LAMENESS OF THE HORSE VETERINARY PRACTITIONERS' SERIES, NO. 1 TEXT

surfaces of the tibia, to the tarsal bones, the collateral ligaments (internal and external lateral) and to the metatarsus. [Illustration: Fig. 43--Right stifle joint; lateral view. The femoro-patellar capsule was filled with plaster-of-Paris and then removed after the cast was set. The femoro-tibial capsule and most of the lateral patellar ligament are removed. M. Lateral meniscus. (From Sisson's "Anatomy of the Domestic Animals.")] The common ligaments of the tarsal joint are the collateral, the plantar (calcaneo-metatarsal and c. cuboid) and dorsal ligaments (oblique). The medial (internal lateral) ligament serves to join the medial (internal) tibial malleolus with tibial tarsal (astragalus) and other tarsal bones. The lateral (external lateral) ligament is inserted to the lateral (external) tibial malleolus and its distal portions are attached to the tibial tarsal (astragalus), fibular tarsal (calcaneum) bone, fourth tarsal (cuboid) and metatarsus bones. [Illustration: Fig. 44--Left stifle joint; medial view. The capsules are removed. (From Sisson's "Anatomy of the Domestic Animals.")] The plantar ligament (calcaneo-cuboid) is a strong flat band which is attached to the plantar surface of the fibular and fourth tarsal bones (calcaneum and cuboid) and the head of the lateral metatarsal (external small) bone. The dorsal (oblique) ligament is attached above to the distal tuberosity on the inner side of the tibia. It is inserted below to the central (cuneiform magnum) and third (c. medium) tarsal bones, to the proximal ends of the large and outer small metatarsal bones. The tarsus is a true hinge joint and because of the great strain which it sustains, is subject to frequent injury. About seventy-five percent of cases of lameness affecting the hind leg may be said to arise from disease of the hock. As members of locomotion the legs receive strains of two kinds: those of concussion and weight-bearing and strains of propulsion; the latter are the greater. In the horse as a work animal, the hind legs are probably subjected to greater strains than are the front but the manner of construction of the various parts of the pelvic limbs with the possible exception (according to some authorities) of the tibial tarsal joint, offsets this condition. The femur may be considered analagous to the humerus in that it bears a similar relationship to the ilium, that exist between the humerus and scapula. Further flexion during repose is prevented chiefly by the glutens medius (maximus) muscle and its tendons. The larger tendon inserts to the summit of the trochanter major of the femur and corresponds to the biceps brachii in the action of the latter on the scapulohumeral joint, except that the gluteus medius, in attaching to the femoral trochanter, exerts its effect as a lever of the first class. Because of the relationship between the long axes of the femur and iliac shaft it is evident that the angle formed by these two bones is maintained chiefly by the gluteus muscles during weight bearing. Contraction of muscular fibers of the gluteus medius causes extension of the femur and muscular strain is prevented to a great degree by the inelastic portion of this muscle. The chief physiological antagonistics of the glutei are the quadriceps femoris and tensor fascia lata. While the leg is supporting weight the stifle joint is fixed in position mainly by the quadriceps femoris group of muscles which are attached to the patella. Tendinous fibres intersect this muscular mass and relieve muscular strain during weight bearing. Because of the manner in which the patella functionates with the trochlea of the femur, comparatively little energy is required to prevent further flexion of the stifle joint. The patella, according to Strangeways, may be considered a sesamoid bone. [Illustration: Fig. 45--Left stifle joint; front view. The capsules are removed. 1. Middle patellar ligament. 2. Stump of fascia lata. 3. Stump of common tendon of extensor longus and peroneus tertius. (From Sisson's "Anatomy of Domestic Animals.")] The quadriceps group of muscles is assisted by the anterior digital extensor (extensor pedis) peroneus tertius and tibialis anticus (flexor metatarsi) muscles. The latter pair (flexor metatarsi, muscular and tendinous portions, because of their attachment to the external condyle of the femur and to the metatarsal bone) are enabled to automatically flex the tarsal joint when the stifle is flexed. The hock is kept fixed in position by the gastrocnemius and the superficial digital flexor (perforatus). The latter structure, which is chiefly tendinous, originates in the supracondyloid fossa of the femur and has an insertion to the summit of the fibular tarsal (calcis) bone. It relieves the gastrocnemius of muscular strain during weight bearing. Smith[35] styles the function of the stifle and hock joints a reciprocating action, and we quote from this authority the following: From what has been said, it is evident that flexion and extension of stifle and hock are identical in their action. When the stifle is extended, the hock is automatically extended, nor can it under any circumstances flex without the previous flexion of the stifle. There is no parallel to this in the body. The two joints, though far apart, act as one, and they are locked by the drawing up of the patella, and in no other way. The so-called dislocation of the stifle in the horse is a misnomer. That the patella is capable of being dislocated is beyond doubt, but the ordinary condition described under that term, when the stifle and hock are rigid while the foot is turned back with its wall on the ground, is nothing more than spasm of the muscles which keeps the patella drawn up. The moment they relax the previously immovable limb and useless foot have their function restored as if by magic, but are immediately thrown out of gear in the course of a few minutes as a recurrence of the tetanus of the petallar muscle takes place. The fascia of the thigh, like that of the arm, is a most potent factor in giving assistance to the constant strain imposed on the muscles of the limbs during standing. Below the hock the hind limb is arranged like that of the fore, the deep flexor (perforans) receiving its additional support from the "check ligament," as in the fore leg. The natural attitude of standing adopted by the horse is to rest on three legs--one hind and two fore. If he is alert, he stands on all four limbs; but if standing in the ordinary manner, he always rests on one hind leg. He does not remain long in this position without changing to the other. Hour by hour he stands, shifting his weight at intervals from one to the other hind leg, and resting its fellow by flexing the hock and standing on the toe. He never spares his fore-limbs in this manner in a state of health, but always stands squarely on them. Hip Lameness. Fortunately, because of the heavy musculature which goes to form a part of the locomotive apparatus of the rear extremity, hip lameness is comparatively rare. While the term is in itself ambiguous and signifies nothing more definite than does "shoulder lameness," yet diagnosis of almost any condition that may be classed under the head of "hip lameness" is not easy except in cases where the cause is obvious, as in wounds of the musculature and certain fractures. To the complexity which the gait of the quadruped contributes, because of its being four-legged, there is added the complicated manner of articulation of the bones of the hind leg. This involves the hip in the manner of diagnostic problems and because of the inaccessibility of certain parts, owing to the bulk of the musculature of these parts, diagnosis of some hip ailments becomes an intricate problem. Consequently, in some instances, before one may arrive at definite and enlightening conclusions, repeated examinations are necessary as well as a knowledge of reliable history and recorded observations of the subject over a considerable period. Rheumatic affections, when present, usually cause recurrent attacks of lameness; myalgia, due to subsurface injury occasioned by contusion, generally produces an ephemeral disturbance; and while these are examples of cases where occult causes are active, they are by no means unprecedented. In cases where the cause of lameness is not definitely located, and when by the process of exclusion one is enabled to decide that the seat of trouble is in the hip, a tentative diagnosis of hip lameness is always appropriate. In one instance a Shetland pony evinced a peculiar form of intermittent lameness which affected the left hip, and repeated examinations did not disclose the cause of the trouble. After about a year there was established spontaneously an opening through the integument overlying the region of the attachment of the psoas major (magnus), through which pus discharged. With the occurrence of this fistula, lameness almost entirely disappeared, but the emission of a small amount of pus persisted for more than a year. The subject was not observed thereafter and the outcome in this case is not a matter of record. Whether there existed a psoic phlegmon due to metastatic infection or necrosis of a part of a lumber or dorsal vertebra is a matter for speculation. Thus the presence of some anomalous conditions which affect the pelvic region and cause lameness may be discovered, yet both in hip and shoulder regions causes may not be definitely located by means of practical methods of examination. Injuries of all kinds are the more frequent causes of hip lameness. In such cases, lameness may result directly and resolution be prompt, or the claudication become aggravated in time, due to muscular atrophy or degenerative changes affecting the hip joint or nerves. Rheumatism or metastatic infection may be the cause of hip lameness as well as affections of the pelvic bones, lumbar and sacral vertebrae. Hip lameness may also be provoked by melanotic or other tumors. In the diagnosis of hip lameness, one is guided in a general way by the character of the impediment manifested. Swinging-leg lameness is often present and the impediment is more accentuated when the animal is caused to step backward. In many cases lameness is mixed, being about equally noticeable during weight bearing and while the member is being swung. By exclusion of causes which might affect other parts; one may definitely locate the cause of the trouble or determine that a certain region is affected. The sudden manifestation of lameness is indicative of injury; thermic disturbances may signalize metastatic infection; history, if dependable, is always helpful. Repeated observations, taking into account the course which the affection assumes during a period of a few days, often serve to afford a means of establishing a diagnosis in baffling cases. Fractures of the Pelvic Bones. The os innominatum may be so fractured that the pelvic girdle is broken, as in fracture of the iliac shaft, or in a manner that the girdling continuity of the innominate bones is not interrupted. It naturally follows that greater injury is done when the pelvic girdle is broken than when it is not, except in cases where the acetabulum is involved and its brim not completely divided. Etiology and Occurrence.--Pelvic fractures are usually caused by falls or other manner of contusion. Cases are reported where it would seem that fracture of the iliac angle resulted from muscular contraction, but it is certain that most fractures of this kind are due to collisions with door jambs or similar injuries. In old horses especially, fracture of pelvic bones occurs frequently. This form of injury is of more frequent occurrence in animals of all ages that work on paved streets. The country horse is not subjected to the uncertain footing of the slippery pavement, nor to injuries which compare with those caused by contusions sustained in falling upon asphalt or cobble-stones. Symptomatology.--While in many cases of pelvic fracture lameness or abnormal decumbency are the salient manifestations, yet the pathognomic symptoms are crepitation or palpable evidence which may be obtained by rectal or vaginal examination. In fractures of the angle of the ilium and the ischial tuberosity, perceptible evidence always exists. In cases where fracture of some portion of the pelvic girdle is suspected and the subject is able to walk, crepitation is sought by placing one hand on an external angle of the ilium and the other on the ischial tuberosity and the animal is then made to walk. Or, by placing the hands as just directed, an assistant may grasp the horse's tail and by alternately exerting traction on the tail and pushing against the hip in such manner that weight is shifted from one leg to the other, crepitation may be detected. Fracture of the pubis near its symphysis constitutes a grave injury, as there is danger of the bladder becoming caught in the fissure and perforation of its wall may result. Such a case is reported by Bauman[36] wherein a three-year-old gelding bore the history of having been lame for ten days. Upon rectal examination the bladder was found to be hard and tumor-like and about the size of a baseball. The body of the ischium in this case was fractured and a rent in the bladder was caused by a sharp projecting piece of bone. Autopsy revealed, in addition to the fracture and rent of the bladder wall, a large quantity of urine in the peritoneal cavity. In other instances hemorrhage caused death and not infrequently infection was responsible for a fatal issue. Moller,[37] quoting Nocard, describes a case where fracture occurred through the region of the foramen ovale and paralysis of the obturator nerve followed. Fractures which include the acetabular bones cause great pain. This is manifested by marked lameness, both during weight bearing and when the member is swung. Such cases terminate unfavorably--complete recovery is impossible. Where small portions of the angle of the ilium are broken, and the skin is left intact, there exists the least troublesome class of pelvic fracture. If large portions of the ilium are fractured, considerable disturbance results. There eventually occurs more or less displacement in such cases, if such displacement does not take place at the time of injury. The same may be said of fracture of the tuber ischii, but when these bones are fractured a more serious condition results. Treatment.--When a case is found to be uncomplicated, that is, if the fracture is such that recovery seems possible and after having determined that treatment may be practicable, the first consideration is that of confining the subject in suitable slings. In many cases of pelvic fracture, the affected animal will need to be kept in slings from six weeks to three months, and it becomes a difficult problem to minimize the distress during this long period of confinement in the peculiar manner required for favorable outcome. The pattern of sling employed should be the best that is obtainable and the matter of its adjustment is quite important lest unnecessary chafing or even necrosis of skin result. Frequent readjustment may be necessary, and time is well spent in this manner since this contributes materially toward a favorable termination by encouraging the subject to remain quiet so that coaptation of the broken bones may be maintained. Aside from slings, mechanical appliances that are helpful in the treatment of these cases are not yet in use. A regimen that is nutritive and at the same time laxative is essential and in some cases cathartics and enemata are necessary. Also, during the first few days, if there is retention of urine, catheterization is imperative. In a word, the handling of such cases consists largely in keeping the subject inactive, as comfortable as possible, and giving attention to suitable diet. Simple fracture of the external iliac angle needs no particular attention, except that the subject is kept quiet until lameness subsides. In all cases where much of the bone is broken, the animal is blemished, but interference with function does not follow. If infection results because of a compound fracture, loose pieces of bone must be removed surgically and drainage provided for. In fracture of the ischial tuberosity, infection is more apt to result than in like injury of the ilium, and greater displacement of bone occurs. This displacement, due to contraction of the attached muscles, is in some instances a contributing cause to the infection which often follows in these cases. In females where the body of the ischium is fractured, lacerations of the vagina may be present, and this constitutes a serious complication which usually terminates fatally. After-care in fracture of the pelvic girdle consists principally in allowing a protracted period of rest before subjects are put to work. Fractures of the Femur. Etiology and Occurrence.--This is a comparatively rare injury in the horse because of the protection afforded the femur by the heavy musculature. Fragilitas of the bone probably exists in many cases when fracture of its diaphysis occurs. It is generally conceded that the neck of the femur is rarely broken because of a lack of constriction in this part, but fracture of the trochanters has been recorded rather frequently. However, Lienaux and Zwanenpoete[38] state that fracture of the neck of the femur is of frequent occurrence in Belgian colts. Tapley[39] reports in the Veterinary Journal (English) fracture of the head and internal trochanter of the femur and patellar luxation occurring simultaneously affecting a mule. In this case the mule was found decumbent on a concrete floor. After three weeks, the subject was destroyed and autopsy revealed rupture of the left pubiofemoral ligament, tearing with it a portion of the articular surface of the femur. The internal trochanter was also fractured in four small pieces. In this case it is fair to suppose that the mule in trying to regain footing on a slippery floor violently abducted the legs and fracture resulted. It is possible also that a temporary luxation of the patella took place first and caused the animal to struggle in such manner that fracture followed. [Illustration: Fig. 46--Oblique fracture of the femur of a 1,500 six-year-old draft horse. Showing shortening of bone, owing to a lateral approximation of the diaphysis because of muscular contraction. Photo by Dr. Edward Merillat.] Symptomatology.--According to Cadiot and Almy,[40] "regardless of the location of femoral fractures, the subject is usually intensely lame, the animal frequently walking on three legs--fractures of the diaphysis are characterized by an abnormal mobility." As a rule, crepitation is to be recognized in fractures of the shaft of the bone, by passively moving the leg to and from the medial plane (adduction and abduction). Fracture of the trochanter major is signalized by local swelling and evidence of pain; the forward stride is shortened because this movement tenses the tendon of the gluteus major (maximus) which is attached principally to the trochanter. [Illustration: Fig. 47--Same bone as in Fig. 46 after about six months' treatment. In this case Dr. Merillat employed a weight to counteract muscular contraction. It is noticeable that very little provisional callus has formed in this case, and in spite of unusual ingenuity and good facilities for caring for the subject, union of bone did not occur.] Treatment.--Reduction of femoral fracture in the horse is practically impossible, and retaining the broken bones in coaptation is not possible by means of mechanical appliances. Consequently, prognosis is unfavorable in fracture of the body of the femur. When union of bone