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How to Assess and Treat Acute-Onset Non–Weight-Bearing Lameness in an Ambulatory Emergency Setting

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How to Assess and Treat Acute-Onset Non–Weight-Bearing Lameness in an Ambulatory Emergency Setting HOW TO MANAGE CRITICAL FIELD EMERGENCIES How to Assess and Treat Acute-Onset Non–Weight-Bearing Lameness in an Ambulatory Emergency Setting C. Ryan Penno, DVM Author’s address: The Equine Clinic at Oakencroft, 880 Bridge Street, Ravena, NY, 12143; e-mail: [email protected]. © 2012 AAEP. 1. Introduction 2. History and Physical Examination Acute-onset non–weight-bearing lameness is a com- A thorough and complete history is important in the mon emergency complaint to the ambulatory prac- examination of horses with non–weight-bearing titioner. The initial consultation commonly lameness. Factors such as age, sex, breed, and dis- contains the phrase “he was fine yesterday and to- cipline can predispose a horse to particular injuries. day cannot bear any weight on the leg,” or, “he was Historical details such as prior lameness or recent sound while being ridden and suddenly came up farriery can help further narrow the list of differen- severely lame.” The most common causes of acute tial diagnoses. Horses engaged in different disci- non–weight-bearing lameness include subsolar ab- plines may sustain discipline-specific injuries, which scessation, penetrating hoof injury, fracture, may help focus the differential diagnosis list and laminitis, severe soft tissue injury, and cellulitis.1,2 reduce time to diagnosis. It is important to observe the horse’s attitude, Diagnosis of the lameness can be difficult especially level of distress, and respiratory effort from outside if the initial cause was not witnessed. Using the the stall to ascertain the level of pain the horse is AAEP lameness scale, these emergency cases would experiencing without the added stress of a veteri- be classified as Grade 4 to 5 of 5. Grade 4 is defined nary examination. A rapid assessment of the nat- as “obvious lameness with a marked nodding, hitch- 2 ural environment of the patient including number ing, or shortened stride” and Grade 5 is defined as and character of pasture mates, quality of fencing “lameness produces minimal weight bearing in and housing, loose structural materials, and charac- motion and/or at rest or a complete inability to ter of the footing can also affect the diagnosis. 2 move.” Once a full history and visual inspection of the en- This article is intended to assist the ambulatory vironment is complete, a gross examination of the practitioner in preparation of appropriate diagnostic horse in its own environment is very useful. tools and therapeutic options for an acute-onset A brief but thorough physical exam should be non–weight-bearing lameness emergency. completed before focusing on the affected limb. NOTES AAEP PROCEEDINGS ր Vol. 58 ր 2012 201 Orig. Op. OPERATOR: Session PROOF: PE’s: AA’s: COMMENTS ARTNO: 1st disk, 2nd beb meadel 11 3286 HOW TO MANAGE CRITICAL FIELD EMERGENCIES The patient’s posture and stance can guide the prac- should prompt the practitioner to give the distal titioner to the affected limb. A visual assessment structures a more thorough inspection. Given the of swelling, hemorrhage, or trauma should be per- prevalence of subsolar abscessation, this is a good formed. In an ambulatory setting, a horse may location to begin the examination of the limb. Ele- spend significant time outdoors and can be covered vate the limb, if possible, and remove debris from in dirt and mud. Cleaning off all dust or mud and the sole and frog, allowing a thorough exam of the removing all blanketing materials is necessary to foot for foreign bodies, penetrating wounds, or drain- complete a thorough examination. Although it age. Apply the hoof testers to all areas of the sole, may be obvious to the practitioner which limb or frog, and across the heels searching for a pain re- limbs are affected, other factors can help to deter- sponse such as an increase in muscular tension, mine severity, secondary complications, or the pos- jerking the foot away, or behavioral changes such as sibility that multiple lesions need to be addressed. attempting to bite the handler or pinning of the ears. Temperature, heart rate, and respiratory rate can Once the examination of the foot is complete, begin help determine severity, character of a lesion and moving proximally on the limb analyzing each struc- the presence of systemic disease. An increased ture in careful detail. Examine the limb thor- body temperature can also help determine if an in- oughly while the horse is weight bearing and also fectious agent, bacterial or viral, is present, whereas with the limb elevated, as lesions in deeper struc- tachycardia and tachypnea can indicate the level of tures such as the suspensory ligament may not be pain the horse is experiencing. This is particularly easily accessible without flexion of the limb. Each helpful in our more stoic patients. Mucous mem- joint should be carefully flexed and extended and branes can help determine hydration status, an im- evaluated for lateromedial motion as well. The cli- portant consideration in horses injured while nician should pay close attention to the response of working. Occasionally, the horse is in such signif- the horse as this can help guide the isolation of the icant pain that a tranquilizer or sedative must be source of pain. Some common responses indicating administered immediately, but performing a thor- local discomfort include reluctance to allow full flex- ough physical exam before sedation or tranquiliza- ion or extension and jerking the limb away from the tion is preferable. If sedation is required, use the practitioner. A noticeable reduction or unexpected minimum amount necessary to ensure proper re- increase in the range of motion indicates possible straint and safety of the patient and handler with- pathology of the joint or periarticular structures, out significantly altering the clinical picture. such as collateral ligaments, requiring closer atten- Once an overall assessment of the horse and a tion. While performing flexion and extension mo- basic physical examination is completed, examine tions, it is important to remember that multiple the affected limb or limbs. Each practitioner has ongoing conditions may be present and a positive his or her own procedure for performing a lameness test may not indicate the cause of the acute non– examination, and it should be the goal of a new weight-bearing lameness. Perform a careful evalu- practitioner to develop a system that works well for ation of the limb, noting any abnormalities such as him or her. No one method is superior, provided obvious trauma, heat, swelling, discharge, pain on that all structures are thoroughly examined and palpation, and change in the size or character of palpated and the same procedure is followed with tendons, ligaments, or muscles. Once a thorough each subsequent case, reducing the possibility of exam is complete, the practitioner should be able to missing a subtle lesion. Diagnosis becomes more narrow down the list of differentials and formulate a challenging when multiple limbs are affected, as diagnostic plan to confirm a diagnosis. with acute-onset laminitis or a front and hind limb Many diagnostic tools are available to the ambu- concurrently affected. The safety of the practitio- latory practitioner to aid in diagnosis. Radiogra- ner and handler during examination and manipula- phy remains one of the most important tools tion of limbs must remain the primary priority. available. Portable digital radiography has signif- Watching the horse move in the stall or alley, even icantly increased the accuracy and speed of diagno- for a minimal number of steps, is very important. sis with the ability to image the affected limb on site Analyzing the foot placement; engagement of the and assess the severity immediately. Radiography pastern, fetlock, and proximal joints; and amount of should be used when a bony abnormality is sus- weight being borne on the limb can help determine pected given the history of the lesion and the clinical location of pain. exam findings. Perineural analgesia is a very im- Start the examination with the most distal struc- portant diagnostic tool and can be used to locate a tures and move proximally in a methodical manner. source of lameness, especially if the clinical exam Palpate the hoof capsule and coronary band for in- findings are not conclusive, such as with subsolar creased temperature or defects, and palpate the dig- abscessation or severe soft tissue trauma at the level ital arteries at the level of the fetlock for an of the distal phalanx. However, radiography may increased or “bounding” digital pulse to determine if be required to first rule out the possibility of a bony the hoof is affected. Typically, an increased digital fracture before performing local anesthesia so that pulse indicates inflammation or pain originating excess weight is not borne on the injured limb, fur- from an area distal to the point of palpation and ther complicating the problem. Other diagnostic 202 2012 ր Vol. 58 ր AAEP PROCEEDINGS Orig. Op. OPERATOR: Session PROOF: PE’s: AA’s: COMMENTS ARTNO: 1st disk, 2nd beb meadel 11 3286 HOW TO MANAGE CRITICAL FIELD EMERGENCIES modalities that are useful to the ambulatory practi- ture,a or a medicated poultice pad.b The diaper or tioner include ultrasonography and thermography, cotton is applied to the solar surface, wrapped with which confirm or rule out diagnoses once the exam an elastic cohesive bandage material,a and coated has finished. with a protective layer such as duct tape. Another treatment option includes flushing the tract with 3. Subsolar Abscessation water and an iodine solutiond to aid in disinfection of One of the most common causes of acute-onset non– the underlying tissue. Soaking or poulticing is con- weight-bearing lameness in an ambulatory setting tinued until drainage has ceased and the patient is is subsolar abscessation.1,2 Horses affected with comfortable bearing weight on the limb.
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