Acute Lameness Flashcards
What to say on first contact over the phone ?
- Don’t move horse until vet assessment
- If haemorrhage -> pressure bandage
-> If foreign body say wether to remove or leave in situ
(if nail at risk of being pushed further into foot => remove but note direction)
if embedded -> leave in foot
How to do the initial assessment for acute lameness?
- CE - mm colour, Hr, RR, neuro status
- History -> trauma, sendduen onset, when seen last normal, any wounds ?
- Sedate if safe to prevent further injury
- If fract -> bandage/splint to prevent worsening
What further asessment should you do?
- Full hx & CE
- Plapation / hood testers
What are we looking for on palpation?
➢ Swelling/Joint effusion
➢ Wound
➢ Elevated digital pulses?
➢ Solar penetration?
➢ Hoof tester examination*******
➢ Pain on palpation /manipulation
➢ Reduced range of motion
➢ Crepitus
➢ Asymmetry
What are the main 8 causes of Acute severe lameness?
- Solar abscess/penetration
- Laminitis
- Cellulitis/lymphangitis
- Tendonitis/desmitis
- Synovial infection
- Fracture
- Tendon laceration/rupture
- Myopathy
Which diagnostic test would you choose for each condition?
HOW to TRANSPORT horses with MSK injury?
- Minimise walking distance
- Confine horse for leaning
- Sufficient head/ neck mov to aid balance
- Slings in ambulance if want to reduce load on all limbs
- Unload carefully & slowly
Which direction fo transport horse with hind vs front limb issue?
-> Forward for fract of HL
-> Backward for fract of FL
What should you ALWAYs try to rule out in acute single limb lameness?
Solar abscess/ Nail bind
What is the clinical presentation for nail bind/ solar abscess?
Progressive/acute unilateral lameness
Increased digital pulses
Increased heat in foot
+ve hoof tester examination
+/- softening of coronary band/heel bulbs
+/- cellulitis of distal limb
What relevant history fo solar abscess/ nail bind case?
Recent farriery (nail bind)
Duration
Any objects removed from the foot
History of laminitis
Tetanus status
What particular test for nail bind?
Hoof tester over individual nails can identify painful one
How to manage solar abscess? (pt 1)
- Remove shoe
- Pare foor & identify tract
- Follow tract & open abscess (black brown/yellow fluid)
- Admin of anti-tet & toxoid
- Hot tub
- Iodine / epsom salts
How to manage solar abscess? (pt 2)
-> Apply poultice to draw out infection
➢ Animalintex most commonly used
➢ Apply hot and wet while abscess draining
➢ Switch to dry poultice when discharge stops
➢ See video for refresher on poulticing technique
NSAIDS
Are ABs indicated for uncomplicated abscesses ?
NO
Describe solar bruising?
- Caused by blunt trauma
- Haemorrhage and inflammation
- Horses with thin soles/poor conformation
- Unshod horses
- Shod horses- shoeing overdue/shoes too small
- Corn formation – ‘Seat of corn’
- Can lead to abscess formation
- May need hoof hardener/pads/hoof boots
- Treat as abscess – see below
What is the classic presentation of laminitis?
- Acute onset multi-limb lameness
- Shifting weight/rocking on heels
- Reluctant to walk with short choppy gait
→ worse on tight turns - ‘Bounding’ digital pulses
- Heat and pain on hoof testers
What are the 3 clinical categories of laminitis?
- Endocrinopathic (80%) -> EMS, PPID
- Inflamamtory (systemic dx, grain overload, RFM)
- Traumatic
How to treat Laminitis?
- Strict rest and support the foot
- Soft, deep bed
- +/- remove shoes
- Sole and frog supports
- Pain relief and suppress inflammation
What pain releif woudl u use in laminitis?
- Phenylbutazone 4.4 mg/kg IV/PO for 24-28 hrs
2.2 mg/kg PO BID after 48 hrs
Additional pain relief?
* Paracetamol – not licensed
* Gabapentin – not licensed
* Opioid analgesia if severe
What is an ongoing tx for laminitis?
- Ertuglifozon/Canagliflozin -> Sodium-glucose cotransporter 2 inhibitors (SGLT2i)
- Dietary restriction
- Low quality or soaked hay
- Stop concentrates
- Balancer should be given (vitamin and mineral supplement)
What else can we do for ongoign tx of laminitis?
REMEDIAL FARRIERY
- Reduce breakover
- Frog support
- Heart bar shoes
- Wooden shoes/ clogs
Solar panatrations are usually?
nails embedded in sole
What sensitive structures may or may not get involved in solar penetrations that we need to be aware of?
➢ Deep digital flexor tendon
➢ Distal Interphalangeal Joint
➢ Navicular Bursa
➢ Digital Flexor Tendon Sheath
➢ Navicular bone
➢ Pedal bone
What should we look for with solar penetration ?
- Effusion of DIP/ DFTS -> Pare area aroudn tract - find haemorrhage, follow tract -> leakage? ; sterile probe in tract
What diagnostics might we wanna do for solar penetration?
- Xray of foot -> ideally object in situ +/- probe or +/- contrast in tract
- MRI
- Synoviocentesis of DIP, Nb, DFTS
What meds to give for solar penetration?
- Broad ABs (penicillin/ gentamicin)
- NSAIDS
+/- tetanus
IF synovial structures are involved what to do?
arthroscopic debridement and lavage
Whta does prognosis depend on?
What structure involved & duration from penetration to sx
Pathogenesis of septic arthritis?
- Same as in small animals
- Inflammatory response
- Cartilage destruction – extends to subchondral bone
- PAIN and swelling of infected join
- Ultimately leads to degenerative OA
Tx for septic arthritis?
- Joint lavage ASAP
- Check tetanus status
Septic arthritis causes in adult vs foals?
Adults-> laceration near joint or Iatrogenic
Foals -> Wound or haematogenous spread
Presentation of septic arthritis?
➢ Acute onset/progressive severe lameness
➢ If synovial structure is draining → evidence of synovial fluid and variable lameness
➢ +/-Wound close to/overlying synovial structure
➢ Heat, pain and swelling (joint effusion/tendon sheath effusion)
How should we do our CE in septic arthritis case?
- Assess location & depth of wound
- Clip hair to visualise
- Effusion of synovial structures or evidence of cellulitis
- synovial leakage
-> prep aseptically & evaluate with sterile gloved finger
If unlikely to be septic arthritis what to do?
- Anti-microbials?
- Tetanus?
- Pain relief?-> ongoign admin avoided as it can mask worsening lameness indicating sepsis
What is it is likely septic arthritis?
- confirm with synoviocentesis (DONT do through cellulitic skin)
- Sample collected & sent for: cytology, C & S
- Pressure test -> distent joint with saline -> see communication
- Contrast study
What is abnormal synovial fluid like?
➢Serosanguinous/turbid/reduced viscosity
➢High white blood cells and total protein
➢>90 % Neutrophils
Tx for septic arthritis?
- Joint lavage (large vol polyionic solution)
- Arthroscopy ‘Godl standard’ +/_ synovial biopsy?
- Through and through needle lavage
- Systemic ABs (broad but ideally base don C & S)
- Intra-articular AB
- Intravenous regional perfusion
- Nsaid
Prognosis for septic arthritis?
- Early diagnosis and aggressive management achieve best outcome
- Affected by concurrent damage – worsens prognosis
- Osteomyelitis
- Soft tissue damage
When might septic arthritis caes not present as NWB lame?
if joint open and draining
What is Synovitis? (Joint flare)
-Occurs after chemical tx/ anaesthesia (steroids, LA ..)
- Low incidence
when does joint flare happen?
3-24h post injection
Prevention, dx & tx fo joitn flare?
- Prevention - NSAIDs given at time of injection and for 3 days after
- Diagnosis – synoviocentesis
- Treatment – rest, NSAIDs, cryotherapy +/- corticosteroids
What to be careful with in tx of joint synovitis?
Don’t mask signs of septic arthritis
Describe Acute tendinitis/ Desmitis
- Most commonly sustained during intense exercise
- Flexor tendons/suspensory ligaments of forelimbs
- Uni- or bilateral
- Re-injury of previously injured tendon
Clinical Presentation of Acute Tendonotis? Desmitis?
- Localised heat, swelling, pain
- Lameness
- Often no wound/external trauma
Other ddx for desmitis/ tendonitis?
Fracture
Bruising /stone in shoe
INITIAL tx for acute tendonitis/ Desmitis?
- Cold therapy
- Nsaids
- Steroids iv?
- Bandage limb -> reduce swelling & infl ; RJ bandage + dorsal splint for severe injuries
- US exam
What diagnostics might we do for acute tendonitis/desmitis?
- Regional anaesthesia?
- Radiographs
- US
- MRI
What is the complete TX for tendonitis/ desmitis?
- NSAIDs +/- other anti-inflammatories
- Cryotherapy
- Bandaging
- Box Rest
- Remedial farriery
- Treatment plan – see Chronic Lameness lecture
- Physiotherapy
- Re-evaluation
- Rehabilitation plan
Why do we see lymphangitis & cellulitis?
- Inflammation that causes swelling, pain +/- lameness
- Most commonly in hindlimbs
- Compromised immune system
T/F Lymphamgitis may not respond to conservative tx?
FALSe - it usually does!
What does conservative tx involve of lymphangitis?
- Cryotherapy – cold hosing/ice boots
- Hand walking or turnout in clean/dry area
- Can lead to cellulitis
Describe cellulitis
- Bacterial infection
- Usually only one hindlimb
- Variable lameness, but can be severe
- Affects dermis and subcutaneous tissues
- Bacteria enter body through a break in skin
Signs of cellulitis?
- Heat, pain and lameness
- Pyrexia
- Pitting oedema
- May get fluid leakage/lethargy/anorexia if severe
Txfor lymphangitis & cellulitis?
- NSAID’s
- Antimicrobials (ab stewardship)
- Cryotherpay
- +/- box rest or some exercise as appropriate
CLs of tendon laceration, rupture/ dispalcement
- Lameness-
Maybe not - extensor tendon
Will be - flexor tendons & suspensory ligament - Distress-> SDFT luxation
- Postural abnormality
What postural abnormality for which injury?
Draw it
What to do in case of tendon/lig rupture
- REFER
-Admin of NSAId, AMs? +/- sedation +/- IV fluids - Apply dressing
- Provide limb support
- Immediate euthanasia?
What limb support for what rupture?
➢ Flexor tendon – align dorsal cortices RJB plus
splint or cast bandage
➢ Extensor tendon – RJB
CLS of Fractures?
➢ Acute, severe lameness
➢ Local heat, pain, swelling
➢ Limb instability
➢ Crepitus
➢ Reduced range of motion
➢ Resentment of flexion/extension
➢ Severe distress
Initial tx for fract?
- Control haemorrhage
- +/- sedation
- NSAID analgesia
- +/- Antimicrobials and tetanus prophylaxis
- IV fluids
then
Radiography -> Immobilise -> Transport
What aims of immobilisation?
- Prevent further injury
- Assist weight bearing
- Relieve anxiety
- Counteract forces that will displace the fracture
- Joint above and below fracture
What is exertional rhabdom?
‘tying up’ -> rule out pelvic fracture / laminitis
Dx of ER?
- Blood sample –
CK/AST/urea/creatinine - Urine sample - myoglobin
- Muscle biopsy
Tx for ER?
Initial treatment
* Fluid therapy
* NSAIDs – care
* ACP
* Vit E Selenium
Ongoing management
* Diet
* Avoid stress
* Avoid rest days/turn out
* Dantrolene
