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 dorsal aspect of the distal interphalangeal joint of the horse

Ultrasonographic examination of the dorsal aspect of the distal interphalangeal joint is part of the routine examination of the foot structures. The purpose of this paper is to describe the ultrasonographic anatomy of the area, and normal transverse and longitudinal images. Clinical cases are presented to illustrate abnormal findings and lesions of the dorsal aspect of the joint. Ultrasonography can complement radiography for the diagnosis and documentation of many soft tissue and joint abnormalities such as synovitis, fluid distension, cartilaginous defects, periarticular osteophytes and bone fragments.     

Risk of intra‐articular injection with longitudinal ultrasound‐guided injection of collateral ligaments of the equine distal interphalangeal joint

Desmopathy of the collateral ligaments of the distal interphalangeal joint is a common cause of equine foot lameness and carries a poor prognosis with conservative management. Intralesional injections may improve healing, although accuracy of radiographically guided injections is significantly less than when guided by MRI, which requires special needles. Longitudinal ultrasound‐guided injection of the distal collateral ligament has not been evaluated objectively. In this prospective, anatomic study, seven equine cadaver limbs (14 collateral ligaments) were injected with methylene blue dye and radiographic contrast medium using ultrasound to guide the needle longitudinally into the collateral ligaments until contacting bone. The insertion site of the needle proximal to the coronary band was measured on the limb and the needles left in place for radiography and CT to evaluate the needle angulation, location of the contrast medium, and whether the contrast entered the distal interphalangeal joint. The limbs were frozen and sectioned with a band saw to identify the location of the dye. Fifty percentage of injections were in or around the collateral ligaments. However, the percentage of “successful” injections, defined as in the collateral ligament but not in the joint, was only 36%. All legs had dye and contrast in the joint after both ligaments had been injected. There were no significant differences between the needle angle and entry site for “successful” and “unsuccessful” injections. Findings from this study indicates that the success rate is low for injecting the distal portions of the distal interphalangeal joint collateral ligaments using ultrasound guidance alone.     

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.     

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.     

The collateral ligaments of the distal interphalangeal joint: magnetic resonance imaging and post mortem observations in 25 lame and 12 control horses

Reasons for performing study: Magnetic resonance imaging (MRI) is used with increasing frequency to diagnose injuries of the collateral ligaments (CLs) of the distal interphalangeal (DIP) joint, but the results have not been verified by histology and the mechanism of injury is poorly understood. Hypothesis: Abnormal signal intensity and tissue contour represents change in tissue structure detected on histology. Objectives: To compare results in horses free from and those with chronic lameness and to describe possible progression of lesions. Methods: One or both feet of horses free from lameness (Group N: n = 12) and with foot‐related lameness (Group L: n = 25) were examined using MRI and by gross post mortem examination. The magnetic resonance (MR) images were graded. Sagittal sections from the proximal and distal aspect of each CL were examined histologically and each ligament assigned a score. Scintigraphic images from lame horses were also evaluated. Results: In Group N, 25 CLs were graded normal on both MR images and histology, 2 CLs were grade 1 on MR images, but were histologically normal, and 2 CLs had MR abnormalities verified histologically. However, 2 CLs appeared normal on MR images but were histologically abnormal. In Group L, 18 CLs were deemed normal on both MR images and histology, and 54 CLs had MR abnormalities verified histologically. However, 13 CLs appeared normal on MR images but were graded abnormal histologically. Lesions appeared to be degenerative, characterised by extensive fibrocartilaginous metaplasia and development of multiple, intercommunicating fissures within the degenerate collagen in severe lesions. There was an association between increased radiopharmaceutical uptake and a higher histological score. Conclusions: High‐field MRI is reasonably reliable for detection of lesions of the CLs of the DIP joint, but may underestimate their prevalence. Clinical relevance: Collateral ligament injury appears to be a primary degenerative process, which may explain the poor response to conservative treatment and a need for promotion of regeneration.     

Influence of the position of the foot on MRI signal in the deep digital flexor tendon and collateral ligaments of the distal interphalangeal joint in the standing horse

Reasons for performing study: Hyperintense signal is sometimes observed in ligaments and tendons of the equine foot on standing magnetic resonance examination without associated changes in size and shape. In such cases, the presence of a true lesion or an artifact should be considered. A change in position of a ligament or tendon relative to the magnetic field can induce increased signal intensity due to the magic angle effect. Objectives: To assess if positional rotation of the foot in the solar plane could be responsible for artifactual changes in signal intensity in the collateral ligaments of the distal interphalangeal joint and in the deep digital flexor tendon. Methods: Six isolated equine feet were imaged with a standing equine magnetic resonance system in 9 different positions with different degrees of rotation in the solar plane. Results: Rotation of the limb induced a linear hyperintense signal on all feet at the palmar aspect of one of the lobes of the deep digital flexor tendon and at the dorsal aspect of the other lobe. Changes in signal intensity in the collateral ligaments of the distal interphalangeal joint occurred with rotation of the limb only in those feet where mediolateral hoof imbalance was present. Conclusions: The position and conformation of the foot influence the signal intensity in the deep digital flexor tendon and in the collateral ligaments of the distal interphalangeal joint. Potential relevance: The significance of increased signal intensity in the deep digital flexor tendon and in the collateral ligaments of the distal interphalangeal joint should be interpreted with regard to the position and the conformation of the foot.     

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.     

Osseous abnormalities associated with collateral desmopathy of the distal interphalangeal joint: Part 1

Reasons for performing study: Osseous abnormalities. associated with collateral ligament (CL) injury of the distal interphalangeal (DIP) joint have been documented using magnetic resonance imaging (MRI) but there is currently limited information about the frequency of osseous pathology associated with CL injury. Objectives: To determine the frequency of occurrence of osseous abnormality coexistent with CL injury of the DIP joint and describe the distribution and character of osseous lesions; and to establish if there was an association between osseous abnormality and increased radiopharmaceutical uptake (IRU). Hypotheses: There would be a higher incidence of osseous abnormality at the insertion of an injured CL than at the origin; and a relationship between the presence of osseous abnormality and duration of lameness. Materials and methods: Magnetic resonance images of 313 feet of 289 horses with foot pain and a definitive diagnosis of collateral desmopathy of the DIP joint were analysed retrospectively for presence and type of osseous abnormality in the middle and distal phalanges. Scintigraphic images were examined and the presence of IRU in the middle or distal phalanges recorded. Results: Osseous abnormalities were detected in 143 (45.7%) feet, 27 (18.8%) of which had osseous and CL injury alone, while the remaining 116 had CL related osseous injury and multiple injuries within the hoof capsule. Entheseous new bone and endosteal irregularity of the middle and distal phalanges were the most frequent types of osseous abnormality. There was a higher incidence of osseous abnormalities medially than laterally and at the ligament insertion than at the origin. There was a significant association between presence of IRU and osseous injury. Conclusions: A variety of osseous lesions of differing severity are associated with CL injury. Normal radiopharmaceutical uptake does not preclude significant osseous pathology associated with CL injury. Clinical relevance: Further studies are necessary in order to determine if osseous abnormalities associated with CL injury influence prognosis for return to performance.     

Ultrasonographic diagnosis of septic arthritis of the distal interphalangeal joint in cattle

Diagnosis of septic arthritis in the distal interphalangeal joint (SADIJ) is often difficult, particularly when arthrocentesis or probing of the joint space are inconclusive. The aim of this prospective study was to investigate the usefulness of ultrasonography in reinforcing a tentative clinical diagnosis of SADIJ in 60 Holstein–Friesian cows with septic arthritis in one distal interphalangeal joint (DIJ). The diagnosis of septic arthritis was based on the results of clinical examination and radiographic images, as well as surgical findings. The DIJ of the partner claw of the same foot and the normal DIJs of 18 healthy Holstein–Friesian cows were used as controls. Visualisation, echogenicity and flow phenomena of the synovial fluid were assessed ultrasonographically. The size of the dorsal pouch of the distal interphalangeal joint (DPDIJ) was determined by measuring two defined distances.The DPDIJ could be imaged in all cows with SADIJ, although the quality of the image varied from good (63%) or moderate (30%) to poor (7%). The echogenicity of the synovial fluid in joints with SADIJ did not differ from those of the partner claws. Flow phenomena were seen in only 30% of the DPDIJs with septic arthritis and in none of the DPDIJs of the partner claws. The DPDIJ was larger in DIJs with septic arthritis than in those of the partner claws and controls (P < 0.05). The dorsopalmar/plantar distance of the DPDIJ indicated a suitable sensitivity (0.97) and specificity (1.0) for the diagnosis of septic arthritis when a threshold value of 6 mm was used. Ultrasonographic examination of the DIJ appeared to be a reliable method for confirming a tentative clinical diagnosis of septic arthritis in cattle.     

Osteochondral fragmentation of the palmarolateral/plantarolateral aspect of the distal phalanx in four horses: A novel location

Four horses presenting for lameness were diagnosed with unilateral osteochondral fragmentation (OCF) of the palmarolateral/plantarolateral aspect of the distal phalanx within the distal interphalangeal joint (DIPJ). Histological evaluation of one case supported a diagnosis of osteochondritis dissecans (OCD), with patient age and history from two cases suggesting a traumatic origin. Lesion appearance on conventional radiography, computed tomography (CT), nuclear scintigraphy and magnetic resonance imaging (MRI) are described. Fragmentation was best identified on dorsal 65° proximal-palmaro/plantarodistal oblique (D65°PrPDiO/D65°PrPlDiO) and dorsal 65° proximal-palmaro/plantarodistal lateral oblique (D65°Pr45°L-PDiMO/D65°Pr45°L-PlDiMO) radiographic projections of the foot, but articular pathology appeared more severe on cross-sectional imaging modalities. In all cases, lameness was refractory to conservative management. Arthroscopic evaluation of the DIPJ was performed in three horses, although the lesion was inaccessible in two. In one horse, access to the lesion was possible due to increased joint laxity, presumably due to concurrent soft tissue injury. One horse was euthanased after failed conservative management, one was pasture sound following palmar digital neurectomy 12 months after initial presentation, one returned to racing and one was lost to follow-up. Osteochondral fragmentation at this location has not previously been described, treatment options are limited and the prognosis appears to be poor.     

Comparison of conventional and alternative arthroscopic approaches to the palmar/plantar pouch of the equine distal interphalangeal joint

Reasons for performing the study: The conventional arthroscopic approach to the palmar/plantar aspect of the distal interphalangeal joint (DIPJ) may result in the inadvertent penetration of the digital flexor tendon sheath (DFTS) and the navicular bursa (NB). This iatrogenic communication would be undesirable subsequent to arthroscopic lavage of a septic DIPJ. Hypothesis: A lateral/medial approach to the palmar/plantar aspect of the DIPJ will result in a significantly lower rate of inadvertent penetration of the DFTS and NB, whilst still providing adequate intra‐articular evaluation. Methods: The conventional palmar/plantar approach or a novel lateral/medial approach to the DIPJ was performed on cadaver fore‐ and hindlimbs (30 limbs/approach). Subsequently, India ink was injected into the dorsal pouch of the DIPJ, and the DFTS (n = 60) and NB (n = 20) were examined for the presence/absence of ink. In addition, observations of the number of attempts made to access the joint, evidence of iatrogenic intra‐articular trauma and occurrence of incomplete visualisation of the palmar/plantar pouch were recorded. Results: With the conventional approach, DFTS penetration was noted in 18/30 (60%) of the limbs, compared to 1/30 (3.3%) with the lateral/medial approach (P≤0.001). NB penetration was seen in 5/10 limbs with the palmar/plantar approach compared to 0/10 with the lateral/medial approach (P = 0.01). No significant differences were found between the approaches in the number of attempts made to access the joint, the incidence of iatrogenic intra‐articular trauma, or the occurrence of incomplete visibility of the palmar/plantar pouch. Conclusions: The novel lateral/medial approach to the DIPJ significantly decreases the risk of inadvertent penetration of the DFTS and NB. Potential relevance: The novel lateral/medial approach to the DIPJ is an effective technique to gain access to the palmar/plantar pouches, and is particularly advantageous for arthroscopic lavage of a septic DIPJ.     

Transrectal ultrasonographic examination of the sacroiliac joints of the horse: Abnormal findings and lesions

Transrectal ultrasonography is a useful technique for the assessment of sacroiliac osteoarthrosis because of the ventral localisation of lesions. Comparison between the right and left side is essential. Due to the deep localisation of the sacroiliac joints, other imaging modalities have limitations for diagnosing osteoarthrosis. A grading system from 1 to 4 is suggested in order to classify the severity of lesions based on the shape of the articular margins and architecture of the ventral sacroiliac ligament. Abnormal ultrasonographic findings should be correlated with clinical manifestations.     

Ultrasonographic guided injection of the scapulohumeral joint in horses

Intra‐articular injections of the scapulohumeral joint (SHJ) in horses are difficult to perform because of the thick muscles covering the area and a reduced articular space. Ultrasonographic guidance was demonstrated to be helpful to perform intra‐articular injections. This technique applied to the SHJ can be performed in the field with a portable machine. The joint space is firstly imaged in transverse and proximodistal scans. After aseptic preparation of the shoulder area, the probe is placed to image the SHJ space in transverse section and the needle is inserted cranially in the ultrasound beam. The progression of the needle is followed towards the SHJ space, limiting joint injuries and side effects.     

Evaluation of intra-articular injection of autologous platelet lysate (PL) in horses with osteoarthritis of the distal interphalangeal joint

Background: Regenerative medicine has become one of the most promising therapies of equine osteoarthritis. Platelet lysate (PL) is rich in bioactive proteins and growth factors that play a crucial role in tissue healing.

Objective: To evaluate the efficacy of intra-articularly injected autologous PL in equine athletes with naturally occurring osteoarthritis.

Animals and methods: Fifteen warmblood geldings aged 8–19 years with osteoarthritis of the distal interphalangeal joint were included in this study. They were randomly divided into two groups; 10 horses received intra-articular injections of PL and 5 of normal saline (controls). Before treatment, platelet-derived growth factor (PDGF) levels in basal plasma and prepared PL were estimated. Each joint was injected twice within a three-week period. Lameness was evaluated using the American Association of Equine Practitioners grading system, before treatment and 10 days after each intra-articular injection. Horses were examined fortnightly for one year. Radiographic examination was performed six months post-treatment. The generalized estimating equation test was used for statistical analysis.

Results: Acceptable levels of PDGF were detected in PLs (mean ± SD: 258.0 ± 52.3 pg/ml). The majority of horses (9/10) responded positively to PL treatment presenting lower lameness grades (p < 0.0005) compared to controls 10 days after the second injection, and returned to normal athletic activity. Radiographs revealed no changes in osteoarthritis lesions six months after treatment. One year post-injections, however, all horses relapsed to their initial degree of lameness.

Conclusion: Intra-articularly injected autologous PL is an efficient method for temporarily managing osteoarthritis of the distal interphalangeal joint in athletic horses.     

Influence of morphometric parameters on the size of collateral ligaments of the distal interphalangeal joint of equines

The physiological measurements of collateral ligaments of distal interphalangeal joint (CL-DIPJ) differ in the literature. The factors that influence these differences are not well described. The aims of this study are to compare CL-DIPJ sizes in equines with different withers height, as well as to correlate body weight and hoof size to the size of these ligaments. In total, 52 horses were used in the study. They were divided into two groups according to wither height: Group 1 (G1) - 21 animals with up to 147 cm - and group 2 (G2) - 21 animals with greater than 148 cm. CL-DIPJ was ultrasonographically measured in order to find the mean of dorso-palmar (DPD) and latero-medial (LMD) diameters and the cross-sectional area (CSA). Hoof width and length were measured, and the results were used to calculate the hoof surface area. Withers height and body weight were also measured. Groups were statistically compared by Student's t test and Pearson's correlation application to each group. Groups were different in body size, HS and CL-DIPJ size when p < .05, except for the LMD of the medial collateral ligament of left thoracic limb. Withers height and body weight did not show significant correlations to CL-DIPJ size in G1, but they had little influence on the size of CL-DIPJ on G2. No correlation between the hoof size and the CL-DIPJ was noted in any of the two groups. In conclusion, the CL-DIPJ were larger in taller horses and their sizes were correlated to their height and weight, but they were not correlated to hoof size.     

Desmitis of the medial tarsal collateral ligament in 7 horses

Severe lameness, tarsocrural joint effusion and medially focused peritarsal swelling combined with focal pain on palpation are clinical signs suggestive of acute injury to the medial tarsal collateral ligament. Diagnosis can be made on physical examination and ultrasonographic findings; however, magnetic resonance imaging may provide more information especially with subtle injury. Acute exacerbation of the injury during the prolonged convalescence is common. The prognosis for medial tarsal collateral ligament desmitis appears good for survival but fair for return to previous levels of performance and requires prolonged periods of rest and a controlled exercise programme.