Magnetic Resonance Imaging of the Equine Fetlock

Sue Dyson, MA, VetMB, PhD, and Rachel Murray, MA, VetMB, MS, PhD

Indications for magnetic resonance imaging (MRI) of the fetlock region are discussed.
Normal anatomy is described by reference to figures illustrating sagittal, transverse, and
dorsal plane scans using T1-weighted spoiled gradient echo, T2ⴱ gradient echo, and short
tau inversion recovery (STIR) sequences. Examples of the more common abnormalities
identified using MRI are provided.
Clin Tech Equine Pract 6:62-77 © 2007 Elsevier Inc. All rights reserved.

KEYWORDS MRI, metacarpophalangeal joint, metatarsophalangeal joint, digital flexor tendon

sheath, deep digital flexor tendon, superficial digital flexor tendon, suspensory ligament,
oblique sesamoidean ligament

N ormal magnetic resonance imaging (MRI) anatomy of

the metacarpophalangeal joint has been described us-
ing a low-field magnet,1-4 but to date there are no published
studies of normal findings using a high-field magnet. There
are isolated references to identification of lesions of the sub-
chondral bone in the fetlock region,3,5 but to date there no
more detailed descriptions of lesions that might be detected
using MRI that are not detectable using conventional means.
The aims of this paper are to describe normal anatomy
with reference to the metacarpophalangeal (MCP) joint, to
discuss indications for the use of MRI and its potential limi-
tations, and to discuss the results of clinical experience using
high-field MRI in both MCP and metatarsophalangeal (MTP)
joints from January 2001 to August 2005.
Normal Anatomy
Normal MRI anatomy of an adult metacarpophalangeal joint
is illustrated in Figs. 1– 6. The subchondral bone thickness of
the distal aspect of the third metacarpal bone varies from
dorsal to palmar and from abaxial to axial, being thinnest
axially (Figs. 1C and 2C) and thickest in the middle of each
condyle, especially toward the palmar aspect (Figs. 1A and B,
2A and B, 4A and B, 5D, and 6C). The subchondral bone
thickness of the proximal phalanx increases slightly toward
the palmar aspect of each condyle. There is reasonable me-
diolateral symmetry in subchondral bone thickness of both
the third metacarpal bone and proximal phalanx. The artic-
ular cartilage is best evaluated in a combination of T1- and
T2-weighted images and is a thin layer of intermediate signal
intensity. The insertion of each branch of the suspensory
ligament and the short, cruciate, oblique, and straight sesa-
Centre for Equine Studies, Animal Health Trust, Suffolk.
Address reprint requests to: Sue Dyson, Centre for Equine Studies, Animal
Health Trust, Lanwades Park, Kentford, Newmarket, Suffolk, CB8 7UU,
England. E-mail: sue.dyson@aht.org.uk
moidean ligaments have more heterogeneous and higher sig-
nal intensity compared with the superficial digital flexor ten-
don (SDFT), deep digital flexor tendon (DDFT), and the
common (dorsal) and lateral digital extensor tendons. There
is focal hyperintense signal in the axial palmar aspect of the
DDFT, representing a blood vessel (Figs 5A, B, F–H, and 6A
and G).
Indications for MRI
of the Fetlock Region
The fetlock region is more accessible than the foot for imag-
ing using radiography, ultrasonography, nuclear scintigra-
phy, arthroscopy, and endoscopy, thus the indications for
MRI are fewer than in the foot. The primary circumstance
when MRI is indicated is if (1) pain has been localized to the
fetlock region using perineural analgesia, or by intrasynovial
analgesia of the metacarpophangeal (MCP) (or metatarsopha-
langeal [MTP]) joint or the digital flexor tendon sheath
(DFTS); (2) there are no radiological or ultrasonographic
abnormalities sufficient to explain the degree of lameness; (3)
there is no effusion in the joint (effusion may indicate that
arthroscopy is likely to be useful), or arthroscopic evaluation
revealed no abnormality; and (4) there is no effusion in the
DFTS, warranting endoscopic exploration. It should be rec-
ognized that palmar (plantar) digital nerve blocks performed
at the level of the base of the proximal sesamoid bones have
the potential to influence fetlock region pain. Intra-articular
analgesia may also influence extra-articular structures, such
as the proximal aspect of the oblique sesamoidean ligaments.
MRI may also be indicated if there is effusion in the DFTS, but
no other detectable ultrasonographic abnormality. Whereas
endoscopic evaluation of the DFTS may reveal surface defects
of the SDFT, DDFT, or manica flexoria, abnormalities of the
internal architecture of these structures may only be detected
using MRI. Occasionally, in very thick-skinned cob-type

62 1534-7516/07/$-see front matter © 2007 Elsevier Inc. All rights reserved.

doi:10.1053/j.ctep.2006.11.006
MRI of the equine fetlock 63

Figure 1 Refer to key for figure labeling for Figs. 1– 6. All trans-
verse and dorsal (frontal) plane MR images are orientated with
lateral to the left. Figs. 1– 6 all illustrate the same limb, which
had chronic distension of the digital flexor tendon sheath of no
clinical significance. Parasagittal (A and B) and sagittal (C) T1-
weighted SPGR MR images of a metacarpophalangeal joint of a
mature Grand Prix showjumper. Key to labelling figures 1-6: 1,
Third metacarpal bone; 1a, Sagittal ridge of third metacarpal
bone; 2, Proximal phalanx; 2a, Palmar eminence of proximal
phalanx; 3, Proximal sesamoid bone; 4, Suspensory (interosse-
ous) ligament; 5, Oblique sesamoidean ligament; 6, Fluid in
digital flexor tendon sheath; 7, Fluid in metacarpophalangeal
joint; ¡, Articular cartilage; 8, Common (dorsal) digital exten-
sor tendon; 9, Dorsal synovial fold or plica; 10, Metacarpopha-
langeal joint capsule; 11, Deep digital flexor tendon; 12, Straight
sesamoidean ligament; 13, Intersesamoidean (palmar) ligament;
14, Superficial digital flexor tendon; 15, Palmar annular liga-
ment; 16, Lateral digital extensor tendon; 17, Collateral ligament
metacarpophalangeal joint; 18, Manica flexoria; 19, Accessory
digital extensor tendon; 20, Proper palmar digital vein; 21,
Proper palmar digital artery; 22, Extensor branch of suspensory
(interosseous) ligament; 23, Proper palmar digital nerve; 24,
Skin; 25, Cruciate sesamoidean ligament; 26, Oblique sesam-
oidean ligament; 27, Short sesamoidean ligament; 28, Ergot; 29,
Proximal scutum.
64 S. Dyson and R. Murray

Figure 2 Parasagittal (A and B) and sagittal (C) T2ⴱ GRE MR images of a metacarpophalangeal joint.
MRI of the equine fetlock
Figure 3 Parasagittal (A) and sagittal (B) STIR MR images of a metacarpophalangeal joint.
horses, it may be physically impossible to image the palmar
soft tissue structures ultrasonographically and MRI may be
indicated.
Common Abnormalities
Examples of typical lesions are illustrated in Figs. 7–13. The
most common abnormalities seen involved the third meta-
carpal bone, reflecting trauma of the subchondral bone, with
or without associated cartilage pathology. Comparison of T1-
and T2-weighted images and fat suppressed images is crucial
to determine the nature of the pathological changes
(Figs. 7-9). The proximal phalanx was less frequently af-
fected (Figs. 10 and 11). Lesions of the SDFT and the DDFT
were identified in the absence of detectable ultrasonographic
abnormalities (Figs. 12 and 13), usually in association with
distension of the DFTS. A lesion of the proximal aspect of an
oblique sesamoidean ligament was seen in a horse that had
not been examined ultrasonographically because a positive
response to intraarticular analgesia had suggested intraartic-
ular pathology. In 1 of approximately 50 horses examined,
no lesion was identified to explain the lameness.
65
Conclusions
MRI has the potential to provide additional information
about lesions causing lameness in the fetlock region, but
knowledge of normal anatomy and its variations is essential
for accurate interpretation.
References
1. Park R, Nelson T, Hoopes J: Magnetic resonance imaging of the normal
equine digit and metacarpophalangeal joint. Vet Radiol 28:105-116,
1987
2. Martinelli M, Kuriashkin I, Carragher B, et al: Magnetic resonance im-
aging of the equine metacarpophalangeal joint: three-dimensional re-
construction and analysis. Vet Radiol Ultrasound 38:193-199, 1997
3. Martinelli M, Baker G, Clarkson R, et al: Correlation between anatomic
features and low-field magnetic resonance imaging of the equine meta-
carpophalangeal joint. Am J Vet Res 57:1421-1426, 1996
4. Martinelli M, Baker G, Clarkson R, et al: Magnetic resonance imaging of
degenerative joint disease in a horse: a comparison to other diagnostic
techniques. Equine Vet J 28:410-415, 1996
5. Zubrod C, Schneider R, Tucker R, et al: Diagnosis of subchondral bone
damage using magnetic resonance imaging in eleven horses. J Am Vet
Med Assoc 24:411-418, 2004
66 S. Dyson and R. Murray

Figure 4 Dorsal (frontal) images from dorsal (A) to palmar (C) of a metacarpophalangeal joint.
MRI of the equine fetlock 67

Figure 5 Transverse T1-weighted SPGR MR images of the fetlock region from proximal (A) to distal (H).
68 S. Dyson and R. Murray

Figure 5 (Cont’d)
MRI of the equine fetlock 69

Figure 6 Transverse T2ⴱ GRE MR images of the fetlock region from proximal (A) to distal (G), equating to Figs.
5B–H.
70 S. Dyson and R. Murray

Figure 6 (Cont’d)
MRI of the equine fetlock 71

Figure 7 Lateral parasagittal SPGR (A) and T2ⴱGRE (B), dorsal SPGR (C), trans-
verse SPGR (D), and transverse STIR (E) MR images of a right metatarsophalan-
geal (MTP) joint of a Grand Prix showjumper. There was no effusion of the joint,
but lameness was improved by intraarticular analgesia. There was moderate focal
increased radiopharmaceutical uptake in the lateral condyle of the third meta-
tarsal bone (MtIII). There is diffuse decreased signal intensity in the lateral
plantar condyle of MtIII in T1- and T2-weighted images (white arrows) consis-
tent with mineralization and fluid, with focal increased signal intensity in the
cortex extending into the cancellous bone (black arrow), consistent with pro-
teinaceous fluid. In the STIR image, there is a diffuse mild increase in signal
intensity throughout the plantar two-thirds of the condyle (arrow heads) consis-
tent with loss of fat signal. Subsequent arthroscopic evaluation via the plantar
pouch of the MTP detected no cartilage surface abnormality. The horse has
returned to competition following prolonged rest.
72 S. Dyson and R. Murray

Figure 8 Parasagittal SPGR (A) (i ⫽ lateral; ii ⫽ medial), T2ⴱGRE (B), and transverse T2ⴱGRE (C) MR images of the left
metatarsophalangeal (MTP) joint of a 4-year-old Thoroughbred flat racehorse with recurrent left hindlimb lameness
abolished by plantar and plantar metatarsal nerve blocks and improved by intraarticular analgesia of the MTP joint.
There was mild diffuse increased radiopharmaceutical uptake throughout the fetlock joint region. There is a larger area
of decreased signal intensity in the plantar aspect of the lateral condyle (AI, B [arrows], and C) in both T1- and
T2-weighted images compared with the medial condyle (aii). Signal intensity was normal in fat suppressed images. This
is consistent with mineralization. There is also decreased signal intensity in the dorsal aspect of the lateral proximal
sesamoid bone (C, arrow). Recurrent lameness persisted.
MRI of the equine fetlock 73

Figure 9 Lateral parasagittal SPGR (A), dorsal SPGR (B), dorsal T2ⴱG RE (C), lateral parasagittal STIR (D), and
transverse STIR (E) images of the left metacarpophalangeal (MCP) joint of a 4-year-old Warmblood dressage horse with
sudden onset lameness improved by intra-articular analgesia. There was intense increased radiopharmaceutical uptake
in the distal aspect of the third metacarpal bone (McIII). In (A), there is diffuse decreased signal intensity extending
from the dorsal to plantar aspects of the lateral condyle of McIII (white arrows). In (B) and (C), there is decreased signal
intensity in the lateral and medial condyles of McIII and the proximomedial aspect of the proximal phalanx (white
arrows), consistent with mineralization, with focal increased signal intensity laterally in the subchondral bone (arrow-
head), consistent with proteinaceous fluid and altered signal intensity in the overlying cartilage. In (D), there is mild
increased signal intensity on the dorsal aspect of McIII (arrows), and in (E), there is intense increased signal intensity
laterally adjacent to the origin of the lateral collateral ligament of the MCP joint. No abnormality of the ligament was
detected.
74 S. Dyson and R. Murray

Figure 10 Sagittal SPGR (A) and sagittal (B), dorsal (C), and transverse (D) STIR MR images of the right metatarsopha-
langeal (MTP) joint of an 8-year-old Warmblood showjumper with lameness abolished by plantar and plantar meta-
tarsal nerve blocks, but not affected by intraarticular analgesia of the MTP joint. In the T1-weighted image there is focal
linear decreased signal intensity in the proximal aspect of the proximal phalanx (black arrow) and focal increased signal
intensity in the opposing subchondral bone of the third metatarsal bone (white arrow). In the STIR images, there is focal
increased signal intensity in the cancellous bone in the proximal aspect of the proximal phalanx (white arrow).
Lameness persisted and post mortem examination revealed a cyst-like lesion in the proximal phalanx.
MRI of the equine fetlock 75

Figure 11 Dorsal SPGR (A), T2ⴱ GRE (B), and STIR (C) and transverse SPGR (D) images of the left metacarpophalangeal
joint of an 8-year-old Thoroughbred event horse with lameness of 2 months duration. Lameness was abolished by
palmar (abaxial sesamoid) nerve blocks. There was subtle sclerosis of the proximomedial aspect of the proximal
phalanx evident radiographically and focal intense increased radiopharmaceutical uptake in the proximal aspect of the
proximal phalanx. There is diffuse decreased signal intensity in the proximal medial aspect of the proximal phalanx
(black arrows) in both T1- and T2-weighted images (A, B, and D), involving only the cancellous bone, with more focal
decreased signal intensity in the opposing aspect of the third metacarpal bone (white arrow). There was mild increased
signal intensity in STIR images in the same region (C) (black arrows), consistent with both mineralization and fluid. The
horse returned to full athletic function.
76 S. Dyson and R. Murray

Figure 12 Transverse SPGR (A and B), sagittal GRE (C), and sagittal STIR MR images of the right metacarpophalangeal
joint of a 3-year-old Thoroughbred racehorse. The horse had a sudden onset of severe lameness after racing associated
with distension of the digital flexor tendon sheath. Repeated ultrasonographic examinations had revealed slight
enlargement in cross-sectional area of the superficial digital flexor tendon (SDFT) in the distal metacarpal region but no
other abnormality. There is increased signal intensity (arrows) in the enlarged SDFT in all image sequences (arrows).
The lesion extended from the distal aspect of the metacarpal region to the insertion of the medial branch of the SDFT.
MRI of the equine fetlock 77

Figure 13 Transverse T2ⴱGRE (A and C) and SPGR (B) images of the right front fetlock region of a 9-year-old Grand Prix
showjumper with recurrent lameness associated with distension of the digital flexor tendon sheath (DFTS). There are
irregularities of the dorsal medial aspect of the deep digital flexor tendon (DDFT) (A and C) (arrows) and a medial defect
(B) (arrow). Note also the focal hyperintense signal in the superficial digital flexor tendon (arrowhead; C). The DFTS
was explored endoscopically and the DDFT lesions identified using MRI corresponded with fibrillation and granulation
tissue on the dorsal aspect of the tendon, and a medial split. However the internal lesion within the SDFT was not
apparent. Other focal lesions were also seen on MR images within the DDFT, and these lesions may account for the
rather disappointing success rate of surgical debridement of superficial defects.