Medial collateral ligament desmitis of the distal interphalangeal joint in the hindlimb of a horse: treatment with cast immobilisation

A 12‐year‐old show‐jumping mare was presented for investigation of a chronic hindlimb lameness of 16 weeks duration. Perineural anaesthesia and ultrasonography localised the lesion to the medial collateral ligament of the distal interphalangeal joint of the left hindlimb. Treatment consisted of a heavily padded distal limb cast for 6 weeks, strict box rest and a strictly regulated hand walking program. Serial ultrasonographic examinations were performed throughout the rehabilitation period. Collateral ligament desmitis of the distal interphalangeal joint is a commonly diagnosed condition of the forelimb; however, hindlimb collateral ligament desmitis has been rarely reported. Ultrasonographic examination in this case was an invaluable diagnostic and follow‐up tool. Immobilisation of the foot by means of a heavily padded distal limb cast allowed excellent healing of the ligament and is presented as a novel treatment for collateral ligament desmitis. At the time of writing the mare had returned to her previous level of exercise and was showing no signs of lameness.     

Magnetic resonance imaging and histological findings in the proximal aspect of the suspensory ligament of forelimbs in nonlame horses

Reasons for performing study: Detailed magnetic resonance imaging (MRI) and histological appearances of the proximal aspect of the suspensory ligament (PSL) in the forelimb of nonlame horses have not been previously documented. Objectives: 1) to describe detailed anatomy of the PSL, 2) describe high‐ and low‐field MRI and histological appearances of the PSL and surrounding structures in the forelimb of horses with no carpal or proximal metacarpal pain, 3) assess the relationship between age, breed, gender, height, bodyweight and MRI findings and 4) describe the histological appearance of the PSL and compare this with MRI findings. Methods: High‐ and low‐field MR images of the PSL and related structures from 30 cadaver limbs of nonlame horses were analysed subjectively and objectively. Univariable and multivariable linear regression analyses were used to assess the association of age, breed, gender, height and bodyweight with MRI findings. Histological and MRI findings of the PSL of 9 limbs were compared subjectively. Results: The collagenous tissue of the PSL had low to intermediate signal intensity depending on the pulse sequence. There was a large variation among horses in the amount, shape and signal intensity of the muscle and adipose tissue within the PSL. Comparison of MR images with histological slides revealed that the high signal intensity areas corresponded to adipose tissue and intermediate signal intensity areas to muscle tissue. The medial lobe of the PSL had a smaller cross sectional area (CSA) than the lateral lobe; there was a positive association between CSA of the PSL and both horse height and bodyweight (P<0.001). Conclusions and potential relevance: The large variability in the MRI appearance of the PSL in nonlame horses should be borne in mind when interpreting MR images of lame horses.     

Osseous abnormalities associated with collateral desmopathy of the distal interphalangeal joint. Part 2: Treatment and outcome

Reasons for performing study: There are currently few long‐term follow‐up data relating to recovery from injury of a collateral ligament (CL) of the distal interphalangeal (DIP) joint and limited information about the effect of associated osseous injury on prognosis. Objectives: To describe long‐term follow‐up results for horses with CL injury, with and without associated osseous injury; and to determine the effect of extracorporeal shock wave therapy (ECSWT) or radial pressure wave therapy (RPWT) on outcome. Hypotheses: Prognosis for return to performance for horses with CL‐related osseous injury would be worse than for horses with CL injury alone. Methods: Magnetic resonance images from 313 feet of 289 horses with foot pain and a definitive diagnosis of collateral desmopathy of the DIP joint were analysed retrospectively for presence of osseous abnormality associated with the ligament origin or insertion and the middle and distal phalanges. Horses were assigned to groups according to the combination of their injuries. Type of treatment was recorded and follow‐up information obtained. Thirty‐two horses with additional sources of lameness were excluded from analysis of outcome. Results: Follow‐up data were available for 182 horses, 55 of which had follow‐up information for up to 2 years after presentation. Twenty‐seven percent of horses with CL injury alone and 34% of horses with CL related osseous injury returned to their previous performance level. Prognosis for a combination of injuries to multiple soft tissue and osseous structures within the hoof capsule was substantially worse. There was no effect of ECSWT or RPWT on outcome. Conclusions: The presence of mild to moderate CL related osseous injury does not appear to influence prognosis compared with CL injury alone. Clinical relevance: Further studies of a larger number of horses are necessary in order to ascertain if specific types of osseous pathology influence return to performance levels.     

Cross-sectional area of the tendons of the tarsal region in Standardbred trotter horses

Reasons for performing study: The assessment of a normal range for cross‐sectional area (CSA) of tendons in the tarsal region is important in order to use them as reference values in the identification of pathological changes of dimensions. Objectives: To provide normal reference values for the CSA of the tendons of the tarsus of Standardbred trotter horses (STH) by means of ultrasonography. Methods: Transverse echographic images of the tendons were obtained at different levels proximodistally; these images were digitised and CSA values (mean ± s.d.) were obtained for each structure. Results: The largest structure corresponded with the lateral digital flexor/caudal tibial tendon complex at Level 1 and the smallest was the medial digital flexor tendon at Level 4. Almost all tendons showed a slight decreasing in their CSA when crossing the tarsus. Conclusions: The normal CSA values of tendinous structures in the tarsal region of the STH are reported. These data could be used as anatomical references. Potential relevance: The establishment of reference values could serve as a tool to discriminate between normal and abnormal dimensions of tarsal tendons in STH. Other horse breeds should need their own reference values.     

Anatomical, magnetic resonance imaging and histological findings in the accessory ligament of the deep digital flexor tendon of forelimbs in nonlame horses

Reasons for performing the study: Detailed magnetic resonance imaging (MRI) and histological appearances of the accessory ligament of the deep digital flexor tendon (AL‐DDFT) have not been documented previously in detail. Objectives: To: 1) describe anatomical connections between the AL‐DDFT and adjacent structures; 2) describe high‐field and low‐field MRI and histological appearances of the AL‐DDFT in the forelimb of horses with no carpal or proximal metacarpal pain; and 3) assess the relationship between age, breed, gender, height, weight and MRI findings. Methods: Ten forelimbs were dissected to determine anatomical relationships among the AL‐DDFT and adjacent structures. High‐ and low‐field MR images of the AL‐DDFT and related structures from 29 cadaver limbs of nonlame horses were analysed subjectively and objectively. The relationship between age, breed, gender, height, weight and MRI findings was assessed using a Chi‐squared test. Twelve ALs‐DDFT were examined histologically. Histological and MRI findings were compared subjectively. Results: Fibrous bundles were seen between the AL‐DDFT and the lateral aspect of the superficial digital flexor tendon (n = 9) and the DDFT (n = 2). The AL‐DDFT had low to intermediate signal intensity in most limbs in most high‐field and low‐field MRI sequences. In 69% of limbs, oblique bands of higher signal intensity than the rest of the ligament were identified in high‐field images of the AL‐DDFT. The cross‐sectional area of the AL‐DDFT in the proximal 7 cm of the metacarpal region ranged from 68.1–299 mm². There was no significant relationship between age, gender, weight or height and either the cross‐sectional area of the AL‐DDFT or the presence of oblique higher signal intensity bands. Histological examination revealed that the AL‐DDFT had thick collagen bundles arranged in large crimps and sometimes crossing in oblique directions. The cellularity was greater than in the deep digital flexor tendon in all limbs. Conclusion and potential relevance: The large variability in the MRI appearance and size of the AL‐DDFT in nonlame horses should be borne in mind when interpreting MR images of lame horses.     

Concurrent proximal suspensory desmopathy and injury of the proximal aspect of the accessory ligament of the deep digital flexor tendon in forelimbs or hindlimbs in 19 horses

Clinical features of proximal suspensory desmopathy (PSD) and concurrent injury of the proximal aspect of the accessory ligament of the deep digital flexor tendon (ALDDFT) have not been documented. The objectives were to describe clinical signs and diagnosis. This was a retrospective study. Patient details, lame limb(s), response to diagnostic analgesia, and radiographic and ultrasonographic findings were recorded. PSD and injury of the proximal aspect of the ALDDFT were identified in 19 horses, 14 with forelimb lameness (unilateral 5, bilateral 9) and 5 with hindlimb lameness (unilateral 2, bilateral 3). Localising clinical signs were seen in 7/31 lame limbs (subtle thickening in the region of the ALDDFT [n = 3], pain on palpation of the body of the suspensory ligament (SL) [n = 6], heat in the proximal metacarpal or metatarsal region [n = 2]). Forelimb lameness was abolished by perineural analgesia of the palmar metacarpal (subcarpal) nerves in 17/23 limbs. In the remaining limbs intra‐articular analgesia of the middle carpal joint (n = 2) or an ulnar nerve block (n = 4) were required to eliminate the lameness. Hindlimb lameness was abolished by perineural analgesia of the deep branch of the lateral plantar nerve (n = 2) or local infiltration of the proximal plantar aspect of the metatarsus (n = 3); a tibial nerve block resolved lameness in the remaining 3 limbs. Lesions of the SL and of the ALDDFT were characterised ultrasonographically by enlargement, heterogeneous echogenicity and loss of long linear echoes in longitudinal images. In 3 horses adhesions between the ALDDFT and the SL were identified post mortem. Close apposition of these structures seen ultrasonographically may indicate adhesion formation. It was concluded that the clinical features of PSD and concurrent injury of the ALDDFT are similar to those for PSD alone, highlighting the need for comprehensive and systematic ultrasonographic assessment.     

Musculoskeletal disease and injury, now and in the future. Part 2: Tendon and ligament injuries

Tendon and ligament injuries continue to be one of the most frequent causes of orthopaedic injury and early retirement in the Thoroughbred racehorse. In the UK, the Horserace Betting Levy Board has invested considerable research funding in the last decade in order to investigate aspects of tendon epidemiology, biology and therapy, in order to decrease both the welfare and economic consequence of such injuries. This review summarises key aspects of this research effort and identifies specific research directions for the future.     

Synoviocoeles associated with the tarsal sheath: description of the lesion and treatment in 15 horses

Reasons for performing study: To describe the presentation, clinical, ultrasonographic and endoscopic features associated with a defect in the tarsal sheath wall, to define the cavity created and to describe a method of treatment. Hypothesis: So called ‘false thoroughpins’ can be caused by defects in the tarsal sheath wall creating a one way valve effect, removal of which could be therapeutic. Methods: Case records and diagnostic images of horses with synoviocoeles associated with the tarsal sheath were reviewed retrospectively and follow‐up information obtained. Results: Synoviocoeles were diagnosed in 15 horses. All were managed similarly and 10 horses had clinical resolution and returned to work. Conclusion: Terminology previously used to describe lesions involving the tarsal sheath does not define accurately the condition described and the term synoviocoele is recommended. Endoscopic enlargement of the sheath wall defect produced good clinical results in 10/15 horses. Potential relevance: Clinicians should include synoviocoele in the list of differential diagnoses of fluid filled cavities associated with the tarsal sheath and should consider endoscopic surgery as a treatment modality.     

Ultrasonographic examination of the collateral ligaments of the distal interphalangeal joint in horses: Part A: Technique and normal images

The collateral ligaments (CL) of the distal interphalangeal joint (DIPJ) are important structures for DIPJ stability. Collateral ligament injuries must be considered in the differential diagnosis of foot pain. An accurate examination of the CL‐DIPJ can be performed with an adequate ultrasonographic technique and equipment. This paper describes the technique and normal ultrasonographic images as reference data for the diagnosis and documentation of CL‐DIPJ desmopathies and enthesopathies.     

Ultrasonographic examination of the collateral ligaments of the distal interphalangeal joint in horses. Part B: Abnormal findings and lesions

Ultrasonography is an easy and rewarding technique for the assessment of collateral ligaments of the distal interphalangeal joint (CL‐DIPJ) desmopathies and enthesopathies. Comparison between ligaments of both feet and oblique incidence improve sensitivity and specificity of the ultrasonographic diagnosis. The main limitation of the procedure is imaging the distal part of the CL‐DIPJ and corresponding fossa of the distal phalanx. Alone, or in combination with other imaging procedures, ultrasonography is valuable in the diagnosis of the injured structures, which may help to determine the corrective shoeing and the rehabilitation programme of the horse.     

Collateral desmitis of the distal interphalangeal joint in conjunction with concurrent ossification of the cartilages of the foot in nine horses

The purpose of this study was to describe the frequency of occurrence of severe ossification of the collateral cartilages (sidebone) coexistent with collateral desmitis of the distal interphalangeal joint (DIPJ) in lame horses. Sidebone was diagnosed and graded on standard radiographs and soft tissue injuries of the foot were diagnosed using standing low‐field magnetic resonance imaging (MRI). Of 15 horses with forelimb lameness and severe sidebone, 9 had evidence of concurrent collateral desmitis of the DIPJ. All 15 horses had damage to other structures (including the deep digital flexor tendon, distal sesamoidean impar ligament, collateral sesamoidean ligament, navicular bone and distal phalanx) within the affected feet as identified on MRI. The clinical and pathophysiological significance of concurrent collateral desmitis of the DIPJ and sidebone is currently uncertain. However, this study shows that injuries to multiple structures within the foot are common and that collateral desmitis of the distal interphalangeal joint is frequently seen in lame horses in conjunction with severe ossification of the collateral cartilages.