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  Discussion on Lame after superficial cut on pastern
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Member:
Mbh851

Posted on Wednesday, Sep 27, 2006 - 6:42 am:

Ten days ago, my horse came out of his stall acutely lame on his right hind. He had a superficial cut on the inside of his pastern. I was away but the barn manager poulticed the leg and kept him on stall rest. When the vet saw him on Monday, he felt there was a cellulitis and recommended stall rest with hand-walking, cold-hosing, 3 days of bute, and a five day course of SMZs. He didn't want to do any blocks because of the soft tissue infection.

He has improved tremendously and after 1 week we got the go ahead to turn him out. The swelling has resolved and the cut hs almost completely healed over. He has been out 2 days and yesterday I lunged him as the vet had said we could begin light work. He was still slightly lame to the left but at the trot was visibly lame to the right.

I was surprised that he was still so sore to the right given his overall progress and the fact that the swelling was gone. Should I be concerned about some tendon trauma from the injury? I suspect he may have caught himself with the other hoof especially as his toes were quite long (I had just gotten him and had not reshod him at that point). I plan to call the vet back and wonder if I should ask him to ultrasound the leg?
Member:
Mbh851

Posted on Wednesday, Sep 27, 2006 - 10:02 pm:

I forgot to mention that the vet did Xrays so at least I know there is no fracture altough there is some arthritis in the fetlock. He is still lame today so I will go ahead and get the vet out tomorrow or Friday. In the meantime he's back in his stall.
Moderator:
DrO

Posted on Thursday, Sep 28, 2006 - 7:18 am:

Hello Linn,
Without examining the wound it is difficult to assess what might be the important concerns. But without significant swelling of the tendon sheath it is hard to see how the tendon in the pastern region could be significantly effected. First thing you want to do is localize the lameness.
DrO
Member:
Mbh851

Posted on Wednesday, Oct 4, 2006 - 11:11 am:

Thanks, DrO. I knew my questions were a bit premature, but I needed some moral support! I do have some more information as the vet was out yesterday (took a little longer than expected for him to get back).

Before the recheck, I definitely was seeing improvement although the horse was still off two weeks from the original evaluaton. The vet felt there was some swelling/effusion in the fetlock. He did the following (taken from the report I received, complete with abbreviations). Unfortunately b/o rescheduling I couldn't be there when he did the evaluation.

Diag. anes. LO Palm/Plant; RH 75% improvement.
IA injection DIP/PIP/FET with LSA; RH pastern
He advised 2 Grams of bute that night, then usual turnout and resuming light work in 3 days if improved.

Looking at the diagrams, I am pretty sure that he injected each of the lower three joints: between the DP and MP, the MP and PP and the PP and cannon bone. At this point, his thinking is that the original trauma caused some inflammation in the fetlock area, and that the injections will help to resolve this more quickly. I will let you know how he does. Any additional thoughts/comments welcome as well.

Linn
Moderator:
DrO

Posted on Thursday, Oct 5, 2006 - 9:29 am:

I think we just wait and see. On a front I would have done a distal sesmoidean block to rule out foot vs ankle, but if not done carefully it may run into the fetlock. On a rear I would only attempt this is in a very cooperative horse.
DrO
Member:
Mbh851

Posted on Saturday, Oct 14, 2006 - 3:48 pm:

DrO,

There have been some additional developments in the situation with my gelding that I wanted to run by you. After the fetlock injection last week, he continued to improve, although the right hind pastern was still slightly swollen. On the lunge, he showed slight toe-dragging still in that leg, but looked good otherwise, and the vet OKed light work. He was lunged 2 days then lunged and worked under saddle one day, and was stable to improvng with the work. The next day, he was running in the field, and must have interfered again behind, knocking an old scab off of the LEFT medial pastern, and somehow getting a superficial laceration above the hock on the medial aspect of the right leg. At that point, I purchased fetlock rings. I checked him last night and left the rings for his turnout today. However....after I left, he had some loose stools, and the staff noted that he was stocking up on the left hind. By this am, he was significantly stocked up on both hind legs and his left front. He had fever maximum at 101.8 DrOpping to 101.2 (no blanket) and was initially slightly off his feed. No cough or nasal discharge. His stool was firmer between when the staff left and this am. His pasture-mate had loose stool transiently but no fever or other signs.

The vet came out and drew a CBC which had normal white count and mild anemia with Hct of 28+. She checked his field for toxic plants but didn't see anything suspicious. There is limited grass and he is mostly getting hay from the same source with no changes there. She suggested banamine for 5 days and gave him the first dose. He was less lethargic with better appetite after that, and the stocking up looked better after hand-walking. I hot packed both recent scrapes and both looked clean without any drainage or local swelling.

Could this all be due to the trauma? If so, does it suggest any underlying problem that I should be concerned about? During the first episode he was quite lame on the affected leg (the right hind) with local swelling and no fever. This seems slightly different with no clear lameness at the walk and the fever/loose stoolbut both occurred after local relatively minor trauma.

Let me know if there is something you think we may be overlooking.
Moderator:
DrO

Posted on Monday, Oct 16, 2006 - 6:14 am:

Certainly the swelling could have been from trauma Linn but this is not the way you start to diagnose a disease course: you don't try and limit the number of problems you consider possible.

Instead you cast a wide net and list all the abnormalities and then try to rule in or out those possibilities. On the information you have given I don't see anything obvious other than antibiotic administration is a common cause of diarrhea and NSAID's, like phenylbutazone, a rare cause. For other possibilities see, Diseases of Horses » Colic and GI Diseases » Diarrhea in Horses » Diarrhea an Overview.
DrO
Member:
Mbh851

Posted on Saturday, Oct 21, 2006 - 9:01 am:

I see that my question wasn't clear; I was actually asking about what other possibilities I should be considering as I wasn't comfortable attributing it all to the trauma.

I'm not sure that there is an answer to my main question (outside of a crystal ball!) which is whether the occurence of these two episodes suggests an underlying problem that would be expected to continue to cause trouble.
Moderator:
DrO

Posted on Sunday, Oct 22, 2006 - 11:20 am:

I had thought this answered your question Linn: "On the information you have given I don't see anything obvious other than antibiotic administration is a common cause of diarrhea and NSAID's, like phenylbutazone, a rare cause."
DrO
Member:
mbh851

Posted on Sunday, Jan 28, 2007 - 8:34 pm:

DrO,

I am overdue to follow up with you as eventually I did get a diagnosis. On re-evaluation in mid November, repeat X-rays did show a fracture. It turns out there was a chip on the lateral aspect of the distal proximal phalanx and a hairline fracture below in the middle phalanx. The chip was seen on the original X-rays but thought to be old. On repeat films, the hairline crack was visible and there was remodeling/healing of the chip, so apparently it was new when he was first lame. So it turned out there was a problem that was missed as I feared and the key was to have an accurate diagnosis, as you said. In the future, I would definitely have a higher level of suspicion for a fracture with persistant problems after an apparently minor injury; the fever etc was a red herring in the end. After stall rest and hand-walking, he is just beginning limited turn-out and doing well so far with good healng by X-ray.

Linn
Moderator:
DrO

Posted on Monday, Jan 29, 2007 - 6:48 am:

Great case Linn and as you say demonstrates the importance of accurately determining where the pain is coming from as almost every lameness case has one or two red herrings.Please keep us appraised on how your horse turns out.
DrO
Member:
mbh851

Posted on Thursday, Mar 8, 2007 - 4:41 pm:

DrO, I thought I would give you an update on my horse with the pastern fracture. After diagnosis in mid-Nov, he had 2 mos of strict stall rest. He had good healing by Xray, so moved on to 2 weeks of hand-walking, followed by 3 weeks restricted turnout. He jogged sound at that point and went on to walking under tack. Unfortunately, at the end of the two weeks he was a bit slow to the right and then became frankly lame again after advancing to trot for just 2 days. He blocked out to the pastern joint and has just gotten a steroid injection.

My sense from the vet is that this setback suggests that we are considerably less likely to get through this without some long term issues. I am hoping that the steroid injection will get him back on track, but if it doesn't, we may be looking at fusion since it is the PIP joint that is involved. Is there any experience with the chemical fusion in this area? The article implies that surgical fixation is preferred for the PIP joint but I wondered does this reflect limited experience or negative experience with chemical injection at this site? It certainly sounds as though it would be worth considering, given the substantially lower morbidity. I would be interested in your thoughts overall and on this point in particular.
Moderator:
DrO

Posted on Friday, Mar 9, 2007 - 7:12 am:

It is a great question Linn and frankly I am uncertain. Surgical fixation goes back as far as I can remember. I have always believed early failures led to the use of internal fixators but when I look for proof of this I cannot find it. I do have some much older texts packed away, perhaps if I reviewed them I could find an answer.

There are differences between the PIP joint and the two distal tarsal joints that do make fusion more difficult. First there is a good deal more movement naturally in the PIP joint. 6 - 8 degrees of motion sticks in my mind but I need to recheck that. The pastern joint also sits at an angle to the direction of force (gravity) applied to the it creating more torque centered on the joint. The smaller surface area for fusion, the list goes on. It is easy to see how fixation solves some of these problems.

We have had some recent discussions on the use of ethyl alcohol for arthrodesis and the possibility of using it in the pastern. But no one is doing it that I am aware of.
DrO
Member:
mbh851

Posted on Wednesday, Mar 14, 2007 - 9:02 pm:

Thanks, DrO. The discussion on ethyl alcohol was very helpful. It sounds like it will be a while before the role for that technique is fully established, promising as it is.

As far as my horse, I think I am going to be looking at surgery - he did not come sound or even show much improvement after the steroid injection last week. I will call the vet tomorrow and expect he will re-Xray the area, but it is hard for me to imagine what else there will be to do other than the surgical fusion.

Since it is the PIP joint in the hind leg I am cautiously hopeful that the procedure would have a chance of improving his situation. Is it realistic to think he might return to his prior level of activity or is that unlikely? What should I be anticipating as far as duration of the healing/rehab following the procedure? It is helpful to have some idea what to expect when I talk to the vet.

Thanks for your input.
Member:
mrose

Posted on Wednesday, Mar 14, 2007 - 10:59 pm:

Dr.O, could there be any chance at all of this horse having some bacterial infection as a result of the initial cuts which would be making the horse lame? I realize this is a totally different scenerio than with Libby, but am wondering if infection should be considered with any injury when the horse remains lame after it seems like it should be sound again. Swelling in the fetlock, especially made me wonder. Would a scan be a good idea to rule infection out?
Moderator:
DrO

Posted on Thursday, Mar 15, 2007 - 5:40 am:

Linn your question puts the cart in front of the horse, let's get a firm diagnosis before we banter a prognosis. However if you are just interested you will find the prognosis for pastern joint arthrodesis in the article, Diseases of Horses » Lameness » Joint, Bone, Ligament Diseases » Arthrodesis and Joint Fusion for Arthritis.

When you ask is there any chance Sara, most things are possible if "any chance" is your guage. But the history and clinical signs above are consistent with a non-infectious problem for a number of reasons but most important being the horse came lame again after the wound was healed.
DrO
Member:
mrose

Posted on Thursday, Mar 15, 2007 - 11:19 am:

I think I fixated on the "swollen fetlock" and thought the fetlock was still showing some swelling even though the wound above had healed, which led me to the possibility of infection.
Moderator:
DrO

Posted on Thursday, Mar 15, 2007 - 5:26 pm:

You have to remember this horse fractured a bone in the pastern and swelling extending proximally into the fetlock would be an expected consequence.
DrO
Member:
mbh851

Posted on Thursday, Mar 15, 2007 - 7:57 pm:

Sara,

Thanks for your comments. He did get antibiotics early before the fracture was diagnosed because the original thought was a cellulitis. Right now there is very little swelling and it is below the fetlock.

DrO,

I know I keep asking for a crystal ball! Here is where things stand at present. The vet repeated the Xrays and did not see much change. The fracture has healed radiographically and the joint itself looks good, with no evident damage to the cartilage (although I know that arthritis may not show up on the Xrays especially early on). The clinic is recommending IRAP injections to the joint. The thinking is that there is inflammation that did not respond to the steroids and my understanding is that this treatment may help when steroids have not. The hope is that this will control the situation and perhaps avoid the need for fusion. That remains an option if he does not come sound. It seems worth a try from what I have been able to find out about the treatment.

I will not know for a while as the plan is for 4 injections, one every 2 weeks. I'll let you know what happens.

Linn
Moderator:
DrO

Posted on Friday, Mar 16, 2007 - 6:58 am:

Linn did they tell you what treatment protocol (product, dosage, frequnecy) they are going to use? Currently viral vectors for delivery of IRAP (Interleukin-1 Receptor Antagonist Protein) are being developed to get around the requirement of daily administration (see below) but I am not aware they might be clinically available yet.

Best Pract Res Clin Rheumatol. 2006 Oct;20(5):879-96.
Is IL-1 a good therapeutic target in the treatment of arthritis?

Burger D, Dayer JM, Palmer G, Gabay C.
Clinical Immunology Unit, Division of Immunology and Allergy, Department of Internal Medicine, University Hospital, 24 rue Micheli-du-Crest, CH-1211 Geneva 14, Switzerland.

Inflammation is an important homeostatic mechanism that limits the effects of infectious agents. However, inflammation might be self-damaging and therefore has to be tightly controlled or even abolished by the organism. Interleukin 1 (IL-1) is a crucial mediator of the inflammatory response, playing an important part in the body's natural responses and the development of pathological conditions leading to chronic inflammation. While IL-1 production may be decreased or its effects limited by so-called anti-inflammatory cytokines, in vitro IL-1 inflammatory effects are inhibited and can be abolished by one particularly powerful inhibitor, IL-1 receptor antagonist (IL-1Ra). Recent research has shown that in the processes of rheumatoid arthritis (RA) IL-1 is one of the pivotal cytokines in initiating disease, and IL-1Ra has been shown conclusively to block its effects. In laboratory and animal studies the inhibition of IL-1 by either antibodies to IL-1 or IL-1Ra proved beneficial to the outcome. Because of its beneficial effects in many animal disease models, IL-1Ra has been used as a therapeutic agent in human patients. The recombinant form of IL-1Ra, anakinra (Kineret, Amgen) failed to show beneficial effects in septic shock and displays weak effects in RA patients. However, IL-1 blockade by anakinra is dramatically effective in systemic-onset juvenile idiopathic arthritis, in adult Still's disease and in several autoinflammatory disorders, most of the latter being caused by mutations of proteins controlling IL-1beta secretion. Importantly, to be efficacious, anakinra required daily injections, suggesting that administered IL-1Ra displays very short-term effects. Better IL-1 antagonists are in the process of being developed.
DrO
Member:
mbh851

Posted on Friday, Mar 16, 2007 - 9:50 pm:

DrO,

The procedure they are suggesting is the intra-articular injection using the horse's own serum after stimulating the white blood cells to produce anti-inflammatory mediators. It is the same procedure described in another post and studied at CSU in a small trial. I guess it is more properly termed autologous conditioned serum as they don't really know exactly what is being produced but it may include the IL-1Ra (although apparently they couldn't measure it in the serum). I found the the website of the German company that developed the procedure in the other post: www.equine-irap.com. There is a link to the study there.

The clinic is a large referral practice that does a lot of lameness work. The vets there sat down and reviewed the Xrays and the course so far. I believe at least one of them has experience with this. They are recommending injecting the joint every 2 weeks for a total of 4 injections. Not sure why every 2 weeks as the limited information I found refers to weekly injections. The large veterinary teaching hospital in our area offers this as well.

This is being recommended in the hope of avoiding having to go to the fusion procedure. Given the time in lay up and the discomfort to the horse that the surgery entails, I was willing to try the alternative. Since it is the horse's own serum, my understanding is that it is well-tolerated and unlikely to have adverse effects, other than the risk associated with injections in general. It is new enough that I know the data is limited as far as success rate.

That's as much as I know so far. I'll let you know what happens.

Linn
Member:
mbh851

Posted on Friday, Mar 16, 2007 - 9:59 pm:

I've also included the link to the newsletter describing this at the Marion DuPont Scott Equine Center in Leesburg, VA
https://emc.vetmed.vt.edu/newatEMC.html
Member:
mrose

Posted on Friday, Mar 16, 2007 - 10:26 pm:

This is very interesting! I'll be anxious to see how this treatment works, as I'm sure you will be also.
Moderator:
DrO

Posted on Saturday, Mar 17, 2007 - 10:43 am:

Got it Linn. You seem to have a good understanding this is a experimental procedure were the IL-1Ra component is unknown. By all means let us know how it works out.
DrO
Member:
mbh851

Posted on Sunday, Mar 18, 2007 - 4:57 pm:

Thanks, Sara and DrO. I will let you know how it turns out.
Member:
mbh851

Posted on Thursday, Apr 26, 2007 - 6:18 am:

DrO,

I thought I'd give you an update on Polo since the ACS/IRAP injections. He received a total of 3, one each week. After the third one, he became acutely lame on that leg, with heat and swelling suggesting a reaction. Since he had tolerated the first two, the thinking was of possible trauma or cellulitis, as he was not very cooperative for the last injection. He improved rapidly with cold hosing, bute, SMZs and rest. Two weeks later, the vet has pronounced him the best he has been in 6 months, and Ok'd resuming walking under tack, for 3 weeks this time. If we can successfully advance from there, I think that he will have a chance of getting through this without the surgery. I will let you know what happens

Linn
Moderator:
DrO

Posted on Friday, Apr 27, 2007 - 6:45 am:

Thanks Linn,
I appreciate the update. Since the reaction are they still planning to do the 4th injection?
DrO
Member:
mbh851

Posted on Tuesday, May 8, 2007 - 12:27 pm:

At this point, the plan is to hold at 3 injections due to the reaction. We are continuing walking under saddle, and so far he looks good. He is still only turned out 2 hours/day but is now in a bigger paddock. He is due for another check by the vet next week, to see if we can advance.
Member:
mbh851

Posted on Monday, Jul 23, 2007 - 10:03 pm:

I am happy to report that we are continuing to make progress. A couple of weeks after my last post, the vet OK'd full turnout and advancing at the trot. We have slowly moved up to 30 minutes of trot at each ride and in another week will go on to canter. His right pastern does have some bony changes in the region of the original fracture but has not developed any swelling as we have gone forward. We are still working on his conditoning and managing his old hock arthritis which needed attention including injections after his long lay-up, but he continues to improve and the vet is cautiously optimistic that he will be useful as the schoolmaster I had hoped he would be when I bought him. We'll both be glad when we can do more than circles in the ring, but I am delighted to be riding him at this point. I can't help but think the IRAP injections helped him turn the corner, although time has no doubt helped as well. Thanks for your input over this long process.
Moderator:
DrO

Posted on Tuesday, Jul 24, 2007 - 8:23 am:

Delighted to hear of your continued progress Linn.
DrO
Member:
mbh851

Posted on Friday, Sep 7, 2007 - 6:33 am:

Final update: as of yesterday, the vet has released my horse to full work with no restrictions. It is almost exactly one year since his pastern fracture but it appears he has made a full recovery. Thanks for your interest and support along the way.

Linn
Moderator:
DrO

Posted on Friday, Sep 7, 2007 - 7:50 am:

A great instructional story with a wonderful ending. Thanks for sharing.
DrO
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