Soft Tissue Trauma Flashcards
What conditions present true veterinary emergencies?
- Respiratory distress
- Neurological abnormalities
- Bleeding from body orifices
- Rapid, progressive abdominal distension
- Dystocia
- Collapse
- Extreme pain
- Fractures
- Severe wounds
- Urinary obstruction
- Persistent vomiting
- Toxin ingestion
Outline the advice that should be given to an owner in case of a veterinary emergency
- Encourage bringing to practice ASAP
- Need to protect the spine (lift gently on rigid board)
- Place in confined space if suspect fracture to minimise movement
- Direct pressure on active haemorrhage
- Calm owner before transport, ensure know the route
Outline the criteria for a P1 (top priority) emergency case
- History of head or spinal trauma
- History consistent with internal injuries
- Life threatening haemorrhage (chest, abdomen worst)
- Cardiorespiratory compromise
- Diagnose based on history, observation and physical examination
- Re-assess -cardiovascular function can deterioratem, CNS signs may become more obvious
What action is required for a P1/top priority emergency case?
Immediate action, high risk of death
Outline the criteria for P2 emergency cases
- Do not move, need stabilisation prior to moving e.g. fracture, tendon rupture/laceration, joint instability, vascular or neurological damage
- Esp. important for large animals
Outline the criteria for P3 emergency cases
- Require urgent attention, but may not be immediately life threatening
- Synovial involvement (can wait 24-48hrs)
- Bony involvement
- Contaminated wounds
Outline the criteria for P4 emergency cases
- Delayed action
- Do not require emergency treatment or urgent action
- Must rule out all previous problems, be prepared to evaluate findings and diagnosis
- Explain to owner what to look for in case of deterioration
In an emergency case, outline the initial assessment of the patient
- If lame, assess degree, appearance of limb may not match up with degree of lameness
- Conformation/gross abnormalities
- Location and discharge from wound
- Degree of blood loss
- Contamination
Outline what should be investigated in the physical examination of an emergency case
- Presence/absence of crepitus
- Degree of contamination
- Soft tissue involvement
- Bony involvement
- Swellings and effusions
List and justify the diagnostic tests that should be included in the assessment of an emergency case
- Radiogrpahy esp. traumatic injury, abdo and thoracic, assess cardioresp., diaphragm, bladder, pelvis
- Ultrasonography (AFAST, assess effusion, haemorrhage, bladder trauma)
- Synoviocentesis if synovial involvement
- PCV/TP to assess blood loss later in disease progression
- Assessment of other body system function using haematology, biochem, urinalysis esp. if may need surgery
- +/- MRI, CT, gamma scintigraphy
Identify the key features of first aid for acute trauma/wounds
- Control haemorrhage
- Control pain
- Reduce contamination
- Bandaging wounds
- Wound closure
- Splinting of fractures/tendon injuries
How can haemorrahge be controlled in acute trauma/wounds?
- Pressure (bandage or manual)
- Tourniquet
- Ligatures for large vessels
What are the components of analgesia in acute trauma/wound cases?
- NSAIDs
- +/-Opioids (NOT cattle/ruminants)
- Splinting/bandaging to prevent movement of limbs
- +/- sedation
List the NSAIDs that can be used in trauma cases for dogs
- Robenacoxib
- Meloxicam
- Carprofen
List the NSAIDs that can be used in trauma cases for cats
- Robenacoxib
- Meloxicam
- Ketoprofen
List the NSAIDs that can be used in trauma cases for horses
- Flunixin meglumine
- Meloxicam
- Ketoprofen
List the NSAIDs that can be used in trauma cases for cattle
- Ketoprofen
- Meloxicam
What conditions would containdicate the use of NSAIDs in an acute trauma/wound case?
- Hypovolaemia
- Severe haemorrhage
- Renal/liver compromise
List the opioids that can be used in acute trauma/wounds in dogs
- Methadone
- Buprenorphine
- Fentanyl
List the opioids that can be used in acute trauma/wounds in cats
- Methadone
- Buprenorphine
List the opioids that can be used in acute trauma/wounds in horses
- Butorphanol
- Buprenorphine
- Morphine
What is a potential complication when using opioids in horses?
- Can lead to excitation, combine with alpha 2 agonist to reduce this
- Pethidine will lead to horse becoming completely uncontrollable
What are the potential risks when using opioids in acute trauma/wound cases?
- Respiratory depression
- Bradycardia
- NB: Do not let this stop you using them!
How can wound contamination be reduced in an emergency case?
- Gross decontamination
- Clipping
- Lavage
- Antiseptics
- Debridement
- KY jelly in wound
List the different categories of wound closure, and identify the factors that underlie the decision making process
- Primary closure, delayed primary closure, delayed secondary closure, second intention healing
- Depends on contamination, ability to appose wound edges, degree of dead space below
Briefly outline splinting of fractures in emergency cases
- Depends on region, in SA, proximal limb fractures difficult to splint
- Splint the joints above and below
- Open fractures must be splinted
- Robert Jones adequate for distal limb fractures
- Do not pull exposed tissue back through skin
What are the main functions of applying bandages in acute trauma/wound cases?
- Reduces fluid accumulation
- Reduces contamination
- Reduces movement
- Prevents dehydration
What are the potential consequences of incorrect bandaging?
- Tissue maceration and infection
- Continued contamination
- Sloughing of new epithelialisation
- Continued pain for the patient
- Impairment of vascular supply
What are the key client considerations in decisions regarding equine wounds?
- Prognosis for athletic function
- Prognosis for pasture soundness
- Cost
- Duration of box rest
- Time out of work
- Amount of nursing required
Which equine injuries carry a poor prognosis for recovery?
- Compound, open fractures with significant contamination of soft tissue
- Complete fractures involving the femur, humerus and tibia
- Complete lacerations of SDFT, DDFT, SL
- Complete laceration of SDFT, DDFT and distal sesamoidean ligaments
What are the 2 broad categories of soft tissue injuries?
- Percutaneous
- Overstrain
What is the key determinant of prognosis for percutaneous soft tissue injuries?
Location and degree of damage
In which locations do percutaneous injuries carry a worse prognosis?
Palmar/platar aspect injuries worse, more difficult to heal
How do overstrain soft tissue injuries occur?
- Overload leading to breakdown of structure
- Can be acute onset overload or chronic condition
Compare the incidence of chronic and acute overstrain soft tissue injuries and briefly explain this
- acute onset overload: overwhelm tensile strength
- Chronic: more common, microdamage progressing to degree where structure breaks down in one event
Which tendons are most commonly affected by soft tissue injury in horses?
- SDFT (esp. race horses)
- DDFT
Which tendons are most commonly affected by soft tissue injury in dogs?
Tendons of achilles and biceps brachii
Which ligaments are most commonly affected by soft tissue injury in horses?
- Suspensory ligament (proximal suspensory desmitits, esp. dressage)
- Suspensory branch desmitits
Which ligaments are most commonly affected by soft tissue injury in dogs?
- Cruciate stifle ligaments
- Collateral ligaments
Which questions are relevant to the investigation of a horse with suspected tendon or ligament disease>
- Duration of problem?
- Onset, and signs at onset?
- Exacerbation of problem?
- Presenting signs?
- Response to treatment?
Outline the clinical evaluation of a horse with suspected tendon or ligament disease
- Evaluate stance/posture
- Palpate limbs with animal standing for swelling, heat, pain on palpation
- Lift limb and palpate when soft tissue relaxed
- Lift contralateral limb
- Check ROM
What injury is indicated by hyperextension of the fetlock in a horse (sunken fetlock)?
Marked injury of suspensory apparatus/suspensory ligament
What commonly occurs in the contralateral limb following recovery from soft tissue injury, and explain why?
- Both limbs will have experienced same stresses/forces throughout life, when one is injured, likely that the other also has subclinical disease
- Will likely suffer strain/rupture once back in exercise
What injury is indicated in a horse with a sunken fetlock where the toe is also off the ground?
SDFT and DDFT dysfunction
What injury is indicated in a horse with a collapsed fetlock and toe off the ground?
SDFT, DDFT, SL dysfunction
What injury is indicated in a horse with knuckling that is not a result of neurological condition?
Extensor tendon dysfunction
Which imaging modalities are of use with non-emergency soft tissue injuries
- Ultrasound
- Radiography
- MRI
- Arthroscopy/tenoscopy/bursography
What are the advantages of ultrasonography in the investigation of soft tissue injuries?
- Good for soft tissue assessment
- Good for bony surface assessment e.g. for avulsions
- Quick and easy
- portable unit
- GA not needed
- Oedema of soft tissue injury provides excellent contrast
What are the weaknesses of ultrasonography in the investigation of soft tissue injuries?
- Expensive equipment
- Experience in interpretation needed
- 2D images obtained
Justify the use of radiography in the investigation of soft tissue injuries
- Primary soft tissue injury may have bony involvement e.g. avulsion injury, esp. with suspensory ligament
- Allows assessment of joint angles
Justify the use of MRI in the investigation of soft tissue injuries
- Distal limb especially useful
- Fast evaluation of of acute injuries
What are the most common indications for use of arthroscopy, tenoscopy or bursography in the investigation of soft tissue injuries?
- More chronic management
- Or acute cases with wounds that may have resulted in septic processes in joint
When should ultrasonography of soft tissue injuries be carried out and why?
- Repeat ~7 days after injury in order for fibres to become more destroyed by proteinases, macrophages, more oedema will be present allowing better contrast
- Allows assessment of full extent and progression of damage
What ultrasonographic features may change with soft tissue injury?
- Echogenicity
- Cross sectional area
- Fibre alignment
- Margins of the structure
- Shape of the structure
- Location of the structure
What soft tissue injury is most likely to cause the following clinical signs?
Heat and pain on palpation of the palmar metacarpal region of the equine limb, bowed appearance of the palmar metacarpus, vascular engorgement, lameness
Superficial digital flexor tendonitis
What may be found on palpation of the metacarpal region of a limb with SDF tendonitis?
- Thickened SDFT
- Soft swelling of the SDFT (change in texture, more spongy)
- Pain on gentle pinching
Describe the common ultrasound findings in a case of superficial digital flexor tendonitis
- Core lesions most common
- Transverse: loss of normal echogenicity depending on stage of disease, increased cross sectional area
- Longitudinal: loss of normal parallel fibre alignment, and lesions of mixed echogenicity, shorter fibres
Compare the echogenicity of acute, subacute and chronic superficial digital flexor tendonitis lesions
- Acute: anechoic (filled with blood)
- Subacute: hypoechoic
- Chronic: hyperechoic areas
Give the approximate severity, time out of training and prognosis for return to racing for an SDFT lesion where the total lesion CSA/total tendon CSA = 0-15%
- Mild severity
- 10 months out of training
- 63% prognosis for return to racing
Give the approximate severity, time out of training and prognosis for return to racing for an SDFT lesion where the total lesion CSA/total tendon CSA = 16-25%
- Moderate severity
- 11 months out of training
- 30% prognosis for return to racing
Give the approximate severity, time out of training and prognosis for return to racing for an SDFT lesion where the total lesion CSA/total tendon CSA = >25%
- Severe
- 18 months out of training
- 23% prognosis return to racing
Outline the value of ultrasonography in monitoring the progression of SDFT injury
- Used for management of re-initiation of training and intensity
- re-scan before increasing/changing exercise
- Re-scan every 2-3 months and before any change in exercise
- If >10% increase in CSA, reduce exercise level
Compare the occurrence of particular tendon injuries depending on the work done by the horse
- SDFT rupture more common in racehorses
- Suspensory ligament rupture more common in dressage or show jumpers
Describe the normal ultrasonographic appearance of the suspensory ligament
Heterogenous due to presence of ligamentous fibres, muscle fibres and fat
Describe the diagnosis of proximal suspensory ligament desmitis in the hindlimb of a horse
- Rare to palpate swelling/heat as is deep to other soft tissue structures and surrounded by fascia
- Pain on deep palpation
- Diagnostic analgesia and imaging findings (ultrasound +/- MRI)
- Usually present with lameness, uni or bi lateral
Describe the diagnosis of proximal suspensory ligament desmitits in the forelimb
- Radiography may indicate small zone of sclerosis, indicating origin lesion of suspensory ligament
- Ultrasound
Discuss the prognosis for proximal suspensory desmitis
- Forelimb: good
- Hindlimb: acute desmitis reasonable prognosis
- Chronic: poor, improves with treatment
List the treatment options for chronic suspensory desmitis
- Extracorporeal shockwave therapy
- Fasciotomy and neurectomy
What signs would be seen with suspensory branch desmitits in the horse?
- Palpable pain
- Peri-ligamentous heat
- Peri-ligamentous and ligamentous swelling
- Variable lameness
Outline the diagnosis of suspensory branch desmitis in the horse
- History, physical examination
- Ultrasonography (most useful), MRI (possible, usually not needed)
What commonly develops with chronic suspensory branch demitis?
Peri-ligamentous fibrosis
Describe the method for, and typical ultrasonographic appearance with suspensory branch desmitits
- Brnaches are on lateral and medial aspects of the limb, image these directly
- Distorted, disrupted appearance
- Central anechoic region
- In longitudinal view will see areas of disruption and hyperechogenicity
For which conditions is extracorporeal shockwave therapy particularly useful?
Enthesious problems (where tendons/ligaments inert onto bone)
Discuss the prognosis of suspensory branch demitis
- Reasonable, but recurrence common
- Chronic desmitis carries worse prognosis
- PRP and stem cell treatment may improve prognosis
What conditions would the following signs be suggestive of?
Swelling in proximal metacarpal region, pain on palpation, heat, vessel engorgement, lameness variable, acute onset lameness usually with fetlock flexural deformity
- Desmitis of the ALDDFT
- Desmitis of the SDFT
- Distinguish by distribution of swelling - ALDDFT more proximal, SDFT causes bowing
Describe the ultrasonographic appearance of desmitis of the ALDDFT
- Increased CSA
- Loss of normal fibre pattern
- Loss of normal contour
Which tendon is the one most commonly injured within the digital flexor tendon sheath?
DDFT
What are the 2 types of tenosynovitis of the digital flexor tendon sheath?
- Primary (usually associated with some kind of injury)
- Or secondary
Which structures run through the digital flexor tendon sheath that commonly cause secondary tenosynovitis and how does this occur?
- Pathology of soft tissue structures running through the sheath leads to inflammation of sheath
- Superficial digital flexor tendon
- Deep digital flexor tendon
- Manica flexoria
- Palmar annular ligament
What are the functions of tenoscopy?
- Diagnostic value
- Therapeutic value
What are the key features in the treatment of tenosynovitis of the digital flexor tendon sheath?
- Intrasynovial anti-inflammatories e.g. steroids, hyaluronic acid
- Tenoscopy
Discuss lesions of the DDFT that occur further distally in the foot (diagnosis and treatment)
- Increasingly recognised as a cause of lameness
- Impossible to use ultrasound through the keratinised hoof wall - MRI required
- Treatment options: rest, farriery, intrabursal/intraarticular medications
- Bursoscopy
What emergency treatment should be used where flexor tendon dysfunction is suspected?
Bandage limb and apply palmar or dorsal splint, or Kimsey splint
What emergency treatment should be used where extensor tendon dysfunction is suspected?
Bandage and dorsal splint
Outline the emergency treatment of all tendon/ligament injuries
- Stabilise limb, restore biomechanical function by creating alignment of single bony column and reduce pressure on soft tissues
- Local wound care
- Antibiotics and anti-inflammatories
Briefly describe the characteristics of healed tendons
- Stiffer than normal tendons as tendons fibrose rather than regenerate
- Less efficient energy store leading to poorer performance due to limited elastic energy storage
Outline the acute phase treatment of tendon/ligament injury in the horse
- Physical therapy: cold, compression, rest
- Medical: NSAID analgesia e.g. phenylbutazone and anti-inflamm, steroids controversial (can be used short term to reduce initial inflammation)
Outline the subacute phase treatment of tendon/ligament injury in the horse
- Fibroplasia phase
- Mobilisation: early and progressive, train tenocytes back to normality, passive manipulation if on box rest, mobilisation from 7-14 days onwards ideally
- Monitor with ultrasonography (CSA, fibre pattern)
Outline the chronic phase treatment of tendon/ligament injury in the horse
- Remodelling
- Controlled ascending excercise
- Ultrasonographic monitoring
Outline some examples of treatment options for tendinitis
- Stem cells (mesenchymal stem cells), must be used in acute phases
- Platelet rich plasma - provides biological scaffold as well as containing cytokines, proinflamm growth factors etc. that may promote healing
Outline how tendonitis can be prevented
- Maximise quality of tendon prior to skeletal immaturity (tendon training of immature horses)
- Reduce degeneration after skeletal maturity (avoid tendon training)
- Reduce risk factors for tendonitis (decreased speed, fatigue, jumping, weight, improve ground surface, shoeing)
- Detect tendonitis early with ultrasound and structure training around this
