When Is A "Wind Puff" Abnormal?

Figure 1

 The "wind puff" noted in the right hind leg is not necessarily an immediate cause for alarm (Figure 1) . However, when you compare it to the left hind leg, there is a significant difference in the size of the wind puff between legs (Figure 2). This is a reason for concern!

A "wind puff" refers to the accumulation of synovial fluid with the distal flexor tendon sheath of the lower leg. All 4 limbs have a distal flexor tendon sheath and they extend from just above the fetlock down to the coffin bone area. Most people notice the swelling once it is above the fetlock joint however there is often significant fluid within the pastern area that goes unnoticed. For many horses that are in regular work a mild amount of fluid accumulation within the flexor tendon sheath is normal and should be symmetrical. When there is more fluid in one leg or a sudden increase in fluid then there is reason to be concerned.

Figure 2

Within the flexor tendon sheath there are a various tendons and ligaments. Any inflammation within these tendons and ligaments may result in a sudden increase in fluid within the sheath and eventually a reduction in performance. To thoroughly assess these soft tissues, an ultrasound exam should be performed and the soft tissue structures above AND below the fetlock should be evaluated. The image below is that of a abnormal deep digital flexor tendon. The area of concern is at the level of the fetlock joint and within the flexor tendon sheath.  The tendinitis has been chronic and there is evidence of tendon mineralization!. This horse was lame on presentation and there was significant fluid within the distal flexor tendon sheath.

Figure 3

Clostridial Myositis and Banamine Injections

Intra-muscular Banamine is not recommended by this veterinarian!

The picture above is that of a horse that was treated by its owner with 10cc of Banamine (Flunixin Meglumine) in the muscle (IM) of the left hind leg for colic symptoms. The good news was that the horse's symptoms of colic resolved however 2 days later the injection site was swollen and painful to the touch. The following day, the horse was febrile and lame at the walk. The wound was examined via ultra-sound and a large, fluid filled pocket was noted deep to the swelling. The pocket was drained of purulent (pus) fluid and the horse was started on antibiotics. Fortunately, the horse recovered fully with only a minor scar.

This type of reaction may occur secondary to any intra-muscular injection. However, the big concern with injection site abscesses caused by IM Banamine is the association with the bacteria Clostridium and the resulting Clostridial myositis.  These bacteria are anaerobic and thrive in low oxygen environment, hence treatment involves aggressive surgical exposure and drainage of the contaminated tissue. Severe Clostridial myositis can readily result in death of the horse!!

The preferred route of administration for Banamine is either intra-venous or by mouth.

Core Biopsy Please!!

The only way to know for sure would require a core biopsy. This procedure is quite simple to perform in the field and will save significant time with regards to treatment and resolution of clinical signs. The first image was treated unsuccessfully as a "summer sore" with medication that actually worsened the clinical signs. The biopsy results were consistent with Pythiosis and aggressive medial/surgical treatment was instituted. The prognosis for full recovery is not good once there has been significant disruption of the soft tissue structures and in a case that involves the lower pastern/coronary band area. Early diagnosis is key!

The case below was treated as a suspect "summer sore" with minimal improvement. Biopsy results indicated that it in fact it was a case of Habronemiasis that was not responsive to the treatment provided (systemic and topical ivermectin). Habronemiasis or "Summer Sores" is a condition that results from flies depositing larvae within the skin causing a significant allergic reaction. Treatment involves medication to kill any living fly larvae and most importantly medication to suppress the local allergic reaction. Treating with ivermectin systemically and topically is often not enough!! Yet that is how many try to treat this condition! For small lesions, topical treatment with concentrated cortisone can be effective, however, for more aggressive lesions, systemic administration with corticosteroids is necessary. Importantly, systemic treatment with corticosteroids is the treatment you definitely want to avoid if you are dealing with Pythiosis! Hence the importance of a core biopsy.

Equine Strangles

Equine Strangles!!

(Figure 1)

(Figure 2)

The disease process that may cause throat latch swelling AND limb swelling is commonly known as Equine Strangles. This disease is caused by a bacteria known as Streptococcus Equi subspecies Equi. Most commonly it results in enlargement of the lymphnodes within the throat latch area that may narrow the airway of the horse, hence the term "strangles". In severe cases, a temporary tracheotomy is necessary to save the horses life! (Figure 1). These lymph nodes may rupture and drain purulent debris from the outside or from within the guttural pouches (Figure 2). These horses are typically febrile, depressed, and highly contagious! Occasionally, the horse will develop a hyper-immune response known as purpura hemorrhagica. This immune response to the bacteria results in severe swelling of one or multiple limbs (Figure 3)  and can be triggered by the vaccination of a horse that was recently sick with the disease.

(Figure 4)

For more information check out the following links:

http://en.wikipedia.org/wiki/Strangles

http://www.aaep.org/strangles.htm

Mesotherapy 

These small bumps were caused by micro-injections of medication just under the skin, or also known as Mesotherapy. This treatment has been used effectively for over 30 years in humans and horses. The primary objective of this treatment in horses is to block or break the pain cycle associated with chronic back pain. 

Technically, mesotherapy treatment stimulates the mesoderm or middle layer of skin by stimulating the giant fibers present within this layer of skin. Commonly, a combination of lidocain and dexamethasone is injected via multiple extra small needles (30g). These micro-injections result in stimulation of the giant nerve fibers located within this layer of skin that also communicate with major nerve tracts within the spinal chord. These nerve fibers INHIBIT the conduction of pain signals to the brain.

Typically, one or two mesotherapy treatments are applied to a horse's back and often are combined with shockwave treatments. Mesotherapy is used primarly as an aid to alleviate back pain followed by treatment of the primary cause of the back pain/spasm. This typically involves a source of lameness in either the forelimbs or hindlimbs. In addition, osteo-arthritis of the thoraco-lumbar spine and "kissing spines" are causes of chronic back pain. 

The response to mesotherapy is usually within 2-3 days and may last for 3-4 months. 

Asymmetric pelvis

The pictures above are those of a horse with an asymmetric pelvis. Specifically, the left tuber sacrale is lower than the right. Less severe varieties of this problem have been described as "hunters bumps". The appearance of asymmetric tuber sacrale or "hunters bump" is in indication of a pathological problem within the pelvis/sacrum area. In the case above, the gelding suffered a fractured pelvis that was diagnosed via ultrasound. This patient presented for non-weight bearing lameness however many with only mild changes do not present for lameness but rather "poor" performance.

In the image above, the left gluteal region was examined via ultrasound and an irregular margin was noted along the body of the ileum. Note the "step" along the bony margin in the pic below.

Less severe cases involve inflammation within the sacro-iliac joint and/or inflammation of the dorsal sacroiliac ligaments. These areas should be assessed for evidence of inflammation and treatment may include shockwave treatment, mesotherapy, and/or sacro-iliac joint injections.

Suspensory Break Down!

The suspensory ligament has been significantly stretched and strained, resulting in the "dropped fetlock" conformation seen below. The suspensory ligament (blue structure in drawing below) originates just below the hock in the hind limbs and the carpus in the forelimbs. The ligament splits into a medial (inside) and lateral (outside) suspensory branch. The split occurs approximately half way down the metatarsus. Each suspensory branch inserts on a sesamoid bone at the level of the fetlock and play a role in "suspending" the fetlock. For the fetlock to drop, the suspensory branch and body have been strained and maybe even ruptured. For definitive diagnosis, an ultrasound exam is performed that will evaluate the entire suspensory ligament. If the process is slow (months to years), it may result in reduced performance and low grade lameness. However, if sudden, significant lameness is associated with the limb or limbs affected. Unfortunately, this is a progressive condition that will ultimately result in retirement of the horse and may be life-threatening. Management of this condition includes reduced exercise, daily ice therapy, corrective shoeing, and daily pain management. This condition carries a poor prognosis for return to work and a guarded prognosis for over-all soundness.

The blue structure depicts the suspensory ligament in the forelimb. Note the upper region is one structure (body) which then splits into two branches.

These are known as "fish tail" shoes and are quite effective in reducing the strain on the suspensory ligaments. For obvious reasons, this type of shoe, with significant heel extension, can only be used in the hind limbs. 

What is that bug?

Blister beetle is his name and death is his game! 


Ingestion of just a few of these insects results in Cantharidin toxicosis. The poison from these beetles results in large scale ulceration of the oral mucosa, esophagus, and stomach. In addition, the horses often are stricken by acute kidney failure, laminitis and death shortly there after, despite significant medical intervention. The beetles live in alfalfa hay and are often transported in bales of hay from the western part of the United States. 


Check out the following website for more details regarding this horrible bug!


http://www.ca.uky.edu/entomology/entfacts/ef102.asp

Poisonous Plants Quiz

The plants in the pictures were:

1- Creeping Night Shade (bottom pic with black berries)
2- Crotalaria "Rattle Box" (top pic with yellow flowers)

Both are quite common in the state of Florida and both are highly toxic to horses. Toxicity due to Crotalaria ingestion is more common and can result in end-stage liver failure. You can purchase a book that has a great description of the most common poisonous plants in the state of Florida @

http://ifasbooks.ifas.ufl.edu/p-510-poisonous-pasture-plants-of-florida.aspx

Shockwave treatment for horses: More than just bowed tendons!

Shock-wave treatment has been used in veterinary medicine for over a decade.  Initially, the primary use was for inflamed tendons and ligaments; however, this modality of treatment is now commonly applied to chronic wounds (Figure 1 and 2), bone fractures (Figure 3), navicular disease, back pain, sacro-iliac (SI) pain, muscle pain/inflammation, osteoarthritis, and chronic foot pain. 

Shock-wave treatment consists of exposing a specific area of interest to acoustic waves of varying intensity. There are different size probes which correspond to the depth of tissue penetration. A more shallow probe is used for tendonitis of the superficial digital flexor tendon and the deepest probe is used for chronic pain within the epaxial musculature of the horse's top line. The number of shock waves and intensity is adjusted depending on the specific area being treated. For most conditions, the area is treated with 3 sessions that are separated by 10-14 days. For chronic wound healing, low energy is applied and the sessions are every 5-7 days. 

Generally speaking, shock-wave therapy has its greatest benefit by enhancing the development of new blood vessels and thus increasing the blood supply to a region of interest. This will increase the quality and quantity of "healing". In addition, shock-wave therapy will provide short term pain relief to the soft tissues that are inflamed. 

It is very important to remember that shock-wave therapy is only 1 part of managing the above mentioned conditions. It does not replace time nor the benefits of medical treatment and corrective shoeing. However, it does improve the "quality" of healing which is evident in the final product. 

Chronic wound over elbow which has stopped
shrinking in size 2 months after initial injury.

Chronic wound after 3 shockwave treatments.
The cross sectional area has decreased by nearly 30%

A chronic exostosis or splint bone fracture is treated with
shockwave treatment to stimulate healing