MODULE-1: BODY CONFORMATION OF THE HORSE IN RELATION TO

LAMENESS

Learning objectives

This module deals with

• Conformation
• Lameness and its classification
• Grading the lameness

CONFORMATION

• The conformation of the horse is the key to its method of progression. Poor conformation of
limbs contributes to certain lamenesses.

Conformation of the forelimb

• The forelimb bears 60 to 65 % of the weight of the horse.

• The forelimbs are subjected to more injuries from concussion and trauma than the
hindlimbs because the forelimbs not only bears weight if the body in the movement, but
also aid the hindlimbs in propelling the body.

FAULTS IN THE CONFORMATION

Faults in the conformation of the forelimbs

• Base narrow
• Base wide
• Toe in or pigeon toed
• Toe out or splay footed
• Base narrow and toe in
• Base narrow and toe out
• Base wide and toe in
• Base wide and toe out
• Plaiting
• Calf knees
• Camped in front
• Short upright pastern
• Long sloping pastern
• Long upright
• Bucked knees or knee sprung
• Carpus valgus (medial deviation of carpus)
• Carpus varus
• Open knees
• Ofset or bench knees
• Tied in knees
• Cut out under the knees
• Standing under in front

Faults in conformation of hind limbs

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 • Base wide
• Tarsus valgus/ cow hock
• Sickle hock
• Straight behind
• Straight under behind
• Camped behind

GRADING THE LAMENESS

Grade I

• Lameness is not observed in walk but recognizable in trot. Forelimb- head and neck
movements will be evident, but not in the hind limb.
• Hind limb- mild asymmetry in the gluteal rise will be noticed.
• Observed in chronic, non progressive disease causing lameness.

Grade II

• An alteration in gait is noticed at a walk but no evident head movements associated with it.
• At trot the lameness becomes obvious with head and neck movements are evident.
• Hind limb- A greater degree of asymmetry of gluteal rise and shortened duration.

Grade III

• Lameness is evident at walk and trot. Head lifting during weight bearing is the prominent
feature of the forelimb.
• In hind limb head nodding when the opposite forelimb hits the ground while trotting is
obvious

Grade IV

• A non weight bearing lameness is present.

RELATIONSHIP BETWEEN CONFORMATION AND LAMENESS

• Poor conformation of limbs contributes to certain lamenesses, for example base narrow
forelimbs lead to interference and may predispose to side bone.

DEFINITION AND DISEASES OF LAMENESS

Definition

• Any structural or functional disorder of locomotor system is called lameness. These may be
congenital or acquired in nature and may be caused by a variety of etiological agents such as
trauma, poor conformation, defeciency of calcium, phosphorus, vitamin A, D or E, infection,
metabolic disorders, circulatory or nervous disorders, etc.

Diseases

• Gonitis
• Rupture
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 • Fibrotic myopathy
• Stringhalt/ Springhalt
• Chondromalacia of the patella
• Thorough pin
• Spavin
• Curb and Capped hock
• Ulceration of sole,Interdigital fibroma and sore shin
• Ring, side and navicular bone
• Pyramidal and Sand crack
• Fractures
• Canker and Corn
• Paralysis
• Bicipital bursitis and Omarthiritis
• Knee
• Wind puff/ Wind gull, Osselets and Septic arthritis
• Ostochondritis dissecans and degenerative joint disease
• Laminitis and Hoof avulsion

Classification

• Supporting limb lameness

o This is evidenced when the horse supports the weight on the foot.
o e.g., injury to bones, joints, collateral ligaments
• Swinging limb lameness
o This is evident when the limb is in motion.
o e.g., pathologic changes involving joint capsules, muscles, tendons, and tendon
sheaths.
• Mixed lameness
o This is evident both when the limb is in motion and when it is supporting the weight.
• Complementary lameness
o Pain in one limb cause uneven distribution if weight on the another limb or limbs
which can produce lameness in lameness in previously sound limb.

Diagnosis of lameness

• Anamnesis
o The questions to be answered in the anamnesis:
o How long the horse been lame?
o Has the horse been rested or exercised during the lameness period?
o What caused the lameness?
o Does the horse warm out of the lameness?
o Does he stumble?
o What treatment has been done and was it helpful?
o When was the horse shoed?
• Procedure for examination
o Visual Examination
o At rest
 Careful visual examination from a distance and then close up
 Conformation, body condition, alteration in posture, weight shifting and
pointing is noted.
o At exercise

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  Gait of all limbs should be observed from a distance. This is done to identify
the limb(s) involved, the degree of lameness and in-coordination of in
movement.
o Handle the horse during the exercise
 Should not be held loose to avoid head and neck swaying from one to another
which will create asymmetric gait.
 If the head is held tight the nodding during the gait will be difficult to observe.
o Selection of the surface
 Hard surface is preferred for the lameness evaluation
 The unsound foot makes less noise because less weight is taken on that foot.
 Gravel surface is preferred for evaluation of sole and frog.
o Forelimb
 As the result of lameness of forelimb, the head will drop when the sound foot
lands and rises when weight is placed on the unsound foot or limb.
o Hind limb
 The head and neck movements can be best appreciated from the side in the
trotting gait.
 In moderate and severe lameness, the head and neck will rise as the
unaffected limb contacts the ground and lowers when the unsound limb
contacts the ground.
• Examination by palpation and manipulation
o Palpation is started from the bottom and complete examination of the limb should be
done.
o Size and shape of the lame foot should be compared with the normal opposite
member.
o Each part of the limb is manipulated and palpated for any abnormality and pain
perception.
• Local Anaesthesia
o Local anaesthetic solutions are infiltrated in suspected limb for the diagnosis of
lameness
o Types of local anaesthesia
 Perineural infiltration
 Field block
 Direct infiltration of a sensitive region
 Intra-synovial anaesthesia

Other diagnostic procedures for lameness

• Radiography
• Arthroscopy
• Scintigraphy
• Thermography

SYMMETRY OF HOOF PAIRS

• Generally, the toe length of a hoof should be equal to that of its counterpart.
• Variation in hoof angle, however, often occurs in paired limbs because of individual limb
conformation.
• In some horses, the difference should be minimized through trimming and shoeing; but in
many animals, the mismatched hooves should be allowed to be different.
• Dynamic balance may indicate which path the farrier should choose.
• The hoove will be trimmed and shod differently so that they move the same.
• There is a normal difference in shape and hoof angle between forefeet and hindfeet.

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 • The forefeet are usually larger, rounder, and wider at the heels and have flatter soles than
the hindfeet. Hindfeet are commonly one shoe size smaller, are more pointed at the toe, and
have a more convcave sole and higher hoof angle.

MODULE-2: LAMENESS

Learning objectives

This module deals with

• Diseases of lameness and its clinical signs, diagnose and treatment

GONITIS

• Gonitis is an inflammation of the stifle joint.

• It leads to degenerative joint disease and more common in bullocks than in horses.
• Multiple factors are responsible for gonitis.
• It includes- osteochondosis, persistent upward fixation of the patella, injuries to the medial
or lateral collateral ligaments, injuries to the cruciate ligaments or the menisci, erosion of
the articular cartilage or bacterial infection.
• Two types of gonitis- acute and chronic gonitis.

Acute gonitis

• Acute gonits is occasionally found in working bullocks and breeding bulls. Most common
region is the trauma .Overextension of the stifle joint e.g. accidental slipping.
• Symptoms
o Clinical signs vary with the cause and extent of the pathologic changes.
o Synovitis and arthritis
o Painful and swollen joint
o Incomplete flexion and stiffness of the joint during progression
o Shortening of the stride
o Dragging of the toe
• Diagnosis
o Diagnosis depends on relevant history, clinical findings and radiograph,
ultrasonograph.
• Treatment
o General treatment for acute inflammation

Chronic gonitis

• More incidences in bullocks, heavy draft horsed and breeding bulls

• Causes
o Excessive strain on the joint may be an exciting factor. It may also be due to
rheumatism or toxins.
• Symptoms
o Symptoms appear gradually and in the initial stages are not pronounced.
o During rest repeatedly flexes the stifle and keeps the limb slightly raised form the
ground.
o Dragging of the toe during progression
o Boggy enlargement of the joint due to distension of the joint capsule
o Pain may be evinced on palpation

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 o Erosion of articular surfaces and crepitation may be heard on flexion of the joint.
• Prognosis: Incurable
• Treatment
o Treatment is not effective. However, following measures should be taken
 Prolonged rest is indicated.
 Repeated intra-articular injections of steroids or hyaluronic acid may be
useful.
 Firing and blistering may be tried.

RUPTURE

Rupture of tendo-achilles

• Rupture of tendo-achilis (gastrocnemius muscle or its tendon) is relatively rare and can be
seen in horse, cattle, dog and cat.
• Causes
o Excessive strain on the tendon during jumping or while pulling the heavy craft
o External violence
o Malicious injury
o Deficiency of Ca, P and Vit-D
o Prolonged recumbency with myositis and struggling to rise
• Symptoms
o Affected limb is not able to bear weight
o Flexed of all joints below the hock
• Treatment
o Tendon sutures may be tried and immobilized the affected limb in extended position.
Keep the hock extended by putting plaster of Paris cast or splint or PVC splint
bandage. Healing will notice four to six weeks. Restricted movement should be
advised and provide adequate vitamins and minerals.
• Prognosis
o Favourable in small animal if properly treated but in large animal healing is difficult
when tendons are completely cut.

Rupture of peroneus tertius muscle

• The peroneus tertius muscle can be forcibly avulsed from its insertion by accidents
associated with mounting or the inexperienced use of ropes to restrain a hind limb.
• Clinical signs
o The hock is abnormally extended
o Not able to weight bearing in affected limb
o The calcaneal tendon is flaccid and the hoof may be dragged
o Painful to touch the avulsion part
• Treatment
o Treatment includes restricted the movement for several months depending on the
condition.

FIBROTIC AND OSSIFYING MYOPATHY

Fibrotic myopathy

• Fibrotic myopathy is a chronic, progressive, idiopathic, degenerative disorder affecting the

semitendinosus, gracilis, quadriceps, infraspinatus and supraspinatus muscles primarily in
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 dogs and uncommon condition is seen in working horses as a result of trauma to the
semimembranosus, semitendinosus and biceps femoris muscles.
• Affected muscles are contracture and fibrosis. Normal tissues are replaced by dense
collagenous connective tissues.
• Etiology: Unknown
• Clinical sings: Nonpainful in contracture area and mechanical lameness. Neurologic
function is normal.
• Treatment: Surgical treatment includes release of affected tissues via tenotomy,
myotenotomy, Z-plasty, or complete resection.
• Prognosis: Guarded due to recurrence

Ossifying myopathy

• Ossifying myopathy results from fibrotic myopathy. Usually it is unilateral and involves a
progressive fibrosis with local adhesions of the affected muscles which eventually ossify.
• Clinical signs
o Characteristic gait- the forward phase of the stride is jerky and the foot is jerked back
a short distance before being placed on the ground.
o The hardening of the muscles can be palpable.
• Diagnosis
o Relevant history
o Characteristic clinical findings
o Radiography
o Ultrasonography
• Treatment
o Treatment includes surgical intervention to incise the medial ligament of
semitendinosus at the stifle.
• Prognosis: poor.

STRINGHALT/SPRINGHALT

• It is a condition of horse characterized by brisk, involuntary flexion of one or both hind

limbs during the protraction phase of the gait. Or it is an involuntary overflexion and lifting
of the limb during progression.
• It occurs in two form- ordinary or classic stringhalt and spreads throughout the world,
usually as a unilateral problem in individual horses.
• Etiology
o The cause is obscure but possible causes are articular lesions of hock or stifle, some
reflex irritation in the flexor muscles of the hock.
o Lesions of peripheral neuropathy have been identified in the sciatic, peroneal and
tibial nerves.
• Symptoms
o The characteristic flexion of the limb is recognized only during progression. All
degrees of hyperflexion are seen.
o In mild form, spasmodic lifting and grounding of the foot and to the extreme cases in
which the foot is drawn sharply up until it touches the belly and is then struck
violently on the ground.
o The symptoms are mostly noticeable after a period of rest.
o Muscle atrophy may be noticed in the distal aspect of the affected limb.
• Diagnosis
o Diagnosis can be made from clinical signs and electromyography.
• Treatment

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 o Some cases resolve spontaneously otherwise surgical intervention. Peroneal
tenotomy gives relief in certain cases.
o The tendon of the peroneus muscle is cut below the hock on the lateral aspect of the
metatarsus.

CHONDROMALACIA OF THE PATELLA

• It is a degenerative change in the articular cartilage of the patella which is possible caused
by inflammation and local pressure in osteochondrosis.
• Factors responsible for development of chondromalacia of the patella are repetitive trauma
to the patellar region, if the patellar is malalignment and it may also develop by upward
fixation of patella. Medial patellar desmotomy also may cause alteration of the articular
cartilage of the apex of the patella. This may due to lateral displacement of the patella
within the groove and medial rotation of the apex.
• Clinical signs
o The mail clinical findings are pain and in some cases synovial effusion and
crepitation of the patella.
• Diagnosis
o Diagnosis is based on relevant history of trauma, clinical sings and radiography
• Treatment
o No specific treatment. Palliative treatment consists of administer the intra-articular
injections of hyaluronic acid or glycosaminoglycan. It may have some beneficial
effect. Rest also may be indicated.
• Prognosis: Guarded

THOROUGH PIN

• Chronic synovitis or distension of the tarsal sheath

• Etiology
o More common in young stall resting and in draught horses
o Straight hock conformation
• Clinical signs
o Oedema cranio proximal to tuber calcaneus
• Diagnosis
o Clinical signs
o Plain and contrast Radiography
o Ultrasonography
• Treatment
o Pressure bandage administration
o Stable confinement
o Topical DMSO and NSAIDs application
o Intrathecal short acting corticosteroid administration
o Line firing
o Aspiration from the sheath and tincture iodine application
o Synoviotomy
• Prognosis for soundness
o Favourable to guarded

SPAVIN

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 • Exostosis in the posterio-inferio
internal aspect of hock below the
level of tibio-tarsal articulation
with osteo arthritis of the hock
joint. Usually noticed in the
young age.

Types

• High spavin – Spavin noticed

above the posterior-inferio
interanal aspect of the hock
• Anterior spavin – Spavin
Anterior to hock
• Jack spavin – spavin with Very
large exostosis
• Occult spavin - Spavin lameness
without exostosis

• Etiology
o Hereditary
o Defective conformation
o Improper calcium phosphorus ratio
o Trauma
o Septic arthritis
• Clinical signs
o Presence of exostosis
o Lameness
o Imperfect flexion of hock
o Dragging of toe
o Long stride
o Atrophy of the gluteal muscle
• Diagnosis
o Clinical signs
o Radiography
o Spavin test
• Treatment
o Cunean tenotomy
o Promoting local ankylosis by needle point firing and blistering
o Anterior and posterior tibial neurectomy
• Prognosis for soundness
o Animal with spavin is considered as unsound

Bog spavin

• Distention of tibio tarsal joint capsule at the superio-anterio internal aspect of the hock
• Etiology
o Deformity of the hock joint
o Constant hard work
• Clinical signs
o Absence of lameness and pain
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 o Decreased range of motion due to mechanical interference
• Diagnosis
o Clinical signs
o Radiography
o Spavin test
• Treatment
o Injection of intra-articular irritant solution
o Aspiration of the joint effusion
o Needle point firing
o Blistering
• Prognosis for soundness
o Animal with bog spavin is considered as unsound

CURB

CURB (Desmitis of the plantar ligament)

• Enlargement at the postero-inferior aspect of the hock causing a backward curvature of the
normal straight line between the point of hock and the fetlock.
• Etiology
o Mal conformation– sickle shaped or curby, tied-in hock
o Powerful quarter muscles
o Violent exertion
o Hereditary Predisposition
o Violent attempt during extension
• Clinical signs
o Localised pain, swelling
o Bow shaped enlargement on a level of chestnut
o Mild lameness – going on toe posture
• Diagnosis
o Clinical signs
o Ultrasonography
• Treatment
o Moderate exercise provision
o Cold and astringent application
o High heel shoeing
o Local application of DMSO
o Blistering with biniodide of mercury
o Needle point firing
• Prognosis for soundness
o If observed as hereditary it is an unsound condition

CAPPED HOCK

Capped hock (Hygroma or distension of the superficial bursa on the point of the hock)

• Distension of the small bursa situated between the gastrocenemius and superficial flexor
tendons noticed as swelling on either side slightly above the point of the hock without any
pain and lameness.
• Occasionally noticed in cattle and larger breed dogs
• Etiology
o Contusion at the hock
o Repeated injury due to kicking in the stable
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 o Sudden rising on hock
o Lymphangitis or purpura haemorrhagica
• Clinical signs
o Inflammatory swelling at the point of hock
o Abscess formation if infected
o Chronic cases – painless fibrosed thickening
o Occasional lameness
• Diagnosis
o Clinical signs
o Radiography
o Ultrasonography
• Treatment
o Provision of the soft litter
o Aspiration of cystic contents and injection of tincture iodine
o Needle point firing
o Surgical excision of fibrosed mass
o Application of iodine ointment
• Prevention
o Padding the sides of the stall
o Application of hock cap

ULCERATION OF SOLE, INTERDIGITAL FIBROMA AND SORE SHIN

Ulceration of sole

• Commonly noticed in grazing cattle and may occur in any digit but are more common in
lateral claws of hind limb and medial claws of forelimb. The seat of lesion is at the corium
that overlies the flexor process of the third phalanx
• Etiology
o Over trimming of toes
o As secondary to interdigital dermatitis
• Clinical signs
o Slight haemorrhage, necrosis of the corium and surrounding tissues
• Treatment
o Corrective trimming and lowering the heel horn of the affected claw
o Application of hoof block to healthy claw to avoid weight bearing on the affected limb
o If adequate heel depth of healthy toe is available “heelless method of trimming”-
removal of all wall and sole from the posterior half of the digit to a depth with
preservation of thin layer of sole and application of hoof block on the healthy toe for
a period of four weeks.

Interdigital fibroma

• Etiology
o Usually hereditary in nature associated with lax interdigital ligaments resulting in
splay-toed condition
o Unhygienic management with lack of footbath
o Secondary to chronic interdigital dermatitis
o Painless growth on the initial stages until the lesion interferes with walking and
weight bearing
• Treatment

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 o Surgical removal under local infiltration analgesia by avoiding injury to distal
interphalangeal joint capsule and cruciate ligament with antibiotic powder dressing
and application of bandage.

Sore shin

• Osteoperiosteitis of the front portion of the large metacarpal and less frequently of the
metatarsal regions commonly met with in young race horses of one and half to three years
old in training. More common in the forelimbs and rarely in the hind limbs.
• Etiology
o Trauma
o Severe concussion
o Rigorous training with exercise stress mismatch
• Clinical signs
o Swelling over the third metacarpal
o Bilateral shortening of the stride
o Palpable callus
o Absence of lameness after exostosis
• Diagnosis
o Clinical signs
o Radiography
o Nuclear scintigraphy
• Treatment
o Rest followed by moderate exercise
o Cold astringent application
o Blistering
o Periosteotomy with pressure bandage
• Prognosis for soundness
o Favourable – in early stages
o Guarded – in exostosis condition

RING, SIDE AND NAVICULAR BONE

Ring bone

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 • Exostosis on the Phalangeal bones – bony
enlargements on the pastern or phalangeal bones.
A typical ring bone is an osteoarthritis involving
the inter-phalangeal joints.
• Incidence – common in both the fore and hind feet
• Animal with ring bone is usually considered as
unsound

Types

• True ring bone - Exostosis at the level of one of the interphalangeal joints
• High true ring bone - Exostosis involving the suffragino-coronal joint
• Low true ring bone - Exostosis involving the corono-pedal joint
• False ring bone - Exostosis devoid of the interphalangeal joints and are noticed on the shaft
of the phalangeal bones
• High false ring bone - Exostosis on the shaft of the os-suffraginis
• Low False ring bone - Exostosis on the shaft of the os-corona

• Sub types
o Articular ring bone – Exostosis associated arthritis at the joint level
o Periarticular ring bone – Exostosis noticed periphery to the joint with an intact
articular surface and dry arthritis
• Etiology
o Hereditary predisposition – young horses
o Defective shoeing
o Poor conformation of the limb
o Pathological bone diseases
o Strain of the articular ligaments
o Fissured fracture of the os- suffraginis or os corona
o Uneven loading of the limb
o Direct external trauma
o Tearing of common digital extensor tendon
• Clinical signs
o Moderate to severe lameness depending on the joint involvement
o Mechanical interference of the contralateral foot during progression
o Increased digital pulse amplitude
o Increased pain at the pastern
• Diagnosis
o Clinical signs
o Radiography
o Palmar/Plantar nerve block at abaxial sesamoid level
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 o Intra-articular analgesia
• Treatment
o Immobilisation of the lower limb
o Stall confinement for 4 weeks
o Controlled exercise
o Needle point firing
o Median and external plantar neurectomy
• Prognosis for soundness
o Considered as very serious if low /articular ring bone condition noticed

Side bone

• Ossified lateral cartilage of the foot

• Etiology
o Hereditary predisposition in draft and heavier breed horses
o Developmental deformity – premature ossification
o Incorrect trimming and or shoeing
o Improper confirmation of the foot
o Increased loading
o Concussion
o Direct violence
• Clinical signs
o Usually absence of lameness
o If lameness noticed, it is usually due to inflammation and ossification
o Pain during turning the animal to the direction of the affected foot
o Absence of flexibility of the cartilage
o Upright foot condition with bulging of coronary band region
• Diagnosis
o Clinical Signs and shape of the foot
o Radiography
o Unilateral or bilateral palmar digital nerve block
• Treatment
o Corrective shoeing
o Resting for 6-8 weeks
o Long term NSAIDs
o Thinning of the hoof wall at the quarters and the heel level
o Digital neurectomy
o Partial removal of lateral cartilage
• Prognosis for soundness
o Good in early stages
o Guarded to poor in extensive stages of ossification

Navicular bone

• Chronic ostitis of the navicular bone associated usually with chronic synoviitis of the
navicular bursa and inflammation of the plantar aponeurosis noticed commonly as bilateral
in the fore feets.
• Commonly noticed in the fore feet of light horses around seven years of age than in young or
heavy horses.
• Etiology
o Hereditary
o Defective shoeing
o Fast work on hard roads

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 o Repetitive concussion overloading
o Pressure from the deep flexor tendon
o Degeneration of the fibrocartilage, flexor cartilage, synovial fluid of the navicular
bursa
o Thrombosis of the arteriole supplying navicular bone
o Abnormal foot conformation
• Clinical signs
o Intermittent forelimb lameness
o Pottery or stilted gait of forelimb
o Groggy or shuffling or boxy gait
o Screwing of the forelimb rather than lifting during turning
o Wearing of the toe of the shoe
o Pointing of the affected foot
o Rocking horse stance – with forelimb in the front and hind limb at the back
• Diagnosis
o Clinical signs
o Radiography
o Palmar digital nerve block
• Treatment
o Correction of foot abnormality or imbalance
o Corrective trimming and shoeing with wide webbed egg-bar shoe
o Thinning and grooving of the hoof wall
o Administration of vasoactive drugs isoxsuprine 0.6 – 1.2 mg/kg bid PO for 6-12
weeks
o Warfarin – 0.018 mg/kg sid PO increased to 20% in every ten days until
prothrombin time increased by 2-4 seconds.
o Plamar digital neurectomy and medial and lateral suspensory ligament desmotomy
• Prognosis for soundness
o Unfavourable

MEDIAN AND ULNAR NEURECTOMY

Median neurectomy

• Indications: As a symptomatic treatment for aseptic, chronic inflammatory conditions and

navicular disease.
• Anaesthesia: General Anaesthesia / Regional anaesthesia
• Control: With narcosis cast position.
• Site: Site below the medial radial tuberosity in the groove between the posterior border of
radius and the flexar metacarpi interuns adjascent to blood vessels..

Techniques

• Make a 2” incision parallel to bone edge on medial aspectradius and ulna .

• Expose posterior superficial pectoral muscle.
• Isolate the nerve which is located deep along with vein and artery.
• Remove a 2 cm piece of nerve
• Suture the skin in a routine way.

Ulnar neurectomy

• Indications: Chronic inflammatory condition of hoof, limbs, splints

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 • Anaesthesia: General Anaesthesia or Regional anaesthesia
• Control: with narcosis cast position.
• Site: Along the imaginary line drawn 4” above upper border of pisiform bone (Accessary
carpel bone) the line joining the point of elbow with pisiform bone.

Technique

• Make 3” longitudinal incision along the mentioned imaginary line

• The location of nerve is superficial
• Identify the nerve by its texture and location
• Cut and remove 2” length of nerve
• Suture the skin in a routine way

PYRAMIDAL DISEASE AND SAND CRACK

Pyramidal disease or buttress foot

• Osteoperiosteitis, soft tissue swelling and consequent exostosis of the pyramidal process of
the ospedis (3rd phalanx).
• Buttress foot – Deformed foot condition due to oedema at the coronary band region
• Incidence is more common in the hind feet
• Etiology
o Strain of the common or long digital extensor tendon at the insertion level.
o Direct trauma
o Fracture of the extensor process
o Defective conformation of the hoof - upright or forward broken hoof –pastern axis
• Clinical signs
o Varying degrees of lameness
o Shortened stride bearing of the weight on heal
o Swelling on the dorsal coronary band
o Pain at the distal interphalangeal joint
o V-shaped foot
• Diagnosis
o Clinical signs
o Radiography
o Abaxial sesamoid/Palmar digital nerve block
• Treatment
o Pressure bandage with cast application
o Stall rest
o Hoof trimming and corrective shoeing
o Neurectomy
• Prognosis for soundness
o Guarded in early stages
o Poor in advanced stages

Crack repair

Sand crack

• Fissure in the wall of the hoof, parallel to the horn tubules, commencing at the coronet and
extending a variable distance down the wall, usually to its plantar aspect. It may occur at

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 any part of the wall and even in the bar, but its commonest situations are the toes of the
hind foot and the inner quarter of the fore foot.
• Types
o Superficial or deep, complete or incomplete, simple or complicated, straight, recent
or old
• Etiology
o Thinness of the hoof wall
o Excessive rasping of the wall
o Injury to the coronet
o Violent extension of the corono-pedal joint
• Clinical signs
o Fissure in the hoof wall
o Oozing of blood, serum or pus
o Swelling of coronet
o Necrosis of lamina
o Lameness depending on the severity
o Spasmodic lifting of the limb
• Diagnosis
o Clinical signs
o Radiography
o Ultrasonography
• Treatment
o Corrective shoeing
o Application of hoof bandage or clasps or horseshoe nail
o Metal plate screwing, wiring or lacing the hoof wall in shoe lace pattern overlaid with
fibreglass or acrylic patches
o Thinning/stripping the horn wall and removal of necrotic tissues, pus and
application of antiseptic foot baths, hoof repair material
o Blistering the coronet region to stimulate the growth of new horn
• Prognosis for soundness
o Good – for superficial cases
o Guarded in long standing cases due to deformity of coronary band

FRACTURES

Fractures of 3rd phalanx

• Etiology: Acute trauma due to kick

• Classification: Based on the anatomic location of the fracture
o Type I - Non articular fractures of palmar or plantar process of the bone
o Type II - oblique articular fracture from distal interphalangeal joint to solar margin
of the
o bone
o Type III - mid sagittal articular fracture that divide the distal phalanx in two equal
parts
o Type IV - fracture of the extensor process
o Type V - comminuted fracture or secondary to foreign body penetration
o Type VI - Non articular fracture of the solar and parietal cortices
o Type VII - Non articular fractures of palmar or plantar process of the bone in foals
• Clinical signs: Lameness
• Diagnosis
o Radiography
o Local analgesia

17
 • Treatment: For fracture of
o Chronic type I – Palmar digital neurectomy to relieve the lameness
o Types I to V – Non surgical management by applying bar shoe with quarter clips for
6-10 months
o Type VI - Rest and application of shoe with pad
o Type VII - Complete rest for 3 to 4 months
o Sagittal and oblique fracture
 Should be treated before fibrous union with internal fixation using 4.5 or 5.5
mm cortical or shaft screws in lag fashion
 Pressure bandage application with antiseptic soaked guaze dressing

Fracture of carpal bone

• Injuries to the tarsus, carpal injuries may consist of fractures,ligamentous injuries, and
various combinations.
• Aetiology and pathogenesis
o Carpal slab fracture is an injury of the fast gaited horse. It is likely that intra-articular
stresses create initially a fissure fracture.
• Clinical signs
o Fissure fracture will show as a non-specific, low grade lameness. There is a variable
amount of joint distension.
o The distal intercarpal joint capsule is tight and will not distend. when fissures
progress to slab fracture there is severe pain and marked lameness with
unmistakable joint distension. Pain is evinced on palpation and flexion of the joint.
• Diagnosis
o The fissure and non-displaced slab fractures are difficult to see unless the beam
passes along the fracture line.
o Skyline views will show fracture lines and other sagittal fractures.
• Treatment
o The treatment of choice for slab fractures is undoubtedly internal fxation. The size of
the slab in most cases precludes its removal.
o The technique for lag screw fixation is described under the section on fractures.
Sagittal fractures of the 3rd carpal bone do occur and only visualized on skyline views.

Multiple carpal fracture

• Each case of multiple carpal fractures must be carefully evaluated radiographically.

Individual fractures may be amenable to fixation and varying degrees of carpal arthrodesis
is possible. If multible repairable fractures are present, other small fragments, many
undetectable or inaccessible, will usually be present too; their presence will compromise full
recovery.
• In very severe cases pan- carpal arthrodesis should be considered, although it is extremely
difficult surgery. The animal will be fit only as a pet or for breeding purposes.

Fracture of the accessory carpal bone

• The accessory carpal bone fractures in a characteristic manner; the main fracture line being
vertical and running along the vertical groove which lies on the outside of the bone and
accommodates the ulnaris lateralis tendon. This groove also coincides with the thinnest
portion of the bone. The fractures are often comminuted and occasionly with multiple
fragments.

18
 • Etiology
o Overloading of the limb with the carpus with the carpus in slight flexion may be the
cause. The author believes that hyperextension of the carpus coupled with a sideways
compressive effect from the taut annular ligament may also be an effective disruptive
force.
• Clinical signs
o The onset of lameness is usually immediate on fracturing; lameness is severe, the leg
being held in a neutral, non-weight bearing, toe-tipping position at rest. Within an
hour or so swelling of the area is apparent and of course there is pain on palpation or
manipulation of the area.
o The gentle medial concavity of the accessory bone forms the lateral wall of the carpal
canal or tunnel and, therefore, fractures will affect the carpal synovial sheath
resulting in synovitis and distension. In animals where fracture has occurred some
time previously, the synovial distension can be the most obvious sign of problems in
this area.

Treatment

• Conservative and surgical therapy would seem to meet with about equal success in
returning animals to work but this may be the result of the technical difficulties involved in
the surgery.
• Conservative treatment is pressure bandaging for 6-8weeks with box rest continuing for a
total of 5-6months; unrestricted activity must not be allowed for 8 months. In the early
stages, tube casts can be used to minimize movements.
• Surgical treatment is feasible only in the simple; vertical fractures and consists of lag-
screwing the palmar fragment on to the dorsal one. It is technically difficult to do because of
the curved nature of the bone and its central waist. If internal fixation is feasible and
successfully carried out, its benefits will be stabilization of the palmar fragment preventing
it from rotating inwards
• Towards the canal; encouragement of bone healing and minimizing callus and obviating the
necessity for very prolonged bandaging with its attendant risks of pressure rubs and not
inconsiderable expanse.

Canker (Necrotic pododermatitis)

• Chronic hypertrophic moist eczematous dermatitis involving the frog, sole and wall of the
foot.
• Common in the heavy draft horses especially in the hind feet
• Etiology
o Unhygienic stable
o Poor foot care
o Prolonged exposure to moisture
o Hereditary
• Clinical signs
o Peeling of horns as soaked in oil
o Ergot formation - finger like hypertrophic growth with foul smelling condition
covered with Friable crust over the frog
o Progressive lameness
o Cheesy foul smelling exudates from the frog
• Clinical signs
o Inflammation, hypertrophy, necrosis, dyskeratosis at the frog region
• Treatment
19
 o Removal of the infected horns under general anaesthesia and application of triple
sulph powder (Zinc sulphate, Copper sulphate and Ferrous sulphate)
o Debridement and dressing with noncaustic antiseptic sugar and iodine preparation
o Daily dressing with dry sterile water proof pressure bandage
o Coverage of sole with metal or leather
• Prognosis for soundness
o Good – in early cases
o Unfavourable in long standing cases

Corn

• Contusion of the sensitive corium and sole at angle between the wall and the bar
• Types
o Moist , dry, suppurating or festered and complicated corns.
• Etiology
o Defective conformation of the foot
o Improper shoeing for long period
o Excessive weight bearing on the heel
o Secondary to side bone formation
• Clinical signs
o Pointing of the limb
o Bilateral forelimb lameness with shortened stride
o Bruised condition at the angle between the wall and the bar
• Diagnosis
o Shoeing history
o Clinical signs
o Radiography
• Treatment
o Removal of improper shoes
o Rest
o Foot bath and antiseptic dressing
o Debridement of a thin layer of sole horn over the corn
o Corrective shoeing with full and long fitted heels or wide webbed egg-bar shoe
• Prognosis for soundness
o Good at early stages
o Guarded – in collapsed heel or pedal osteitis condition

PARALYSIS

Suprascapular nerve paralysis (Sweeney or shoulder slip)

• The suprascapular nerve is a short but thick nerve. It arises from C6 and C7 in the brachial
plexus and then courses laterally to turn sharply around the cranial edge of the scapula
some 6-7 cm dorsal to the supraglenoid tubrosity and into the supraspinous fossa.
• Etiology
o The nerve is vulnerable to trauma as it crosses over the front of the scapula.
o Loss of nerve conduction leads to paralysis of the supra and infraspinatus muscles
o De innervation of the muscles for more than a few days also leads to a rapid
neurogenic atropy.
• Clinical signs
o Progressive atrophy of the supra and infraspinatus muscles. In addition there is
usually a varying degree of instability in the scapulohumeral joint, usually manifest
20
 in a sharp outward rotation of the shoulder during the weight bearing phase of the
stride.
o The trauma may have caused additional pathology such as a scapular fracture and
symptoms of pain and swelling may be superimposed on the neurogenic atrophy.
• Diagnosis
o The first sign of atrophy will be an increased prominence of the scapular spine
compared to the other side. pain on pressure and manipulation must be looked for
and if these are present the shoulder should be radio graphed.
o Instability of the shoulder joint in association with a developing atrophy is, in the
absence of major fractures, virtually pathognomonic of suprascapular nerve
paralysis.
• Treatment
o Adams suggests that removal of a 3*2 cm piece of the leading edge of the scapula
where the nerve crosses might lead to a re-establishment of function.

Radial paralysis

• Radial nerve is the largest nerve from the brachial plexus. It passes downwards and outward
along the musculospiral groove of the humerus. It supplies the triceps brachii, extensors of
the carpus and digits.
• Radial paralysis is more commonly seen in the horse.
• Etiology
o Compression of the nerve between the shoulder and thorax while casting the horse
on a hard ground. Over –stretching of the nerve. Injury to the nerve accompanying
fracture of the first rib.
• Symptoms
o In complete paralysis of the radial nerve all its branches are affected .partial paralysis
involving either the branch supplying the triceps muscle, or the branches supplying
the extensors of the digit and carpus may be noted. In complete paralysis affecting
the entire nerve, all joints below the elbow are in a flexed state, and the point of the
elbow is dropped.
o If the branches supplying the extensors of the digit only are affected, the animal will
be able to use the limb almost normally when walking on level ground but on uneven
ground it stumbles and the foot is dragged.
o If the branch to the triceps muscle only is affected, there is inability to bear weight on
the limb, because it is not possible to extent of the elbow. The limb presents an
abnormal appearance since the point of the elbow is dropped and the knee is semi-
flexed, but the planter surface of the foot touches the ground almost normally.
• Treatment
o If the paralysis is due to a callus or tumor pressing on the nerve, it is desirable to
remove the same.
o Application of counter-irritants locally may accelerate recovery. Pottasium iodide
may be given internally to promote absorption of inflammatory exudates pressing on
the nerve.
o Nerve tonics like vitamin-B1,Phospholecithin are advisable.
o Administration of calcium.
o Nervine stimulants such as strychnine may also be useful.
o To prevent muscular atrophy, mild exercise, massage and application of liniments or
blisters are indicated.
o Electro- therapy accelerates recovery and prevents muscular atrophy.
o Infra-red rays can penetrate into deeper tissues and being hot rays they stimulate
regenerative processes largely by favouring hyperemia.
o If paralysis is due to rheumatism, sodium salicylate is indicated
o Corticosteroid preparations may be effective in some cases to quicken the recovery.
21
 BICIPITAL BURSITIS AND OMARTHIRITIS

• Trauma to the point of the shoulder can damage the tendon of origin of biceps Brachialis
which, after arising from the tuber scapulae, courses forward and downwards through the
bicipital groove on the proximal humerus just cranial to the humeral head.The movement of
this tendon over the intertuberal groove is facilitated by the large bicipital bursa which may
also suffer damage.
• Clinical signs
o Symptoms include a sudden onset of severe lameness or in case of septic bursitis, an
increase in severity to non-weight bearing over 2-3 days. The animal is reluctant to
stand on the leg and in more severe cases may absolutely refuse to do so active
extension of the shoulder will also cause pain and in most cases, the leg will be
dragged behind and not advanced.
o Swelling of the region is often not noticeable.
• Diagnosis
o Local pain with pressure over the intertuberal groove and manipulation, especially
flexion of the scapulohumeral joint and extension of the elbow, will indicate that
there is pain in the region. Elimination of shoulder and scapular conditions by
negative radiographic findings and normal scapulohumeral joint synovial fluid
analysis will then tent to concentrate interest on the bursa.
o Paracentesis of the bursa is possible especially if it is distended, though it is never a
simple task. A 6-8 cm needle is inserted over the intertuberal groove and, applying
suction to an attached syringe, the area is probed. on penetrating the bursa, fluid
enters the syringe.
• Treatment
o Traumatic bursitis without the presence of infection will respond to rest-a minimum
of 3 months box confinement being necessary followed by a further 6 months or so of
restricted exercise.
o Steroid therapy should be used with used with extreme care as the risk of subsequent
osseous metaplasia is high.
o Systemic antibiotics alone produced only mild and temporary remission.

Omarthiritis (Osteoathritis of the Scapulo Humoral joint)

• Omarthritis is the sequel to most conditions affecting the joint fractures, joint trauma and
osteochondrosis being the principle instigating factors.
• The clinical signs will tend to be the same whatever the initial cause except that
osteochondrosis may super impose its own symtamatology on that of the degenerative
condition. Local signs such as muscle wasting are present; diagnosis is usually by
elimination of lower limb conditions by clinical examinations and especially nerve blocks.
Intra-articular anesthesia is extremely valuable with a marked reduction in the severity of
the lameness though not necessarily abolition of all the signs at the same times synovial
fluids can be taken for laboratory examinations.
• Radiography under general anesthesia is preferable so that the leg can be drawn well
forward and the caudal portion of the joint well visualized. The osteophytes are seen
principally on the caudal aspect of the humoral head and less often on the cranial glenoid.
• Steroids will cause only temporary remission and probably the treatment of choice is intra-
articular injection of sodium hyaluronate. The response is variable with the prognosis better
in early cases. A return to lameness is inevitable at some stage and it is wise to inform
oweners of this before embarking on expensive therapy.

KNEE

22
Bent knee or knock knee

• Conformation variations are important in the pathogenesis of carpal disease since they will
distrupt the normal loading pattern of the joint and lead to abnormal stresses and strains.
• Common abnormalities are where the carpal bones are set more palmar than normal in
relation to the mid line of the radius, back in the knee, carpus valgus or knock knees, carpus
varus, bowed knees or where the carpal bones are more medially placed relative to the
radius, the so called bench knee.

Hygroma of knee

• Fluid carpal swellings. Apart from the joint and carpal sheath distensions already
mentioned the carpus can display a variety of acquired fluid-filled swellings.
• Hygromas originate as extensions of tendon sheaths, herniations of synovial structures and
organized seromas. They are probably traumatic in origin, in their chronic state, are not
usually locally painful.
• The site of hygromas may sometimes give an indication of its origins but the simple
technique of contrast injection followed by radiography will give the answer in most cases.
• Treatment
o Traditionally the treatment of all synovial swellings has been aspiration and pressure
bandage with or without corticosteroid injection.
o The results are disappointing since the distension returns rapidly once pressure is
removed. Surgery is often the best hope for non-recurrence, but not all cases are
amenable.

Blemished knee

• Operation for blemished knee in equine other wise known as cherry’s operation.
• Site: Anterior surface of the knee where the scar (blemish) is situated.
• Technique
o The scar or cicatrix is removed by including it in an elliptical skin incision vertically
on the anterior aspect of the knee. This wound is closed by interrupted apposition
sutures after relaxing the skin by placing additional vertical skin incisions on either
side of it.
o After healing, the three wounds will only appear as three narrow streaks of scar
covered by hair.

Carpitis

• An acute or chronic inflammation of the joint capsule of the carpus and the associated
structures in horses. There is pain and swelling and there may be exostoses in chronic cases
called also popped knee in horses.

Open knee

• Immature knees on front legs otherwise known as open knees. Depression over knee area
heavy young warm bloods.
• Allow to mature probably not a long term problem correct calcium imbalance. ( example:
grazing fertilized kikuzu pastures ).

WIND PUFF, OSSELETS AND SEPTIC ARTHRITIS

23
Wind puff/Wind gall

• Distension of the joint capsule of metacarpophalageal joint with over distension of joint
capsule between the suspensory ligament and third metacarpal bone.
• Etiology
o Full trained horse with suddenly not exercised
o Heavily parasitized horse
o Inadequate nutrition
• Clinical sign
o Joint capsule distension
o Lameness
• Diagnosis
o Clinical sign and history
o Radiography
o Ultrsonography
• Treatment
o Application of glycerine and alcohol with elastic wrap
o Drainage of joint capsule
o Intra-articular corticosteroid administration
• Prognosis
o Permanent correction of condition is difficult but not affect racing performance.

Osselets

• Inflammation of the fibrous joint capsule of the metacarpophalangeal joint present

bilaterally in young horse
• Green osselets - No bony proliferation
• True osselets - Bony proliferation presents
• Etiology
o Frequent heavy training to horse
o Trauma and violence
• Clinical signs
o Metacarpophalangeal joint enlargement, warm to touch, pain on palpation
o Pits on digital pressure
o Shortened stride
o Resistance on extreme flexion and extension of joints
• Diagnosis
o Clinical sign and history
o Radiography
o Ultrsonography
• Treatment
o Rest followed by decreased training activity
o Poultice application with soft cotton bandage
o Blistering of joint after inflammation subside
o Radiation therapy
o Corticosteroids administration
• Prognosis - Good

Septic arthritis

• Infection of joint by pathogenic bacteria

24
• Etiology
o Partial/Complte failure
o Failure of passive transfer of immunoglobulin from dam/colostrums
o Traumatic injury
o Haematogenous spread of bacteria
o Navel cord infection
o Unhygienic condition
• Clinical signs
o Joint effusion
o lameness
o Pain
o Open wound with discharge
o Swelling
• Diagnosis
o Clinical signs and history
o Radiography
o Ultrasonography
o Synovial fluid evaluation
o Arthroscopy
• Treatment
o Systemic sensitive antibiotic treatments
o Through and through lavage of joints
o Regional intravenous antibiotic therapy
o Slow release intra articular antibiotic therapy

OSTEOCHONDRITIS DISSECANS

• Developmental joint disease of rapidly growing animal of articular surface including

vertebral articulation, joints.
• Growth cartilage focal damage during endochondaral ossification with joint mice formation
• Etiology
o Nutrition
o Overfeeding
o Mineral imbalance
o Toxicity
o Excess digestible energy
o Deficiency in copper
o Growth/ body size
o Endocrinology
o Heredity/ genetic predisposition
o Biomechanics/exercise
• Clinical signs
o Effusion of affected joint
o Variable lameness (mild to moderate)
o Muscle wasting
• Diagnosis
o Clinical signs and history
o Radiography
o Neurological examination for cervical vertebral affection
• Treatment
o Restriction of exercise
o Correction of minearals and vitamin deficiency
o Restriction of excessive grain feeding
o Hyaluronic acid with polysulphated glycosaminoglyval treatment
25
 o Arthroscopic surgical treatment

DEGENERATIVE JOINT DISEASE

• Etiology
o Ostochondritis dissecans
o Intra-articular fractures
o Chronic low grade trauma
o Septic arthritis
o Poor confirmation or action
• Pathology
o Loss of cartilage elasticity
o Decrease in content of PSGAGS and hyaluronic acid
o Liberation of degradative enzymes which results in damage to articular surface and
remodeling of subchondral bone
• Clinical signs
o Soft tissue swelling around joint
o Low grade chronic lameness
o Joint effusion with/without joint distension
• Diagnosis
o Clinical signs
o Flexion test
o Intra-articular analgesia
o Radiography
o Ultrasonography
o Arthroscopy
• Treatment: Primary goals of treatment are
o To minimize ongoing degenerative change
o Repair of damaged articular cartilage
o Pain management
o Medical therapy with PSGAGS and hyaluronic acid
o Intra-articular corticosteroids (methyl prednisolone acetate @60-80mg for smaller
joints and 120mg for large joints
o DMSO as an anti-inflammatory and bacteriostatic and to inactivate superoxide
radicals @ 10-30 ml of 10-40% concentration
o NSAIDS – Phenylbutazone @ 4.4mg/kg daily for 1-2 days then 2.2mg/kg twice daily
3-5 day

LAMINITIS (FOUNDER) AND HOOF AVULSION

Laminitis

• Complex systemic metabolic disease that results in acute degeneration of laminae. Mostly
fore limb affected
• Three phases of laminitis
o Developmental phase - initiation with trigger factor that lead to change in foot
o Acute phase - onset of clinical signs
o Chronic phase - 48 hrs of continuous pain
• Etiology
o Carbohydrate overload (grain founder)
o Lush grass over load (grass founder)
o Obesity
o Endometritis

26
 o Severe systemic infection
o Colic
o Stress/exhaustion
o Drinking large amount of cold water
o Toxins ingestion
o Hormone imbalance
o Over exercise on hard ground
• Clinical signs
o Lateral recumbancy for long period
o Increased respiratory rate with muscle tremors, sweating
o Arched back condition
o Laminitic gait
o Hot to touch around coronary band
o Digital pulsation
o Pain response to digital pressure
o Dropped sole
o Laminitic ring around wall
• Diagnosis
o Clinical signs and history
o Radiography
• Treatment
o Medical treatment with NSAIDS – phenylbutazone, acetylsalicyclate, flunixin
meglumine
o Complete box rest
o Use of frog support to reduce pressure on laminar band
o Removal of shoe
o Balance diet provision
o Corrective trimming and shoeing
o Realignment of distal phalanx

Hoof avulsion

• Detachment of hoof wall from underlying corium which involves quarter and heel of foot
• Etiology
o Trauma
• Clinical signs
o Varying degree of lameness with detachment of hoof wall
o Oedema of coronary band with fissure
o Pain on palpation
• Diagnosis
o Clinical signs and history
o Radiography
o Fistulogram of draining tract
• Treatment
o Removal of detached part with hoof knife or nipper
o Coronary band suturing
o Topical astringent (povidone iodine with sugar) with soft cotton bandage
o Corrective shoeing

Seedy toe

27
 • It describes a condition in which dermal and epidermal layers are separated in the toe
region of the foot. Newly formed horn follows the line of separation and perpetuates the
defect. After sometime the separation is visible in the white line in the toe region and the
dermal structures are exposed to ascending infection.
• Etiology
o Focal haemorrhage
o Seroma formation
o Failure of damaged laminae to produce keratin
• Clinical signs
o Brown crumbly horn like matter along the white line
o Lameness in severe cases
o Percussion of dorsal hoof wall produces characteristic hollow sound
• Diagnosis
o Careful exploration of the undermined wall with a blunt radio opaque allows
radiological documentation of the extent of separation.
o Gas shadow in the soft tissues dorsal to the 3rd phalanx on lateromedial radiographs
of the foot.
• Treatment
o Regular cleaning of the defect and shoeing with wide webbed, flat shoes to increase
the base of
o In more severe cases the separated hoof must be removed from the solar margin of
the toe to a level where normal inter laminar band is present. The exposed laminae
are medicated under a dressing.

Thrush

• It is a degenerative condition of the central and collateral sulci of the frog, characterized by
disintegrating horn and the presence of grey to black material in the affected areas.
• Etiology
o Unhygienic ,moist stabling with poor foot care.
o Fusobacterium necrophorum is mostly involved.
• Clinical signs
o Black discharge in the sulci of the frog with very offensive odour.
o Only when sensitive structures are involved lameness occurs.
o Mainly hind limbs affected.
• Treatment
o Debridement of affected and separated horn .
o Daily topical astringent medication under dressing. Sterile bandaging after each
debridement and continue treatment under plate shoe.

QUITTOR/NECROSIS OF THE LATERAL CARTILAGE AND TENDINITIS

Quittor/necrosis of the lateral cartilage

• It is a localized necrosis within a collateral cartilage of the 3 rd phalanx. Purulent discharge

and sinus formation above the coronary band results.
• Etiology
o Lacerations ,punctures , bruises to the side of the foot above the coronary band.
o Possible extension of subsolar or submural abcessation.
• Clinical signs

28
 o Chronic , suppurative draining tracts above the coronet that intermittently tend to
heal and resume drainage.
o Localized pain , heat and swelling over collateral cartilage.
o Lameness occurs in the acute stages of infection.
o Extensive fibrosis and deformity of hoof wall in chronic cases.
• Treatment
o It consists of surgical excision of the necrotic core of the cartilage. Care must be
taken to avoid opening and contaminating the joint.
• Prognosis
o It is favourable unless the collateral cartilage is involved extensively.

Tendinitis

• It is inflammation of tendon usually caused by excessive strain . Tendo synovitis is

inflammation of a tendon and its sheath.
• Etiology
o Mechanical stress , subclinical fibrillar damage or intratendinous degeneration.
o Injuries usually occur towards the end of an exercise ,when fatigue sets in.
o v Avascular and acellular areas are mostly affected.
• Clinical signs
o Immediate moderate to severe lameness
o Swelling rapidly develops(bow)
o Some are not apparent for 1 to 2 days
o Some cause localized heat and swelling but no lameness
o Lameness usually improves with box rest
o Sinking of the fetlock joint occurs
• Dignosis
o Palpation
o Ultrasonography of the tendon
o A core lesion is the most common finding
o As the injury heals the borders become indistinct and echogenic.
o Peritendinous edema disappears early in convalescence.
• Prognosis
o It depends on the following things
o v Location of the injury
o v Severity
o v Level of exercise
o v Usually guarded
• Treatment
o Acute
 Ice packs,cold hosing
 Pressure bandage
 Box rest
 Use of intralesional PSGAG
 Shoeing with raised heals
 Tendon splitting
 Superior check ligament desmotomy
o Subacute
 Stall rest with controlled walking
 Intralesional injections like sodium hyaluronidate and PSGAG
o Chronic
 Regime of increasing exercise
 Superior check ligament desmotomy

29
 CRACKS OF THE HOOFWALL

• Vertical defects in the hoofwall occur along the direction of the lamellae.They are classified
as follows
o Toe cracks
o Quarter cracks
o Heel cracks
• Superficial cracks do not involve the sensitive laminae but deep cracks do. Deep cracks are
often accompanied by localized infection of the dermis. Cracks can originate from the
coronary band or the solar margin and can be partial or complete.
• Etiology
o Overgrown hoofwall may lead to splitting upwards from the solar margin
o Dry poor quality horn and poor foot balance increase the incidence of sand cracks
o Defects can be caused by tearing away of shoes and part of the wall
o Chronic traumatic defects in the coronary band
o High incidence in toe of draught horses and medial quarter of standardbred race
horses
• Clinical signs
o Obvious hoof wall defect with or without local discharge , heat , lameness
o Hoof testers and unilateral nerve blocks are used to determine the significance
o Pain is caused by the irritation of of the laminar and coronary dermis by differential
movement of both sides of the horn.
o Hemorrhage from repetitive irritation
o Purulent discharge due to secondary infection
• Treatment
o Application of oil to hoof to prevent dryness and oral administration of biotin and
methionine to promote good quality horn growth
o Groove or burn transversely down to healthy continuos horn at the proximal limit of
incomplete cracks to prevent progression
o Adequate immobilization can be done as follows
 A full bar shoe with clips drawn on either side of the crack
 The hoof wall can be lowered either to the defect or directly beneath the defect
to eliminate upward pressure
 Heartbar shoes and frog pads to transfer he load of weight bearing from the
walls to frog
 Hoof binding resins , acrylics, prosthetic repair materials used after
elimination of infection and thorough debridement
 Transversely placed nails , screws, wire , metal plate
 Partial hoof wall resection for complicated cracks that prove refractory to
stabilisation

ILIAC THROMBOSIS - INTRODUCTION

• This is the thrombosis in the iliac arteries - the vessels into which the abdominal aorta
breaks up beneath the lumbar spine, and whose branches are distributed to the hind-
quarters and extremities.
o Causes
o Symptoms
o Diagnosis
o Treatment

Causes

30
 • The causes of thrombosis are chiefly injuries such as wounds, severe contusion, and
stretching , diminish its vitality may determine the coagulation of blood within it. It is also a
consequence of degenerative changes in the structure of the vessel, and of arrest of the
circulation from aneurism or any other cause which induces the blood to stagnate.
• Thrombosis from stagnation of blood
o It will be found that wherever the circulation is so altered that, while the blood moves
more or less freely in the general current, there are subsidiary currents or eddies,
thrombosis is liable to begin in the situation of the latter.
• Thrombosis from alteration of the wall
o Wounds of vessels induce thrombosis, If the blood is stagnating in the veins, as is the
case in passive hyperemia from heart disease, a trivial wound may start a thrombosis.
Thus, in cases of valvular disease the legs are not infrequently punctured to relieve
the oedema which is so common in such cases, and the punctures may be the starting
points of thrombosis. Ligature of vessels causes thrombosis, as there is rupture of the
internal and middle coats. Acute inflammation of the walls of the heart or vessels
induces coagulation, as one sees so frequently in acute endocarditis. Chronic
endocarditis and atheroma, by producing palpable alterations in the endocardium or
internal coat of arteries, are frequent causes of thrombosis, more particularly when
calcareous matter is deposited and becomes exposed to the blood. An occasional
cause is the protrusion of tumours through the walls of vessels, but this scarcely ever
occurs in arteries and is rare in veins.
• There are cases in which coagulation occurs apparently in consequence of the sudden
setting free of the ferment in the general circulation. This has been mostly in cases of
transfusion, where blood from one of the lower animals has been used.
o For the most part thrombosis of the iliac vessels is the result of sprain inflicted by
violent backward stretching of the hind legs, would result when a horse falls short in
jumping and slips down, or when his legs fly back from under him, or " spread-
eagle", while drawing a heavy load over a slippery surface, or out of deep heavy
ground.
• In all these positions there would be sudden and severe stretching of the vessels and injury
to their coats.

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Symptoms

• The symptoms of iliac thrombosis will vary with the stage of the disease.They are very
diagnostic. Slight stiffness of one or both hind-limbs, more especially on rising from the
recumbent posture, slight swelling of the limbs are the initial sign.
• As the arteries become more and more blocked, and the circulation obstructed, the legs are
found to be cold, and the large veins are distended. This distension of the veins results from
the absence of force to move on the blood within them, consequent upon the blocking up of
the arteries, and is most strikingly seen during rest.
• When the animal is made to move, the blood disappears from the veins, and returns but
slowly. The horse's movements are observed to be somewhat unsteady behind, especially
during work. In the more advanced stages of the disease exertion brings on a rolling gait
behind, and, if continued, results in paralysis of the posterior part of the body. At this time
the animal breaks out into a profuse perspiration, the breathing is hurried, the muscles
quiver, and the pulse is much accelerated. In some cases the affected animal strikes the
belly, looks round to the flank, and shows signs of acute pain, as if the subject of colic.
• After a short period of rest the symptoms subside, and the horse resumes his normal
condition, and will most likely continue in apparent good health until the exertion is again
repeated.
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Diagnosis

• Although the symptoms described are very indicative of iliac thrombosis, the diagnosis may
be rendered still more complete by a careful manipulation of the affected vessels.
• The iliac arteries are to be found striking off right and left beneath the lumbar spine, and
quite within reach of the hand when pushed well forward into the rectum.
• In carrying out this examination the hand and arm must be well anointed with oil or
vaseline, and after entering the bowel the arm is turned so that the palm is presented
upward; the fingers are then directed to that part of the spine where the loin joins on to the
quarters, immediately beneath which the great iliac vessels - two on either side - will be felt
branching off right and left from the posterior aorta.

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Treatment

• Treatment in these cases is of no avail.

• The fibrinous matter plastered over the inner surface of the vessel in successive layers, or
free within it and occluding the passage of the blood, cannot be removed, and the animal
should therefore be destroyed.

MONDAY MORNING SICKNESS (Equine Rhabdomylosis)

• Monday Morning Sickness (or disease) is an old slang term used for a condition properly
known as Azoturia. It is also referred to as Exertional Myopathy. It is a potentially fatal
condition that makes it very difficult and painful for the horse to move and can cause failure
of the kidneys. Azoturia is most commonly found in horses that are heavily exercised on a
regular basis, and then not worked for one or two days but still fed the same amount of
food. This results in glycogen (a carbohydrate) building up in the muscles. When the horse
returns to work, this glycogen breaks down quickly and produces an overload of lactic acid.
The lactic acid damages skeletal muscles, releasing muscle enzymes and myoglobin, which
can lead to acute kidney failure.
• Tying-up is a milder form of the condition that is usually seen in race and performance
horses after a hard workout. While cooling down, the muscles stiffen and tremor. The
muscles of the hindquarters are particularly tense, hard and painful. The pain causes
anxiety and sometimes sweating.
• The horse, is subject to muscle problems due to abnormal metabolism of energy. The
byproducts of abnormal metabolism cause inflammation of muscle cells, which leads to
painful spasms of the large muscles of the back and hindquarters. The clinical result is a
horse that can’t move due to these painful muscle spasms.
o Causes
o Symptoms
o Treatment
o Prevention

Causes

• The most common cause of Monday morning sickness or Azoturia is from a carbohydrate
overload combined with time off. This used to be very common with draught horses who

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 would have Sunday off and then have an episode of Azoturia on the Monday, hence the term
Monday Morning Sickness.
• The glycogen in the hard feed builds up in the muscles and produces an excess of lactic acid
to be produced when the horse resumes work, the lactic acid in turn damages the muscle
tissue and subsequent blood flow to the muscles. As the Lactic Acid cannot be dispersed
quickly enough it causes an episode of Azoturia to occur.

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Symptoms

• These can vary depending on the severity of the attack.

o Horse will show a reluctance to move.
o Horse will refuse to move, hence the term tying-up.
o The muscles will tighten up and go hard and often be quite hot.
o The urine will be dark brown in colour due to the muscle pigment myoglobin going
into the blood stream and subsequently being urinated.
o The horse may show signs of repeatedly trying to urinate with no affect.
o The horse may sweat up.
o The horse will be distressed.

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Treatment

• The use of pain killers and anti inflammatory drugs are used initially to make the horse
more comfortable Fluids are often administered to help flush out the toxins.
• The horse should then have box rest followed by gentle exercise and a new feeding program
that is appropriate for the level of work. If you are riding when the horse develops
symptoms then dismount immediately and place rugs over the horse to keep the horse
warm.
• Put them directly into a warm stable with plenty of bedding and water and do not want to
ride them as this will only further damage muscles and cause more pain.

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Prevention

• Carefully warm up your horse and use an exercise blanket on cold days.
• Ensure that if the horse has a rest day that the hard feed is reduced.
• On rest days ensure that the horse is turned out as this will allow them to gently exercise.
• Feed according to the work being done and if the horse is prone to Rhabdomyolysis reduce
the carbohydrate in the feed, the use of soya oil for energy can be a useful addition in the
diet.
• The use of some supplements may be of value, for example the addition of Selenium and
vitamin E are known to be good at reducing free radicals and the correct balance of
electrolytes is essential to provide a natural balance.

MYOSITIS OF PSOAS

• Inflammation of muscle is known as myositis, especially a voluntary muscle

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 • This type of muscle disease (myopathy) represents a group of different diseases which all
share the feature of inflammatory cells within the muscle.
• Myositis is the early stage of muscular infection.
• A psoas abscess is defined as a purulent infectious collection within the psoas muscle
• Myositis can affect
o One muscle
o Groups of muscles

Etiology

• Infection, autoimmune conditions, genetic disorders medication adverse events, electrolyte

disturbances, and diseases of the endocrine system.
• Some idiopathic cases of polymyositis are suspected to be related to infectious agents,
especially viruses such as the paramyxoviruses or enteroviruses .

Signs

• Pain
• Tenderness
• Swelling
• Weakness

Diagnosis

• Laboratory evaluation reveals leukocytosis with a left shift and an elevated erythrocyte
sedimentation rate.
• In cases of secondary psoas abscesses, pyuria and positive urine cultures may be found
when the genitourinary tract is the originating site of infection. The diagnosis is established
by radiological imaging. A psoas abscess may be detected on ultrasound evaluation, but this
test is not as sensitive as CT or MRI scans.

Treatment

• Surgical drainage and intravenous antibiotics are recommended.

• Drainage may involve either CT-guided percutaneous drainage or an open surgical
procedure.

TROCHANTERIC BURSITIS

• Trochanteric bursitis is characterized by painful inflammation of the bursa located just

superficial to the greater trochanter of the femur.
• The term greater trochanteric pain syndrome (GTPS) is now being commonly substituted
for trochanteric bursitis, because the inflammatory etiology of the pain is being refuted by
current research, using ultrasonographic, magnetic resonance imaging (MRI) – based, and
histologic evidence.
o History
o Causes
o Symptoms
o Treatment

History

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 • The classic symptom is pain at the greater trochanteric region of the lateral hip.
• Pain may radiate down the lateral aspect of the ipsilateral thigh;
• The symptoms are made worse when the animal lies on the affected bursa
• Hip movements (internal and external rotation), walking, running, weight bearing, and
other strenuous activities can exacerbate the symptoms.
• Onset may be insidious or acute.

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Causes

• Acute trauma, such as a fall that causes the animal to land on the lateral hip region can
result in trochanteric bursitis.
• More commonly, repetitive (cumulative) trauma is involved. Such trauma is caused by the
repetitive contracture of the gluteus muscle
• Conditions that predispose to trochanteric bursitis include underlying lower leg gait and
back or sacroiliac disturbances.

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Symptoms

• Symptoms are often related to increased activity or exercise.

• The most classic finding is point tenderness over the greater trochanter, which reproduces
the presenting symptoms.
• Palpation may also reproduce pain that radiates down the lateral thigh.
• Bursal swelling may be present, but this may be difficult to appreciate in many patients.
• Overlying skin changes of ecchymosis with abrasions may occur with recent trauma.
• Lateral hip pain can often be elicited by passive external rotation of the hip without
provoking such symptoms by internal rotation. Also, the external rotation can be combined
with passive hip abduction.
• Lateral hip pain can be reproduced with flexion of the hip and followed by resisted hip
abduction.

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Treatment

• The primary treatment is rest ie., avoiding actions which result in aggravation of the pain.
• Icing the joint may help.
• A non-steroidal anti-inflammatory drug may relieve pain and reduce the inflammation.
• If these are ineffective, the definitive treatment is steroid injection into the inflamed area.
• Physical therapy to strengthen the hip muscles and stretch the iliotibial band can relieve
tension in the hip and reduce friction.
• Surgical removal of bursa. The procedure is known as bursectomy. Tears in the muscles
may also be repaired, and loose material from arthritic degeneration of the hip removed.

RUPTURE OF PERONEUS TERTIUS, ROUND LIGAMENT AND ACHILLES

TENDON

Rupture of peroneus tertius

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 • Peroneus tertius is a muscular band lies between long digital extensor and tibialis cranialis
muscles of rear limb.
• Origin: Extensor fossa of distal lateral femur.
• Insertion: third metatarsal bone and laterally on 4th metatarsal bone. It is important part of
reciprocal apparatus mechanically flexing the hock when the stifle joint is flexed.
• Causes
o Due to over extension of hock
o Exertion of fast start, such as jumping
o After application of full limb cast to the rear limb
• Symptoms
o Stifle joint flexes as the limb advances, and the hock is carried forward with little
flexion. Portion of the limb below hock tends to hang limp, giving the appearance of
being fractured as it is carried forward. When the foot is put down, the horse has no
trouble in bearing the weight and shows little pain. Hock can be extended without
extending the stifle which is not possible in normal limb.
• Treatment
o Complete rest. Should be kept in box stall and kept quiet at least 4 – 6 weeks. Then
limited exercise given for the following 2 months.

Rupture of round ligament

• A partial tear or rupture of round ligament or accessory ligament of coxo-femoral joint is a

rare condition that can affect any age or breed of horse.
• Causes
o Trauma, the same injury that can cause luxation of coxo-femoral joint can cause
injury to the accessory ligament without resulting in joint luxation.
• Symptoms
o History of trauma or acute onset of lameness.
o Similar to those of luxation except that the hind limbs are of same length.
o The characteristic signs include toe out, stifle out, and hock-in appearance of the
affected limb.
o In chronic cases, atrophy of the gluteal muscles.
o Direct firm intermittent pressure over the greater trochanter will result in pain.
o Limb manipulation and flexion of hip is painful.
o Crepitation over the joint.
o Signs associated with partial tear are less clear than those seen with complete
rupture of the ligament.
• Diagnosis
o Complete rupture – based on signs like stifle-out, toe-out, and hock-in with equal
length of limbs.
o Radiograph of the joint – severe DJD in chronic cases. Other wise abnormal position
of the femoral head in acetabulum.
• Treatment
o No effective treatment. Affected horses remain lame. Arthroscopy of hip joint for
debridement of partial tears of accessory ligament to perform synovectomy.

Rupture of achilles tendon

• Rupture of the gastrocnemius muscle or its tendon (tendo-achilis) has been met with in the
horse, cattle, dog and cat.
• Etiology
o Excessive strain on the tendon during jumping or while pulling heavy draft.
o External violence.

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 o Due to malicious injury. Malicious cutting of the tendon is called hamstringing. The
tendo-achilis and portion of the superficial flexor tendon situated close to it are
usually cut simultaneously.
• Symptoms
o The hock and all joints below it are flexed. The affected limb is not able to bear
weight.
• Treatment
o In small animals like dogs and cats suturing may be tried.
o Keep the hock extended by putting plaster of paris bandage.
Healing and re-union of the tendon takes four to six weeks and will depend on
whether the hock has been properly immobilized in the extended position.
• Prognosis
o In small animals like dogs and cats recovery usually takes place if properly treated. In
large animals healing is difficult when the tendons are completely cut.

CORDING UP AND CRURAL PARALYSIS

Cording up

• Myopathy that occurs after active muscular exertion. Horses affected are usually on high
grain ration and tested for one or two days.
Painful condition of iliopsoas muscle that occurs within minutes after exertion of race.
• Signs
o Stiffness after racing
o Back is rigid
o Palpation of iliopsoas muscle- painful.
o Muscles hard to touch.
o Involvement of gluteal and quadriceps
o Mild myoglobinuria
• Diagnosis
o Clinical signs and history.
• Treatment
o Walking horse for 30-40 minutes.
o Calcium gluconate intravenous injection.
o Tranquilizers.
o Alkalization of blood with sodium carbonate.

Crural paralysis

• The crural nerve supplies the quadriceps extensor cruris muscle situated in front of the
femur. This muscle, also known as the quadriceps femoris muscle, actually consists of four
muscles, viz., vastus medialis, rectus femoris and vastus internus muscles.
• When there is paralysis of the crural nerve the quadriceps extensor cruris muscle becomes
functionless and the stifle remains “dropped”. When the animal tries to put weight on the
limb there is sudden flexion of stifle and then automatically of the hock and therefore no
weight can be borne on the limb. The loose powerless appearance of the limb may resemble
some fracture.
• Treatment
o If the paralysis is due to a callus or tumor pressing on the nerve, it is desirable to
remove the same.
o When the paralysis is due to a minor injury and is of a temporary nature, application
of counter-irritants locally may accelerate recovery. Pot. Iod may be given internally
to promote absorption of inflammatory exudates pressing on the nerve.
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 o Nerve tonics like vitamin-B1 (Thiamine), phospholectin etc. are advisable.
o Administration of calcium.
o To promote muscular atrophy, mild exercises, massage and application of liniments
or blisters are indicated. Manual movements of the joints will induce activity of the
paralysed muscles and thereby prevent atrophy.
o Electro-therapy accelerates recovery and prevents muscular atrophy.
o Infra-red rays can penetrate into deeper tissues and being hot rays they stimulate
regenerative processes largely by favouring hyperaemia.
o If paralysis is due to rheumatism, sodium salicylates is indicated.
o Corticosteroid preparations may be effective in some cases to quicken the recovery.

CAPPED ELBOW (BURSITIS OF THE ELBOW/ OLECRANON BURSITIS/ SHOE

BOIL)

• Most commonly observed in draft breeds, light horses less frequently affected. It primarily
affects one elbow. The characteristic movable swelling over the point of olecranon
tuberosity develops from trauma, which inturn creates an acquired or false sub cutaneous
bursa. It becomes lines with a membrane that produces a synovial like fluid. This fluid
differs from joint synovial fluid in its viscosity and mucin clot.
• Chronic bursitis is characterized by the accumulation of bursal fluid and thickening of the
bursal wall by fibrous tissue. Fibrous bands and septa may develop in bursal cavity and sub
cutaneous tissues around bursa continue to thicken.
• Causes
o Acute bursitis is the result of trauma
o American saddle bred and standard bred horses may hit elbow with the foot during
exercise
o Infected bursa may also develop after needle aspiration and injection of
corticosteroids
• Clinical signs
o Prominent, often freely movable
o Swelling over the point of the elbow
o lameness usually not present unless the bursa is greatly enlarged or infected
o Infected bursa feel warm and firm pressure causes pain
o If infected bursa ruptures, it is characterized by exuberant granulation discharging
sinuses and the formation of the fibrous tissue
• Diagnosis
o Physical findings
o Radiography can be taken to rule out trauma or infection involving the olecranon
process. If draining tract is present, contrast material may be injected to identify its
depth and course.
o Ultrasonography can also be used to determine if deeper structures are involved.
• Treatment
o In the acute stage, to prevent further trauma shoe boil or a boot can be used
o Aseptic injection of steroids may be used beneficial after the fluid has been removed
o Removal of initiating cause
o Bursal drainage followed by the injection of orgotein may reduce swelling
o In chronic bursitis
o Intralesional injection of 7% iodine, incision intobursa and insertion of gauze soaked
in 7% iodine, insertion of penrose drains for 10-14 days, en bloc resection of the
bursa is best if bursa is large and composed primarily of fibrous tissue.

PEDAL OSTEITIS

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• Pedal posterities is an inflammatory condition of the foot that results in demineralization of
the distal phalanx.
• Two recognized classifications are
o non septic and
o septic

Racing joint

• Etiology
o Primarily it is associated with severe or chronic sole bruising, concussion
o Secondary is most common, caused by persistent corns, laminitis, puncture wounds,
bruised wound sole, conformational faults.
o Septic Pedal osteitis develops from introduction of environmental microbes either
into the soft tissues of the foot or distal phalanx.
o It causes includes chronic severe laminitis, sub solar abscess, solar margin fracture,
deep hoof wall cracks, avulsion of hoof injuries, penetrating wounds of the foot.
• Clinical signs
o Non septic PO commonly affects forelimb and the condition can be either unilateral
or bilateral. Severity of the lameness depends upon on the cause and degree of injury.
o Hoof tester examination often reveals a focal or a diffuse region of increased
sensitivity when pressure is applied to the sole and to the hoof wall.
o Septic PO commonly affects the forelimb; lameness grades ranging from 2-4.5 are
common. On palpation, increase in temperature and prominent digital pulses can
often be felt in the affected foot.
• Diagnosis
o Radiographic assessment of distal phalanx for nonseptic PO includes atleast 3 views:
65º dorsopalmar, medial and lateral oblique projections.
o Radiographic signs include demineralization, widening of the nutrient foramina at
the solar margin, irregular bone formation along the solar margins of dorsal surface
of distal phalanx. Lateral border usually more roughened than medial.
o Radiographic signs of septic PO are loss of trabacular detail with indistinct margins
fading into the surrounding bone, osteolysis at the margins of the distal phalanx.
• Treatment
o Non septic PO
 Rest, administration of NSAIDs, the avoidance of exercise on hard surfaces,
application of protective shoes should be useful.
 A handmade, wide web, egg bar shoe whose solar surface is deeply concave is
more useful. In horses in which the sole is thin and soft can be medicated
topically with equal parts of phenol, formalin and iodine to toughen them.
 Palmar digital neurectomy recommended.
o Septic PO
 Debridement of the tract, removal of infected bone. Infected bone appears
grayer and is softer than the normal soft bone of the normal distal phalanx.
 Tract is packed with gauze soaked in dilute povidone iodine and protective
bandage is applied.plastic or rubber boot can be applied to protect the
bandage.
 A shoe with a removable metal plate can be applied.
• Prognosis
o Nonseptic PO: good if condition is primary and acute unfavourable, if chronic
o Septic PO: good if infection is controlled.

SESAMOIDITIS

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• Observed frequently in racing horses between the 2-5 years age. The condition is
characterized by pain associated with proximal sesamoid bones and insertions of
suspensory ligament, resulting in lameness.
• Causes
o Any unusual strain to the fetlock region may produce sesamoiditis.it is caused by
injury to the attachment of the suspensory ligament to sesamoid bones.
o Sesamoid bones have substantial interosseous blood supply , this will enlarge in
sesamoiditis, indicating bone resoption. If stresses exceed bone’s capability to
strengthen themselves would microfracture and damage occur.
• Clinical signs
o Swelling, increased heat over the abaxial surface of the sesamoid bone, pain on
palpation and flexion of the fetlock is also painful.
o Lameness varies according to acuteness of the injury. Fetlock flexion test exacerbates
the lameness.
• Diagnosis
o Radiological changes – increased numbers and irregularity of the vascular channels,
Increases coarseness and mottling of the bone trabaculation.
o Nuclear scintigraphy indicates increased radioactivity in the region of the sesamoid
bones.
o Ultrasound of the suspensory and distal sesamoid ligaments.
o Perineural anaesthesia or intra synovial anaesthesia are used infrequently to
diagnose sesamoiditis.
• Treatment
o Cold or hot packs as well as antiphlogistic packs should be used to reduce swelling.
Rest should be given. In chronic stages firing and blistering have been used.
Radiation, laser heat, shock wave therapy, balanced mineral diet should be provided.
• Prognosis
o Guarded to unfavourable depending on the amount of periosteal reaction and new
bone growth.

SPLINTS (METACARPAL / METATARSAL EXOSTOSIS)

• Splints is a condition of young horses most commonly affects the proximal medial aspect of
the limb between second and third metacarpal bones.the interosseous ligament consists of
dense fibrous tissue that can tear with the strain applied during independent motion of the
splint bones and the cannon bone. Initially inflammatory desmititis and periosteitis
develops subsequently new bone is produced that fuses the splints to the cannon bone and
stabilizes the source of irritation.
• A true splint refers to a sprain or tear of the interosseous ligament.
• Blind splint refers to an inflammatory process of the interosseous ligament
• Knee splint refers to the enlargement of the proximal portion of the splint bone may lead to
osteoarthritis.
• Causes
o Tearing of the interosseous ligament that binds small metacarpal to large metacarpal
or metatarsal bone, external trauma or healing of transverse or longitudinal fracture
are the causes.
o The second metacarpal bone is more frequently involved because of the difference in
articulation with the carpus.
o Conformational abnormalities that increase the stress on the small metacarpal
bones, improper shoeing and trimming can cause enough alteration in the foot flight.
o Imbalanced nutrition or over nutrition in young animals , deficiency of calcium and
phosphorus, young animals that are poorly conformed, over weight and vigorously
over exercised have a greater chance of tearing the interosseous ligament.
• Clinical signs
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 o Most common in 2 year old horses undergoing heavy training, most often found on
medial aspect of the limb because second metacarpal bears increase weight than
fourth metacarpal.
o Lameness is obvious in the trot. Heat, pain, swelling over the affected region may
occur any where along the length of the splint bone. If new bone growth occurs near
the carpal joint, it may cause knee splints.
o Lameness more marked with exercise on hard ground. In mild cases, no lameness
may be evident in the walk, but lameness is exhibited during the trot.
• Diagnosis
o Radiography – osteomyelitis between second and third metacarpal bones, periostitis
of the splint bones results from superficial trauma to the periosteum causes a
proliferative periostitis
o Ultrasound examination can demonstrate concomitant injury to the suspensory
ligament
o Nuclear scintigraphy may be needed to confirm a blind splints.
• Treatment
o In acute phase, administration of NSAID’s coupled with hypothermia and pressure
support wraps beneficial to reduce inflammatory signs, hand massage,ice
application, application of DMSO/ furacin/ steroid sweat is logical. After
inflammation gone,mild liniment may be given.
o Intra lesional corticosteroid can reduce inflammation and may help prevent
excessive bone growth.if splint results from interference, splint or shin boots may
help to prevent further trauma.
o Corrective trimming and shoeing
o Pin firing, local injection of sclerosing agents, topical application of blisters, radiation
for sub acute or chronic cases.
o Surgery to remove exostosis for medical or cosmetic reasons has resulted in fir to
good success.
• Prognosis
o Good to excellent except in which the exostosis is large and encroaching.

CONTRACTED FOOT AND WHITE LINE DISEASE

• Bruise results from the rupture of blood vessels in dermis beneath the sole, frog or hoof
wall. Haemorrhage spreads into deep layers of the epidermis and becomes visible as the
hoof grows. Bruise is visible, when haemorrhage is superficial and hoof is non pigmented.
Corn is defined as bruise that involves the tissues of the sole at the angle formed by hoof
wall and the bar. This site is called “seat of corn”. Mainly it affects the inner angle of forefoot
because of more weight bearing.

• Etiology
o Trauma, bare foot, flat feet with thin soles, trimming of hoof wall too short.
o Corn – rare in bare footed. Caused by pressure from horse shoes or when stone
become wedged between the shoe and sole.
• Clinical signs and diagnosis
o This can be divided into three types. Dry, moist, suppurative
 Dry – red stains will be noticed, moist – serum accumulates beneath the
injured epidermis. Suppurative – infected bruise may involve sensitive
lamina.
o Varying degree of lameness, if acute / infected – warmer hoof and incrased digital
pulsation noticed. Hoof testers used to identify the site of pain. Stippled,reddened
region or bluish discoloration indicates chronic bruise. Chronic condition may cause
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 demineralization, increased vascular channels, irregularity of the solar margin of the
distal phalanx.
• Treatment
o Remove the source
o Application of well padded shoe
o Administration of NSAIDs
o If bruise abscess is there, drain it, soak it in antiseptic solution, apply anti septic
ointment and waterproof bandage.
o Corn – remove the cause
o Heel of the shoe extend well back on the buttress and fit full on the wall at the
quarters and heels.
o Removal of some of the tissue over the bruise helps relieve pressure, but sensitive
tissue should not be exposed.
o Full support shoe that allow to absorb full concussion to frog
o Wide web shoe also applied.

OCKED UP TOE, FLAT FOOT AND BOXY FOOT

• Primary deformity is not usually in the tendon itself. In many instances the effective
functional length of the muculo tendinous unit is less than necessary for normal limb
alignment.
• Flexural deformities are considered congenital / acquired.

Congenital flexural deformity

• Pathogenesis
o This has been attributed to uterine malpositioning. It is very common as the foetus
commonly changes position. It includes genetic factors and teratogenic insults
during the embryonic stage of pregnancy.
o It results from dominant gene mutation in the sire, ingestion of locoweed by
pregnant mares.
o Defects in cross linking of elastin and collagen due to lathyrism will cause Flexural
deformities in foals, goiter, arthrogryposis.
• Clinical manifestations
o It may affect one or more limbs. The common manifestations are fetlock and carpal
Flexural deformities.
o With Flexural deformities the foals may be able to stand but knukle over at the
fetlock. In severe instances, the foals will walk or the dorsal surface of the fetlock –
both DDF, SDF tendon units are shortened.
o Involvement of the DDF tendon alone may manifest as a Flexural deformity of the
distal interphalngeal joint (DIP).
o Congenital deformity of carpus are common.
• Treatment
o Most fetlock Flexural deformity usually respond well to splinting. Splint can be made
from 4 inch diameter thick walled pipe. Severe fetlock deformity, a straight splint is
used. DIP deformities can respond to the application of the extensions, that prevent
excessive wear of the toe.
o Glue on shoes is the use of a toe extension device made of PVC. The use of
oxytetracycline to treat congenital Flexural deformity. Cast may be used to provide
extensions.Flexor tenotomies and carpal check desmotomies have been used
successfully.
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Acquired flexural deformity

• Pathogenesis
o It can be unilateral or bilateral and usually occur as Flexural deformity of distal inter
phalangeal or metacarpo phalangeal joint. Physitis is commonly observed in animals
with Flexural deformity.
o Flexural deformity associated with OCD in the shoulder and stifle joint, poor
nutritional management, over feeding and imbalanced rations.
o Trauma, lack of exercise, genetic predisposition, rapid bone growth with out exercise
results in a failure of tendons and ligaments to develop.
• Clinical manifestation
o Clinically, there are two distinct entities
o Flexural deformity of DIP results in a raised heel and clubbed foot
o Stage 1 – when the dorsal surface of the hoof does not pass beyond vertical
o Stage 2 - when the dorsal surface of the hoof passes beyond vertical
o Radiographically, varying degree of osteomyelitis in the distal part of distal phalanx
was observed
o Flexural deformity of DIP may occur rapidly over 3-5 days. So that the heel of the
hoof rises off the ground causing the foal to walk on the toe
o Flexural deformity of the fetlock joint has been referred to as contracture of SDF
tendon. It is characterized by knuckling at the fetlock with hoof itself remaining in
normal alignment. The angle of the affected join t increases from a normal angle of
135º to 180 º or more.
• Treatment
• Conservative methods of treatment including dietary changes, exercise and hoof trimming
should be used. The animal should be exercised and anti inflammatory agents used.
o Non-Surgical treatment
 ANIMALS WITH Flexural deformity of DIP joint should have the heels
trimmed, so that the tension is placed on the flexor tendons to induce the
myotatic reflex.
 Hoof trimming works for mild cases. Heel trimming with acrylic is important
whrn the toe is worn or deformed.corrective shoeing should be recommended.
Use of wedges on the heels produce DDF straine but has very little effect on
reducing SDF strain.
o Surgical treatment
 Stage 1 DDF contracture should be treated by carpal check ligament
desmotomy. Compared with tenotomy of DDF tendon. Inferior check ligament
desmotomy causes less post operative pain and long term functional capability
of the operated limb.
DDF tenotomy indicates for severe longstanding cases of DDF contracture. If
the SDF tendon is the most taut, either SDF tenotomy or superior check
ligament desmotomy may be performed. SDF tenotomy is simple and not
drastic as DDF tenotomy in terms of cosmetic appearance and post operative
functional ability.
 Following carpal check ligament desmotomy and PVC splint is used to hold
the fetlock in position. Suspensory ligament contracture may be final
secondary effect of prolong Flexural deformity of the metacarpophalangeal
joint. Suspensory ligament desmotomy is a drastic final measure and sub
luxation of proximal inter phalangeal joint is a possible sequel.

MODULE-3: LAMENESS IN CATTLE

Learning objectives
43
This module deals with

• Upward fixation of patella

• Hoof Deformities
• Interdigital Hyperplasia/Fibroma
• Septic laminitis
• Toe ulcer/Horn fissue/Heel abcess

UPWARD FIXATION OF PATELLA

• Impaired patellar function is characterized by jerky movements during flexion to complete

immobilization of joints. Since the animal fixes its limb in extension while the patella glides
up over the trochlea to its maximum height on the articular surface, this condition called as
recurrent or permanent upward fixation of patella.
• The condition is one of the most commonly seen non inflammatory functional disorders of
the femoro patellar articulation in cattle, buffaloes. it seriously interferes the locomotion.

Anatomy

• Stifle joint consists of two separate joints, femoro patellar and femoro tibial. Trochlea
bounded by two ridges, medial and lateral, medial ridge is longer and wider.
• The patella is a sesamoid bone which is connected to the cranial tuberosity by three patellar
ligaments, medial, middle and lateral. The middle patellar ligament is thick and strong.
• The medial one is widely separated from the middle ligament at both the ends. The lateral
ligament is flat and lies close to the middle one.

Causes

• Laxity of patellar ligaments predisposes the upward fixation of patella.if the limb is over
extended e.g. due to muscular cramps or a conformatory defects, the patellar apex may get
jammed between the trochlear ridges by hooking the medial fibrocartilage over the medial
ridge. This would lead to complete extension of the limb.
• Occupational trauma, age of the animal or climatic conditions acts as a secondary factors.
The condition may be unilateral or bilateral. Signs are more severe during winter and in
draught purpose animals.

Clinical signs

• The posture of the animal is normal at rest, when allowed to leave the stall, the animal
shows jerky flexions during movement or drags the affected limb with flexed pastern.
• The signs disappear after few steps but reappear after prolonged rest. In some cases, due to
constant dragging the toes are worn out and blood may ooze out. Some animals keep the
limb in extension during progression, raise the hind quarter and move by swinging the limb
outward and forward. Animal sit, keeping the affected limb stretched.

Treatment

• Sub cutaneous division of medial patellar ligament is common. The animal is cast with
affected limb lower most and other three legs are tied together. The affected limb drawn
slightly backward. The site is prepared aseptically and infiltrated with local anaesthetic
solution.

44
 • The index finger is moved upward along the cranial border of the tibia till the cranial tibial
tuberosity is reached. The cranial ligament is traced as a broadest and thickest among the
three. The finger is slipped inwards at the level of medial condyle of the tibia into the groove
between cranial and medial ligaments. Medial one is felt as a prominent cord.
• For the open method, a small incision is made in the skin over the medial ligament, starting
immediately infront of the medial tibial tuberosity.skin is separated from fascia and fascia is
dissected to expose white glistening medial ligament.
• The ligament is exteriorized by passing a curved scissor flatwise under the ligament. Then it
cut at near its insertion.the cutaneous wound is sutured.
• In closed method, a stab incision is made into the akin immediately infront of the
medial tibial tuberosity. Grooved knife is passed between medial and middle ligaments and
the sharp edge of the instrument is directed towards the ligament. It is transected by
withdrawing the knife. A small quantity of tincture iodine is instilled into the wound which
is left unsutured.
• Some animals may show recurrence after successful surgery or counter irritant injection. In
bovines a piece of ligament is removed to prevent the reunion of cut edges of the ligaments.

HOOF DEFORMITIES

• Foot conformation depends on inherited and environmental factors. An acquired abnormal

conformation may result as a sequel to primary foot lesion or may result from stresses
imposed by the upper part of the limb. The initiating factors may be latent until the animal
is sufficiently heavy to stress the weaker structures of the foot for the lesion to manifest
itself.
• This is divided into 3 sub divisions
o general structural abnormalities
o abnormalities of skin
o abnormalities of horn

General structural abnomalities

1. SYNDACTYLY ( MULE FOOT)

1. Fusion of digits to a single hoof
2. Clinical features: 2 forms are recognized
1. teratologic (fusion of digits)
2. atavistic (failure of separation of the primordial elements) more common
congenital defects in American HF cattle. More common in the forelimbs and
may be uni / bi / quadrilateral.
2. POLYDACTYLY (POLYMELIA)
1. Increase in normal number of digits
2. Clinical features : the supranumery digit is usually located on the medial / lateral
aspect of main digits 3 and 4. numerous breeds are involved. The mode of
inheritance of a sex linked recessive in Hereford or a dominant in Normandy and
Swedish cattle.
3. MISCELLANEOUS
1. Flexed pastern or fetlock is the one of the most common congenital abnormalities.
The German Fresian breed is commonly affected.
2. Normal angle of divergence of the digits is about 15º in normal weight bearing, but
may abnormally reach 70 º. a condition called ‘ toeing out’ has been described in
which the sagittal axis of each digit is deviated abaxially.
3. Misshapen feet with synonyms of ‘splay toes’ or ‘spray toes’ were responsible for a
progressive lameness in jersey calves, thought to be due to a single autosomal
recessive gene.
45
 splay toes is a term which should be reserved only for those digits where separation
of phalanges is visible from the fetlock joint downwards.
4. ABNORMAL OF SKIN
1. Keratogenesis imperfecta hereditaria bovina
2. It involves the coronet and coronary corium. Primary epithelial defect in new born
calves involves both mouth and feet. Secondary infections rapidly and the disease is
soon fatal.
3. Interdigital hyperplasia
5. ABNORMALITIES OF HORN
1. Overgrowth of horn is one of the most frequent causes of disturbed gait.mildly
deformed hooves usually cause only a slight degree of lameness or awkward gait.
Abnormalities of horn may result from various factors affecting horn produce and
wear including.
1. Breed: light coloured hooves usually composed of horn of softer texture than
darkly pigmented hooves.
2. Seasonal factors: during prolonged wet weather horn becomes softened and
more liable to distortion under stress. However, in hot and dry weather
hooves are much more likely to split and crack.
3. Nutritional factors: high protein diet accelerates the abnormal hoof growth of
the horn. Erythema of the coronet is a common sequel to heavy
feeding.defective feeding for short periods produces poor horn growth in the
form of deep grooves parallel to the coronet.
4. Stress factors: horn of fore feet was harder than hind feet. Pregnancy,
lactation disturbs bone mineral metabolism.
5. Individual variation: congenital predisposition to abnormality which is
influenced to a greater or lesser extent by a wide variety of external factors.
6. BEAK CLAW
1. Abnormal hoof in which dorsal wall is concave from coronet to toe and the weight
bearing borders of the walls are convex from heel to toe.
2. Incidence: low
3. Clinical features: this condition is primarily a congenital deformity. The animla rocks
from toe to heel when standing and walking may be difficult. The rotation of the digit
ia primarily on a transverse axis. The condition is incurable the animal should be
eliminated from the breeding herd as soon as possible.
7. CORKSCREW CLAW
1. An abnormal hoof with the lesion primarily in the lateral especially of the hindlimb,
the horn of which takes the form of a coarse medially turning spiral. Rotation
towards axial plane.
2. Incidence: low
3. Clinical features: Inherited
4. In early stages the claw is narrower, longer and more curved than unusual. The axis
is no longer straight but inclined axially to intrude towards the oppositedigit. Bony
exostosis occurs on the abaxial aspect of the distal joint. The joint may be ankylosed.

Abnormal angulation of distal joint → abnormal strains on

lateral collateral ligament of
distal joint
↓
localized periostitis
↓
localized exostoses
↓
increases horn production on abaxial wall

46
 ↓
axial rotation of the horn of digit

o Treatment
1. Foot trimming may be practiced.
2. Palliative treatment may be practiced by chiropody
3. Breeding of affected animals should be avoided.
CLAW HYPOPLASIA
o Reduction the size of ome claw, usually bilateral and in the hindlimb.
o Clinical features
o The lateral claw of the hind foot is smaller than medial claw. It is narrower than
normal terminates in a long sharp point. it strongly curved medially and may touch
or overlie the medial claw. It may impede locomotion and contribute to lameness. It
may be seen in mature as well as young animals.
SCISSOR FEET (CROSSED TOES, SLIPPER FOOT, STRADDLE CLAW)
o Extensive overgrowth of both claws of a foot with overlapping.
CLINICAL FEATURE: severe overgrowth seen in the extreme form of chronic
laminitis.
REGULAR OVER GROWTH (STALL CLAW, STABLE CLAW, DEFORMED CLAW)
0. Elongation of foot with increased length of walls and sole and a lessened angle of the
dorsal border with the bearing surface. An uneven weight distribution on the sole
and heel is characteriscitc.
1. Clinical features
 This condition most commonly occurs in hindlimbs. Normal horn growth may
average 0.5-1.3mm/ month. Mild cases may grow 2mm, moderate cases 4mm,
severe cases 6 mm or more.commonly noticed in lateral digit because lateral
digit bears less weight. The sensitive laminae are whitish instead of pink, firm
and measure 2-3mm longer than. Obvious inflammatory changes noticed at
the junction of sensitive laminae and skin / horn.
2. Etiology: when animal confined on soft surfaces too little wear of the hoof takes place
and the horn grows excessively long.
3. Control: animal should be regularly driven over hard surfaces.
4. Treatment: hoof trimming required, 2.5cm horn twice yearly is removed.

INTER DIGITAL HYPERPLASIA (INTER DIGITAL FIBROMA, KELOID,

PAPILLOMA, CORN, WART, LIMAX, TYLOM, BONE CYST)

Definition

• A variable excess of epidermal and hypodermal tissue occupying part or all of the inter
digital space especially dorsal.

Incidence

• Sporadic
• Relatively high in association with particular breeds such as Friesian in Germany and
Hereford in Britain.
• Commonly greater in males than in females
• Commonly more than one foot is affected larger lesions in hind feet may be unilateral or
bilateral.
• Commonly in young animals 1-2 yrs old, it begins to decrease at 6 years old.

47
Predisposing factors

• The defect was genetic origin, but is uncertain as to whether inheritance is dominant or
recessive.
• The under developed ligamentous arrangement
• Hereditary especially the smaller light boned animal
• Splay toes related to inter digital hyperplasia and which is definitely inherited.
• An asymmetrical lesion of this type (tylom) develops sometimes following an abaxial wall
lesion, wall abscesses, or other chronic foot diseases/

Clinical features

• The degree of lameness depends on the size and situation of the lesion, the degree of the
infection and the stress placed on the affected foot.
• The lesion appears as a protruberance of skin, partially eroded in the interdigital space,
when large invariably appears to originates from the middle of the space rather than
laterally and is more frequent in the dorsal half of the cleft.
• Most of the lesion found on lateral claw than medial claw.
• Lesions tend to be larger in older animals and are hairless, firm and relatively painless on
palpation.
• Chronic inflammatory lesion resulting from microtrauma of the skin as principally fibrous
connective tissue with some fat. The whole structure being comparatively avascular.
• Sub acute / chronic inflammatory process with hyperkeratosis and parakeratosis with
superimposed secondary damage such as wounds, pressure necrosis, splitting of the
keratinized layer and local infection.

Diagnosis

• Physical examination

Differential diagnosis

• True papilloma, inflammatory swelling, cellulitis.

Treatment

• Radical removal under anaesthesia (local I/V, ring block / specific nerve blocks, epidural
anaesthesia for hindlimb).
• Foot is cleaned and inter digital space may be separated by a pair of wound retractors.
Tourniquet is applied; the lesion is removed with a knife of hot iron. Haemostasis achieved
as far as possible, lesion dressed with sulphanilamide powder and firmly bandaging using a
figure of eight formation.
• Wire should be inserted through or around toes to prevent further splaying of foot.
• Removal of small lesions by use of the ointment containing salicylic acid, boric acid and
phenol.

Prevention

• Affected animals should not be used for breeding purposes.

Interdigital skin
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 hyperplasia

Interdigital fibroma

• A wart-like mass of fibrous tissue which develops in the anterior part of the interdigital cleft
of cattle causing chronic lameness

CONTUSION OF SOLE (PODODERMATITIS CIRCUMSPECTA/BRUISED SOLE)

Definition

• A specific lesion affecting the sole or sole-heel junction starting as a hemorrhage in the
corium and leading to loss of horn over the area with the resulting track to the bearing
surface. There is a passage of infection to the solar corium with the development of
secondary septic laminitis.

Incidence

• The condition commonly affects adult cattle. Female cattle tend to be affected most
frequently in the lateral claws of the hind feet, while bulls are affected more in medial claws
of fore feet.

Clinical features

• Sudden onset of lameness and limb may be held in an abnormal position, abduction of limb,
excessive pulsation of the artery over the metatarsal / metacarpal region, break in the
continuity of the integument, pain on pressure are noticed.
• If the condition has progressed, granulation tissue from the corium rapidly grows through
the defect to form a cauliflower or rosette like protruberance. This lesion frequently bleeds.
Extensive under running of the sole in all the directions.
• Severe continuing lameness leads to considerable strain on the opposite supporting limb,
ligamentous tendinous and joint changes may result. If the course is chronic, interdigital
hyperplasia may develop.

Aetiology

• Greater weight bearing by particular digits, intensive feeding of oilseed cakes, cow-hocked
animals and abnormal hoof lengths leads to the excessive tension on deep flexor tendon
may result from an abnormal posture.
• Thrombosis in digital arteries, it is sequelae of partially used chronic laminits.
• Heavy bulls have a higher incidence than lighter breeds.
• Hereditary factors involved in absorption of concussion may also play a role like an upright
hindlimb may predispose to damage.

Diagnosis

• The lesion is at a characteristic point and readily observed after cleaning.

• Under run horn should be pared away and a probe passed down the tract.

49
 • The presence of thin, yellow pus indicates extensive pododermatitis into the navicular bursa
or pedal joint, dark pus is usually from more superficial necrosis.

Differential diagnosis

• Aseptic / septic puncture of sole

• White line disease
• Chronic necrotic pododermatitis
• Inter digital necrobacillosis
• Acute laminitis

Treatment

• Adequate exposure of the diseased tissues and removal of necrotic horn, corium and
exuberant granulation under local anaesthesia or nerve block. Necrotic tissue should not be
cut by the knife and should be left to slough. Excessive haemorrhage must be avoided.
• Salicylic acid, iodine compounds, copper sulphate, dilute sulphonamide suspensions can be
used.
• Application of chlormycetin tincture effectively dries superficial sensitive corium act as a
specific antibiotic cover against fusobacterium necrophorus infection.
• Chlorhexidine ointment followed by a daily soaking of the bandaged foot in copper sulphate
solution.
• Defect should be covered with a firm padding of gauze and a compressive waterproof
bandage.
• Local antibiotic injection. (e.g) neomycin, bacitracin, chlortetracycline, penicillin.

Prophylaxis

• Effective, regular trimming of feet must be carried out by experienced person.

• Animal should always be permitted a period of walking exercise in winter, when normally
kept for much of the time indoors.

• It results when a foreign body punctures the solar corium directly. Dirt and bacterial
organisms accompany the foreign body up the traumatic pathway. The result is invariably a
purulent and necrotic infection of the damaged tissues which depends on the precise site of
penetration.

Dorsal region

• The distal surface of the distal phalanx is most likely to be damaged. Osteomyelitis and
pathological fracture may result of such a process. The animal may hold the affected limb
off the ground and generalized trumbling noticed. In other cases which are less painful,
paddling of feet may be noticed. When the abscess is relieved, pus usually pinkish yellow,
spurts forth as a jet.
• Another type of lesion encountered in the dorsal region is small, hard to detect and caused
by a sharp hared foreign body.

Sole, heel and junction region

50
 • The deep flexor tendon, navicular bursa or navicular bone may be contacted by the foreign
body.
• In superficial cases a tendency for the infection or pus to extend towards the heel bulbs
causing complete detachment of the horn through the whole area over the bulb. The horn is
softer and more pliable and may favour the relative ease of separation of the sole.

Plantar region

• Penetration is into the dense heel cushion of white fibrous tissue.

• Signs associated with this condition may be intermittent, sudden flexion of the affected limb
in recumbency, acute pain of fluid under pressure between sensitive corium and sole, stilted
gait to lameness.
• In bilateral cases affecting medial digits,the forelimb may be crossed. Swollen heel and
necrosis of the superficial epithelium at coronary band.

Differential diagnosis

• Simple trauma, distal phalanx fracture, inter digital necrobacillosis, pododermatitis

circumspecta, pododermatitis profunda.

Diagnosis

• History
• Examination of the foot

Treatment

• Anaesthesia may not be required. The horn is naturally non sensitive and the underlying
diseased laminae also appear completely desensitized in the presence of pus.
• In traumatic penetration the dark track must be followed down to its full depth. Discharges
should be drained under pressure. Necrotic solar corium should be removed. Care must be
taken to avoid healthy tissues, especially deep flexor tendon.
• The defect should be dressed with sulphonamide or antibiotic powder preceded by
superficial spraying with a spirit based chloramphenicol preparation, packed firmly with a
sterile gauze swab and cotton wool. The foot is bandaged and a water proof dressing
applied.
• Special cases may be shod with a steel shoe supporting a 1-2 cm thick wooden shoe on the
sound digit in order to avoid pressure on the damaged sole.
• Resin material can be used to raise the affected digit from the ground.
• In severe cases, where almost the entire sole has been stripped it is possible to drill the
abaxial and axial wall and to thread embryotomy wire across the sole, then to pour the
plastic on to form a thick slab.

Complications

• The navicular bone may undergo septic changes and loosely resorbed. The pedal joint may
have a septic arthritis.

Prognosis

• Good in cases of bruises. Poor prognosis if it is entered into joints in draught animals.

51
 MODULE-4: SACROILIAC LUXATION IN LARGE ANIMALS

Learning objectives

This module deals with

• Anatomy, signs, diagnosis and treatment of sacroiloac luxation

ANATOMY

• The pelvis consists of two symmetrical sets of bones that are fused together to form a solid
bone. The pelvis is attached to the lower part of the spine, called the sacrum, by a left and
right sacroiliac joints. Unlike the hip, knee, elbow and other joints, the sacroiliac joints have
limited movement.
• The sacrum consists of five spinal bones that are fused together
• The sciatic nerve runs immediately below the sacroiliac joint, thus this nerve is susceptible
to damage.

SIGNS

• Sacroiliac luxation usually is caused by a very traumatic blow to the hind end of an animal.
• Varying degrees of lameness on the side of the luxation.
• Pain is noted when the sacroiliac joint is palpated.
• The pelvis may feel crunchy when a force is applied to the front of the pelvis.
• If the sciatic nerve was also injured, no or decreased sensation to the outside toe of the
affected hindlimb will be noted; complete evaluation of the sciatic nerve may be difficult
due to bruising of muscles and the nerve itself.

DIAGNOSIS

• Prior to surgery the following tests are usually performed:

o Bloodwork such as CBC and chemistry profile
o Radiographs (x-rays) of the chest to rule out trauma to the lungs or ribs
o Radiographs or ultrasound of the abdomen to rule out internal organ damage and
internal bleeding
o Radiographs of the pelvis; the unfractured pelvis should fit within an imaginary box
and if it does not, there is a fracture +/- dislocation the sacroiliac joint a part of the
pelvis will be shifted outside this box. In this case, take note of the sacroiliac luxation
and fractures of the pubis and ischium of the pelvis.

TREATMENT

• There are three options for treatment of a sacroiliac luxation

o Conservative treatment is acceptable if only one side of the pelvis has been damaged,
and minimal displacement of the sacroiliac joint is present. These patients will be
painful for a much greater time versus having the luxation surgically repaired.
o Traditional surgery involves making a sizeable incision along the side of the pelvis
and peeling the muscles off the bones to expose the dislocated joint. Screws are used
to secure the dislocated joint in place.

52
 o Minimally invasive surgery involves manually reducing the joint back into place from
the outside, making a small incision (about 1 to 1.5 cm) over the side of the pelvis in
the location of the sacroiliac joint and securing the sacroiliac joint in place with
screws with the aide of fluoroscopy or digital radiography.

Details

• The patient is placed on the x-ray table with the affected pelvis up. Digital radiographs are
made (or fluoroscopy used) to assist the surgeon in the placement of the screws. The ilium
is manually pushed back into place and a small pin is inserted.
• Next, a hole is drilled over sacral body and the position of the drill bit is radiographed. If the
positioning is good, the drill bit is advanced deeply into the sacrum. The drill bit is removed
and a screw (premeasured screw length from the radiographs) is seated into the bones to
hold the sacroiliac joint in place. Another screw is placed just behind the first screw using
the same method.
• The benefits of this minimally invasive approach is that a very small incision is used and
there is minimal dissection of the soft tissues, resulting in less pain.
• In addition, the surgeon can very accurately place the screws into the body of the sacrum,
thereby preventing damage to the nerves that are located in the spinal canal of the sacrum.
The length of time that it takes to perform the minimally invasive versus traditional surgery
is similar.

POST OPERATIVE CARE

• Limit activity until the fractures have healed

• Provide a soft bed to prevent bed sores
• Turn the animal from side to side
• Check the incision for infection
• Use slings

POTENTIAL COMPLICATIONS

• Sciatic nerve damage

• Nonhealing of the fractures
• Breakage of the screws
• Infection
• Anesthetic death
• Chronic constipation if a lot of callus or scar tissue develops in the pelvic canal
• Entrapment of the urethra (tube from the bladder for urination) by fracture fragments

PROGNOSIS

• Most patients heal well following surgical repair. It may take about 2 months for full
recovery.
• Patients that have sciatic nerve injury frequently will regain normal or near normal
function; occasionally the function of the nerve does not come back and the pet does not
have any useful function of the limb.

MODULE-5: MANAGEMENT OF FRACTURE IN LARGE ANIMALS

Learning objectives

53
This module deals with

• Technique of insertion
• Preparation of the site
• Operative technique
• Post operative care

INTRODUCTION

• Indications: K- nailing is indicated for middle third, transverse or short oblique fractures of
the humerus, tibia and femur when no longitudinal cracks or fissures of the bony cortex are
present.
• Biomechanics: K- nail provides better rotational stability by filling the marrow cavity of
femur and contacting as much of the cortical surface due to its clover leaf shape.
• Anaesthesia
o For goats: General anaesthesia with Xylazine hydrochloride at the rate of 0.22
mg/kg body weight intramuscularly and ketamine at the rate of 11 mg /kg body
weight intramuscularly. To prolong the duration of anaesthesia supplemental
intramuscular injection of ketamine at the dose rate of 6mg/kg body weight.
• The special instruments required for the surgery
o Hohmann retractor
o Bone holding forceps
o Universal hand drill
o Orthopaedic mallet
o Kuntscher nail reamer
o Guide pin
o Kuntscher nails
o K- nail retractor

TECHNIQUE OF INSERTION

• The K-nail is best inserted from the proximal end of the bone distally.
• The technique of insertion of the K- nail is described for a mid shaft femoral fracture in
goats.

PREPARATION OF THE SITE

• The area from the mid line of the sacrum, tip of the ilium to the tuber ischii and distally
upto the mid tibial region is prepared for aseptic surgery by clipping and shaving.
• After cleaning the area with soap and water the area is painted with povidone iodine.
• A sterile bandage is wrapped from the mid tibial region to the digits. The surgical site is
drapped following aseptic precautions

OPERATIVE TECHNIQUE

• A 10-15 cm long skin incision is made laterally from below the trochanteric major upto the
point above the lateral condyle.

• The fascia lata is divided, the biceps femoris and the vastus lateralis are reflected to expose
the shaft of the fractured femur. Then the fragments are reduced and held in place using a
bone holding forceps.
54
 • A small incision on the skin and the muscles are made and a K-nail reamer is inserted just
medial to the greater trochanter, into the subtrochanteric fossa.
• The reamer is pushed distally and reamed into the proximal fragment to pierce the proximal
end to facilitate easy insertion of the nail. The determination of size of the nail to be used is
made by introducing the nail into the marrow cavity of the smaller fragment at the fracture
site.
• The proper length of the nail may be obtained using the Steinmann pin after stabilization of
the reduced fracture and cutting the nail to this length.
• The length of the K-nail should be such that when seated in the distal metaphysis, the head
of the nail is located just distal to the greater trochanter in the subtrochanteric fossa.

• A Steinmann pin (guide pin) is inserted through the hold made by the reamer and the pre
measured K- nail of appropriate length and diameter is hammered with an orthopaedic
mallet until the distal end of the nail reach beyond the fracture site.
• The guide pin is withdrawn and the nail is gently driven into the distal fragment of the bone
until it lodges in the distal cortex.

• The fascia lata and biceps femoris muscles are sutured with chromic catgut in a simple
continuous fashion. The cutaneous wound is closed with a row of simple interrupted sutures
using silk.

Cutaneous wound closure

POST OPERATIVE CARE

• The surgical wound is dressed with antiseptic lotion and post operative antibiotics are
administered for 5-7 days.
• The skin sutures are removed on 8-10 days after clinical union of the skin.
• The K- nail is removed using K- nail retractor on 8 weeks to 12 weeks after radiographic
healing of the bone.

TRANSFIXATION PINNING FOR FRACTURE MANAGEMENT IN CALVES

• Transfixation is a general term for methods of fracture immobilization in which wires, pins
or screws inserted in a bone are controlled externally by splints, casts or clamps.

Indications

• Transfixation is suitable for the treatment of difficult fracture situations involving non-
union, osteoporotic bone, osteomyelitis, open wounds, unstable comminution, articular and
periarticular fractures and correction of growth deformities as well as for stabilization of
joint fusions, osteototomies and limb lengthening procedures. Moreover the technique is
adaptable for application at various skeletal locations. It allows care of external wounds,
resulting in control of infection and leaves vascular supply undisturbed.

Pins

• Steinmann pins with diameter of about 20% of the bone diameter are commonly used for
transfixation. If the diameter is too small, the pins will be more flexible and will result in
excessive motion with loss of fracture reduction. On the other hand use of too large pins

55
 may result in pin hole fracture due to weakening of the bones. Centrally threaded pins are
used for prolonged healing conditions as it maintains good stability at pin bone interface
but smooth pins may get loosened quickly. But threaded pins are likel to bend/break at the
junction threaded and non-threaded portion.
• Minimum two pins should be inserted per segment. Stiffness of the fixator bone composite
increases with increase in bone number up to 4 pins per segment but there is no significant
increase in stiffness with the use of more than 4 pins per bone segment.

Fixator

• Transfixation pins inserted into bone fragments can be immobilized by various types of
fixators. Tubular connecting rods and AO and Aesculap type clamps are commonly used in
calves.
• Cost of transfixation can be minimized by use of various acrylics and casting material in
place of clamps and rods. It also allows flexibility in pin positioning. But the disadvantage of
this technique when compared to use of clamps and rods is the inability to adjust reduction
and treat soft tissue wounds after application.

PROCEDURE

Anesthesia

• After fasting for 24 hours, general anaesthesia can be induced in calves by administering
xylazine @ 0.2 mg / kg body weight intramuscularly and 10 minutes later ketamine @ 5 mg
/ kg body weight intravenously. Intravenous regional analgesia can be used as adjunct if the
duration of the surgery extends more than 30 minutes.

Technique

• Transfixation pins are inserted after closed or open reduction of the fracture. In most of the
distal long bones the pins are inserted medio-laterally thus avoiding thick muscles as well as
major blood vessels and nerves.

Method of pin insertion

• Pins can be inserted directly into the bone or after predrilling with a drill bit of about 90 %
of pin diameter. Direct insertion of trocar or spade pointed pins in cortical bones may cause
mechanical, vascular and thermal damage and necrosis of the surrounding bone and
loosening of pins.
• Hand chuck, hand drill or power drill may be used for pin insertion. Chucks are used for
insertion of pins in cancellous bone. Direct insertion of pins in dense cortical bone using
hand drill may cause wobbling thus creating pin-track larger than pin and loosening of pins.
• Predrilling a pilot hole with twist drill bit (90% of the pin diameter) is recommended when
the resistance of the bone to pin insertion generates considerable heat and the progress is
slow and when inserting pins with a diameter larger than 3.5 mm.

Transfixation pinning and casting

• With fracture held in reduction drill a pilot hole on the proximal fragment about 3 cm
proximal to fracture line. Subsequent pilot holes are drilled parallel to first hole and at 3 cm
interval. Then insert trocar pointed Steinmann pins through the pilot holes using power

56
 drill at slow speed. Make a stab incision on the skin, to allow the pin to penetrate the skin as
it emerges from the opposite side of the bone.
• Pouring of sterile cool normal saline while drilling will help to eliminate the tissue debris
and to dissipate heat. Two are three pins are inserted in the distal fragment in the similar
fashion. Cut the pins using pin cutter leaving 3 cm fro the skin surface. With fracture held in
reduction, Indian ink is painted at the cut surface of the pins and on the splints take
impressions on the PVC splints to mark the distance between the pins.
• Fix the splints on either side with proper padding to stabilize the alignment of fracture ends
before cast application. The pin-splint assembly is held in position by plaster cast.

Transfixation using clamps and rods

• Drill two guide holes, one 6 cm proximal to the fracture line in the proximal fragment and
another 6 cm distal to the fracture line in the distal fragment using twist drill bit.
• Insert Steinmann pin at each hole using the power drill at low speed. Attach connecting bar
on each side using clamps. Adjust the clamps so as to keep the fracture site under
compression and tighten it. Insertion of other pins parallel to and in line with connecting
rod is important for construction of bilateral frames.
• An aiming device or sliding guide pin gripper technique is useful for this purpose. In sliding
guide pin gripper technique additional connecting rods and clamps are attached to one side.
Then guide holes as well as pins should be inserted through both the additional clamps in
the two connecting rods on the same side.
• Finally the additional connecting bars and clamps are removed. With fracture held in
reduction, tighten all the clamps to maintain fracture reduction.

ADVANTAGE AND DISADVANTAGE

Advantage

• External skeletal fixation provides good fracture alignment and rigid fixation. It is a
minimally invasive technique thus reduces post-operative pain associated with extensive
tissue dissection and accelerates the healing process due to decreased disruption of soft
tissue.
• They are excellent for comminuted fractures when alignment of comminuted fragments is
not possible. It allows care of external wounds. No hardware remains in the animal once the
fracture is healed.
• Advantages of transfixation pinning and casting in management of fractures include
flexibility in pin positioning, adequate maintenance of reduction, early return to weight-
bearing status, preservation of joint mobility, and ease of ambulation.

Disadvantage

• External skeletal fixators require a much greater degree of postoperative care to ensure that
additional damage does not occur to the animal or the device.
• It is be difficult to apply in areas with thick muscle and if applied in such areas is associated
with more pain. Bilateral frames cannot be used for fractures of the femur and humerus.
• External skeletal fixation may not be as rigid a form of fixation as compared to plating and
interlocking nail fixation.

COMPLICATIONS

57
 • Pin loosening, pin tract infection, fixator problems and impalement of neurovascular /
muscular tissues are some of the problems with use of transfixation technique.
• Premature loosening of fixation pins causes severe pain, poor limb function, fracture
instability, delayed union and non-union. Mechanical bone damage around hand chuck
inserted pins, thermal bone necrosis around high speed power inserted pins and increased
inflammation around hand drill inserted pins are the causes for pin loosening.
• Pin tract sepsis is caused by the invasion of necrotic bone by skin bacteria and is
characterized by persistent and excessive purulent drainage and soft tissue inflammation.

MODULE-6: ORTHOPAEDIC EXAMINATION - SMALL ANIMALS

Learning objectives

This module deals with

• Physical examination for lameness

• Musculoskeletal disorders

PHYSICAL EXAMINATION FOR LAMENESS

Goals

• To determine which limb(s) is/are affected,

• To determine whether the problem is orthopedic or neurologic
• To determine in which region of the affected limb the cause of the lameness is localized,
• To determine - if possible - which particular structure and pathology is causing the
lameness.

Physical examination

• History
o Assessment of activity at home
• General physical examination
o TPR
o Mucous membranes
o Lymph nodes
• Inspection/observation of gait
o Observation
o Head goes up during the swing phase of the affected fore limb
o Instrumented gait analysis
o Kinetics – forces – force plate analysis
o Kinematics – motion – motion analysis system
o Paw pressure analysis – gait cycle, forces
• Neurological examination
o Conscious proprioception
o Normal CP -> assume that the patient has an orthopedic problem; neuro exam not
needed
o Delayed or absent CP -> patient may have a neurologic problem -> do complete
neuro exam
• Palpation
o Superficial palpation of the trunk and the extremities
o Detection of asymmetry of size, shape, heat, and sensitivity
58
• Evaluation of joints
o How do you determine whether a joint is abnormal?
o Primary indicators (screening)
 Pain on hyperextension/hyperflexion of the joint
 Decreased range of motion (“guarding” or old injury)
o Secondary indicators
 Pain on flexion, extension, endorotation, exorotation,
 Abnormal sounds, crepitus
o Evaluation of joint stability
o Collateral ligaments
 Stretching of ligaments with joints in extension (stressing” the ligaments)
 Pain (mild-moderate sprain) or instability (moderate-severe sprain)
o Shoulder (mediolateral instability)
 Abduction of the limb with joint in extension (pain and/or increased
abduction)
o Hip
 Barden's sign
 Ortolani sign - preferred
 Barlow's sign
 Hip asymmetry for coxofemoral luxations
o Stifle
 Patella luxation
 Collateral ligament instability
 Drawer movement – “positive drawer”
 Tibial compression test – “positive tibial thrust”
• Evaluation of bones
o How do you determine whether a bone is abnormal?
o Primary indicators (screening)
o Pain on deep palpation
o gentle, deep palpation over the distal, middle, and proximal ends of long bones
o detection of bone or periosteal pain
o abnormal findings mostly indicative of bone disease
o Abnormal motion
• Evaluation of muscle-tendon units
o MTU = Muscle tendon unit = muscle origin-muscle belly-myotendinous junction-
tendon-tendon insertion
o How do you determine whether a muscle-tendon unit is abnormal?
o Primary indicators (screening)
o Pain on stretching of the affected MTU
o Secondary indicators
o Pain on deep palpation
o Three muscle that can be selectively stretched
o Biceps maneuver - simultaneous flexion of the shoulder and extension of the elbow
joint
o Infraspinatus (teres minor?) maneuver - simulateous extension and internal rotation
of the shoulder joint
o Iliopsoas maneuver - simultaneous internal rotation and extension of the hip joint
• Assessment
o localize lameness and establish differential diagnosis
o establish causal relationship
o if possible determine the affected tissue type
• Diagnostic or therapeutic plan

MUSCULOSKELETAL DISORDERS
59
An Overview

• Musculoskeletal disorders are an important group of diseases and are a major part of the
case load in almost any practice.
• Patients with musculoskeletal disorders usually present with a lameness or with one or
more fractures following automobile accidents.
o Lameness
o Lameness of growing animals
o Lameness of mature animals

LAMENESS IN GROWING ANIMALS

Developmental orthopedic diseases

Hip dysplasia

• Abnormal development of the hip joint

• Initial joint laxity (subluxation) may result in joint deformity (shallow acetabulum, flattened
femoral head) and severe DJD
• Seen primarily in medium and large breed dogs especially German Shepherds, Old English
Sheepdogs, Retrievers, Newfoundlanders, St. Bernards
• Usually bilateral
• Hip dysplasia has many different presentations, ranging from an asymptomatic to a
crippling disease. Lameness may appear at any age.
• Risk factors
o Genetic predisposition
o Increased calcium and/or energy intake
o Rapid growth
• Clinical signs
o Lameness in young dogs usually due to joint laxity; in older dogs the lameness is
usually due to secondary DJD
o Signs vary depending on the severity of disease and temperament of the animal
o Intermittent or continuous hind limb lameness, stiffness or difficulty in rising,
reluctance to run and jump, short choppy steps of the hind limbs, loose or waddling
gait, bunny-hopping when running, pain
• Diagnosis
o Physical examination (laxity, pain and/or crepitus of the hip joints)
o May need sedation to evaluate laxity
• Radiography
o Extended ventrodorsal and lateral pelvic radiographs maybe taken anytime there is a
problem with the hips. The severity of clinical signs often does not correlate with the
severity of radiographic signs
o Radiographs to screen for presence or absence of hip dysplasia to select dogs that are
suitable for breeding
• Prevention
o Dogs younger than 1 year of age (laxity)
o 3/5 body conditioning score
o Large breed growth diets
o Limited food intake
o Dogs older than 1 year of age (DJD)
o 3/5 body conditioning score

60
 o Chondroprotectives
• Treatment
o The type of treatment depends upon many factors including the age, weight,
progression of the disease, use of the animal and economic factors
o Medical management (weight control, exercise control, analgesics) may be adequate
if signs are mild or intermittent
o Surgery may be necessary if signs are severe and unresponsive to medical therapy or
chronic

Osteochondrosis

• A disease of young medium, large and giant breed dogs where there is a disturbance of
articular cartilage growth and endochondral ossification (replacement ofd cartilage with
bone)
• Joints which may be affected include the shoulder, elbow (fragmented coronoid
process=FCP, OCD medial humeral condyle, ununited anconeal process=UAP), and less
frequently the stifle and talocrural joint
• The articular cartilage separates from the underlying bone resulting in a loose flap of
cartilage in the joint. Once a flap has been developed, the disease is called osteochondritis
dissecans (OCD)
• Osteochondrosis also can occur in the growth plate (Ununited Anconeal Process)
• Often bilateral
• Risk factors
o Genetic predisposition
o Increased calcium and energy intake
o Rapid growth
• Clinical signs
o Lameness
o usually begins at 4-8 months of age; varies from mild to severe; usually weight
bearing
o lameness in dogs older than 1 year of age usually secondary DJD
• Diagnosis
o Physical examination (pain on manipulation, crepitus, joint swelling, reduced range
of motion)
• Prevention
o Dogs younger than 1 year of age
o 3/5 body conditioning score
o Large breed growth diets
o Limited food intake
o No supplements
o Dogs older than 1 year of age
o 3/5 body conditioning score
o Chondroprotectives?
• Treatment
o The type of treatment depends upon many factors including the age, weight,
progression of the disease, use of the animal and economic factors
o Conservative management (weight control, exercise control, analgesics) may be
adequate if signs are mild or intermittent
o Surgical exploratory and debridement of the affected joint (arthrotomy or
arthroscopy) is indicated if signs are severe or if patient is unresponsive to medical
therapy
• Post-operative care
o Routine home post-operative care

61
 o Observe suture line daily for swelling or seroma formation; seromas are fairly
common after surgery on the shoulder
o The dog's activity should be limited for about 4 - 6 weeks after surgery

LAMENESS OF MATURE ANIMALS

Cranial cruciate ligament rupture

• In the stifle joint there are two cruciate ligaments (cranial and caudal cruciate ligaments)
which attach the femur to the tibia and stabilize the joint in cranio-caudal direction
• Stifle injuries are very common in dogs; the most common injury is rupture of the cranial
cruciate ligament
• May be seen in any dog, but most common in small overweight dogs over five years of age
• In chronic cases a meniscal tear may develop
• Clinical signs
o sudden onset of lameness
o pain in stifle area
o swelling around the stifle
• Diagnosis
o Physical examination – drawer sign
o Radiography – effusion and arthritis
• Treatment
o Surgery to stabilize the affected joint is the treatment of choice. It will slow down the
progression of DJD, but will not stop it
o There are many, many surgical techniques that can be classified as either intra-
articular (joint stabilization by intra-articular reconstruction of cranial cruciate
ligment) or extra-articular techniques (joint stability obtained by using extra-
articular stabilization technique(s))

Fractures

Fracture care

• Fractures are most commonly the result of trauma such as automobile accidents
• Occasionally a fracture may be caused by a disease process, such as a tumor, weakening the
bone
• There are several ways to classify fractures: the veterinary technician should be familiar
with the commonly used classifications
• Open vs. Closed
o Open fracture — any fracture in which there is a break in the skin over the fracture;
formerly called a compound fracture
o Closed fracture — a fracture with no breaks in the skin
• According to the extent of damage
o Complete fracture — total disruption of the bone, often with marked displacement
o Green-stick fracture — one side of the bone is broken and the other side is bent; seen
in young growing animals
o Fissure fracture — fine cracks in the cortex, usually in a spiral or longitudinal
direction
• According to direction and location of fracture line
o Transverse — fracture at right angle to the axis of the bone
o Oblique — fracture line is diagonal
o Spiral — fracture line is a curve
o Comminuted — multiple fracture lines which meet at a common point
62
 o Multiple — the bone is broken into 3 or more segments, but the fracture lines do not
meet at a common point
o Impacted — the bone fragments are driven firmly together
o Avulsion — fracture at the attachment of a tendon, ligament or muscle
o Salter fracture — fracture through a growth plate
o Intra-articular fracture — fracture involving and extending into a joint
• Clinical signs
o Sudden onset of pain
o Loss of function
o Swelling
o Deformity of structure
o Crepitus or grating sounds of bone ends rubbing together
• Diagnosis
o Physical examination
o Radiography
• Treatment
o There are two main types of fracture treatment
 External fixation - immobilization of a fracture by using external means such
as casts, splints, bandages or external fixators
 Internal fixation - immobilization of a fracture by surgically exposing the
broken plates to repair the fracture; with internal fixation the fixation device is
inside the leg
o In general, external fixation is less expensive than internal fixation, but external
fixation requires more care at home by the client than internal fixation
o The type of treatment used depends on the type of fracture, the type of animal, age of
the animal, use of the animal and economics

Fracture complications

• Delayed union - healing takes longer than anticipated

• Non-union - healing does not occur
• Malunion - bone heals in an undesired reduction
• Osteomyelitis - most commonly seen following the use of internal fixation

Miscellaneous

• Thoracolumbar disc disease

o Protrusion and/or extrusion of disc material into vertebral canal, compressing spinal
cord
o Most commonly seen in middle-aged, small breeds (Dachshund, Poodle etc)
o T12-T13 #1 site; 65% occur between vertebrae T 11-12 and L 1-2
o Clinical signs
 May vary from mild ataxia (muscle weakness) to complete paralysis
o Diagnosis
 Neurological examination
 If surgery considered: radiographs ± myelography
o Treatment
 Conservative management: cage confinement, ± corticosteroids
 Surgical management: fenestration, hemilaminectomy or dorsal laminectomy
 Repeat neuro examination frequently
 General management of paralyzed or incontinent dog
 Urinary bladder care: express TID or QID
 Keep dry and well padded

63
  Physical therapy TID
 Patient usually released when there is voluntary urination

DIFFERENTIAL DIAGNOSIS OF COMMON ORTHOPEDIC CONDITIONS OF THE

PECTORAL AND PELVIC LIMB
Petoral limb lameness in large
breed
Skeletally immature dogs
General/Multiple
Petoral limb lameness in small
breed
Skeletally immature dogs
General/Multiple

• Trauma-fracture, luxation • Trauma-fracture, luxation

• Panosteitis • Atlantoaxial luxation
• Hypertrophic osteodystrophy
• Cervical cord lesion-vertebral
instability

Shoulder Region Shoulder Region

• Osteochondritis Disseccans • Congenital luxation

(OCD) of humeral head

Elbow Region Elbow Region

• Osteochondritis disseccans of • Congenital luxation

medial trochlear ridge • Subluxation due to premature
• Ununited Anconeal Process physeal closure
(UAP)
• Fragmentation of the medial
coronoid process (FCP)
• Avulsion and calcification of the
flexor tendons of the medial
epicondyle
• Subluxation due to premature
physeal closure

Carpal Region Carpal Region

• Subluxation/valgus or varus • Subluxation/valgus or varus

deformity due to premature deformity due to premature
physeal closure physeal closure
• Valgus deformity due to retained
cartilage cores in the ulna

Petoral limb lameness in large breed Petoral limb lameness in small

breed
Skeletally mature dogs Skeletally mature dogs
General/Multiple General/Multiple

64
 • Trauma-fracture, luxation, muscle
and nerve injuries
• Panosteitis
• Cervical cord lesion-disk,
tumor,vertebral instability
• Brachial plexus tumor
• Bone and cartilage tumor
• Hypertrophic osteoarthropathy
• Trauma-fracture, luxation,
muscle and nerve injuries
• Cervical cord lesion-disk, tumor
• Brachial plexus tumor
• Hypertrophic osteoarthropathy

Shoulder Region Shoulder Region

• Osteochondritis Disseccans (OCD) • Degenerative joint disease

of humeral head • Medial luxation, nontraumatic
• Degenerative joint disease
• Contracture of infraspinatus muscle
• Tenosynovitis of biceps brachii
tendon
• Luxation

Elbow Region Elbow Region

• Degenerative joint disease • Degenerative joint disease

• Fragmentation of the medial • Subluxation due to premature
coronoid process (FCP) physeal closure
• Avulsion injury of the medial
epicondyle
• Subluxation due to premature
physeal closure
• Luxation

Carpal Region Carpal Region

• Ligamentous • Degenerative joint disease

instability/hyperextension
• Subluxation due to premature
physeal closure
• Degenerative joint disease
• Inflammatory joint disease
• Subluxation due to premature
physeal closure
• Inflammatory joint disease

Pelvic limb lameness in large breed Pelvic limb lameness in small

breed
Skeletally immature dogs Skeletally immature dogs
General/Multiple General/Multiple

• Trauma-fracture, luxation • Trauma-fracture, luxation

• Panosteitis
• Hypertrophic osteodystrophy

65
 Hip Region Hip Region

• Hip dysplasia • Avascular necrosis/Legg-

• Luxation Calvé-Perthes disease

Stifle Region Stifle Region

• Osteochondrosis disseccans of • Patellar luxation

femoral condyle
• Patellar luxation
• Avulsion of the origin of the long
digital extensor muscle
• Avulsion of cruciate ligament
• Rupture of cruciate ligament
• Valgus or varus deformity due to
premature physeal closure

Tarsal Region Tarsal Region

• Valgus or varus deformity due to • Varus deformity due to

premature physeal closure premature physeal closure
• Osteochondritis disseccans of talus

Pelvic limb lameness in large breed Pelvic limb lameness in small breed
Skeletally mature dogs Skeletally mature dogs
General/Multiple General/Multiple

• Trauma-fracture, luxation, muscle and • Trauma-fracture, luxation, muscle and

nerve injury nerve injury
• Spinal cord lesion • Spinal cord lesion-disk, tumor
• Cauda equina lesion
• Bone and cartilage tumor
• Hypertrophic osteoarthropathy

Hip Region Hip Region

• Degenerative joint disease • Degenerative joint disease

• Luxation • Luxation
• Iliopsoas strain

Stifle Region Stifle Region

• Degenerative joint disease • Degenerative joint disease

• Rupture of cruciate ligament • Rupture of cruciate ligament
• Patellar luxation • Patellar luxation

Tarsal Region Tarsal Region

66
 • Ligamentous instabilies/hyperextension
• Avulsion of gastrocnemius tendon
• Luxation of the tendon of the superficial
digital flexor muscle
• Degenerative joint disease
• Luxation of the tendon of the
superficial digital flexor muscle
• Degenerative joint disease
• Inflammatory jont disease

MODULE-7: OSTEOCHONDROSIS -DOGS

Learning objectives

This module deals with

• DD Shoulder Lameness
• DD Elbow Lameness
• DD Stifle Lameness
• DD Hock Lameness

INTRODUCTION

• Ostechondrosis is a failure of the conversion of epiphyseal or growth plate cartilage into

bone. The disease is mostly seen in large and giant breed dogs.
• The pathologic changes associated with the disease usually develop during the period of
rapid growth (16-20 weeks of age), but clinical signs usually develop later (after 18 weeks).
• The etiology is not completely understood, but genetics, nutrition, rapid growth and trauma
have been identified as risk factors. Osteochondrosis of the epiphysis is seen in the
shoulder, elbow, stifle and hock joint. Ununited anconeal process and retained
cartilagenous core are considered an osteochondrosis of the growth plate.

OCD OF THE HUMERAL HEAD

General

• Shoulder lameness in young large or giant breed dogs

• Developmental Orthopedic Disease (DOD)
o Group of acquired, multifactorial skeletal disorders in adolescent dogs, often with a
genetic and nutritional etiology
o May affect bones or joints

Joint DODs Bone DODs

Hip dysplasia Craniomandibular osteopathy

Osteochondrosis Hypertrophic osteodystrophy

Legg-Perthes diseases Panosteitis

Patella luxation
ETIOLOGY AND PATHOGENESIS OCD

• Local disturbance of endochondral ossification of the epiphysis of the proximal humerus

• Multifactorial etiology
67
 Genetics
o
Nutrition (calcium, energy)
o
Rapid rate of growth
o
Trauma
o
• Strong breed predisposition
o Labrador Retriever, Golden Retriever, Rottweiler, Great Dane, German Shepherd
dog, Newfoundlander, Border Collie, English Setter, Bernese Mountain dog, Irish
Wolfhound, Great Pyrenees, German Shorthair Pointer, Old English Sheepdog,
Dalmatian, Mastiff, Standard Poodle, St. Bernard, Kuvasz, Bouvier, German
Wirehaired Pointer, Greyhound, Bullmastiff, Australian Shepherd, Chesapeake Bay
Retriever, Irish Setter, Munsterlander
• Young dogs
o 4 - 8 months of age - m:f -> 2 : 1 - 3 : 1

Orthopedic examination and diagnosis

• Clinical findings
o Lameness
o Often bilateral (27 - 68%)
o Pain on hyperextension and/or hyperflexion shoulder joint

DD SHOULDER LAMENESS
Large Breed Small Breed
Skeletally Osteochondritis Disseccans (OCD) of humeral Congenital luxation
head
Immature
Skeletally • Osteochondritis Disseccans (OCD) of • Degenerative joint disease
humeral head • Medial luxation,
Mature • Degenerative joint disease nontraumatic
• Contracture of infraspinatus muscle
• Tenosynovitis/rupture of biceps brachii
tendon
• Shoulder instability
• Traumatic luxation

Radiographic findings

• Flattening caudal humeral head

• Mineralized cartilage flap
• Joint mouse
• DJD

Treatment

• Conservative treatment
• Young dogs < 6 - 7 months of age
• Rest
• NSAIDs
• Nutrition
• Large breed growth diet (reduced Ca intake)
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 • Time limited feeding (reduced energy intake)
o Determine appropriate amount
o Check body conditioning score

Surgical treatment

Indications

• patient > 6 - 7 months of age

• lameness > 6 weeks
• mineralized cartilage or joint mouse

ARTHROTOMY AND ARTHROSCOPY

Elbow dysplasia - FCP, UAP, OCD and elbow incongruity

• Elbow arthrosis is caused by FCP, UAP, OCD, articular cartilage anomaly, and/or joint
incongruity , and is the manifestation of inherited elbow dysplasia . . . . . ( International
Elbow Working Group; IEWG)

Etiology

• It is thought that elbow incongruity plays a central role in the etiology of elbow dysplasia
• Incongruity due to asymmetrical growth of the radius and the ulna, resulting in an intra-
articular “step” between radius and ulna

• Ulna relatively short • Anconeal growth plate normally closed at approx. 22

• UAP weeks → diagnosis only can be made after 22 weeks
• Cartilage erosions • Check other elbow because different breeds may have
• DJD different growth plate closure times!

Ulna relatively long

• OCD
• FCP
• Cartilage erosions
• DJD

Risk factors

• Genetics
o Incongruity
o UAP
o FCP
o OCD
• Elbow dysplasia registry: OFA (Orthopedic Foundation for Animals; www.offa.org)
o Nutrition
o Calcium
o Energy
o Trauma

69
 o Rapid growth

Presentation

• Young dogs
o Strong breed predisposition
o m>f
o 4 - 8 months of age
o Often bilateral
o Presented because of primary problem
• Older dogs (> 1 year of age)
• Usually presented because of secondary DJD

Diagnosis

• Orthopedic examination
o Pain on hyperextension/hyperflexion
o Joint swelling
o Crepitus
o Pain on Campbell maneuver

DD ELBOW LAMENESS
Large Breed Small Breed
Skeletally Immature • Ununited Anconeal Process (UAP) • Congenital elbow
• Fragmented Medial Coronoid Process luxation
(FCP)
• Osteochondritis Disseccans (OCD) of
the medial humeral condyle
• Elbow incongruity
• OCD Medial Epicondyle

Skeletally Mature • O CD of the medial humeral condyle • Degenerative joint

• UAP disease
• FCP • Traumatic luxation
• Degenerative joint disease
• Traumatic luxation
• Avulsion Medial Epicondyle

Radiographic examination

• views
o AP
o Flexed ML
o 45o ML
o Incongruity
o Difficult diagnosis
• UAP
o Radiolucent line between anconeal process and olecranon (ML)
• DJD
o OCD medial humeral condyle
70
 o Radiolucent area medial condyle (AP)
o DJD medial joint compartment (AP)
o Difficult diagnosis
• FCP
o Fragmented medial coronoid process
o DJD medial joint compartment (AP)
o Sclerosis
o Difficult diagnosis

Diagnostic problem

• Orthopedic exam points towards elbow problem False negative

• No radiographic changes or radiographic diagnosis results!!
• CT and MRI not 100% specificity and sensitivity either
• Exploratory (arthrotomy or arthroscopy) may be needed to make final
diagnosis

Treatment

OCD medial humeral Conservative treatment Surgical treatment

condyle
• Rest • Arthrotomy
• NSAIDs • Arthroscopy
• Nutrition – large breed growth • Dynamic ulnar
diet osteotomy

Fragmented Coronoid Conservative treatment Surgical treatment

Process
• Rest • Arthrotomy
• NSAIDs • Arthroscopy
• Nutrition - large breed growth • Dynamic ulnar
diet osteotomy

Ununited Anconeal Conservative treatment Surgical treatment

Process
• Patient younger than 5 months • Arthrotomy
of age • Removal UAP
• Rest • Screw fixation
• NSAIDs • Dynamic ulnar
• Nutrition - large breed growth osteotomy
diet

Incongruity Conservative treatment Surgical treatment

• Rest • Arthrotomy
• NSAIDs • Arthroscopy
• Nutrition • Dynamic ulnar
osteotomy

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Prognosis

• Progressive DJD
• Often intermittent and sometimes permanent lameness

OSTEOCHONDROSIS OF THE STIFLE JOINT

• Osteochondrosis
• OCD stifle
o Medial or lateral femur condyle
o uncommon
• OCD patella
o Greyhound, Pit Bull terrier, Staffordshire terrier
o No radiographic changes
o Rare
• Etiology
o Disturbance epiphyseal endochondral ossification

Risk factors

• Genetics
o Breed predispositions: Labrador Retriever, German Shepherd dog, Rottweiler, Boxer,
Mastiff, Irish Wolfhound, Bulldog, Golden Retriever, Great Dane
o Gender predisposition: m > f
• Nutrition (↑calcium, ↑energy)
• Rapid growth
• Trauma

Diagnosis

• History
• Clinical findings
o Lameness
o Joint swelling
o Pain on hyperextension/hyperflexion
o Often bilateral
• Radiography
• Arthroscopy

Treatment

• Conservative management
o Rest
o NSAIDs
o Large breed growth diet
• Surgical management
o Arthrotomy
o Arthroscopy

Prognosis

• Usually progressive DJD

72
 • Often recurrence of lameness at later age

DD STIFLE LAMENESS
Large Breed Small Breed
Skeletally • OCD femoral condyle • Patella luxation
Immature • OCD patella • Fractures
• Patella luxation
• Cranial cruciate rupture
• Avulsion long digital extensor
tendon
• Fractures

Skeletally Mature • Patella luxation • Patella luxation

• Cranial cruciate rupture • Cranial cruciate rupture
• Meniscal trauma • Degenerative joint disease
• Caudal cruciate rupture • Traumatic luxation
• Avulsion long digital extensor • Fractures
tendon
• Degenerative joint disease
• Traumatic luxation
• Fractures

• Radiography
• Arthroscopy

Treatment

• Conservative management
o Rest
o NSAIDs
o Large breed growth diet
• Surgical management
o Arthrotomy
o Arthroscopy

Prognosis

• Usually progressive DJD

• Often recurrence of lameness at later age

OSTEOCHONDROSIS OF THE HOCK JOINT

Types

• OCD medial trochlear ridge of the talus (most common)

• OCD lateral trochlear ridge of the talus

Etiology

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 • Disturbance epiphyseal endochondral ossification

Risk factors

• Genetics
o Breed predispositions: Labrador retriever, rottweiler, bullmastiff
o Gender predisposition: m > f
• Nutrition (↑calcium, ↑energy)
• Rapid growth
• Trauma

Diagnosis

• History
• Clinical findings
o Lameness
o Joint swelling
o Pain on hyperextension/hyperflexion
o Often bilateral

DD HOCK LAMENESS
Large Breed Small Breed
Skeletally • Valgus or varus deformity due to • Valgus or varus
Immature premature physeal closure deformity due to
• Osteochondritis disseccans of premature physeal
talus closure
• Fractures • Fractures

Skeletally • Ligamentous • Luxation of the tendon

Mature instabilies/hyperextension of the superficial
• Avulsion of gastrocnemius digital flexor muscle
tendon Luxation of the tendon • Degenerative joint
of the superficial digital flexor disease
muscle • Inflammatory jont
• Degenerative joint disease disease
• Fractures • Traumatic luxation
• Fractures

• Radiography
• Arthroscopy

Treatment

• Conservative management
o Rest
o NSAIDs
o Large breed growth diet
• Surgical management
o Arthrotomy
o Arthroscopy
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Prognosis

• Usually progressive DJD

• Often recurrence of lameness at later age

MODULE-8: DEGENERATIVE JOINT DISEASE - DOGS

Learning objectives

This module deals with

• Arthritis
• Degenerative joint disease
• Treatment of Degenerative Joint Disease

ARTHRITIS

Arthritis

• Arthritis is a disease that can affect any joint in the body

• There are several different types of arthritis
o Degenerative joint disease (DJD): due to abnormal wear and tear following
improper bone to bone contact such as with hip dysplasia or luxating patellas. Most
common type of arthritis
o Immune mediated arthritis: may be caused by a disease of the immune system such
as rheumatoid arthritis or systemic lupus erythematosus (SLE)
o Infectious arthritis: may result from a puncture wound or from contamination
during surgery. Infectious arthritis is rarely caused by infection spreading via the
bloodstream from one area of the body to another
• Progressive, self perpetuating disease

• Clinical signs
o Lameness
o Stiffness after resting
o Joint swelling
o Pain
• Diagnosis
o Physical examination (joint swelling, decreased range of motion, pain on
manipulation, crepitus)
o Radiography
o Synovial fluid analysis
o Laboratory tests such as Rheumatoid Factor (immune mediated arthritis)

DEGENERATIVE JOINT DISEASE

Introduction

• Your major reference for degenerative joint disease is in the Handbook of Small Animal
Orthopedics and Fracture Repair 3rd Ed., by Piermattei and Flo, pages 170-200.

75
Orthopedic examination

• Findings indicative for degenerative joint disease may include

o Pain on hyperextension/ hyperflexion of the affected joint
o decreased range of motion
o Peri-articular swelling (soft/effusion or firm/fibrosis/crepitus)

Arthropathies

• Arthropathies may be classified as follows:

Non-inflammatory arthropathies Inflammatory arthropathies

• Osteoarthrosis • Infectious
• Primary • Local
• Secondary (DJD) • Systemic
• OCD • Non-infectious
• Trauma • Immunologic
• Neoplasia • Erosive
• Others • Non-erosive
• Others

Degenerative Joint Disease

• Non-inflammatory joint disease

• sequel of other, primary joint disease, usually of immature joint or trauma
• may get inflammatory component at later stage
• synonym: secondary osteoarthritis or secondary osteoarthrosis

Pathophysiology of Joint Diseases

• Joint diseases, including degenerative joint disease, rarely are a disease of just the articular
surface, the joint capsule or the joint cavity. These structures are usually affected
simultaneously, although one component may be more affected than the other. Medical
treatments usually target only one of the 3 joint structures.

Articular cartilage damage and healing

• Articular cartilage damage

o Chemical injury
o Mechanical injury
o partial thickness defects
o full thickness defects
• Articular cartilage repair
o may heal completely, or become irreversible
o Partial thickness defects
o No healing
o Full thickness defects
o Fibrocartilage
• The treatment of mechanical cartilage oinjuries is rapidly changing with the advent of tissue
engineering and a renewed interest in post-operative rehabilitation.

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Diagnosis of Joint Diseases

No evidence DJD
systemic
disease
Orthopedic Radiographs
examination affected joint(s)
Evidence of CBC, serum Other
systemic chemistry, UA tests
disease
Arthrocentesis Cytology Culture

Serology
Biopsy
TREATMENT OF DEGENERATIVE JOINT DISEASE

• Treatment of primary joint problem

o Medical or surgical correction of the primary joint problem. One of the most
common examples of this principles is the treatment of DJD following surgical
correction of a ruptures cranial cruciate ligament.
• Weight control
o 3/5 body conditioning score
• Exercise control
o Rest (10-14 days) – acute lameness
o Self-controlled exercise – if chronic lameness
• Medical treatment
o Non-steroidal anti-inflammatory drugs
 Treats inflammation synovial membrane
 COX 1/Cox 2 inhibitors are cheaper but may have side effects
• Steroidal anti-inflammatory drugs
• Corticosteroids
o Treat inflammation synovial membrane
o May have side effects
 Isoflupredone IA
 Prednisone 0.5 mg/kg PO, taper to alternate, low or no dose therapy
• Chondroprotectives
o May treat joint capsule and articular surface
o Adequan, 5 mg/kg IM every 4 days until no further improvement
o Cosaquin
 Dog <25 lbs - 1 capsule PO SID; >50 lbs - 2 capsules PO SID
 Cat 1/2 - 1 capsule PO SID
• Miscellaneous
o Doxycycline
 May treat joint capsule and articular surface
o Superoxide radical scavengers
 May treat joint capsule and articular surface

Surgical treatment DJD

• Joint debridement – Cartilage flaps, joint mice, etc. Rarely osteophytes

77
 • Curettage and forage (microfracture) – small holes penetrating subchondral bone
• Muscle release – i.e. pectineal myectomy as treatment for hip dysplasia
• Osteotomy – i.e treatment of elbow dysplasia
• Arthroplasty – i.e. total hip replacement as treatment for hip dysplasia
• Pseudarthrosis – i.e. femoral head and neck removal as treatment for hip dysplasia
• Arthrodesis – carpal arthrodesis as treatment for intractable carpal DJD
• Amputation – i.e. toe amputation for treatment of DJD secondary to toe luxation

MODULE-9: DISEASES OF THE ELBOW REGION - DOGS

Learning objectives

This module deals with

• Elbow dysplasia
• Elbow Luxation

DISEASES OF THE ELBOW REGION

Introduction

• Your major reference for diseases of the elbow region is in the Handbook of Small Animal
Orthopedics and Fracture Repair 3rd Ed., by Piermattei and Flo, pages 288-320.

Orthopedic examination

• Findings indicative for diseases of the elbow region may include:

o Pain on hyperextension/ hyperflexion of the elbow
o Decreased range of motion
o Swelling
o Crepitus etc.

DD Elbow lameness

Large Breed Small Breed

Skeletally • Ununited Anconeal Process (UAP) • Congenital elbow
Immature • Fragmented Medial Coronoid Process luxation
(FCP)
• Osteochondritis Disseccans (OCD) of the
medial humeral condyle
• Elbow incongruity
• OCD Medial Epicondyle

Skeletally • OCD of the medial humeral condyle • Degenerative joint

Mature • UAP disease
• FCP • Traumatic luxation
• Degenerative joint disease
• Traumatic luxation

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 • Avulsion Medial Epicondyle

ELBOW DYSPLASIA

Elbow dysplasia - FCP, UAP, OCD and elbow incongruity

International Elbow Working Group (IEWG)

• Elbow arthrosis is caused by FCP, UAP, OCD, articular cartilage anomaly, and/or joint
incongruity , and is the manifestation of inherited elbow dysplasia,
• The purpose of this Group is to coordinate efforts to lower the incidence and prevalence of
elbow dysplasia by
o coordinating worldwide research,
o dissemination of information,
o guidelines for national registries,
o education about elbow arthrosis, and
o assuming the responsibility to continue the international discussions regarding the
needs for coordinating information on canine elbow disease.
• Etiology
o It is thought that elbow incongruity plays a central role in the etiology of elbow
dysplasia
o Incongruity due to asymmetrical growth of the radius and the ulna, resulting in an
intra-articular “step” between radius and ulna
o Ulna relatively short
 UAP
 Cartilage erosions
 DJD
o Ulna relatively long
 OCD
 FCP
 Cartilage erosions
 DJD
• Risk factors
o Genetics
o Incongruity
 UAP
 FCP
 OCD
 OFA (Orthopedic Foundation for Animals; www.offa.org) and GDC
(Institute for Genetic Disease Control in
Animals; http://www.vetmed.ucdavis.edu/gdc/gdc.html#RER) screening
for elbow dysplasia
o Nutrition
 Calcium
 Energy
o Trauma
o Rapid growth
• Presentation
o Young dogs
 Strong breed predisposition
 m>f
 4 - 8 months of age

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  often bilateral
 presented because of primary problem
o Older dogs
 usually presented because of secondary DJD
• Diagnosis
o Orthopedic examination
 Pain on hyperextension/hyperflexion
 Joint swelling
 Crepitus
o Radiographic examination
 views
 AP
 Flexed ML
 45o ML
 Incongruity
 Difficult diagnosis
 UAP
 Radiolucent line between anconeal process and olecranon (ML)
 DJD
 OCD medial humeral condyle
 Radiolucent area medial condyle (AP)
 DJD medial joint compartment (AP)
 Difficult diagnosis
 FCP
 DJD medial joint compartment (AP)
 Fragmented medial coronoid process
 Sclerosis
 Difficult diagnosis
• Diagnostic problem
o orthopedic exam points towards elbow problem
o no radiographic changes or radiographic diagnosis-False negative results!!
o Exploratory (arthrotomy or arthroscopy) to make final diagnosis-False negative
results!!

Treatment

• OCD medial humeral condyle

o Conservative treatment
 Rest
 NSAIDs
 Nutrition
o Surgical treatment
 Arthrotomy
 Arthroscopy
 Dynamic ulnar ostectomy
• Fragmented Coronoid Process
o Conservative treatment
 Rest
 NSAIDs
 Nutrition
o Surgical treatment
 Arthrotomy
 Arthroscopy
 Dynamic ulnar ostectomy
80
 • Ununited Anconeal Process
o Conservative treatment
 Patient younger than 5 months of age
 Rest
 NSAIDs
 Nutrition
o Surgical treatment
 Arthrotomy
 Removal UAP
 Screw fixation
 Dynamic ulnar osteotomy
• Prognosis
o Progressive DJD
o Often intermittent and sometimes permanent lameness

ELBOW LUXATION

• Elbow stability
o Joint capsule
o Collateral ligaments
o Muscles
o Medial epicondyle
• Diagnosis
o Non-weight bearing
o Flexed elbow with abduction and external rotation
o Joint swelling
o Pain on manipulation
• Radiography
o Watch for avulsion fractures
• Treatment
o Closed and open reduction
o General anesthesia
o “hang” patient on front limb so that weight of the patient relaxes peri-articular
structures
o Perform closed or open reduction
o Treatment after reduction
 Spica bandage in extended position for 2 weeks
 passive flexion and extension
 3-4 weeks rest
• Prognosis
o Good for normal limb function
 short term complication is re-luxation
 long term complication is decreased ROM and DJD

MODULE-10: DISEASES OF THE SHOULDER REGION -DOGS

Learning objectives

This module deals with

• Diseases of the shoulder region

• OCD of the humeral head

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 DISEASES OF THE SHOULDER REGION

Introduction

• Your major reference for diseases of the shoulder region is in the Handbook of Small
Animal Orthopedics and Fracture Repair 3rd Ed., by Piermattei and Flo, pages 228-260.

Orthopedic examination

• Findings indicative for diseases of the shoulder region may include:

o Pain on hyperextension/ hyperflexion of the shoulder
o Decreased range of motion
o Pain on simultaneous flexion of the shoulder joint and extension of the elbow joint
(Biceps M.)
o Pain on simultaneous extension and internal rotation of the shoulder joint
(Infraspinatus M.)

DD Shoulder Lameness

Large Breed Small Breed

Skeletally • Osteochondritis Disseccans (OCD) of • Congenital luxation
Immature humeral head

Skeletally • Osteochondritis Disseccans (OCD) of • Degenerative joint

Mature humeral head disease
• Degenerative joint disease • Medial luxation,
• Contracture of infraspinatus muscle nontraumatic
• Tenosynovitis/rupture of biceps brachii
tendon
• Traumatic luxation

OCD OF THE HUMERAL HEAD

General

• Shoulder lameness in young large or giant breed dogs

• Developmental Orthopedic Disease DOD
o Group of acquired, multifactorial skeletal disorders in adolescent dogs, often with a
genetic and nutritional etiology
o May affect bones or joints

Joint DODs Bone DODs

• Hip dysplasia • Craniomandibular osteopathy
• Osteochondrosis • Hypertrophic osteodystrophy
• Legg-Perthes diseases

82
 • Patella luxation • Panosteitis

Etiology and Pathogenesis OCD

• Local disturbance of endochondral ossification of the epiphysis of the proximal humerus

• Multifactorial etiology
o genetics
o Nutrition (calcium, energy)
o rapid rate of growth
o trauma
• Strong breed predisposition
o Labrador Retriever, Golden Retriever, Rottweiler, Great Dane, German Shepherd
dog, Newfoundlander, Border Collie, English Setter, Bernese Mountain dog, Irish
Wolfhound, Great Pyrenees, German Shorthair Pointer, Old English Sheepdog,
Dalmatian, Mastiff, Standard Poodle, St. Bernard, Kuvasz, Bouvier, German
Wirehaired Pointer, Greyhound, Bullmastiff, Australian Shepherd, Chesapeake Bay
Retriever, Irish Setter, Munsterlander
• Young dogs
o 4 - 8 months of age
o m : f -> 2 : 1 - 3 : 1

Orthopedic examination and Diagnosis

• Clinical findings
o lameness
o often bilateral (27 - 68%)
o pain on hyperextension and/or hyperflexion shoulder joint
• Radiographic findings
o Flattening caudal humeral head
o Mineralized cartilage flap
o Joint mouse
o DJD

Treatment

• Conservative treatment
• Young dogs < 6 - 7 months of age
• Rest
• NSAIDs
• Nutrition
o Large breed growth diet
o Determine appropriate amount
o Time limited feeding
o Check body conditioning score

Surgical treatment

• Indications
o patient > 6 - 7 months of age
o lameness > 6 weeks
o mineralized cartilage or joint mouse
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 • Arthrotomy and Arthroscopy

MODULE-11: DISEASES OF THE HIP REGION - DOGS

Learning objectives

This module deals with

• Hip dysplasia
• Legg-Calvé-Perthes disease
• Coxofemoral Luxation

DISEASES OF THE HIP REGION

Introduction

• Your major reference for diseases of the hip region is in the Handbook of Small Animal
Orthopedics and Fracture Repair 3rd Ed., by Piermattei and Flo, pages 422-468.

Orthopedic examination

• Findings indicative for diseases of the hip region may include

o Pain on hyperextension/ hyperflexion of the hip joint
o Decreased ROM
o Pain on abduction or circumduction
o Pain on simultaneous flexion and internal rotation
o Pain over lumbo-sacral junction
o Crepitus etc.

DD Hip lameness

Large Breed Small Breed

Skeletally Immature • Hip dysplasia (laxity) • Legg-Perthes disease
• Fractures • Fractures

Skeletally Mature • Hip dysplasia (DJD) • Degenerative joint disease

• Iliopsoas strain • Traumatic luxation
• Lubo-sacral instability • Fractures
• Degenerative myelopathy
• Degenerative joint disease
• Traumatic luxation
• Fractures

HIP DYSPLASIA

• Abnormal development hip joint(s)

• Developmental Orthopedic Disease
• History
o Lameness

84
 o Problems rising
o Problems with stairs
o Exercise intolerance
o Arthritis history
• Clinical diagnosis
o Pain on extension
o Decreased extension
o Pain on abduction or circumduction
o Laxity
o Crepitus
• Radiographic diagnosis
o Laxity
o Traditionally extended VD (OFA; www.offa.org)
o Distraction radiography (PennHIP®;
www.vet.upenn.edu/ResearchCenters/pennhip//)
o Wear dorsal acetabular rim
o DJD
o Traditionally extened VD (OFA)
o Distraction radiography (PennHIP®)

Treatment

Canine Hip Without DJD With DJD

Dysplasia
Conservative • Goal is to increase muscle • Goal is pain control
management mass!! • Exercise control (DJD)
• Exercise • Weight control (DJD)
• Weight control • Medical management
• Medical management • NSAIDs (pain)
• NSAIDs • PSGAG (pain and/or
• PSGAG ??? chondroprotection)

Surgical • Triple pelvic osteotomy • Femoral head and neck

management (TPO) ostectomy (FHO)
• Intertrochanteric osteotomy • Total hip replacement (THR)
(ITO)
• Pectineal myectomy

TPO

85
 General indications TPO/ITO
• Hip laxity and lameness
• No or minimal evidence of DJD
• Patient < 11 months of age
• Minimal wear dorsal acetabular
rim
Specific indications TPO/ITO
• Ineffective conservative management
• Potential athletes??
• Owner desire to minimize the risk for lameness at
later age??

Femoral head and Neck Ostectomy (FH(N)O)

• Chronic lameness, not responding to conservative management

• Patients < 25 kg
• Not for working dogs
• Aggressive aftercare
• Pain medication
• Physical therapy
• Rest until suture removal followed by unrestricted activity
• Good prognosis

Total Hip replacement (THR)

• Chronic lameness, not responding to conservative management

• Patient > 25 kg
• Working dog

LEGG-CALVE-PERTHES DISEASE

• Developmental Orthopedic Joint Disease

• Small breeds (min Pinscher, Pug, West Highland White terrier, Yorkshire terrier, etc.)
• 6 - 12 months of age

Treatment

COXOFEMORAL LUXATION

• Joint stability
o Joint capsule + joint shape
o Muscles and/or tendons
o Ligament
86
Clinical signs

• Severe lameness
• Usually cranio-dorsal
• Pain on manipulation
• Affected leg shorter and externally rotated
• Assymmetric “triangles”
• “Gap” between greater trochanter and tuber ischium

Treatment

• Treatment goal
o Reduce and maintain articulating bones in their anatomical position
o Regain normal range of motion and normal function

Closed reduction Open reduction

• No chip or avulsion fractures
• General anesthesia
• Fatigue muscles
• Reduction
• Passive manipulation
• Assess stability
• Joint immobilization for 2 weeks
• Restricted activity for 6 weeks
• Select optimal surgical approach
• Explore, debride and reduce
• Evaluate articular surface
• Repair ligaments and/or close joint capsule
• Asses stability
• Joint immobilization for 2 weeks
• Restricted activity for 6 weeks

Surgical stabilization of the hip joint

• Capsuloraphy
• Pre-articular stabilization suture
• Prosthetic capsule
• Trans-articular pin
• Toggle pin
• DaVita pin

Prognosis

• Up to 65% failure rates have been reported following closed reduction.

MODULE-12:DISEASES OF THE STIFLE REGION -DOGS

Learning objectives

This module deals with

• Etiology, diagnosis, prognosis and treatment of patella luxation

• Breed predisposition

DISEASES OF THE STIFLE REGION

87
Introduction

• Your major reference for diseases of the stifle region is in the Hanbook of Small Animal
Orthopedics and Fracture Repair 3rd Ed., by Piermattei and Flo, pages 516-580.

Orthopedic examination

• Pain on hyperextension/hyperflexion of the stifle joint

• Decreased ROM
• Positive drawer
• Medial or lateral patella luxation
• Joint swelling (soft or firm)
• Crepitus
• Click etc.

Large Breed Small Breed

Skeletally • OCD femoral condyle • Patella luxation
Immature • OCD patella • Fractures
• Patella luxation
• Cranial cruciate rupture
• Avulsion long digital extensor
tendon
• Fractures

Skeletally Mature • Patella luxation • Patella luxation

• Cranial cruciate rupture • Cranial cruciate rupture
• Meniscal trauma • Degenerative joint disease
• Caudal cruciate rupture • Traumatic luxation
• Avulsion long digital extensor • Fractures
tendon
• Degenerative joint disease
• Traumatic luxation
• Fractures

ETIOLOGY OF PATELLA LUXATION

• Patella out of trochlea.

• Different permutations.
• Medial or lateral patella luxation.
• Patella alta (high; patellar tendon too long; often significantly contributing to luxation) or
baja (low; rarely a problem).
• Rotating patella.

BREED PREDISPOSITIONS

Small and medium size breeds

• Yorkshire Terrier • Cairn Terrier

• Chihuahua • Bichon Frise
• Sharpei • Wirehaired Fox Terrier
88
 • Bulldog • Cavelier King Charles Spaniel
• Boston terrier • Bull Terrier
• Chow • Silky Terrier
• Shih Tzu • Australian Terrier
• West Highland White Terrier • Manchester Terrier
• Keeshound

Large breeds

• Pyrenese Mountain dog,

• Akita,
• Flatcoated Retriever.

DIAGNOSIS

• Lameness
• “Shaking in” of the patella
• Pain on hyperextension/flexion
• Cruciate ligament rupture?
• Luxation of the patella + crepitus
• Change(s) of anatomical relationships – insertion patellar tendon
• Radiography
• Radiographs may give false negative diagnosis
o Exception - Type 4 – always luxated
• Usually not much DJD, except for large breed dogs
• Orthopedic examination
o Pain on hyperextension/hyperflexion of the stifle joint
o ROM
o Medial or lateral patella luxation
o Joint swelling (soft or firm)
o Crepitus

DIFFERENTIAL DIAGNOSIS
Large breed Small breed
Skeletally • OCD femoral condyle • Patella luxation
Immature • OCD patella • Fractures
• Patella luxation
• Cranial cruciate rupture
• Avulsion long digital extensor
tendon
• Fractures

Skeletally • Patella luxation • Patella luxation

Mature • Cranial cruciate rupture • Cranial cruciate rupture
• Meniscal trauma • Degenerative joint disease
• Caudal cruciate rupture • Traumatic luxation
• Avulsion long digital extensor • Fractures
tendon
• Degenerative joint disease
89
 • Traumatic luxation
• Fractures

PROGNOSIS AND TREATMENT OF PATTELAR LUXATION

Treatment

• General – 2.5-3/5 body condition score

• Conservative management
o Type 1 or 2
• Manual reduction patella
• Surgical management
o Type 2, 3, or 4

Surgical treatment

• Deepening of the trochlea

• Trochlear wedge recession
• Trochlear block recession Trochlear sulcoplasty (older technique)
• Trochlear chondroplasty (<18 weeks of age)
• Transposition insertion patellar ligament
• Osteotomy + transposition tibial tubercle
• Patellar-fabellar suture (young dogs; growth plates open)
• Soft tissue stabilization
• Release contracted side joint capsule (desmotomy)
• Imbrication non-contracted joint capsule (excision or fascial overlay)
• Osteotomy distal femur or proximal tibia

Prognosis

• Good
• 90% lame free after surgery
• Often incomplete reconstruction
• + 50% less severe patella luxation than before surgery
• + 65% type 1 patella luxation
• Usually mild to moderate DJD

RUPTURE OF CRUCIATE LIGAMENT

Etiology

• Cranial cruciate rupture in over 95% of affected patients

• May occur in cats
• Violent internal rotation
• Hyperextension
• Immune complexes
• Anti-collagen antibodies
• Hypothyroidism

Signalement

90
 • Younger dogs: 0.5 – 4 years; Larger breeds; Breed predispositions
• Older dogs: 5 – 8 years; Smaller breeds

Diagnosis

• Lameness
• Joint swelling
• Pain on hyperextension/flexion
• Medial buttress
• Crepitus
• “Click”
• Joint instability (positive drawer or tibial compression test)
o Different angulations
o Mild drawer in young dogs
o Partial or complete rupture
• Radiography

Cranial cruciate rupture

• Complete rupture
o Acute lameness
o Peri-articular (soft) swelling
o Pain on hyperextension
o Severe drawer sign
o + “Click”
• Incomplete rupture
o Chronic lameness
o Peri-articular (firm) swelling
o Pain on hyperextension
o Mild drawer sign
o + “Click”

Differential diagnosis

• Young dog
• Patella luxation
• Caudal cruciate rupture
• Meniscal trauma
• Arthropathy

Meniscal injuries

• Concomitant medial meniscal injuries common

• Partial or total meniscectomy

Treatment

• General – 3/5 body condition score

• Conservative treatment
o Surgical treatment preferred
o < 10-15 kg
o Rest, Robert Jones or Spica bandage
91
 • Surgical treatment
o > 10-15 kg
o Intra-articular techniques – reconstruction cranial cruciate ligament
 fascia lata, patellar tendon, etc.
 synthetic material
 Often in combination with extra-articular and augmentation techniques
 Long term stability provided by peri-articular fibrosis!!
o Extra-articular techniques
 Soft tissue imbrication (augmentation)
 Suture(s) “in plane” of the cranial cruciate ligament (DeAngelis technique,
MRIT, enz.)
 Lateral collateral ligament (fibular head transposition)
 Tibial plateau leveling osteotomy (TPLO)
 Long term stability provided by peri-articular fibrosis!!

Prognosis

• Limb function dependent on the weight of the patient and the presence of meniscal injuries
• Always progressive DJD, usually no lameness
• 50% of the patients with a cranial cruciate rupture will get a cruciate rupture on the
contralateral side!!

MODULE-13: SPINAL CORD TRAUMA AND ITS MANAGEMENT

Learning objectives

This module deals with

• Thoracolumbar disc disease

• Pathophysiology of spinal cord trauma
• Spondylosis
• Spondylitis
• Intervertebral disc disease in dogs
• Basic Spinal neurology and pathology

THORACOLUMBAR DISC DISEASE

• Protrusion and/or extrusion of disc material into vertebral canal, compressing spinal cord
• Most commonly seen in middle-aged, small breeds (Dachshund, Poodle etc)
• T12-T13 #1 site; 65% occur between vertebrae T 11-12 and L 1-2
• Clinical signs
o May vary from mild ataxia (muscle weakness) to complete paralysis
• Diagnosis
o Neurological examination
o If surgery considered: radiographs ± myelography
• Treatment
o Conservative management: cage confinement, ± corticosteroids
o Surgical management: fenestration, hemilaminectomy or dorsal laminectomy
o Repeat neuro examination frequently
o General management of paralyzed or incontinent dog
o Urinary bladder care: express TID or QID
o Keep dry and well padded

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 o Physical therapy TID
o Patient usually released when there is voluntary urination
• Client education
o Strict confinement is indicated to prevent exacerbation of the clinical signs
o The patient may or may not regain full function (or in severe cases no function) in
rear legs
o Recurrence of the disease may occur if a disc in another location ruptures
• Inform owner about commitment to and duration of convalescences

PATHOPHYSIOLOGY OF SPINAL CORD TRAUMA

Pathophysiology

• Spinal cord trauma trauma may be direct or indirect. Spinal cord injury secondary to
vertebral fracture may be direct from penetration or tearing of the spinal cord. Other types
of vertebral fracture or intervertebral disc herniation cause indirect trauma by concussive
and compressive injury (1, 2) . Direct trauma and concussion of the spinal cord acutely
damages meninges, blood supply and neural tissue (primary injury). Following primary
injury, a cascade of vascular, biochemical and cellular events results in additional secondary
injury to the cord. Compression of the spinal cord following intervertebral disc herniation
may result from a mass of herniated disc material and hematoma within the vertebral canal
(extradural compression) or spinal cord swelling within a rigid dura mater (intramedullary
compression). Slowly compressive injury mainly results in white matter pathology with
lesions ranging from demyelination to severe malacia (3, 4) .
• Clinically, the severity of neurological deficits correlates with the severity of the spinal cord
damage (5) . First loss of conscious proprioception is observed. Then, there is the
progressive loss of motor function, superficial pain and finally deep pain sensation. Patients
also may become incontinent.
• Following a severe concussive injury, spinal cord damage may continue in cranial and
caudal directions. This process may occur over a few days following the initial spinal cord
trauma and results in ascending-descending diffuse myelomalacia (1, 3, 4) . Following a
thoracolumbar disc herniation, this may clinically be characterized by systemic signs of
toxemia, a flaccid abdomen, the level of “cut-off” of the cutaneous trunci reflex response
migrating cranially, a shift from upper motor neuron to lower motor neuron signs in the
rear limbs, progressive involvement of the forelimbs, and eventually respiratory paralysis.

TREATMENT OF SPINAL CORD TRAUMA

Treatment

• Treatment of spinal cord injuries depends on the severity of the condition. In general,
patients with loss of proprioception and ataxia, but with voluntary motor function should be
treated conservatively. For patients with a disc rupture, such a treatment may consist of
strict cage rest. Methylprednisolone sodium succinate (MPSS; 30 mg/kg IV) may be
administered at presentation to combat reperfusion injury. Patients with spinal cord trauma
due to vertebral fracture also may need a neck or back brace.
• Patients with loss of voluntary motor function require immediate treatment with MPSS ,
emergency surgical decompression of the injured spinal cord, spinal stabilization if needed
and appropriate supportive care.

Medical treatment

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 • Methylprednisolone sodium succinate (MPSS) therapy should be initiated as soon as
possible, usually within 24 to 48 hours after injury (6) . It is administered at a dosage of 30
mg/kg IV, followed by two additional injections at 15 mg/kg given two and six hours
following the first injection. A constant rate infusion of MPSS at 2.5 mg/kg/h for 42 hours
may be initiated immediately after the third bolus. This protocol is based on studies in cats.
• Once the neurological condition has stabilized, MPSS is probably not beneficial. The
perioperative use of MPSS, when performing decompressive spinal cord surgery minimizes
the consequences of surgical manipulation. Methylprednisolone sodium succinate efficacy
studies have not been performed in dogs (7) .
• To combat potential side effects with short-term administration of MPSS, a combination of
famotidine (H2-blocker) at a dosage of 0.5 mg/kg once or twice daily orally or IV and
sucralfate at a dosage of 0.5g to 1g three times daily orally can be used (7) . Sucralfate and
famotidine should be administered at least two hours apart. Concurrent administration of
non-steroidal anti-inflammatory agents and corticosteroids is contra-indicated.
• The combined use of these drugs has been associated with gastric and colonic perforation
(8) . There is no reported beneficial effect of dexamethasone in the management of spinal
cord injury (9) . Experimental treatments like 4-aminopyridine and polyethylene glycol are
currently under investigation in dogs (7) .

SURGICAL MANAGEMENT AND SUPPORTIVE CARE

Surgical management

• The goals of surgical intervention are decompression of the spinal cord, and vertebral
stabilization in case of fracture/luxations (5, 7, 10) . Other goals may be macroscopic
evaluation of the spinal cord in case of severe neurological dysfunction and intra-operative
irrigation. Decompression usually is accomplished with a hemilaminectomy, a dorsal
laminectomy, or a ventral slot. Herniated disc material and hematoma should be removed
to further relieve spinal cord compression. The type of vertebral stabilization depends on
the type of fracture. Guidelines for the choice of fixation are given in standard surgery
textbooks (10).
• Durotomy permits evaluation of the cord for myelomalacia and relieves the intramedullary
compression. The diagnosis of myelomalacia usually is based on the gross appearance of the
exposed pia mater and underlying spinal cord and is characterized by a focal or diffuse
pasty consistency to the cord. Ascending-descending diffuse myelomalacia carries a poor
prognosis and euthanasia should be considered. Irrigation of the spinal cord with
normothermic or chilled saline may protect against sequels of intraoperative spinal cord
trauma and decreases the amount of free radical mediated lipid peroxidation catalysts. The
healing of the spinal cord may be augmented with the application of an oscillating field
stimulator (7) .

Supportive care

• Suppotive care may be needed to prevent complications associated with recumbency, loss of
voluntary urination and perhaps even voluntary defecation. Recumbancy may cause
decubital ulcers over bony prominences, muscle atrophy and decreased range of joint
motion (5, 7) .
• Recumbant animals should be turned every 2 hours and provided with a soft, dry bedding,
like a foam mattress, a waterbed, or sheepskin. Special carts and harnesses to facilitate
ambulation may reduce the incidence of decubital ulcers. Physical therapy and loading
exercises with passive range of motion may minimize or prevent muscle atrophy and
decrease in range of joint motion. Passive flexion-extension “cycles” (at least 10 per joint
twice daily) of should be started about 2 days after the injury.
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 • Following intervertebral disc herniation and the loss of deep pain perception, two bladder
syndromes may be observed: upper or lower motor neuron bladder syndromes. With either
syndrome, loss of voluntary micturition may occur and, in both syndromes, urinary tract
infection and urine scalding may occur.
• Upper motor neuron bladder syndrome (UMN bladder syndrome) is characterized by
increased urethral resistance and a bladder that is difficult to express. This may cause
chronic overdistention, overflow incontinence, and with detrusor atony. Upper motor
neuron bladders must be emptied three to four times a day. Phenoxybenzamine (alpha
adrenergic blocker; 5-15 mg PO sid) and diazepam (skeletal muscle relaxant; 2-10 mg PO
tid) may be used may reduce smooth muscle tone in the proximal urethra and facilitate
bladder expression. Bethanechol may be added in cases with detrusor atony.
• When manual expression is not possible, intermittent aseptic catheterization can be
performed and is preferred over the placement of an indwelling catheter (lower infection
rate). With lower motor neuron bladder syndrome (LMN bladder syndrome) the external
urethral sphincter is hypotonic to atonic. Continuous urine dripping may occur, and manual
bladder expression (3-4 times per day) is easily performed. An increased residual volume of
bladder urine in incontinent patients predisposes them to the development of urinary tract
infection (UTI). Emptying of the bladder three to four times daily should reduce the
incidence of UTIs. When a UTI has developed, antibiotic therapy should be started,
preferably based of urine culture and sensitivity results.
• Skin irritation, infection and necrosis (urine scalding) may develop, particularly if UTI is
present. Bladder expression and treatment of UTI may reduce the severity of urine scalding.
Clipping and bathing the perineum and modified diapers also may prevent urine scalds.
Treatment consists of local application of petroleum jelly, zinc oxide cream or antibiotic
ointment.
• Fecal incontinence can also result in fecal scalding of the skin. Treatment is similar to that
described for urine scalding. A low residue diet may be used to decrease the volume of feces
produced.

SPONDYLOSIS DEFORMANS

Introduction

• Spondylosis is the term used to describe a non inflammatory and proliferative bony
changes which occur on the ventral and the lateral aspects of the vertebral bodies. It was
proposed earlier that spondylosis was caused by stretching of the vertebral longitudinal
ligament as a result of ventral disk protrusions.
• More common in larger breeds and older animals. Affected vertebral bodies will be sclerotic
and disk spaces will be narrowed. Spondylosis usually occurs at the site of instability and
more commonly in type 2 disk protrusions in the cervical and lumbar regions.Occurs more
commonly at the lumbosacral junction.
• Etiology
o Formation of spondylosis deformans may or may not occur with clinical signs.
Associated loss of normal range of movement. Bony spurs create pressure on the
exiting spinal nerve roots and may result in a neurological deficit.
o Spondylosis deformans may occur due to instability of the ivd’s in conditions like
congenital vertebral deformities,following disk surgeries,trauma and also disk or
vertebral body infection. Also proposed that spondylosis occurs due to stretching of
ventral longitudinal ligament and periosteum as a result of ventral disk protrusions.
• Pathogenesis
o Osteophytes occur on the ventral margins of the vertebral end plates which grow
larger, bridge the gap between the neighbouring vertebrae-bridging
spondylosis.Bony spurs originate from circumference of end plates and are peri-

95
 articular in nature.Myelography required to diagnose definitively the presence of
significant disk lesions or instability at an affected site. Changes in the annulus
fibrosus plays a major role in in the development of vertebral osteophytes.Nucleus
pulposus plays a secondary role in the disease process.
o Earliest lesions in the annulus are focal lesions which progress to major intradisk
fissures.More severe disk changes consist of further damage to already ruptured
annular lamellae and an increase in amount of debris within the disk.
o Advanced cases-disk tissue almost disappears,bone of adjacent vertebrae is ground
and appears polished. In nuclear pulposus, nuclear changes with chondroid and
fibroid metaplasia seen.Degeneration of nucleus pulposus in chondrodystrophoid
breeds occurs at a younger age and preceeds damage of annulus
fibrosus.Degeneration occurs mainly due to calcification of the nucleus. Pathogenesis
of spondylosis is mostly associated with disk degeneration.
• Clinical significance
o Spondylosis is an incidental finding-rarely a cause of neurological signs although
there maybe pain or stiffness. But it may result in nerve root compression due to
impingement of the proliferated bone as they exit from i-v foramina. Lumbosacral
junction most common site of nerve root pain and as a part of ‘wobbler syndrome’ in
combination with stenosis of intervertebral foramina.
• Radiology
o Radiographic signs consist of osteophytes which are most easily visible on the ventral
margins of the vertebral end plates. These may grow to large size and span the gap
between neighbouring vertebrae-termed ‘bridging spondylosis. There will be an
associated loss of normal range of movement.
o Care must be taken to distinguish between spondylosis which is a degenerative
condition associated with bony proliferation and spondylitis which is an
inflammatory condition in which bony destruction as well as proliferation occurs. On
lateral radiographs it is possible for early osteophytes to be confused with
degenerated disk material within the vertebral canal. Use of ventrodorsal
radiographic views will help to ascertain clearly the position of such osteophytes.
o Formation of osteophytes in spondylosis deformans is without any clinical signs.
However as the bony spurs create pressure on the exiting spinal nerve roots the
possibility of resulting neurologic deficit must be considered. While the osteophytes
typically do not project into the spinal canal, this possibility with its resulting cord
pressure must also be recognised.
• In general
o Spondylosis may occur at the site of instability and there certainly appears to be a
high incidence of spondylosis at the sites of type 2 disk lesions in the cervical and
lumbar regions of the vertebral column. Instability of the intervertebral disks may
result from other conditions including congenital vertebral deformities following
disk surgery, trauma and also following disk or vertebral body infection.
o The vertebral that form around these individually injured or weakened disks are
better considered separately and not included within the generalised condition of
spondylosis deformans. Histological changes in the bony spurs however are identical
regardless of the etiology. Spondylosis occurs with considerable frequency at the
lumbosacral junction but is not always associated with type 2 disk protrusions at that
site.
o Spondylosis is usually regarded as an incidental finding and rarely is a cause of
neurological symptoms in itself, although it may give rise to pain or stiffness.
o Occasionally spondylosis is thought to result in nerve root compression because of
impingement of the proliferated bone as they exit from the intervertebral foramina.
In dogs the most likely sites to cause detectable nerve root pain would be at the
lumbosacral junction and as a part of the wobbler syndrome in combination with
stenosis with the intervertebral foramina. It is usually demonstrated by myleography
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 that spondylosis cannot be the cause of the cause of spinal cord compression but the
diagnosis of nerve root compression is very much more difficult.
o The affected vertebral bodies are sclerotic and disk spaces narrowed. Spondylosis
deformans is similar to type 2 disk protrusions where partial rupture of annulus
fibrosus with a resulting bulging of the dorsal surface of the disk. Many of the causes
of neurologic deficit in the hind legs are not clearly evident on survey radiographs.
The use of mylelographs assists in identifying only those diseases that create a mass
lesion within the cord involving the meninges or are located in an extra-Dural space.
o Changes within the annulus fibrosus plays a major role in the development of
vertebral osteophytes. In many affected disks, the earliest changes are focal lesions in
the annulus that progresses to major intradisk fissures. These changes are noted
more commonly in the ventral aspect of the disk. The more sever disk changes
consist of further damage to already ruptured annular lamellae and a noticeable
increase in the amount of debris within the disk.
o The narrowing of the disk space appears to have followed rather than preceded the
early formation of the osteophytes. Nucleus pulposus plays only a secondary role in
spondylosis.
o Nuclear changes consist of chondroid and fibroid metaplasia within the
chondrodystrophoid and non chondrodystrophoid breeds. It must be appreciated
that osteophytes may occur at any location along the circumference of the end-plate
of the vertebral body except for the area that creates the floor of the spinal cord. Thus
lateral radiographs will clearly demonstrates only bony osteophytes that project
laterally.
o Although symptoms of pain caused by spondylosis in dogs are generally mild, or even
symptomic,certain individuals may be very severely incapacitated. In cats, severe
spondylosis can be found as a result of vitamin A intoxication, which frequently
affects the cervical region of the vertebral column in this species and can cause a
dramatic reduction in its mobility.
• Treatment
o Spondylosis rarely requires treatment as such as it is usually asymptomatic. NSAID’s
can be used as symptomatic treatment for the stiffness exhibited by some individuals
who cannot be explained by other lesions. Medical treatment merely suppresses the
symptoms but will not cause regression of the lesion.

SPONDYLITIS

• It is also called diskospondylitis. It refers to infection of the vertebral disks and the
neighbouring vertebral end plates. Spondylitis refers to osteomyelitis of the vertebrae alone.
• The typical sign is pain (which maybe severe) and in some cases neurological dysfunction
will also develop. Neurological are usually the result of instability or subluxation of the
affected region.
• The cause of the condition is usually systemic infection, with haematogenous spread (i.e.,
bacteraemia) and in many cases is thought to originate from the urinary system.
• In some cases foreign body migration from the digestive or respiratory tracts allows grass
seed awns to find their way to the ventral aspect of L1\L2 region and lodge in the
intervertebral disks and cause diskospondylitis.
• Immunosuppressed patients may also be predisposed to diskospondylitis. Rarely, bacteria
migrate dorsally and cause epidural abscess formation.
• Areas of spine most commonly affected are lumbosacral junction,cervicothoracic region,
thoracic junction and mid thoracic disks.
• Diskospondylitis most commonly affects young large breed dogs and the most commonly
affected is T5\6 followed by L7 and the caudal cervical region.
• The most common bacterial isolates are staphylococci most of which are penicillin resistant.

97
• Symptoms include subtle lameness, difficult jumping,anorexia,depression,weight loss.
Chronic paraparesis or tetra paresis may occur later.
• The hallmark of patients with diskospondylitis is spinal hyperpathia(ie, neck or back pain
on deep palpation) associated with systemic disease.
• Diagnosis of discospondylitis can usually be made from plain radiographs. There is
destruction of dense bone of the vertebral end plates with some bony proliferation at the
margins of the lesion. Radiographically it is possible to confuse spondylosis with
discospondylitis; however, in spondylosis there is only bony proliferation whereas in
diskospondylitis there is concurrent bony destruction.
• Signs in the radiographs become evident at 10 to 14 days. As the infection progresses there
is continued proliferative bony changes, sclerotic changes and ventral osseous proliferation
with varying degree of bridging spondylosis.
• Mylelography is mandatory in patients requiring surgical intervention. Bone scintigraphy is
also helpful in early diagnosis of diskospondylitis.
• Diagnosis of the type of bacteria involved is usually not required for initial treatment.
Therapy is based on the assumption that there will be a penicillin resistant staphylococcal
infection.
• Appropriate antibiotic treatment should be given for about 3 months or more in order to
eradicate infection. If signs persists or progresses or if there is an obvious instability at the
affected site, then surgical exploration maybe required for a bacterial culture and
stabilization maybe required.
• In rare cases abscesses may occur in the epidural space. Associated symptoms are those of
pain and transverse myelopathy and any mimic those of a tumour from which they must be
differentiated.
• Exploratory surgery is likely to be required in such cases allowing cord decompression and
retrieval of material for microbial culture.Not all spondylitis\diskospondylitis lesions will
be caused by bacteria, some are the result of fungal or cryptococcal infections but are
uncommon.

INTERVERTEBRAL DISC PROLAPSE AND ITS MANAGEMENT

• Thoracolumbar intervertebral disk (IVD) extrusion, a common disease encountered in dogs,

is often associated with severe neurologic dysfunction. Presenting clinical signs include
spinal hyperesthesia, ataxia, paresis, and paralysis. In severe cases, loss of deep pain
perception to the pelvic limbs may occur.
• In 1952, Hansen classified IVD disease into two types of disk herniation.
o Type I lesions refer to the extrusion of material from the central portion of the disk
through the outer fibrous layers into the vertebral canal. Type I disk disease is
usually described in small, typically chondrodystrophoid breeds of dogs
(e.g.,dachshunds, Pekingese,). When a type I lesion occurs in the thoracolumbar
spine, clinical signs are usually acute and neurologic deficits can be dramatic.
o Type II lesions refer to the protrusion of the outer fibrous layers of the disk and
result from alterations in the normal biomechanical properties of the disk that cause
it to protrude into the vertebral canal. Type II disk disease may be asymptomatic or
may present as a chronic condition with a slow progression of neurologic signs.
• Intervertebral disks are located in every intervertebral space along the spinal column,
except in the atlantoaxial joint (C1-2). Each disk comprises three distinct anatomic regions:
the annulus fibrosus, nucleus pulposus, and cartilaginous endplates. The dorsal and ventral
longitudinal ligaments bind the IVD dorsally and ventrally The annulus fibrosus encircles
the nucleus pulposus and consists of lamellae of fibrocartilaginous tissue.
• The direction of the fibrous bundles in each lamellar layer alternates sequentially, enabling
fibers to slide on each other during biomechanical loading. The nucleus pulposus is an
amorphous, gelatinous mass consisting of water, collagen fibers, proteoglycan molecules,
and a variety of other cells (e.g., chondrocytes, fibrocytes).
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 • The majority of the force of a compressive load is absorbed by the nucleus pulposus. For the
cervical and lumbar regions of the vertebral column, the nucleus is located eccentrically in
the disk, with the ventral aspect of the annulus fibrosis being two to three times wider than
the dorsal aspect. This eccentric location correlates with the neutral zone between the
tensile and compressive forces that act on the vertebral column during normal activity.
• The cartilaginous endplates resemble hyaline cartilage and form the cranial and caudal
boundaries of the disk. From the second to the tenth thoracic vertebra, the intercapital
ligament between opposite rib heads lies ventral to the dorsal longitudinal ligament and
dorsal to the disks. This thick ligament is thought to be the reason disk extrusion is
uncommon in the cranial thoracic area.
• Hemorrhage from the vertebral sinuses can accompany disk extrusion or can obstruct
visualization during surgical decompression. The spinal cord is located within the bony
vertebral canal and is further protected by the meninges (dura mater, arachnoid membrane,
pia mater).
• The cerebrospinal fluid (CSF) is contained within the subarachnoid space. Obesity,
muscular fitness, and spinal length (i.e., long spine compared with leg length [e.g.,
dachshunds]) are other factors that have been implicated in increasing the risk of
intervertebral herniation.
• An acute compressive lesion can vary from mild demyelination to irreversible necrosis of
both gray and white matter. The larger, heavily myelinated fibers that mediate
proprioception are affected first, followed (in descending order) by the intermediate-sized
fibers involved in voluntary motor function; the slightly smaller fibers that mediate
superficial pain sensation; and, finally, the small, unmyelinated fibers that mediate deep
pain sensation. Uncommonly, a progressive hemorrhagic myelomalacia may occur
associated with an acute IVD extrusion. Rapid neurologic dysfunction is noted, and death
due to respiratory failure may follow in 3 to 10 days.
o Signalment and clinical signs
o Grading
o Hemilaminectomy and pediculectomy

SIGNALMENT, CLINICAL SIGNS AND DIAGNOSIS

• Acute IVD disease occurs in all breeds of dogs; however, chondrodystrophoid Breeds are at
greater risk. The dachshund reportedly has a 10- to 12-fold greater risk than all other breeds
combined. Approximately 75% of disk herniations occur in animals between 3 and 6 years
of age. Eighty-five percent of all disk herniations occur in the thoracolumbar region, and the
most frequent sites are from T11-12 to L2-3.
• Although most animals with acute IVD extrusion usually present with serious neurologic
dysfunction, spinal pain may be the only presenting clinical sign in some patients.
• Dogs commonly present non ambulatory in the pelvic limbs. Voluntary bladder control is
often lost and pain sensation is altered, depending on the degree of spinal cord injury. Less
severely affected dogs may present with varying degrees of ataxia and paresis that, if left
untreated, can progress to complete paraplegia A thorough orthopedic examination should
be included in the diagnostic workup of such animals.

Diagnosis

• Signalment, history, and physical examination is essential to make a tentative diagnosis of

acute thoracolumbar disk extrusion.
• A complete neurologic examination should be performed in all cases of suspected acute
thoracolumbar IVD extrusion to accurately localize the lesion. Disk extrusion in spinal cord
segments L4-S3 may have decreased to absent patellar, gastrocnemius, withdrawal, and
perineal reflexes, indicative of lower motor neuron (LMN) disease. A positive crossed

99
 extensor reflex is a sign of UMN disease. Palpation of the paraspinal musculature may
demonstrate the presence of hyperesthesia in the area of the affected disk space. The
cutaneous trunci (panniculus) reflex can be useful in localizing a lesion; the level of lack of
contraction of the subcutaneous muscles suggests a spinal cord lesion that is one to four
segments more cranial. The neurologic examination should conclude with the evaluation of
conscious pain sensation in the affected limbs.
• Deep pain sensation is evaluated by pinching a hemostat across the bone of a digit.

GRADING

• Based on Neurologic Signs

o Grade 1: Spinal hyperesthesia (pain) only
o Grade 2: Mild ataxia with enough motor function for weight-bearing
o Grade 3: Severe ataxia without weight-bearing ability
o Grade 4: No motor function, but deep pain sensation is present
o Grade 5: No deep pain sensation is present
• An assessment of bladder function should also be obtained during the history and via
abdominal palpation.
• In anesthetized patients, plain radiography aids in ruling out diskospondylitis, Vertebral
neoplasia and spinal fracture/luxation. Narrowing or wedging of the IVD space,
• Narrowing of the intervertebral foramen, radio opaque material (calcified disk material) in
the intervertebral foramen, and collapse of the articular facets are evidence a disk extrusion
is present
• Myelography is performed under general anesthesia and requires the injection of a radio
opaque contrast agent into the subarachnoid space.
• On a lateral view, an extradural lesion elevating the ventral contrast column and causing
narrowing or absence of the dorsal contrast column is the classic myelographic lesion
indicating spinal cord compression at that site. The use of ventrodorsal and 45° oblique
views can aid in determining the exact location or lateralization of the disk extrusion.

Decision making and prognosis

• Dogs with grade 1 and 2 disease are candidates for appropriate medical management and
that dogs exhibiting clinical signs consistent with grades 3,4, and 5 are candidates for
decompressive spinal surgery. Progression of spinal cord parenchymal tissue damage can
become irreparable within 24 hours; therefore, both medical and surgical treatments should
be performed within this time. A loss of the myelographic contrast column greater than five
times the length of the second lumbar vertebra (L-2) was a moderately negative prognostic
indicator. .Development of progressive hemorrhagic myelomalacia carries a grave
prognosis. Animals with loss of ambulation are not considered candidates for surgery

Medical management

• Dogs with grades 1 and 2 clinical signs based on thorough neurologic examination may be
considered candidates for medical management.
• Other indications for medical management are dogs with loss of deep pain sensation for
more than 48 hours, owners who decline surgery for their dogs, and dogs with systemic
illness that greatly increases anesthetic risk.

Confinement therapy

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 • The key factor in confinement therapy is strict immobilization of animals in a cage or crate
for at least 3 weeks. This period of inactivity enables resolution of spinal cord and IVD
inflammation, some resorption of any extruded disk material, and fibrosis of the ruptured
annulus fibrosus.
• Leash walking is permitted for urination and defecation. Nonambulatory animals require
intensive recumbency management. In dogs that have lost the ability to urinate voluntarily,
bladder expression should be performed three to four times daily.
• Urinary catheterization (intermittent or indwelling) may be necessary, particularly in dogs
with a hypertonic urethral sphincter. Pharmacologic agents can improve bladder and
urethral function. Soft, dry, padded bedding material (e.g., foam, air, or water mattresses
and blankets) should be provided to prevent urine scalding and decubital ulcers. Physical
therapy, including gentle massage combined with passive and active exercise therapy, can
also be helpful in maintaining 7 muscle strength and range of motion in joints. The use of
carts and other walking aids should be restricted to dogs with prolonged or permanent
paralysis.
• Following the initial 3week confinement period, dogs should be gradually returned to
normal activity while avoiding such strenuous exercise Dogs with grade 1 and 2 clinical
signs that have repeated episodes of severe spinal hyperesthesia despite medical
management or have worsening neurologic deficits should be considered for surgical
treatment.

Pharmacologic therapy

• Drugs acting on the lower urinary tract

• Alpha antagonist –Phenoxybenzamine- Dog 0.25–0.5 mg/kgPO q12 h Hypotension
• Cat Per cat—1.25–7.5mg PO q12–24 h
• Start at lowest dose
• Alphaantagonist- Prazosin Dog 1 mg /15 kg PO q12–24 h Hypotension
• Cat Per cat—0.25–0.5mg PO q12–24 h
• Start at lowest dose
• Care in CRF ,seizures
• Alphaantagonist -Terazosin -Dog Per dog—1–2 mg up to 11 kg, 2–5 mg upto 50 kg; PO q12 h
• Start at lowest dose
• Hypotension
• Cat -Percat—0.5–1 mg PO q12 h
• Priapism,rare, needs immediate treatment
• Skeletal muscle -Diazepam -Dog Per dog—2–10 mg PO q8 h Give 10–20 min before
relaxant
• Cat not recommended expression
• Corticosteroids have been used extensively in treating the spinal cord trauma associated
with IVD extrusion. High dose methyl prednisolone is believed to be beneficial because of
its inhibition of oxygen free-radical lipid peroxidation in the spinal cord. Current
recommendations are to administer 30 mg/kg of methyl prednisolone by slow IV injection
within 8 hours of spinal cord trauma. This initial dose is followed 2 and 6 hours later with
another IV dose at 15 mg/kg. However, patients who were similarly treated more than 8
hours after injury actually showed decreased recovery of motor function compared with
those treated . Recurrent clinical signs or worsening neurologic deficits that may require
surgical intervention.
• Grades 3, 4, or 5 (i.e., dogs unable to walk unassisted) are regarded as candidates for
surgery. Dogs with loss of deep pain sensation (grade5) for longer than 48 hours may not
benefit from surgery. These dogs have a poor prognosis for functional neurologic recovery,
and durotomy should be considered as a diagnostic procedure to evaluate the spinal cord
for evidence of myelomalacia.in dogs.

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 HEMILAMINECTOMY AND PEDICULECTOMY

• Hemilaminectomy and pediculectomy are surgical methods for Spinal cord decompression
and removal of extruded disk material. These techniques can be accomplished using only
bone rongeurs. However, using pneumatic drill and bone burs allows more rapid and
precise bone removal. Because most disk extrusions result in a ventral or ventrolateral
compressive mass, hemilaminectomy is the preferred surgical technique for spinal cord
decompression and removal of disk material. This technique can be performed over four or
five IVD spaces if necessary and allows access to the ventral and lateral aspects of the spinal
cord without adversely affecting vertebral stability. Extruded disk material can be removed
through the bony window that is created, thereby decompressing the spinal cord.
• A standard dorsal approach to the selected side of the vertebral column is made centered on
the affected IVD space. Visualizing the cranioventrally projected transverse process of the
first lumbar vertebra (L-1) and the lateral transverse process and rib head of the thirteenth
thoracic vertebra (T-13) makes identification of the correct disk space possible. Initially, the
articular processes over the disk space are removed using a bone rongeur. The laminar bone
is then removed to the level of the floor of the vertebral canal. This can be performed using
rongeurs;
• Hemorrhage is controlled with bipolar cautery and bone wax. After the inner cortical layer
of bone is gently removed with the drill, a small nerve-root retractor or dental scaler is used
to open the periosteum and expose the spinal cord.
• Extruded disk material is often readily seen and is removed using small forceps or a nerve-
root retractor .The dura is elevated with small forceps or a hooked hypodermic needle and
then incised with a No. 11 or 12 scalpel blade along the length of the hemilaminectomy site.
Oozing a “paste like” substance from the durotomy site indicates that myelomalacia is
present and the prognosis for neurologic recovery is poor.
• Placement of a free fat graft over the hemilaminectomy site before closure of the surgical
wound has been advocated to prevent perineural fibrosis and dural adhesion. The
thoracolumbar fascia and subcutaneous tissues are closed thoroughly to eliminate dead
space.

Pediculectomy

• Pediculectomy is the removal of the lateral bony wall of the spinal canal between the
vertebral body and the articular processes. This technique is reportedly less destabilizing to
and minimizes manipulation of the spinal cord compared with hemilaminectomy but still
provides spinal cord decompression and allows removal of extruded disk material.

Source: Acute thoracolumbar disc extrusion in dogs-I and II: Compendium of small animal
practice21(10); October 1999

BASIC SPINAL NEUROLOGY

• The ability to initiate and coordinate movement depends on the flow of information
between the brain and the skeletal muscles of the body and limbs. The pathway that unites
the brain and the skeletal muscles is divided into two parts:
o Communication between the brain and the spinal cord.
o Communication between the spinal cord and the skeletal muscles.
• The first part of this pathway is called the upper motor neuron pathway. Cell bodies in the
motor centre of the brain produce long fibres (or axons) that travel along the while matter
of the spinal cord for variable distances. These make connections with the cell bodies in the

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 grey matter of the spinal cord produce axons that travel out of the spinal cord along the
nerve roots and peripheral nerves to the skeletal muscles of the limbs and body.
• All areas of the spinal cord contain both white and grey matter (Figure 1a). However, there
are two areas of the spinal cord grey matter that have specific importance in relation to limb
function. These are called the cervical and lumbar enlargement.
• The cervical enlargement is present between C5 and T2. The grey matter in this region
supplies the lower motor neurones to the forelimbs. An injury to this area may affect the
reflexes in the forelimb as well as affecting the upper motor neurones of the hind limbs. The
lumbar enlargement is present between L4 and S2. This area gives rise to the lower motor
neurones to the hind limbs.
• Thus the spinal cord from C1 to C4 and between T3 and L3 are not directly involved with
either fore or hind limb function. Injury to these areas, however, can have a profound effect
on the patient's ability to walk. That is because these areas carry the upper motor neurons
and the sensory pathways between the brain and the limbs.

Table 1 : The effect of location of spinal cord injury on limb function

Lesion C1- C5- T3-13 L4-S3

C4 T2
Forelimbs UMN LMN Normal Normal
Hind UMN UMN UMN LMN
limbs

• Lesions between C1 and T2 will often result in all four limbs being involved (quadriplegia),
while those caudal to T2 (with a few exceptions) will produce abnormalities in hind limb
function (paraplegia) with the forelimbs appearing normal. This is because the spinal cord
between C1 and C4 carries the upper motor neurons to the forelimbs and the hind limb
limbs, while C5 to T2 carries the upper motor neurons to the hind limb and the lower motor
neurons to the forelimbs. Caudal to T2, however, carries to the hind limb.

Causes of spinal cord dysfunction

• The list of possible causes of spinal cord dysfunction is lengthy. These can be broadly listed
using the `DAMNIT' mnemonic degenerative, autoimmune, metabolic, nutritional,
neoplastic, infectious, inflammatory, idiopathic, traumatic and toxic.
• The majority of spinal patients present as a result of spinal cord dysfunction arising from
intervertebral disc disease (IVDD).

SPINAL RADIOGRAPHY AND MYELOGRAPHY

Introduction

• The investigative techniques applied to the spinal patient have five main goals
o Defining the likely cause of the spinal cord dysfunction.
o Defining the site of spinal cord pathology.
o Defining the optimal treatment method for the current problem.
o Pre-surgical planning.
o Assessing the prognosis for recovery.

Plain radiography
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 • Plain radiolography of the spinal column is used to define the following features
o Vertebral pathology such as bone loss or bone production (focal or generalised).
o Intervertebral disc pathology such as mineralization of the nucleus, narrowing of the
intervertebral space, widening of the intervertebral space.
o Pathology of the articular facets such as luxation, subluxatiton, degenerative joint
disease.
o Pathology of the intervertebral foramen such as the presence of mineralized nuclear
material, narrowing or widening.
o The presence or absence of vertebral anomalies such as hemi vertebrae fused
vertebrae, transitional vertebrae and so forth.
o Plain radiography should always be performed prior to the use of myelography.
o At least two views of an area are required to evaluate the radiographic anatomy and
thus visualise the presence or absence of plain radiographic pathology in that area.

Myelography

• Myelography is a positive contrast radiographic technique. The contrast agent is introduced

into the subarachnoid space, where it mixes with the cerebrospinal fluid. The contrast agent
does not `mix' with the spinal cord itself. Thus the contrast defines the area between the
dura and the spinal cord. In other words the spinal cord `excludes' the contrast agent and is
thus revealed.
• Not all contrast agents are suitable for myelography. The type of contrast agent used is a
non - ionic iodine - based contrast agent. An example of a myelographic contrast agent is
omnipaque (lohexol)
• The contrast agent can be introduced at one of two sites:
o The atlanto - occipital junction (cisterna puncture).
o In general, the former technique is used to delineate cervical spinal pathology, while
the latter is used to assess the thoracic and lumbar spinal cord.
• In order to perform myelography the following equipment is required
o Spinal needles
o Contrast agent
o Surgical skin preparation agents
o Radiographic equipment.
• The CSF should be evaluated prior to introduction of the contrast agent if an inflammatory
spinal condition is suspected. The area should be clipped and the skin prepared with a
suitable skin disinfectant. The assistant should position the patient. For cisternal
myelography the neck is ventroflexed in order to open up the atlanto-occipital space. This
results in kinking the endotracheal tube. For this reason the cuff should be deflated first,
allowing the patient to breathe around the endotracheal tube. Cisternal puncture should not
be used in patients who are suspected (on the basis of plain radiographic techniques) to
have cervical vertebral fractures or luxations. Lumbar puncture requires that the
interarcuate space between L4 and L5 be opened to the maximum. In order to do this, the
hind limbs are pulled through the space between the forelimbs. Following administration of
the contrast agent, the head should be elevated in order to minimize cranial extension of the
agent into the cranium. Short duration apnea following administration of the contrast is not
uncommon.
• Myelography should be used with caution in patients with a history of seizures as the
contrast agent may increase the risk of seizures upon recovery. The suspicion of increased
intracranial pressure is also a contraindication for myelography as there is a risk of
herniation of the cerebellum resulting in death.
• Myelography permits the delineation of the following types of lesions affecting the spinal
cord
o Extradural Compression.
o Intradural - Extramedullary compression (IDEM)
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 o Intramedullary compression.

COMPRESSION AND SPINAL SURGERY

Extradural compression

• This arises from compression by lesions outside of the dura mater. These are therefore
lesions between the dura and the walls of the spinal canal. The most common example of
extradural compression is the compression that follows extrusion of disc material into the
spinal canal (type 1 disc disease).

Intradural - extramedullary compression (IDEM)

• These are lesions within the subarachnoid space itself. Thus they are inside the dural sheath
(intradural) but outside of the substance of the spinal cord (extramedullary). An example of
this type of compression is that association with a meningioma.

Intramedullary compression

• This arises from a lesion within the spinal cord itself. It is usually associated with neoplasia
of the cord substance such as a neurofibrosarcoma. It is also seen in association with cord
swelling as a result of cord trauma.

Spinal surgical techniques

Differences between surgical and non-surgical management

Success Recurrence Predictability Requirement Ease of

rate rate of recovery for performance
confinement of
physiotherapy
Non-surgical 70% 50% Low Strict Some
management confinement techniques may
for 6 weeks or be hazardous
more
Surgical 95% <50% High Minimal Safe to perform
management

Goals of spinal surgery

• The main goal of spinal surgery is to create an environment within the spinal canal or spinal
cord function. In case of disc extrusion, the surgery is performed on the spinal canal in
order to permit the cord to occupy a spinal canal of normal dimensions, thus relieving the
compressive effect of the extruded disc material. The actual improvement of the patient
depends upon the reversal of the intraspinal biochemical events that followed acute spinal
cord compression.
• Spinal surgical techniques can be divided into decompressive and non-decompressive
surgical techniques. A surgical technique might only be described as decompressive if it

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 removes the compressive mass. Making a hole, however large, in the spinal canal does not
relieve compression on the spinal cord.
• "Laminectomy" means to cut out or remove the vertebral arch. If the lateral part of the
lamina (the: wall”) including the articular facets is removed, this is a hemilaminectomy. If
the dorsal aspect (or the roof) of the lamina is removed, this is a dorsal laminectomy. If the
intervertebral foramen is merely enlarged without removing the articular facets this is
termed a mini-hemilaminectomy or a foraminotomy.
• Dorsal laminectomy is mainly reserved for cases of spinal neoplasia, where it gives good
access to the entirety of the dorsal and dorsolateral aspects of the spinal cord. It is less
useful in cases of disc extrusion, where a large component of the extruded disc material is
ventral to the spinal cord. In order to retrieve this material, excessive handling and
manipulation of the cord is required.
• The word `fenestration' comes from the French for window, fenetre, and refers to the
surgical technique of cutting a window in the intervertebral disc in order to remove the
nucleus
• The ventral slot procedure is used in the treatment of cervical disc disease only.
o Fenestration
o Ventral slot
o Laminectomy
o Hemilaminectomy
o Foraminotomy (mini - hemilaminectomy)
o Distraction fusion technique
• A routine fenestration of the disc is performed. A channel is then cut into the vertebral
bodies either side of the disc from the ventral aspect into the spinal canal. The extruded
material is removed via this channel. Fenestration therefore is never a decompressive
technique as it is not a method of access to the canal and the only disc material that is
removed is the disc material that has not extruded into the spinal canal. Fenestration is
always performed simultaneously with the other techniques. In this way these techniques
are superior in that they permit removal of the disc material that has caused the current
spinal cord injury, and by performing fenestration, the possibility of future extrusion at this
site is avoided by removing the non - extruded, intra - discal material. Fenestration is
routinely performed on the disc cranial and caudal to the affected disc. This minimizes the
likelihood of recurrence.
• Distraction - fusion of the cervical vertebrae is often employed in the surgical treatment of
cervical spondylomyelopathy or `Wobbler Syndrome’. In this technique the intervertebral
disc is resected almost in its entirety. A washer is then placed between the vertebrae in
order to distract the vertebral bodies. This stretches the soft tissue that is compressing the
spinal cord, thus recreating a normal spinal canal diameter. The washer is held in position
by a screw and a cancellous bone graft is applied to the ventral surface, resulting ultimately
in fusion of the vertebrae (it is hoped) in this distracted position.

Spinal surgical equipment

• Spinal surgery requires certain equipment, which is listed below

o Rongeurs for making access to the spinal canal.
o High - speed air drill and burrs for making access to the spinal canal through thick
bone.
o Periosteal elevator to permit retraction of soft tissues with minimal haemorrhage.
o Sheas curette and Rosen Mobiliser .These are used to remove disc material from the
spinal canal and from the spinal canal and from the disc itself.
• The risks of spinal surgery are
o Haemorrhage
o Iatrogenic spinal cord injury
o Sepsis
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 o Spinal column destabilization resulting in postoperative vertebral subluxation.

PRACTICAL NURSING OF THE SPINAL PATIENT

• Neurological deterioration
• Problems associated with urinary management
• Problems associated with recumbency
• Problems associated with the non - surgical management of high `movement risk' patients.
• Problems associated with communicating with the owners of spinal patients.
• Problems associated with urinary management
• This is probably the most problematic nursing challenge. Failure to manage bladder
dysfunction may lead to urine scalding of the skin, cystitis, bladder over - distension
(leading potentially to long - term urinary dysfunction) and inadvertent bladder rupture
during manual expression.
• Urine `scalding' can be avoided by emptying the bladder two to three times daily.
• In longhaired breeds the tail may be bandaged and hair should be clipped around the
perineum and ventral abdomen. Vaseline or other water - repelling agents should be applied
at least three times daily following bathing, and the skin dried thoroughly prior to
application of the cream. The bedding should be checked regularly and should be of a type
that allows fluids to run off rather than be absorbed into the fabric.
• Manual expression is always preferable to catheterization. The latter has an increased risk
of inducing cystitis as a result of the mechanical irritation of catheterization and the
difficulty in performing the procedure in a completely sterile way. The technique of manual
expression of the bladder is as follows
o Gently palpate the caudal abdomen with a hand either side until the bladder is
located.
o Gently and evenly increase the pressure between the two opposing hands until urine
begins to void. In recovering patients this will initiate the patient to complete the act
of urination. In patients with urinary retention the pressure should be applied
constantly to the bladder wall until the residual volume is too low for further
expression.

Problems associated with recumbency

• Many spinal patients are temporarily recumbent. This may be paraplegia (hind limbs only)
or quadriplegia (all four limbs affected). The paraplegic patient may be able to voluntarily
alter its own position within certain limits and will be able to sit up unassisted. However,
the quadriplegic patient will be entirely dependent upon assistance for even the most minor
postural changes.
• Main problems associated with recumbency
o Pressure - related injury
o As a result of prolonged focal contact with a non - deforming surface, the local blood
flow to the contact area of skin and the subcutaneous tissues is reduced. Ultimately,
if the contact is unchanged, the skin will die and a non - healing wound will develop.
This tends to occur over bony prominences such as the greater trochanter, acromial
processes, lateral epicondyle of the elbow and stifle and the distal fibula. The
likelihood of pressure sores developing is dramatically increased if the skin becomes
macerated by chronic contact with urine.
o Pressure sores are much easier to prevent than they are to treat. There are four main
aspects to the prevention of this problem:
 Prevent prolonged recumbency in one position.
 Use well - padded bedding (or local padding in the form of `doughnut
dressings').

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  Be attentive to bladder management.
 Groom the patient at least once daily.
o General massage and grooming is very important in these patients. The period of
personal contact improves most patients' feeling of wellbeing. Grooming the patient
will improve skin circulation and, equally importantly, will mean that the entirety of
the patient's skin has been examined for early indicators of pressure sore
development such as focal erythema. Bathing is also very helpful if this is not
contraindicated by he movement risk assessment, however even in these patients, a
bed bath is very beneficial. The skin and hair should be thoroughly dried before the
patients are returned to bed.

Hypostatic pneumonia

• This also develops as a result of failing to change the patient's position regularly. It
generally results from prolonged unilateral recumbency.
• One position should not be maintained for more than four hours. Coupage or manual
percussion of the chest wall with a cupped hand may reduce the accumulation of airway
secretions and may be beneficial in these patients.
• Problems associated with the non - surgical management of high `movement risk' patients.
o All patients with neurological deficits resulting from spinal cord dysfunction will
benefit greatly from physiotherapy and assisted walking. The danger of performing
many of these techniques in dogs with conservatively managed disc disease or spinal
fracture will often preclude their use.
o Opiates and opiods may be used in the early stages of management, but the
transition to non - steroidal analgesics is potentially hazardous if the patient is not
adequately immobilized.
o In general, the only safe activities for these patients are massage of the limbs,
grooming and passive flexion - extension of the limb joints.
o When voluntary limb function returns, assisted walking may be commenced as long
as it is done with care and the patient is under control at all times.
o In general, the technique of assisted walking uses a towel or blanket placed under the
abdomen in order to elevate the hind limbs from the ground or to provide support in
the case of patients that have begun to weight bear on the limbs

Source: Compendium of small animal practice-Nursing the spinal patient.

DISCHARGE INSTRUCTIONS FOR SPINAL TRAUMA\ SPINAL SURGERY CASES

INITIAL

• Your dog will need STRICT REST for 6 weeks to allow his/her spine to heal and to prevent
damage during this healing time. To achieve this he/she must be restricted to her cage for
6weeks. His/Her exercise will consist of towel and leash walking four times per day for 10-
15 minutes each time. You may also towel and leash walk your dog for elimination purposes.
It is important that your dog does not run, jump or climb during this period. Stairs and
slippery floors should be avoided.
• Check the incision on your dog’s back twice a day for any swelling, inflammation, heat, pain
or discharge. If you observe any of these signs call us. Pad the kennel with 1 inch of padding
(6 towels). Keep the kennel clean and dry by frequently changing the bedding. Remove
sutures at hospital on 10th post operative day.
• Move your dog’s legs through their normal range of motion 3-4 times daily for 10-15
minutes by gently but fully extending and flexing the hip, knee, ankle and toes. This will
help to prevent the joints from becoming stiff. The physical therapy is very important for
since your dog is not using his/her back legs. After the incision has healed, or at least two
108
 weeks following the surgery, being swimming your dog in the bathtub 3-4 times per day for
2-3 minutes at a time or until he/she becomes tired. Gradually increase this exercise over
the next five weeks to 10-15 minutes. Be sure to support his/her weight while in the water,
and never leave your dog alone in or near the water. Fill the tub with just enough water to
allow him/her to float. In addition, please practice sitting-standing exercises with your dog
by placing him/her with all four feet squarely underneath then support your dog’s weight
with a towel. As your dog collapses, pull him/her back up. Repeat this exercise for 10
repetitions, three times per day or until your dog becomes tired, gradually increasing this to
2-3 minutes three times per day over the next five weeks.
• Please express your dog’s bladder four times daily with gentle pressure. It is easier if you
squeeze gently but firmly on her bladder and then wait a few minutes for the urine to begin
to flow. If it becomes difficult to express the bladder, please call us. Urinary tract infections
are a potential complication for your dog, so please watch for brown colored or malodorous
urine. If you notice these signs, please contact the Small Animal Orthopedic Unit, MVC. To
prevent urine scaling thoroughly rinse any urine sprayed areas with warm water then towel
dry.

Discharge instructions – 3 week recheck

• Your dog will need STRICT REST for the next 3 weeks to allow his/her spine to heal and to
prevent damage during this healing time. To achieve this he/she must be restricted to her
cage of 3 weeks. His/Her exercise will consist of towel and leash walking four times per day
for 10-15 minutes each time. You may also towel and leash walk your dog for elimination
purposes. It is important that your dog does not run, jump or climb during this period.
Stairs and slippery floors should be avoided.
• Pad your dog’s kennel with 1 inch of padding (6 towels). Keep the kennel clean and dry by
frequently changing the bedding.
• Please continue to move your dog’s legs through their normal range of motion 3-4 times
daily for 10-15 minutes by gently but fully extending and flexing the hip, knee, ankle and
toes. This will help to prevent your dog’s joints from becoming stiff. The physical therapy is
very important for since your dog is not using his/her back legs. After the incision has
healed, or at least two weeks following the surgery, being swimming your dog in the bathtub
3-4 times per day for 2-3 minutes at a time or until he/she becomes tired. Gradually
increase this exercise over the next two weeks to 5-10 minutes. Be sure to support his/her
weight while in the water, and never leave your dog alone in or near the water. Fill the tub
with just enough water to allow him/her to float. In addition, please practice sitting-
standing exercises with your dog by placing him/her with all four feet squarely underneath
then support your dog’s weight with a towel. As your dog collapses, pull him/her back up.
Repeat this exercise for 2-3 minutes per day or until your dog becomes tired, gradually
increasing this to 2-3 minutes three times per day over the next three weeks.
• Please continue to express your dog’s bladder four times daily with gentle pressure. It is
easier if you squeeze gently but firmly on the bladder and then wait a few minutes for the
urine to begin to flow. If it becomes difficult to express the bladder, please call us. Urinary
tract infections are a potential complication for your dog, so please watch for brown colored
or malodorous urine. If you notice these signs, please contact the Small Animal Orthopedic
Unit, MVC. To prevent urine scaling thoroughly rinse any urine sprayed areas with warm
water then towel dry.

MODULE-14: CLASSIFICATION AND GENERAL PRINCIPLES OF FRACTURE

REPAIR

Learning objectives

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This module deals with

• Fracture classification and clinical signs

• Stages of fracture healing
• Bone diseases and nutrition
• Bone graft

FRACTURE

Classification

• Fractures most commonly result due to trauma such as road traffic accidents
• Occasionally , a fracture may be caused by a disease process such as tumor or a nutritional
disorder
• It is essential to classify the fracture to help determine the type of treatment

Open vs. Closed

• Open fracture - any fracture in which there is a break in the skin over the fracture; formerly
called a compound fracture
• Closed fracture- a fracture with no break in the skin

Stable vs. Unstable

• Stable-fracture fragments have more than 50% contact and can be further stabilized with
external manipulation
• Unstable- fracture fragments have very limited apposition and need to be converted to
stable fracture to promote healing

According to the extent of damage

• Complete fracture-complete break of bone with marked displacement

• Green stick fracture-One side of the bone is broken and the other side is bent Often seen in
young animals
• Fissure fracture-Fine spiral on longitudinal cracks in the bone cortex

According to direction and location of fracture line

• Transverse- fracture at right angles to the bone

• Oblique-fracture line is diagonal
• Spiral-fracture line is a curve
• Comminuted- Multiple fractures meet at a common point
• Multiple-the one is broken in to 3 or more segments but fracture lines do not meet
• Impacted- the bone fragments are driven firmly together
• Avulsion - fracture at the attachment of a tendon, ligament or muscle
• Intra-articular fracture - fracture involving and extending into a joint
• Salter fracture-fracture through a growth plate

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Unger et al. (1990) developed a computer filing system for the classification of fractured long
bones that included definition of terms and a method of classification based on fracture criteria
seen on radiographs. With this classification system, the fractures were ranked in increasing
severity and complexity for various anatomical locations and provided prognostic and therapeutic
information. The first symbol of the alpha-numeric code represented the fractured bone : 1
humerus, 2 radius/ulna, 3 femur 4 tibia/fibula. The second symbol represented the segment of the
long bone in which the fracture was centered : 1 proximal, 2 diaphyseal, 3 distal. Diaphyseal
fractures were divided into 3 types : simple (A), wedge (B) and complex fractures (C)

Clinical signs

• sudden onset of pain

• Loss of function
• Swelling
• Deformity of structure
• Crepitus or grating sounds of bone ends rubbing together

Diagnosis

• Physical examination
• Radiography

Treatment

• There are two main types of fracture treatment:

o External fixation - immobilization of a fracture by using external means such as
casts,splints, bandages or external fixators
o Internal fixation - immobilization of a fracture by surgically exposing the broken
bones to repair the fracture; with internal fixation the fixation method, the fracture
immobilization device is placed on the fracture site inside the leg
• In general, external fixation is less expensive than internal fixation, but external fixation
requires more care at home by the client than internal fixation
• The type of treatment used depends on the type of fracture, the type of animal, age of the
animal, use of the animal and economics. In general, external bandaging is applicable for
long bone fractures in which the broken bones have more than 50% contact between them

STAGES OF FRACTURE HEALING

• Stage 1: Inflammation
o Bleeding from the fractured bone and surrounding tissue causes the fractured area to
swell. This stage begins the day you fracture the bone and lasts about 2 to 3 weeks.
• Stage 2: Soft callus
o Between 2 and 3 weeks after the injury, the pain and swelling will decrease. At this
point, the site of the fracture stiffens and new bone begins to form (see figure). The
new bone cannot be seen on x-rays. This stage usually lasts until 4 to 8 weeks after
the injury.
• Stage 3: Hard callus

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 o Between 4 and 8 weeks, the new bone begins to bridge the fracture. This bony bridge
can be seen on xrays. By 8 to 12 weeks after the injury, new bone has filled the
fracture.
• Stage 4: Bone remodeling
o Beginning about 8 to 1 2 weeks after the injury, the fracture site remodels itself,
correcting any deformities that may remain as a result of the injury. This final stage
of fracture healing can last up to several years.
• The rate of healing and the ability to remodel a fractured bone vary tremendously for each
person and depend on your age, your health, the kind of fracture, and the bone involved.
For example, children are able to heal and remodel their fractures much faster than adults.

Factors affecting fracture healing

• Energy transfer of the injury

• The tissue response
• Two bone ends in apposition or compressed
• Micro-movement or no movement
• Blood supply (scaphoid, talus, femoral & humeral head)
• Type of bone
• No infection
• The patient
• The method of treatment

BONE DISEASES AND NUTRITION

Introduction

• Good references for bone diseases are:

o Small Animal Surgery. Ed: Fossum TW, Mosby, St. Louis, 2007.
o Brinker, Piermattei, and Flo’s Handbook of small animal orthopedics & fracture
treatment. Fourth Ed. Saunders, Philadelphia, 2006.

Craniomandibular Osteopathy

• General
o West Highland White, Cairn and Scottish terrier predisposed.
o Hereditary
o 6-12 months of age
o etiology unknown
o reluctance to eat and chew food
• Clinical findings
o Intermittent fever
o ROM and pain on manipulation TMJ
• Radiographic findings
o Soft tissue and osseous proliferation of mandibulae and/or tympanic bullae.
o CBC, chemistry, UA
o If patient has systemic illness
• Treatment
o Nutritional support
o Analgesics
o Corticosteroids
o Relapse may occur

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 • Prognosis
o Good if patient survives initial crisis

Hypertrophic Osteodystrophy

• General
o Rapidly growing, large breed dogs
o Great Dane, Weimaraner, Boxer, etc.
o 3-8 months of age
o Males more affected than females
o Etiology unknown
 Hereditary? Breed predispositions
 Nutritional component?
 Infectious component?
• Clinical findings
o Lameness, refusal to walk
o Inappetence, lethargy
o Diarrhea may precede lameness
o Mild lameness to inability to stand
o Swollen and painful metaphyses
o Sometimes depressed, anorexic, pyrexic and recumbant
o CBC, serum chemistry and UA normal
• Radiographic findings
o Early radiographic findings
o Irregular radiolucent zone with surrounding sclerosis in metaphysis
o Later radiographic signs
o Metaphyseal periosteal proliferation
o Late radiographic signs
o Disappearance of periosteal proliferation and metaphyseal line
• Differential diagnosis
o Panosteitis
o Septic arthritis
• Treatment
o Mild/moderate HOD
o Analgesics
o Restricted activity
o Large breed growth diet
o Severe HOD
o Fluid support
o Nutritional support
• Prognosis
o Recovery within 7-10 days
o Relapses occur
o Sometimes asymmetrical growth and limb deformity
o In severe cases, euthanasia may be indicated

Panosteitis

• General
o Intermittent often shifting lameness
o Etiology unknown
o Strong breed predisposition-German shepherd, Retrievers, etc.
o Male > female

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 o 4-30 months of age
o Pectoral limb long bones more often affected than pelvic limb long bones
• Clinical findings
o Chronic intermittent lameness
o Single limb or shifting leg lameness
o Pain on deep bone palpation
o Few days to couple weeks
• Radiographic findings
o Phase I
 widening nutrient foramen
 blurring and accentuation trabecular pattern
o Phase II
 radiodense, patchy, or mottled bone in medullary canal, particularly around
nutrient foramen
o Phase III
 remodeling medullary canal
• Prognosis
o Self-limiting disease
o Large breed growth diet
o NSAIDs
o Recurrence common

THE SURGICAL APPROACH TO DONOR SITES FOR BONE GRAFTS

• Proximal Humerus – a 2 to 3 cm incision is made over the craniolateral aspect of the

greater tubercle (cranial to the acromial head of the deltoideus muscle). Subcutaneous
tissue is separated by sharp dissection to reveal the periosteal surface of the bone.
• Proximal Tibia – a 2 to 3 cm incision is made about 2 cm below the tibial plateau midway
between the tibial tubercle and the medial collateral ligament. Subcutaneous tissues and
underlying muscle (insertions of sartorius and gracillis muscles) are separated with sharp
and blunt dissection to reveal the bone.
• Iliac Crest – a 4 to 8 cm incision is made directly over the dorsal aspect of the iliac crest.
Deep fascia is incised along the entire length of the incision. The middle gluteal muscle is
sharply incised from its attachment to the dorsal aspect of the iliac crest and then is
subperiosteally elevated from the wing of the ilium to reveal the bone.
• Equipment used for harvesting cancellous bone graft material includes
o Intramedullay pin or drill bit to penetrate the cortex
o Bone curettes to scoop out cancellous bone
o Stainless steel cup to hold graft material during the collection process
o Small pair of Gelpi self-retaining retractors to maintain exposure of the donor site
throughout the collection process
o Osteotome and mallet to remove a wedge of cortical bone from the dorsal aspect of
the wing of the ilium to provide increased exposure of the underlying cancellous
bone
o Rongeurs to cut cortical bone into tiny chips which can then be used as cancellous
bone “extender”
• When the graft is to be applied to a repair site which is contaminated or infected, the
following procurement and application procedure is recommended
o Perform the fracture repair and any necessary debridement, lavage and culturing and
then cover the repair site with moist sponges
o Change gloves and use a separated set of surgical instruments to harvest the
cancellous graft.
o Close the donor site
o Apply the cancellous graft to the repair site
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 o Close the repair site

MODULE-15: MANAGEMENT OF FRACTURES IN SMALL AND LARGE ANIMALS

Learning objectives

This module deals with

• Limb and Bone splinting techniques

• External fixation
• Internal fixation

INTRODUCTION

Management of fractures in Small animals

• The primary aim of every fracture treatment is to restore the anatomical shape of the
fractured bone and full function of the traumatized osseous and associated soft tissues.
Muscle contraction and local inflammation represent an attempt by the body to immobilize
the fracture.
• In 1958 a group of Swiss orthopedic and general surgeons joined together (AO/ASIF) to
study the methods of internal fixation which were being used for human surgery. They
concluded that absolutely rigid fixation of the fragments and early mobilization of the
traumatized limb was of primary importance for successful fracture healing.
• State of the art of internal fixation techniques and implants were produced for maximal
stability of the fracture by rigid fixation, with minimal adverse bone reaction to the implant.
Emphasis was placed on treatment of the whole traumatized limb, including the fracture,
adjacent joints, and associated soft tissues, thus facilitating return of normal vascularity,
nourishment of joint cartilage through pain-free movement, prevention of fracture disease,
and early return of full limb function.

Fracture forces

• Compression
• Tension
• Bending
• Shear (transverse)
• Torsion

Loading mode

Fracture patterns

• Compression Short oblique

• Tension Transverse
• Shear Short oblique
• Bending Transverse or short oblique with butterfly fragments of compression surface
• Torsion Oblique spiral fracture
• Combined Complex fracture with communications fissures and fractures lines

External co-aptation

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 • Suitable for greenstick fractures, interdigitating transverse fractures with 50% contact
between fragments, paired bones (R&U,T&F)
• AVOID CASTING femur,humerus,scapula
• AVOID CASTING comminuted fractures, distal radial fractures, stifle joint in immature
animals
• Maintain normal limb angulation
• AMPUTATION is the price paid for poor cast techniques
• Other complications are joint laxity, joint stiffness, pressure sores, limb swelling,refracture,
delayed/non union

Common techniques

• Full limb cast

• Modified Robert Jones bandage
• chroeder Thomas splint

The check list

• Fracture type and location

• Age, size of patient
• Type and quality of bone
• Open/closed
• Single/Multiple limb
• Equipment

The plan

• Avoid using NSAID and Glucocorticoids together

• Use of prophylactic antibiotics does not compensate for poor preparation or surgical
technique-We use third generation cephalosporin or Clavulanate potentiated amoxycillin
• Use of Preemptive analgesia mitigates post operative pain

Tenets

• Always have two plans of fracture reduction unless absolutely sure

• Familiarity with anatomy and approaches(Piermattei 1993)
• Hemostasis, Irrigation, Tourniquets

PINNING, SCREW AND WIRES

Intramedullary Pinning

• Normograde(Recommended)
• Retrograde
• Use smooth trocar pointed pins
• Filling the medullary cavity at the fracture site maximizes the resistance to bending and
horizontal shear forces, however it can result in damage to the medullary blood supply.
• It is generally recommended to choose an IM pin diameter that fills approximately 60-70%
of the medullary cavity.
• An IM pinning technique in which multiple small-diameter pins are placed down the
medullary cavity rather than a single larger pin is called stack pinning

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Screws

• Cancellous screws
o Cancellous screws are used in cancellous bone tissue and have a thin core and a deep
thread. This large area of thread-bone contact in cancellous bone enhances good
holding power. One type of cancellous screw is fully threaded; the other two types
have an unthreaded portion.
o The screws are manufactured in different lengths. They are designed to be used in
cancellous bone and have less holding power in cortical bone. Removal of cancellous
screws that are not fully threaded may be difficult or lead to screw fracture due to
deposition of solid bone around the nonthread portion of the shaft.
• Cortical screws
o Cortical screws are designed for use where cortical bone predominates. The screw
thread is not as steeply pitched as the cancellous screw. Cortical screws are fully
threaded.

Wire

• In orthopedic surgery different types of wire are used. They include the rigid Kirschner wire,
the flexible orthopedic wire, and suture wire.
• Orthopedic wire
o Orthopedic wire is monofilament, soft, and flexible and may be used with the wire-
tightener or with the flat-nosed pliers. It is primarily used as cerclage wire, or tension
band wire. To avoid loosening, the wire should be fixed perpendicular to the long axis
of the bone and the knot must be twisted down snugly. Cerclage Slipping on wedge
shaped bones can be avoided by using hemicerclage wire.
• Kirschner wire
o Single-pointed Kirschner wires 0.6 – 1.6 mm in diameter are in the Small Animal
Set. They are available up to 3 mm in diameter and also double – pointed. Kirschner
wires are used for temporary fixation of fragments, tension band osteosynthesis,
intramedullary fixation in small bones, certain epiphyseal fractures in young animals
etc. Kirschner wires should be inserted with a hand chuck or low-speed drill.
• Tension Band wiring
o Tension band wiring is an engineering principle in which tensile or distractive forces
are converted into compressive forces at the fracture site. Tension band wiring is a
useful technique for stabilizing bone fragments that are under tension in one
direction due to the pull of muscles, tendons, or ligaments, such as the olecranon,
greater trochanter, and malleoli.

AO/ASIF TECHNIQUE

Aim of the AO / ASIF technique

• The aim of the AO/ASIF techniques is a rapid return to full function by the portion of the
skeleton involved. This is achieved by
o anatomical reduction of the fracture fragments, especially articular surfaces in joint
fractures
o preserving the blood supply to bone fragments and soft tissue by delicate atraumatic
surgery
o stable internal fixation, satisfying the biomechanical requirements and
o early active pain-free movement full weight – bearing of the traumatized limb,
avoiding “fracture disease”.

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Principles of the AO/ASIF Technique

• The basis of rigid fixation of fractures must fulfill at least one of the two basic biomechanical
principles
o interfragmentary compression and
o rigid bone- splinting. Only internal fixation carried out according to these principles
will permit healing without callus formation and an early use of the limb. The two
principles have their own indications and contraindications but may be combined
under special circumstances.
• Interfragmentary Compression
o If two fragments are pressed together, the friction that develops between them will
be increased and the forces that cause micromovement neutralized. Weight – bearing
and muscle tension further compress the fracture gap. With good vascularization,
primary bone healing will occur. Interfragmentary compression is achieved by
implants brought under tension (screws, plates, or wires). Ideally, the entire fracture
surface should be equally compressed.
o Interfragmentary compression is maintained by static and dynamic forces. In the
static state, the pressure is maintained by the elasticity of the implants that have
been brought under tension. Technical components used for static compression are
the lag screw and the compression plate. In dynamic compression the
interfragmentary pressure is produced by muscular forces and by weight-bearing,
and maintained by the elasticity of the implant (plate, screw, wire).
• Bone - Splinting
o Bones may be splinted by a rigid metallic implant fixed directly to the fragments that
transmits all the forces from one fragment to another. However, this type of fixation
does not always eliminate micromovement between the fragments to the same extent
as does interfragmentary compression. The aim is to decrease the amount of
movement as much as possible by means of the rigid implants. Consequently, some
fibrocartilagenous and bony callus formation at the fracture site may be seen on the
radiographs. Bone-splinting is accomplished by means of intramedullary pins,
buttress plate fixation or rigid external skeletal fixation.
o Combination of Interfragmentary Compression and Bone-Splinting
o In oblique or butterfly shaft fractures compression fixation by lag screws alone is not
sufficient in weight-bearing long bones. Consequently, the lag screw fixation must be
protected by plates. This additional means of internal bone splinting is called
neutralization plating.
• Adaptation Osteosynthesis
o In adaptation osteosynthesis, fragments are fixed in their normal anatomical
position by weak implants. These techniques will only withstand very small forces. In
very young animals compression of the physis is contraindicated, as this may cause
growth disturbances. In these cases Kirschner wires are used to immobilize the
fragments after correct reduction. Fixation of some flat bone fractures, such as the
scapular body or skull, where there is little interfragmentary movement, may be
brought about by adaptation osteosynthesis.
o Adaptation osteosynthesis is contraindicated in all slow-healing fractures where
bending and rotational forces produce high shearing forces during body movement
o Common implant system used to repair long bone fractures as Internal fixation
 Intramedullary (IMP) pins
 Cerclage/hemicerclage
 Kirschner wires
 Plate and screws
 Interlocking nails

Fracture forces Vs Implant systems

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 • Fixation device tension compression shear bending torsion
o Single IM pin - - + + -
o Multiple IM pins - - - + +
o Bone plate + + + + -
o Plate - rod + + + + +
o ILN + + + + +

EXTERNAL FRACTURE FIXATION

• The ESF integrates the use of a transfixation pin with an externally placed fixation frame
• It is used primarily to promote biologic osteosynthesis thus decreasing healing times and
complications
• Ex fix and combination with IMP is an appropriate method for management of
comminuted and open infected shaft fractures
• Predrilling with a battery powered drill is recommended.
• Insertion of transfixation pins using hand chuck was found suitable.
• The diameter of the pin should be 20-30% of bone diameter
• Safe corridors should be used for pin insertion.
• Place pins at divergent angle 30 degree to 40 degree
• About 2cm acrylic is suitable for a medium size fixator
• Ex fix is more biologic from healing less invasive more difficult to apply requires intensive
PO care, easy to remove
• The advantages of the ESF system were
o Closed or minimally invasive open application
o Fracture alignment can be adjusted during or after surgery
o Fixation rigidity can be changed to suit the needs of the injured tissue during healing
process
o Fixation can be removed without performing major surgery
o Relatively affordable with many reusable components
o Indicated for highly comminuted diaphyseal fractures, open infected fractures,
mandibular fractures, osteotomy and transarticular immobilization

AAA Score for fracture evaluation

• Activity (bone healing)

• Alignment (apposition of fragments)
• Appliance (apparatus or implant stability)

DYNAMIC COMPRESSION PLATE

• The DCP is a special implant development by the AO group for compression and
stabilization of a fracture. Using this plate, compression is achieved by tightening the
screws inserted in a specially designed hole in the plate. There are three sizes of DCP in the
Small Animal Set (2.7mm, 3.5mm, and 4.5mm). The plates are named according to the size
of cortical screw used to fix the plate to the bone. Each plate size requires a special set of
drill guides.

Mode of action

• The specially designed plate hole is characteristic of this plate and functions according to
principles of an inclined plane. If a screw is inserted on each side of the fracture gap (the
unperforated part of the plate is over the gap), the plate and bone move longitudinally
relative to one another. The plate comes under tension and the bone under compression).
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 Enough screws should be used so that six cortices on each side of the fracture are engaged
by screw.
• Plate classification according to Function
Each of the plate types may fulfill one or more different functions, depending on the
fracture type and location.
• Compression Plate - Static compression (a transverse or short oblique fracture)
• Neutralization plate -Splinting of a lag screw fixation (Comminuted fracture anatomically
reconstructed)
• Buttress plate - Splinting or bridging a fracture area with buttress of the main fragments

Plate-Rod construct

• The combination of a bone plate and an IM pin that occupies approximately 50% of the
marrow cavity. Generally plate rod construct are used when a plate must buttress a section
of bone because anatomic reconstruction could not be performed.
• Combination an IM pin with a bone plate reduces the bending strain in the plate by twofold.
• The IM pin increase the fatigue life of the plate by ten times.

Interlocking nail (ILN)

• An ILN is a large diameter pin 6 or 8 mm in diameter with holes to accept screw. The nail is
placed into the medullary cavity of a fracture bone and locked to the bone by inserting
screws though the holes in the IN and corresponding holes drilled into the cis-cortices and
trans-cortices of the bone using a specialized designed jig.
• An IN is placed along the neutral axis of the bone similar to an IM pin instead of
eccentrically located similar to a bone plate.
• An IN provides superior bending stiffness resistance to torsional forces, axial stability and
lower implant failure rates than IM pins or bone plates.

Complications of internal fixation

• Nonunion
• Malunion
• Delayed union
• Acute or chronic osteomyelitis
• Fracture disease.

Removal of implants

• Prior to removal of an implant used for fixation of a fracture, the following factors should be
considered in arriving at the decision that clinical union is present:
o Age of patient
o Location and type of fracture
o History of fracture treatment – single or multiple surgeries, interrupted or
inadequate fixation, impaired circulation, inadequate reduction, infection.
o Lapse of time since reduction and fixation – has there been sufficient time for
healing to occur
o Type of fixation – optimal or less than optimal stabilization
o Radiographic examination (at least two views) – clinical union.

PLASTER OF PARIS CAST IN DOGS AND CALVES

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 • Plaster of Paris can shaped be molded with ease and should usually be chosen for
immobilizing severely displaced or unstable fractures that require a closer fit when
coaptation is indicated.
• Plaster of Paris is made of calcium sulfate crystals that have been reduced to powder and
subjected to intense heat to expel the water. The resulting chalky white powder is then
incorporated into gauze bandages. When water is added to the plaster, a crystallization
process occurs, and the material hardens in an exothermic reaction, the time from which
water is added to the plaster bandage until the material becomes hard is called its setting
time. Plaster of Paris sets in 3 to 8 minutes, depending on weather it is fast or extra fast
setting, the temperature of the water used, and the amount of water left in a roll after
immersion. As the cast dries, the interlocking of the calcium sulfate crystals gives the plaster
strength. Further molding after a plaster cast has begun to set can prevent this interlocking
of the crystals and may weaken the cast.
• After the cast sets, the excess water must evaporate from the surface before the cast attains
maximal strength. This period while the cast is still wet varies from 8 to 48 hours,
depending on how large and thick a cast is, the type of plaster used, humidity and air
temperature. Excessive weight bearing during drying of the cast should be avoided. A
plaster cast is heavy at first, but it becomes lighter as the water in the Plaster evaporates.

Application technique

• No special equipment is required for preparation and application of a plaster cast, and a
standard cast cutter can be irritation to the hands/ the patient and casting area in the
hospital should be protected from dripping plaster by the liberal use of newspaper of cloth.
• Preparation of plaster bandages involves immersing them in tepid water (70 - 75°C) for a
few seconds until the bubbling from the roll has stopped; the plaster rolls then are squeezed
to remove excess water. A plaster bandage should be unrolled on the leg, as it is applied, in
an encircling manner with overlapping of half of the roll’s width; it should never be
stretched or tightened around the limb. It should be applied in a smooth, conforming
manner so no thick or thin spots result. Tucks can be made in the rolls to change directions
or to contour the plaster smoothly. Molding the cast by rubbing each section with wet hands
before the plaster is set is essential for proper lamination, to produce a smooth surface, and
for confirming the material to the proper configuration of the affected limb. During
application, the cast should be supported by the palms of the hands and not indented with
the fingers, because the “dimples” that result could produce pressure points on the interior,
which can lead to skin excoriation.
• Once the cast is dry, and rough edges should be covered with adhesive tape. The cast should
not be washed, although a damp cloth can be used to remove excessive dirt of the residual
moisture is wiped away afterward. Immersion of the plaster cast can cause deterioration of
the plaster, resulting in skin irritation and maceration.

Plaster of Paris in calves

• Plaster of Paris casting material is both economical and adequate for younger animals
provided that housing and maintenance are consistent with good cast care. Even older,
heavier cattle may have plaster included in the external fixation device if other materials are
incorporated into the cast to overcome the shortcomings of excess weight and limited final
strength inherent in plaster.
• The use of aluminium walking bar or combinations of plaster and fiberglass are two
methods of overcoming such limitations.

PINS AND WIRES

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Orthopedic pins

• Orthopedic pins are used for internal fixation as a primary method of stabilization, but are
used more frequently in combination with wires, bone plating, or external skeletal fixation.
• Steinman and kirschner pins are the 2 types of the pins available. The use of multiple pins,
or pins in combination with wires, or pins locked with screws such as the interlocking nail,
increases their resistance to fracture forces.
• Steinman pins, often referred to as intramedullary (IM) pins, are available in many
diameters, lengths and point designs. The larger the IM pin diameter, which ranges from
1/16 to ¼ inch, the greater its mechanical stiffness.
• Sharp tips available include a trocar point with 3 edges useful in cutting cancellous bone.
Threaded ends are available, but have not been shown to increase the stability of the
fixation.
• Pins placed in the medullary canal neutralize bending forces in all directions, but alone do
not resist compressive, torsional, or shearing forces. To decrease bending potential, IM pins
should engage the proximal and distal cortical surfaces without penetrating the joint
surface. Pins can be inserted in a normograde or retrograde fashion and should fill atleast
70% of the diameter of the bone’s medullary cavity at its diaphysis.
• Intramedullary pins minimally traumatic as they interfere with endosteal not periosteal
callus formation; however, care must be taken not to damage the surrounding soft tissues
during placement, especially during retrograde insertion.
• Stacking multiple smaller pins can minimally increase resistance to rotational forces.
Because IM pins alone do not resist forces in or around alignment with the long bone axis,
they are not a recommended method of solitary repair. They are frequently used in
combination with other fixations or to facilitate temporary reduction of a fracture while a
more stable fixation is applied.
• IM pins are best used for diaphyseal fractures of the humerus, femur, and tibia. The bowed
shape and small medullary cavity of the radius make IM pin placement difficult.
Normograde pin placement difficult. Normograde pin placement is recommended in the
femur, with the tip being inserted in the craniolateral position of the trochanteric fossa
extending as far distally as possible. This method allows the pin to be seated the greatest
distance from the sciatic nerve because of the natural caudal bowing of the canine femur;
the pin usually ends in the proximal metaphyseal region. In the cat, however ,the pin ends
more distally than in the dog in the humerus, either normograde or retrograde pin insertion
is used in an attempt to place the pin craniolateral in the greater tubercle, and extending
into the medial humerus condyle. Normograde pin insertion is recommended in the tibia to
protect the stifle joint.
• The pin is inserted from the medial aspect at the base of the tibial tuberosity. If retrograde
pin placement is used, it is necessary to direct the pin craniomedially to prevent damaging
the cranial crucial ligament.
• Kirschner pins are smaller than Steinman pins and are used to stabilize smaller bone
fragments or cerclage wires. They also are used to temporarily hold fracture reduction with
minimal damage to surrounding tissues before definitive stabilization.
• As with Steinman pins, they only resist bending forces, but multiple k- wires can be placed
parallel to each other to increase resistance forces, as is used in femoral capital physeal
fixations.
• Cross pinning is the use of multiple smaller divergent Steinman pins or k-wires to stabilize
fractures are stabilized using this method. Exciting the pins through the cortical bone
increases the stability. Dynamic cross pins (rush pins) do not penetrate the opposite cortex,
but bend along the endosteal surface of the bone providing stability through a springing
effect.
• Complications associated with the use of pins are secondary to instability or inappropriate
placement. Damage to soft tissues can occur if pins protrude excessively from the bone or
migrate over time. Temporary or permanent damage to the sciatic nerve can occur from
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 incorrect placement or migration of a femoral IM pin. Delayed healing or nonunion can
occur from a lack of rigid fixation.

Orthopedic wires

• Orthopedic wire is used to maintain bone fragment apposition and to provide

interfragmentary compression. Orthopedic wires rarely neutralize forces well enough to be
used alone but are frequently used as an auxiliary method of fixation. Wire is available in
multiple sizes ; the most commonly used are 16,18,20,22 gauges. Strength is directly
proportional to the diameter of an orthopedic wire ; however ,the weakest portion is where
the wire is secured to itself .there are 4 methods of wire usage; tension band, cerclage,
hemicerclage, and interfragmentary wires.
• A tension band wire resists the pull on a fragment by a tendon or ligament, such as the
gluteal muscles on the greater trochanter, its use is frequently supplemented by k- wires to
assist in resisting bending and rotational forces.
• The tension band wire is placed in a figure –of- eight fashions around the ends of the pins in
a bone fragment under tension through a bone tunnel created in the main bone segment.
This “ banding” of the tensile forces by the wire converts the tension into interfragmentary
compressive forces ,thereby enhancing primary bone healing .the wire end is then tightly
twisted, thereby removing slack and providing increased compression. This is
recommended in areas of extreme tensile forces such as those associated with the
calcaneous.
• Tightening of the figure –of eight is performed by creating a loop in the continuous side and
the loop and ends are simultaneously tightened.
• A cerclage with encircles the entire bone to hold long oblique diaphyseal fractures or
fissures under compression .anatomic reconstruction of the entire circumference of the
bone is required, or the cerclage wire will collapse the bone.
• Cerclage wires are best used when the length of oblique fracture is greater than 2.5 times
the diameter of the diaphysis of the bone. More than 1 wire is used, and they are spaced
approximately 1 bone diameter from each other and a half bone diameter from the fracture
end. If the obliquity of the fracture is less then desired, an interfragmentary K-wire may be
used to stabilize the cerclage wire and decrease shearing forces.
• A hemicerclage wire is placed through the bone tunnels in 1 cortex on either side of a
fracture .these wires resist rotation in a single direction and their strength is dependent on
the bone itself. Hemicerclage wires are weaker than full cerclage wires are weaker than full
cerclage wires and are primarily used for temporary fracture reduction to allow a more
durable fixation to be applied .they should to be applied .they should not be used as the
single method of fixation for long bone fractures.
• Interfragmentary wires are placed through bone tunnels , in both cortices on either side of a
fracture, although stronger than hemicerclage wores, they are again ,rarely used for
stabilization of long bone fractures, but they may be used for simple mandibular fractures.
Interfragmentary wires are recommended to temporarily stabilize a fracture before
definitive fixation.
• For orthopedic wires to be functional, it is essential they be placed tightly .the method of
securing them greatly affects their tightness. Method for securing orthopedic wire include a
twist knot and a single and double loop knots a twist knot is created by twisting the2 ends of
the wire while pulling on them. This assures that the 2 wires twist on each other, becoming
tight around bone. The remaining knot should be cut no shorter than 1 full twist.
• Excessive twisting can damage or break the wire, and any manipulation of the tie will loosen
it. For tension bands, the knot can be folded over, as wire tightness is not as critical.
Cerclage wires secured with a single loop allow increased tension, but the amount of load
necessary to cause loosening is similar to the twist knot.
• A single loop cerclage wire is made by passing a single wire back through a loop created in
one end. It is then placed under tension with a tightner and folded back over itself. Single
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 loop cerclage wires can be made from orthopedic wire or are available commercially
cerclage wires secured with a double loop allow even greater loop tension and load
resistance than either the twist knot or the single loop.
• Double loop cerclage wire is made by folding a wire in half, and passing both ends around
the bone and back through he loop created at he fold. They are then tightened as single loop
but with both ends simultaneously. Each end is then folded back over itself.
• The most common complications of orthopedic wiring are wire breakage and loosening.
because wires provide minimal resistance to the forces acting on the fracture, they are rarely
used as the sole method of fixation. when they loosen, orthopedic wires may interfere with
bone healing, or they may migrate ,causing significant morbitity and requiring removal.
Stable cerclage wire, however,should not interfere with the blood supply to the fracture
callus .

EXTERNAL SKELETAL FIXATORS (ESF) FOR FRACTURE MANAGEMENT IN

DOGS

• The ESF system offers a variety of advantages to the orthopedist when compared to other
orthopedic fixation systems:
o Closed or minimally invasive open application methods are possible.
o Fracture alignment can be adjusted during and after surgery.
o Fixation rigidity can be changed to suit the physiologic needs of the injured tissues
during the healing process.
o Fixation can be removed without performing major surgery.
o Relatively affordable devices - often with many reusable components.
o Just as each device within the ESF system shares certain advantages, there are
several disadvantages that are inherent to the ESF system including:
o Fixation pins penetrate soft tissues between the skin and the bone and may impair
function of the neurovascular bundles and musculotendinous units.
o Soft tissue corridors for the fixation pins (pin tracts) represent an avenue for entry of
contaminating bacteria.
o Eccentric placement of the ESF connecting bar (far from the central axis of the bony
column) puts ESF devices at a mechanical disadvantages when compared to systems
where bridging elements are placed in (intramedullary pins, interlocking nails) or
near (plate and screw system) the central axis.
o Postoperative care is more demanding and must address issues such as pin tract
hygiene and the potential for components of the external frame to injure the patient
or the owner.
o The learning curve is high due to the many decision - making variables unique to the
ESF system.
• An external fixator has three basic elements
o Fasteners - percutaneous fixation pins, wires, or screws which transfix bone
segments.
o Connectors - connecting rods or acrylic columns which unite the pins and the pin -
grippers.
o Linkage Devices - pin - gripping clamps or other devices which attach the fasteners to
the connectors.
• An external fixation frame is formed by the connectors and the linkage devices
o A half - pin penetrates the near cutaneous surface and both the near and far cortices
of the bone.
o A full - pin or "through - and - through" pin enters the near cutaneous surface,
transfixes the bone, and exits through the far cutaneous surface of the limb.
o A unilateral frame interconnects two or more half - pins and has a connector on one
side of the limb.

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 o A bilateral frame interconnects two or more full pins and has two connectors, one on
the medial side of the limb and a second on the lateral side.

Classification scheme

• Type I fixators are always unilateral, but can be either uniplanar or biplanar.
• A type I - a fixator is a unilateral / uniplanar frame.
• A type I - b fixator is a unilateral / biplanar montage. An example of this would be the
placement of a Type I - a fixator on the craniomedial aspect of the radius, placement of a
second Type I - a fixator on the craniolateral aspect of the radius, and interconnection of
these with articulations or diagonals.
• Type II fixators are always bilateral / uniplanar frames. A maximal Type II frame has full -
pins in all positions, whereas a minimal Type II frame has one full - pin proximally, one full
- pin distally, and the remaining positions are filled in with half - pins.
• Type III fixators are always a bilateral / biplanar montage

Types

• Kirschner-Ehmer (K-E) splint

o Connecting rods and single clamps are the essential frame components of the K-E
splint. K-E components are available in three sizes, small, medium, and large.
o The K-E single clamp has a small pin-gripping channel in the bolt portion of the
clamp, and a larger rod-gripping channel at one end of the U-shaped body of the
clamp. The primary use of this component is to attach fixation pins to a connecting
rod. It can also be used in several different ways for making articulations in biplanar
fixators, and for connecting an intramedullary pin to an external fixation frame.
• IMEX-SK External Fixator
o The connecting rod diameters utilized by the SK fixator are significantly larger than
those used by the other two clamp and rod ESF devices (K-E and securos).
o Connecting rods are made from carbon fiber composite, titanium, or aluminum,
instead of stainless steel. These materials enable increased connecting rod diameter
and strength without excess weight.
• The Acrylic and Pin External Fixator (APEF)
o Acrylic frame fixators are devices in which the pin-gripping clamps and connecting
rods have been replaced with acrylic columns. Acrylic frame fixators use a methyl
methacrylate product to form the fixation frame

METHODS OF EXTERNAL FIXATOR PIN PLACEMENT

Pin selection

• Fixator pin designs include nonthreaded (smooth) pins and threaded pins. Threaded pins
have "cut threads" (negative-thread profile) or "enhanced-threads" (Positive-thread profile).
Pins are end threaded or centrally-threaded and have a cortical (fine) or cancellous (coarse)
thread design.
• Cancellous positive profile pins are routinely used in the metaphyses of the proximal tibia,
proximal humerus and distal femur. Cortical positive profile pins are used in the distal
humerus, radius, proximal femur and distal tibia. Smooth pins can be used in the middle
clamp positions for technical ease in placement and retrieval, and to stimulate bone loading
since these pins may loosen earlier during healing compared to threaded pins. Likewise,
placement of full-or half-pins in the middle position is variable and depends on the
surgeon's preference and the patient's fracture assessment score (PFAS).

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 • Pin size selection (small, medium or large sets) is based on the size of the bone so that pin
diameter does not exceed 20% of the bone diameter. In general, the small KE is used
patients weighing between 5 to 12 kgs, the medium set is used for animals weighing 12 kgs
to 30 kgs and the largest set is used in dogs greater than 30 kgs. The small SK can be used in
patients weighing between 5and 20 kgs, while the large SK is used for dogs weighing more
than 30 kgs

Pin placement through soft tissues

• Knowledge of limb cross-sectional anatomy helps avoid musculotendinous or neurovascular

injury due to impalement or irritation. In addition, soft tissue tension (including skin) must
be relieved around the pin to prevent premature loosening or tissue necrosis/sepsis.
Intermuscular soft tissue tunnels for pin placement must be selected away from critical
gliding muscle masses (biceps brachii, quadriceps femoris, antebrachial extensors and
flexors etc
• Soft tissue tunnels are made by creating 1 cm skin incisions over the area of proposed pin
placement. A hemostat is used to bluntly dissect down to bone thereby creating a tissue
tunnel that will relieve any tension on the pin. Once contacting bone, the hemostat is
opened and used to retract tissues so the bone can be visualized or palpated. The soft tissues
should be protected by a drill sleeve or hemostat when placing the pins or drill bits. Full-
pins are inserted until the skin is tented by the point. A skin incision is made over the point
for the pin to exit this site and attach to the contralateral pin clamp. A haemostat or # 11
blade is used to create a soft tissue tunnel around the pin on its exit side.

Pin insertion into bone

• Direct insertion of ESF pins into bone with high-speed drills is not recommended.
Currently, preferred techniques are placement of smooth pins with a battery powered slow-
speed drill (Makita) and placement of threaded pins with a hand chuck after high-speed
predrilling (Bausch), the bone tunnel with a smaller (0.1mm less than core) diameter drill
bit or Kirschner wire. Another option for threaded pin placement is predrilling and final pin
placement with the slow-speed Makita drill. Direct hand chuck drilling with smooth ESF
pins can be performed on small or immature (soft) bones. Predrilling is routinely performed
prior to placement of positive profile threaded pins to prevent iatrogenic fractures. Direct
insertion of pins with a hand chuck causes operator fatigue and leads to wobble of the hand
chuck. This creates a pin tract larger than the pin and subsequent premature pin loosening,
discomfort and poor limb function. Placement of pins with a high-speed drill generates
excessive frictional heat causing necrosis of bone surrounding the pin. This can lead to
increased patient morbidity and ESF failure.
• The safest pin insertion technique is to predrill with a twisted-drill bit to create a pin tract in
the bone. The bone tunnel for the pin should be in the area of greatest cross-sectional
diameter of the bone. For middle position pins, one must drill through the pin clamp. The
size of the drill bit should be 1.0 to 1.5 mm smaller than the threaded diameter of the
positive profile ESF pin. After the bone tunnels have been predrilled, a hand chuck is used
to place the pin into the bone.
• Post surgical radiographs should always be evaluated to assess proper placement of the
fixation pins in bone. Half-pins should be placed so that the entire trochar point of the pin
exists the far cortex of the bone to maximize stability of the pin-bone bond. Because
retraction of the pins that have been inserted too deeply causes premature pin loosening,
advance the pin a little deeper after reviewing postoperative radiographs rather than
retracting a pin inserted too far.
• Angling of pins to increase fracture stability may not be necessary with the use of threaded
pins. Angling of smooth pins 60° to 70° to the long axis of the bone may increase pin - bone

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 contact; however, placement may be more critically affected by location of fracture,
overlying soft tissue injuries and spacing for pin clamps along the connecting bar.

Pin insertion through pin clamps

• Insertion of smooth and negative thread profile pins is simple because passing these pins
through the KE pin gripper is relatively easy. Inserting positive - profile threaded pins can
be difficult because the "enhanced thread" does not fit through the KE pin clamp.
• Positive - profile threaded pins dramatically reduce patient morbidity; therefore, at least
one such pin should be incorporated on each side of the fracture in all but the most basic
ESP applications. The simplest positions in which to use raised threaded pins are the most
proximal and distal pin positions because these are the first two pins placed and do not
requires placement through a pin clamp.
• When placing "enhanced - thread" pins into the middle KE clamps, the non threaded end of
the pin must first be backed through the clamp and then advanced into the soft tissue
tunnel and bone. This backing maneuver usually requires the connecting bar be positioned
about four fingers width from the skin. Once all the pins are positioned, the connecting bar
is slid down the pins into the recommended one finger's breadth from the skin.

"Open" vs "Closed" vs "Mini" approaches

• Open approaches may lead to wound contamination and disruption of blood supply to the
injured tissues, including bone. Therefore, open approaches are indicated when the
mechanical advantage of accurate fracture reduction (and stabilization with cerclage wire
and pins) outweighs the biological disadvantages.
• Closed repair preserves the biological environment of the hard and soft tissues: functional
rather than anatomic reduction is often obtained. Cancellous bone grafting to enhance
fracture healing whenever an open approach is performed is recommended.
• A compromise between open and closed approaches is the "semi - open" or "mini"
approach:
o A 2 to 3 cm keyhole incision is used to attain accurate fracture reduction when this
cannot be accomplished in a closed fashion.
o The surgical incision is carried through the skin and subcutaneous tissues, but the
periosteal and muscular tissues surrounding the fracture are not disrupted.
o This approach is useful in obtaining approximate reduction, restoration of limb
length, and access for cancellous grafting

Removal of external skeletal fixators

• Radiography and removal of ESF devices can be performed on an outpatient basis after
deeply sedating the animal.
• Initially, all pin clamps are loosened and each pin is felt by hand. All palpably loose pins are
removed. Full - pins are cut off on the far side and cleaned with antiseptic solution prior to
retraction through soft tissues and bone. Half - pins require no special preparation because
no contaminated portions of the pin are pulled through the patient's tissues.
• After the loose pins are removed, the remaining firmly attached pins are manipulated as
handles to test the fracture for clinical union. If clinical and radiographic evidence of union
has been achieved, the remaining pins are removed.
• Threaded pins must be unscrewed. There is often a small amount of bleeding from the pin
tract after pin removal; this is easily controlled with temporary gauze bandage pressure or a
light bandage wrap.

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 • Removal of a fixator is based on clinical and radiographic evidence of healing and directly
related to the patient's fracture assessment score. In general, radiographic examinations are
performed at 3 - to 6 - week intervals during the convalescent period.

DYNAMIC COMPRESSION PLATE APPLICATION IN FRACTURE MANAGEMENT

• The primary objective of fracture management is to restore the anatomical shape of the
fractured bone and return the injured limb to early and full function. Many conservative
procedures result in the development of Fracture disease which is unfortunate sequelae to
failed fracture healing and is characterized by osteoporosis, joint stiffness, tissue adhesions
and muscle atrophy.
• The development of AO/ASIF principles of fracture management revolutionized the
treatment of fractures in Humans and subsequently these techniques were adopted
successfully in Veterinary practice. The principles emphasize rigid immobilization of
fracture fragments and early pain free mobility was of primary importance in fracture
healing.
• One of the best methods of obtaining a stable fixation is by bringing about axial
compression using the Dynamic compression plate. A properly applied bone plate
counteracts bending, shear and rotational forces and brings about rigid stability. The
Dynamic compression plate arguably represents the most outstanding innovations in
bone plates in the latter part of this century.
• Compression has no osteopgenic properties. It increase fracture stability thought frictional
impact loading and narrowing the gap between fragments providing a optimum condition
for direct bone union. Healing takes place either by contact healing (gap<1 mm) wherein the
fractured bone heals via haversian system to haversian system or by contact healing
(gap>1mm) wherein the healing takes place by formation and reorganization of lamellar
bone.

Principle of the dynamic compression plate (DCP)

• The dynamic compression plate is a special implant developed by the AO/ASIF group for
compression and stabilization of the fracture. Compression is achieved through eccentric
placement of screws in the oval hole of the plate. Because of the design of the screw holes,
the plate moves as the screw head is seated. The plate and the bone move longitudinally to
each other, the plate comes under tension and the bone under compression. The primary
objective is to ensure fracture healing by negating micro movement at the fracture site.
• Application of the plate to the tension surface of the bone will allow the tension band effect
to apply and will result in axial compression of the bone under the plate. Thus is called
dynamic compression and is the best technique for repairing transverse or short oblique
fractures.
• Axial compression of comminuted fractures is not desirable. Fracture fragments may be
reconstructed using the lag screws which bring about static compression and the plate is
used to protect the repaired fracture from loading when weight bearing occurs. This
represents Neutralization technique. Comminuted fractures may be reconstructed with
Buttress plating.
• Compression, Neutralization and Buttressing are descriptions of plate applications rather
than design. The DCP is used for the techniques.

Instrumentation

Basic Instruments

• Basic surgical set

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 • Hohmann retractors
• Bone and plate holding forceps
• Pointed reduction forceps
• Serrated reduction forceps
• Bone cutter
• Rongeurs
• Gelpis retractors
• Volkmann’s rake
• Bending pliers and bending press
• Oscillating saw
• Pneumatic bone drill

Special AO Instruments

• Hexagonal screw driver 2mm,2.7mm,3.5mm.4.5mm

• T-Handle
• Cortical tap 2mm,2.7mm,3.5mm.4.5mm
• Cancellous tap
o 3.5 mm 2mm (thread hole) 3.5mm(gliding hole)
o 4 mm 2mm (thread hole) 4mm (gliding hole)
o 6.5 mm 3.2mm (thread hole) 6.5mm(gliding hole)
• Drill bits
o For 2.7mm DCP 2mm (thread hole) 2.7mm(gliding hole)
o For 3.5 mm DCP 2.5mm (thread hole) 3.5mm(gliding hole)
o For 4.5 mm DCP 3.2.mm (thread hole) 4.5mm(gliding hole)
• Tap sleeves(3.5mm,45mm) and drill sleeves (2/2.7mm,2.7mm/3.5mm,3.2mm/4.5mm)of
appropriate sizes
• Eccentric and neutral drill guide(2/2.7mm,2.7mm/3.5mm,3.2mm/4.5mm)
• Counter sink (2mm,3.5mm.4.5mm)
• Depth gauge

Implants

• Dynamic compression plate 2mm,2.7mm,3.5mm,4.5mm

• Fully threaded cortical screws 2mm,2.7mm,3.5mm,4.5mm of various length
• Cancellous screws Full thread/partly threaded 3.5mm,4mm,6.5mm

Indications

• Transverse or short oblique fractures.

• Comminuted fractures
• Fracture with a butterfly fragment

Approaches for plate application

• Mandible : Lateral aspect

• Scapula : Craniolateral
• Humerus : Craniolateral
• Radius : Craniomedial
• Ilium : Lateral aspect
• Femur : Craniolateral
• Tibia : Medial

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Post operative management

• Place operated limb in Modified Robert jones bandage to prevent post operative swelling
• Encourage early use of operated limb to prevent muscle wasting. Avoid excess activity.
Client education is a must. The owner must be madder aware that the animal would begin
using the limb long before fracture is healed
• Periodic radiographic study to assess healing of fractures is essential
• Post operative antibiotic coverage needs to be given to prevent osteomyelitis

Indications for removal of bone plates

• Accomplishment of fracture healing

o Non Function
o Corrosion
o Thermal conduction
o Irritation
o Infection
o Interference with growth in young animals
o Stress protection

Suggested time for removal of bone plates

• Age time
o Up to 3months One month
o 3-6 months 2-3 months
o 6-10 months 3-5 months
o Over 10 months 5-14 months
• Post operative care following removal
o Modified Robert jones bandage over affected area for 1-2 days to help prevent
formation of haematoma/seroma
o Restriction of activity for 3-6 weeks
o Supportive measures if radiographic healing seems inadequate
• Possible complications following removal
o Formation of Haematoma/Seroma
o Refracture following removal
o Little or no callus formation at the time of plate removal
o Lack of bone substance in the healed fracture area

COMPLICATION OF FRACTURE HEALING

• Fracture healing complications are not uncommon problems in both small and large
animals for fracture management. The most common complications of fracture healing are
delayed
o Union
o Nonunion
o Malunion and osteomyelitis.

COMPLICATION OF FRACTURE HEALING - DELAYED UNION

• In normal fractures, a certain amount of times is required before bone healing. This normal
time may vary according to age, species, breed, bone involved, level of the fracture and
associated soft tissue injury. So, delayed union refers to a fracture that has not healed in the
usual time for that particular fracture. It occurs in any fractures.
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 Average times to clinical union

Age of animal ESF ( typeI and II), IMP Plate fixation, ESF( type III)
< 3 month 2-3 wk 4 wk
3-6 month 4-6 wk 6-12 wk
6-12 month 5-8 wk 12-16 wk
>1 yr 7-12 wk 16-30 wk

Causes

• The most common causes of delayed union are local factors

o Inadequate or interrupted fixation of the fracture fragments
o Inadequate blood supply
o Malalignment of fracture fragments
o Interposition of soft tissues in the fracture site
o Bone loss
o Infection
• Some systemic factors also involve for delayed union like
o Heavy steroid doses
o The use of nonsteroidal anti-inflammatory drugs
o Starvation
o Advanced age
o Other metabolic disease

Diagnosis

• History-more time than normal healing time

• Radiographic examination
• The fracture line remains evident and characterized by feathery or wooly appearance and
there is no sclerosis of the bone ends
• Evidence of osteogenic activity (callus) is visible but is minimal and may not bridge the
fracture line.
• Uneven fracture surface
• Open medullary cavity

Treatment

• Line of treatment of delayed union is as follows

o Treatment is a prolonged period of appropriate immobilization
o If immobilization is not being used, it should be instituted
o If the method of fixation appears adequate, activity should be restricted and
radiographs should be obtained after 4 weeks

Conclusion

• With adequate time and immobilization, most fractures unite. When immobilization is
inadequate and continues over a prolonged period, a delayed union becomes a nonunion.

COMPLICATION OF FRACTURE HEALING - NONUNION

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 • Nonunion refers to a fracture which is characterized by ceased or stopped of all evidence of
osteogenic activity at the fracture site, movement is present at the fracture site and union is
no longer possible without surgical intervention. Nonunion is common in diaphyseal
fracture management in dogs and cats. Highest incidence of nonunion is found in radial
bone and then in tibial bone.

Radiographic fractures of nonunion

• Gap between fracture ends

• Closed medullar cavity
• Smooth fracture surfaces
• Sclerosis
• +/- hypertrophy or atrophy of bone ends

Classification of nonunion

• Nonunion is broadly classified into two groups: These two groups are further subdivided
according to their cause and/ or radiographic appearance.
o Those that are biologically active ( or viable)
o Those that are biologically inactive ( or nonviable)
• Biologically active or viable nonunion
o This usually results from instability at the fracture site and characterized by a
variable degree of proliferative bone reaction with interposed cartilage and fibrous
tissue which is evidenced radiographically and histologically. There are three
subtypes of this group and they represent the types most commonly seen in small
animals
o Hypertrophic or elephant foot nonunion: there is abundant callus formation but
failure to bridge the fracture gap usually due to rotational instability. This type is
most commonly seen in simple transverse or short oblique humeral or femoral
fractures with an intramedullary pin.
o Moderately hypertrophic or horse hoof nonunion: There is some callus formation but
without bridging of the fracture gap.
o Oligotrophic nonunion: In this case there is no or very limited callus formation. This
type is sometimes difficult to distinguish from the nonviable types.
• Biologically inactive or nonviable or nonreactive or avascular nonunion
o This type of nonunion fortunately is not common. Instability of fracture ragments is
one of the major causes of this type.
o Dystrophic nonunion: One or both sides of the fracture line are poorly vascularised.
o Necrotic nonunion: If bone fragments are not “captured” by invading callus due to
motion or more often infection, they may never become vascularised.
o Defect nonunion: Large fragments may be missing from open fractures, especially
high energy gunshot fractures. If this gap is more than 1.5 times the bone diameter,
there may not be enough osteogenic potential in the local area to bridge the gap with
the callus.
o Atrophic nonunion: Fortunately this is rare in small animal orthopaedics. This is the
end point of most nonviable nonunion with resorption and rounding of the bone
ends with or without disuse osteoporosis.

Diagnosis

• Diagnosis is based on relevant history, clinical and radiographic findings.

Treatment
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 • The aim of the treatment of nonunion is first to identify the cause and treatment of
nonunion relies on the ability of the surge to reverse the etiology of the problem. Line to
treatment as follows
o When a fracture is unstable, adequate stability must be provided
o When the nonunion lacks of osteogenic ability, autogenous cancellus bone should be
added
o When the nonunion is avascular, vascularity is encouraged by adding an autogenous
cancellus graft.
• Infected nonunion poses a challenging problem for the surgeon, however by combining the
treatment plans of osteomyelitis and nonunion, the bone will heal. All dead and necrotic
bone (sequesta) of nonunion site must be removed and the bone cultured for identification
of organism and antibiotic sensitivity. Rigid internal fixation is provided and an autogenous
cancellus graft is packed into the nonunion site.
• The use of electrostimulation in the treatment of fracture nonunions has been reported.
Nonunion in dogs and cats are rarely treated with electric current. However, electric
stimulation of nonunion in dogs and cats may replace or supplant conventional orthopaedic
techniques.
• Non union in IMP and wiring in Labrador Non-union in cat distal tibial fracture.

COMPLICATION OF FRACTURE HEALING - MALUNION

• Malunion is defined as a healing of the bones in an abnormal position or bones are allowed
in a nonfunctional anatomic position.
• Malunion can be classified as functional or nonfunctional. Functional malunions are usually
those that have small deviations from normal axes.
• This is a common complication of premature pin removal from a femoral diaphyseal
fracture in which the degree of fracture healing was not assessed radiographically before
removal the pin. Malunion of long bones commonly results in degenerative arthritis of the
joint above and below the malunion.

Causes

• Fractures that were never treated

• Fractures in which the internal or external method of fixation was removed prematurely.

Treatment

• Correction of malunion is undertaken when the malunion is a functional liability to the

animal. Treatment of malunion requires osteotomy of the site and realignment followed by
rigid internal or external fixation or both.
• Compartment syndrome: Severe swelling after a fracture can put so much pressure on the
blood vessels that not enough blood can get to the muscles around the fracture. The
decreased blood supply can cause the muscles around the fracture to die, which can lead to
long-term disability. Compartment syndrome usually occurs only after a severe injury.
• Neurovascular injury: Some fractures are so severe that the arteries and nerves around the
injury site are damaged.
• Infection: Open fractures can become infected when the jagged bone ends are exposed to
the air where they have torn through the skin.
• Post-traumatic arthritis: Fractures that extend into the joints (intra-articular fractures) or
fractures that cause the bones to meet at an abnormal angle in the joint can cause
premature arthritis of a joint.

LONG BONE FRACTURE MANAGEMENT

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Preparation of the site

• In the case of metacarpal fracture, the forelimb was shaved from the knee joint upto the
level of the digits distally and in the case of metatarsal fractures from the hock joint up to
the digits distally (plate 6.). The area was washed with soap and water followed by
scrubbing with povidone iodine scrub and finally with 5 per cent povidone iodine. The line
of incision was painted with 5 per cent povidone iodine.

Premedication and anaesthesia

• The calves wee premedicated using atropine sulfate at the does rate of 0.04 mg/kg body
weight intramuscularly.
• For metacarpal fracture, xylazine hydrochloride was given at the rate of 0.1mg/kg
intramuscularly initially followed by ketamine hydrachloride 5 (10 minutes later) at the
dose rate of 5 mg/kg intravenously. Subsequently incremental does of xylazine and
ketamine were given as and when required.
• For metatarsal fractures, initially xylazine hydrachloride was given at the dose rate of
0.1mg/kg body weight intramuscularly to sedate the animals. Later epidural anaesthesia
was induced with 2 per cent lignocaine hydrochloride6 at the does rate of 1 ml/5kg body
weight. Incremental doses of xylazine and lignocaine hydrochloride were administered as
and when required.

Instrument used

• The special orthopaedic implants and instruments developed by AO/ASIF group or human
patients to achieve the concept of rigid internal fixation were utilized for the
study. Additional instruments were also used for atraumatic surgery, easy reduction and
preliminary fixation of fragments.
• Implant box and screws (plate 1)
o Implant box
o Plates (DCP or LC-DCP)
o Cancellous and cortical screws.
• Drilling instruments and drill bits (plate 2)
o Drill bits
o Hand drill
o Bosch electric drill.
• AO/ASIT basic instruments (3.5 mm and 4.5 mm )(plate 3)
o 4.5 mm, 3.5mm eccentric and neutral DCP drill guide
o 4.5mm and 3.5mm tap sleeves.
o 6.5 mm cancellous tap
o 4.5 mm, 3.5 mm cortical tap
o T-handle
o 4.5mm counter sink
o Depth gauge
• Accessory instruments for bone plating (plate(4)
o Pointed bone reduction forceps
o Periosteal elevators
o Speed lock reduction forceps
o Bone holding forceps
• Plate bending instruments 9plate 5)
o Bending press
o Bending irons
• Hexagonal screw drivers (pate 5)
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 • General surgical instrument pack for large animal surgery.

Surgical approach

• The calf was kept in the lateral recumbency with the limb to be operated down. The limb
was suitably draped (plate 7). A 8 to 10 cm long curvilinear skin incision (plate 8) was made
on the medial aspect of the metacarpus/metatarsus. The incision was continued through
the layer of fascia. The digital flexors and the extensor tendons in the case of metacarpus
and the extensor tendons, the flexor tendons and the suspensory ligaments in the case of
metatarsus were carefully separated and retracted using Hohmanns retractor to expose the
fracture site. The periosteum was elevated using periosteal elevator. Normal saline mixed
with gentamicin was used to flush the operative site during the entire procedure. After plate
osteosynthesis, the skin incision was sutured with No.2 braided silk by simple interrupted
sutures.

Surgical procedure

• Immobilization using 4.5mm DCP

• Fracture fragments were reduced with the help of reduction and bone holding forceps.
• A template was moulded to the surface of the bone and a slightly prestressed plate was
contoured to the shape of the template.
• A hole was drilled 5 to 15 mm from the fracture through both the cortices of the first
fragment with a 3.2 mm drill bit (the same diameter as the core of the cortical screw used)
using an electric drill (plate 12). During drilling, sterile normal saline was irrigated to cool
the drill bit, bone and to flush the debris away.
• The length of the hole was measured with the depth guage 9plate 13)
• The threads were cut in the bone with the 4.5mm tap through a tap sleeve (plate 14) The
tap was advanced two half turns and then backed off one quarter turn to clean the bone
debris from the threads of the tap.
• The plate was fixed to the bone with a screw 1 to 2 mm longer than measured in such a way
that the screw pressed the plate against the bone but was not fully tightened.
• The fracture was reduced and the second fragment fixed to the plate with bone forceps.
• Using the proper load drill (yellow) guide inserted in the plate hole next the fracture gap, a
hole was drilled through both the cortices of the second fragment, measured, tapped and
the screw was inserted.
• Both screws were alternately tightened until the fracture was under compression. If the
fracture was not sufficiently compressed, the load drill guide was used for the second hole
on either side.
• The remaining plate holes were filled with screw using the neutral drill guide (Green colour
)(plate 15)
• Finally all the screws were tightened using the hexagonal screw driver beginning from the
centre outwards, to ensure that all screws were tight. This was repeated two or three times,
as any movement of one screw would cause plate translocation, hence loosening of other
screws.

Immobilisation using 4.5 mm LC-DCP

• The LC-DCP was utilized in the same manner as described for the DCP except for the use of
a separate neutral and load drill guide meant for LC-DCP.

Post operative care

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 • The surgical wound was cleaned with povidone iodine solution and bandaged with a
povidone iodine gauze dressing. Then a Robert Jones bandage was applied upto the digits
and was reinforced with polyvinyl chloride splint on the caudal aspect of the limb and again
bandaged. Benzathine penicillin at the rate of 40000 units/kg. body weight was
administered intramuscularly once in 48 hrs for fourteen days. The skin sutures were
removed on the 8th post operative day. The Robert Jones bondage was changed every
alternate day and the polyvinyl chloride splint was removed after 2 weeks post-operatively.

MODULE-16: AFFECTIONS OF MUSCLE-TENDON UNITS

Learning objectives

This module deals with

• Definitions
• Types of traumatic muscle injuries
• Types of tendon injuries

DEFINITIONS

Definitions

• Muscle-Tendon Unit (MTU): Unit consisting of an origin or insertion of a muscle, the

muscle belly, a muscular tendon junction, a tendon body and an origin or insertion of the
tendon.
• Contusion (bruise): Direct injury, resulting from blunt - usually non-penetrating trauma,
producing swelling, pain and tenderness at the location of trauma. Muscle contusion are
often seen following automobile accidents. Tendon contusions are rare.
• Laceration: Direct injury, usually resulting from penetrating trauma, producing a mangle
or tear at the location of the trauma. Both tendons and muscles can be lacerated.
• Strain (muscle pull, muscle tear): Indirect injury to the muscle tendon unit, caused by
stretching or a combination of activation and stretching of the affected MTU. Pathology
associated with strain injuries is usually located near the region of the myotendinous
junction.

MUSCLES

• In less than half a percent of all dogs presented with a problem of the musculoskeletal
system, a traumatic injury is diagnosed. It has been suggested that these injuries may have a
much higher incidence, but that, because of diagnostic limitations, an appropriate diagnosis
may not be made.
• In this presentation, an overview of the different types of traumatic muscle injuries, as well
as recent developments in the diagnosis of these disorders is given.
o Healing of striated muscle
o Mechanical muscle injuries
o Muscle contractures

HEALING OF STRIATED MUSCLE

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 • Two main phases of muscle degeneration have been recognized following muscle injuries:
degeneration of injured muscle fibers, followed by a phase of cell-mediated fragmentation
(mostly macrophages) of the damaged fibers. The latter phase is dependent on, and only
will start in the presence of an adequate bloodsupply.
• Following the invasion of macrophages, satellite cells proliferate and differentiate into
myoblasts. The myoblasts then fuse with one another to form syncitial myotubes. The newly
formed myotubes gradually transform into muscle fibers. The final stages of transformation
only take place after a functional neuromuscular junction has become established. This
process is called discontinuous regeneration and it is characterized by de novo formation of
muscle fibers.
• An alternative way of muscle regeneration is called continuous regeneration. This form of
regeneration mostly occurs after muscle transections and is characterized by a sprouting or
budding of sarcoplasm from the healthy ends of the muscle fibers. In simple transections,
the budding muscle fibers often become embedded in dense connective tissue, and further
development ceases.

MECHANICAL MUSCLE INJURIES - DIRECT

• Mechanical muscle injuries can be divided in direct and indirect muscle

injuries. Direct trauma to muscles usually results in contusions (blunt, non-penetrating
trauma) or lacerations (penetrating trauma with a sharp object). Indirect muscle trauma is
caused by stretching or a combination of activation and stretching of the affected muscle.
The resulting injury is called a muscle strain, muscle pull, or muscle tear.

Muscle contusion

• Contusions are characterized by capillary ruptures in the affected muscle, infiltrative

hemorrhage, and subsequent edema and inflammatory response. It may cause varying
degrees of swelling, redness, pain or tenderness. Muscle contusions usually heal by the
formation of scar tissue with variable amounts of muscle regeneration.
• The treatment of uncomplicated contusions consists of rest and may include cold
compresses (only in acute stage to stop hemorrhage), bandages (to control edema), and
non-steroidal antiinflammatory medication. The patient should be free of major pain within
10 days.
• If excessive swelling of the muscle occurs, a so-called compartment syndrome (local
neuromuscular ischemia) may develop. Muscle compartments recognized in the dog are: 1)
craniolateral compartment of the crus, 2) caudal compartment of the crus, 3) caudal
compartment of the antebrachium, and 4) femoral compartment (3 fascial envelopes:
quadriceps, hamstring, adductor muscles). A compartment syndrome is almost always a
sequel of an automobile accident. Treatment consists of a fasciotomy to release the
increased muscle compartment pressure.
• Another complication that may arise following muscle contusions is myositis ossificans.
The hematoma from the contusion now undergoes fibrosis and subsequent dystrophic
calcification. Myositis ossificans is also seen in dogs with bleeding disorders like Dobermans
with von Willebrandt disease. The disease (von Willebrand heterotopic
osteochondrofibrosis) has a predilection for the muscles around the hip joints. Patients
exhibit chronic lameness with subsequent muscle atrophy, possibly neurological deficits,
and pain after exercise. The diagnosis is based on the results of physical (lameness,
restricted range of motion hip joint) and radiographic examination (periosteal reaction
caudal to acetabulum). Surgical excision of the offending tissue is the treatment of choice.

Muscle laceration

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 • The diagnosis of muscle lacerations is based on physical examination (pain and swelling),
radiography (soft tissue swelling) and ultrasound (definition and genesis of the swelling).
• Partial lacerations may be treated conservatively with 2-3 weeks of rest and immobilization.
A complete muscle laceration is an indication for surgical repair. Because most lacerations
are associated with open wounds, the mode of surgical treatment depends on the condition
of the wound. If the wound is clean with minimal tissue damage, primary repair is
indicated. However, if the wound is contaminated, wound management with delayed repair
is more appropriate.
• Surgical repair of muscle laceration is accomplished by apposition and suturing of the
epimysium. Absorbable suture material (i.e. PDS ® or Maxon ® ) and the use of simple
interrupted horizontal mattress sutures is recommended. The suture line may be fortified
with some buttoned tension sutures. Aftercare includes immobilization for 2-3 weeks
followed by a gradual return to function over a period of 4-6 weeks. The prognosis for
complete return to function for working dogs is guarded.

MECHANICAL MUSCLE INJURIES - INDIRECT

Muscle strain

• Muscle strains are characterized by fiber disruptions and small amounts of hemorrhage at
the myotendinous junction. The injury may encompass the entire muscle (complete strain,
muscle rupture) or only a part (incomplete strain). The clinical findings associated with
strains are dependent on the severity of the injury. The diagnosis of acute incomplete strain
injuries is based on physical examination (pain and swelling), radiography (soft tissue
swelling) and ultrasound (may aid in the definition of the swelling).
• Examples of acute incomplete strain injuries in dogs are strains of the infraspinatus muscle
and the iliopsoas muscle. These injuries are difficult to diagnose and require special
diagnostic maneuvers. Treatment consists of rest and non-steroidal anti-inflammatory
medication. Acute incomplete strain injuries usually heal in 2-3 weeks.
• The diagnosis of complete strain injuries is as for incomplete strain injuries and muscle
lacerations. However, because of the increased severity of the clinical signs, they are easier
to diagnose. Treatment is as for muscle lacerations.

Characteristic clinical findings in strain injury in the dog

Disorder Physical findings Rongenological findings
Mild Minimal lameness, which Usually no radiographic
Strain(incomplete) may be imperceptible to all abnormalities.
but the owner.
Moderate Easily perceived lameness, Mild, often deceptively
Strain(incomplete) which appears to be the generalized regional soft-tissue
result of localized swelling, frequently associated
discomfort as opposed to with abnormality of associated
frank, persistent pain. fascial planes.
Severe Obvious lameness, which is Mild to moderate regional soft
Strain(complete) often rapidly progressive. tissue swelling with distinct
Pain is easily elicited. discrepancies of regional fascial
planes.

• Examples of muscles affected by complete strain injuries are:

o Pectoral limb
 biceps brachii muscle
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  long head of the triceps muscle
 humeral head of the deep digital flexor tendons
o Pelvic limb
 gracilis muscle
 gluteal muscles
 gastrocnemius muscle

Muscle contractures

• Muscle contracture is a relatively common, but infrequently discussed muscle condition in

veterinary practice. We speak of a contracture if the affected muscle(s) are fibrotic and non-
functional, resulting in reduced mobility or immobility of adjacent joints. Patients can be
presented with a primary complaint related to the contracture, but more commonly, the
contracture is a natural or iatrogenic complication of the presenting complaint, most
commonly trauma.
• Whether a contracture is presented as a primary complaint or as a complication of another
injury, the pathophysiology is similar. The condition starts with a muscular insult, usually
trauma, resulting in inflammation, muscle atrophy and muscle fibrosis (muscle
contracture). Muscle fibrosis reduces the mobility of adjacent joints and eventually may
completely immobilize them. Due to the reduced mobility or immobility of the adjacent
joints, their joint capsules will contract, resulting in even more joint stiffening. Muscle and
joint capsule contractures also result in lameness and reduced loading of bone and articular
cartilage. Because loading is an important stimulus for maintenance of bone and cartilage,
reduced loading will result in atrophy of bone and cartilage. Together, these processes will
result in even more reduced usage of the limb, and the condition will become irreversible
without therapeutic intervention.

Contractures as primary complaint

• Although the precise etiology and pathogenesis of muscle fibrosis and contractures is
unknown, it is thought that many of them are the result of either acute or chronic muscle
trauma. Resulting damage to muscle fibers, nerves and blood vessels may lead to fibrosis,
adhesions and contractures. These changes are irreversible and often result in lameness
ranging from minor changes in gait to complete loss of limb function.
• Reported contractures are:
• Pectoral limb
o Infraspinatus/supraspinatus muscle contracture
o Deep digital flexor muscle contracture
• Pelvic limb
o Quadriceps muscle contracture
o Gracilus muscle contracture
o Semitendinosus/semimembranosus muscle contracture
o Gluteal muscle contracture
• The diagnosis of muscle fibrosis is mostly based on the clinical signs, i.e. characteristic
posture and gait, decreased range of motion (ROM), and muscle atrophy. Ultrasound may
help with the definition of the affected muscle(s). Surgical intervention is the treatment of
choice. First, a myectomy and/or tenectomy of the affected muscle tendon unit(s) is
performed. If this does not result in correction of deformities and/or restoration of
function, joint capsule incisions (capsulotomy/ectomy), and myotomies or tenotomies of
surrounding muscles and tendons may be indicated. In general, the aftercare consists of
restricted activity and passive flexion and extension of the affected joint(s) for 1 week,
followed by unrestricted activity.

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 • An example of a muscle contracture in this category is the infraspinatus/ supraspinatus
muscle contracture. Patients presented with this condition generally have a history of
trauma. The affected leg is relatively long, which results in circumduction of the affected
limb. Affected animals also have a valgus deformity, originating at the level of the shoulder
joint. The treatment of choice is a tenomyectomy of the infraspinatus muscle. The
supraspinatus muscle may be tenomyectomized if affected too. If following these
procedures the range of motion of the shoulder joint still is restricted, joint capsule
contracture is likely and a capsulotomy is indicated. After surgery, the patient is confined
and physical therapy is performed (flexion and extension; 10-30 repetitions; 3-6 times per
day). Following suture removal, activity is unrestricted.

MYOFASCIAL PAIN SYNDROMES AND ILIOPSOAS MUSCLE INJURIES

Myofascial pain syndromes

• The myofascial pain syndromes are a group of syndromes, all resulting from pain and/or
autonomic phenomena referred from active myofascial trigger points.
• Myofascial trigger points are hyperirritable spots, usually within a muscle that are painful
on compression and that can give rise to characteristic referred pain and tenderness.
Trigger points can be activated by trauma.
• Myofascial pain syndromes have been reported in the dog. Muscles identified as causing
symptoms are the triceps brachii, infraspinatus, adductor, pectineus, peroneus longus,
gluteus medius, iliocostalis lumborum and quadriceps femoris.
• Treatment consists of injection with a local anesthetic or needling of the trigger point, and
usually is very successful.

Iliopsoas muscle injuries

• Injuries of the iliopsoas muscle are clinically characterized by pelvic limb lameness, exercise
intolerance, and problems with getting up, stairs or jumping.
• On a routine orthopedic exam, decreased range of motion and discomfort on extension of
the hip joint may be detected. Stretching of the muscle by simultaneous extension and
internal rotation of the limb elicits signs of discomfort and pain.
• In addition, pain may be elicited by direct palpation of the muscles attachment to the lesser
trochanter, by indirect palpation of the muscle ventromedially to the ilium, or by palpation
of the lumbar hypaxial muscles. Finally, transrectal palpation of the muscle's attachment to
the pubic rim may be painful.
• The injury is often bilateral. Occasionally, radiographs show avulsions of the lesser
trochanter or intramuscular calcifications close to the muscle's insertion to the femoral
lesser trochanter. Ultrasound may reveal changes in the size and texture of the affected
muscle.
• The genesis of the disease is unknown, but a strain injury or a myofascial pain syndrome is
suspected. Acute injuries may be treated conservatively with 2-3 weeks of strict
confinement and bufferin or piroxicam as needed. In severe strains, prolonged confinement
may be indicated. In many dogs, acute injuries convert into chronic injuries, or the disease
will recur. Tenomyectomy of the affected muscle may then be indicated. Iliopsoas muscle
injuries are significant, because the course of the disease and its clinical signs may mimic
hip dysplasia.

Carpal hyper-extension and hypo-extension in two month old pups

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• Carpal hyper- and hypo-extension is an infrequently seen abnormality in pups from 7-10
weeks of age. The etiology of this condition is unknown although it has been suggested that
a magnesium deficiency and poor muscle tone is responsible for this deformity.
• Suggested treatment consists of exercise and change to an adult dog food. The prognosis is
excellent if treated immediately and within a few days the carpal configuration is back to
normal.
• However, the longer treatment is delayed, the more chance that the condition is
unresponsive to conservative treatment. Rest and support bandages are contra-indicated.

HEALING OF TENDONS

• Three phases are recognized in the repair of tendon lacerations

o an inflammatory phase,
o a reparative (collagen-producing) phase and
o remodeling phase.
• During the inflammatory phase (the first couple of days after injury), cells from extrinsic
peritendinious tissue and/or intrinsic tissue from epitenon and endotenon invade the
lacerated area.
• Many cells assume a phagocytic function. Other cells become fibroblasts, settle at the injury
site and start to produce collagen (mostly type III) from approximately day 5 (reparative
phase). Collagen is deposited in a random manner. Both cells and collagen fibrils are
initially oriented perpendicular to the long axis of the tendon.
• During the remodeling phase (at approximately 2 months), type III collagen is replaced by
type I collagen, collagen matures (cross-linking) and realignes itself parallel to the long axis
of the tendon. During this phase, the tendon reduces the mass of scarr tissue and increases
its tensile strength.
• It is thought that all tendons can heal both intrinsicly and extrinsicly, and that the
contribution of each may depend on the type and site of tendon injury.
• For example, following lacerations within the tendon sheath, peritendinious structures
(synovial sheath, periosteum, subcutaneous tissue, deep adventitia and fascia) provide most
of the fibroblastic and vascular components. Although there is an intrinsic response, it is
completely overwhelmed by the extrinsic response.
• In the absence of a synovial sheath, the intrinsic response plays a more significant role.
Furthermore, there is also evidence that early mobilization may promote the intrinsic
response, and consequently reduce scar formation and adhesions.
• Although our knowledge regarding tendon healing and repair has significantly increased
during the last decades, tendon injuries are still a significant clinical problem, and complete
functional recovery after tendon repair is rare
o Tendon lacerations
o Tendon dislocations
o Tendon avulsions
o Tendinitis/Tendinosis

TENDON LACERATIONS

• Tendon lacerations are usually associated with skin discontinuities. They are readily
identified because of the abnormal range of motion of adjacent joint(s).
• Radiography and ultrasonography may be helpful in the further definition of the lesion.
• If the wound is fresh and clean with minimal tissue damage, primary repair is indicated.
• If the wound is contaminated or significant tissue damage is present, wound management
and delayed tendon repair is recommended.
• Surgical repair with a modified Kessler (locking loop) or a triple pulley suture pattern, using
non-absorbable suture material (Novafil ® ) is recommended.

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• Aftercare consists of immobilization for 4-6 weeks, followed by a Robert Jones bandage for
7-10 days. The activity is then restricted for another 3-4 weeks.

TENDON DISLOCATIONS

• Four different tendon dislocations are recognized

o Pectoral Limb (dislocation of the biceps tendon (rare))
o Pelvic Limb (dislocation of the patellar tendon)
o dislocation of the proximal tendon of the long digital extensor muscle
o dislocation superficial digital flexor tendon (rare; most commonly seen in Shelties)
• Dislocation of the patellar tendon (patella luxation) is a very common disease. Patella
luxations can be congenital or acquired, permanent or intermittent, and medially or
laterally.
• In small dogs and toy breeds the luxation is congenital and usually in medial direction,
while in larger breeds the luxation often is acquired and usually in lateral direction.
• If tendon dislocations are causing clinical problems, surgical treatment is indicated.
Surgical treatment usually consists of reconstruction of the anatomical relationships. Both
patella luxation and lateral luxation of the superficial digital flexor tendon are hereditary.

TENDON AVULSIONS

• Tendon avulsions are usually the result of indirect MTU trauma and have a similar etiology
as strain injuries.
• Examples of the Pectoral Limb are
o Avulsion of the biceps tendon (from scapula)
o Avulsion of the humeral head of the deep digital flexor tendons (from medial
humeral epicondyle)
• Examples of avulsions of the Pelvic Limb are
o Avulsion of the gluteal muscles (from greater trochantor)
o Avulsion of the lateral or medial head of the gastrocnemius muscle (from distal
femur)
o Avulsion of the gastrocnemius muscle (from the calcaneus)
o Avulsion of the long digital extensor tendon
• Four basic types of tendon - bone injuries occur
o separation of tendon from bone,
o avulsion of a small piece of bone with the tendon,
o avulsion fractures, and
o physeal fractures (in immature animals).
• Radiography and sonography may aid in the diagnosis of the lesion. Surgery is indicated for
tendon - bone injuries. Severated tendons are reconstructed using non-absorbable suture
material (i.e. Novafil) in a horizontal mattress, a Bunnel or modified Kessler suture pattern
in the avulsed segment, which is then reattached to the bone by drill holes place at the site
of the tendon insertion. If a small fragment of bone has been avulsed with a tendon, it can
be either discarded or left with the tendon.
• The aftercare is as with tendon lacerations, and consists of immobilization for 4-6 weeks,
followed by a Robert-Jones bandage for 7-10 days. Activity is then restricted for another 3-4
weeks.
• If the bone segment is large enough, the suture can pass through it or it can be secured with
Kirschner wires or a small bone screw with or without spike washer.
• Most avulsion fractures in young dogs involve traction growth plates and are repaired using
a tension band device or bone screw. Avulsion fractures involving the epiphysis are
reattached with a bone screw with spike washer or treated as a tendon separation.

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 TENDINITIS/TENDINOSIS

• The etiology of tendinitis is very similar to the etiology of strain injuries. Just as strain
injuries, tendinitis is an indirect injury is caused by stretching of the affected MTU, but now
the pathology as located in the tendon. Furthermore, in several muscles both strain injuries
and tendinitis have been diagnosed.
• Stretching of the tendon beyond the elastic limit results in plastic deformation,
histologically characterized by loss of the collagen "wave-pattern" (crimp).
• At the molecular level, it is related to intrafibrillar sliding (within collagen fibers) beyond
the elastic limit. If the process of disruption continues, tendon rupture may occur.
• Fortunately, with rest the initial lesions may heal, most likely via intrinsic repair processes.
However, if healing is inadequate or if additional microtrauma is superimposed,
tendinitis/tendinosis may result.
• Examples of tendon ruptures following indirect trauma are:
o Pectoral Limb
 Rupture of the biceps brachii tendon
o Pelvic Limb
 Rupture of the Achilles tendon
• Treatment of tendon ruptures following indirect trauma is as in tendon lacerations.
• Tendinitis is histologically characterized by fragmentation of collagen, edema with
increased ground substance, separation of collagen and tenocytes, proliferation of small
vessels, and mesenchymal tissue. There are no inflammatory changes within the tendon,
thus tendinosis may be a more appropriate term. Inflammatory changes only become
apparent following total tendon or major vascular disruption.
• Tendinitis is an uncommon diagnosis in small animals and in fact only recognized as a
cause of lameness in the biceps brachii muscle (bicipital tendinitis). Clinical evidence of
bicipital tendinitis is pain on deep palpation of the biceps tendon and pain or discomfort on
flexion of the shoulder joint while the elbow is extended.
• Synovial analysis, radiography (arthrography), sonography and arthroscopy are
recommended to confirm the diagnosis. Treatment consist of rest and anti-inflammatories.
Surgical treatment consists of a tenotomy of the tendon alone (preferably arhroscopically)
or tenotomy with reattached to the proximal humerus.
• Acute or chronic tendon trauma may also lead to dystrophic calcification of the affected
tendon. Examples of tendon calcifications are
o Dystrophic calcification of the biceps tendon
o Dystrophic calcification of the infraspinatus tendon
o Dystrophic calcification of the supraspinatus tendon
o Dystrophic calcification of tendons may or may not be associated with active
inflammation, and may or may not be associated with lameness. It is only considered
as the cause of lameness if no other cause of lameness can be identified.
• Treatment may consist of rest, anti-inflammatories or if conservative treatment is
unsuccessful surgical debridement, tenodesis or tendon release.

MODULE-17: PHYSIOTHERAPY

Learning objectives

This module deals with

• Principles of treatments
• Classification
• Hydrotherapy
• Thermotherapy
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 PHYSIOTHERAPY

“ Treatment by physical means ‘ dictionary – Tending to the cure of disease. Physiotherapist –

restore to right, privileges reputation.

• Physiotherapy deals with the treatment of diseases by physical methods.Rehabilitation

means restoration of the functional utility of the effected part.These two accelerates tissue
healing by galvanizing normal physiological processes so that the functional normalcy
physiological processes so that the functional normalcy of an effected part is restored
faster.Physiotherapy helps
o To correct deformities,
o Develops the paralyzed muscles,
o Makes joint movement more supply,
o Prevents deforming tendencies.
• The main aim of physiotherapy is the restoration of function and promotion of tissue
healing by assisting normal physiological process. The prime physiological response to
physiotherapy is its effect on vascular supply.
• Physiotherapy in Veterinary practice is still in infancy because of obvious handicaps.
However,it is a high potential area and various methods can be used to reduce the
convalescence period and to increase the postoperative utility of the animal especially in
ruminents.
• Physiotherapy in veterinary Practice is considered to be fun and fascinating subject but
useful especially in companion animals and race horses.

PRINCIPLES OF TREATMENTS

• The ultimate aim of physiotherapy is the restoration of the fullest functional activity
possible. Physical therapy can be achieved by some principles
o Increase / maintenance of tissue fluid interchange: This will be necessary in the
intrest of healing in order to alleviate symptoms in the intrest of general health of
tissues. By stimulating circulation and metabolic interchange locally it is possible
 To promote healing incases where it is required.
 Minimize risk of adhesion by absorption of excess inflammatory exudates.
 To disperse metabolic waste products / oedema
 To reduce pain and limiting the mumme due to precure or toxins.
 To compact the effects of inactivity and there by reduce the risk of tropic
change or disuse atrophy.
 To prepare muscles to work.
 To maintain unaffected tissue in a healthy functional state.
o Increased / Maintenance of joint mobility: Any interference in joint mobility will
throw strain on unaffected joints and this endanger their health and function.
o Muscle power must be maintained and increased
o Adequate perspiration – tissue ventilation
o Specific symptoms must be relieved as per as possible/ decrease metabolism and
joint muscle activity
o Complications must be prevented.
o General health may need improvement.
o Use and care of aids and applications

Transmission of heat

• Conduction: Transfer of heat energy from a hot body to cold. HotSpoon – other end of
spoon– hot.
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 • Convection: heat transference takes place by movement of a mass. Room can be heated with
a stove – air in contact with heat warms the room. Liquids and gases are heated.
• Radiation: Heating of body by the radiation Eg: earth is warmed by sun’s radiation.
• Other: Heat energy may convert from some other form of energy. High frequency electrical
currents – Diathermy. High frequency mechanical energy – Ultra sound.

CLASSIFICATION

• Physical methods
o Massage
o Exercise etc.,.
• Physical agents
• Conduction–Water-Hydrotherapy: Treatment by using water, either cold or hot.
• Thermo therapy: Treatment by using heat through conduction, convention,radiation and
conversive methods.
• Radiation: Infrared therapy, UV therapy
• Conservation: Diathermy: Use of high frequency currents
• UltrasonicTherapy : Use of high frequency currents with oscillations
• Electrotherapy: Treatmentusingelectricalcurrent,Electrical
stimulation,electrodiagnosis,faradism,and galvanisation

Classification of radiant energy

• A beam of white light passing through glass prism it is not only reflected but also dispersed
and a series of colour bands called spectrum is seen on the prism.

MASSAGE

• Manipulation of soft tissues with hand and fingers. Massage improves

o Circulation
o Nutrition supply
o Removes waste products
o Reduces edema
o Reduces indurations
o Loosens contracted tendons, ligaments and muscles.
• Indications
o Subacute, Chronic inflammatory conditions can be combined with the use of
linaments
• Contradications
o Acute inflammatory conditions
o In danger of hemorrhage
o Presence of foreign bodies under skin
o Existence of new growth.
• Effects
o Stimulation/ Sedation of Sensory nerve endings in skin assists in local and general
relaxation.
o Local hyperemic effect : direct stimulation of sensory nerve endings, indirectly slight
cellular damage leading to liberation of H substance both these effects results in
dilatation of article.
o Mechanical assistance by alternative pressure and relaxation due to venous and
lymphatic return.
o Stretching and softening effect of fibrous tissue due to movement of skin and
subcutaneous tissue.

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• Lubricants
o These soften the skin during massage. Olive, mustard or coconut oil or fine grouned
talcum powder can be used to reduce friction while massaging.
• Methods
o Stroking, kneading or friction. Stroking is useful to begin and end a massage session.
Massage comprises a serious of maneuvers including:
 Slight Friction: It is performed with the tips of the fingers or the flant of the
hand in centripetal direction. It be uses of feeling of ‘ warmth’ and has a
numbing effect after which more vigorous rubbing may be practice. This
disperses exudates and extravasate over a large area., where it is acted upon
by more absorbents and more readily removed.
 Methodical pressure: this consists of applying firm pressure on to tissues
with the pulp of the thumb or with fingers or the heel of the palm or with
closed fist so as to act no deep seated structures.
 Individual Compression of Muscles: A portion of the muscle is seized between
the fingers and thumbs and manipulate from its insertion towards its origin
compressing and displacing it. It excites contraction and promotes absorption
of intramuscular exudates.
 Percussion: Consists of superficial or deep percussion of the tissues by
striking the part perpendicularly with the fingers or the closed hand.
• Precautions
o Practiced as for as possible in the direction of the venous and lymphatic streams.
o Should be fasciculate by smearing the part with Vaseline or by using mild lineament.
o This should be continued for 5 – 10 min at a time.
o In case of joints it should be associated with passive movement and exercise.
o Should be done in the direction of muscle fibers / across the fibers.
o While massaging extremity it may be directed if possible to make use of gravity to
assist venous return.
o The motion should be rhythmic and pressure moderate. A lowrhythemic massage
results in sedation.
o It is advisable to apply compression with cotton wool and a bandage to the part after
massaging to support the returning circulation and favour the process of absorption.
• Techniques
o Hand massage: The strokes may be linear, circular or direct compression and should
be directed to influence venous return. Massage should be done daily for 10-20
minutes.
o Friction massage: The stroke is small and is performed by using the tip of one finger
reinforced by a second. Apply for 2-7 minutes on alternative days followed by 15-20
minutes of general massage.
o Ice massage: local areas can be massaged with a handhold ice cube or cube frozen
around a lolly stick.
o Machine massage: Massage machines have a series of fitments and vibrate rather
than massage and can safely be used even by an unqualified person.
o Lineaments and rubs: Preparatory lineaments can be rubbed over and around the
areas of soft tissue damage.

EXERCISE

• Exercise constitutes active and passive movement of a part or whole of the body so as to
strengthen or maintain the muscle and skeletal system. Exercise plays a great role in
rehabilitation especially following injuries in disorders of locomotar system and muscular
weakness.
• Indications
o Joint stiffness
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 o Poor posture
o Spasticity
o Paralysis
o Orthopedic problems.
• Effects
o Mechanical pumping effect due to movement, joint and muscles assist in venous and
lymphatic return.
o Sensory stimulation by keeping cortical pathways open.
o Mobility and range of movement can be increased by all forms of movement.
o Passive movements stretch and soften the fibrous tissues. (prevents induration)
o Restricted movement will build up muscles power.
o Balance and coordination can be improved.
o Cardiovascular and Respiratory capabilities – General circulatory rate will be raised
through the effect of exercise on heart.
• Methods
o Passive exercise: In this method, the affected joint is grasped and its flexion and
extension is done 10 – 15 times. If the joint is painful, the hand can be padded with a
towel. The movement should not be forced but gradual so as to avoid discomfort, fear
of muscular spasms.
o Active exercise: This includes walking, grazing and slow running up on a slope.
Active exercise is coupled with passive exercise and massage can help in improving
circulation, Joint mobility, muscle power and coordination. However, the animal
should not tire and exercise should be stopped if there is any increasing in odema
and pain or decrease in the mobility of the joint.
• Techniques
o Walker: The animals have been tied to the revolving arm of the walker. The latest
devices allow the animals to be free in an enclosed pen allowing natural balanced
movements.
o Use of weight: Place atleast 1.5 to 2.0 kg weight with a piece of gamgee above the
fetlock and bandage. Work the horse for 10-45 minutes twice daily till the muscle
recovery (10-21 days).
o Treadmill: The moving belt of the treadmill ensures that the horse must move using
all four limb evenly in order to remain in balance, it is excellent for the reduction of
the gait pattern in horses.
o Swimming: An excellent way to rehabilitate and condition the musculature of a
horse without concussion to the limbs .The animal must swim in sraightlimbs for
rehabilitation.

HYDROTHERAPY

• Water absorbs more heat per unit of weight than any other substance. The solvent
properties of water help checking infection and accelerate wound healing by removing dirt
and necrosed tissue. A treatment time of 10-30 min. is sufficient for this effect.
• Buoyancy of water: These can be used to relieve pressure on effected parts. The method is
used in the form of an aqua lift system to treat downers cow syndrome if muscles damage
has not occurred.
• Whirlpool hydrotherapy: It is essentially a water bath in which an extremity or the entire
body is submerged in either warm or cold swirling water. The water is kept in constant
agitation and mixed with air by the action of turbine thus producing a gentle massaging
effect.
• Irrigation: Irrigating the affected part with a stream of water through a house pipe is a
simple and cheap method. This is often used for necrotic wounds, like those following sub-
cutaneous infiltration of urine in cattle, as a adjacent to the main therapy.
• Precautions
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 o Animal with recent skin grafts
o Acute edema
o Fever
o Marked circulatory disturbances should not be treated.

Cold water application

• The normal temperature of skin is 68-860 F.

• The temperature of cold water varies from 46.5-590 F.
• The best result are obtained when the water is at a temperature of 50 0 F.
• In Veterinary practice the water is usually applied directly to the part instead of being
allowing to flow through a coil of rubber or metal tubing laid on the part.
• Indications
o Acute congestion,
o Acute inflammation
o Septic lesions with diminished blood supply.
• Effects
o Hypothermia of tissues induces Vasoconstriction and decreases extravasation of
blood
o Pain, muscle spasms and tissue metabolism are also reduced.
• Methods of application
o It is generally combined with compression bandage and rest, to limit the swelling.
o It is used during the first 24 – 48 hrs after trauma.
o Each application should last for 10 – 30 minutes with one hour application.
o For deep seated lesions like sprains, water at a lower temperature may be applied.
• Methods
o Cold effect may be produced by
 Ø Blowing air
 Ø Evaporation of volatile liquids
 Ø Applications of ice packs
 Ø By running cold water on the affected part
• Techniques
o Running stream: A pen built in a preferably fast running stream enables a horse to be
stored in water for varying time and is labour free.
o Whirlpool tube: The injured leg is palced in to a container. Treat for 20-30 minutes
and suitable for knee or hock curbs.
o Wille boots : place the leg in boot ,fill with water and treat for 20-30 minutes.
o Housing : Run cold water over the injured area for 15-20 minutes from a hose tube
connected to the cold water tap.
o Cold bandaging: the bandages are designed with materials that when damped and
placed in deep freeze, reduce to and remain it 6 0 for 10 minutes.
o Frogen gamgee/ Cotton wool pads : Apply to the injured area over a towel to avoid
ice burn.
o Ice massage: Rub ice over the area.

Hot water application

• Indications
o Substance and chronic inflammations
o Recent inflammation after the acute stage has passé
o Septic lesions in which the vitality of tissues lowered and they are threatened with
deaths.
• Effects

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 o Analgesia by softening and relaxing the tissues.
o Hyperemia- exudation- interstitial infiltration, leucocytosis- phagocytosis.
o Reabsorbing of exudates.
• Methods
o The temperature gradually rose from 30 – 1130 F or even 1220 without scolding.
o At temperature 1130 F moist heat diminishes the resistance of the tissues.
Hot applications must be frequently renewed by adding, occasionally, more hot
water.
o It is impossible to maintain a local superifical temperature equal to that of the blood.
o Hydrothermo-regulator regulate temperature of 107 – 1130 Fmaintained for 12 – 24
hours with excellent effect.
• Application
o Baths
o Fomentations
o Compressor
o Poulties, etc.,

THERMOTHERAPY

• Indications
o Sub acute and chronic inflammatory conditions
o Sprains, contusions, sprains and myositis
o To hasten the suppuration process Ex.: abscess maturation.
• Effects
o Heat increases the tissue temperature which leads to sedation and analgesia.
o Heat produce vasodilatation and promote phagocytosis, helps in the healing process.
o Heat enhances metabolism and lymph flow .
• Adverse effects
o Increased permeability of blood vessels leading to tissue edema
o Increased absorption of toxins.
o Heat should not be applied if infection is present due to spread bacteria and toxic
products deep into the tissues
o Thermo therapy should not be used during the initial 24 to 48 hrs after trauma.

Conductive heat

• Conductive heat is superficial and does not penetrate beneath the skin so helps in reducing,
swelling because of its higher osmotic property. The source of heating includes
o Hot water bottles
o Hot moist pack
o Hot water bath
o Fomentation
o Poultice
o Electrical Heating Pads
o Well constructed electrical blankets
o Paraffin Both
o Hot water poultices
o Hot water whirlpool is used for application of moist heat
o Various drugs. Ex: magnesium sulphate
• Commercial hot packs are available in different sizes, shapes and conversions.
• The packs are soaked in water at a temperature of 750 C, heat is retained for 20 to 30 min.
Adequate padding with a towel should be provided to prevent burns from hot packs.
Exposures to desirable heat for 15 to 20 minutes are sufficient.

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 • Hot packs are more affective when used in a combination with massage, exercise or
electrical stimulation.

Radiant heat

• Infrared therapy
• Ultraviolet therapy

INFRARED THERAPY

• Infrared rays are the radiant energy with wave length of 770 to 1,00,000 mu immediately
after the visible light in electro magnetic spectrum.

Classification

• Long wave infrared

o Emitted by all heated bodies,Low temperature bodies like hot water bottles, electric
heating pads ,dull red heaters are good sources
o Wave lengths extend mostly from 1500 to 12,000 mu.
o Do not penetrate to deeper than 2mm
o Strongly absorbed in upper layers of the skin.
• Short wave infrared
o Emitted by all incandescent bodies such as sun, electric incandescent lamps and
specially designed high temperature infraradiators
o Wave length extends from770 – 1500 to 1800 mu
o The employment of special red glass filter restricts these sources
o Penetrate to 5 to 10mm of skin tissues and influence blood vessels, lymph vessels,
nerve endings and other subcutaneous structures directly.
o Source
o Natural: Sun light is most important natural source of intra red radiation and
comprise over 60% in an average sunlight, the rest being UV and visible light.
o Artificial: These are of two types
 Low temperature / Non luminous / IR radiators: A bare wire carbon held in
suitable non conducting material is used.It emits red glow and a quantity of
red radiation.
 High temperature/ Luminous / Heat lamps: Incandescent filament radiators
are the principal sources of luminous heat radiation consists of tungsten
filament enclosed in a glass help mounted at the center of concave reflector in
an evacuated or gas filled glass bulb.
o Effects:
 Heating the superficial tissue of the body with infrared radiation exerts local
as well as central effects.
 Local effects
 Effect on circulation
 Effect on nerve endings

Effect on circulation

• With in a few minutes of exposure to radiant heating the skin turns red and feels hot.
• This results in erythema in the form of a red spot or a network of red lines.
• It persists depending upon the length of exposure from 10 minutes to 1 hour.
• This exists an inherent tone in the capillaries that causes vasoconstriction and subsequent
release of vasodilator substance.
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 • Upon the absorption of vasodilator substance more capillaries become active and more
blood is supplied to the body.

Effect on nerve endings of the skin

• Mild heating results in sedation or relief of pain while strong heat stimulates marked
counter irritation.
• General effects: Every local application of heat brings about a certain amount of general
heating. The local excess heat is taken up by the blood stream and carried into the general
circulation. The temperature control mechanisms of the body will immediately through off
the additional heat by mild perspiration. The general recognized effects of mild general
body heating are
o Increased heat limitation and professed perspiration.
o Circulation, a rise of the pulse rate
o Lowering of blood pressure
o Increased respiration
o Increased elimination through the kidney.
• Clinical uses
o Sub acute and chronic traumatic and inflammatory conditions in locations accessible
to external heating such as contusions and muscle strains, traumatic synovitis and
tenosynovitis, sprains, dislocations and fractures.
o Various forms of arthritis and rheumatic conditions,neuralgia
o Acute, sub acute and chronic catarrhal conditions of the mucous
membranes/Conjunctivitis coryza, sinusitis
o Circulatory disturbance of the extremities
o Infections of the skin, folliculitis,furunculous and deep abscess in the skin.
o As preliminary heating to other physical measures, like massage, voluntary and
passive exercise.

Technique of application

• The patient should be placed in a comfortable and relaxed position

• Direct the radiation from the generator over the part at a distance
• The distance will average from 2 to 3 feet according to the sensitivity of the parts
• Exposure is continued for10 to 15 minutes when the objects is nearly to warm up the parts
preliminary to some form
• Treatment for 20 to 30 minutes is sufficient if heat radiation is the source of treatment.

Dangers and Precautions

• Exposure to infrared radiation results normally in an erythemal response consists of

individual dark red spots or a confluent net work of these part.
• Excess radiation, hypersensitivity or other causes may produce after the initial erythemal,
wheal formation, local edema and eventually blistering.
• Special precautions are imperative in patient whose skin sensation is impaired in those
which scars on the skin after burns or other injuries that have destroyed part of the normal
skin or its nerve conditions.

ULTRAVIOLET THERAPY

• The range of radiant energy designated as Ultraviolet extends from 390 to 180. Very hot
bodies and ionized gases emit Ultra violet rays.

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Classification

• Near Ultraviolet radiation: Which is continuous to the luminous rays and consists of
comparatively long range extending downward to 290 mu
• For ultra violet radiation: Consists of comparatively short rays extending from 290 to
180mu wave length.
• Source:
o Natural: The chief natural source of ultra violet radiation is the sun.
o Artificial: Radiation from artificial sources represent only approximations to sun
light and no two are alike in respect to the spectral distribution of the energy they
emit.
o Electric arcs between electrodes of metals and of carbon

Mercury in quartz

• Mercury Vapor Lamp: Mercury is a liquid metal at a room temperature when vaporized in a
quartz container by intense heat emits a spectrum rich in UV light characterized by a series
of intense spectral lines or bars. Quartz or silicone dioxide gas is extremely heat resistant
and at the same time freely transmits UV radiation. These are classified as
o Hot Quartz Lamps – High Pressure – 1 to 10 atmosphere.
o Moderately warm lamps – Medium pressure 0.1 atmosphere
o Cold Quartz Lamps Low pressure 0.001 atmosphere.
• Fluorescent Sun Lamp : -These Lamps may be used without a reflector. The 20w lamps will
produce minimal erythemal at a distance of 2 feet in 20 minutes, the bare lamp produce in 7
minutes with a reflection.
• R.S.types sun lamp (Reflector): -These consists of a mercury arc tube enclosed in a special
glass bulb .These lamps emit Ultra violet radiation of minimum perceptible erythema in 5
minutes at 24 inches.

Effects

• Physical properties: UV rays penetrate to a very limited extent through bodies.

• Physiological effects
o Erythemal production: Radiant energy between prevalence of 320 to 240 mu
produce erythema of the skin within 2 to 8 hrs.Erythema of the skin is a true
inflammatory reaction and can be described according to its intensity as a four
different degrees depend on dosage of UV irradiation.
 Minimal erythema dose (First degree, tonic dose) a slight reaction.
 Second degree: Definitive erythema like sun burn results exfoliation of skin.
 Third Degree: Intense erythema, epidermis can be peeled off.
 Fourth degree: Blister formation capillaries dilate, epidermal cells swell up the
nuclear substance, absorbs the rays and chromatin breaks up. The result is
broked skin which is caused by presence of melanin granules. This forms a
screen around the cells and protects them from a further over dosage.
o Nerve endings: stimulation produce marked analgesia.
o Blood: Absorbed by blood consequently bactericidal effects of blood are increased.
Calcium phosphorus, iron and iodine contents are also increased.
o Pigmentation: Repeated irradiation with erythema doses between 280 to 300 mu
causes a pigmentation that consists of deposition of granules of melanin in the basal
cells of the epidermis.
• Metabolic effects
o Activation of Vitamin D(Ante rachitic Effect):-
 UV irradiation of argosterol and 7 -Dehydrocholestrol

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  Vitamin D is the byproduct of this exposure and it is essential for the
promotion of normal anabolism of calcium and retention of phosphorus.
 This effect is vital for the prevention and treatment of rickets and other
calcium deficiency conditions such as tetany and also for the development and
care of the teeth in the absence of adequate dietary intake of Vit. D.
• Other Metabolic Changes: UV irradiation claims of numerous effects on circulating blood
cells and a great variety of Metabolic Processes.
• Bactericidaleffects: Spectral Band at 265.2 mu produces maximum bactericidal effects.

Technique of UV irradiation

• For general irradiation entire undraped body should be exposed. Hence the treatment room
should be warm and also well ventilated.
• The genetalia should be covered by a cloth.
• The centre of the part to be exposed to be in direct line of irradiation.
• A timer should be used to measure the time of exposure.

Dosage

• The erythemal response of the individual patient serves as a guide for dosage for general
irradiation the first dose is usually one that causes minimal erythema. The principle factors
of dosage are distance of burner and duration of exposure. These very according to the
efficiency of the operators, the individual sensitivity of the patient and the progress of the
treatment.
• Distance of the Burner: It is advisable to start treatment at a standard skin / burner
distance of 30 inches with a calculated exposed time. It is better to keep the distance factor
constant, there is less chance of confusion or error.
• Duration of Exposure: Local : 3 to 5 minutes, Systemic:15 minutes -5 days usually 20
exposures are required to effects a complete cure.

Clinical uses

• General tonic effect

• Chronic Ulcers
• Tuberculosis.
• Skin conditions a) Psoriasis b) Acne
• For Diagnosis – In dermatological cases with the aid of woods lamp to detect fungal
infection.

Dangerous of UV Irradiation

• Dermatitis due to UV energy – It forms a simple erythema to bulbous eruption with pain,
chills, fever and shock.
• Local ulceration: impetigo, folliculitis etc.,
• Excessive irradiation of a large area of a skin may cause death from general toxemia.
• Exposure for a longer period produces atrophy, wrinkling and small warty excretionsresult
in a basal or squamous cell.

DIATHERMY

• The principal physical effect of high frequent current is the heating of the tissue. It is not a
specific property of the high frequency current any current will heat the tissue (Joule’s
Law).
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 • Low frequency currents are not suitable for tissue heating because their electrolytic or
dolarity effect will bring about tissue destruction at any strength. Radiant sources of heating
(UV & infrared) as well as conducting heating (Fomentations) produces mostly superficial
heating. It is also evident that in any external hating through the skin increased circulation
and perspiration will tend to disperse some of the heat and preclude deeper penetration. So
it is not possible to heat the deeper parts without overheating the skin with above methods.
Thus high frequency tissue heating is an important heating modality in physical medicine.
• A high frequency current is defined as an alternative current consisting of a million or more
oscillations per second.
o Long wave diathermy – Oldest, now-a- days not using, oscillations of a frequency of
about million per second and applied through bare metal electrodes placed in direct
contact with the skin or mucus membrane. This can be produced by obsolete spark
gap technique.
o Short wave diathermy - most commonly used method, oscillations from 10 to 100
million per second applied through a spacing of air or rubber. This can be produced
by tube apparatus.
o Micro wave diathermy – Oscillations of 3000 millions per second which are used by
focusing single beam of electro magnetic emery from some distance to the region to
be created. This can be produced by magnetron oscillator.

Effects of diathermy

• Thermal Effects: The temperature distributed by the high frequency electrical energy is
modified by physiological factors such as the temperature of the tissues.
• As diathermy is applied an increase in blood flow may occur locally as a result of changes in
the tissue temperature.

Clinical effects

• Effects on circulation
o Local Effects: The local application of diathermy results in an active arterial
hyperemia – in increased flow of lymph – an increase in the volume of the part thus
effected.
o General Effects: Rapid dilatation of peripheral blood vessals – visa in blood
temperature an increase in the pulse rate and respiration and perspiration – an
increase in the general body metabolism.
• Effects on nervous tissue
o Diathermy exerts a marked sedative effect on the irrigative conditions of sensory
nerves ( spasms and cramps)

Clinical uses

• Placing of the electrodes directly over the heated parts prevents cooling by evaporation.
• Deep hypermia causes: An increased arterial flow with more oxygen and improved nutrition
while the greater venous flow carries away larger degree the products of local metabolism.
• It promotes disintegration of inflammatory exudates and assist in their resort from by
decreasing the swelling, relief of pain and restoration of the function clinically.
• The pain and spasm relieving effect of diathermy makes its used indicated in irritation of
sensory and motor nerves.
• In traumatic and inflammatory conditions of bursas, bones and joints after the acute stage.
• In painful and exuberant callus formation and fibrous ankylosis, joint injuries.
• In post operative adhesions in extremities.
• Spastic conditions of the stomach.
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 • In the treatment of neuritis and certain conditions of neuralgia or myalgia.
• In the treatment of chronic infections.

Contra Indications

• In acute inflammatory process accompanied by fever and suppuration

• In tendency to hemorrhage recent hemoptysis
• In malignant tumors.

APPLICATION OF DIATHERMY

Methods of applications

• Heating in the electrical field

o It is the physical characteristic of electrical oscillation of very high frequency that in a
capacitor arrangement with conductive tissue placed in between two electrodes, part
of the electric charge will pass is a conduction current of heat the higher the
frequency of current applied the greater is the capacitative component and the
smaller is the conductive current component. These high frequency oscillation can
therefore be conveyed to the body through a layer or air, insulating pad or an
insulated cable.
• Heating in the electro magnetic field
o A flexible heat insulated cable in the form of the coil or loop is placed in the form of a
pancake over part of the body.
o The high frequency current traversing such a coil creates a magnetic field and in
conducting substance placed inside this field induced currents known as eddy
currents and these flow in a direction opposite to that of changing current in the coil.
o The eddy current induced in the more conductive materials will be more intense.
Meeting in an electro magnetic field is especially effective is vascular tissue
(Inductothermy).
• Microwave heating
o This is eradiated electro magnetic fild the energy is deemed from an antenna or
redistor and no contact is required for its transmission. Physiological effects.
o Physiological and clinical effects of diathermy are due to raising of the temperature
of the parts under influence of the heating currents.
• Irritation to the tissues by the body maintains a constant temperature when heat is applied
to apart from any external source the vasomotor mechanism response with an effort to
dissoate the excess heat.
• Irritation to the tissues by the application of heat produces releases of vaso dilator
substance (Histamine) which in turn results in the dilation of the capillaries and produce
local hyperemia.
• Local thermal stimulation of skin area exerts reflex reactions of deeper structures localized
hyperemia in the corresponding inner organ.
• With a general rise in the temperature of the body the warm blood circulating through the
heat regulating centers in this hypothalamus will bring about a discharge of impulses to
increase the dissipation of heat results in
o Generalized vaso dilatation
o heat loss by increased radiation conduction and convention.

TECHNIQUE OF SHORT WAVE AND MICROWAVE DIATHERMY

Technique of short wave diathermy

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 • Each of the forms of short wave diathermy application involve the use of different types
electrodes.
o Electric or condenser field meeting – flexible condenser pads, air spaced plate, single
and double cuffs.
o Electro magnetic field heating – Inductance cable wound around part or placed upon
body in from of loop paheaka col of treatment drum.
o Electric or condenser field heating Electric field heating consists of supplying two
space metal electrode condenser pads and cuffs or air space electrodes on either posit
surfaces or the same body surfaces to heat the interposed parts.
 Condenser pads are held in place by elastic bandaging or perforated rubber
band – the advantages of the pad is this pliability, which allows bending or
shaping them to conform with the surfaces to be treated.
 Double Cuffs: Consists of a pair of long or narrow condenser pads that are
applied along lymph flow at suitable distance from each other. They should be
so placed that they include only or the part to be heated and the skin
electrodes distance under both cuffs should be equal.
 Air spaced condenser plates: Consists of circular metal plates or disks covered
with insulating material.
 Inductance Coil: For coil fill heating or inductothermy 2 or 4 thickness of
Turkish toweling should be placed between the cable and skin. There should
be 2 or 4 turns of the cable spaced one inch or more apart. In all inductance
cable treatment the ends of the cable leading to the apparatus should be of
equal length and should be supplied by at least the distance of the outlets of
the apparatus.

Technique of microwave diathermy

• The minimum spacing with any director is 1-2 inches. In applying microwave diathermy one
should see that the surfaces treated are dry and no toweling should be placed over the skin,
equip mental moisture can be wiped off from time to time.
• The director should not be used without their protective coverings.
• The directory should never be placed with an open side against the metal surface of a table.
• Special care is advised in treating the region of the head speciality the eyes.

ELECTRO THERAPY

• Electricity employed for the diagnosis of certain nerves and muscular legions is called as
Electro Diagnosis and the treatment of different affections by electricity is called electro
therapy.
• Electro Diagnosis Electricity used in this respect reveals information on the degree of
contractibility of muscles, the integrity of alterations of motor nerves. To ascertain the
degree of contractibility of muscles, the continuous and reduce currents are applied.

Technique

• The positive electrode is usually placed at the level of spinal cord in the anterior part of the
dorsal vertebrae for the examination of the muscles of the forelimb and in the lumbar
region for the examination of the hind limbs. The other electrode is placed on the motor
nerves or the muscles to be examined. The excitement is said to be direct when it acts on the
muscle itself and indirect when it acts on the muscle itself and indirect when it acts on the
motor nerve.
• Diagnosis of the affections will depend upon
o Whether there is hyper excitability or hypo excitability.

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 o Whether contractions are produced with both faradic (AC) and Galvanic (DC)
currents or by DC or only by AC.
o Whether any difference in the contractions (excitability) is noticed by stimulation
with
• Galvanic current after inter change of the electrode.
o Hypo or Hypor excitability: Type excitability is present when a strong current then
normal is required to induce contraction. In hyper excitability contraction is
obtained with relatively weak current.
o Response to AC / DC Currents: Either DC or AC currents produce normal
contractions. In case of pertiel degeneration of muscles only galvanic current ( DC)
produce milk contraction of the muscle whereas with faradic current no contraction
will occur. In case of complete degeneration both currents (AC/DC) will not produce
contractions.
o Response to inter change of electrodes – On Galvanic stimulation of normal muscle
maximim response in flow of current will be seen when the cathode is placed distally
(KCC ACC i.e. the cathode closing current is higher than the anode closing current).
In case of partically degenerated muscles maximum response will be soon in the flow
of the current when the anode is placed distally (ACC KCC). This is called as
inversion formula of muscle currents under galvanic currents.
• Continuous currents (DC) Galvanization
o Induced currents (AC) Faradisation
o High frequent currents – Dorsonavalisation
o Electrical sparks and flashes – Fulguration.
• Indications mainly in case of paralysis and muscular atrophy. Galvanic current is used for
performance, the current should be feable and should not cause pain. The electrodes will be
placed so that the current travels the brain or cord longitudinally from the forebead or from
pole towards the lumbar region or traversly from one temple to the other, or
perpendicularly from the dorso lumbar region towards the sternum or abdomin. Electricity
does not seen to have any curative effect on legions of CNS it simply counteracts certain
accidents arising from these lesions especially muscular contractions and tropic trouble.
• To act on limbs one pole is applied on the spine at the level of cervical or lumber region and
other at the extremity of the limb. The current is applied for 5 to 6 minutes daily. In case of
paralysis of peripheral origin it acts on nerve to hasten its reparation and on the muscles to
prevent their atrophy.
• If muscles respond to faradic current the positive electrode should be at the distal part of
each muscle, the negative electrode should be on the course of the nerve at any point of its
emergence or where it is superficial 3-4 minutes is the duration of the time. If the muscle do
not react of to faradic current then use galvanic current. It is always advantageous to apply
friction to the paralysed region with or without the use of light friction.

IONOPHOROSIS

• Electricity used to cause penetration of the tissues by medicaments dissolved in water. By

the action of current the molecules agent are decomposed to or several as of which some
charge positively descend the current and other charge negatively ascend the current.
• Agents
o Sodium chloride, Salicylate of Soda, lodide of potassium, Quinine, Zinc and lithium.

Technique

• The solution must be prepared with distilled water and galvanic current is employed. The
electrode positive or negative according to the active ion of the medicament negative or
positive covered with a thick layer of cotton wool saturated with solution is placed on the
region affected and fixed by an elastic bandage to ensure close contact with the skin. The
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 other electrode is placed at a point so that the current gradually increased to a tolerate
degree for 10 – 30 minutes of every alternative day.
• Conditions: Ulcers, Neuralgia, Nuritis, Phematic arthritis and count.

Fulguration

• Employment of electrical sparks or splashes in the treatment. It is affected by means of high

frequency currents brought to an electrode which is placed at a certain distance from the
tumour projects on to it a series of long flashes.
• Strong splashes of 8-10 cm long are projected on to the wound for effects. 10-30 times are
required upon the type of tumor.
• The hemorrhage is immediately arrested and the surface of the wound becomes blackish
gray, then the paid disappears or diminishes a capacious flow of lymph occur and after a few
days granulations from followed by cicatrisation on the production of fibrous tissue which
encloses the affected part and prevent extension of the disease.
• Conditions: Ulcers, Neuralgia, Nuritis, Phematic arthritis and Gout.

ULTRASONIC THERAPY

• Ultrasound is classified as a heating agent when used therapeutically. Therapeutic heating

agents are divided into two categories. Those that heat superficial tissues and those that
heat deeper tissues. Those agents that produce temperature changes in the skin and
subcutaneous tissue to a depth of approximately 10m include hot packs and warm water
baths. These agents only elevate skin temperature with little changes in the temperature of
the under lying structures.
• Deep heating agents cause temperature elevations in tissues to depths or 3 cm or more,
without over heating the superficial tissues. Besides ultrasound, short wave and microwave
diathermy are ingluded in this category but of these, ultrasound is by far the most
appropriately designed tool.
• Ultrasound is used for diagnosis imaging of internal structures. For tissue destruction
surgery for tumour irradiation and liportripsy, for physical therpy to promote deep tissue
healing and restores function in points. The various properties of ultrasounds are listed
below.

Physical properties

• A molecule set in motion will cause its neighbour to move, and in turn its neighbour, until
the vibration has propagated throughout the material. Propagation of vibratory motion is
the basic element of sound wave production.
• The vibratory frequency of sound wave affects its absorption into body tissue.
• The higher the frequency, the less the sound waves diverge. Sound waves at greater than the
audible sound range (20-20000 Hz) appear to spread out in all directions.
• Physical therapy devises products – beam of sound at a frequency of one million cycles per
second (1 MHz) that is sufficiently collimated to penetrate to selected target tissues.
• As sound wave frequency increases, its absorption by the tissue increases. As absorption
increases there is less sound energy available to propagate further through the tissues.
• The rapeutic frequencies of 1 MHz penetrate as deep as 4 – 6 cm into the tissues. Tissues
with a high fluid content, such as blood and muscle, will absorb sound waves better than
less hydrated tissues.
• Nerve tissue has a high coefficient of ultrasound absorption. This expands treating
possibilities to sounding nerve roots that are associated with peripheral conditions.

Treatment method
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 • Which will result in deep overdosing means an application schedule that is too high in
intensity level or too frequent or prolonged result is deep tissue damage. Beneficial results
should be noted reuses the lesion and the dosage.
• Limit total treatments to twice. Once the treatment has begun the therapist must keep the
sound head moving slowly and steadily over the target area.
• Avoid holding the wound head stationary since this will produce hot spots with the potential
of tissue damage. The deep should cover about 4 cm sec-1. the purpose or the motion is to
distribute energy as evenly as possible though our the tissue.
• Under water or immersion fechning under water or immersion technique. It is
recommended where body curvature or body prominences make it difficult to keep the
sound hard flit on the skin surface. Ultrasound can be administered by the immersion
technique when the roof is to be crated.
• For the immersion technique the sound head is held 0.5 to 3.0 cm from the surface of the
area of the area to be treated. As air bubbles accumulates on the skin surface or on the face
of the sound head they must be wiped away.

THERMAL, CHEMICAL AND THERAPEUTIC EFFECTS

Thermal effects

• The ultrasound wave travels through the medium, mechanical energy is converted to heat.
The heat diffuses into surrounding tissues by waves reflecting off acoustic inhomogenetics
such as tissues interfaces or dissolved gas bubbles.
• With in the body tissue, wave reflection is greatest at interfaces of bone and soft tissue
because of the greatest difference in their acoustical absorption.
• Soft tissues in the body behave as liquids, and bone behaves as a solid in the way they
sustain sound waves. (Reflected waves called transverse or a hear waves, interact with
incoming longitudinal waves. Although liquids cannot sustain a hear waves, solids etc.,
• Blood vessels and membranes in the path of the interacting waves could also suffer thermal
damage. When the highly innervated periosteam isovarheated, pain results.
• Thermal damage can be avoided by using low intensities and by steadily moving the sound
head over an area if done is close to the skin surface.
• Absorption of ultrasound takes place on the molecular level and protein molecules are the
major absorbers skin and subcutaneous fat do not absorb ultra sound well, so the skin
surfaces may remain cool while underlying structures are heated. This unique
characteristics among heating modalities makes ultrasound an ideal therapeutic total for
sports insures, such insures usually occur to the nerves, ligaments, tendons, joint capsules
and muscles, all tissues with a high protein component and high coefficients of ultrasound
absorption.
• Sound wave reflection occurs at interface such as nerve and nerve sheath, muscles sheath
and muscle, point capsule tissue and the tissue surroundings it. The interaction of incoming
and reflected waves at these interfaces causes selective heating of these tissues.

Chemical effects

• Ultrasound is unique among the heating modalities because of it supplementary non-

thermal effects, these chemical changes that must be attributed to mechanism other than
tissues temperature increases.
• Ultrasound waves are made up of alternating areas of compression and rarefaction
increased density and pressure (compression) areas of decreased density and pressure
(Rarefaction).
• Rarefaction causes air bubbles in the blood or tissues fluids to expand because of the
decrease in pressure. During expansion gas enters the bubble.

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 • The compression phase for the wave caused the gas to flow out of the bubbles.
• Rarefaction and compression phase forms the gaseous exchange with exerts mechanical
stress on the surrounding called cavitations, a nerve that refers so to variety of bubble
activities ranging a from stable vibration in response to the regularly repeated pressure
change induced by the sound wave, to violent implosion of the bubbles under high
ultrasound intensities.
• Cavitations produces some of the therapeutic benefits of ultrasound. Ultrasound
administered with the therapeutic range produces stable cavitations. Stable cavitations
produce
o An increase in prote in eventhes is and cell permeability.
o It has a electrolytic effect.
o Useful in the breaking up of calcified deposits.
o Increasing in the extensibility of tight capsule tissue.
o Cavitations can occur readily in a point into which effusion has occurred due to the
lower viscosity of the fluid.
o Higher intensities than those used therapeutically produce unstable cavitations. It
results in the collapse of bubbles under the influence of changing pressures in an
ultrasonic wave. Bubble implosion causes high temperature and pressure which can
be destructive. Locally, cells are destroyed and free radicals are produced.
o Acoustic streaming: an other non – thermal effect of ultrasound is acoustic streamed.
Sometimes called micro streaming or micro massage. It refers to liquid flow along
cell membranes pushed by the pressures of the sound wave. It is therapeutically
valuable
 in facilitating diffusion of ions and metabolites across the membrane.
 change in membrane permeability to sodium ions could be involved in the
altered electrical activity in nerves, resulting in pain relief.
 increased membrane permeability to sodium and calcium exchange may
explain the effect on contractile tissue in reduction of muscle spasm.

Therapeutic effect

• An increase in point range of motion

o stiffness and a decrease in flexibility must be addressed with stretching exercise to
region normal point function. Stretching exercises are facilitated by the heating
effects of ultrasound.
o Elevating the tissue temperature before passive or active stretching will enhance the
effects of the stretch.
o Preheating connective tissue before it is stretched produces a greater residual
increase in tissue length with less potential damage.
o Heating of the deep tissues alters the elastic properties of collagen tissue and its
molecular bonding. Deep tissues surrounding a joint are rich in collagen. Because
ultrasound selectively heats this type of tissue, it is the ideal modality for pre-streatch
heating.
o scar tissue is rich in collagen and more dense than the surrounding tissue. It can be
selectively targeted by ultrasound.
• Decrease in pain and muscle spasm
o It reduce pain following injury or surgery.
o Ultrasound has an effect on nerve fibre conduction
o Ultrasound therapy was used successfully on painful neuromas and post –operative
scars.
o It is useful in back pain and herniated intervertebral disc syndrome.
• Calcium deposits: Ultrasound can be used to stimulate the resorption of calcium deposits
splints.
• Wound healing
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 o Wound healing is more rapid when wounds are treted with ultrasounds. Acoustics
streaming may play a part tissue repair.
o Ultrasound promotes the healing of pressure sores increase the rate of protein
synthesis by fibroblasts, increased lysosomal permeability.
o It anhances tendon repair.

PHONOPHORESIS

• It is a special use of ultrasound in which the sound waves aid in the transport of
medications through tissue membranes. The sound wave drives whole molecule
subcutaneously up to a depths of 6 cms.
• The medications used in phononhores is are anti-inflamatory agents and anaesthetics.
Hydrocorotisone is the drug used most often in the treatment to tendoints, epicondylitis,
burnitis and other myofacial pathologies. For this technique mix the drug in proportions of
5 to 10% into the transmission gel. Use the continuous wave ode and an intensity range of
0.3 to 0.5 Wcm-2. The duration of application is up to ten minutes for a 5cm-2 area.

Continuous versus pulsed wave

• Most ultrasound units offer a choice of wave modes, the continuous wave and the pulsed
wave. The mode choices allow therapist to treat a broader range of conditions and offer the
opportunity to produce a greater range of effects. Use the continuous wave form when
heating is desired. This mode delivers an uninterrupted rain of sound waves and is useful
for treating heavily muscled areas such as the gluts, the back, or the shoulder muscles.
• Muscles blood flow provides a cooling mechanism so tissue interfaces are notoverheted in
such area as long as the sound head is moved steadily. The wave train is interrupted at
specific intervals in the pulsed mode. This reduces the total number of waves produced in
any second of treatment. Breaks in the wave train occur so that heat can be dissipated by
circulation.
• Use pulsed ultrasound then effects other than heat are desired. The non-thermal effects of
ultrasounds include acoustic streaming. Which enhances the process of diffusion. In this
regard, pulsed ultrasound would be effective in reducing the oedema associated with recent
soft tissue injuries. Pulsed ultrasound is also useful when the areas to be treated as small
and there s little room for sound hear movement.

Dosages

• To arrive at the appropriate usage, consider power output intensity (Watts), the duration of
exposure, and the size of the surface areas over the structures to be treated. The intensity
dosage is determined by the amount of soft tissue in the target area. Higher soft tissued 1.5
to 2.0 Wcm-2 than less of tissue. 0.5 to 1.0 wcm-2 before stretching exercises higher
intensities for pain, reduction, spasms relief and oedema dispersal low intensities –0.3 to
5.0 wcm-2.
• Duration of treatment depends on the condition treated and the size of the treatment site.
The size of the area to be treats is two to three times the sins of the surfaces of the sound
head. An area of this size should be sonated for it should be subdivided into small treatment
areas each treated for five minutes.

Treatment precautions

• The occurrence of pain during treatment can be attributed to over heating of superficial
compact bone. This may lead to the eventual thinking of bone. It is caused by prolonged use
or use at top high an intensity.
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• The uterus should not be exposed to therapeutic ultrasound during pregnancy because of
the possibility of caviatation in the amniotic fluid.
• The heart should not be directly sonated at therapeut wcm levels because the possibility
exists that it may change action potentials and contrtactile properties of the myocardium.
• Ultrasound should not be used repeatedly over or near growth centers of bone until bone
growth is essentially complete. Laboratory experiments demonstrate high number of
exposures at therapeutic levels or a low number of exposures at high level of intensity
results in damage to the epiphyseal cartilage. Widening of the epiphyseal plate and
premature closure. The number of treatment should be kept under ten with low intensity.
• Ultrasound should not be used on an injured area immediately after exercise. Irrigation for
the exercise would be increased by ultrasound sprains, water at a lower temperature may be
applied, but if it is very cold, it should only be used intermittently. In Veterinary practices
the water is usually applied directly to the part instend of being allowing to flow through a
coil of rubber or metal tubing laid on the part short wave length Ultra violet. These lamps
emit Ultra violet radiation a minimum perceptible erythemal at 5 minutes at 24 inches.

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