The treatment recommended by us for open joints, in which we wish to prevent ankylosis, is, first, to shave all hair from the area surrounding the wound, following with a thorough cleansing of the skin and disinfection of the wound, and then to inject a twenty per cent Lugol's solution in glycerin into the wound. This should be repeated two or three times a day, each time enough of the solution being injected to fill the joint capsule, thereby securing the flushing effect. As this solution does not cause irritation to the tissue and yet is a strong antiseptic, it serves to shorten the period of congestion and inflammation and to overcome the infection without causing a destruction of the secreting membrane until the external wound has had time to heal. The injection of this solution seems to retard the excessive secretion of synovia. The larger the joint capsule and the smaller the external wound, the longer our antiseptic will remain in contact with the inflamed tissues as the glycerin, being thick, does not flow through a small opening.
After-care.—Following the initial cleansing and treatment of open joint, subsequent dressing is necessary as frequently as conditions demand. If the parts are badly infected and profuse discharge of pus exists a daily change of dressings is necessary. In the average instance, however, semi-weekly treatments are sufficient. And in many instances where one is obliged to travel a considerable distance to handle the affected animal one weekly dressing of the wound will suffice after the second treatment.
The same general plan of treatment concerning the subject's comfort that has been previously mentioned in arthritis, is carried out here. A further and detailed consideration of the subject of handling of open joints follows.[20]
* * * Such wounds may be classified in two general groups as follows: First, wounds in which the trauma has exposed the articulation to view, and second, those the result of punctures, in which the external wound is small and free drainage is lacking.
Wounds in which the articulation is exposed to view have drainage either all ready provided for, or it is established without hesitancy surgically. With free drainage thus established there is little or no chance for the adjacent tissues to become infiltrated with infected wound discharge. This prevents an extension of the injury and the establishment of a good field for the growth of anaerobic bacteria.
Open joints caused by punctures, unless the puncture is aseptic, produce a swelling which is more painful than is the open wound which exposes the joint to view. Especially is this true if the puncture is of small diameter, allowing the tissues to partially close the opening immediately after the wound has been made. Where drainage is lacking there follows an exudation which congests the tissues surrounding the injury and all factors favoring germ growth are present. It is perhaps advisable to establish good drainage in such cases as soon as a diagnosis is made.
It is not always an easy matter to recognize an open-joint, when first made, but twelve to twenty-four hours later there is no cause for doubt. The condition is then a very painful one; lameness is excessive; there is rise in temperature; acceleration of the pulse and manipulation or palpation of the region affected, occasions great pain.
The treatment of open joints must be varied to suit the disposition of the animal, the nature and location of the injury, the length of time intervening between the infliction of the wound and the first attention given, and the surroundings in which the patient is kept.
In each and every case in which there exists an open wound the surface surrounding the wound is cleansed thoroughly, the hair is shaved if possible, and the margin of the wound is curretted and cleansed thoroughly with antiseptic solutions.
If there is evidence that the articulation contains infective material, it is washed out with copious quantities of peroxide of hydrogen—usually as much as six or eight ounces. This is followed by injection of an ounce or two of tincture of iodin. Even though the joint appears to be clean some tincture of iodin is used, as it checks the secretion of synovia and is, in every way, beneficial. Care is taken to apply the iodin also to the surface immediately surrounding the wound. The entire wound is then covered with a dusting powder composed of zinc oxide, boric acid, exsiccated alum, phenol and camphor.
This powder is used in abundance and the wound is then covered with a heavy layer of absorbent cotton and well bandaged. This bandage is not disturbed for at least three days and may be left in place for a week. In cases in which it is necessary to keep the dressing on for a week, or in cases where the patient is, through necessity, kept in quarters that are wet or unclean, the first bandage is covered with a layer of oakum which has been saturated in oil of tar and this in turn is held in place by means of several layers of bandages. The bandages are also saturated with oil of tar.
In from one to two months wounds so treated, unless they are foot-wounds, will be ready to dress without being bandaged. It is ordinarily unnecessary to dress foot-wounds oftener than every second week after the discharge of synovia has ceased. When the wound has filled with granulation, a protective dressing is applied which is rendered water proof by the use of bandages covered with oil of tar. The patient can now be turned out for a month or six weeks without disturbing the dressing. After the removal of the bandages, the only treatment necessary is an occasional application of some mildly antiseptic ointment.
Except in nail pricks of the foot, occasioned by punctures, a five per cent tincture of iodin is injected into open joints, if the wound remains sufficiently open, and this treatment is continued so long as there is a discharge of synovia. Surgical drainage is established if it is considered practicable and the remainder of the treatment is about the same as for wounds which are open.
Open joints occur in horses at pasture and are sometimes not discovered until several days or a week after the injury, and in some instances the wounds are filled with maggots. The only difference in the treatment of these cases is that more time and care is taken in cleansing the wound, more curetting is necessary, and after cleansing the wound with peroxide of hydrogen, the joint is thoroughly washed out with equal parts of tincture of iodin and chloroform. This is followed by the injection of a quantity of seventy-five percent alcohol and the wound is dressed and bandaged as already described. At each subsequent dressing of infected wounds so treated less suppuration is noticed and the synovial discharge usually ceases in from one to two months.
About ninety percent of all cases of open joint make complete recoveries, about four per cent partially recover and six per cent are fatal. Among the fatal cases are the open joints with complications as severed tendons, those occasioned by calk wounds in horses that are stabled, and nail punctures of the feet. The following report of twelve favorable cases is taken from a record of sixty-two cases. The favorable ones are reported, chiefly because there are now enough reports on record of such cases which have terminated fatally.
Case 1.—A gray gelding used as a saddle pony received a horizontal wire cut laying completely bare the scapulohumeral articulation. The margins of the wound were cleansed as heretofore described, a drainage was provided surgically, tincture of iodin was injected and the wound was covered with equal parts of boric acid and exsiccated alum. The horse was kept tied and a diluted tincture of iodin was injected into the wound once daily and the powder applied often enough to keep the wound covered. The case made a complete recovery and the pony was again in service within sixty days.
Case 2.—A twelve-hundred-pound bay mare with an open carpal joint. The wound was an open one about two and one-half inches in length, and made transversely and when the member was flexed the articular surface of the carpal bones were presented to view. An ounce of tincture of iodin was injected into this joint after having cleansed the margin of the wound and the mare was cross-tied in a single stall to keep her from lying down. The owner was instructed to keep the outside of the wound powdered with air slaked lime and a very unfavorable prognosis was given.
I heard nothing further from this case until fifty-nine days from the date of the injury, when I met the owner driving this mare to a buggy. The wound had healed by first intention and at that time so little cicatrix remained that it was difficult to find it.
Case 3.—A brown mare with an open fetlock joint due to a spike-nail puncture. Lameness was excessive, and joint greatly swollen. Tincture of iodin was injected into the wound and towels dipped in hot antiseptic solutions were applied for several hours daily until the acute stage had passed. Later the mare was turned out to pasture and a vesicant was applied once or twice a month until recovery was complete which was in about six months.
Case 4.—A four-year-old bay mare having a wire-cut which opened the tarsus joint was treated as heretofore described. The wound was kept bandaged for about two weeks and later it was dressed without being bandaged. In ninety days she had completely recovered.
Case 5.—A twelve-year-old mare with an open fetlock joint due to a puncture wound. The margins of the wound were cleansed and the external wound enlarged to facilitate drainage. Tincture of iodin was injected; the wound was bandaged and dressed for a month in the manner heretofore described, when all discharge had stopped. A vesicant was applied; the mare was put to pasture and within sixty days from the date of the injury she was being driven on short trips.
Case 6.—A two-year-old brown gelding with a wire-cut on the left front foot. The wound extended down through the sole and opened the navicular joint. This colt was very wild and it was necessary to tie it down each time the wound was dressed. The wound was dressed weekly for a month and less frequently thereafter. It was handled eight times; the last dressing was left in place until worn out. Six months later the colt was practically well, a very little lameness being shown when walking on frozen ground.
Case 7.—A seven-year-old saddle-horse weighing eleven hundred and fifty pounds received a wound of the tarsus, laying bare the articular surfaces of a part of the joint. It was impossible to keep this wound bandaged because of the restless disposition of the subject. Injections of a dilute tincture of iodin were employed every second or third day for a month and the wound was kept covered with the antiseptic dusting powder referred to heretofore. In five months complete recovery had taken place, with the exception of a stubborn skin disturbance which was successfully treated six months after the wound was inflicted. The horse is still in use and is absolutely free from lameness.
Case 8.—A two-year-old brown gelding with a wire-wound opening the scapulohumeral joint. This wound was large enough to expose to view the articular portion of the humerus. The same treatment as that given case No. one was instituted and in ninety days the colt was practically well.
Case 9.—A three-year-old bay filly was found at pasture with one fore foot badly injured. The owner intended to destroy her, but a neighbor prevailed upon him to have her treated. Apparently the wound was of about a week's standing and in a very bad condition, filled with maggots and dirt. Both the navicular and coronary articulations were open. This wound was cleansed in the usual manner and the owner cared for the case the balance of the time because the distance from my office was too great to give her personal attention. She made an almost complete recovery in five months.
Case 10.—At two-year-old mule with an open navicular joint due to a barbed wire wound. Usual care was given this case and in five months recovery was complete and little scar is to be seen. This case received seven treatments.
Case 11.—An eighteen-months-old colt at pasture was found down and unable to rise without help. In addition to several wounds of lesser importance there was a large wound on the inner side of the elbow, the joint was open and the entire leg was greatly swollen and in a state of acute infectious inflammation. The colt could not walk, its temperature was 105°, pulse was rapid and respiration was a little hurried. After advising the owner to put the poor animal out of its misery I left the place. Four days later the owner came to my office and asked if he could borrow some old shears to "trim off some loose hide from that colt." He left the colt in the pasture and all the care it received was the regular application of a proprietary dusting powder. It made a complete recovery.
Case 12.—A family mare, heavy in foal, received a vertical wound of the fetlock joint inflicted by a disc-harrow. The cul-de-sac of the ligament of this joint was opened freely. The wound was dressed in the usual manner and again three days later when no suppuration had taken place. Four days later the patient gave birth to a colt and suckled it right along through her convalescence. This wound healed by first intention and seventy-nine days from the date of the injury the mare was driven to town, two and one-half miles distant, and showed but little lameness.
This term is applied to exostoses involving the first and second phalanges (suffraginis and corona), regardless of their size, extent or location. It is a misnomer, in a sense, and the veterinarian is frequently obliged to spend considerable time with his clients in order to convince them that a spherodial exostosis of the proximal phalanx, in certain cases, is in reality "ringbone," even though there exists no exostosis which completely encircles the affected bone.
Etiology and Occurrence.—Exostosis of the first and second phalanges is usually due to some form of injury, whether it be a contusion, a lacerated wound which damages the periosteum, or periostititis and osteitis incited by concussions of locomotion, or ligamentous strain. Practically the only exception is in the rachitic form of ringbone which affects young animals.
There are predisposing causes that merit consideration, chief among which is the normal conformation of the coronet joint. This proclivity is constant; the normal interphalangeal articulation is an incomplete ginglymoid joint and while its dorso-volar diameter is great, this in no wise compensates for its disproportionately narrow transverse diameter. The pivotal strain which is sometimes thrown upon this articulation when an animal turns on one foot, as well as the tension which is put on the collateral ligaments when the inner or the outer quarter of the foot rests in a depression of the road surface, tends to detach the insertion of these ligaments or to cause fibrillary fractures of their substance.
Short, upright, pasterns receive greater concussion during fast travel on hard roads than do the longer more sloping and well formed extremities. Those who are advocates of the theory that this type of osteitis with its complications has its origin in the articular portion of the joint, claim that the upright pastern constitutes an important tendency toward ringbone. Howbeit, ringbone is an active, serious and frequent cause of lameness and it affects animals of all ages and occurs under various conditions. Horses having good conformation and kept at work wherein no great amount of strain is put upon these parts, are occasionally victims of this affection.
Classification.—The arrangement employed by Moller[21] is intensely practical and logical. He considers ringbone as articular, periarticular, rachitic and traumatic. A mode of classification that is common and in a practical way, good, is, high and low ringbone. When prognosis is considered, for instance, it is very convenient to state that the chances for recovery are much better in high ringbone than in low ringbone. The classification of Möller will be followed here.
Fig. 17—Phalangeal exostoses.
Fig. 17—Phalangeal exostoses.
Symptomatology.—In all forms of incipient ringbone except rachitic, the first manifestation of its existence, or of injury to the ligaments in the region of the pastern joint which causes periostitis, or affections of the articular portions of the proximal inter-phalangeal joint, is lameness. Lameness which typifies ringbone is of the supporting-leg variety and by compelling the subject to step from side to side, marked flinching is observed, especially in periarticular ringbone; causing the affected animal to turn abruptly on the diseased member, using it as a pivot, likewise accentuates the manifestation. In fact, many subjects that exhibit no evidence of locomotory impediment while walking or trotting in a straight line on a smooth road surface, will manifest the characteristic form of lameness from ringbone when the aforementioned side to side movement is performed.
When the manner in which pain is occasioned is considered, it will be understood why lameness is intermittent in the early stages of this affection and may even be unnoticed by the driver. An animal may travel on a smooth road without giving evidence of any inconvenience, but as soon as a rough and irregular pavement or road surface is reached, will limp. As the subject is driven farther on level streets the lameness may disappear. This intermittent type of lameness may continue until there is developed a large exostosis, or until articular involvement causes so much distress during locomotion that lameness is constant. On the other hand, resolution may occur during the stage of periosteal inflammation, or, an exostosis forms which causes no interference with function.
Fig. 18—Rarefying osteitis in chronic ringbone and ossification of lateral cartilages.
Fig. 18—Rarefying osteitis in chronic ringbone and
ossification of lateral cartilages.
Before there is evidence of an exostosis, diagnosis of ringbone is not easy, for it is then a problem of detecting the presence of a ligamentous sprain, periostitis, or osteitis. The diagnostician should take note of local manifestations of hypersensitiveness, or heat if such exist, and, in addition, other conditions must be excluded before definite conclusions are possible.
In articular ringbone as soon as there is developed an exostosis, it occupies a position on the dorsal (anterior) part of the articulation and extends around the sides of the joint.
Periarticular ringbone is characterized by exostoses which are situated on the sides of the phalanges and not extending around to the anterior part of the joint. This type of ringbone as well as the articular may occur "high" or "low."
Fig. 19—Phalangeal exostoses in chronic ringbone. Museum specimen of the Kansas City Veterinary College.
Fig. 19—Phalangeal exostoses in chronic ringbone. Museum specimen of the Kansas City Veterinary College.
With the traumatic form of ringbone, all consequences, as to the size and form the exostosis is to assume, depend upon the nature and extent of the injury.
Rachitic ringbone is frequently observed in some sections of the country and does not ordinarily cause much if any lameness. It is a disease of colts and may affect one or all of the phalanges at the same time. As the subject advances in age there is more or less diminution in the size of the enlargements.
Treatment.—Rest is essential in the treatment of ringbone. If diagnosed during its incipiency, remedial measures such as are usually employed to treat sprains, are indicated and later the parts should be blistered. When an exostosis has developed puncture firing is the remedy par excellence. Not that this method of treatment is infallible, for to any thinking one who takes into consideration the pathological anatomy of this condition, it is evident that no manner of treatment is beneficial in some cases. If the exostosis is so situated that it does not mechanically interfere with function, and is not so large that it may inhibit flexion and extension, and where the articular portions of the joint are not eroded, good results attend the use of the actual cautery.
In firing, after having anesthetized the extremity, and prepared the surgical area, the cautery is deeply inserted in numerous places, taking care, however, not to open the joint. The parts are immediately covered with aseptic absorbent cotton and this dressing is left in position for forty-eight hours and if perchance there is evidence of synovial discharge, the parts are again aseptically dressed in order to prevent infection of the articulation. If, as is the case usually, no perforation of the joint capsule exists, the openings made by the cautery have been closed by the coagulation of serum and there is then little chance of infection causing trouble, even though the member is left unbandaged.
In several instances, the author has treated ringbone by this method where the periarticular type existed and lameness was marked, and in three weeks the subjects were in service and not lame—this, in one instance in a valuable polo pony where the subject continued in service for more than a year without any evidence of recurrence of the lameness. The production of a deep-seated and acute inflammation with the actual cautery is preferable to any sort of counter-irritation which may be produced by vesicants.
There is no occasion for any difference in the treatment of either of the first three classes of ringbone, but in the rachitic type where treatment is given, the application of a vesicant is all that is required. In most instances treatment is not necessary.
The affected animals require a month to three months' time for recovery to take place in the average favorable cases of ringbone.
Median neurectomy is of service in many instances where lameness is not completely relieved by the use of the actual cautery and no bad results attend the performance of this operation even though no benefit is derived thereby. Plantar neurectomy is contraindicated in all cases where there exists much lameness. If lameness is due to acute inflammation bad results such as sloughing and loss of the hoof may follow; and if large exostoses mechanically interfere with function of the joint, or where articular erosions exist, no possible good can come from neurectomy. Careful discrimination should be employed in selecting cases for neurectomy for this operation; otherwise, it is very likely to prove disappointing.
This condition does not differ from a like affection involving other tendons except that the function of these tendons is such that large synovial sheaths are necessary, and when synovitis exists, the condition then becomes more serious.
Infectious synovitis involving these tendons in the fetlock region is of more frequent occurrence than a like affection of carpal or tarsal sheaths. With the exception of the extent of the involvement and distress occasioned thereby, synovitis the result of open tendon sheaths, is similar wherever it occurs.
Etiology.—The same conditions which are responsible for open fetlock joint and other wounds of the pastern region, cause open tendon sheaths of the flexor tendons.
Symptomatology.—Because of the size and extent of this sheath and the different manner in which it is opened, there is manifested dissimilar symptoms in different cases. A nail puncture which perforates the sheath in the pastern region and at the same time produces an infectious synovitis, will cause a markedly different manifestation than will a wound which freely opens the sheath above the fetlock. In the first instance, the condition is much more painful; swelling is intense in some cases; and if the subject does not possess sufficient resistance so that spontaneous resolution promptly occurs, surgical evacuation of pus is usually necessary. When these tendon sheaths are opened, there follows a reaction which is quite analogous to that which exists in arthritic synovitis, but instead of ankylosis, adhesions with thecal obliteration occur. Rarely there result cartilaginous and osseous formations.
The constitutional disturbances which characterize this condition vary with the degree of distress occasioned. As the infection is virulent and causes serious destruction of the affected parts, so does evidence of malaise and finally distress appear. Detailed discussions of symptomatology in similar conditions have heretofore been given, and further repetition is unnecessary.
Treatment.—The same general plan of treatment which is employed for handling open joint is put in practice in these cases. Following the preoperative cleansing of the external wound and adjacent surfaces, where liberal drainage exists, tincture of iodin is injected into the sheath, the parts covered with a suitable dressing powder, and the entire member is carefully dressed with cotton and bandages.
Subsequent treatment is the same as has been outlined in the discussion of open fetlock joint on page 112. The same general plan of after-care is necessary. Recovery, however, does not require so much time ordinarily, yet punctures of the sheath occasioned by nails or other small implements make for long drawn out cases of infective synovitis.
Etiology and Occurrence.—The manner of construction of the fetlock joint is such that disarticulation without irreparable injury resulting, is practically impossible. Logically, this joint in the fore legs (not so in the pelvic limbs) should disarticulate in such manner that either all of the inhibitory apparatus (flexor tendons and suspensory ligament) must rupture or a lateral luxation is necessary. Lateral disarticulation must necessarily sever the attachment of one of the common collateral ligaments. Because of the width (transverse diameter) of the articulating surfaces of this joint, lateral luxation requires a great strain; and a force that is sufficient to occasion this trauma usually causes serious additional injury. Therefore, the condition is considered one wherein prognosis is always unfavorable in so far as practical methods of treatment are concerned.
Mr. A. Barbier[22] reports a case of bilateral luxation of the fetlock joints of the hind legs in a horse. This was done in jumping, and the extensor tendon of each leg was ruptured and the anterior portion of the metatarsus was protruding through the skin. Profuse hemorrhage had taken place due to tearing of the blood vessels.
Symptomatology.—Entire luxation of this joint when present is so evident that one cannot fail to recognize the condition. Complete disarrangement of normal relation occurs and there is either a breaking down of the inhibitory apparatus, or if a lateral disarticulation exists, the normally straight line formed by the bones of the front leg, as viewed from the front or rear, is broken at the fetlock.
Often fracture of bones are concomitant and then, of course, mobility is increased and not decreased as is the case in uncomplicated luxation.
Such violence occurs at times, when this joint is disarticulated, that the joint capsule is also completely ruptured and the articular portion of the bones is exposed to view.
Treatment.—The condition being practically a hopeless one, destruction of the subject is the thing which should be promptly done. In valuable breeding animals, owners may prefer that treatment be attempted when a lateral luxation and detachment of but one common ligament have permitted luxation without complete disarticulation and rupture of the joint capsule. In such cases, by immobilizing the affected parts as in fracture, and confining the subject in a sling for about sixty days, partial recovery may occur in some instances.
Experience has shown that where luxation with detachment of a collateral ligament occurs, recovery is slow and incomplete—there always results considerable exostosis at the site of injury.
Etiology and Occurrence.—Inflammation of the proximal sesamoid bones is caused by any kind of irritation which may involve this part of the inhibitory apparatus. Positioned as they are, between the bifurcations of the suspensory ligament and the pastern joint, they serve as fulcra and effectively assist in minimizing concussion which is received by the suspensory ligament. The flexor tendons also, in contracting, exert strain upon the inter-sesamoidean ligament, which has a similar effect upon the sesamoid bones as that which is produced by the suspensory ligament.
The condition occurs quite frequently, and because of the important function performed by these bones, active inflammation of the sesamoids constitutes a serious affection. Because of the fact that these bones have proportionately large articular surfaces, when they are inflamed to the extent that degenerative changes affect the articular cartilage, complete recovery seldom results.
The same pathological changes occur here that are to be seen in any case of arthritis. No special pathological condition characterizes sesamoiditis but this condition causes incurable lameness when the sesamoid bones are much inflamed.
Symptomatology.—In acute inflammation, there exist all the symptoms which portray any arthritic inflammation of like character. The parts are readily palpable and are found to be hot, supersensitive, and more or less infiltration of the tissues contiguous to the joint causes swelling. There is volar flexion of the phalanges when the subject is at rest. Lameness is intense; in some acute inflammatory disturbances the subject is unable to bear weight on the affected member.
In chronic sesamoiditis, constant lameness is the one salient feature which marks the condition. While it is possible for one sesamoid bone to become involved without its fellow being affected, this is not usual. Considerable organization of tissue surrounding the joint is present and no particular evidence of supersensitiveness exists. However, supporting weight brings sufficient pressure to bear upon the inflamed and more or less eroded bones so that pain is occasioned and lameness results.
Treatment.—During acute inflammation, absolute quiet is, of course, of first consideration. Cold packs are to be kept in contact with the parts until acute inflammatory symptoms subside. The fetlock region is then enveloped with a poultice or an iodin and glycerin combination (iodin one part to seven parts of glycerin) is applied and a dressing of cotton is kept in contact with the inflamed region. Following this, a vesicant is employed and the subject is allowed a month's rest.
In sub-acute cases, the entire region surrounding the pastern is blistered or the actual cautery is used. Line-firing is preferable. The subject is given a month or six weeks rest and one may be guided by the presence or absence of lameness as to whether improvement or recovery is taking place.
Old chronic cases, and particularly those where there are considerable induration and fibrous organization of tissue surrounding the joint, are not to be benefited by treatment.
The chief consideration in handling sesamoiditis is checking inflammation as early as possible and preventing, if this can be done, the erosion of articular surfaces. If destruction of any part of the articular surfaces can be prevented and the patient allowed ample time for complete resolution of the affected parts to occur, permanent relief is possible.
Etiology and Occurrence.—Fracture of the proximal sesamoid bones is caused by violent strain when there exists fragilitas osseum, or by contusions. The author treated a case where fracture of one sesamoid was occasioned by a horse receiving a puncture wound wherein the sharp end of a steel bar was protruding from the ground where it was firmly embedded. The subject in this case was injured while being driven along a country road. Frost[23] reports simultaneous fracture of all of the proximal sesamoids occurring in a sixteen-year-old pony. The condition is of rather common occurrence in some countries because of the fragile condition of horses' bones.
Symptomatology.—If the parts can be examined before extravasation of blood and swelling mask the condition, crepitation may be detected. In other instances, it is possible to note a displacement of parts of the sesamoid bones—this in horizontal fracture. There occurs more or less descent of the fetlock which must not be attributed to rupture of the superficial flexor tendon (perforatus). By outlining the course of this tendon with the fingers, when it is passively tensed sufficiently to follow its course, one may exclude rupture of the superficial flexor. Finding the suspensory ligament intact from its origin to the sesamoid attachments, one may also eliminate rupture of this structure as a cause of the trouble. Needless to say, marked lameness and swelling of the fetlock soon take place. The condition is painful, and ordinarily, recovery is impossible.
Treatment.—Where treatment is attempted, immobilization as in luxation is in order. The patient's comfort is sought, and if the fractured parts can be kept in close proximity, their union may occur in time. However, chances for partial recovery (which is the best to be hoped for) are so remote that early destruction of the subject is the humane and economical thing to do.
Where treatment is instituted, it is found that there is required a long time for union of the fractured bones to occur (where union does take place) and the cost of treatment together with the uncertainty of even partial recovery, makes for an unfavorable outcome. When the best possible results succeed treatment, a large callosity is formed and movement of the pastern joint is restricted. Lameness, though not intense, in the case referred to, where one bone was broken, was permanent and the subject was out of service for nearly a year.
Anatomy.—The ligaments here involved are the four volar ligaments described by Sisson[24] as follows: "The volar ligaments (Ligg Volaria) consist of a central pair and a lateral and medial bands which are attached below to the posterior margin of the proximal end of the second phalanx and its complementary fibro-cartilage. The lateral and medial ligaments are attached above to the middle of the borders of the first phalanx, the central pair lower down and on the margin of the triangular rough area."
This portion of the inhibitory apparatus is described by Strangeways' Anatomy as two posterior ligaments which run each from three points on the sides of the os suffraginis to a piece of fibro cartilage, described as the glenoid cartilage, and attached to the postero-superior edge of the os coronae; between them is the insertion of the inferior sesamoidean ligament.
Etiology and Occurrence.—Everything tending to increase strain upon these ligaments is contributory to possible fibrillary fracture of these structures. Excessive leverage as furnished by long toes, long toe-calks and low heels increases the normal tension on the posterior ligaments of the pastern joint. Faulty conformation, which throws an abnormal strain on these ligaments, is a predisposing cause of inflammation of these structures. Hard pulling upon slippery and rough or frozen roads is a common exciting cause of this injury. The condition is of comparatively frequent occurrence and is seen affecting draft horses frequently, in the hind legs.
Symptomatology.—Lameness is the first manifestation of this affection and weight bearing is painful in direct proportion to the extent of injury present. Volar flexion of the phalanges relieves tension on the parts; therefore, this position is assumed while the subject is at rest. When considerable tissue has been ruptured, and the condition is very painful, the foot is held off the ground as in all painful affections of the extremity.
By palpation evidence of pain is discernible, though very little swelling occurs. Pain is increased by manual tension of the parts which is done by grasping the toe of the foot and exerting traction on the flexor apparatus. Care must be taken in executing such manipulations, and it is only by comparison of the affected member with the sound one and noting the difference in the manifestations of discomfort that we may arrive at the proper conclusion.
Some hyperthermia is to be recognized in acute inflammation, by comparing the extremities. In the fore legs, navicular disease is differentiated by noting absence of contraction at the heel. By use of the hoof testers one may recognize evidence of inflammation of the navicular apparatus. In inflammation of the posterior ligaments of the pastern joint, there is also absence of the characteristic stumbling which is seen in navicular disease.
Treatment.—Rest is the first requisite, and in addition every mechanical means possible to change the center of gravity in the phalangeal region, is to be employed. This is best accomplished by shortening the toe and paring the sole at the toe as much as conditions will permit. The heel is raised by means of a shoe with moderately high heel calks.
The iodin-glycerin combination heretofore mentioned may be applied and the parts covered with cotton and bandage. Subjects require from three weeks to several months' rest and must be returned to work carefully, lest the incompletely regenerated tissues suffer injury.
Regeneration of tissue in such cases, as has been pointed out, is slow and sufficient time for complete recovery must be allowed or relapses will occur.
Etiology and Occurrence.—Fractures of the first phalanx (suffraginis) occur with respect to frequency, second to pelvic fractures. Often, almost insignificant injuries cause phalangeal fractures. On city streets, horses shod with shoes having long calks get caught in frogs of street railways or by slipping on rails, and phalangeal bones are often broken. The author observed a case of comminuted fracture of both the first and second phalanges (suffraginis and corona) in a polo pony caused by making a sudden turn while in action in a contest on the turf.
Symptomatology.—Fracture of the phalanges is nearly always signalized by lameness, and this is marked during the period of weight bearing. Lameness is usually intense and where the pathognomonic symptom (crepitation) is not recognized, the intensity of the claudication, when other causes are absent, is indicative of fracture. The subject does not bear weight upon the affected member and where pain is intense, the foot is held in an elevated position and swung back and forth. In hind legs the member is often flexed in abduction and held in this position for several minutes, being rested on the ground only during short intervals. When compelled to walk, if pain is excruciating, the animal hops with the sound leg, no weight being supported by the fractured member.
When an examination of the subject is possible before the extremity is swollen, crepitation is usually found without great difficulty, except in a subperiosteal break or in some cases of vertical or oblique fracture. Great care is necessary in handling the injured extremity in these cases, and particularly in nervous subjects or in excited animals that have been recently injured in runaways, is it necessary to be gentle in manipulating the extremity, if definite deductions are to be made. As has been mentioned in the chapter on diagnostic principles, if the condition is so painful that the subject does not relax the parts and crepitation is masked, local anesthesia is necessary. An anesthetic solution of cocain or novocain may be applied to the metacarpal or metatarsal nerves and an entirely satisfactory examination is then possible.
Passive movement of the phalanges in all directions is practised in order to produce crepitation. When rotation of the parts does not occasion crepitation, gentle flexion and extension may do so. And in many instances, considerable manipulation of the phalanges is necessary before the pathognomonic symptom is to be recognized.
In cases where crepitation is not found and lameness is pronounced, out of proportion with other possible existing causes, one may by exclusion of other causes establish a diagnosis of fracture in the course of forty-eight hours. In the meanwhile, support is given the affected member by applying an effective leather splint, so that pain may be diminished. To combat inflammation, a suitable cataplasm may be applied directly to the skin, the extremity bandaged, and the temporary immobilizing appliance may be secured over all. In this manner one may make repeated examinations of the subject, and if slings are used and every other necessary precaution taken to promote comfort for the subject, no harm will result in delaying for several days the application of permanent immobilization—bandages and splints or casts. In fact, where much swelling exists at the time one is called to treat such cases, it is advisable to delay the application of a permanent dressing or cast until inflammation has somewhat subsided.
Course and Prognosis.—Where conditions are favorable, the nature of the fracture one that will yield to treatment, the subject not aged, and facilities for giving good attention to the affected animal are ample, fractures of the first and second phalanges recover completely in from six weeks to four months. Only simple fractures are considered curable from a practical and economical point of view, excepting in foals, where compound, and even comminuted, fractures may be so handled that animals may eventually become serviceable though blemished.
Age retards the process of osseous regeneration, but in one instance at the Kansas City Veterinary College, a very aged mare suffering from a multiple fracture of the first phalanx was treated and at the end of sixty days was able to walk into an ambulance. Large exostoses had developed and the subject remained lame, but union of the broken bone took place in a surprisingly prompt and effective manner, when age of the subject and nature of the fracture are considered.
As a rule, one is loath to recommend treatment, even in a simple transverse fracture of the first phalanx, in animals ten years of age or older. The conditions which exist in any given locality that regulate the expense of caring for an animal during the period of treatment, especially influence the course to be pursued in treating fractures.
Treatment.—For permanent immobilization of the phalanges in fracture, materials which might adapt themselves to the irregular contour of the member and at the same time contribute sufficient rigidity to the parts without doing injury to the soft structures, would constitute ideal means of treatment; but no such materials have yet been devised, and opinions are various as to the most efficient and practical method to employ.
After the fetlock has been shorn of hair and the ergot trimmed, the skin is thoroughly cleansed and allowed to dry. Several thin layers of long fiber cotton are then wrapped around the extremity—enough to pad well the member—and this is retained in position with a wide bandage. Gauze bandages are preferable to heavier bandages of cotton fabric because they are somewhat more elastic and yield to the irregular contour of the parts to a better advantage. Layers of three inch gauze bandages, which are soaked with a cold starch paste are wound about the extremity. Strips of leather that are flexible and not more than an inch in width are placed in a vertical position around the leg and these are also covered with the starch and securely held in position with the bandages. In this way, one is able to provide a sufficient degree of rigidity and at the same time, where the cast is carefully applied, little if any injury is done the skin. Such a cast is not difficult to remove and is so inexpensive that it may be removed and reapplied at any time it should be thought preferable to do so. Of course, this does not constitute an effective means of support if the parts are to be frequently and thoroughly soaked with water, but animals undergoing this sort of treatment are usually kept sheltered.
The same after-care is necessary in such cases as is given in fractures of other bones. Two months after the injury has been done, the application of a blistering ointment to the entire region is of benefit.
Results.—Much depends on the nature of fractures as to the success one may attain in approximating the parts of a broken bone, and in some cases of oblique fracture for instance, complete recovery is impossible, despite the most skillful and painstaking attention given. On the other hand, cases of simple transverse fractures make perfect recoveries in some instances. All fractures are serious, and in every instance the practitioner would best be careful to impress his client with the many difficulties which usually attend the treatment of fracture in horses.
One of the most common causes of lameness in light harness and saddle horses is tendinitis, and because of the character of the structure of tendons and because of their function, an active inflammation of these parts is always serious.
Being almost inelastic and not well supplied with blood, tendinous tissue is slowly regenerated, and so much time is required for complete recovery to take place in tendinitis, that affected animals seldom fully recover before they are in service or vigorously exercising at will. As a result, complete recovery is delayed or prevented.
The extensor tendons, because of the nature of their function, are very seldom strained; they are often bruised and occasionally divided, but unlike this condition in the flexors, tendinitis of the extensors is of rare occurrence.
For a concise discussion of this subject the most practical classification is one made on a chronological basis and we may then consider tendinitis as acute and chronic.
ACUTE TENDINITIS.
Etiology and Occurrence.—Causes of tendinitis, as in almost all diseases, may be considered under the heads of predisposing and exciting. Among the predisposing causes of tendinitis may be mentioned, faulty conformation. Everything which has to do with increasing the strain upon tendons adds to the probability of their being over-taxed. Long, sloping, pastern bones; disproportionate development of parts, such as a heavy body and small, weak tendons and long hoofs, are the principal factors which usually predispose to tendinous sprains. Degenerative changes which take place in tendons following constitutional diseases such as influenza may also be classed as a predisposing cause.
Excessive strain when put upon tendons in any possible manner, such as is occasioned in running and jumping; making missteps and catching up the weight of the body with one foot, when the force thus thrown upon the supporting structure is great because of momentum gained at a rapid pace, are exciting causes of tendinitis.
Symptomatology.—In all cases of acute tendinitis there is presented a characteristic attitude by the subject. Volar flexion in a sufficient degree to relax the inflamed structures is always evident. The foot may be rested on the toe or placed slightly in advance of the one supporting weight, but the fetlock is always thrown forward. More or less swelling of the inflamed tendons is present. Where the deep flexor (perforans) is involved swelling is marked and with swelling there is present the other symptoms of inflammation—heat and supersensitiveness.
In manipulating tendons for the purpose of detecting supersensitiveness, care must be taken so that no false conclusion be drawn, because of the aversion many horses have to submitting to palpation of the tendons even when they are in a normal condition.
Supporting-leg-lameness is present and varies in degree with the intensity of the pain caused by weight bearing. In many instances, as soon as the subject has traveled a considerable distance, lameness diminishes or discontinues. As soon as the affected animal is permitted to stand long enough to "cool out" there is a return of the lameness, which is then marked.
No difficulty is encountered in making a practical diagnosis in tendinitis; that is, one may fail to readily recognize the extent of the involvement as it affects the superficial flexor tendon, for instance, but this has no practical bearing on the prognosis and treatment, when existing inflammation of the deep flexor is recognized.
The course of each tendon is readily outlined by palpation; all parts are easily manipulated; and with experience one may readily recognize the extent and degree of the inflammation.
Treatment.—In some cases of acute tendinitis, pain is intense and the application of cold packs during this stage is very beneficial in that pain is controlled and inflammation subsides. The extremity may be bandaged with a liberal quantity of absorbent cotton or with woolen material. Ice water is then poured around the bandaged member every fifteen minutes and this should be continued for about forty-eight hours. In some cases this treatment is not necessary for more than twelve hours; at the end of this length of time, pain has subsided and the acute stage of inflammation has passed or its intensity has been diminished.
Following the application of cold packs, the use of a poultice such as some of the sterile, medicated muds, is of marked benefit. The author has made use of tincture of iodin and glycerin in the proportion of one part of iodin to seven parts glycerin, with very satisfactory results. This combination is hygroscopic, anodyne and antiseptic and is easily applied. A liberal quantity is directly applied all around the affected tendons and the leg covered with a heavy layer of cotton, and this is snugly held in position with bandages. The application may be used once or twice daily, or if it is thought necessary, an attendant may pour a quantity of the iodized-glycerin around the leg and under the bandage once daily without removing the cotton and bandage. Needless to say, absolute rest is imperative.
When all evidence of acute inflammation has subsided vesication is indicated. At this stage walking exercise is beneficial and the subject may be allowed the freedom of a paddock.
Some practitioners are partial to the use of the actual cautery in these cases, but it is doubtful if it is necessary to produce such a great degree of counter-irritation in cases where the subject is suffering the first attack of tendinitis.
As has been indicated, ample time should be allowed for recovery and depending upon conditions, it takes from three weeks to six months for complete recovery to become established.
Etiology and Occurrence.—Acute inflammation of the flexor tendons may result in chronic tendinitis. Recurrent attacks in cases where insufficient time is allowed for complete recovery to result, is followed by chronic inflammation and hypertrophy of the tendons. Again, in subjects where conformation is faulty, no amount of care will be sufficient to prevent a recurrence of the inflammation and the condition must become chronic.
Symptomatology.—On visual examination of the subject at rest, one may note the hypertrophied condition of the affected tendons. Their transverse diameter is usually perceptibly increased and in many cases, there is an increase in the antero-posterior diameter. The latter condition causes a bulging of the tendon that is so noticeable, because of the convexity thus formed, it is commonly known as "bowed tendon."
Fig. 20—Contraction of the superficial digital flexor tendon (perforatus) of the right hind leg, due to tendinitis.
Fig. 20—Contraction of the superficial digital flexor tendon (perforatus) of the right hind leg, due to tendinitis.
In chronic tendinitis there occurs repeated attacks of inflammation wherein lameness is pronounced and there exists in reality, at such times, acute inflammation of a hypertrophic structure, where at no time does inflammation completely subside. Therefore, in chronic tendinitis there is to be found at times the same conditions which characterize acute inflammation, except that there is usually a variance of symptoms because of the difference in the degree of inflammation and pain.
The diagnosis of contraction of tendons is an easy matter because of the fact that relations between the phalanges are constantly changed with tendinous contraction. If one bears in mind the attachments and function of the digital flexors, no difficulty is encountered in recognizing contraction of either tendon.
Contraction of the superficial digital flexor (perforatus), when uncomplicated, is characterized by volar flexion of the pastern joint. The foot is flat on the ground and the heel is not raised because the superficial flexor tendon does not have its insertion to the distal phalanx (os pedis) and therefore can not affect the position of the foot.
By causing the subject to stand on the affected member, one may outline the course of the flexor tendons by palpation, and in this way recognize any lack of tenseness or contraction of tendons or of the suspensory ligament.
Fig. 21—Contraction of the deep flexor tendon (perforans) of the right hind leg, due to tendinitis.
Fig. 21—Contraction of the deep flexor tendon
(perforans) of the right hind leg, due to tendinitis.
Contraction of the suspensory ligament would cause the pastern joint to assume the same position as is occasioned by contraction of the superficial digital flexor (perforatus) tendon, but when the subject is bearing weight on the affected member, it is easy to determine that no contraction of the suspensory ligament exists, by noting an absence of abnormal tenseness of this structure. And finally, contraction of the suspensory ligament is of rare occurrence.
Contraction of the deep flexor tendon (perforans) causes an elevation of the heel. The foot can not set flat because the insertion of the deep flexor tendon to the solar surface of the distal phalanx (os pedis) causes when the tendon is contracted—a rotation of the distal phalanx on its transverse axis—hence the raised heel. No other tendon has this same effect on the distal phalanx and the condition is correctly diagnosed without difficulty.
Fig. 22—A chronic case of contraction of both flexor tendons of the phalanges. In this case (presented at a clinic of the Kansas City Veterinary College) because of long continued contraction of the flexors, which prevented weight being supported with any degree of comfort, there resulted a partial paralysis of the extensors, and consequently the extremity was dragged on the ground.
Fig. 22—A chronic case of contraction of both flexor tendons of the phalanges. In this case (presented at a clinic of the Kansas City Veterinary College) because of long continued contraction of the flexors, which prevented weight being supported with any degree of comfort, there resulted a partial paralysis of the extensors, and consequently the extremity was dragged on the ground.
Course and Complications.—This condition may exist for years without causing the subject any serious inconvenience, if the affected animal is kept at suitable work. In other instances recurrent attacks of lameness are of such frequent occurrence that the subject is not fit for service. Many affected animals that are kept in service in spite of lameness (and in some instances where no lameness is present), soon become unserviceable because of contraction of the inflamed tendon. This, in fact, is the condition which eventually becomes established in most instances.
Treatment.—Where conformation is not too faulty so that recovery may be expected, good results are obtained by line-firing the tendons and allowing the subject a few months' rest. In some cases median neurectomy is advisable. This is recommended by Breton[25] as being productive of good results even where contraction of tendons exists and tenotomy is done.
Fig. 23—Contraction of the superficial and deep flexor tendons (perforatus and perforans) of the left fore leg.
Fig. 23—Contraction of the superficial and deep flexor tendons (perforatus and perforans) of the left fore leg.
By shoeing with high heel-calks considerable strain is taken from the inflamed tendons because of the changed position of the foot which alters the distribution of weight on different parts of the leg. Rubber pads materially diminish concussion and should be made use of when the subject is returned to work, if the character of the work is such as to occasion much concussion.
It is to be remembered, however, that in sprains there occurs fibrillary fracture of soft structures and time is required for regeneration of tissue which has been injured or destroyed. Absolute rest is necessary where inflammation is acute and in sub-acute or chronic tendinitis avoidance of all work which causes irritation to the affected tendons is imperative.
Fig. 24—Contraction of superficial digital flexor and slight contraction of deep flexor tendon.
Fig. 24—Contraction of superficial digital flexor and
slight contraction of deep flexor tendon.
Where contraction of tendons exists surgical treatment is necessary. No good comes from appliances which are calculated to stretch the affected tendons; in fact, they aggravate the inflamed condition and hasten complete loss of function of the affected member. Where there exists no articular or ligamentous diseases which would defeat the purpose, tenotomy is the only remedy for contracted tendons.
Etiology and Occurrence.—This condition is occasionally observed and no positive explanation of the reason for its existence can be given. That mal-position en utero causes the metacarpal bones to develop in length so rapidly that the tendons are too short, is an explanation that is offered. Be that as it may, in breeding sections of the country the general practitioner is obliged to handle these cases and successful methods of treatment are essential even though cause is not removable.
Symptomatology.—The superficial flexor tendon (perforatus) alone, is the one usually contracted, and while both flexors are at times involved, this rarely occurs. The condition is usually bilateral.
The degree of contraction varies greatly in different cases. In some, contraction exists to such extent that it is impossible for the colt to stand, and because of continual decubitus where no relief is given, the subject is lost because of gangrenous infection occasioned by bed sores. Otherwise the same symptoms are to be observed in this condition, that exist in contraction of tendons of the mature animal.
Treatment.—Wherever contraction is not too marked and weight is borne with the affected members, and where the feet can be kept on the ground in a nearly normal position, it is possible to correct the condition without doing tenotomy. That is, in cases where the subject is simply "cock-ankled", where volar flexion of the pastern joint exists but the foot is kept flat on the ground, correction is possible without tenotomy.
In such instances the foal must be treated early—before the skin on the anterior pastern region has been badly damaged by knuckling over. It is possible in many cases to stretch the flexor tendons by grasping the colt's foot with one hand, and with the other hand one may push the pastern in the direction of dorsal flexion. This may be tried and when a reasonable amount of force is employed, no harm is done, even though no material benefit results. Some veterinarians claim good results from this treatment alone and direct their clients to repeat the stretching process several times daily.
Whether the tendons are manually stretched or not, splints should be adjusted to the affected members. The legs are padded with cotton and bandages and a suitable splint is applied on either side of the members and securely fixed in position by bandaging.
The splints are kept in position for four or five days and then removed for inspection of the affected parts. If necessary, they are reapplied and left in position for a week; however, this is unnecessary in the average case that is treated in this manner.
Where contraction exists to the extent that the subject can not stand and where no weight is borne by the feet, it is necessary to divide the affected tendons surgically. The same technic is put into practice that is employed in the mature subject but there is much greater chance for a favorable outcome in the foal. Further, if necessary, one may divide with impunity, both tendons on each leg, at the same time. In all cases this operation is done by observing strict aseptic precautions and the legs are, of course, bandaged. If both tendons are divided, splints should be employed and kept in position for ten days or two weeks. Primary union of the small surgical wound of the skin and fascia occurs in forty-eight hours.
The reader is referred to William's "Veterinary Surgical and Obstetrical Operations," for a complete description of this operation.