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Discussion on Non articular coffin bone fracture
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Member:
dvjl
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Posted on Thursday, Sep 13, 2007 - 9:30 am:
X-rays confirmed it yesterday - my gelding has a non articular coffin bone fracture. He came up lame mid July, had the vet out, sensitive to hoof testers, diagnosis abscess. Nothing ever popped, but he improved so further diagnosis was hoof bruise. I started riding him again, but he never felt quite right, always better after warmup though. People were saying he is just a bit foot sore due to the dry conditions and the rocks on the property. After 4 weeks of this I called the vet again and after blocking he took digital x-rays and it showed up. The fracture is on the outside of the left coffin bone and doesn't extend to the tip of the bone. He said to put a barshoe on that foot and a regular shoe on the other (the horse is barefoot). He also said for me to continue to work him lightly, which is pretty much the opposite of what your article suggests. Additional shockwave treatment could expedite the healing, but is really expensive, so he felt that if I am not pressed for time to go with the bar shoe and to x-ray again in 6 to 8 weeks. He said it should heal up 100%.
Now, your article suggested total stall rest. I am interested in your take on my vet's treatment recommendation.
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Member:
juliem
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Posted on Thursday, Sep 13, 2007 - 10:34 am:
Doesn't it seem intuitive that to heal a fracture, the less movement the better? That's the reason for the bar shoe as I understand it--to inhibit movement. I personally would forgo riding and hope for a faster and permanent recovery. I don't see the upside to riding vs the risk. That's just what I would do.
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Member:
dvjl
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Posted on Thursday, Sep 13, 2007 - 10:53 am:
Well, the vet explained that the latest research shows that rest doesn't give the bone sufficient stimulation to encourage healing. He said that's why horses after 3 months stall rest are still lame. Shockwave would increase stimulation much more than riding would and they have race horses racing sound again in incredibly short periods. Considering that I have been riding this horse for the past 4 weeks with this unknown fracture I am amazed that it didn't get worse. The bar shoe will inhibit the spread, but he said the weight and the movement of the joint will increase circulation and hence advance healing.
Made sense to me yesterday, but I am posting to hear other opinions.
Thanks.
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Moderator:
DrO
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Posted on Friday, Sep 14, 2007 - 7:33 am:
I would be interested in where I can look up this research Delia as I can find no such work in PubMed, when I get into the office this morning I will search recent AAEP Proceedings. I have never seen the recommendation to work a fractured coffin bone while healing. Stabilization is critical to get any bone to heal properly which is why you cast bones. In a way the coffin bone has its own cast: the hoof wall but unlike a normal cast the joint above it is not stabilized. This allows the flexors to pull and tug on the bone which will cause motion at a fracture site and the reason for the recommendation of stall resting. While all of this is hypothetical it is logical and I have not seen the work to support your veterinarians contention.
I have successfully healed at least half a dozen fractured coffin bones in the stall and every report I have ever seen that reviews large numbers of cases, stall rested the horses while healing with a good outcome in uncomplicated (non-articular, non-comminuted, non-compound) fractures of the coffin bone. We do have one case on these boards of a articular fracture lag screw stabilized, stall rested, that is at last we heard is back training for racing. It is true that refracture rate in race horses that are returned to racing is fairly high compared to other equine pursuits.
DrO
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Moderator:
DrO
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Posted on Friday, Sep 14, 2007 - 9:36 am:
Delia, reviewing the latest texts on lameness and the latest published research findings that I can find (2002 AAEP) all recommend 2 to 3 months of stall rest.
DrO
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Member:
dvjl
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Posted on Friday, Sep 14, 2007 - 11:02 am:
Hi Dr.O.,
yeah, I have been doing some research as well and found that every single article recommended the same thing. I will have to call my vet to discuss his different approach. I should mention that my horse is a 8 year old warmblood used for dressage (2nd/3rd level). The reference to the race horses was just because the vet works with them a lot.
When this diagnosis came I was doing my best to think that this is the end of his dressage career, but the vet said that it should heal 100% without problems. He wants to x-ray again in 6 weeks. Maybe it's because the fracture is not all the way through and nothing is really broken off. The horse never showed any signs of swelling and even the super sensitive thermoscan camera didn't pick up on anything. I had to convince people that there is actually something wrong with my horse.
Even if I wanted to do the stall rest thing, with this horse it's next to impossible. He freaks out when his neighbors leave and doesn't stop pacing and tearing around in his stall until they get back (which is a real pain when one just leaves to get ridden). He would do more damage to his foot in the stall than grazing in the paddock.
So, Dr. O., what do you think of the shockwave therapy then, which will really put stress on that region? The vet said they have amazing results with this treatment.
Thanks.
Delia
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Moderator:
DrO
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Posted on Saturday, Sep 15, 2007 - 9:05 am:
I do not think of ECSW as a primary therapy for fracture Delia. It has shown usefulness in the treatment of non-union of healing fractures in humans but this is different than trying to get normal fractures healed. It may delay normal healing. Consider that it works by creating disruption of normal tissue. During a delayed or nonunion this is a good thing because the tissues are becoming whole but not spanning the fracture. You have to reopen the fracture to get healing across the defect. But if bone is healing well is this a sensible action? I don't know the answer for sure but the scientific and medical literature does not have support that I can find for ECSW therapy and healing fractures that do not have complications.
DrO
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Member:
dvjl
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Posted on Wednesday, Sep 26, 2007 - 12:46 pm:
Since the diagnosis of my horse two weeks ago I have been talking to all race horse trainers/owners in our barn. All of them had one or the other experience with a hairline fractured bone and several had shockwave treatment done on their horses. All of them said that it works amazingly well and that many of the horses returned to racing within 4 to 6 weeks, remaining sound after.
After 2 weeks of just turnout I started to ride my horse again, taking him on walk hacks around the galloping track at the farm. Yesterday I trotted him just a bit and to my delight he was totally even, which was the prediction of the vet because now he has a bar shoe on.
After lots of discussion with many people I decided to trust the vet and will continue to ride my horse lightly. I will post an update when we take the next x-ray. If it shows improvement maybe I can figure out how to post x-rays and show the before and after.
Cross your fingers.
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Moderator:
DrO
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Posted on Thursday, Sep 27, 2007 - 5:14 pm:
Delia,
The only relevant experience I can relate is two cases that were allowed pasture rest for 3 to 6 months while the front limb lameness went undiagnosed and they did not heal until stalled. Perhaps there are horses out there healing with exercise but I (an equine orthopedic specialist who write the books) are unaware of it. I look forward to viewing the radiographs. If they are not already digitized they can be scanned in and posted using the guidelines at Help & Information ยป Uploading Images and Files Into a Posting.
DrO
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Member:
dvjl
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Posted on Tuesday, Oct 9, 2007 - 12:30 pm:
Hi Dr. O,
I just received images of the digital x-rays of my horse's foot at diagnosis and thought I post them for your review. It will be another 2 or 3 weeks before we take the next x-ray. I would love to hear what you think.
Thanks.
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Moderator:
DrO
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Posted on Wednesday, Oct 10, 2007 - 9:52 am:
Delia, perhaps it is the quality of the images on my screen, which appear quite good subjectively, but I do not see a fracture above. Can you describe the location or place a pointer on it?
DrO
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Member:
dvjl
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Posted on Wednesday, Oct 10, 2007 - 12:27 pm:
Hi Dr. O.,
Thanks for looking at this - I appreciate your input and interpretation. The fact that you don't see an obvious fracture is very encouraging to me. I mentioned before that it's not really a full fracture, but more of a hairline crack in the coffin bone. Maybe that explains the different approach in the treatment.
I tried to point some arrows at the crack and hope to not have messed up the picture too much.
The horse is going sound in his bar shoe. I ride him for about 20 min. per day, mainly walk, some trot, no canter.
Thanks.
Delia
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Member:
dvjl
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Posted on Wednesday, Oct 10, 2007 - 12:31 pm:
Dr.O.,
I forgot to ask - would it be possible for you to post a x-ray of a totally healthy coffin bone as a comparison. It would be really interesting.
Thanks.
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Moderator:
DrO
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Posted on Thursday, Oct 11, 2007 - 10:31 am:
Hmmm...I am not saying it is not possible but have trouble hanging my hat on the changes in that image. The image you have chosen to highlight the fracture on has been enhanced by selectively reversing the light and dark on part of the image. Someone has to determine where to make the cut for the reversal. Going back to the original above it, it appears that some of the coffin bone margin has been left in the remain dark part of the image giving the appearance of a marginal defect that is not obviously not in the original: you can see the part left out. There is a small linear opacity at this point and it is interesting to note the slightly sclerotic nature, the increased darkness in the original and increased lightness in the manipulated image, distal to the line. But there are similar opacities though smaller on the other side. And a larger linear opacity with a smaller area of slightly more sclerotic bone distal to it (see image below). This amount of variability in these regions is common.
Because of the great variability in the coffin bone with age and between horses you should compare one side of the same coffin bone against the other or against the opposite foot of the same horse. Further proof of this being a fracture would have been pain with pressure at this location and partial resolution with a nerve block on just this side of the foot. If this is a partial hairline fracture it would be fairly stable under just about any situation but if I was convinced it was a fracture I would still stall rest. As long as your horse remains sound however you are probably doing OK.
DrO
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Member:
dvjl
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Posted on Thursday, Oct 11, 2007 - 12:48 pm:
Hi Dr. O.,
thank you very much for taking so much time to look at this. I read your post about 20 times and used your medical term dictionary to understand terms like distal and sclerotic - I think I got it though. 
I was wondering about the various shades in the images as well, but still even in the original image I can detect the same line that I marked in the reverse image. That line looks different to me than the other shading variations. Just because it has a somewhat linear appearance I can imagine it being a hairline fracture. Of course I have nothing else to compare it to. However, I have already decided to get the other front foot x-rayed as well, for my peace of mind. Then I could compare the two feet.
Since the horse was lame in the beginning, weeks before the actual diagnosis, and since we did the blocking with positive result it stands to reason that this line would be interpreted as a hairline fracture. One thing that still confuses me though is the kind of pointy projection of the P2 bone.
I placed lines on this image, one right on where I thought the hairline is, another one on that point.
Does all of that look normal to you?
Thank you very much.
Delia
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Moderator:
DrO
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Posted on Friday, Oct 12, 2007 - 6:00 am:
You are looking at the overlie of the edge of the navicular bone and P2. If your horse is sound why waste time and money with more radiographs on a bone that is highly variable? That is of course unless you have plenty of both. I am interested in the follow up of this bone however.
DrO
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Member:
dvjl
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Posted on Wednesday, Oct 24, 2007 - 12:41 pm:
Hi Dr.O.,
Just an update. Vet x-rayed again yesterday, 6 weeks after diagnosis, and determined that it's healing well. He showed me the differences in the old and new x-ray in a side by side comparison. Part of that line in the old x-ray has disappeared and part of it is more of a blotchy darker area now, which the vet indicated is healing bone tissue. No real line is apparent anymore. Vet said that it's about 80% healed and that we should give it another 6 weeks of bar shoe and light exercise and x-ray again to make sure it's completely healed. I don't have the x-ray files yet and will post them when I get them. Of course I am quite happy about the progress.
One could argue of course that it would have been healed under stall rest conditions......
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Moderator:
DrO
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Posted on Thursday, Oct 25, 2007 - 8:06 am:
I look forward to the images Delia. Don't confuse the treatment of the what we see in your images with what most folks experience as a coffin bone fracture. Most nonarticular coffin bone fractures run clearly through the body of the bone starting at the back and carrying through the front and fracturing off a whole "wing" and that type of fracture should have stall rest.
The changes within your images fall within normal limits in an area that can be highly variable. So though it may be a small nondisplaced crack it should be very stable which might allow healing while ridden. I would have stall rested it if convinced of fracture however. But the message here is I do not want anyone thinking they can heal most types of coffin bone fractures that we see by riding their horse, however lightly.
DrO
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