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Equine distal limb fractures

Description
Distal Phalanx (P3) Fractures


Incidence
  • racehorses (Standardbred), forelimb
  • trauma
  • foals

    Diagnosis
  • weight bearing lameness
  • accentuated with hard surface, circling
  • positive hoof testers, percussion, digital pulse
  • +/- swelling coronary band, arthrocentesis
  • +/- palmar digital nerve block, positive abaxial nerve block

    Radiography
  • multiple 60 degrees dorsoproximal-palmardistal views
  • repeat in 10-14 days

    Classification
  • I alar wing fracture - nonarticular
  • II alar wing fracture - articular
  • III midsagittal articular
  • IV extensor process avulsion
  • V miscellaneous or marginal (secondary to laminitis, pedal osteitis, pathologic fracture)

    Treatment
  • I stall rest (3-6 wks), therapeutic shoeing, +/- ipsilateral neurectomy
  • II stall rest (6-12 wks), therapeutic shoeing, +/- neurectomy, internal fixation
  • III stall rest, therapeutic shoeing, internal fixation
  • IV stall rest, removal of fragment or internal fixation (3.5 ASIF Navicular Screw)
  • V stall rest, therapeutic shoeing assess healing radiographically

    Prognosis
  • Type I and V, young horses-- good; all others guarded due to secondary DJD





    Navicular Bone Fractures


    Incidence
  • uncommon, Racehorses, forelimb
  • pathologic fracture
  • trauma

    Diagnosis
  • acute lameness, resist placing heel, accentuated hard surface and circling
  • positive hoof testers heel and frog
  • PD nerve block ameliorates lameness, bilateral lameness?
  • Radiography - confirms diagnosis
  • 60š dorsoproximal palmardistal
  • evidence healing not associated with degree of lameness
  • rule out bipartite or tripartite navicular bone - radiograph opposite limb

    Classification
  • simple transverse or oblique
  • avulsion, chip (pathologic)
  • comminuted

    Treatment
  • stall rest, therapeutic shoeing
  • +/- neurectomy (after 6--8 wks)
  • internal fixation -- athletic horse, lag screw (fluoroscopy)
  • fibrous union common

    Prognosis
  • depends on inciting cause
  • fair to guarded due to DJD, tendon-bone adhesions, bursitis





    Middle Phalanx (P2) Fractures


    Incidence
  • acute injury, Western event horses and polo ponies
  • rim shoes and heel caulks (increase torsional stress)
  • higher incidence in hindlimbs

    Diagnosis
  • acute onset lameness, often non-weight bearing
  • swelling +/- crepitation pastern area
  • positive flexion
  • Radiography
  • four views (lateral-medial, dorsopalmar, DLPMO, DMPLO)

    Classification
  • proximal caudal eminence, frontal, and subchondral fractures
  • comminuted 4X more common

    Treatment
  • casting 3-5 months
  • internal fixation / autogenous cancellous bone graft
  • T-plate
  • ASIF compression plates
  • Pastern arthrodesis: Screws (3 parallel, divergent, or two criss-cross)
  • external fixator device
  • cast 4-8 weeks, followed by 4-8 wks stall/small paddock rest

    Prognosis
  • depends on configuration and articular involvement (hind>fore)
  • casting poor to guarded
  • internal fixation fair





    Proximal Phalanx (P1) Fractures


    Incidence
  • common
  • Racehorses, 2-6 years of age

    Diagnosis
  • lameness dependent on type and severity
  • metacarpal phalangeal effusion
  • positive fetlock flexion test
  • NO NERVE BLOCKS !
  • Radiography
  • multiple views
  • Scintigraphy

    Classification
    1. Midsagittal: short, long, complete
    2. Dorsal Frontal
    3. Distal joint
    4. Palmar/Plantar Process
    5. Physeal (usually Salter II)
    6. Oblique/Transverse Diaphyseal Fracture
    7. Comminuted: intact / lacking strut

    Treatment
  • Midsagittal: 4.5 or 5.5 mm cortical lag screw fixation, stab incisions
  • Dorsal Frontal, Distal Joint, Palmar/Plantar Process:
  • conservative: stall rest
  • internal fixation: reduction and 3.5 , 4.5 or 5.5 mm lag screw fixation
  • Physeal: reduction, casting, +/- internal fixation
  • Oblique/Transverse Diaphyseal Fracture: lag screw, narrow DCP plate(s), cast 6-12 wks
  • Comminuted: lag screw fixation/external skeletal fixation
  • monitor fracture radiographically every 4-6 wks, passive flexion
  • 4-6 months pasture rest after bony union (comminuted fx)

    Prognosis
  • non-comminuted: good to excellent
  • comminuted: with supporting strut -fair; all others poor





    Metacarpal/Metatarsal Fractures


    Incidence
  • Common among racehorses
  • Thoroughbred, Standardbred, mostly 2-4 years old
  • Thoroughbred: fore > hind
  • Standardbred: fore = hind

    Diagnosis
  • Acute lameness following training/racing
  • moderate to non weight bearing
  • marked synovial effusion (intra-articular), painful palpation MC/MT III
  • transverse or comminuted: pain, crepitation, med-lat instability
  • NO NERVE BLOCKS !
  • Radiography
  • Dorsopalmar (plantar), obliques, multiple views
  • 125š dorsopalmar with partial fetlock flexion

    Frequently Accompanying Lesions
  • distal MC/MT III subchondral chip fracture
  • proximal first phalanx chip fracture
  • proximal axial sesamoid fracture
  • suspensory desmitis

    Classification
  • complete/incomplete; displaced/non displaced; open/closed

    Treatment
  • depends on configuration, comminution, location, size of horse
  • non displaced
  • conservative: stall rest, wraps.....fracture propagation?
  • internal fixation: cast, lag screw fixation, DCP plate(s)

    Improved articular surface healing, decrease convalescence
  • displaced
  • comminuted: DCP plates and full limb cast, external fixation device, autogenous cancellous bone graft

    Prognosis
  • excellent with minimal displacement, foals, closed fractures
  • decreases with comminution and articular involvement

    Complications
  • osteomyelitis, implant failure, sequestration, ischemic necrosis,
  • breakdown of contralateral limb





    Fractures of Small Metacarpal/Metatarsal Bones


    Incidence
  • direct trauma (kick, interference) - all ages (MC/MT IV)
  • acute injury; young racehorses MC/MT II
  • sequela to suspensor desmitis (Standardbred)
  • faulty conformation (benched knees)
  • articular / non articular; open / closed

    Diagnosis
  • +/- lameness
  • localized heat, pain, swelling
  • chronic purulent draining wound
  • local anesthetic infiltration
  • Radiography
  • DLPMO / DMPLO

    Treatment
  • Distal Fracture: stall rest 30-60 days, NSAID's, wraps, sweats
  • Surgical removal -- distal two thirds only (except MT IV)
  • Proximal Fracture/Open Fracture:
  • MC II - insertion medial collateral ligament, flexor carpi radialis, extensor carpi oblique muscle
  • MC IV - insertion lateral collateral, ulnaris lateralis

    Internal Fixation
  • lag screw fixation?
  • 3.5 mm DCP/reconstruction plate
  • open fracture: thorough debridement
  • removal (MT IV only)

    Prognosis
  • Distal splint: excellent
  • **concurrent suspensory desmitis is the limiting factor





    Proximal Sesamoid Fractures


    Incidence
  • Most common in racehorses
  • Standardbred: hind > fore; lateral > medial
  • Thoroughbred: fore > hind; medial > lateral
  • Severe dorsiflexion (hyperextension fetlock)

    Diagnosis
  • acute onset during or after training
  • swelling, heat, over sesamoid and corresponding suspensory
  • +/- effusion proximal pouch fetlock
  • painful upon palpation, positive fetlock flexion
  • unilateral low volar (2 pt) nerve block
  • Radiography
  • four views
  • 120šproximodorsolateral-distal palmar medial oblique

    Classification
    1) Apical Fracture: most common
    2) Midbody Fracture/Transverse: TB breakdown injury
    3) Basilar Fracture: "T-fracture"
    4) Abaxial Fracture
    5) Axial (Sagittal) Fracture: secondary to MC/MT III fracture

  • poor healing due to lack periosteal and endosteal activity lead to weak, fibrous union
  • suspensory attaches to proximal palmar/plantar and abaxial sesamoid
  • **treatment aimed at normalizing the suspensory apparatus


    Treatment Apical Fracture:
  • Palmar/plantar arthroscopy/arthrotomy and removal
  • Treat concurrent suspensory desmitis


  • Prognosis
    Good if less than 1/3 involved; hind > fore

    Treatment Midbody Fracture:
  • Interfragmentary compression (distal-proximal) plus autogenous cancellous bone graft
  • Circumferential wiring plus autogenous cancellous bone graft


  • Prognosis:
    dependent on amount distraction, comminution and size of fragment

    Treatment Basilar Fracture:
  • palmar/plantar arthrotomy and fragment removal
  • circumferential wiring plus autogenous cancellous bone graft
  • stall rest


  • Prognosis:
    dependent on amount distraction, comminution, size of fragment and extent of distal sesmoidean ligament damage

    Treatment Abaxial Fracture:
  • non-articular - stall rest
  • articular - palmar/plantar arthrotomy and removal
  • interfragmentary compression


  • Prognosis:
    non-articular - good


  • Prognosis:
    articular - dependent on size of fragment

    Treatment Sagittal/Axial Fracture:
  • interfragmentary compression plus autogenous cancellous graft


  • Prognosis:
    poor
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