsular stabilization technique: cortical screws
and tension bands have also been used to correct a luxated
joint in the avian patient. Jaffe et al. (2000) fixed a
1.5 mm and 16 mm long cortical bone screw to the lateral
femoral condyle of a macaw in order to reduce a medial
patellar luxation. A single strand of 0-nylon suture was
threaded to the proximal cnemial crest and anchored to
the screw head with the stifle aligned in a normal position.
Villaverde et al. (2005)) used a similar technique in their
experiments. Stifle-luxated pigeons were treated with a
cortical screw and a 3-0 nylon band through the fibular
crest while a second group was treated with an extra nylon
suture to the space between fibula and tibiotarsus ventral
to the fibular head. Another stifle reduction technique
using solely a 20-gauge cerclage wire was tested (Holz
1992). The wire was passed lateromedially, through predrilled holes in distal femur and proximal tibiotarsus, and
knotted laterally to act as collateral band, preventing the
mediolateral movement of the stifle. To further tighten the
fixation, the muscles were sutured with 4-0 Dexon. Additionally, a Thomas splint was applied for 15 days. In

another study, the tendinous origin of the lateral head of

the gastrocnemius muscle was tightened to the tibial
tuberosity using a non-absorbable suture with good results
(Fukui et al. 2005). Two stifle luxations one in a trumpeter
hornbill (Bycanistes bucinator) and one in an African grey
parrot (Psittacus erithacus) were reduced with a nylon
suture drilled through the tibial tuberosity and anchored
around femoral origin the lateral collateral ligament or
craniocaudally through a hole in the lateral femoral condyle (Chinnadurai et al. 2009). Intertarsal joint luxations
were also successfully reduced using cerclage wire, Teflon, or polyester suture in figure of eight pattern passed
through drilled holes in distal tibiotarsus and proximal tarsometatarsus (Roush 1980; Harcourt-Brown 1996; Demirkan & Kilic 2003; Zsivanovits 2011)
Bone plate: The only case of luxation repair with bone
plating has been reported by Guzman MigallonSanchez et al. (2007) in a bald eagle (Haliaeetus leucocephalus). A caudoventral coracoid luxation in a bald
eagle, affecting both clavicular and sternal articulations,
was successfully repaired using a combination of a fourhole, 1.5 mm T-plate, a six-hole, 2.0-mm dynamic compression plate, and two cerclage wires. The distal coracoidsternum luxation was reduced with the two plates
placed side by side, whilst the claviculo-coracoid luxation
reduced with the two cerclage wires in a simple interrupted pattern.
3.3.3. External skeletal fixation
The ESF is a well-established method for fracture management in small animal and avian surgery (Bennett &
Kuzma 1992; Bennett & Altman 1997; Kraus et al. 2003;
Hatt 2008). The method is characterized by two fundamental components; the fixation pins and the connecting
bar (fixation frame), regardless of the applied device or
system (Kraus et al. 2003).
3.3.3.1.

Biphasic fixators in a transarticular Type I

scheme. Biphasic fixators consist of Kirschner
wires of various sizes, Ellis pins or Steinmann pins, and a
connecting bar made by acrylic polymer. Polymethylmethacrylate (PMM), dental acrylics, hexcelite or epoxy
glue inserted in a Penrose drain can be used (Bennett &
Kuzma 1992). Such a fixator formed by Kirschner wires
and epoxy as connecting bar was proposed for a stifle
luxation in psittacines (Clipsham 1991b). Preferably,
three pins should be fixed in each bone, with the femoral
pins placed first. Post-operatively bruising may appear for
three to five days, as well as after pin removal. According
to the author, the healing time ranged within 21 days in
smaller species (e.g. parakeets, cockatiels) to 40 days in
larger ones (e.g. cockatoos, macaws), with mild tolerance
of the device. Rosenthal et al. (1994) used fifteen 0.8-mm
Kirschner wires, linked to a PMA bar, to stabilize in functional angle a stifle luxation in a Moluccan cockatoo
(Cacatua molucccensis) and a Barn Owl (Tyto alba). Stifle arthodesis with a Type I ESF has been similarly
achieved (Donato 2000; Villaverde et al. 2005) while a

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combination of Type I (femur) and Type II (tibiotarsus)

was used to reduce a craniolateral luxation of femur in an
Amazon parrot (Amazona aestiva). After 60 days, a
complete osseous union of the stifle could be detected
(Alievi et al. 2001). Additionally, arthrodesis of a
metacarpophalangeal joint luxation in two raptors, with
full functional flight restoration and return to the wild,
was achieved using a transarticular ESF (Type I) consisting of four positive-profile threaded stainless steel pins
(van Wettere & Redig 2004). Finally, an elbow luxation
repair in two raptors with Type I ESF resulted in 95%
function restoration (Martin et al. 1993b). The technique,
with the two acrylic connecting bars parallel to each other
was modified by Forbes in 1995 (Coles 1997) in a way
that the K-wires are already fixed to the bars before inserting the bone in order to save time. Moreover, a slight flexure and simultaneous rotation of ulna and radius may help
in repositioning.
3.3.3.2. Triangular transarticular type I fixator. Triangular transarticular Type I fixator has been proposed to
repair closed elbow dislocations with minimal soft-tissue injuries in five raptors (Ackermann & Redig 1997).
The fixator was produced by inserting two semi-threaded
pins into the dorsal humerus and two into the dorsal ulna.
Two plastic tubes were placed to connect the humeral and
ulnar pins separately. To provide additional stability, two
0.062-mm stainless steel pins, one at the apex and the
other at the base, were bent to fit in the tubing, connecting
the pins with Technovit (Laboratories, Inc, Loveland, CO,
USA) in a triangular mode. The post-release survival of
the birds is not known due to lack of long-term monitoring. A similar technique was proposed for stifle luxation
formed by four positive profile pins connected with one
acrylic-filled latex (Olsen et al. 2000). A second fixator
bar would connect the proximal femoral pin with the distal tibiotarsal pin forming a triangle.
3.3.3.3. Type II fixator. A Type II fixator was tested to
reduce a caudodorsal elbow luxation in a prairie falcon
(Falco mexicanus). The two 0.062-inch K-pins were
linked to two methylmethacrylate bars (Martin et al.
1993b).
3.3.3.4. Hinged linear external transarticular fixator.
Recently, chronic intertarsal joint luxations with subsequent tibiotarsal rotation and tendon displacement, as well
as distal humeral fractures in pigeons have been corrected
with a prototype of HLTEF (Ferraz & Ferrigno 2008;
Ferraz et al. 2010). The prototype fixator was constructed
of three-hinged titanium bars (with 6 mm diameter and
lengths of 3.5, 3.0, and 2.5 cm). The joints were allowed a
free uniplanar range-of-motion, but could also be fixed
with a 3-mm screw. The total weight of the fixator was
9.5 g and together with the fixation pins approximately
reached the 14 g. Finally, a combination of Fixateur
Externe du Service de Sant
e des Arm
ees (FESSA) HLTEF
and lateral collateral ligament replacement was experimentally used to reduce experimental stifle luxations in
pigeons (Azmanis 2011).

3.3.3.5. Fixation of coxofemoral luxations. Two newer

open techniques than the transfixation pinning previously
reported (Roush 1980), have been described to reduce
coxofemoral luxations in birds: excision arthroplasty
with femoral head resection (Campbell 1987; MacCoy
1989) and femoral head stabilization with two polypropylene sutures (Martin et al. 1994; Risi et al. 2005).
Femoral head and neck excision arthroplasty has also
been proposed for management of simple femoral neck
fractures (Moisuk-Burgdorf et al. 2011). An aggressive
approach is proposed in order to avoid secondary complications. The surgical approach may be caudolateral
(MacCoy 1989; Martin et al. 1994) or dorsal (Campbell
1987). The femoral head exposure is similar to the one
used in mammals; after aseptic preparation, a linear incision from a point dorsal to the antitrochanter to proximally two-thirds the distance to the stifle is made. The
iliotibialis and iliofibularis muscles are identified and
retracted. The femoral neck is transected with a bone cutter and any rough edges are smoothened with a rasp. An
iliofibularis muscle stripe is used to form a muscle sling,
encircling the femoral shaft and attached to the main muscular belly (MacCoy 1989). After femoral head reduction,
two 4-0 polypropylene sutures are passed through the
major trochanter and then through the ilium on each side
of the acetabulum. The ends are tied together. Afterwards,
a Spica-type splint is applied using a 20-gauge wire dorsal
to the pelvis along the opposite leg (Martin et al. 1994).
According to the authors this technique is safer and provides post-operatively full range of motion of the hip
joint.
4. Conclusion
Avian luxations occur mainly in synovial joints but not
exclusively. Each luxation follows a unique pattern,
attributed to the cause and anatomy. Diagnosis is usually
based upon clinical signs and radiographic findings. Prognosis may vary mostly from guarded to poor, unless the
luxation is uncomplicated, diagnosed early, and treated
promptly. In avian medicine, treatment options of luxations typically rely on case reports or case series. Future
studies have to focus on experimental comparative studies
of the different treatment methods, the use of new tools
for more accurate diagnosis and the role of post-operative
physical therapy modalities to allow evidence-based recommendations for each luxation to be made.
Acknowledgements
The authors would like to thank Prof. Marcus Clauss for the critical reading of the final manuscript.

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