Assessment of the tissue diffusion

of anesthetic agent following administration

of a low palmar nerve block in horses
Kathryn A. Seabaugh, ms, dvm; Kurt T. Selberg, ms, dvm; Alejandro Valdés-Martínez, mvz, dacvr;
Sangeeta Rao, bvsc, mvsc, phd; Gary M. Baxter, vmd, ms, dacvs

Objective—To investigate tissue diffusion of anesthetic agent following administration of

low palmar nerve blocks (LPBs) in horses.
EQUINE

Design—Randomized clinical trial.

Animals—12 adult horses.
Procedures—In 9 horses, mepivacaine hydrochloride–iohexol (50:50 dilution) injections
were administered bilaterally (2 or 4 mL/site) to affect the medial and lateral palmar and
palmar metacarpal nerves (4 sites). Lateral radiographic views of both metacarpal regions
were obtained before and at 5, 15, 30, 60, 90, and 120 minutes after block administration;
proximal and distal extents of contrast medium (and presumably anesthetic agent) diffusion
from palmar and palmar metacarpal injection sites were measured and summed to deter-
mine total diffusion. Methylene blue solution was injected in forelimbs of 3 other horses
that were subsequently euthanized to determine the potential route of anesthetic agent
diffusion to the proximal suspensory ligament region.
Results—Mean extents of proximal and total contrast medium diffusion were 4.0 and 6.6 cm,
respectively, for the palmar metacarpal nerves and 4.3 and 7.1 cm, respectively, for the palmar
nerves. Subtle proximal diffusion secondary to lymphatic drainage was evident in 17 of the 18
limbs. Contrast medium was detected in the metacarpophalangeal joint or within the digital
flexor tendon sheath in 8 and 7 limbs, respectively. In the cadaver limbs, methylene blue solu-
tion did not extend to the proximal suspensory ligament region.
Conclusions and Clinical Relevance—In horses, LPBs resulted in minimal proximal diffusion
of anesthetic agent from the injection sites. Limbs should be aseptically prepared prior to LPB
administration because inadvertent intrasynovial injection may occur. (J Am Vet Med Assoc
2011;239:1334–1340)

T he use of local anesthesia is an integral aspect of a thor-

ough lameness evaluation in horses. Intra-articular or
perineural anesthesia can be a more specific and sensitive
diagnostic tool for the localization of lameness than palpa-
tion and joint flexion tests. The LPB, also known as the
low volar, low 4-point, or palmar and palmar metacarpal
nerve block, is frequently used for localization of a source
of lameness in the forelimbs of horses. A similar block can
be performed in the hind limb, but the anatomic features
differ slightly. In the study reported here, only the LPB was
of interest.
An LPB anesthetizes the medial and lateral branches
of both the palmar metacarpal and palmar nerves proxi-
mal to the MCP (fetlock) joint.1–6 The palmar metacarpal
nerves are located axial to the second and fourth metacar-
pal bones and innervate the deep structures of the MCP
joint.5,6 The palmar nerves are located within the groove
From the Departments of Clinical Sciences (Seabaugh, Rao, Baxter)
and Environmental and Radiological Health Sciences (Selberg,
Valdés-Martínez), College of Veterinary Medicine and Biomedical
Sciences, Colorado State University, Fort Collins, CO 80523. Dr.
Baxter’s present address is Veterinary Teaching Hospital, College of
Veterinary Medicine, University of Georgia, Athens, GA 30602.
Presented as an abstract at the 55th American Association of Equine
Practitioners Annual Convention, Las Vegas, December 2009.
Address correspondence to Dr. Seabaugh (Katie.Seabaugh@colostate.edu).
CI
Abbreviations
Confidence interval
DFTS Digital flexor tendon sheath
LPB Low palmar nerve block
MB Methylene blue
MCP Metacarpophalangeal
formed by the suspensory ligament and the deep digital
flexor tendon.2,5,6 These nerves innervate structures on the
palmar aspect of the MCP region such as the digital ten-
don sheath, proximal sesamoid bones, palmar MCP joint
capsule, and distal sesamoidean ligaments. Local anesthe-
sia of the palmar metacarpal nerves and the palmar nerves
at the level of the distalmost aspect of the small metacarpal
bones anesthetizes all distal structures in the foot as well
as the MCP joint and DFTS.
Techniques for anesthetizing the palmar metacarpal
and palmar nerves in the distal portion of the forelimbs
of horses have been described in multiple publications.1–7
For anesthesia of the palmar metacarpal nerves, needles
for injection of the anesthetic agent are placed just distal
to the distalmost aspect of the second and fourth meta-
carpal bones.1–7 Some variability exists regarding the nee-
dle placement for anesthesia of the palmar nerves. The
most commonly described needle position is level with

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the distal aspect of the small metacarpal bones between
the suspensory ligament and the deep digital flexor ten-
don.1,3–6 A second technique describes placing the nee-
dle in the same groove but more proximal to the distal
aspect of the second and fourth metacarpal bone.1,2,7
All publications1–7 describe anesthesia of each of the
4 nerves individually with 4 separate needle place-
ments. Alternatively, a longer needle can be used to
anesthetize both the medial and lateral palmar nerves
via a single injection. In that instance, the needle is in-
serted laterally and advanced to the medial side, where
anesthetic agent is deposited, and then the needle is
retracted and more anesthetic agent is deposited on
the lateral aspect.1
Tissue diffusion of anesthetic agent is a risk associ-
ated with all diagnostic anesthetic procedures. Bassage
and Ross1 suggested that proximal diffusion of local an-
esthetic solution after perineural anesthesia can lead to
desensitization of structures other than those intended.
The ability of agents injected for intra-articular anesthe-
sia to diffuse and anesthetize nearby structures is also
described.8–11 In regard to perineural anesthesia, quanti-
tative data describing the ability of the anesthetic agent
to diffuse are limited. Schumacher et al12 determined that
use of 2 different sites for needle placement to anesthe-
tize the palmar digital nerve resulted in significantly dif-
ferent anesthetic results. Those needle placement sites
were only 1 cm apart, suggesting minimal diffusion of
anesthetic agent. More recently, Nagy et al13 reported that
perineural injection of contrast medium on the palmar
aspect of the sesamoid bones resulted in an elongated
distribution pattern, suggesting diffusion of contrast me-
dium along the neurovascular bundle. A similar study14
evaluating diffusion following a low 4-point block re-
vealed that the injected contrast medium extended along
the neurovascular bundle for the palmar nerve block and
diffusely around the injection site for the palmar meta-
carpal nerve block. A significant increase in contrast me-
dium diffusion was evident during the first 10 minutes
after injection but not thereafter.13 Anecdotally and ex-
perimentally, gas artifacts in the region of the proximal
suspensory ligament can be visualized during ultraso-
nographic examination following administration of an
LPB.14,15 This raises the question of possible proximal
diffusion of anesthetic agent following administration
of an LPB, thereby confounding the localization of the
lameness to the regions distal to the site of the LPB.
The objective of the study reported here was to in-
vestigate diffusion of anesthetic agent following admin-
istration of LPBs in horses. To enable measurement of
the extent of diffusion, LPBs were performed by use of
a combination of anesthetic agent and contrast medium,
and forelimbs were monitored radiographically at inter-
vals after injection. It was hypothesized that contrast me-
dium (and presumably anesthetic agent) diffusion from
the injection site in the proximal direction would be evi-
dent within 15 minutes after injection and that diffusion
to the region of the proximal suspensory ligament would
be evident within 30 minutes after injection.
Materials and Methods
Horses—Twelve adult horses owned by the univer-
sity were included in the study. In the main portion of the
JAVMA, Vol 239, No. 10, November 15, 2011
study, 9 horses (age range, 5 to 29 years old; weight range,
510 to 660 kg [1,122 to 1,452 lb]) were used. Three addi-
tional horses were euthanized for reasons unrelated to the
study, and limbs were used to determine evidence of and
the potential route responsible for anesthetic agent diffu-
sion to the region of the proximal suspensory ligament.
For the main portion of the study, the hair on both
forelimbs of each of the 9 horses was clipped, and injec-
tion sites were aseptically prepared with chlorhexidine
solutiona and alcohol prior to injection. Five horses were
sedated with xylazine hydrochlorideb (0.3 to 0.5 mg/kg
[0.14 to 0.23 mg/lb], IV) prior to performance of the
LPBs. All horses received 1 dose of phenylbutazonec (4
EQUINE
to 5 mg/kg [1.8 to 2.3 mg/lb], PO) on completion of the
study. The horses were returned to their regular housing
and were monitored daily for any signs of lameness for 7
days. The Institutional Animal Care and Use Committee
at Colorado State University approved the experimental
protocols used in the study.
LPB administration—The LPBs were performed
by injection of a combination of mepivacaine hydro-
chlorided and iohexole (50:50 dilution) with the third
metacarpal bone supported and the MCP joint in an
extended position (n = 4 limbs) or in a weight-bear-
ing position (14 limbs), depending on the compliance
of the horse. Prior to the study, 1 limb of each horse
was randomly assigned via coin toss to receive 2 mL
of the solution/injection site, and the other limb re-
ceived 4 mL of the solution/injection site. A 5/8-inch
(1.59-cm), 25-gauge needle (n = 12 limbs/6 horses) or
1-inch (2.54-cm), 22-gauge needle (6 limbs/3 horses)
was used for each injection. Needle size was not ran-
domly assigned because the 1-inch, 22-gauge needles
were used initially and then changed to the 5/8-inch,
25-gauge needles because the smaller needles provided
better handling and more consistent injections.
Placement of the needles to achieve the LPB was per-
formed on the basis of a published description.6 To anes-
thetize the medial and lateral palmar metacarpal nerves,
the needle was placed just distal to the distalmost aspect
of the small metacarpal bones between the third metacar-
pus and the suspensory ligament. The needle was directed
at a 45° angle proximad in an attempt to deposit the an-
esthetic agent–contrast medium solution under the distal
end of the small metacarpal bones. To anesthetize the me-
dial and lateral palmar nerves, the needle was placed in
the groove between the suspensory ligament and the deep
digital flexor tendon at the level of the distalmost aspect of
the small metacarpal bones. The needle was directed per-
pendicular to the skin. The 1-inch needles were inserted
approximately halfway. The 5/8-inch needles were often
inserted all the way to the hub. All injections were per-
formed by 1 author (KAS).
On completion of the injections (designated as 0
minutes), the limbs were cleaned with alcohol to remove
any contrast medium from the skin. A horizontal, lin-
ear, radiopaque marker was placed on the dorsolateral
aspect of the third metacarpal bone at the level of the
injections. The marker was held in place with nonelastic
tape for the duration of the study. Each horse was walked
or jogged a distance of approximately 46 m (50 yards) in
the intervals between time points at which radiographic
images were obtained.
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 Radiography—Prior to obtaining the first radio-
graphic image, the proximolateral aspect of each limb
was labeled with a radiopaque number for identifica-
tion. Lateral preinjection radiographic views of the
metacarpal region were obtained in 14 of the 18 limbs.
Preinjection radiographic views were not obtained for
the first 2 horses evaluated because initially we did not
expect that such views were necessary. The purpose of
the preinjection radiographic views was to ensure that
there were no radiographic artifacts that could be con-
fused with subtle lines of contrast medium. Lateral ra-
diographic views of the metacarpal region of each limb
were obtained at 5, 15, 30, 60, 90, and 120 minutes
EQUINE
Diffusion of MB solution in forelimbs—Methy-
lene blue solutiong was injected in both forelimbs of 3
horses to determine the potential route responsible for
anesthetic agent diffusion to the region of the proxi-
mal suspensory ligament. Because of the propensity of
MB solution to spread via fascial planes, only 1 mL of
a 0.05% solution of MB was used for each nerve in all
horses. In 2 of the 3 horses, the MB solution was inject-
ed in a manner similar to the method used for horses in
the main portion of the study. In the third horse, the MB
solution was injected 1 to 1.5 cm proximal to the distal-
most aspect of the small metacarpal bones to simulate
the block for the medial and lateral palmar metacarpal

after administration of the LPBs. All radiographic im-
ages were obtained with a digital radiography unitf by
the same person (KTS).
On each radiographic view, the maximum extent of
contrast medium diffusion was measured from the points
of injection for the palmar nerves and palmar metacarpal
nerves in proximal and distal directions. Each point of
injection was identified by use of the radiopaque marker
that had been placed on the dorsolateral aspect of the
third metacarpus immediately after the anesthetic agent–
contrast medium solution injections. Proximal and distal
extents of contrast medium diffusion from the injection
sites were measured on the radiographic images; total
extent of diffusion was calculated as the sum of those 2
measurements (proximal plus distal diffusion). The ex-
tents of proximal diffusion and total diffusion of the pal-
mar metacarpal nerve block and the extents of proximal
diffusion and total diffusion of the palmar nerve block
were analyzed further. Four measurements were ana-
lyzed for each limb. Measurements were performed sep-
arately by 2 individuals (KAS and AVM). The measure-
ments determined by the authors were then averaged for
further analysis. Subtle proximal diffusion away from the
primary bulk of contrast medium was also noted, and
the presence of contrast medium within the DFTS or
MCP joint was determined from the radiographic views.
and palmar nerves. All 3 horses were then euthanized
with pentobarbital sodiumh (88 mg/kg [40 mg/lb], IV)
for reasons unrelated to this study and were not used
in the main portion of the study. The forelimbs were
dissected within 2 hours after euthanasia and within 3
hours after injection.
Statistical analysis—The association of diffusion
distance following anesthesia of each of the 4 nerves
with the volume of anesthetic agent–contrast me-
dium solution injected, time required for diffusion,
needle size (gauge), or position of limb was evaluated
via linear regression analysis. Prior to performance
of linear regression analysis, the data for diffusion
distances were evaluated for normality and linearity.
A logistic regression analysis was performed to evaluate
the probability of placement of contrast medium within
the DFTS and MCP joint with the volume of anesthetic
agent–contrast medium solution used, time required to
diffuse, needle size, and position of the limb. In both
analyses, volume of anesthetic agent–contrast medium
solution used, time required to diffuse, needle size,
position of limb, and evaluator were included as fixed
effects. Both analyses were performed using bivariable
as well as multivariable approaches. Limb side nested
within horse was included as a random effect to control

Table 1—Adjusted* mean (95% CI) proximal and total diffusion distances of contrast medium from the sites of injection of mepivacaine
hydrochloride–iohexol solution (50:50 dilution; 2 or 4 mL of solution/site) administered to achieve LPBs (2 injections affecting both the
medial and lateral branches of the palmar metacarpal and palmar nerves) in both forelimbs of 9 horses.

Palmar metacarpal nerve block Palmar nerve block

Variable Proximal diffusion (cm) Total diffusion (cm) Proximal diffusion (cm) Total diffusion (cm)
Injection volume (mL/site)
2 4.01 (3.61–4.41) 6.95 (6.53–7.36) 3.77 (3.21–4.32)a 6.11 (5.42–6.81)a
4 4.56 (4.01–5.11) 7.14 (6.68–7.60) 5.24 (4.58–5.90)b 7.99 (7.30–8.69)c
Limb position
Weight bearing 3.70 (3.30–4.10)a 6.05 (5.69–6.41)a 4.37 (3.87–4.87) 7.24 (6.71–7.76)
Non–weight bearing 4.87 (4.60–5.14)c 8.04 (7.50–8.57)c 4.63 (4.14–5.12) 6.87 (6.11–7.64)
Needle size (gauge)
22 4.12 (3.83–4.41) 6.90 (6.39–7.41) 4.61 (4.10–5.13) 7.28 (6.42–8.14)
25 4.45 (4.06–4.84) 7.19 (6.84–7.54) 4.39 (3.90–4.89) 6.83 (6.40–7.26)

To anesthetize the medial and lateral palmar metacarpal nerves, the needle was placed just distal to the distalmost aspect of the small
metacarpal bones between the third metacarpal bone and the suspensory ligament. To anesthetize the medial and lateral palmar nerves, the
needle was placed in the groove between the suspensory ligament and the deep digital flexor tendon at the level of the distalmost aspect of
the small metacarpal bones. Diffusion distances were measured on lateral radiographic views of both metacarpal regions obtained before and
at 5, 15, 30, 60, 90, and 120 minutes after LPB administration; for each injection site in each limb, proximal and distal extents of contrast medium
diffusion were measured, and total diffusion distance was calculated as the sum of those 2 measurements. In the non–weight-bearing position,
the third metacarpal bone was supported and the MCP (fetlock) joint was in an extended position.
*The adjusted mean was the mean (mean outcome in a specific category of the variable) after controlling for the effect of other variables in
the analysis model.
a–c
For a given variable, different superscript letters within a column indicate a significant difference between the 2 compared categories (a
and b, P = 0.003; a and c, P , 0.001).

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Figure 1—Lateral radiographic view of the metacarpal region of
the left forelimb of a horse obtained 5 minutes after injection of
2 mL of mepivacaine hydrochloride–iohexol solution (50:50 dilu-
tion) to achieve an LPB. Injections were administered at 4 sites
in the forelimb to affect the medial and lateral palmar and palmar
metacarpal nerves. Arrows indicate areas of subtle proximal dif-
fusion of contrast medium at this time point. The contrast visible
at the lower right is associated with the primary injection sites
for the palmar and palmar metacarpal nerves as indicated by the
horizontal linear radiopaque object (wire). The radiopaque object
present in the midmetacarpal region was placed to identify the
limb (ie, horse 3).
for the repeated measurements on the horses over time.
Data analysis was performed by use of commercially
available statistical software.i Diffusion distances were
expressed as the adjusted mean and 95% CI. The ad-
justed mean was the mean (mean outcome in a specific
category of the variable) after controlling for the effect
of other variables in the model. A value of P < 0.05 was
considered significant.
Results
Contrast medium diffusion—The LPBs were
placed successfully in all horses. None of the horses in
the study developed clinical signs of lameness or sy-
novial inflammation or infection following the nerve
blocks. Fourteen preinjection and 108 postinjection
JAVMA, Vol 239, No. 10, November 15, 2011
EQUINE
Figure 2—Lateral radiographic view of the region of the MCP joint
in the right forelimb of a horse obtained 30 minutes after injection
of 2 mL of mepivacaine hydrochloride–iohexol solution to achieve an
LPB. Injections were administered at 4 sites in the forelimb to affect
the medial and lateral palmar and palmar metacarpal nerves. Notice
that contrast medium is visible in the DFTS (large arrow) and MCP
joint (small arrow). The horizontal linear radiopaque object (wire) was
placed to indicate the site of primary injection.
radiographic views were evaluated. There were 18
limbs evaluated for each of the 6 postinjection time
points. Minimal diffusion of the bulk of the perineural
injections was evident over time. There were 4 mea-
surements of interest: the extents of proximal diffu-
sion and total diffusion of the palmar metacarpal nerve
block and extents of proximal diffusion and total diffu-
sion of the palmar nerve block. For all measurements of
interest, there was a significant difference between the
mean diffusion distances at 5 and 30 minutes after LPB
injections. However, there was no significant difference
between findings at the 15-minute time point and the
5-minute time point for any measurement of interest.
The mean proximal and total diffusion distances of the
contrast medium injected over the palmar metacarpal
nerves were 3.96 cm (95% CI, 3.75 to 4.17 cm) and
6.61 cm (95% CI, 6.40 to 6.82 cm), respectively. The
mean proximal and total diffusion distances of the contrast
medium injected over the palmar nerves were 4.33 cm
(95% CI, 4.12 to 4.54 cm) and 7.06 cm (95% CI, 6.85 to
7.27 cm), respectively.
The mean (and 95% CI) diffusion distances for the
palmar metacarpal and palmar nerve blocks in relation
to needle size (gauge), limb position, and volume of
anesthetic agent–contrast medium solution were evalu-
ated (Table 1). The diffusion distances for the palmar
metacarpal nerve block were not significantly affected
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EQUINE
Figure 3—Photograph of the palmar aspect of the left forelimb from
a horse that was injected with 1 mL of a 0.05% solution of MB in a
manner similar to the method used to achieve an LPB in horses in the
main portion of the study. The horse was subsequently euthanized;
the limb was dissected within 2 hours after euthanasia and within 3
hours of injection. Notice that MB solution is present within the DFTS.
by needle size or injection volume. Both the proximal
and total diffusion distances for the palmar metacarpal
block were significantly influenced by limb position.
Injections performed with the third metacarpal bone
supported and the MCP joint in an extended position
resulted in greater diffusion distances than those asso-
ciated with injections performed in a weight-bearing
position. The diffusion distances for the palmar nerve
block were not significantly affected by needle size or
limb position. The proximal and total diffusion distanc-
es of the palmar nerve block were significantly greater
when 4 mL of solution was injected, compared with
findings when 2 mL of solution was injected.
Evidence of subtle, linear proximal diffusion of
contrast medium was detected radiographically in 17
of the 18 limbs (Figure 1). This diffusion was appar-
ent at the 5-minute time point in 16 limbs and at the
15-minute time point in the remaining limb and was
detected for up to 90 minutes after LPB administration.
The presence of subtle proximal diffusion of contrast
medium was not affected by the volume of anesthetic
agent injected, size of the needle, or position of the
limb when the needle was placed.
Intrasynovial deposition—Contrast medium was
identified in the MCP joint in 8 limbs and in the DFTS
in 7 limbs (Figure 2). Only 2 horses received LPBs
after which contrast medium was not visible in the
DFTS or MCP joint of either limb. In 3 limbs, con-
trast medium was detected in both the MCP joint and
DFTS. Injection into the DFTS was not significantly
associated with volume of anesthetic agent injected (P
= 0.62), size of needle (P = 0.64), or position of limb
(P = 0.54) when the needle was placed. Injection into
the MCP joint also did not correlate with volume of
anesthetic agent injected (P = 0.33), size of needle (P
= 0.60), or position of limb (P = 0.27) when the needle
was placed.
Diffusion of MB solution in cadaver limbs—In
all 3 horses, MB solution was easily identified in the
region of the palmar nerves and palmar metacarpal
1338 Scientific Reports
Figure 4—Photograph of the lateral aspect of the left forelimb
from another horse that was injected with 1 mL of a 0.05% solu-
tion of MB in a manner similar to the method used to achieve an
LPB in horses in the main portion of the study. Notice that the
MB solution has tracked proximally within the lymphatic vessels.
nerves during limb dissection. The MB solution was
detected in the DFTS in 4 of 6 limbs (Figure 3) and
in the MCP joint in 2 of 6 limbs. No MB solution was
evident in the MCP joints or DFTSs of the third horse
in which the nerve block in each forelimb was per-
formed 1 to 1.5 cm proximal to the distalmost aspect
of the small metacarpal bones to simulate the block
for the medial and lateral palmar metacarpal and pal-
mar nerves. Movement of the MB solution up all limbs
via small vessels was visible (Figure 4). Histologic
examination confirmed that these small vessels were
lymphatic vessels.
Discussion
The purpose of the present study was to investi-
gate proximal or distal tissue diffusion of anesthetic
agent following administration of LPBs in horses. To
enable measurement of the extent of diffusion, LPBs
were performed by use of a combination of anesthet-
ic agent and contrast medium, and forelimbs were
monitored radiographically at intervals after injec-
tion. Results of the present study indicated that in
the forelimbs of horses, the proximal diffusion of lo-
cal anesthetic agent administered to achieve an LPB
is minimal. Following LPB injections, one should ex-
pect the most proximal aspect of the anesthetic agent
bulk to extend to no more than 5 cm proximal to the
injection site, a location that is not near the proximal
suspensory ligament region. In addition, diffusion of
the anesthetic agent (represented by diffusion of con-
trast medium in the present study) did not appear to
increase over time beyond the first 30 minutes. Inad-
vertent intrasynovial deposition of contrast medium
occurred during this study and should be considered
a risk associated with this type of perineural block.
Alternative techniques should be used in an effort
to minimize the risk of intrasynovial deposition of
anesthetic agent.
In equine forelimbs, the proximal extent of the
DFTS is a few centimeters proximal to the MCP joint16
or within the distal fourth of the metacarpus.17 The
DFTS in horses can extend proximal to the distal aspect
of the small metacarpal bones; therefore, it should not
be surprising that contrast medium entered the DFTS
in some horses in the present study. Some publications
mention that location of needle placement for the me-
dial and lateral palmar nerve blocks should be more
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proximal than the distalmost aspect of the small meta-
carpal bone1,2,7 to avoid the DFTS, and this technique is
supported by the findings of this study. Clinically, this
more proximal needle location is well tolerated by pa-
tients and would likely avoid deposition of anesthet-
ic agent into the DFTS without the risk of anesthetic
agent diffusing too far proximally.
The palmar joint capsule of the MCP joint has been
reported to extend proximally to the distal end of the
small metacarpal bones.16 Nearly all publications de-
scribe the technique for anesthetizing the medial and
lateral palmar metacarpal nerves just distal to the dis-
talmost aspect of the small metacarpal bones,1,3–7 yet
the potential for inadvertent intrasynovial deposition of
anesthetic agent is not mentioned. It was therefore sur-
prising that, in 8 of the 18 limbs injected in the present
study, contrast medium was detected within the MCP
joint. The contrast medium within the MCP joint was
quickly identified in some horses, whereas in others,
the radiopacity within the MCP joint was subtle at first
and increased in intensity during the first 30 minutes
after LPB administration. This suggests the possibility
of diffusion of contrast medium into the MCP joint fol-
lowing the LPB. To the authors’ knowledge, there are no
reports of diffusion of contrast medium into a synovial
structure as a result of a perineural injection. Therefore,
it seems more plausible that there was direct placement
of contrast medium into the MCP joint, as likely oc-
curred with some of the DFTSs. Penetration of the MCP
joint would most likely occur if the needle was not di-
rected up under the distal end of the small metacarpal
bones when the palmar metacarpal nerves were being
blocked. It may also occur in horses where the palmar
pouch of the MCP joint is more proximally located than
typically expected or in horses that have effusion of the
joint.
Modification of the technique for anesthetizing the
medial and lateral palmar metacarpal nerves is difficult
to achieve. In the present study, MB solution was in-
jected in the forelimbs of 3 horses prior to euthanasia.
In one of those horses, a more proximal needle place-
ment was evaluated; the MB solution was injected 1 to
1.5 cm proximal to the distalmost aspect of the small
metacarpal bones to investigate the potential effect of
anesthetic agent administered at that location on the
palmar metacarpal nerves and palmar nerves. Dissec-
tion of these limbs revealed successful deposition of
the MB solution around the medial and lateral pal-
mar metacarpal nerves and medial and lateral palmar
nerves. This more proximal needle placement was well
tolerated when used to affect the palmar nerves. It was
not well tolerated when used to affect the palmar meta-
carpal nerves as frequent contact with the periosteum
on the small metacarpal bones or the palmar surface
of the third metacarpal bone resulted in a strong nega-
tive response from the horse. In the few clinical cases
in which this altered block technique was performed,
the horses have reacted with apparent resentment. Be-
cause this altered technique for anesthetizing the pal-
mar metacarpal nerves is technically challenging and is
not well tolerated by patients, this modification of the
technique may not be clinically acceptable. The authors
suggest that inadvertent MCP joint placement of anes-
JAVMA, Vol 239, No. 10, November 15, 2011
thetic agent could be avoided by directing the needle
upward, keeping the needle placed superficially, and
ensuring that a subcutaneous bleb can be seen.
In the present study and 2 studies by Nagy et al,13,14
subtle proximal diffusion of the contrast medium in
a linear fashion from the injection sites was evident
radiographically. The presence of MB solution within
the lymphatic vessels, which reflected the path of the
contrast medium in the forelimb radiographic views in
both studies, strongly suggests that the anesthetic agent
diffuses proximally in injected limbs via that route.
Harkins et al18 reported that the highest dose of mepi-
vacaine that resulted in no effect was 2 mg/site. This
EQUINE
would suggest that > 0.1 mL of mepivacaine would have
to be present at the precise site of injury to desensitize
the proximal suspensory ligament. On the basis of the
small diameter of the lymphatic vessels and the limited
amount of anesthetic agent traveling through them at
any given time, it would seem unlikely that the amount
of anesthetic agent within the lymphatic vessels would
be sufficient to diffuse out of the vessel and desensitize
the region of the proximal suspensory ligament.
Variables including limb position, needle size, and
volume of injected solution were evaluated for their
effect on the extent of contrast medium diffusion in
the present study. Limb position was not randomly as-
signed but was based on the compliance of each horse
because the authors usually perform this nerve block
with the horse in a weight-bearing position. The study
findings indicated that when limbs were injected with
the third metacarpal bone supported and the MCP
joint in an extended position, the diffusion distance of
injected contrast medium for the palmar metacarpal
nerve block was significantly greater than that observed
after administration of the nerve block in weight-bear-
ing limbs. In a non–weight-bearing position, the sus-
pensory ligament may be less taut, thereby allowing
for greater diffusion. For either the palmar metacarpal
nerve block or palmar nerve block, needle size had
no significant effect on the extent of contrast medium
diffusion. In the initial stage of the study, the authors
used 22-gauge needles, suspecting that the larger-bore
needles would be necessary because of the viscosity
of the mepivacaine hydrochloride–iohexol solution.
However, it soon became apparent that 25-gauge nee-
dles were easier to handle and their function was not
affected by the viscosity of the solution. Not surpris-
ingly, the greater the volume of solution injected, the
greater the diffusion distance from the injection site;
however, injections of 4 mL of solution/nerve resulted
in significantly greater diffusion for the palmar nerve
block only. This should be taken into consideration
when repeating an injection of anesthetic agent to
overcome a failed nerve block.
On the basis of the findings of the present study,
aseptic preparation of the skin at the site of an LPB is
recommended prior to needle placement because of the
potential of intrasynovial injection of the anesthetic
agent. Placement of the needle for local anesthesia of
the medial and lateral palmar nerves should be at least
1 cm proximal to the distalmost aspect of the small
metacarpal bones, especially in horses that lack obvious
DFTS effusion. Clinicians should expect that the extent
Scientific Reports 1339
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 of anesthetic agent diffusion in a proximal direction
from the site of needle placement will be approximately
5 cm, and this should be taken into consideration when
a more proximal needle placement is used. For the pal-
mar metacarpal nerve block, needle placement at the
distalmost aspect of the small metacarpal bones is ap-
propriate, but the needle should be directed proximad,
and a subcutaneous bleb should develop at the injec-
tion site. Finally, given that the extent of proximal dif-
fusion of anesthetic agent can be as much as 5 cm, the
soft tissue structures proximal to the MCP joint should
not be ruled out as the source of lameness when an LPB
results in partial improvement. Results of the present
EQUINE
study have suggested that localization of lameness to a
region distal to the distalmost aspect of the small meta-
carpal bone following an LPB may not always be ac-
curate. However, it appears unlikely that this particular
technique will anesthetize lesions in the proximal sus-
pensory ligament region.
a. Chlorhex Maxi Scrub, 41%, VEDCO Inc, St Joseph, Mo.
b. AnaSed, 100 mg/mL, Lloyd Laboratories, Shenandoah, Iowa.
c. Superiorbute Powder, Superior Equine Pharmaceuticals, Pleas-
ant Grove, Utah.
d. Carbocaine-V, 20 mg/mL, Pfizer, New York, NY.
e. Omnipaque, 350 mg of I/mL, GE Healthcare AS, Oslo, Norway.
f. Eklin Mark III digital radiography unit, Sound-Eklin, Carlsbad,
Calif.
g. MB injection, USP, 1% (10 mg/mL), American Reagent Inc, Shirley,
NY.
h. Beuthanasia-D Special, 390 mg/mL plus 50 mg/mL phenytoin
sodium, Schering-Plough Animal Health Corp, Union, NJ.
i. SAS for Windows, version 9.2, SAS Institute Inc, Cary, NC.
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