Treatment of soft tissue injury

Question 1

Aims of 1st aid

Answer 1

1) Prevent injury becoming worse.
2) Reduce pain.

→ Reduce inflammation
→ Provide stability
→ Reduce tendon loading

Question 2

1st aid tx of the inflammatory phase

Answer 2

• NSAIDs
• Steroid
• External support
• Cold therapy
• Confinement

Question 3

1st aid tx of the inflammatory phase - NSAIDs

Answer 3

• IV dose as soon as see the horse, oral course for several weeks afterwards
• Rule of thumb: NSAIDs/anti-inflammatories continue for as long as the inflammation is there (i.e. as long as the leg is hot, painful & swollen)

Question 4

1st aid tx of the inflammatory phase - steroids

Answer 4

• Along with NSAIDs give a single dose of IV steroid (corticosteroid) on the 1st day after injury
• Again stops inflammatory cascade/cycle
• Dexamethasone IV

Question 5

1st aid tx of the inflammatory phase - external support

Answer 5

• Bandage usually, but could be cast or splint if the injury if severe
• Role: to compress (reduces oedematous swelling present), pain relief

Question 6

1st aid tx of the inflammatory phase - cold therapy

Answer 6

• In between bandages (i.e take bandage off, cold therapy, dry leg, re-bandage)
• 10 mins of cold hosing or ice bandages
• Trying to reduce inflammation
• Continue for as long as there is obvious heat in the leg

Question 7

1st aid tx of the inflammatory phase - confinement

Answer 7

• Stable or small yard.
• Unable to charge around / get to speed

Question 8

What is the mainstay of all tendon and ligament injuries?

Answer 8

• time and rest

Question 9

Why is 1st aid tx in the inflammatory phase so important?

Answer 9

• Tendon and ligament injuries are self propagating - the inflammation within the tendon/ligament due to injury causes the injury to worsen
• So have to fight the inflammatory cycle early on to stop the injury being worse than it otherwise would have been

Question 10

When to use intralesional therapies?

Answer 10

§ At start of repair phase
§ Suitable only when a hole / space is present
§ Under US guidance
§ Not a substitute for long term rest and controlled exercise

Question 11

Aim of intralesional therapies

Answer 11

improve speed and quality of healing
→ supra-physiological healing

Question 12

Stem Cell Therapy

Answer 12

§ Autologous graft of mesenchymal stem cells
§ Collected from bone marrow or fat
– Usually collected from the tuber coxae or sternum
§ Cultured in laboratory (3 weeks)
§ Differentiate into tenocytes once in the deficit to promote healing
§ 2 stage procedure, expensive
§ Does have good effects

Question 13

Platelet Rich Plasma (PRP)

Answer 13

§ Autologous graft of platelets suspended in plasma
§ Collected from blood by filtration or centrifugation
§ Injected into the tendon/ligament under US guidance
§ Stimulate angiogenesis and proliferation & differentiation of tissues

Question 14

Bone Marrow Aspirate Concentrate (BMAC)

Answer 14

§ Autologous graft of fluid & cells from within bone marrow
§ Collected from sternum or tuber coxae
§ Contains mesenchymal stem cells, platelets & growth factors
§ Fluid is centrifuged to concentrate cells
§ Injected in lesion under ultrasound guidance
§ Fewer stem cells/platelets than stem cell therapy/PRP
§ Single stage procedure

Question 15

Surgical Therapies

Answer 15

§ A few tendon and ligament injuries are amenable to surgical treatment
§ Soft tissue injuries within tendon sheaths or joints heal poorly by medical management due to exposure of tendon fibrils to synovial fluid (it stops the fibres re-joining and healing)
§ Exposed fibres are best treated by arthroscopic removal.
§ Constriction / contraction of some structures following injury can be managed by transection

Question 16

Surgical therapy for palmar/plantar annular ligament desmitis

Answer 16

• PAL desmotomy
  – This allows the DDFT and SDFT to slide up and down the leg freely
  – PAL desmitis causes constriction of them

Question 17

Surgical therapy for SDFT tenodnitis

Answer 17

• Superior check ligament desmotomy
  – damage to the SDFT tends to occur in the mid canon region
  – to release some of the tension within the SDFT or release the weight bearing of it you can perform this surgery

Question 18

Surgical therapy for manica flexoria tear

Answer 18

• manica flexoria removal

Question 19

Surgical therapy for DDFT tear

Answer 19

• DDFT debridement

Question 20

Where does the palmar/plantar annular ligament run?

Answer 20

• from 1 sesamoid bone to the other
• wraps around the back of the fetlock

Question 21

Where does the check ligament run?

Answer 21

• check ligament is above the carpus
• it runs from the SDFT to the side of the radius