- Email: [email protected]
Successful Management of Severe Open Metacarpophalangeal Joint Dorsal Luxation in a Horse
Journal of Equine Veterinary Science 48 (2017) 48–51
Contents lists available at ScienceDirect
Journal of Equine Veterinary Science journal homepage: www.j-evs.com
Case Report
Successful Management of Severe Open Metacarpophalangeal Joint Dorsal Luxation in a Horse Alireza Raayat Jahromi*, Nasser Vajdi Department of Clinical Studies, School of Veterinary Medicine, Shiraz University, Shiraz, Iran
a r t i c l e i n f o
a b s t r a c t
Article history: Received 16 June 2015 Received in revised form 18 February 2016 Accepted 18 August 2016 Available online 26 August 2016
A 3-year-old Darreh-Shuri stallion was presented with left forelimb open dorsal fetlock luxation immediately after being hit by a motorized vehicle. The horse was in a non– weight-bearing position on the affected limb. General physical examination revealed normal vital parameters and no special concurrent abnormality. Radiographic examination in lateromedial and dorsopalmar views of the affected limb showed complete luxation of the metacarpophalangeal joint with no fractures. Ultrasonographic evaluation revealed intact collateral ligaments. Under general anesthesia and following routine preparations, forceful manual pressure was exerted on the distal part of the metacarpus and proximal part of the first phalanx to reduce the luxation. Joint capsule and skin laceration were sutured. Intraarticular amikacin (500 mg) was administered and repeated on the third and fifth days postoperatively. A palmar polyvinyl chloride, synthetic plastic polymer (PVC) splint was placed following adequate padding from the carpus to the toe. The higher and lower third of the splint was casted and the middle part left open to manage the joint and skin lesion. Intraarticular sodium hyaluronate (20 mg) was administered 10 days later. After cast removal following 5 weeks, the stallion revealed no sign of lameness. The owner was instructed to keep the stallion confined to a stall for at least 2 more months with a restricted daily short hand walk. Special casting methods for immobilization of a limb with an open joint luxation can tremendously improve the healing process. Ó 2016 Elsevier Inc. All rights reserved.
Keywords: Metacarpophalangeal joint Open dorsal luxation Horse
1. Introduction The metacarpophalangeal and metatarsophalangeal joints are high-motion joints that require a complex network of stabilizing structures to withstand loading forces. The medial and lateral collateral ligaments limit motion of these joints to the sagittal plane [1]. Lateral and medial luxation of the fetlock joint occurs uncommonly as a result of bending injuries and can affect all ages and breeds [2]. Dorsal luxation happens less frequently. In fetlock * Corresponding author at: Alireza Raayat Jahromi, Department of Clinical Studies, School of Veterinary Medicine, Shiraz University, Shiraz, 71441669155, Iran. E-mail address: [email protected] (A. Raayat Jahromi). 0737-0806/$ – see front matter Ó 2016 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jevs.2016.08.011
luxation, laceration of the joint capsule and rupture of the medial and/or lateral collateral ligament, or of the collateral sesamoidean ligament, or the oblique distal sesamoidean ligaments can be possible. In the acute phase following injury, pain and swelling are common [3]. Persistent laxity can be presumably contributed to the chronic osteoarthritis that is often the sequel after the injury [4]. This injury is frequently managed with cast or splint immobilization. Arthrodesis can be an option in severe cases or in horses that end with severe joint degeneration [5]. In one case report describing luxation of the metacarpophalangeal/metatarsophalangeal joint in horses, one half of the 10 reported cases sustained an open luxation [6]. Horses have been treated by cast immobilization after debridement of soft tissue and joint lavage; antibiotic
A. Raayat Jahromi, N. Vajdi / Journal of Equine Veterinary Science 48 (2017) 48–51
therapy and suture apposition of the ruptured collateral ligaments have also been attempted. An open fetlock luxation of the left forelimb with significant cartilage and periarticular damage in a mule foal has been successfully managed by surgical joint lavage, cartilage debridement, wound repair, and rigid cast immobilization [7]. This report presents the management of a severe open metacarpophalangeal joint dorsal luxation in a DarrehShuri stallion. 2. Case History A 3-year-old Darreh-Shuri stallion was referred to the Teaching Hospital of School of Veterinary Medicine, Shiraz University, with left forelimb open dorsal fetlock luxation immediately following being hit by a car. The horse was in a non–weight-bearing position on the affected limb (Fig. 1). General physical examination revealed normal vital parameters and no special concurrent abnormality. Radiographic examination of the affected limb in lateral view confirmed dorsal luxation of the fetlock with no sign of fracture (Fig. 2A). Ultrasonographic examination revealed intact collateral ligaments. Following fluid therapy and premedication using acepromazine (Neurotrang 1%, Alfasan, Woerden, Holland) (0.05 mg/kg IV) and xylazine (as HCL 2%) (1 mg/kg IV), anesthesia was IV induced by mixture of ketamine (als-hydrochloride 10%) (2 mg/kg IV) and diazepam (Zepadis, Caspian, Rasht, Iran) (0.1 mg/kg). After positioning in right lateral recumbency, the lesion was prepared aseptically and the joint space was lavaged copiously through the wound by normal saline to remove all debris. Precise inspection was carried out to see if there is any ligament or tendon injury. Considering the healthy adjacent structures, forceful manual pressure was exerted on the distal part of the metacarpus and proximal part of the first phalanx to reduce the luxation. Joint capsule was sutured with simple continuous of Vicryl 0. Skin lesion was
49
then apposed with simple interrupted pattern of Nylon 2. Intraarticular amikacin (EXIR, Boroojerd, Iran) (500 mg) was administered through the dorsal aspect of joint capsule and under the lateral edge of the common digital extensor tendon and repeated on third and fifth days postoperatively. Cast immobilization of the affected limb was decided. A palmar PVC splint was placed following adequate padding from the carpus to the toe, considering the extra cotton between the pastern region and the splint. The higher and lower third of the splint was casted and the middle part left open to manage the joint and skin lesion; this region was dressed using sterile nonadhesive gauze and bandage and changed after intraarticular administrations. The stallion recovered uneventfully. Other postoperative cares included phenylbutazone (Vetanyl 20%, Aburaihan, Tehran, Iran) (2.2 mg/kg IV) and penicillin procaine (Kanapen, Nasr, Fariman, Iran) (22,000 IU/kg Intramuscular), for 5 days. Intraarticular sodium hyaluronate (20 mg) was administered 10 days later. Strict restriction and confined stall rest was considered. Radiographic evaluations, after cast removal following 5 weeks, showed no sign of displacement on the joint. There was marked improvement in weight-bearing capacity of the affected limb without any evidence of swelling or pain upon palpation. No obvious lameness was observed during visual examination. The owner was instructed to keep the stallion confined to a stall for at least 2 more months with a restricted daily short hand walk. 3. Discussion Fetlock luxation of the present report was in dorsal direction, whereas most of the previous cases described in the literature are medial and lateral. The most common treatment for fetlock luxation is cast immobilization of the affected limb, with or without suture apposition of torn soft tissues [6]. Luxation of the joints in distal limb must be
Fig. 1. Open dorsal luxation of the non–weight-bearing left front limb.
50
A. Raayat Jahromi, N. Vajdi / Journal of Equine Veterinary Science 48 (2017) 48–51
Fig. 2. Preoperative (A) and postoperative (B) dorsal luxation of the fetlock joint.
stabilized after reduction, and this is most easily achieved with a cast [8]. External coaptation has a key role in protection of the repair, especially during recovery from general anesthesia, it greatly reduces the risk of catastrophic consequent complications [3]. The reduction of the affected joint in this case was supported in an almost innovative combined splint and casting method. Following padding and placement of a palmar PVC splint from the carpus to the toe, the higher and lower third of the splint was casted and the middle part left open to manage the joint and skin lesion that was dressed. Extra padding was considered in pastern region to prevent fetlock flexion. Casts should be replaced within a few days when significant soft tissue swelling is present at the time of application and within 4 weeks afterward in most other situations [8]. A thorough evaluation of a fetlock luxation should include radiography and manipulation of the joint. Manipulation of the injured fetlock joint with the horse under general anesthesia provides a more accurate assessment of the soft tissue damage and joint instability [6]; in this case, the more detailed evaluations after induction of anesthesia revealed healthy and intact adjacent structures. It seemed that a strong sudden blunt stroke had caused the problem in a dorsal direction, so that collateral ligaments could stay intact. In similar cases, radiographs should be taken to identify any avulsion fracture, intraarticular fractures, or damage to the articular surface that has entered into the subchondral bone [4]; none of these were observed in the present case. Damage to the digital vascular supply is uncommon [6]. Open fetlock luxations are contaminated and should be treated aggressively with systemic antibiotics, debridement of devitalized and contaminated soft tissues, and copious lavage of the joint. Complete closure of the soft
tissues has not been recommended because the drainage of synovial fluid and exudates from a contaminated joint is desirable [6]. Early intervention in this case resulted in no requirement for especial debridement; joint lavage was perfectly performed, and wound closure was done. Regional perfusion has been performed in the distal left forelimb with amikacin (amikacin sulfate 100), using the lateral digital vein at the level of the metacarpophalangeal joint [5]. In the present case, intraarticular amikacin besides systemic penicillin was administered. Intraarticular sodium hyaluronate 20 mg was administered 10 days later to restore the synovial fluid elastoviscosity. Acute open luxations of metacarpophalangeal/metatarsophalangeal joint can be immobilized using a cast, a dynamic compression plate, or a modified Cloward’s technique [1], depending on the severity of the situation and also the surgeon’s preference. Although surgical fusion is an alternative in severe cases, it was not a viable option at the time of presentation of this case. The prognosis for acute and open luxation depends on the severity of the trauma, but is generally guarded for athletic performance [7]. Although fetlock luxation is a severe injury, sometimes with a dramatic presentation of deviation of the fetlock and exposure of articular surfaces in open luxations, affected horses have a good prognosis for survival and attaining breeding status [6]. Reduction and immobilization for 4–6 weeks have been shown to result in fibrous restabilization of the joint and a good prognosis for light riding soundness [4], similar outcome was seen in this case. The prognosis for acute and open luxation depends on the severity of the trauma, but is generally guarded to poor for athletic performance [1,7]. One study revealed that only 1 of 10 horses returned to riding after luxation of the fetlock joint [6]. Follow-up radiographs
A. Raayat Jahromi, N. Vajdi / Journal of Equine Veterinary Science 48 (2017) 48–51
3–4 months after injury are recommended to better determine the prognosis [7]. Tenney and Withcomb have studied 17 horses with rupture of collateral ligaments in metacarpophalangeal and metatarsophalangeal joints; all horses have been lame (lameness score range, 2/5 to 4/5), rupture has been more in lateral collateral ligament, and no biaxial ruptures have been detected [1]. The collateral ligaments of the present case were intact. After cast removal following 5 weeks in this case, the stallion revealed no sign of lameness with an acceptable level of weight bearing on the affected limb. Keeping the stallion confined to a stall for 2 more months with a restricted daily short hand walk improved his movement completely. Immobilization of a limb with an open joint luxation can tremendously improve the healing process and prognosis.
51
References [1] Tenney WA, Whitcomb MB. Rupture of collateral ligaments in metacarpophalangeal and metatarsophalangeal joints in horses: 17 cases (1999-2005). J Am Vet Med Assoc 2008;233:456–62. [2] Baxter GM. Adams and Stashak’s lameness in horses. 6th Edition. West Sussex (UK): Wiley-Blackwell; 2011. p. 884–7. [3] Smith M. Management of joint instability. Equine Vet Educ 2010;22: 112–4. [4] Hinchcliff KW, Kaneps AJ, Geor RJ. Equine sports medicine and surgery. London (UK): Elsevier Health Sciences; 2004. p. 299. [5] Brommer H, Weisler S, Tatz A. Facilitated ankylosis of a juvenile, flexurally deformed, open, luxated and infected metacarpophalangeal joint using an alternative approach. Equine Vet Educ 2010;22:412–9. [6] Yovich JV, Turner AS, Stashak TS, McIlwraith CW. Luxation of the metacarpophalangeal and metatarsophalangeal joints in horses. Equine Vet J 1987;19:295–8. [7] Balaam T, Miller S. Severe open metacarpophalangeal joint luxation in a mule foal. Equine Vet Educ 2007;19:528–31. [8] Riggs C. Indications for and application of limb casts in the mature horse. Equine Vet Educ 1997;9:190–7.
Contents lists available at ScienceDirect
Journal of Equine Veterinary Science journal homepage: www.j-evs.com
Case Report
Successful Management of Severe Open Metacarpophalangeal Joint Dorsal Luxation in a Horse Alireza Raayat Jahromi*, Nasser Vajdi Department of Clinical Studies, School of Veterinary Medicine, Shiraz University, Shiraz, Iran
a r t i c l e i n f o
a b s t r a c t
Article history: Received 16 June 2015 Received in revised form 18 February 2016 Accepted 18 August 2016 Available online 26 August 2016
A 3-year-old Darreh-Shuri stallion was presented with left forelimb open dorsal fetlock luxation immediately after being hit by a motorized vehicle. The horse was in a non– weight-bearing position on the affected limb. General physical examination revealed normal vital parameters and no special concurrent abnormality. Radiographic examination in lateromedial and dorsopalmar views of the affected limb showed complete luxation of the metacarpophalangeal joint with no fractures. Ultrasonographic evaluation revealed intact collateral ligaments. Under general anesthesia and following routine preparations, forceful manual pressure was exerted on the distal part of the metacarpus and proximal part of the first phalanx to reduce the luxation. Joint capsule and skin laceration were sutured. Intraarticular amikacin (500 mg) was administered and repeated on the third and fifth days postoperatively. A palmar polyvinyl chloride, synthetic plastic polymer (PVC) splint was placed following adequate padding from the carpus to the toe. The higher and lower third of the splint was casted and the middle part left open to manage the joint and skin lesion. Intraarticular sodium hyaluronate (20 mg) was administered 10 days later. After cast removal following 5 weeks, the stallion revealed no sign of lameness. The owner was instructed to keep the stallion confined to a stall for at least 2 more months with a restricted daily short hand walk. Special casting methods for immobilization of a limb with an open joint luxation can tremendously improve the healing process. Ó 2016 Elsevier Inc. All rights reserved.
Keywords: Metacarpophalangeal joint Open dorsal luxation Horse
1. Introduction The metacarpophalangeal and metatarsophalangeal joints are high-motion joints that require a complex network of stabilizing structures to withstand loading forces. The medial and lateral collateral ligaments limit motion of these joints to the sagittal plane [1]. Lateral and medial luxation of the fetlock joint occurs uncommonly as a result of bending injuries and can affect all ages and breeds [2]. Dorsal luxation happens less frequently. In fetlock * Corresponding author at: Alireza Raayat Jahromi, Department of Clinical Studies, School of Veterinary Medicine, Shiraz University, Shiraz, 71441669155, Iran. E-mail address: [email protected] (A. Raayat Jahromi). 0737-0806/$ – see front matter Ó 2016 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jevs.2016.08.011
luxation, laceration of the joint capsule and rupture of the medial and/or lateral collateral ligament, or of the collateral sesamoidean ligament, or the oblique distal sesamoidean ligaments can be possible. In the acute phase following injury, pain and swelling are common [3]. Persistent laxity can be presumably contributed to the chronic osteoarthritis that is often the sequel after the injury [4]. This injury is frequently managed with cast or splint immobilization. Arthrodesis can be an option in severe cases or in horses that end with severe joint degeneration [5]. In one case report describing luxation of the metacarpophalangeal/metatarsophalangeal joint in horses, one half of the 10 reported cases sustained an open luxation [6]. Horses have been treated by cast immobilization after debridement of soft tissue and joint lavage; antibiotic
A. Raayat Jahromi, N. Vajdi / Journal of Equine Veterinary Science 48 (2017) 48–51
therapy and suture apposition of the ruptured collateral ligaments have also been attempted. An open fetlock luxation of the left forelimb with significant cartilage and periarticular damage in a mule foal has been successfully managed by surgical joint lavage, cartilage debridement, wound repair, and rigid cast immobilization [7]. This report presents the management of a severe open metacarpophalangeal joint dorsal luxation in a DarrehShuri stallion. 2. Case History A 3-year-old Darreh-Shuri stallion was referred to the Teaching Hospital of School of Veterinary Medicine, Shiraz University, with left forelimb open dorsal fetlock luxation immediately following being hit by a car. The horse was in a non–weight-bearing position on the affected limb (Fig. 1). General physical examination revealed normal vital parameters and no special concurrent abnormality. Radiographic examination of the affected limb in lateral view confirmed dorsal luxation of the fetlock with no sign of fracture (Fig. 2A). Ultrasonographic examination revealed intact collateral ligaments. Following fluid therapy and premedication using acepromazine (Neurotrang 1%, Alfasan, Woerden, Holland) (0.05 mg/kg IV) and xylazine (as HCL 2%) (1 mg/kg IV), anesthesia was IV induced by mixture of ketamine (als-hydrochloride 10%) (2 mg/kg IV) and diazepam (Zepadis, Caspian, Rasht, Iran) (0.1 mg/kg). After positioning in right lateral recumbency, the lesion was prepared aseptically and the joint space was lavaged copiously through the wound by normal saline to remove all debris. Precise inspection was carried out to see if there is any ligament or tendon injury. Considering the healthy adjacent structures, forceful manual pressure was exerted on the distal part of the metacarpus and proximal part of the first phalanx to reduce the luxation. Joint capsule was sutured with simple continuous of Vicryl 0. Skin lesion was
49
then apposed with simple interrupted pattern of Nylon 2. Intraarticular amikacin (EXIR, Boroojerd, Iran) (500 mg) was administered through the dorsal aspect of joint capsule and under the lateral edge of the common digital extensor tendon and repeated on third and fifth days postoperatively. Cast immobilization of the affected limb was decided. A palmar PVC splint was placed following adequate padding from the carpus to the toe, considering the extra cotton between the pastern region and the splint. The higher and lower third of the splint was casted and the middle part left open to manage the joint and skin lesion; this region was dressed using sterile nonadhesive gauze and bandage and changed after intraarticular administrations. The stallion recovered uneventfully. Other postoperative cares included phenylbutazone (Vetanyl 20%, Aburaihan, Tehran, Iran) (2.2 mg/kg IV) and penicillin procaine (Kanapen, Nasr, Fariman, Iran) (22,000 IU/kg Intramuscular), for 5 days. Intraarticular sodium hyaluronate (20 mg) was administered 10 days later. Strict restriction and confined stall rest was considered. Radiographic evaluations, after cast removal following 5 weeks, showed no sign of displacement on the joint. There was marked improvement in weight-bearing capacity of the affected limb without any evidence of swelling or pain upon palpation. No obvious lameness was observed during visual examination. The owner was instructed to keep the stallion confined to a stall for at least 2 more months with a restricted daily short hand walk. 3. Discussion Fetlock luxation of the present report was in dorsal direction, whereas most of the previous cases described in the literature are medial and lateral. The most common treatment for fetlock luxation is cast immobilization of the affected limb, with or without suture apposition of torn soft tissues [6]. Luxation of the joints in distal limb must be
Fig. 1. Open dorsal luxation of the non–weight-bearing left front limb.
50
A. Raayat Jahromi, N. Vajdi / Journal of Equine Veterinary Science 48 (2017) 48–51
Fig. 2. Preoperative (A) and postoperative (B) dorsal luxation of the fetlock joint.
stabilized after reduction, and this is most easily achieved with a cast [8]. External coaptation has a key role in protection of the repair, especially during recovery from general anesthesia, it greatly reduces the risk of catastrophic consequent complications [3]. The reduction of the affected joint in this case was supported in an almost innovative combined splint and casting method. Following padding and placement of a palmar PVC splint from the carpus to the toe, the higher and lower third of the splint was casted and the middle part left open to manage the joint and skin lesion that was dressed. Extra padding was considered in pastern region to prevent fetlock flexion. Casts should be replaced within a few days when significant soft tissue swelling is present at the time of application and within 4 weeks afterward in most other situations [8]. A thorough evaluation of a fetlock luxation should include radiography and manipulation of the joint. Manipulation of the injured fetlock joint with the horse under general anesthesia provides a more accurate assessment of the soft tissue damage and joint instability [6]; in this case, the more detailed evaluations after induction of anesthesia revealed healthy and intact adjacent structures. It seemed that a strong sudden blunt stroke had caused the problem in a dorsal direction, so that collateral ligaments could stay intact. In similar cases, radiographs should be taken to identify any avulsion fracture, intraarticular fractures, or damage to the articular surface that has entered into the subchondral bone [4]; none of these were observed in the present case. Damage to the digital vascular supply is uncommon [6]. Open fetlock luxations are contaminated and should be treated aggressively with systemic antibiotics, debridement of devitalized and contaminated soft tissues, and copious lavage of the joint. Complete closure of the soft
tissues has not been recommended because the drainage of synovial fluid and exudates from a contaminated joint is desirable [6]. Early intervention in this case resulted in no requirement for especial debridement; joint lavage was perfectly performed, and wound closure was done. Regional perfusion has been performed in the distal left forelimb with amikacin (amikacin sulfate 100), using the lateral digital vein at the level of the metacarpophalangeal joint [5]. In the present case, intraarticular amikacin besides systemic penicillin was administered. Intraarticular sodium hyaluronate 20 mg was administered 10 days later to restore the synovial fluid elastoviscosity. Acute open luxations of metacarpophalangeal/metatarsophalangeal joint can be immobilized using a cast, a dynamic compression plate, or a modified Cloward’s technique [1], depending on the severity of the situation and also the surgeon’s preference. Although surgical fusion is an alternative in severe cases, it was not a viable option at the time of presentation of this case. The prognosis for acute and open luxation depends on the severity of the trauma, but is generally guarded for athletic performance [7]. Although fetlock luxation is a severe injury, sometimes with a dramatic presentation of deviation of the fetlock and exposure of articular surfaces in open luxations, affected horses have a good prognosis for survival and attaining breeding status [6]. Reduction and immobilization for 4–6 weeks have been shown to result in fibrous restabilization of the joint and a good prognosis for light riding soundness [4], similar outcome was seen in this case. The prognosis for acute and open luxation depends on the severity of the trauma, but is generally guarded to poor for athletic performance [1,7]. One study revealed that only 1 of 10 horses returned to riding after luxation of the fetlock joint [6]. Follow-up radiographs
A. Raayat Jahromi, N. Vajdi / Journal of Equine Veterinary Science 48 (2017) 48–51
3–4 months after injury are recommended to better determine the prognosis [7]. Tenney and Withcomb have studied 17 horses with rupture of collateral ligaments in metacarpophalangeal and metatarsophalangeal joints; all horses have been lame (lameness score range, 2/5 to 4/5), rupture has been more in lateral collateral ligament, and no biaxial ruptures have been detected [1]. The collateral ligaments of the present case were intact. After cast removal following 5 weeks in this case, the stallion revealed no sign of lameness with an acceptable level of weight bearing on the affected limb. Keeping the stallion confined to a stall for 2 more months with a restricted daily short hand walk improved his movement completely. Immobilization of a limb with an open joint luxation can tremendously improve the healing process and prognosis.
51
References [1] Tenney WA, Whitcomb MB. Rupture of collateral ligaments in metacarpophalangeal and metatarsophalangeal joints in horses: 17 cases (1999-2005). J Am Vet Med Assoc 2008;233:456–62. [2] Baxter GM. Adams and Stashak’s lameness in horses. 6th Edition. West Sussex (UK): Wiley-Blackwell; 2011. p. 884–7. [3] Smith M. Management of joint instability. Equine Vet Educ 2010;22: 112–4. [4] Hinchcliff KW, Kaneps AJ, Geor RJ. Equine sports medicine and surgery. London (UK): Elsevier Health Sciences; 2004. p. 299. [5] Brommer H, Weisler S, Tatz A. Facilitated ankylosis of a juvenile, flexurally deformed, open, luxated and infected metacarpophalangeal joint using an alternative approach. Equine Vet Educ 2010;22:412–9. [6] Yovich JV, Turner AS, Stashak TS, McIlwraith CW. Luxation of the metacarpophalangeal and metatarsophalangeal joints in horses. Equine Vet J 1987;19:295–8. [7] Balaam T, Miller S. Severe open metacarpophalangeal joint luxation in a mule foal. Equine Vet Educ 2007;19:528–31. [8] Riggs C. Indications for and application of limb casts in the mature horse. Equine Vet Educ 1997;9:190–7.