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  Discussion on Fetlock issue made worse by joint injection
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New Member:
equisuz

Posted on Saturday, Jan 28, 2017 - 10:00 pm:

I appreciate any thoughts on my mare's case as I work through this with my vet.

Horse sound and being ridden regularly at home farm.
Horse was shipped 5 hours to my trainer's farm on Jan 6th. Trainer rode her Jan 7th and I watched. Horse was spooky in new place so hard to assess but looked a little off. Gave horse previcox.
Trainer rode her Jan 8th and I watched. She looked sound in a straight line but off at the trot on right front in the corner turning right. Dismounted. Gave horse previcox, robaxin and packed her feet. No sign of heat, swelling, etc. some possible muscle soreness in hamstrings.
Jan 9th - barn closed day off. Horse still on previcox.
Trainer rides again Jan 10th and reports no change. Trainer also reports horse buckles on RF when horse is brought out of stall onto concrete floor. Vet called.
Jan 11th turnout only.
Vet lameness exam Jan 12th. Hoof testers. No reaction. Flexion positive RF fetlock and RF coffin joint. Coffin joints injected Oct 2016 so decide to inject fetlock. Inject with hyvisc/vetalog/ab. Continue previcox.
Stall rest Jan 13th.
Hand walked Jan 14th & 15th.
Barn closed Jan 16th.
Trainer rides Jan 17th reports no change. Vet called.
Hand walked Jan 18th & morning of 19th. Nothing unusual. Walking sound. Intermittent reports of leg buckling when stepping from soft footing onto hard.
Vet arrives afternoon Jan 19th and leg is hot, swollen, barely weight-bearing and horse is subdued. No fever. Joint infection suspected. Fluid samples taken, AB injected in joint. Gentamicin and penicillin and bute administered systemically. Hind legs also stocked up and a little warm. US fetlock, suspensories and tendon - no damage. X-ray fetlock - no issue. Lab results - no sign of joint infection. Stall rest, Ice boot, gel-cast, standing wraps.
Vet comes back Jan 20th. More fluid samples. Perfused AB in joint and surrounding tissues. More IV meds as day before. Continue stall rest, ice boots, gel-cast, standing wraps.
Jan 21st horse is lively, nickering to me, hand grazed, walking sound in ice boot, swelling coming down a little each day. Lab results still no sign of infection. Continuing all IV meds and treatment
Jan 22nd hand grazing and light hand walking. Walking sound. Treatment remains the same.
Jan 23rd ice, hand walked, 5th day IV AB. Still improving.
Jan 24th stopped AB and bute. Naquasone and sweating leg at night new treatment.
Jan 25th trainer walks under saddle reports sound. Horse gets shod.. Naquasone and leg sweat at night.
Jan 26th trainer walks under saddle reports a few funky steps but leg looks good. Horse turned out. Last dose of naquasone. Standing wraps no sweat.
Jan 27th horse lame at walk. Walking from soft footing of ring onto concrete right leg buckles on concrete. Vet comes out same afternoon. Horse trots lame in hand. Leg still has very mild filling. Starting to think it's in the foot. Want to nerve block foot but worried about possible recent infection. 2 grams of bute with plan to come back Tuesday. Treatment plan: bute for 2 days, turnout, no riding, no hand walking.
Jan 28th a little more filling around fetlock. Add sweating leg back into treatment plan.

Was this an inflammatory response to the joint injection?
How long should we wait until we start doing nerve blocks to isolate the area of lameness?
Is this increased lameness due to the inflammatory response even though it looks on the outside of the leg to be very minimal at this point?
Did we go the wrong direction to the fetlock? Is it more likely to be an issue in the foot?
Moderator:
DrO

Posted on Sunday, Jan 29, 2017 - 10:55 am:

Welcome SusanM,
Taking your questions one at a time:
1) If the joint fluid had a normal lab result (protein, cell count, and differential) then no, this was not a inflammation of the joint.
2) You should wait until you are sure you are not injecting into a infected area. Infected tissues are usually presented with remarkable swelling and heat with pain on light pressure.
3) and 4) To answer these questions would require an examination at this time and to have examined the horse before the treatment.

The next question continues to be one of localizing the lameness, only then a list of rule outs can be contemplated. Our best article on this is located at rseAdvice.com » Diseases of Horses » Lameness » Localizing Lameness in the Horse and should help you with this goal. When there is diagnostic confusion it always pays to go back and start at the beginning.
DrO
New Member:
equisuz

Posted on Sunday, Jan 29, 2017 - 4:02 pm:

Thank you Dr O. There remains some mild filling in my mares leg but we are sweating it nightly and when the sweat comes off her legs look almost identical. I poked around her fetlock, tendon, sesamoids today and I can find no sign that she feels pain on palpation. I took her out for a short handwalk today and she is walking a little shorter with her RF.... seemed to me worse in the soft footing of the ring rather than on the hard pavers of the barn aisle so I walked her in the barn aisle. Being new to this area, my vet is new to me but I've been very happy with him so far. We've been completely in sync on what to do when. We both agree that the next step is to start blocking to isolate the problem area. We are just delayed in starting due to concerns of any lingering infection. She never had stovepipe type swelling or pitting of that leg nor any fever but it was hot and swollen and because it was one week after a joint injection we aggressively treated it like an infection. There has been no resurgence of that level of heat and swelling and she's been off AB for 6 days now. We are scheduled to do the nerve blocks on Tuesday afternoon.
New Member:
equisuz

Posted on Tuesday, Jan 31, 2017 - 7:22 pm:

We did a PD block of her RF today. Still head bobbing lame after block but better than before the block so she's off for an MRI of her front feet on Thursday.
Moderator:
DrO

Posted on Wednesday, Feb 1, 2017 - 10:16 am:

Sounds like progress, was the improvement 2 grades of lameness?
DrO
New Member:
equisuz

Posted on Thursday, Feb 2, 2017 - 9:07 pm:

My vet said that she was 75% better after the block. My non-vet eyes thought less than that but that's why it's good to have an expert and somebody who is not emotionally attached to the situation. She did have some increased fluid in the fetlock joint as well. She had a bilateral forefeet and right front fetlock MRI study today. We are just waiting for the results.
New Member:
equisuz

Posted on Friday, Feb 3, 2017 - 5:10 pm:

Here are the results from her MRI yesterday. I'd appreciate your thoughts DrO.

CLINICAL HISTORY: Right front lameness. PD nerve block on January 31st improved 80%. History of coffin bone issues. Requesting bilateral fore feet and right front fetlock.

STUDY DESCRIPTION: Bilateral front foot and right front fetlock MRI examinations were performed in a 0.3T standing MRI unit. Multiple imaging planes and sequences were acquired including: T1W 3D, T2*W 3D, STIR FSE in sagittal, T1W 3D, T2W FSE, STIR FSE in dorsal and transverse with additional PDW SE in transverse through the feet. T1W GRE, T2*W GRE, T2W FSE, STIR FSE were acquired in transverse, sagittal and dorsal planes through the fetlock.

MRI FINDINGS: RIGHT FRONT FOOT: A small dorsal border irregularity is present on the lateral lobe of the deep digital flexor tendon (DDFT) at the level of the navicular bursa. The distal, medial margin of the navicular bone is irregular. Minimal solar margin resorption is present in the lateral aspect of the distal phalanx, near the quarter region.

RIGHT FRONT FETLOCK: Mild subchondral sclerosis is present in the metacarpal condyle, medially and laterally. These regions are associated with minimal STIR hyperintensity indicating some interosseous fluid accumulation. Mild STIR hyperintensity is present, regionally in association with the sagittal groove of the proximal phalanx. The increased fluid signal is present centrally in P1 and also slightly medial to the sagittal groove.

A small, hyperintense lesion is present in the distal aspect of the medial suspensory ligament branch.

LEFT FRONT FOOT: One centrally located synovial invagination is enlarged in the distal aspect of the navicular bone. This is surrounded by mild sclerosis.

IMPRESSIONS: Minor abnormalities are identified in the right front. These include a minor, dorsal border the digital flexor tendon abrasion at the level of the navicular bursa. At this time the navicular bursa appears quiet. There is also a small region of solar margin resorption in the lateral aspect of the distal phalanx of the right front.

There is subchondral remodeling associated with the right front fetlock joint to include sclerosis of the metacarpal condyle and some interosseous fluid accumulation associated with the sagittal groove of the proximal phalanx. These findings most likely represent exercise-induced/stress remodeling of the subchondral bone. The fluid accumulation within the sagittal groove is reported as a manifestation of stress remodeling and can be associated with lameness. Minimal fiber abnormalities are present in the medial suspensory branch.

No abnormalities of significance are identified in the left front.
Moderator:
DrO

Posted on Tuesday, Feb 7, 2017 - 8:00 am:

Hello Susan,
The report runs somewhat counter to the nerve blocking results so I would have that repeated making sure the PDN block is done as low in the fetlock as possible with low volumes of blocking agent. This should help rule the navicular lesions in or out. If they are ruled out proceed upwards to see if localization to the fetlock joint is reasonable. Have they given you a prognosis for the lesion in the fetlock and a treatment plan?
DrO
Member:
equisuz

Posted on Tuesday, Feb 7, 2017 - 11:12 am:

Hi DrO,
The nerve block was done only in the heel area nowhere near the fetlock. I did not feel like there was as much improvement after the block as my vet did. When I walked her under saddle the day I realized we had an issue still (after the cellulitis had settled), her lameness was very inconsistent. She would be head bobbing lame and then walk seemingly sound and then be very lame again. I felt like this inconsistency tainted the blocking process and we likely should have done more blocks to nail it down. Vet originally ordered the bilateral forefeet MRI and I wasn't comfortable with that alone so we discussed and he added on the fetlock.

The treatment plan is rest and time. My Florida vet thinks we have a little of both areas causing her discomfort. She had bar shoes put on the front yesterday to help protect the tendon I think. I'm assuming she's staying in bar shoes from now on. She is on stall rest for 7-10 days with light hand walking and then she'll have some small paddock turnout for the rest of February. She'll then ship home to Virginia and get an additional 3 months off mostly turned out. I'm happy to give her more time if anyone thinks that's safer. We discussed OsPhos but I didn't like all the warnings related to future breeding. Everyone is telling me she has a good prognosis but I do worry about not knowing when to bring her back into work.

It seems like the radiologist was pointing more to the fetlock bone bruise than the foot as the source. Is that your interpretation as well? Thank you
Member:
equisuz

Posted on Tuesday, Feb 7, 2017 - 11:22 am:

A few other points to consider. My mare is primarily ridden in a flat ring with good footing and has had the same farrier for two years. At the beginning of December she was shipped to my trainers rented farm in Ocala where she was ridden only in a large hilly field. They also had a new farrier shoe her for the first time and when I rode her the week after being shod she sounded like she was forging all the time at the trot. This is not normal for her and she would only ever forge a little right before she needed to be shod. She felt sound to me at that point but my best guess is that month of hilly riding with newly unbalanced feet led to this problem. For what it's worth my two cents on the cause. I'm not sure if a bone bruise develops over a month or whether it would have been coming on for quite sometime.
Moderator:
DrO

Posted on Wednesday, Feb 8, 2017 - 2:24 pm:

Yes I think that was what the radiologist is intimating but a successful low, low volume PDN will rule it out. Bruises can be acute (high force blunt trauma) or chronic (repetitive low force trauma).
DrO
Member:
equisuz

Posted on Wednesday, Feb 8, 2017 - 6:25 pm:

Thanks DrO. I'll discuss with my vet.
Member:
equisuz

Posted on Wednesday, Feb 15, 2017 - 9:12 pm:

Hi DrO,
I have a three more questions.

1. Stall rest or turnout? When I do an internet search on bone bruises in the fetlock I notice most people seem to have their horses on stall rest for months. Then I read an article about this type of bruise in racehorses and it stated that stall rest was not good and that it was better for bone bruises if the horse was out walking in the pasture. What would you recommend?

2. OsPhos? My vet asked me about OsPhos and I rejected it as there is a high likelihood my mare will have foals in the future. I'm wondering if I'm overreacting to the warnings on the product. Would you give OsPhos to a mare that would be bred in future years.... not in the next year?

3. IRAP? Legend? Adequan? It seems other people use IRAP for bone bruises? I'm a little worried about injecting anything else into the joint right now but would Legend or Adequan be beneficial in her recovery?

Thanks for your advice and education.
Moderator:
DrO

Posted on Sunday, Feb 19, 2017 - 3:46 pm:

1) The reason for the confusion is that this is a relatively unresearched injury. If we look at bruises in general acute injuries should be rested while chronic injuries should receive limited exercise at a level that allows the tissues ti heal. That is the rub: without repeated MRI's how do you know? I would ask this question of the person who made the diagnosis and can see the bruise: if there was active bleeding then rest, if it is resolving consider limited exercise with monitoring for improvement.
2) The Osphos directions read:
Bisphosphonates should not be used in pregnant or lactating mares, or mares intended for breeding. The safe use of OSPHOS has not been evaluated in breeding horses or pregnant or lactating mares. Bisphosphonates are incorporated into the bone matrix, from where they are gradually released over periods of months to years. The extent of bisphosphonate incorporation into adult bone, and hence, the amount available for release back into the systemic circulation, is directly related to the total dose and duration of bisphosphonate use. Bisphosphonates have been shown to cause fetal developmental abnormalities in laboratory animals. The uptake of bisphosphonates into fetal bone may be greater than into maternal bone creating a possible risk for skeletal or other abnormalities in the fetus. Many drugs, including bisphosphonates, may be excreted in milk and may be absorbed by nursing animals.
I really don't have anything to ad to that.
3) These products would be helpful if there are any signs of inflammation in the joint most importantly lab results indicating less than optimal joint fluid.
DrO
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