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EQUINE VETERINARY EDUCATION


Equine vet. Educ. (2012) () -
doi: 10.1111/j.2042-3292.2012.00403.x

Case Report
Can distal border fragments of the navicular bone be a
primary cause of lameness?
M. Biggi, T. Blunden and S. Dyson*
Centre for Equine Studies, Animal Health Trust, UK.
Keywords: horse; distal sesamoidean impar ligament; podotrochlear apparatus; osseous cyst-like lesion; radiography;
MRI

Summary
A horse with unilateral forelimb lameness and pain
localised to the palmar aspect of the foot was evaluated
using radiography and low field magnetic resonance (MR)
imaging. A distal border fragment of the navicular bone,
an osseous cyst-like lesion (OCLL) in the distal third of
the navicular bone and focal distal sesamoidean impar
desmitis were identified as the most likely causes of
pain and lameness. No other lesions likely to contribute to
pain and lameness were identified on MR images or gross
post mortem examination. The OCLL was characterised
histologically by enlarged bone lacunae containing
proliferative fibrovascular tissue. Focal lesions of the distal
aspect of the navicular bone are rarely found in isolation
but can be causes of pain and lameness in horses.

Introduction
There are a variety of abnormalities of the navicular bone,
with or without lesions of the podotrochlear apparatus
(the collateral sesamoidean ligaments [CSL] or the distal
sesamoidean impar ligament [DSIL]) or the deep digital
flexor tendon, which may result in pain and forelimb
lameness (Dyson and Murray 2011; Dyson et al. 2011).
Fragments on the distal border of the navicular bone were
observed with higher frequency in horses with navicular
disease (Wright 1993; Schramme et al. 2005) compared
with horses free from lameness (Kaser-Hotz and Ueltschi
1992). However, fragments were identified in 7% of 523
horses (Kaser-Hotz and Ueltschi 1992) and 8.6% of 676
horses (Verwilghen et al. 2009) in which no lameness was
observed. Therefore, the contribution of a fragment to pain
and lameness is not completely understood. It has been
suggested that movement between a fragment and the
navicular bone may be a cause of pain and lameness
(Schramme et al. 2005).
*Corresponding author email: sue.dyson@aht.org.uk

In a correlative magnetic resonance imaging (MRI)


and post mortem study there was a significant association
between fragments and pathological lesions of the
DSIL (Dyson et al. 2010). In a clinical study there were
associations between the presence of a fragment and
specific lesions involving the distal border of the navicular
bone both on radiographs (Biggi and Dyson 2011b) and
magnetic resonance (MR) images (Biggi and Dyson
2011a). It has been suggested that a pathological fracture
may occur in some horses with advanced navicular
disease (OBrien 2005).
The aim of this report is to document a horse with
unilateral forelimb lameness in which a distal border
fragment was associated with focal navicular bone
pathology and injury of the DSIL as the principle cause
of lameness. Diagnostic imaging findings were verified
by post mortem examination and the histological
appearance of an osseous cyst-like lesion (OCLL) in the
distal third of the navicular bone was determined.

History and clinical findings


A 10-year-old Warmblood gelding used for advanced
dressage had intermittent left forelimb lameness of 4
months duration, which had developed immediately
after purchase. The left front foot was narrower and more
upright than the right front foot, but no other abnormalities
were identified by observation or palpation. No lameness
was observed at walk and trot in hand in straight lines or
on the lunge to the left and right on both soft and hard
surfaces. No changes in the gait were observed after
distal limb flexion tests of the forelimbs. When ridden the
horse showed mild left forelimb lameness (grade 1/8)
(Dyson 2011), only apparent on the right rein, most evident
in small circles. The lameness was completely abolished by
palmar digital nerve blocks; there was mild improvement
after intra-articular analgesia of the distal interphalangeal
(DIP) joint at 5 min after injection.
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Focal lesion in the distal border of the navicular bone

Radiography and radiology

Magnetic resonance imaging

Radiographic examination1 of the front foot was


performed, including lateromedial (LM), dorsopalmar
(DPa), 2 dorsoproximal-palmarodistal oblique (DPr-PaDiO)
images exposed for the distal phalanx and for the navicular
bone, respectively and with slight differences in angulation
of the dorsal hoof wall (perpendicular to the horizontal and
angled 1015 in front of the perpendicular, respectively),
palmaroproximal-palmarodistal oblique (PaPr-PaDiO) and
flexed oblique projections (Butler et al. 2008). Comparative
images of the contralateral limb were also acquired.
In the left forelimb there was a large fragment at the
junction between the distal horizontal and lateral sloping
borders (Fig 1). The distal border of the navicular bone
proximal to the fragment was irregular with an ill-defined
radiolucent area just proximal to it, apparently not
connected with the distal border. Several small radiolucent
areas (synovial invaginations) were observed along the
distal horizontal border of the navicular bone. No fragment
was identified in the right forelimb.

MR images were acquired using a low field (0.27T) magnet2


with the horse standing and sedated. T1 and T2* weighted
gradient echo (GRE), fast spin echo (FSE) and short tau
inversion recovery (STIR) sequences were acquired in
sagittal, dorsal and transverse planes (Smith 2009). Both
front feet were examined. Results are presented for the
lame limb; no significant abnormality was identified in
the nonlame limb.
There was a large fragment at the distal border of the
navicular bone laterally with mild modelling of the distal
border abaxial to the fragment. In the distal third of the
navicular bone, in the same sagittal plane as the fragment,
there was an OCLL which had high signal intensity in
T2* weighted GRE and STIR sequences (Fig 2) and
intermediate signal intensity in T1 weighted GRE images; it
was surrounded by an hypointense rim in both T1 weighted
and T2* weighted GRE sequences (Fig 3). There was no
detectable connection between the OCLL and the joint
space; the distal cortex of the navicular bone at the level
of the OCLL appeared intact. The DSIL had mild increased
signal intensity abaxial to the fragment in T2* weighted GRE
sequences and its palmar border was irregular laterally.
There appeared to be tissue extending from the dorsal
aspect of the lateral lobe of the deep digital flexor tendon
(DDFT) to the palmar aspect of the fragment. The DDFT
had mild diffuse increased signal intensity in T1 and T2*
weighted GRE sequences from the palmar aspect of the
navicular bone distally to its insertion on the distal phalanx.

a)

Post mortem findings and histopathology


b)

Fig 1: Dorsoproximal-palmarodistal oblique radiographic images


of the left navicular bone acquired with the foot at slightly different
angles (b = perpendicular to the horizontal, a = 1015 in front of
the perpendicular); lateral is to the right. a) There is an osseous
fragment (arrows) at the junction between the distal horizontal and
lateral sloping borders of the navicular bone. In the distal border
proximal to the fragment there is an ill defined radiolucent area
(arrowheads). b) The fragment is clearly visible (arrowheads) and
there is a defect in the distal border of the navicular bone proximal
to it (arrows) which was not visible in a). The frog clefts and central
sulcus were not packed.

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The horse, which had been lamer historically when in


regular work, was humanely destroyed because of the
poor prognosis for advanced dressage. The fragment was
embedded in the DSIL and the surrounding ligament was
considerably harder on palpation compared with the
contralateral side. Proximal to the fragment there was a
depression in the distal border of the navicular bone
(Fig 4); no movement between the fragment and the
bone was detected. There was no tissue between the
DDFT and the fragment. Focal, mild partial thickness
fibrocartilage loss was observed on the palmar cortex of
the navicular bone at the level of the sagittal ridge,
midway between the proximal and distal borders. No other
abnormality was identified on gross dissection which may
have contributed to pain and lameness.
Sagittal histological sections of the navicular bone and
DSIL were obtained at medial, axial and lateral sites for
comparison. In the same sagittal plane as the fragment,
the lesional area was characterised histologically by an
island of metaplastic bone located near to the origin of
and within the DSIL; areas of fibrocartilaginous metaplasia
with clefting were present between the metaplastic bone
and the distal border of the navicular bone. Fissuring of the

M. Biggi et al.

a)

Fig 3: Dorsal high resolution T1 weighted gradient echo image of


the navicular bone. Lateral is to the right. There is a large fragment
at the junction between the distal horizontal and lateral sloping
borders (arrows). There is an osseous cyst-like lesion (OCLL) in the
distal border of the navicular bone characterised by an area of
intermediate signal intensity surrounded by an hypointense rim
(arrowheads).

b)

Fig 4: Palmar surface of the left navicular bone; lateral is to the left.
The osseous fragment is embedded in the distal sesamoidean
impar ligament (white arrows). There is a well defined depression in
the contour of the distal aspect of the navicular bone proximal to
the fragment. There is mild fibrocartilage loss around the sagittal
ridge midway from proximal to distal.

Fig 2: Lateral parasagittal T2* weighted gradient echo (a) and short
tau inversion recovery (b) images of the left foot. a) There is a well
defined osseous cyst-like lesion (OCLL) in the distal third of the
navicular bone with mild increased signal intensity surrounded by
an hypointense rim (white arrow). The lesion corresponds to the ill
defined radiolucenct area seen in Figure 1a. The fragment is visible
as an hypointense area embedded in the distal sesamoidean
impar ligament (black arrows). b) There is an oval area of
homogeneous high signal intensity which corresponds to the OCLL
observed in a).

DSIL extended to approximately half the palmarodorsal


depth of the ligament, with large chondrones present
around the fissures (Fig 5a). The distal cortex of the
navicular bone was irregular with loss of the calcified zone
and underlying bone loss. Dorsal to the origin of the DSIL

there were enlarged bone spaces, within the distal border


cortex and extending into the spongiosa, which contained
proliferative fibrovascular tissue (Fig 5b); some bone
trabeculae had spiculated edges. There was <20% loss of
thickness of fibrocartilage at the site of the gross lesion
in the mid-sagittal plane. No significant abnormality of the
DDFT was identified.

Discussion
To our knowledge this is the first report in which a distal
border fragment, associated with focal pathology in the
adjacent navicular bone and DSIL, were considered to be
the most likely causes of pain and lameness. Although
there were low grade signal intensity changes in the lateral
lobe of the DDFT in MR images, no structural abnormality
was identified grossly or histologically. The contribution of
a fragment to pain and lameness has been subject to
debate because fragments have been observed, albeit
with low prevalence, in sound horses, or in conjunction with
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Focal lesion in the distal border of the navicular bone

a)

b)

Fig 5: Sagittal histological section of the navicular bone (NB)


obtained at the level of the lesion in the distal border. Proximal is to
the right of the picture and palmar is to the top. a) There is an area
of transverse fissuring in the distal sesamoidean impar ligament
(DSIL) near the distal cortex of the bone (black arrows); the lesion
is surrounded by large chondrones (arrowheads). The distal border
cortex is very irregular with loss of calcified zone and focal bone
loss (white arrows) (Haematoxylin & eosin 10); b) Distal border
of the navicular bone just proximal to the origin of the DSIL.
There are several enlarged bone spaces containing proliferative
fibrovascular tissue. This lesion corresponds to the osseous cyst-like
lesion (OCLL) observed on magnetic resonance images
(Haematoxylin & eosin 2).

other lesions potentially contributing to pain in lame horses.


Fragments are often associated with more extensive
abnormalities of the navicular bone both on radiographs
(Biggi and Dyson 2011b) and MR images (Biggi and Dyson
2011a). From 2001 to the present we have identified
only one additional horse in which a fragment associated
with focal lesion in the distal border of the navicular
bone (OCLL) and focal DSIL desmitis were considered the
most likely causes of pain and lameness. Similar to the
horse reported, no other lesions of the foot and pastern
were identified using high-field MRI, but post mortem
examination was not performed.
The horse in this report showed low grade unilateral
lameness which was observed only when examined in
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circles on a soft surface. Lameness was seen only when


ridden. It is likely that the low grade lameness detected at
the time of the examination was related to the recent low
level of exercise, because the owner reported that the
horse had been substantially lamer when in regular work,
albeit only when ridden. Historically, lameness associated
with navicular bone pathology has been characterised
by a moderate grade bilateral lameness, usually worst on
a circle on a hard surface. However, in some horses,
lameness is mild and detectable only during ridden
exercise (Dyson 2010). Evaluation of lameness on different
surfaces is extremely important to accurately characterise
the degree and type of lameness (Dyson 2011).
Assessment of a horse when ridden is sometimes essential,
although the biomechanical influences on the limbs
of a horse with or without a rider have been poorly
documented.
Intra-articular analgesia of the DIP joint resulted in only
mild improvement of the lameness. Analgesia of the
navicular bursa may have further substantiated that the
fragment and associated abnormalities were the primary
sources of pain. However this could not be safely
performed because of the temperament of the horse. In a
previous study which compared responses to intra-articular
analgesia of the DIP joint and intrathecal analgesia of the
navicular bursa, 20% of horses with a negative response
to intra-articular analgesia of the DIP joint showed
improvement in lameness after analgesia of the navicular
bursa within 5 min of injection in association with navicular
bone pathology (Dyson and Kidd 1993; Dyson 1995).
In both horses with focal navicular bone and DSIL
pathology, lameness was detectable only when the lame
limb was on the outside of a circle, although the lesions in
the navicular bone were localised laterally and medially,
respectively. The biomechanical influences of a front
foot landing on the inside or outside of a circle have
been poorly documented and may also be influenced
by an individuals limb flight, foot placement and foot
conformation. In an experimental in vivo kinematic study,
the DIP joint of the inside front foot landed flatter and with
less rocking motion on a turn compared with straight lines
and there was less flexion and extension of the DIP joint
(Chateau et al. 2005). However, the DIP joint underwent a
substantial medial rotation and lateral movement of the
middle phalanx relative to the distal phalanx during the
weightbearing phase of the stride, with lateral rotation of
the DIP joint during breakover when horses walked in a
circle compared with straight lines (Chateau et al. 2005).
These rotational movements of the DIP joint will influence
biomechanical loads on the podotrochlear apparatus
because the navicular bone is an integral part of the DIP
joint.
The focal lesions observed in this report suggest that the
navicular bone and/or the DSIL can be sources of pain,
perhaps because of movement of a fragment relative to
the distal border of the navicular bone (Schramme et al.
2005) and/or associated lesions of the DSIL and navicular

M. Biggi et al.

bone. Post mortem evaluation revealed a palpably firm


connection between the fragment and the navicular
bone; however, movement may have occurred in vivo
under maximal loading, especially turning. The DSIL has a
rich sensory innervation (Van Wulfen and Bowker 2002)
which may also be responsible for mediating pain and
lameness. Mild fibrocartilage erosion on the sagittal ridge
of the navicular bone was observed on post mortem
examination grossly and histologically. This type of lesion
can be observed in sound horses (Blunden et al. 2006),
therefore we considered the lesion likely to be an
incidental finding, although we cannot definitively state
that it could not have contributed to pain.
Evaluation of the distal border of the navicular bone
on radiographs is not always easy on a DPr-PaDi oblique
image and agreement in fragment detection between
experienced interpreters was poor (Groth et al. 2009).
Correct positioning of the foot is crucial (Butler et al. 2008).
Acquisition of 2 DPr-PaDi oblique images obtained with
slightly different angles of the dorsal hoof wall relative to
the horizontal are extremely helpful for evaluation of both
the dorsal and palmar aspects of the distal border of the
navicular bone. When the dorsal hoof wall is perpendicular
to the ground the dorsal and palmar distal borders of
the navicular bone are not superimposed making the
identification of a defect or a fragment easier (Biggi and
Dyson 2010). The presence of a radiolucent area or a
defect in the distal border of the navicular bone highlights
the potential presence of a fragment (Biggi and Dyson
2010). We had suspected the presence of adhesion
formation between the DDFT and the fragment which was
not confirmed at post mortem examination. The slice
thickness used during low field MRI may have led to volume
averaging artifact. Nor was any structural abnormality of
the DDFT confirmed, despite low grade alteration in signal
intensity in MR images. This highlights the need to avoid
overinterpretation of subtle abnormalities. Evaluation of
the DSIL can be difficult using low field MRI because often,
in transverse images, only one slice is available through
the body of the ligament (Dyson et al. 2010). However,
the lesion identified using MRI was confirmed on
histopathology. An association between lesions of the
DSIL and distal border fragments has previously been
documented in a comparative MRI and histopathology
study (Dyson et al. 2010).
In the MR images the OCLL appeared as a fluid-filled
lesion surrounded by a hypointense rim in both T1 weighted
and T2* weighted GRE images. This is consistent with a
mineralised rim. In T2* weighted GRE images an hypointense
line at the margin of a lesion could represent a fat-fluid
phase cancellation artifact (Werpy 2009); however, the
presence of a similar line on T1 weighted images indicates
mineralisation. The cortex distal to the OCLL appeared
intact; however, we cannot exclude the possibility that a
connection was missed because of the slice thickness.
To our knowledge, there have been no previous
descriptions of the histological appearance of an OCLL of

this type in the distal third of the navicular bone without


other pathological abnormalities of the navicular bone,
although an association was noted between the presence
of an OCLL and lesions of the DSIL (Dyson et al. 2010).
There was evidence of enlarged bone lacunae and
replacement by fibrovascular tissue. Developing OCLLs at
the insertion of a collateral ligament of the DIP joint had
a similar histological appearance (Dyson et al. 2008).
Histologically, the fragment appeared as an island
of metaplastic bone, suggesting that this dystrophic
mineralisation represents an entheseous reaction in
the DSIL, as previously described (Blunden et al. 2006).
However, definitive differentiation between focal osseous
metaplasia and a fracture of a mature entheseophyte
remains challenging.
This report has some limitations. The lesions were
diagnosed based on low field MRI. It is possible that
subtle lesions elsewhere could have been missed because
of the slice thickness and image resolution. However,
a focal lesion in the DSIL was observed on MR images
and confirmed histologically. In addition, histology was
performed only on the structures that had abnormal signal
intensity on MR images or abnormalities on gross post
mortem examination.
In conclusion we believe that this report provides
new information to suggest that a distal border fragment
of the navicular bone may be of clinical significance
in conjunction with lesions of the adjacent navicular
bone and DSIL in some horses and this should be borne
in mind when interpreting prepurchase examination
radiographs.

Authors declaration of interests


No conflicts of interest have been declared.

Acknowledgements
We thank Ray Wright for preparation of the histological
sections.

Manufacturers addresses
1Carestream
2Hallmarq,

Health, Hemel Hempstead, Herts, UK.


Hallmarq Veterinary Imaging, Guildford, UK.

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