Definition of lameness (claudication)

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1 Lameness diagnostic in the horse Dr. Tóth Péter Definition of lameness (claudication) Structural or functional disorder in one or more limbs and related structures SZIU, Faculty of Veterinary Sciences, Large Animal Clinic Hoof, navicular region Tendons, ligaments, tendon sheath, bursae Functional anatomy Supporting phase landing loading Stance Breakover heel lift toe pivot Swinging phase Phases of the stride Phases of the stride -Swing Swinging phase Flexion (caudal) Extension (cranial) 1

2 Normal gait (by Sue Dyson) Overextension in the fetlock joint Overextension in the coffin joint Mechanism of the hoof Arc of foot flight 2

$stress fracture) Interference forms at$ the trot A: front limb to front limb B:

(diagonal limbs)/ D: ipsilateral hind to

Trauma Congenital I. Causes of lameness 3.

3 Plaiting hind limb (bilateral ilial stress fracture) Interference forms at the trot A: front limb to front limb B: ipsilateral front to hind /C: pacer (diagonal limbs)/ D: ipsilateral hind to front I. Causes of lameness 1. I. Causes of lameness 2. Trauma Congenital I. Causes of lameness 3. I. Causes of lameness 4. Acquired Infection 3

Metabolic disturbances Circulatory disorders

4 I. Causes of lameness 5. I. Causes of lameness 6. Metabolic disturbances Circulatory disorders Aortoiliac thrombosis I. Causes of lameness 7. Nervous system?? II. Causes of lameness Classification of lameness Pain Mechanical Paralytic disorders Supporting limb lameness Swinging limb lameness Mixed lameness Complementary lameness Untipical lameness Special lameness 4

5 Supporting limb lameness Swinging limb lameness Cranial phase is longer Head and neck movement The problem is usually lower Worse in inside circle Cranial phase is shortened It is evident during motion Usually the problem is higher Worse in outside circle Swinging limb lameness- (bicipital bursitis) Mixed lameness Disturbance in function of different structures involved in supporting and swinging phase Compensatory lameness Uneven distribution of weight on another limb Severe left hind limb lameness (med. femorotibial osteoarthritis) 5

6 Untipical lameness When more than one limb is effected Concurrent left hind right front limb lameness Special lameness E.g. rupture of peroneus tertius Upward fixation of the patella DDFT rupture Patella fixation 3 primary causes of upward patellar fixation: 1, Lack of fitness: Lack of quadriceps and/or biceps femoris muscle tone results in an inability to quickly pull the patella up and off of the medial femoral trochlea. 2, Straight or upright pelvic limb conformation: This places the medial femoral trochlea further distad in closer proximity with the patella, facilitating patellar fixation. 3, Excessive distal patellar ligament length: This places the patella proximad in closer proximity with the medial femoral trochlea, where it can inadvertently "catch" or "lock" Patella fixation Stringhalt 6

7 Fibrotic myopathy Degree of lameness Grade I. : very mild Grade II.: mild Grade III.: moderate Grade IV.: sever Grade V.: very sever (non weight bearing) unchanging Changing Character of lameness Improving during training/examination Intermittent Order of lameness examination Anamnesis Visual examination Palpation Provocating tests Diagnostic analgesia Perineural, intrasynovial, infiltration Supplementary diagnostic aids Puncture, laboratory evaluation, etc. X-ray, Ultrasonography, Scintigraphy, CT, MRI Anamnesis Anamnesis How long has the horse been lame? What is the cause of the lameness? Has been rested or exercised? Worm out? Treatment? When was the horse shod??? How long has the horse been lame? What is the cause of the lameness? How did it happened? 7

8 Anamnesis Anamnesis Is he still in work Does he worm out of the lameness? Previous treatments? What was the result? Anamnesis When was the horse shod??? Visual examination at rest At a distance (all directions) Conformation Body condition Positure Atrophy, assymetry Close observation Hoof Swelling, distension etc. Visual examination Visual examination at exercise 1. At rest How to handle the horse? Should be held loosely with their heads Exercised as slowly as necessary Selection of surfaces Hard surface (listen, visualisation, think) On gravel 8

9 Visual examination at exercise 2. Visual examination at exercise 3. Watch all limbs! Which limb is lame? Degree, character, type etc. Walk, little circle, trot, galopp the horse should be exercised under sattle or whatever is necessary (driving, racing, jumping, etc.) Visual examination Supllementary diagnostic aids at exercise RTG Arthroscopy Synovia analysis US CT, MRI What you are able to perform also at the stables Palpation Anamnesis Viual examination Palpation Provocating tests Diagnostic anaesthesia 9

Provocating tests Diagnostic analgesia perineural Intrasynovial

Purpose Find the site of pain causing lameness Confirm suspected site

anaesthetic diffuses proximally 70-80% pozitivity is a pozitive

Deep bony pain is difficult to anaesthetise You can not block out all

10 Provocating tests Diagnostic analgesia perineural Intrasynovial Diagnostic analgesia Why could the site not optimally anesthetised? Purpose Find the site of pain causing lameness Confirm suspected site of pain Bad technique Variation of periferial nerve anatomy Local anaesthetic diffuses proximally 70-80% pozitivity is a pozitive result! Deep bony pain is difficult to anaesthetise You can not block out all intraarticular pain Mechanical lameness What kind of local anaesthetics should we use? Effect duration Less irritant Mepivacaine Prilocaine Bupivacaine Fast acting about 2 hour duration Mepivacaine and prilocaine Slower acting about 4 hour duration Bupivacaine More irritant Lidocaine 10

Depends on horse Minimal restraint is less stressful Good

Twitch Reliable handler No effect on result Diagnostic analgesia

restraint Sedation Small doses Xylazine Detomidine/butorphanol

restraint Leg position On ground Held by clinician Held by

analgesia Clean procedure Clip if hairy Antiseptic scrub until

Diagnostic analgesia patient preparation Intrasynovial Aseptic

11 Depends on horse Minimal restraint is less stressful Good handler is essential Diagnostic analgesia Restraint Physical Twitch Reliable handler No effect on result Diagnostic analgesia Restraint Position yourself safely Diagnostic analgesia restraint Sedation Small doses Xylazine Detomidine/butorphanol Safer Affect result in higher doses Diagnostic analgesia restraint Leg position On ground Held by clinician Held by assistant Diagnostic analgesia patient preparation Perineural analgesia Clean procedure Clip if hairy Antiseptic scrub until clean Povidone iodine Chlorhexidine Alcohol with swab then spray Diagnostic analgesia patient preparation Intrasynovial Aseptic procedure Clip 5 minute antiseptic scrub Alcohol wash Sterile gloves Fresh bottle of anaesthetic 11

Diagnostic analgesia procedure 18-25 gauge needles Use fine needles when possible

still Too much walking could give a false positive Diagnostic analgesia procedure

acts more quickly Shorter duration Diagnostic analgesia procedure Post block

suspicion as to site of pain Block from distal to proximal Use regional blocks

forelimb 1. Ramus pulvinus (low palm dig block) 2.

12 Diagnostic analgesia procedure gauge needles Use fine needles when possible Length depends on site Quantity of anaesthetic depends on site (try to keep it on minimum!) Diagnostic analgesia procedure After block Brief walk out post block then stand still Too much walking could give a false positive Diagnostic analgesia procedure Evaluate 5-10 minutes minutes 60 minutes Intrasynovial analgesia Usually acts more quickly Shorter duration Diagnostic analgesia procedure Post block Sterile wrap (5-10 min) Diagnostic analgesia: Fore limb Strategy No clinical suspicion as to site of pain Block from distal to proximal Use regional blocks Differentiate with intrasynovial blocks later if necessary Perineural analgesia: forelimb 1. Ramus pulvinus (low palm dig block) 2. prox palm digit block (deep volar) 3. low palmar block (middle volar) 4. four point block 5. high palmar block (subcarpal) 6. subcarpal block 7. Ulnar block 8. Medianus et musculocutaneus block 12

Low palm digit block (ramus pulvinus) 23 g 1.5 cm needle 1.

DIP joint +/- distal DDFT lesions Occasionally PIP joint Prox palm digit block (deep volar) 23 g 1.5 cm needle 1.

DIP joint +/- distal DDFT lesions Occasionally PIP joint Low palmar block (middle volar) 22-23 G 1.

13 Low palm digit block (ramus pulvinus) 23 g 1.5 cm needle 1.5 ml anaesthetic At level of collateral cartilages Low palm digit block (ramus pulvinus) Structures anaesthetised Palmar foot Toe DIP joint +/- distal DDFT lesions Occasionally PIP joint Prox palm digit block (deep volar) 23 g 1.5 cm needle 1.5 ml anaesthetic 2-3cm proximal to collateral cartilages Prox palm digit block (deep volar) Structures anaesthetised Palmar foot Toe DIP joint +/- distal DDFT lesions Occasionally PIP joint Low palmar block (middle volar) G 1.5 cm needle 3 ml loc anaesthetic At level of prox sesambones Low palmar block (middle volar) Structures anaesthetised As for PDB (proximal pastern) Sometimes includes Fetlock joint (MCP) Sesamoid bone locally Does block distal DDFT lesions J. Walmsley Anglia 13

In case of positive low or prox palm digit analgesia

structures with: DIP block Navicular bursa block PIP

Dorsal or palmar approach Distal interphalangeal joint

Dorsal sole (toe) (not the heel) 10 ml anaesthetic

procedure Radiographic control 19g 7cm needle 3.

5 ml iohexol contrast solution Navicular bursa

Dorsal sole (toe) Navicular bone Navicular ligaments

14 In case of positive low or prox palm digit analgesia Distal interphalangeal joint analgesia Differentiate structures with: DIP block Navicular bursa block PIP block Aseptic procedure 19g 3cm needle 6 ml anaesthetic Dorsal or palmar approach Distal interphalangeal joint analgesia Structures anaesthetised with 6 ml DIP joint Dorsal sole (toe) (not the heel) 10 ml anaesthetic Blocks heel as well Navicular bursa analgesia Aseptic procedure Radiographic control 19g 7cm needle 3.5 ml anaesthetic 0.5 ml iohexol contrast solution Navicular bursa analgesia Structures anaesthetised Navicular bursa Dorsal sole (toe) Navicular bone Navicular ligaments (not the heel) Proximal interphalangeal joint (PIPJ) Dorsal approach 21g 2.5cm needle 5 ml anaesthetic 30 minutes: DIP joint 14

15 PIPJ Palmar approach 21g 2.5cm needle 5 ml anaesthetic PIPJ Structures anaesthetised PIP joint 4 point block (N. digit. palm., nn. metacarpales) 23 g 1.5 cm needle ml anaesthetic Palmar digital nerves Palmar metacarpal nerves 4 point block Structures anaesthetised As for PDB plus: Metacarpophalangeal (MCP) region PD nerve only Useful for annular ligament analgesia Positive 4 point block: Differentiate structures with: - MCP analgesia Digital sheath analgesia Metacarpophalangeal analgesia Dorsal and palmar approaches 19-22g 3-4cm needle 10 ml anaesthetic 15

16 Metacarpophalangeal analgesia Dorsal approach Easier Articular cartilage easily traumatised Metacarpophalangeal analgesia Palmar approach Between suspensory ligament and MC3 Sometimes difficult to be sure of centesis Metacarpophalangeal analgesia Structures anaesthetised MCP joint Subchondral bone pain slow to respond 30 minutes may anaesthetise: distal suspensory branches sesamoids Prof. Jean M. Denoix Prof. Jean M. Denoix Digital flexor tendon sheath (DFTS) analgesia 20g 2.5cm needle 10-15ml anaesthetic- Proximal approach Digital flexor tendon sheath (DFTS) analgesia 20g 2.5cm needle 10-15ml anaesthetic- Distal palmar approach 16

Digital flexor tendon sheath (DFTS) analgesia Structures anaesthetised

block 20g 3cm needle 5ml in each site Palmar nerves Often only a

Structures anaesthetised Whole metacarpal region 65% chance of

block the skin dorsally Less chance of blocking the CMC joint

Specific for suspensory ligament lesions 19g 5cm needle 10 ml

17 Digital flexor tendon sheath (DFTS) analgesia Structures anaesthetised Digital sheath Local structures with time Annular ligament High palmar block 20g 3cm needle 5ml in each site Palmar nerves Often only a partial improvement Subcarpal block Lateral palmar analgesia Structures anaesthetised Whole metacarpal region 65% chance of penetrating carpometacarpal (CMC) joint More specific for suspensory ligament origin 22g 1.5cm needle 5ml anaesthetic Dorsal branches must be anaesthetised to block the skin dorsally Less chance of blocking the CMC joint Suspensory ligament origin infiltration Positive subcarpal analgesia Specific for suspensory ligament lesions 19g 5cm needle 10 ml anaesthetic From lateral Include palmar metacarpal nerves Perform middle carpal joint analgesia Can diffuse around palmar nerves and block metacarpal structures 17

Middle carpal and antebrachiocarpal analgesia

analgesia and middle carpal joint analgesia may

help to differentiate 19g 3cm needle 5ml

Check in 5-10 minutes 18g 4cm needle 10-15ml

ulnaris analgesia N. medianus analgesia N.

medianus analgesia 5 cm below elbow joint, medial

is locaated caudally from it Fals positive response

18 Middle carpal and antebrachiocarpal analgesia Dorsal pouches Medial or lateral Remember Subcarpal analgesia and middle carpal joint analgesia may block the same structures Clinical findings may help to differentiate 19g 3cm needle 5ml anaesthetic? Check in 5-10 minutes 18g 4cm needle 10-15ml anaesthetic 10 cm prox from accessory carpal bone N. ulnaris analgesia N. medianus analgesia N. medianus N. ulnaris N. palm.lat N. medianus analgesia 5 cm below elbow joint, medial side caudomedial surface of radius jusst cranial from m. flex. carpi radialis 10 ml loc anaesthetic A. and v. is locaated caudally from it Fals positive response because of elbow joint possible N. musculocutaneus analgesia Branch for skin Seldom necessary 4x3 ml V. cephalica cran. caud. V. ceph. access. cran. caud. v. cephalica v. cephalica acc. 18

19 Elbow analgesia Cranial or Caudal pouch 19g 9cm needle 25ml anaesthetic NB radial nerve Lat ulnar bursa not adviced (communicates just in 37%) Cran approach: signs of radial paresis Method: infront of collat lig 2/3 distance between humerus epicondyle and tub radii in cranial diretion 19g 9cm needle 25ml anaesthetic Wait 30 minutes Inbetween tub majus pars cran et caud humeri infront of infraspinatus insertion Shoulder joint analgesia Caud method: infront of olecranon caud fron epicondyle long needle, may need skin loc anaesthesia Bicipital bursa analgesia Thank you for your attention! 19 G 9cm needle 20ml loc anaesthetic Poncture under ultrasonographic controll adviced 4cm dist. and 6-7 cm caudal from tub. majus pars cranialis humeri 19

Case Studies. A. Kent Allen, DVM LAMENESS AND IMAGING IN THE SPORT HORSE

Case Studies. A. Kent Allen, DVM LAMENESS AND IMAGING IN THE SPORT HORSE Case Studies A. Kent Allen, DVM Author s address: Virginia Equine Imaging, 2716 Landmark School Road, The Plains, VA 20198; e-mail: vaequine@aol.com. 2007 AAEP. 1. Case Study #1: Medial Collateral Desmitis