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  Discussion on Medial malleolar fracture, RT hind
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New Member:
sooke

Posted on Friday, Apr 10, 2009 - 10:33 pm:

Hello from Aldergrove, BC! I'm trying to gather some information on how to help a 7 yr old, 17+hh thoroughbred that fractured the medial malleolus in the rt hock with some tearing of the collateral ligaments in that area as well.
The injury occured on 09/20/08, was examined by an emergency vet and x-rays were taken on the following day. Stall rest was recommended as were treatment options but the owner at the time declined to follow these and so stall rest was what he got.
Follow-up x-rays were taken approx. 10 days later and it was determined that healing of the fracture was taking place and so stall rest was continued until mid January this year where he was turned out alone in a small paddock.
He moves around fairly well but does short step in that leg. I have now as of three weeks ago taken him on and had new x-rays done to see where he is at, and Ishould have them on a disc after the Easter weekend on Tuesday.
I've looked all over the 'net for information on rehabbing him and can't find anything except that medial malleolar fractures are rare. Could you please help me? I will be taking digital photos and video of him and I will post that as well as the x-rays when I get them. I'd really appreciate any advise or suggestions you could give!
Member:
mitch316

Posted on Saturday, Apr 11, 2009 - 1:04 am:

Kim, I have to "tap out" on this one. I would think it would be similar to any fracture or ligament injury, but am not sure. I don't remember ever seeing this kind of injury. Was an MRI performed along with the X-ray? How about an ultrasound? And one last thing, do you know exactly how he was injured? I am assuming that the ligaments were not completely torn or ruptured, but still would advise patience and a reminder that any tendon or ligament injury in an animal as heavy as a horse will take a very long time. Swelling? Hot or cool to touch? Any pain upon palpation? Just trying to help Dr. O with as much info as possible here!
New Member:
sooke

Posted on Saturday, Apr 11, 2009 - 2:53 am:

Hi, Jesse. No, there was no ultrasound and the closest MRI setup is down across the US border in Washington. The injury happened when he was turned out with another gelding who is aggressive and I think he was trying to avoid being cornered and kicked in a outdoor sheDrOw. Around the perimeter of this building are "railroad ties" that the property owner used to hold back hogfuel bedding under its roof and when I found him one of these ties was partially knocked out of place. He also had bitemarks and scuffs from being kicked
but no outer visible breaks in the skin around the hock itself so he may have tripped sideways trying to get away from the other horse. Both these horses belonged to the property owner at the time and inspite of being advised that these two shouldn't be out together it was done anyway;
as it was felt the thoroughbred had to "toughen up".
Anyway, rather than hearing that this horse is going to auction or getting "put down" this week or next week again; my husband and I decided that we would take him on and he'll be company for my other gelding. My 24 yr old mare was euthanized Christmas eve due to a torsion colic and took her last two breaths in my lap. We were joined at the hip for 21 yrs and was my gelding's best freind since he was 3 months old so there is a place for this injured horse for the rest of his life. We've had his teeth done, shots, his feet are now on a six week schedule and he will be wormed regularly. I have gradually changed his feed to a diet more appropriate, and new x-rays were taken and will be on a disc for me on this coming Tuesday. There is no heat or swelling; and no notable discomfort on palpation. He has some muscle atrophy up top; but he does track up short on that side so I would expect that. I would just like to get him to a point that he can have a good range of motion and relatively good stability. Looking at both his hocks from any angle you can't tell which one was injured actually. But as I mentioned in my first post, I'll get some good photos and video as well if that will help.
Member:
mitch316

Posted on Saturday, Apr 11, 2009 - 7:54 am:

Kim, glad to see I am not the only night owl on here. I tried to do some research, but I cannot even find the malleolus. Medial is just a location. As for the ligaments, they would take the longest to heal/rehab. I would definitely wait until you get the x-ray results, but (and I may be totally wrong on this) I think those would be a poor choice for ligament damage. You may see the results of a damaged ligament/tendon in the bones, but not the actual ligament itself. But x-rays have come a long way, and the one I am familiar with was like a 1950's version (figure of speech, but you get the point). Once you get the results, post them on here with the pictures and surely someone knows what this injury is exactly...probably will be Dr. O, but since this is such a rare injury, he may have not ever seen it either.

Sorry I could not help more. Hopefully others will chime in here pretty quickly. But boy, is that a painful/bad area to have a ligament injury! You have already done a pretty good job getting him this far.
Moderator:
DrO

Posted on Saturday, Apr 11, 2009 - 8:22 am:

Welcome Kim,
I will be glad to help. Currently there is not enough information to say much but radiographic images of the fracture site and hock should provide plenty of information.
DrO
Member:
gingin

Posted on Saturday, Apr 11, 2009 - 8:57 am:

Here is one article that also describes a case of medial malleolus fractures. Seems like the malleolus fractures were the ones that recovered. I guess it depends on what type of fracture and how deep it goes beyond the malleolus into the joint support area, and whether the attachment of the collateral ligament is compromized...???
---------
Equine Vet J. 1982 Jan;14(1):62-8.

Traumatic fractures of the equine hock: a report of 13 cases.Jakovljevic S, Gibbs C, Yeats JJ.
The clinical features, radiographic findings, management and outcome in 13 cases of traumatic fracture of the hock joint are reported. The principal fracture sites were the distal tibial malleoli (5 cases), the fibular tarsal bone (4 cases), the tibial tarsal bone (3 cases) and the proximal end of metatarsal IV (one case). An additional small chip fracture of the central tarsal was noted in 2 cases. Three horses were destroyed immediately after diagnosis, 2 failed to recover following surgical intervention and one remained lame and was destroyed after 3 months' rest. Seven horses recovered completely and returned to work following periods of rest ranging from 3 to 9 months. The fracture involved the lateral or medial malleolus in 5 of these cases and the fibular tarsal in the other 2.
--------

Here is another link from Adams Lameness in Horses that talks more about anatomy and ligament attachment on the malleoli:
https://books.google.com/books?id=MQTRQvwY2MQC&pg=PA52&lpg=PA52&dq=hock+tibial+ma lleolus&source=bl&ots=IGKvdCrT_8&sig=MUnF3pyjcpDeh-Nj11L-KWRF0KQ&hl=en&ei=4ZHgSb 2mDZuclQfshPjfDg&sa=X&oi=book_result&ct=result&resnum=3#PPA53,M1

Christine
Member:
mitch316

Posted on Saturday, Apr 11, 2009 - 9:47 am:

I knew someone would bail me out! Christine, thanks for the links, as I am always trying to improve what little knowledge I have!

Dr. O, I have a follow up question. If radiographs are all that's needed, how do you evaluate the ligaments and tendons? Is it like I was thinking, by noting the behavior, position, etc, of the surrounding bones, or is it a top secret thing for vets, ha? Only kidding, but am truly interested in your answer. I knew I was in over my head on this one, but had to try. It really is a rare injury, and the bone is not noted on the illustrations here (or at least under the hock section). Thanks in advance for answering my questions.
Member:
3chip

Posted on Saturday, Apr 11, 2009 - 11:24 am:

Do a search for Medial malleolar fracture! There are many sites explaining what, where, the complications and treatments of this.
New Member:
sooke

Posted on Saturday, Apr 11, 2009 - 12:04 pm:

Thank you everyone for your interest and input; it gives me tingles just to have that. At the very least we'll all learn something that may help another in the future.
Comparatively, the malleolus on a human are the two big bumps on either side of our ankle. I've sprained an ankle a time or two and it's pretty painful. But my ankle is not 2 feet off the ground with another 3.5 feet of top heavy weight swaying around above it so those long and short collateral ligaments have a big job in stabilizing the joint. That's how I've tried to understand it.
I've seen the articles and the book listings but I figured that buying the articles and books were only telling me what I already know; nothing really discusses rehabilitation. So, that's why I registered here for guidance and feedback. None of my horses in all my life have ever had a fracture, bowed tendon or torn ligament so that's where I'm in the dark. He's had six months stall rest and restricted movement. I'm wondering if I should be hot/cold compressing that hock, hand-walking, ground driving ( no circles) etc., that sort of thing. Or, leave him in his own paddock next to my other gelding( who is quiet and well behaved) for another six months and just re-evaluate with x-rays in October some time. I' m just concerned with further atrophy on his rt side and all the problems that go along with that.
Member:
mitch316

Posted on Sunday, Apr 12, 2009 - 1:02 am:

Kim, that is what I love about this site...no matter how experienced we are (r think we are), we can always rest assured that we will be pointed in the right direction. Being that he still short steps, the hot/cold therapy will both help any swelling, inflammation, or tenderness and also help loosen things up to prevent atrophy. If he is in a paddock moving around, he may be getting all the exercise he needs at this point, but Dr. O will have to advise you there as I am not familiar at all with this kind of injury, as noted above. I think the main thing now is to wait upon the x-rays Tuesday and then make a decision from there.
Moderator:
DrO

Posted on Sunday, Apr 12, 2009 - 9:22 am:

Jesse, the location of the fracture within the bone tells us which soft tissues are involved. As with all fractures the treatment and prognosis is in the particular configuration of the fracture: you can fracture the malleolus a thousand different ways. Looking forward to the images Kim.

Concerning any disuse muscle atrophy Kim that is completely reversible. As for the other questions lets look at the radiographs and discuss it a bit.
DrO
New Member:
sooke

Posted on Sunday, Apr 12, 2009 - 1:57 pm:

Happy Easter and thanks for your replies. I managed to get a few images of him yesterday,<div><embed><img><img></div>
just to give you an idea.
New Member:
sooke

Posted on Wednesday, Apr 15, 2009 - 5:53 pm:

Hello, again. I finally have the x-rays from Apr.7/09 ( 5 in total ) and the 12 x-rays from Aug. 21/08, the day after the injury occured (It was August, not September - my mistake!) I'm not very computer savvy so I hope the link works this time...https://photobucket.com/sooke
Member:
sooke

Posted on Wednesday, Apr 15, 2009 - 6:20 pm:

The first 5 x-rays are from Apr 7/09, the next 12 are from Aug. 21/08; the day after the injury. The pictures are from Apr. 13, of the horse in question, so that you can see the "outside" of him.
Moderator:
DrO

Posted on Thursday, Apr 16, 2009 - 11:17 am:

Excellent Kim,
The initial images show a nondisplaced simple fracture that is not clearly articular. The last image shows good healing and no evidence of arthritis though I would like a complete set of films to decide. Did anyone looking at the initial set if this was articular?

Your next step is to localize the current lameness to see if it is in this or some other area. The cause of the lameness should then be pursued based on those results. It is not clear from the information presented here that the past fracture is causing your current problem. For more on localizing lameness see, Diseases of Horses » Lameness » Localizing Lameness in the Horse.
DrO
Member:
sooke

Posted on Thursday, Apr 16, 2009 - 11:42 am:

Dr.O, thank you for taking a look. I was said at the time it was non-articular. I'll read through the articles you recommended above and would it help to post video of him walking as well?
Moderator:
DrO

Posted on Friday, Apr 17, 2009 - 6:27 am:

The video will not help with localizing the lameness. Do you question whether lameness is present at all?
DrO
Member:
sooke

Posted on Friday, Apr 17, 2009 - 8:45 pm:

He's definitely not quite right on that leg yet but he doesn't look too far off from 'sound'. The vet that took the most recent set of x-rays said she saw evidence of ligament damage and that's probably what will take longer to heal.
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