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Y4 EQ - Orthopaedics > Diagnosis and management of foot pain > Flashcards

Diagnosis and management of foot pain Flashcards

1
Q

What information would you want to gather on the history of a horse with foot pain?

A
  • Type of problem: acute or chronic, intermittent; uni- or bilateral lameness; shifting lameness; worse when worked/surface type; stumbling
  • Response to previous treatment/farriery
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2
Q

Describe the steps of a clinical examination for a horse with foot pain

A
  • Resting stance (weight shifting)
  • Foot balance/conformation; shoeing type and fitting; hoof capsule quality and distortions; shape and size of foot
  • Presence of wounds/injuries; presence of effusion/swellings; heat/increased digital pulse; presence of scars
  • Hoof testers!
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3
Q

Following history and clinical exam what would you do to diagnostically approach a horse with foot pain?

A

Dynamic examination
Local anaesthesia
Imaging

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4
Q

Which nerve block is being described:
Lateral and medial palmar metacarpal nerves (just below palpable button of the splints) and lateral and medial palmar nerves (dorsal to DDFT laterally and between DDFT and SDFT medially)

A

Low 4 point nerve block

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5
Q

Which nerve block is being described:
Just proximal to collateral cartilage, abaxial to edge of DDFT

A

Palmar digital nerve block

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6
Q

Which nerve block is being described:
Immediately palmar to the neurovascular bundle at the abaxial surface of the base of the proximal sesamoid bone

A

Abaxial sesamoid nerve block

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7
Q

How should a foot be prepared before radiography?

A

Clean, remove dirt, stones, etc. may need remove shoes but not always necessary

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8
Q

What are the 5 standard views for a foot radiography series?

A

Dorsopalmar
Laterodorsal
Dorsoproximal-palamarodistal oblique (P3 and NB)
Palmaroproximal-palmarodistal oblique

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9
Q

Describe how to position a horse for a lateromedial projection

A
  • Horizontal beam
  • Foot on block/weight bearing
  • Centre 1-2cm below coronary band, half way between dorsal hoof wall and heels
  • Look at heels – primary beam perpendicular
  • Do not collimate too tight!
  • Markers (dorsal hoof wall/frog)
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10
Q

What can you assess on the lateromedial projection?

A
  • Phalangeal/solar angle
  • Relationship to dorsal hoof wall and sole/shoe
  • P3/P2/NB/DIP joint (P1/PIPJ)
  • P3 extensor process
  • Navicular bone
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11
Q

How can the navicular bone be assessed?

A

Corticomedullary definition
Cortex = white
Medulla = grey/black
Problem with side bone

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12
Q

What is ‘side bone’

A

Mineralisation of the collateral cartilages
- not detected on lateromedial view due to superimposition

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13
Q

Describe how to position for a horizontal dorsopalmar image

A
  • Horse stood on blocks
  • Important that horse is standing straight!
  • Horizontal beam centred 2cm below coronary band and perpendicular to limb
  • Turning 90 degrees from the lateromedial view, no change in height
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14
Q

What can you assess on the dorsopalmar projection?

A
  1. P3 margins
    - Relationship to hoof wall: lateromedial balance with markers
    - Sidebone
  2. DIPJ and PIP joint space
  3. PIPJ joint margins
  4. Navicular bone margins but not very visible due to superimposition
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15
Q

Name the two versions of positioning for a dorsoproximal-palmarodistal oblique image

A

Upright-pedal
High coronary

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16
Q

Describe upright pedal positioning for a dorsoproximal-palmarodistal oblique image

A

“Truer” image as beam perpendicular to the plate
Horse’s toe in a Hickman block

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17
Q

Describe a high coronary positioning for a dorsoproximal-palmarodistal oblique image

A
  • Easier to perform with horse standing on tunnel containing a cassette
  • Angle down about 65o through coronary band
  • Slight elongation of foot
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18
Q

What can you assess on the dorsoproximal-palmarodistal oblique (P3) view?

A

P3 body, solar margin and wings

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19
Q

How can the dorsoproximal-palmarodistal oblique view be used to image the navicular bone?

A

Upright pedal (as below) or high coronary view
Collimate well – narrow
Centre 1-2cm above coronary band
Aiming for the back of the foot (slightly higher than for P3)
Horses toe is resting in a wedge to get the correct angle

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20
Q

What can you assess on the dorsoproximal-palmarodistal oblique (nav bone) view?

A

Proximal and distal borders of the navicular bone
Lateral and medial wings of the NB
Palmar processes of P3
DIPJ margins

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21
Q

Which radiographic view is known as the skyline view?

A

Palmaroproximal-palmarodistal oblique

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22
Q

Describe how to position a horse for a Palmaroproximal-palmarodistal oblique image

A
  • Foot on cassette tunnel
  • Leg back/fetlock extended
  • Tube head under horse – vulnerable!
  • Centre between bulbs of heels; 45o
  • Look at LM view or foot conformation
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23
Q

What can you assess on the palmaroproximal-palmarodistal oblique (“skyline”) view?

A

Articular surface of the navicular bone
Synovial fossae
Corticomedullary definition
Endosteal surface
Normal variant in sagittal ridge
Flexor cortex and surface
Palmar process of P3

24
Q

List some possible causes of primary pain of the distal interphalangeal joint and associated structures

A
  • Synovitis/DJD/osteoarthritis/osteochondral fragmentation
  • Joint trauma/subchondral bone pain
  • Collateral ligament desmitis
  • OCLL = osseous cyst like lesions
25
How can you diagnose the cause of primary pain of the distal interphalangeal joint and associated structures?
1. Clinical features - Uni- or bilateral lameness - DIPJ effusion (non-specific) 2. Lameness localised to the foot by diagnostic anaesthesia - Beware of lack of specificity of DIP block! 3. Diagnostic imaging - Radiography - Ultrasound – often unrewarding - MRI – collateral ligament desmitis
26
How can you manage/treat synovitis/osteoarthritis/OC frag?
- Intra-articular medication e.g. hyaluranon/corticosteroids, IRAP - NSAIDs - Remove fragment (if significant )
27
What is IRAP?
IRAP = interleukin receptor antagonist protein – can be used in joint disease. Uses the bodies interleukin 1 (one of the main cytokines for osteoarthritis) and blocks it
28
How do you manage/treat joint trauma/subchondral bone pain?
Rest, NSAIDs
29
How do you manage/treat collateral ligament desmitis
Rest Farriery/shoeing (rolled toe) Shockwave, intra-articular medication
30
How do you manage/treat osseous cyst like lesions
Intra-articular medication
31
Are pedal bone fractures common?
One of the more common fractures encountered in equine practice But still relatively uncommon c.f. subsolar abscessation
32
How do pedal bone fractures occur?
Kicking wall; blunt trauma Penetrating injury/hoof wall trauma
33
What are the clinical signs of a pedal bone fracture?
Acute foot pain (occ.chronic) Increased digital pulse Hoof tester +ve; percussion +ve - May not be specific +/- DIPJ effusion
34
How can local anaesthesia be used to diagnose pedal bone fractures?
Usually improves but may not fully block out
35
How is radiography used to diagnose pedal bone fractures?
- Standard views plus other obliques to evaluate the “wings” of P3 - Fracture types described: non-articular/articular, sagittal/ parasagittal, comminuted, extensor process, marginal - Occ. need advanced imaging (e.g. nuclear scintigraphy/MRI/CT)
36
Describe conservative management of pedal bone fractures
- Immobilisation and rest using a bar shoe or hoof/foot cast - Fracture heals by fibrous union - Most foal P3 fractures heal without casting/shoeing (can lead to foot contraction) - Prognosis reduced if articular involvement
37
Describe surgical management of pedal bone fractures
- Removal of fragment(s) e.g. extensor process fractures - Internal fixation e.g. sagittal articular fractures - PD neurectomy for non-healing wing fracture (type I and II)
38
What is non-septic pedal osteitis?
Vague term covering radiographic changes in pedal bone in horses with chronic foot soreness Often associated with foot imbalance
39
How is non-septic pedal osteitis diagnosed?
Lameness localised to foot Variable radiographic changes - demineralisation/widening of vascular channels
40
How is non-septic pedal osteitis treated?
Correct foot imbalance/reduce abnormal stresses through foot
41
Are navicular bone fractures common?
Uncommon Traumatic aetiology Occasionally see bi- or tri-partite navicular bones
42
How are navicular bone fractures diagnosed?
Moderate lameness Diagnostic anaesthesia localised to foot Radiography
43
How are navicular bone fractures treated?
Conservative (heal by fibrous union) Surgical repair difficult
44
How does navicular disease present - history and clinical exam?
- Important cause of chronic bilateral forelimb lameness - History of intermittent chronic forelimb lameness often worse on a hard surface and exacerbated in a circle - Horse may stumble, be unwilling to go forward, refuse jumps etc - Associated with low heel/long toe conformation
45
Describe the pathology/pathogenesis of navicular disease
- Age related: thinning of fibrocartilage and roughening of DDFT - Defects in palmar surface fibrocartilage: palmar cortex erosion and medullary lysis - DDFT damage: surface fibrillation, core lesions, adhesions - Defects in palmar cortical bone: replacement of normal medullary tissue with highly vascularised connective tissue - New bone formation along collateral sesamoidean ligament - Degenerative changes around DIP/NB articulation
46
How is navicular disease diagnosed using clinical evaluation?
History; signalment; age Foot conformation Hooftester+ve over frog not consistent finding
47
How is navicular disease diagnosed using dynamic evaluation?
Land toe first Start to point toe when landing Lameness worse on hard, circle
48
How is navicular disease diagnosed using diagnostic analgesia?
PD+ve; DIP+ve; NB+ve May “switch” lameness or worsen lameness on other limb
49
Describe the radiographic abnormalities seen with navicular disease
- Medullary cyst formation - Flexor cortex erosion/ irregularities - Loss of corticomedullary definition - Endosteal sclerosis - Distal border fragmentation - Entheseophytes on lateral (or medial) border - Enlarged or increased number of synovial fossae
50
What are Entheseophytes?
A bony spur forming at a ligament or tendon insertion into bone
51
How is farriery used to treat navicular disease?
- V. important as navicular disease is primary chronic degeneration due to abnormal biomechanical stress - Balance foot: remove any hoof distortions and improve hoof-pastern axis - Reduce breakover by rolling toe/reducing leverage/improving centre of rotation of DIPJ - Engage frog with ground/shoe and improve heel support
52
How is navicular disease treated using medical management ?
1. NSAID’s - Often mainstay of management with farriery 2. Intra-articular or intra-bursal medication - e.g. hyaluranon/corticosteroids 3. Bisphosphonates - Tiludronate; clodronate licenced - Significantly improved lameness but not resolved
53
How is navicular disease treated using surgical management ?
Neurectomy - certain nerves are blocked or severed to relieve severe chronic pain Around 75% sound after 1yr
54
List the complications linked to a neurectomy
Neuroma formation Incomplete desensitisation Re-innervation DDFT rupture Navicular bone fracture Foot penetration (hoof capsule slough)
55
How are primary DDFT lesions in the foot diagnosed?
- Mild-severe acute onset unilateral lameness - Clinical exam often unrewarding - Diagnostic analgesia: most (but not all) positive to PDNB and NB - Radiography often NAD - MRI diagnosis
56
How are primary DDFT lesions in the foot managed?
Conservative - Rest; shoeing Surgical - Debridement of lesion via navicular bursa

Y4 EQ - Orthopaedics (14 decks)

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