Proximal Suspensory Proximal Suspensory
Ligament DesmitisLigament Desmitis
Luke Bass, DVM, MSLuke Bass, DVM, MS
SignalmentSignalment
�� 9 yr old QH gelding9 yr old QH gelding
�� Function: Barrel racing Function: Barrel racing
(nationwide)(nationwide)
HistoryHistory
�� Forelimb fetlock joint injections, chiropractic adjustments, andForelimb fetlock joint injections, chiropractic adjustments, and acupuncture acupuncture
�� 5/055/05-- LH lameness (2+/5) blocked to TMT jointLH lameness (2+/5) blocked to TMT joint
�� RadsRads-- No Significant findings No Significant findings
�� Stall rest and NSAID Stall rest and NSAID
�� 6/05 6/05 –– Chronic LH lamenessChronic LH lameness
�� Nuclear Scintigraphy Nuclear Scintigraphy
�� DIT & TMT injectedDIT & TMT injected
�� 4/064/06-- RH lamenessRH lameness
�� Chiropractor adjustment & acupunctureChiropractor adjustment & acupuncture
HistoryHistory
�� 5/06 5/06 -- LH lameness (2/5), + flexions, LH fetlock joint block LH lameness (2/5), + flexions, LH fetlock joint block (70%)(70%)�� LH fetlock injectedLH fetlock injected
�� 7/067/06-- Lameness unchanged, LH fetlock U/SLameness unchanged, LH fetlock U/S�� SSL & OSL fiber disruptionSSL & OSL fiber disruption
�� 8/068/06-- ESWT ESWT -- LH fetlockLH fetlock
�� 8/068/06-- LH lameness LH lameness -- 70% improvement with fetlock block70% improvement with fetlock block�� Diagnostic arthroscopy Diagnostic arthroscopy
HistoryHistory
�� 1010--12/06 12/06 -- Chiropractor adjustment, acupunctureChiropractor adjustment, acupuncture
�� 2/072/07-- Bilateral lameness; moderate OA changesBilateral lameness; moderate OA changes
�� Both hocks were medicatedBoth hocks were medicated
�� 2/072/07-- Chronic LH lameness, + flexionsChronic LH lameness, + flexions
�� Proximal suspensory blockProximal suspensory block
�� U/S U/S -- enthesiophyte @ origin, suggested MRIenthesiophyte @ origin, suggested MRI
UltrasoundUltrasound
•Mild desmitis- Origin of the LH SL
•Mild enthesopathy- Origin of the LH SL
MRI and Surgical treatmentMRI and Surgical treatment
�� LHLH-- Acute desmitisAcute desmitis-- thickening, focal bony resorption at that thickening, focal bony resorption at that
origin on MT3, and fluid in origin MT3 & MT4 origin on MT3, and fluid in origin MT3 & MT4
�� RHRH-- Chronic desmitisChronic desmitis-- Thickened, severe scarring (scout images)Thickened, severe scarring (scout images)
�� DecisionDecision-- Bilateral plantar fasciotomy and neurectomyBilateral plantar fasciotomy and neurectomy
MRIMRI
Moderate enlargement – Origin of SL Scarring to SL - Previous injury
MRIMRI
Tenosynovitis – RH tendon sheath
Chronic PSLD in RH
Mild degenerative LH SL
Acute PSLD in LH
Forelimb Proximal SL DesmitisForelimb Proximal SL Desmitis
�� 44--12 cm DACB12 cm DACB
�� Acute casesAcute cases-- Pain and swelling in regionPain and swelling in region
�� Chronic casesChronic cases-- No palpable abnormalitiesNo palpable abnormalities
�� Positive distal limb flexionPositive distal limb flexion-- 50% of cases50% of cases
�� Lameness accentuated on circle, extended trotLameness accentuated on circle, extended trot
�� Foot imbalance Foot imbalance –– predisposing factorpredisposing factor
Perineural AnesthesiaPerineural Anesthesia
�� Lateral palmar nerve Lateral palmar nerve
-- Medial and lateralMedial and lateral
palmar metacarpal nervespalmar metacarpal nerves
�� Ensures that carpal joints Ensures that carpal joints
are not inadvertantly injectedare not inadvertantly injected
�� Palmar outpouching of CMC Palmar outpouching of CMC
joint > TMT jointjoint > TMT joint
Hindlimb Proximal SL DesmitisHindlimb Proximal SL Desmitis
�� 22--10 cm distal to TMT joint10 cm distal to TMT joint
�� Pain on palpation of proximal SL (acute)Pain on palpation of proximal SL (acute)
�� Persistent lameness post restPersistent lameness post rest
�� Hock flexionHock flexion-- Accentuates lameness (85%)Accentuates lameness (85%)
�� Infiltration of anesthetic Infiltration of anesthetic –– Origin of SLOrigin of SL
-- Possible diffusion to TMT jointPossible diffusion to TMT joint
�� Conformational abnormalities Conformational abnormalities -- (21%)(21%)
Perineural AnesthesiaPerineural Anesthesia
�� Subtarsal nerve blockSubtarsal nerve block
-- 12.5% 12.5% -- TMT jointTMT joint
-- 50% 50% -- Tarsal sheathTarsal sheath
�� Deep branch of lateral Deep branch of lateral plantar nerveplantar nerve
-- 0% 0% -- TMT jointTMT joint
-- 12.5% 12.5% -- Tarsal sheathTarsal sheath
Compartment SyndromeCompartment Syndrome
�� Enlargement of SL Enlargement of SL –– pressure to MT bones, pressure to MT bones, plantar plantar
MT nervesMT nerves
�� Persistent pain and lamenessPersistent pain and lameness
�� Early diagnosis and therapy to reduce size and Early diagnosis and therapy to reduce size and
minimize inflammationminimize inflammation
�� Current opinions refute this as 1Current opinions refute this as 1°° problemproblem
-- Ongoing neuritis due to inflammationOngoing neuritis due to inflammation
Compensatory DesmitisCompensatory Desmitis
�� Ipsilateral forelimb w/ 1Ipsilateral forelimb w/ 1°° foot lamenessfoot lameness
�� Contralateral fore/hind Contralateral fore/hind -- overload injuryoverload injury
�� Forelimb ipsilateral to Forelimb ipsilateral to 11°° hind lameness hind lameness -- pacerspacers
�� Contralateral forelimb (LH, RF) Contralateral forelimb (LH, RF) -- trotterstrotters
Differential DiagnosisDifferential Diagnosis
�� Middle carpal joint painMiddle carpal joint pain-- young TBsyoung TBs
�� DJD of middle carpal jointDJD of middle carpal joint
�� Palmar cortical fatigue fracturesPalmar cortical fatigue fractures-- MC3MC3
�� Avulsion fracturesAvulsion fractures-- origin of SLorigin of SL
�� TMT painTMT pain
�� Primary stress reactions of MT3Primary stress reactions of MT3
Radiographic FindingsRadiographic Findings
�� Sclerosis of MC3, lateral MT3 Sclerosis of MC3, lateral MT3 -- DP viewDP view
�� Enthesiophyte formation, subEnthesiophyte formation, sub--cortical cortical
sclerosis sclerosis –– Lateral viewLateral view
�� Hindlimb > ForelimbHindlimb > Forelimb
�� R/O avulsion fx MC3/MT3R/O avulsion fx MC3/MT3
�� Changes Changes –– rare in acute casesrare in acute cases
Ultrasonographic Findings Ultrasonographic Findings
�� Enlargement of the suspensory ligament Enlargement of the suspensory ligament
�� Poor definition of dorsal marginPoor definition of dorsal margin
�� Central core lesionCentral core lesion
�� Larger area of diffuse hypoechogenicityLarger area of diffuse hypoechogenicity
�� Focal demineralizationFocal demineralization
�� Examination of contralateral limbExamination of contralateral limb
Nuclear ScintigraphyNuclear Scintigraphy
�� Unnecessary for diagnosisUnnecessary for diagnosis
�� Bone turnover at insertion of SLBone turnover at insertion of SL
�� No uptakeNo uptake
�� Abnormal uptake w/ no U/S changesAbnormal uptake w/ no U/S changes
MRI FindingsMRI Findings
�� Enlargement/abnormal high signal intensity in Enlargement/abnormal high signal intensity in
ligamentligament
�� Bone injury Bone injury --Fluid in bone at insertion site Fluid in bone at insertion site
�� Comparison to contralateral limb Comparison to contralateral limb –– images side images side
to sideto side
MRI FindingsMRI Findings
�� Axial PD imagesAxial PD images
�� High signal in PSLHigh signal in PSL
�� Axial STIR imagesAxial STIR images
�� High signal in MT3High signal in MT3
PSLD TherapyPSLD Therapy
�� Severity of lesionsSeverity of lesions
�� Level of competitionLevel of competition
�� Urgency of upcoming competitionUrgency of upcoming competition
�� Financial contraintsFinancial contraints
�� Recurrence of problemRecurrence of problem
�� Prognosis for forelimb > hindlimbPrognosis for forelimb > hindlimb
PSLD TherapyPSLD Therapy
�� Stall rest and support bandages w/ slow return Stall rest and support bandages w/ slow return
to exercise (forelimb > hindlimb)to exercise (forelimb > hindlimb)
�� Corticosteroid & PSGAG therapyCorticosteroid & PSGAG therapy
�� Shockwave therapy Shockwave therapy -- 3 treatments3 treatments
PSLD TherapyPSLD Therapy
�� Bone marrow injection Bone marrow injection
�� AA--cell vs stem cell injectioncell vs stem cell injection
�� Internal blisterInternal blister
�� ShoeingShoeing-- Support fetlock w/o raising heelSupport fetlock w/o raising heel
Hindlimb PSLD TherapyHindlimb PSLD Therapy
�� Fasciotomy w/ Neurectomy (Compartment Syn)Fasciotomy w/ Neurectomy (Compartment Syn)
�� Desmoplasty (surgical splitting)Desmoplasty (surgical splitting)
�� Tibial neurectomyTibial neurectomy
�� Prognosis Prognosis –– Guarded to resume athletic functionGuarded to resume athletic function
�� Failure to recognize lameness in early stage of Failure to recognize lameness in early stage of
injuryinjury
Case UpdateCase Update
�� Chronic bilateral hindlimb lamenessChronic bilateral hindlimb lameness
�� History of hock injectionsHistory of hock injections
�� RadiographsRadiographs
�� UltrasoundUltrasound
�� Nuc ScanNuc Scan
�� MRIMRI
�� Surgical TherapySurgical Therapy
Fasciotomy with NeurectomyFasciotomy with Neurectomy
Releases compartment pressure of SLDeep br. of lateral plantar nerve
Postoperative CarePostoperative Care
�� Phenylbutazone Phenylbutazone -- (10 days)(10 days)
�� Stall rest Stall rest –– 2 weeks2 weeks
�� Introduce hand walking Introduce hand walking –– increase slowly over 8 increase slowly over 8
weeksweeks
�� ReRe--check lameness check lameness ±± U/S (8 weeks)U/S (8 weeks)
�� Total of 4Total of 4--6 months until return to full athletic 6 months until return to full athletic
functionfunction
ReRe--check Examcheck Exam
�� 7 wks 7 wks -- 3/5 LH, 1+/5 RH3/5 LH, 1+/5 RH
�� Chiropractor adjustment and acupunctureChiropractor adjustment and acupuncture
�� 15 wks 15 wks -- 1+/5 LH, 1/5 RH1+/5 LH, 1/5 RH
�� Recheck U/S, small paddockRecheck U/S, small paddock
�� 17 wks (7/10)17 wks (7/10)-- No lameness, reNo lameness, re--check U/S, check U/S,
increase exerciseincrease exercise-- over next 2 months over next 2 months
�� 9/079/07-- 6 month re6 month re--check scheduledcheck scheduled
ReferencesReferences
1.1. Auer & Stick, Equine Surgery, 3Auer & Stick, Equine Surgery, 3rdrd Ed. Saunders, p.1106Ed. Saunders, p.1106--7.7.
2.2. Dyson, S.J., et al. Suspensory Ligament Desmitis. Vet Clinics ofDyson, S.J., et al. Suspensory Ligament Desmitis. Vet Clinics of NA, 11: NA, 11: 177177--215, 1995.215, 1995.
3.3. Hewes, CA, White, NA. Outcome of desmoplasty and fasciotomy for Hewes, CA, White, NA. Outcome of desmoplasty and fasciotomy for desmitis involving the origin of the suspensory ligament in horsdesmitis involving the origin of the suspensory ligament in horses: 27 cases es: 27 cases (1995(1995--2004), JAVMA, 229: 4072004), JAVMA, 229: 407--412, 2006. 412, 2006.
4.4. Stashak, T.S, Adams Lameness in Horses, 5Stashak, T.S, Adams Lameness in Horses, 5thth Ed., p.622Ed., p.622--623.623.
5.5. Bathe, A.P. Current thoughts on the pathogenesis of hindlimb proBathe, A.P. Current thoughts on the pathogenesis of hindlimb proximal ximal suspensory desmitis. 13suspensory desmitis. 13thth ESVOT Congress: 169, 2006. ESVOT Congress: 169, 2006.
6.6. Dyson, S.J. Proximal suspensory desmitis in the forelimb and theDyson, S.J. Proximal suspensory desmitis in the forelimb and the hindlimb. hindlimb. AAEP Proceedings:137AAEP Proceedings:137--142, 2000. 142, 2000.
7.7. Schneider, R.K., Sampson, S.S., and Gavin, P.R. MRI evaluation oSchneider, R.K., Sampson, S.S., and Gavin, P.R. MRI evaluation of horses f horses with lameness problems. AAEP Proceedings: 21with lameness problems. AAEP Proceedings: 21--34 , 2005. 34 , 2005.
8.8. Gayle, J.M., Redding, W.R. Comparison of diagnostic anaesthetic Gayle, J.M., Redding, W.R. Comparison of diagnostic anaesthetic techniques of the proximal plantar metatarsus in the horse. EVE,techniques of the proximal plantar metatarsus in the horse. EVE, 5/07, p. 5/07, p. 222222--224.224.
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