As inflammation subsides, a counterirritating application such as a suitable liniment and later blistering or line-firing is helpful in stimulating resolution.



Open Carpal Joint.

Anatomy.—The carpal bones as they articulate with one another and with the radius and metacarpal bones, as classed by anatomists, form three distinct articular parts of the joint as a whole and are known as radiocarpal, intercarpal and carpometacarpal. These three pairs of articulating surfaces are all enclosed within one capsular ligament. On the anterior face of the bones, the capsular ligament is attached to the carpal bones in such manner that an imperfect partitioning of the three joint compartments is formed. Posteriorly, the capsule is very heavy and forms a sort of padding over the irregular surfaces of the bones, and also its reflexions constitute the sheaths of the flexor tendons. The anterior portion of the capsular ligament forms sheaths for the extensor tendons, and both portions of the joint have an attachment around the distal end of the radius and another at the proximal end of the metacarpal bones.



Etiology and Occurrence.—Puncture wounds of any kind may serve to perforate the joint capsule and such traumatisms are occasioned by falls, kicks and in various ways in runaway accidents, and open carpal joint may follow.

Symptomatology.—The pathognomonic symptoms of the existence of an open joint is the exposure to view of articular surfaces of bones or noting the escape of synovia from the joint capsule. As has been previously referred to, there always exists a peculiar suspension of carpal flexion in all cases of carpitis.

Non-infective wounds which may cause open joint are not necessarily productive of an active carpitis—a synovitis may be the extent of the disturbance. Unlike synovitis, which may characterize a non-infectious penetrative wound of the capsular ligament, septic arthritis which may supervene is a very painful inflammatory disturbance. It is characterized by all of the symptoms which attend the case of open joint and synovitis plus the obvious manifestation of great pain. There is an elevation of temperature of from two to five degrees above normal; circulation is accelerated; the pulse is bounding; respiration is hurried; there is an expression of pain as indicated by the physiognomy; and because of rapid erosive changes of cartilages which take place, there is soon so much of the articulation destroyed that death is inevitable. Death is usually due to generalization of the arthritic infection.



In the meanwhile, if the character of the infectious material is not so virulent, the disease will take on a slower course and the subject may experience laminitis from supporting weight upon the sound member, or because of continued recumbency, decubital gangrene and emaciation sometimes cause death. If the subject does not soon succumb, it is compelled to undergo days or even weeks of unnecessary suffering, and too often in such cases, it is later deemed advisable to destroy the animal because of the cost of continuing treatment until the horse is serviceable. Therefore, it is evident that when such joints as the carpus or tarsus are open and infection exists, if they are not promptly treated and the infectious process checked, it is neither humane nor practical to prolong treatment.

Distinction must be made between the different joints when infected as the condition is much more serious in some cases than in others. All things considered, perhaps open joints rank, with respect to being serious cases as follows: elbow, navicular, stifle, tarsus, carpus, fetlock and pastern. This, of course, is restricted to articulations of the locomotory apparatus.

Treatment.—Preliminary care in the treatment of an open carpal joint, is the same as has been described in this condition as it affects the scapulohumeral articulation described on page 65. Likewise the further treatment of such cases is along the same lines except that where it is possible, the parts are kept covered with cotton and bandages. However, in some cases, animals have been successfully treated without bandaging and by keeping the patient in a standing position and on pillar reins until recovery resulted. Such cases were of the non-infectious type and recovery was possible within three or four weeks. Further, the condition is not sufficiently painful in such instances as to prevent the subjects bearing weight with the affected member; hence, no danger of resulting laminitis is incurred. And finally, where bandages are not employed, the frequent use of antiseptic dusting powders is substituted for cotton as a protector.

When bandaged, such wounds need dressing more or less frequently, as individual instances demand. The purulent infective inflammation of a carpal joint will require daily dressing; whereas, in other cases (non-infective), semi-weekly change of bandages is sufficient. Equal parts of boric acid and exsiccated alum constitute a suitable combination for the treatment of these cases, and this powder should be liberally employed. Tincture of iodin may be injected into the joint capsule where there is provision for its ready evacuation, as conditions seem to require. Daily injections for three, four or five days, are not harmful and will control infection in many instances.

Thecitis and Bursitis.

Etiology and Occurrence.—The thecae and bursae of the leg are several in number. In the carpal region, the flexors of the phalanges are contained together in the carpal sheath, and this is the principal theca in the carpal region. Each of the tendons is provided with synovial sheaths which are subject to inflammation and occasionally synovitis and distension of these synovial sheaths occur.

Because of faulty conformation, some animals are subject to inflammation of these sheaths, and all forms of strenuous work which taxes the tendons greatly is apt to result in synovitis. Direct injury such as blows may be the cause of synovial distension of thecae and the affection is to be seen in all horses that have done much fast work on hard road surfaces or pavements.

The usual case as it occurs in practice is a non-infective synovitis, but where puncture wounds cause the trouble, an infectious inflammation obtains.

Symptomatology.—No trouble is experienced in diagnosing distension of tendon sheaths, for the affection is very palpable. During acute inflammatory stages of this affection, some lameness is present—in infectious inflammation lameness is intense. Local heat and pain upon manipulation are readily discernible in all acute cases. And finally, where there is reason for doubt, an aseptic exploratory puncture of the wall of the fluctuating enlargement may be made with a suitable trocar, and the discharging synovia will be proof of the existence of synovial distension.

After the affection becomes subacute or chronic, no lameness or inconvenience is manifested, and the condition is undesirable only because of its being a blemish.

Treatment.—Acute non-infectious synovial distension of tendon sheaths is treated by aspirating as much synovia as possible from the affected theca (this is, of course, done under strict asepsis) and by means of bandages, a uniform degree of pressure is kept over the parts for ten days or two weeks. The patient is kept quiet and in the course of two weeks an active blistering agent is employed over the region affected. Usually, at the end of a month's time, complete recovery has taken place and the subject may be gradually returned to work.

When synovial distensions are of long standing, it is necessary to take special precautions to check excessive secretion of synovial fluid, and, also because of the atonic condition of the tissues affected, resolution is tardy. In addition to aspirating synovia, the introduction of equal parts of alcohol and tincture of iodin into the theca is necessary. The quantity of this combination injected, depends upon the size of the sheath affected and the amount of synovia retained at the time injection is made. Experience is necessary to judge as to this part of the work, but one may consider that a quantity between three and ten cubic centimeters of equal parts of tincture of iodin and alcohol constitutes the proper amount to employ. Where much synovia is contained within the sheath at the time of injection, there occurs great dilution of the agent injected and consequently less irritation results.

The object of such injections is to check synovial secretion, and this is sought by the local effect of iodin in contact with the secreting cells together with the reactionary swelling which occasions pressure. An increase in the local blood supply also follows. In all cases where it is possible to employ suitable bandages, this should be done. The ordinary derby bandages serve well and if their use is continued for a sufficient length of time, good results follow.

There are other methods of treating these affections, and each has its advantages and disadvantages. Line-firing, instead of the vesicant is made use of by some, but the object desired is the same and results obtained are similar.

Sheaths may be opened surgically by means of a knife, and the removal of a portion of the wall of distended and atonic tendon sheaths is possible. These operations belong to the realm of surgery and are not properly a part of this treatise. However, in passing, it may be said that if a perfect technic is possible in doing the last named operation, a permanent recovery is the outcome.

Fracture of the Metacarpus.

Etiology and Occurrence.—As the result of all sorts of violence, such as falls and injuries in accidents of various kinds wherein the metacarpals are subjected to contusions, fractures may result. In the horse it is unusual for fracture of one of the small metacarpal bones to take place without there being at the same time a fracture of the third (large) metacarpal bone.

Classification.—Fractures of the metacarpal bones as they occur, are as likely to be compound as simple, and the multiple and comminuted varieties are occasionally observed. The manner in which the third (large) metacarpus is fractured, largely determines the outcome in any given case.

Symptomatology.—Abnormal mobility of the broken parts of bone and crepitation mark fracture of the metacarpus, and the condition is easily diagnosed. In many instances, when compound fracture exists, broken ends of bone are protruding through the skin. No weight is borne upon the fractured member ordinarily, although during the excitement occasioned by runaways, horses are sometimes seen to support weight with a broken leg even when the protruding bone is sunk into the ground in so doing.

Prognosis.—Generally speaking, fractures other than the simple-transverse in young animals, are considered unfavorable cases. With the metacarpus, however, there are instances where compound fracture occurs in colts that justify treatment. But in all cases of compound fracture, the element of infection in addition to the increased difficulty in maintaining immobility of the broken bone, creates almost insuperable difficulties in the average instance. And unless the practitioner distinctly explains to his client the various reasons which make treatment an economic impracticability, dissatisfaction is likely to follow if treatment is instituted without such an understanding.

Treatment.—Perfect apposition of the broken ends of bone is easily effected and less difficulty is encountered in maintaining such relations in metacarpal fractures than in fractures of the radius. However, reduction and immobilization of this as in all fractures, must be done without delay. In simple fracture, the metacarpus is covered with enough cotton to pad the parts, and this is retained in position by bandages. Splints of heavy leather or of thin pieces of tough flexible wood are placed on each side of the leg and firmly held in position with bandages. Bandages may be put on in layers and a coating of glue applied over each layer if this is thought necessary. The advantage gained in using glue or other adhesive materials is that the cast thus formed is more rigid than where such material is not employed. On the other hand, all elasticity is lost as soon as the cast adapts itself to the contour of the extremity, and because of this rigidity, it is doubtful if anything is gained by the incorporation of glue, except in the way of added strength of the cast. Since the animal does not walk upon the broken leg, it is possible to employ splints of suitable materials which are retained in position without glue and frequent readjustment of a part of the immobilizing apparatus is possible. This is impossible with casts.

In compound fractures, provision ought to be made for dressing the wound of the soft structures. This entails adjusting the splints in such manner that one splint may be retained and others removed for dressing the wound and readjusted as often as wound dressing is necessary.

Splints.

By this term is meant a condition where there exists an exostosis which involves usually the second (inner small) and third (large) metacarpal bones. While an exostosis involving any one of the splint bones, even when directly caused by an injury, is called a "splint," the term is employed here, in reference to exostoses not due to direct injury such as in contusions.

Etiology and Occurrence.—This condition is one wherein there is osseous formation following a periostitis and the region of the upper portion of the second (inner small) metacarpal bone is the usual site of the exostosis. There is incited an inflammation of the periosteum at the site of the interosseous ligament which attaches the small to the large metacarpal bone. This ligament is involved in the inflammatory process, and according to Havemann, whose view is supported by Moller, this inflammation is the origin of the trouble.

Various theories attempting an explanation of the frequent affection of this one certain part so regularly involved have been offered, but no proof of the correctness of any exists. It follows, however, that splints occur in young animals; that the affection seldom starts in subjects that are ten years of age or older, and that when the exostosis has formed, lameness usually subsides. Anything which will cause undue strain or irritation of the metacarpal bones in young animals, is quite apt to result in a splint being formed. Concussion such as is caused by fast work on hard roads, or work on rough or irregular road surfaces which cause unequal distribution of weight, will cause splint lameness and exostosis follows.



Course.—Because of the peculiar manner in which the second and third metacarpal bones articulate in young animals, until the bones become ossified and permanently joined, the inflammation which attends the acute stage of this affection, causes lameness. Later, unless an unusually large exostosis is formed, which may cause a constant irritation due to its size and juxtaposition to the carpus, lameness is discontinued.

Symptomatology.—Lameness is usually the first manifestation of this disorder, and the thing which characterizes splint lameness is its peculiar intermittence. There is a mixed form of lameness which may not be in evidence when an affected animal is started on a drive, but which is marked after the subject has gone some distance. The animal may, however, go lame throughout the whole of a drive and continue to be lame for several days or weeks in some cases. It is noticeable that lameness is augmented or produced when the subject travels on rough road surfaces and that little or no difficulty is encountered when roads are smooth.

The heavy brachial fascia is inserted in part to the head of the second metacarpal (inner small) bone together with the oblique digital extensor (extensor metacarpi obliquus) and this explains the reason for pain being manifested during extension of the member.

Before there is a visible exostosis, supersensitiveness is readily recognized upon palpation of the parts, if careful comparison is made between the sound and unsound members. However, frequently splints occur on both forelegs at the same time and in some instances exostoses are several in number upon each member affected. In some instances, the affection involves the outer splint bone and no evident involvement of the inner one exists.

Treatment.—At the onset complete rest should be provided and the local application of some good cataplasm is in order. A stimulating liniment is beneficial when employed several times daily and massage is also quite helpful. Later, the application of a blistering ointment is good treatment. The use of the actual cautery stimulates prompt resolution, but there is seldom any resorption of products of inflammation following firing. Whereas, in cases where other treatment is begun early, there usually follows considerable diminution in the size of the exostosis. A rest of four or five weeks is necessary and very young animals should not be put to work too soon, if the character of the work is such as to induce a recurrence of the trouble.

Many cases are treated successfully in draft types of animals (where the subjects are not kept at work that occasions serious irritation to the affected parts) by blistering the exostosis repeatedly and allowing the animals to continue in service. In such cases, it is unreasonable to expect to check the size of the exostosis and, of course, such methods are not employed where lameness causes distress to the subject.

Firing usually causes prompt recovery from lameness and is a dependable manner of treating such cases but there remains more blemish following cauterization than where vesication is done.

OPEN FETLOCK JOINT.

This condition, because of the frequency with which it occurs may be taken as typal, from the standpoint of treatment and results obtained therefrom. While it serves to constitute a basis from which other joints, when open, are to be considered, due allowance must be made for the fact that, as has been previously mentioned, some articulations when open constitute cause for grave consequences; while with others an open capsule, even when infected, does not cause disturbance enough to be classed as difficult to handle. Moreover, the fetlock joint is admirably suited, anatomically, to bandaging; and when wounded, is easily kept protected by means of surgical dressings. This fact is of great importance in influencing the course and termination in any given case of open fetlock joint and should not be forgotten.

There is no logical reason for comparing the pedal joint with the pastern on the basis that it may also be completely and securely bandaged. Open navicular joint does not occur, as a rule, except by way of the solar surface of the foot, and the introduction of active and virulent contagium is certain to happen; consequently, an acute synovitis quickly resulting in an intensely septic and progressively destructive arthritis soon follows in perforation of the capsule of the distal interphalangeal articulation.

Etiology and Occurrence.—Wounds of the fetlock region resulting in perforation or destruction of a part of the capsular ligament are caused by all sorts of accidents, such as wire cuts, incised wounds occasioned by plowshares, disc harrows, stalk cutters and other farming implements. In runaways the joint capsule is sometimes punctured by sharp pieces of wood or other objects. In horses driven on unpaved country roads the fetlock is occasionally wounded by being struck against the sharp end of some object, the other end of which is firmly embedded in the ground. In one instance the author treated a case wherein the fetlock joint was perforated by the sickle-guard of a self-binder. In this case there occurred complete perforation causing two openings through the cul-de-sac of the joint. Such wounds are produced by implements which are, to say the least, non-sterile, and this perforation of the uncleansed skin conveys infectious material into the joint capsule. Yet in many instances, especially in country practice, no infectious arthritis results where cases are promptly cared for.

Symptomatology.—A difference in the character of symptoms is evidenced when dissimilar causes exist. Small penetrant wounds which infect the synovial membranes cause infectious arthritis in some cases, whereas a wound of sufficient size to produce evacuation of all synovia will, in many instances, cause no serious distress to the subject, even when not treated for several days. If it is not evident that an open joint exists and the articular cavity is not exposed to view a positive diagnosis may be early established by carefully probing the wound. In some cases where a small wound has perforated the joint capsule, swelling and slight change of relation of the overlying tissues may preclude all successful exploratory probing. In such instances it is necessary to await development of symptoms. Twenty-four hours after injury has been inflicted, there is noticeable discharge of synovia which coagulates about the margin of the orifice, where synovial discharge is possible. Particularly evident is this accumulation of coagulated synovia where wounds have been bandaged—there is no mistaking the characteristic straw-colored coagulum which, in such cases, is somewhat tenacious.

No difference exists between other symptoms in infectious arthritis caused by punctures, and non-infectious arthritis, excepting the intensity of the pain occasioned, the rise in temperature, circulatory disturbances, etc.; all of which have been previously mentioned.

Treatment.—Just as has been stated in discussions on the subject of open joint, probing or other instrumentation is to be avoided until the exterior of the wound and a liberal area surrounding has been thoroughly cleansed—too much importance can not be placed on this preliminary measure. In cases of open joint where ragged wound margins exist and the interior of the joint capsule is contaminated, much time is required to thoroughly cleanse all soiled parts. In some instances an hour's time is required for this cleansing process after the subject has been restrained and prepared. In order to thoroughly cleanse these delicate structures without doing them serious injury, one ought to be skillful and careful in all manipulations of the exposed parts of the joint capsule.

The general plan of treatment, after preliminary cleansing has been accomplished, has been outlined on page 66 in the consideration of scapulohumeral joint affections. The injection of undiluted tincture of iodin in ounce quantities, it must be remembered, is not to be done unless there is provision for its free exit. Where good drainage from the joint cavity exists all infected wounds should be thus treated, and this treatment may be repeated as conditions seem to require—until infection is checked.

If daily injections are necessary, dilution of the tincture of iodin with an equal amount of alcohol is advisable in order to avoid doing irreparable damage to the articular cartilages and synovial membranes.

An antiseptic powder composed of equal parts of boric acid and exsiccated alum is employed to protect the wound surfaces and the margins, and the parts are then bandaged. In bandaging wounds of this kind a liberal amount of cotton should be employed, and after a large surface surrounding the wound has been thoroughly cleansed, it must be so kept thereafter. This is impossible, if one uses a small amount of cotton, particularly if such meager quantity of dressing material is carelessly wrapped in position with an insufficient amount of bandage material. Mention, without description of the elemental problem of applying cotton and bandages to a wound, would be sufficient, were it not that this is a very important part of the handling of such cases, and many practitioners are not only thoughtless in this part of their work, but also apparently careless. What does it profit to prepare a part and cleanse a wound with painstaking care and then neglect to take every possible precaution to prevent its subsequent contamination?

In the handling of open joint capsules where the perforation of the capsular ligament is small and discharge of synovia does not immediately follow, there is presented a problem which is difficult to decide upon and that is the manner in which such wounds are to be handled. One hesitates to enlarge such openings to drain or irrigate the capsule when there is no proof that serious trouble will follow because of infectious material which has probably been introduced at the time the wound was inflicted. It is especially difficult to decide upon the manner of handling such cases where the tarsal joint is wounded, although one hesitates to invade any joint to the extent of incising its capsule, unless there is urgent need of so doing.

Frost[19] offers the following suggestion in such instances:

The treatment recommended by us for open joints, in which we wish to prevent ankylosis, is, first, to shave all hair from the area surrounding the wound, following with a thorough cleansing of the skin and disinfection of the wound, and then to inject a twenty per cent Lugol's solution in glycerin into the wound. This should be repeated two or three times a day, each time enough of the solution being injected to fill the joint capsule, thereby securing the flushing effect. As this solution does not cause irritation to the tissue and yet is a strong antiseptic, it serves to shorten the period of congestion and inflammation and to overcome the infection without causing a destruction of the secreting membrane until the external wound has had time to heal. The injection of this solution seems to retard the excessive secretion of synovia. The larger the joint capsule and the smaller the external wound, the longer our antiseptic will remain in contact with the inflamed tissues as the glycerin, being thick, does not flow through a small opening.

After-care.—Following the initial cleansing and treatment of open joint, subsequent dressing is necessary as frequently as conditions demand. If the parts are badly infected and profuse discharge of pus exists a daily change of dressings is necessary. In the average instance, however, semi-weekly treatments are sufficient. And in many instances where one is obliged to travel a considerable distance to handle the affected animal one weekly dressing of the wound will suffice after the second treatment.

The same general plan of treatment concerning the subject's comfort that has been previously mentioned in arthritis, is carried out here. A further and detailed consideration of the subject of handling of open joints follows.[20]

* * * Such wounds may be classified in two general groups as follows: First, wounds in which the trauma has exposed the articulation to view, and second, those the result of punctures, in which the external wound is small and free drainage is lacking.

Wounds in which the articulation is exposed to view have drainage either all ready provided for, or it is established without hesitancy surgically. With free drainage thus established there is little or no chance for the adjacent tissues to become infiltrated with infected wound discharge. This prevents an extension of the injury and the establishment of a good field for the growth of anaerobic bacteria.

Open joints caused by punctures, unless the puncture is aseptic, produce a swelling which is more painful than is the open wound which exposes the joint to view. Especially is this true if the puncture is of small diameter, allowing the tissues to partially close the opening immediately after the wound has been made. Where drainage is lacking there follows an exudation which congests the tissues surrounding the injury and all factors favoring germ growth are present. It is perhaps advisable to establish good drainage in such cases as soon as a diagnosis is made.

It is not always an easy matter to recognize an open-joint, when first made, but twelve to twenty-four hours later there is no cause for doubt. The condition is then a very painful one; lameness is excessive; there is rise in temperature; acceleration of the pulse and manipulation or palpation of the region affected, occasions great pain.

The treatment of open joints must be varied to suit the disposition of the animal, the nature and location of the injury, the length of time intervening between the infliction of the wound and the first attention given, and the surroundings in which the patient is kept.

In each and every case in which there exists an open wound the surface surrounding the wound is cleansed thoroughly, the hair is shaved if possible, and the margin of the wound is curretted and cleansed thoroughly with antiseptic solutions.

If there is evidence that the articulation contains infective material, it is washed out with copious quantities of peroxide of hydrogen—usually as much as six or eight ounces. This is followed by injection of an ounce or two of tincture of iodin. Even though the joint appears to be clean some tincture of iodin is used, as it checks the secretion of synovia and is, in every way, beneficial. Care is taken to apply the iodin also to the surface immediately surrounding the wound. The entire wound is then covered with a dusting powder composed of zinc oxide, boric acid, exsiccated alum, phenol and camphor.

This powder is used in abundance and the wound is then covered with a heavy layer of absorbent cotton and well bandaged. This bandage is not disturbed for at least three days and may be left in place for a week. In cases in which it is necessary to keep the dressing on for a week, or in cases where the patient is, through necessity, kept in quarters that are wet or unclean, the first bandage is covered with a layer of oakum which has been saturated in oil of tar and this in turn is held in place by means of several layers of bandages. The bandages are also saturated with oil of tar.

In from one to two months wounds so treated, unless they are foot-wounds, will be ready to dress without being bandaged. It is ordinarily unnecessary to dress foot-wounds oftener than every second week after the discharge of synovia has ceased. When the wound has filled with granulation, a protective dressing is applied which is rendered water proof by the use of bandages covered with oil of tar. The patient can now be turned out for a month or six weeks without disturbing the dressing. After the removal of the bandages, the only treatment necessary is an occasional application of some mildly antiseptic ointment.

Except in nail pricks of the foot, occasioned by punctures, a five per cent tincture of iodin is injected into open joints, if the wound remains sufficiently open, and this treatment is continued so long as there is a discharge of synovia. Surgical drainage is established if it is considered practicable and the remainder of the treatment is about the same as for wounds which are open.

Open joints occur in horses at pasture and are sometimes not discovered until several days or a week after the injury, and in some instances the wounds are filled with maggots. The only difference in the treatment of these cases is that more time and care is taken in cleansing the wound, more curetting is necessary, and after cleansing the wound with peroxide of hydrogen, the joint is thoroughly washed out with equal parts of tincture of iodin and chloroform. This is followed by the injection of a quantity of seventy-five percent alcohol and the wound is dressed and bandaged as already described. At each subsequent dressing of infected wounds so treated less suppuration is noticed and the synovial discharge usually ceases in from one to two months.

About ninety percent of all cases of open joint make complete recoveries, about four per cent partially recover and six per cent are fatal. Among the fatal cases are the open joints with complications as severed tendons, those occasioned by calk wounds in horses that are stabled, and nail punctures of the feet. The following report of twelve favorable cases is taken from a record of sixty-two cases. The favorable ones are reported, chiefly because there are now enough reports on record of such cases which have terminated fatally.

Case 1.—A gray gelding used as a saddle pony received a horizontal wire cut laying completely bare the scapulohumeral articulation. The margins of the wound were cleansed as heretofore described, a drainage was provided surgically, tincture of iodin was injected and the wound was covered with equal parts of boric acid and exsiccated alum. The horse was kept tied and a diluted tincture of iodin was injected into the wound once daily and the powder applied often enough to keep the wound covered. The case made a complete recovery and the pony was again in service within sixty days.

Case 2.—A twelve-hundred-pound bay mare with an open carpal joint. The wound was an open one about two and one-half inches in length, and made transversely and when the member was flexed the articular surface of the carpal bones were presented to view. An ounce of tincture of iodin was injected into this joint after having cleansed the margin of the wound and the mare was cross-tied in a single stall to keep her from lying down. The owner was instructed to keep the outside of the wound powdered with air slaked lime and a very unfavorable prognosis was given.

I heard nothing further from this case until fifty-nine days from the date of the injury, when I met the owner driving this mare to a buggy. The wound had healed by first intention and at that time so little cicatrix remained that it was difficult to find it.

Case 3.—A brown mare with an open fetlock joint due to a spike-nail puncture. Lameness was excessive, and joint greatly swollen. Tincture of iodin was injected into the wound and towels dipped in hot antiseptic solutions were applied for several hours daily until the acute stage had passed. Later the mare was turned out to pasture and a vesicant was applied once or twice a month until recovery was complete which was in about six months.

Case 4.—A four-year-old bay mare having a wire-cut which opened the tarsus joint was treated as heretofore described. The wound was kept bandaged for about two weeks and later it was dressed without being bandaged. In ninety days she had completely recovered.

Case 5.—A twelve-year-old mare with an open fetlock joint due to a puncture wound. The margins of the wound were cleansed and the external wound enlarged to facilitate drainage. Tincture of iodin was injected; the wound was bandaged and dressed for a month in the manner heretofore described, when all discharge had stopped. A vesicant was applied; the mare was put to pasture and within sixty days from the date of the injury she was being driven on short trips.

Case 6.—A two-year-old brown gelding with a wire-cut on the left front foot. The wound extended down through the sole and opened the navicular joint. This colt was very wild and it was necessary to tie it down each time the wound was dressed. The wound was dressed weekly for a month and less frequently thereafter. It was handled eight times; the last dressing was left in place until worn out. Six months later the colt was practically well, a very little lameness being shown when walking on frozen ground.

Case 7.—A seven-year-old saddle-horse weighing eleven hundred and fifty pounds received a wound of the tarsus, laying bare the articular surfaces of a part of the joint. It was impossible to keep this wound bandaged because of the restless disposition of the subject. Injections of a dilute tincture of iodin were employed every second or third day for a month and the wound was kept covered with the antiseptic dusting powder referred to heretofore. In five months complete recovery had taken place, with the exception of a stubborn skin disturbance which was successfully treated six months after the wound was inflicted. The horse is still in use and is absolutely free from lameness.

Case 8.—A two-year-old brown gelding with a wire-wound opening the scapulohumeral joint. This wound was large enough to expose to view the articular portion of the humerus. The same treatment as that given case No. one was instituted and in ninety days the colt was practically well.

Case 9.—A three-year-old bay filly was found at pasture with one fore foot badly injured. The owner intended to destroy her, but a neighbor prevailed upon him to have her treated. Apparently the wound was of about a week's standing and in a very bad condition, filled with maggots and dirt. Both the navicular and coronary articulations were open. This wound was cleansed in the usual manner and the owner cared for the case the balance of the time because the distance from my office was too great to give her personal attention. She made an almost complete recovery in five months.

Case 10.—At two-year-old mule with an open navicular joint due to a barbed wire wound. Usual care was given this case and in five months recovery was complete and little scar is to be seen. This case received seven treatments.

Case 11.—An eighteen-months-old colt at pasture was found down and unable to rise without help. In addition to several wounds of lesser importance there was a large wound on the inner side of the elbow, the joint was open and the entire leg was greatly swollen and in a state of acute infectious inflammation. The colt could not walk, its temperature was 105 deg., pulse was rapid and respiration was a little hurried. After advising the owner to put the poor animal out of its misery I left the place. Four days later the owner came to my office and asked if he could borrow some old shears to "trim off some loose hide from that colt." He left the colt in the pasture and all the care it received was the regular application of a proprietary dusting powder. It made a complete recovery.

Case 12.—A family mare, heavy in foal, received a vertical wound of the fetlock joint inflicted by a disc-harrow. The cul-de-sac of the ligament of this joint was opened freely. The wound was dressed in the usual manner and again three days later when no suppuration had taken place. Four days later the patient gave birth to a colt and suckled it right along through her convalescence. This wound healed by first intention and seventy-nine days from the date of the injury the mare was driven to town, two and one-half miles distant, and showed but little lameness.

Phalangeal Exostosis (Ringbone)

This term is applied to exostoses involving the first and second phalanges (suffraginis and corona), regardless of their size, extent or location. It is a misnomer, in a sense, and the veterinarian is frequently obliged to spend considerable time with his clients in order to convince them that a spherodial exostosis of the proximal phalanx, in certain cases, is in reality "ringbone," even though there exists no exostosis which completely encircles the affected bone.

Etiology and Occurrence.—Exostosis of the first and second phalanges is usually due to some form of injury, whether it be a contusion, a lacerated wound which damages the periosteum, or periostititis and osteitis incited by concussions of locomotion, or ligamentous strain. Practically the only exception is in the rachitic form of ringbone which affects young animals.

There are predisposing causes that merit consideration, chief among which is the normal conformation of the coronet joint. This proclivity is constant; the normal interphalangeal articulation is an incomplete ginglymoid joint and while its dorso-volar diameter is great, this in no wise compensates for its disproportionately narrow transverse diameter. The pivotal strain which is sometimes thrown upon this articulation when an animal turns on one foot, as well as the tension which is put on the collateral ligaments when the inner or the outer quarter of the foot rests in a depression of the road surface, tends to detach the insertion of these ligaments or to cause fibrillary fractures of their substance.

Short, upright, pasterns receive greater concussion during fast travel on hard roads than do the longer more sloping and well formed extremities. Those who are advocates of the theory that this type of osteitis with its complications has its origin in the articular portion of the joint, claim that the upright pastern constitutes an important tendency toward ringbone. Howbeit, ringbone is an active, serious and frequent cause of lameness and it affects animals of all ages and occurs under various conditions. Horses having good conformation and kept at work wherein no great amount of strain is put upon these parts, are occasionally victims of this affection.

Classification.—The arrangement employed by Moller[21] is intensely practical and logical. He considers ringbone as articular, periarticular, rachitic and traumatic. A mode of classification that is common and in a practical way, good, is, high and low ringbone. When prognosis is considered, for instance, it is very convenient to state that the chances for recovery are much better in high ringbone than in low ringbone. The classification of Moeller will be followed here.



Symptomatology.—In all forms of incipient ringbone except rachitic, the first manifestation of its existence, or of injury to the ligaments in the region of the pastern joint which causes periostitis, or affections of the articular portions of the proximal inter-phalangeal joint, is lameness. Lameness which typifies ringbone is of the supporting-leg variety and by compelling the subject to step from side to side, marked flinching is observed, especially in periarticular ringbone; causing the affected animal to turn abruptly on the diseased member, using it as a pivot, likewise accentuates the manifestation. In fact, many subjects that exhibit no evidence of locomotory impediment while walking or trotting in a straight line on a smooth road surface, will manifest the characteristic form of lameness from ringbone when the aforementioned side to side movement is performed.

When the manner in which pain is occasioned is considered, it will be understood why lameness is intermittent in the early stages of this affection and may even be unnoticed by the driver. An animal may travel on a smooth road without giving evidence of any inconvenience, but as soon as a rough and irregular pavement or road surface is reached, will limp. As the subject is driven farther on level streets the lameness may disappear. This intermittent type of lameness may continue until there is developed a large exostosis, or until articular involvement causes so much distress during locomotion that lameness is constant. On the other hand, resolution may occur during the stage of periosteal inflammation, or, an exostosis forms which causes no interference with function.



Before there is evidence of an exostosis, diagnosis of ringbone is not easy, for it is then a problem of detecting the presence of a ligamentous sprain, periostitis, or osteitis. The diagnostician should take note of local manifestations of hypersensitiveness, or heat if such exist, and, in addition, other conditions must be excluded before definite conclusions are possible.

In articular ringbone as soon as there is developed an exostosis, it occupies a position on the dorsal (anterior) part of the articulation and extends around the sides of the joint.

Periarticular ringbone is characterized by exostoses which are situated on the sides of the phalanges and not extending around to the anterior part of the joint. This type of ringbone as well as the articular may occur "high" or "low."



With the traumatic form of ringbone, all consequences, as to the size and form the exostosis is to assume, depend upon the nature and extent of the injury.

Rachitic ringbone is frequently observed in some sections of the country and does not ordinarily cause much if any lameness. It is a disease of colts and may affect one or all of the phalanges at the same time. As the subject advances in age there is more or less diminution in the size of the enlargements.

Treatment.—Rest is essential in the treatment of ringbone. If diagnosed during its incipiency, remedial measures such as are usually employed to treat sprains, are indicated and later the parts should be blistered. When an exostosis has developed puncture firing is the remedy par excellence. Not that this method of treatment is infallible, for to any thinking one who takes into consideration the pathological anatomy of this condition, it is evident that no manner of treatment is beneficial in some cases. If the exostosis is so situated that it does not mechanically interfere with function, and is not so large that it may inhibit flexion and extension, and where the articular portions of the joint are not eroded, good results attend the use of the actual cautery.

In firing, after having anesthetized the extremity, and prepared the surgical area, the cautery is deeply inserted in numerous places, taking care, however, not to open the joint. The parts are immediately covered with aseptic absorbent cotton and this dressing is left in position for forty-eight hours and if perchance there is evidence of synovial discharge, the parts are again aseptically dressed in order to prevent infection of the articulation. If, as is the case usually, no perforation of the joint capsule exists, the openings made by the cautery have been closed by the coagulation of serum and there is then little chance of infection causing trouble, even though the member is left unbandaged.

In several instances, the author has treated ringbone by this method where the periarticular type existed and lameness was marked, and in three weeks the subjects were in service and not lame—this, in one instance in a valuable polo pony where the subject continued in service for more than a year without any evidence of recurrence of the lameness. The production of a deep-seated and acute inflammation with the actual cautery is preferable to any sort of counter-irritation which may be produced by vesicants.

There is no occasion for any difference in the treatment of either of the first three classes of ringbone, but in the rachitic type where treatment is given, the application of a vesicant is all that is required. In most instances treatment is not necessary.

The affected animals require a month to three months' time for recovery to take place in the average favorable cases of ringbone.

Median neurectomy is of service in many instances where lameness is not completely relieved by the use of the actual cautery and no bad results attend the performance of this operation even though no benefit is derived thereby. Plantar neurectomy is contraindicated in all cases where there exists much lameness. If lameness is due to acute inflammation bad results such as sloughing and loss of the hoof may follow; and if large exostoses mechanically interfere with function of the joint, or where articular erosions exist, no possible good can come from neurectomy. Careful discrimination should be employed in selecting cases for neurectomy for this operation; otherwise, it is very likely to prove disappointing.

Open Sheath of the Flexors of the Phalanges.

This condition does not differ from a like affection involving other tendons except that the function of these tendons is such that large synovial sheaths are necessary, and when synovitis exists, the condition then becomes more serious.

Infectious synovitis involving these tendons in the fetlock region is of more frequent occurrence than a like affection of carpal or tarsal sheaths. With the exception of the extent of the involvement and distress occasioned thereby, synovitis the result of open tendon sheaths, is similar wherever it occurs.

Etiology.—The same conditions which are responsible for open fetlock joint and other wounds of the pastern region, cause open tendon sheaths of the flexor tendons.

Symptomatology.—Because of the size and extent of this sheath and the different manner in which it is opened, there is manifested dissimilar symptoms in different cases. A nail puncture which perforates the sheath in the pastern region and at the same time produces an infectious synovitis, will cause a markedly different manifestation than will a wound which freely opens the sheath above the fetlock. In the first instance, the condition is much more painful; swelling is intense in some cases; and if the subject does not possess sufficient resistance so that spontaneous resolution promptly occurs, surgical evacuation of pus is usually necessary. When these tendon sheaths are opened, there follows a reaction which is quite analogous to that which exists in arthritic synovitis, but instead of ankylosis, adhesions with thecal obliteration occur. Rarely there result cartilaginous and osseous formations.

The constitutional disturbances which characterize this condition vary with the degree of distress occasioned. As the infection is virulent and causes serious destruction of the affected parts, so does evidence of malaise and finally distress appear. Detailed discussions of symptomatology in similar conditions have heretofore been given, and further repetition is unnecessary.

Treatment.—The same general plan of treatment which is employed for handling open joint is put in practice in these cases. Following the preoperative cleansing of the external wound and adjacent surfaces, where liberal drainage exists, tincture of iodin is injected into the sheath, the parts covered with a suitable dressing powder, and the entire member is carefully dressed with cotton and bandages.

Subsequent treatment is the same as has been outlined in the discussion of open fetlock joint on page 112. The same general plan of after-care is necessary. Recovery, however, does not require so much time ordinarily, yet punctures of the sheath occasioned by nails or other small implements make for long drawn out cases of infective synovitis.

Luxation of the Fetlock Joint.

Etiology and Occurrence.—The manner of construction of the fetlock joint is such that disarticulation without irreparable injury resulting, is practically impossible. Logically, this joint in the fore legs (not so in the pelvic limbs) should disarticulate in such manner that either all of the inhibitory apparatus (flexor tendons and suspensory ligament) must rupture or a lateral luxation is necessary. Lateral disarticulation must necessarily sever the attachment of one of the common collateral ligaments. Because of the width (transverse diameter) of the articulating surfaces of this joint, lateral luxation requires a great strain; and a force that is sufficient to occasion this trauma usually causes serious additional injury. Therefore, the condition is considered one wherein prognosis is always unfavorable in so far as practical methods of treatment are concerned.

Mr. A. Barbier[22] reports a case of bilateral luxation of the fetlock joints of the hind legs in a horse. This was done in jumping, and the extensor tendon of each leg was ruptured and the anterior portion of the metatarsus was protruding through the skin. Profuse hemorrhage had taken place due to tearing of the blood vessels.

Symptomatology.—Entire luxation of this joint when present is so evident that one cannot fail to recognize the condition. Complete disarrangement of normal relation occurs and there is either a breaking down of the inhibitory apparatus, or if a lateral disarticulation exists, the normally straight line formed by the bones of the front leg, as viewed from the front or rear, is broken at the fetlock.

Often fracture of bones are concomitant and then, of course, mobility is increased and not decreased as is the case in uncomplicated luxation.

Such violence occurs at times, when this joint is disarticulated, that the joint capsule is also completely ruptured and the articular portion of the bones is exposed to view.

Treatment.—The condition being practically a hopeless one, destruction of the subject is the thing which should be promptly done. In valuable breeding animals, owners may prefer that treatment be attempted when a lateral luxation and detachment of but one common ligament have permitted luxation without complete disarticulation and rupture of the joint capsule. In such cases, by immobilizing the affected parts as in fracture, and confining the subject in a sling for about sixty days, partial recovery may occur in some instances.

Experience has shown that where luxation with detachment of a collateral ligament occurs, recovery is slow and incomplete—there always results considerable exostosis at the site of injury.

Sesamoiditis.

Etiology and Occurrence.—Inflammation of the proximal sesamoid bones is caused by any kind of irritation which may involve this part of the inhibitory apparatus. Positioned as they are, between the bifurcations of the suspensory ligament and the pastern joint, they serve as fulcra and effectively assist in minimizing concussion which is received by the suspensory ligament. The flexor tendons also, in contracting, exert strain upon the inter-sesamoidean ligament, which has a similar effect upon the sesamoid bones as that which is produced by the suspensory ligament.

The condition occurs quite frequently, and because of the important function performed by these bones, active inflammation of the sesamoids constitutes a serious affection. Because of the fact that these bones have proportionately large articular surfaces, when they are inflamed to the extent that degenerative changes affect the articular cartilage, complete recovery seldom results.

The same pathological changes occur here that are to be seen in any case of arthritis. No special pathological condition characterizes sesamoiditis but this condition causes incurable lameness when the sesamoid bones are much inflamed.

Symptomatology.—In acute inflammation, there exist all the symptoms which portray any arthritic inflammation of like character. The parts are readily palpable and are found to be hot, supersensitive, and more or less infiltration of the tissues contiguous to the joint causes swelling. There is volar flexion of the phalanges when the subject is at rest. Lameness is intense; in some acute inflammatory disturbances the subject is unable to bear weight on the affected member.

In chronic sesamoiditis, constant lameness is the one salient feature which marks the condition. While it is possible for one sesamoid bone to become involved without its fellow being affected, this is not usual. Considerable organization of tissue surrounding the joint is present and no particular evidence of supersensitiveness exists. However, supporting weight brings sufficient pressure to bear upon the inflamed and more or less eroded bones so that pain is occasioned and lameness results.

Treatment.—During acute inflammation, absolute quiet is, of course, of first consideration. Cold packs are to be kept in contact with the parts until acute inflammatory symptoms subside. The fetlock region is then enveloped with a poultice or an iodin and glycerin combination (iodin one part to seven parts of glycerin) is applied and a dressing of cotton is kept in contact with the inflamed region. Following this, a vesicant is employed and the subject is allowed a month's rest.

In sub-acute cases, the entire region surrounding the pastern is blistered or the actual cautery is used. Line-firing is preferable. The subject is given a month or six weeks rest and one may be guided by the presence or absence of lameness as to whether improvement or recovery is taking place.

Old chronic cases, and particularly those where there are considerable induration and fibrous organization of tissue surrounding the joint, are not to be benefited by treatment.

The chief consideration in handling sesamoiditis is checking inflammation as early as possible and preventing, if this can be done, the erosion of articular surfaces. If destruction of any part of the articular surfaces can be prevented and the patient allowed ample time for complete resolution of the affected parts to occur, permanent relief is possible.

Fracture of the Proximal Sesamoids.

Etiology and Occurrence.—Fracture of the proximal sesamoid bones is caused by violent strain when there exists fragilitas osseum, or by contusions. The author treated a case where fracture of one sesamoid was occasioned by a horse receiving a puncture wound wherein the sharp end of a steel bar was protruding from the ground where it was firmly embedded. The subject in this case was injured while being driven along a country road. Frost[23] reports simultaneous fracture of all of the proximal sesamoids occurring in a sixteen-year-old pony. The condition is of rather common occurrence in some countries because of the fragile condition of horses' bones.

Symptomatology.—If the parts can be examined before extravasation of blood and swelling mask the condition, crepitation may be detected. In other instances, it is possible to note a displacement of parts of the sesamoid bones—this in horizontal fracture. There occurs more or less descent of the fetlock which must not be attributed to rupture of the superficial flexor tendon (perforatus). By outlining the course of this tendon with the fingers, when it is passively tensed sufficiently to follow its course, one may exclude rupture of the superficial flexor. Finding the suspensory ligament intact from its origin to the sesamoid attachments, one may also eliminate rupture of this structure as a cause of the trouble. Needless to say, marked lameness and swelling of the fetlock soon take place. The condition is painful, and ordinarily, recovery is impossible.

Treatment.—Where treatment is attempted, immobilization as in luxation is in order. The patient's comfort is sought, and if the fractured parts can be kept in close proximity, their union may occur in time. However, chances for partial recovery (which is the best to be hoped for) are so remote that early destruction of the subject is the humane and economical thing to do.

Where treatment is instituted, it is found that there is required a long time for union of the fractured bones to occur (where union does take place) and the cost of treatment together with the uncertainty of even partial recovery, makes for an unfavorable outcome. When the best possible results succeed treatment, a large callosity is formed and movement of the pastern joint is restricted. Lameness, though not intense, in the case referred to, where one bone was broken, was permanent and the subject was out of service for nearly a year.

Inflammation of the Posterior Ligaments of the Pastern (Proximal Interphalangeal) Joint.

Anatomy.—The ligaments here involved are the four volar ligaments described by Sisson[24] as follows: "The volar ligaments (Ligg Volaria) consist of a central pair and a lateral and medial bands which are attached below to the posterior margin of the proximal end of the second phalanx and its complementary fibro-cartilage. The lateral and medial ligaments are attached above to the middle of the borders of the first phalanx, the central pair lower down and on the margin of the triangular rough area."

This portion of the inhibitory apparatus is described by Strangeways' Anatomy as two posterior ligaments which run each from three points on the sides of the os suffraginis to a piece of fibro cartilage, described as the glenoid cartilage, and attached to the postero-superior edge of the os coronae; between them is the insertion of the inferior sesamoidean ligament.

Etiology and Occurrence.—Everything tending to increase strain upon these ligaments is contributory to possible fibrillary fracture of these structures. Excessive leverage as furnished by long toes, long toe-calks and low heels increases the normal tension on the posterior ligaments of the pastern joint. Faulty conformation, which throws an abnormal strain on these ligaments, is a predisposing cause of inflammation of these structures. Hard pulling upon slippery and rough or frozen roads is a common exciting cause of this injury. The condition is of comparatively frequent occurrence and is seen affecting draft horses frequently, in the hind legs.

Symptomatology.—Lameness is the first manifestation of this affection and weight bearing is painful in direct proportion to the extent of injury present. Volar flexion of the phalanges relieves tension on the parts; therefore, this position is assumed while the subject is at rest. When considerable tissue has been ruptured, and the condition is very painful, the foot is held off the ground as in all painful affections of the extremity.

By palpation evidence of pain is discernible, though very little swelling occurs. Pain is increased by manual tension of the parts which is done by grasping the toe of the foot and exerting traction on the flexor apparatus. Care must be taken in executing such manipulations, and it is only by comparison of the affected member with the sound one and noting the difference in the manifestations of discomfort that we may arrive at the proper conclusion.

Some hyperthermia is to be recognized in acute inflammation, by comparing the extremities. In the fore legs, navicular disease is differentiated by noting absence of contraction at the heel. By use of the hoof testers one may recognize evidence of inflammation of the navicular apparatus. In inflammation of the posterior ligaments of the pastern joint, there is also absence of the characteristic stumbling which is seen in navicular disease.

Treatment.—Rest is the first requisite, and in addition every mechanical means possible to change the center of gravity in the phalangeal region, is to be employed. This is best accomplished by shortening the toe and paring the sole at the toe as much as conditions will permit. The heel is raised by means of a shoe with moderately high heel calks.

The iodin-glycerin combination heretofore mentioned may be applied and the parts covered with cotton and bandage. Subjects require from three weeks to several months' rest and must be returned to work carefully, lest the incompletely regenerated tissues suffer injury.

Regeneration of tissue in such cases, as has been pointed out, is slow and sufficient time for complete recovery must be allowed or relapses will occur.

Fracture of the First and Second Phalanges.

Etiology and Occurrence.—Fractures of the first phalanx (suffraginis) occur with respect to frequency, second to pelvic fractures. Often, almost insignificant injuries cause phalangeal fractures. On city streets, horses shod with shoes having long calks get caught in frogs of street railways or by slipping on rails, and phalangeal bones are often broken. The author observed a case of comminuted fracture of both the first and second phalanges (suffraginis and corona) in a polo pony caused by making a sudden turn while in action in a contest on the turf.

Symptomatology.—Fracture of the phalanges is nearly always signalized by lameness, and this is marked during the period of weight bearing. Lameness is usually intense and where the pathognomonic symptom (crepitation) is not recognized, the intensity of the claudication, when other causes are absent, is indicative of fracture. The subject does not bear weight upon the affected member and where pain is intense, the foot is held in an elevated position and swung back and forth. In hind legs the member is often flexed in abduction and held in this position for several minutes, being rested on the ground only during short intervals. When compelled to walk, if pain is excruciating, the animal hops with the sound leg, no weight being supported by the fractured member.

When an examination of the subject is possible before the extremity is swollen, crepitation is usually found without great difficulty, except in a subperiosteal break or in some cases of vertical or oblique fracture. Great care is necessary in handling the injured extremity in these cases, and particularly in nervous subjects or in excited animals that have been recently injured in runaways, is it necessary to be gentle in manipulating the extremity, if definite deductions are to be made. As has been mentioned in the chapter on diagnostic principles, if the condition is so painful that the subject does not relax the parts and crepitation is masked, local anesthesia is necessary. An anesthetic solution of cocain or novocain may be applied to the metacarpal or metatarsal nerves and an entirely satisfactory examination is then possible.

Passive movement of the phalanges in all directions is practised in order to produce crepitation. When rotation of the parts does not occasion crepitation, gentle flexion and extension may do so. And in many instances, considerable manipulation of the phalanges is necessary before the pathognomonic symptom is to be recognized.

In cases where crepitation is not found and lameness is pronounced, out of proportion with other possible existing causes, one may by exclusion of other causes establish a diagnosis of fracture in the course of forty-eight hours. In the meanwhile, support is given the affected member by applying an effective leather splint, so that pain may be diminished. To combat inflammation, a suitable cataplasm may be applied directly to the skin, the extremity bandaged, and the temporary immobilizing appliance may be secured over all. In this manner one may make repeated examinations of the subject, and if slings are used and every other necessary precaution taken to promote comfort for the subject, no harm will result in delaying for several days the application of permanent immobilization—bandages and splints or casts. In fact, where much swelling exists at the time one is called to treat such cases, it is advisable to delay the application of a permanent dressing or cast until inflammation has somewhat subsided.

Course and Prognosis.—Where conditions are favorable, the nature of the fracture one that will yield to treatment, the subject not aged, and facilities for giving good attention to the affected animal are ample, fractures of the first and second phalanges recover completely in from six weeks to four months. Only simple fractures are considered curable from a practical and economical point of view, excepting in foals, where compound, and even comminuted, fractures may be so handled that animals may eventually become serviceable though blemished.

Age retards the process of osseous regeneration, but in one instance at the Kansas City Veterinary College, a very aged mare suffering from a multiple fracture of the first phalanx was treated and at the end of sixty days was able to walk into an ambulance. Large exostoses had developed and the subject remained lame, but union of the broken bone took place in a surprisingly prompt and effective manner, when age of the subject and nature of the fracture are considered.

As a rule, one is loath to recommend treatment, even in a simple transverse fracture of the first phalanx, in animals ten years of age or older. The conditions which exist in any given locality that regulate the expense of caring for an animal during the period of treatment, especially influence the course to be pursued in treating fractures.

Treatment.—For permanent immobilization of the phalanges in fracture, materials which might adapt themselves to the irregular contour of the member and at the same time contribute sufficient rigidity to the parts without doing injury to the soft structures, would constitute ideal means of treatment; but no such materials have yet been devised, and opinions are various as to the most efficient and practical method to employ.

After the fetlock has been shorn of hair and the ergot trimmed, the skin is thoroughly cleansed and allowed to dry. Several thin layers of long fiber cotton are then wrapped around the extremity—enough to pad well the member—and this is retained in position with a wide bandage. Gauze bandages are preferable to heavier bandages of cotton fabric because they are somewhat more elastic and yield to the irregular contour of the parts to a better advantage. Layers of three inch gauze bandages, which are soaked with a cold starch paste are wound about the extremity. Strips of leather that are flexible and not more than an inch in width are placed in a vertical position around the leg and these are also covered with the starch and securely held in position with the bandages. In this way, one is able to provide a sufficient degree of rigidity and at the same time, where the cast is carefully applied, little if any injury is done the skin. Such a cast is not difficult to remove and is so inexpensive that it may be removed and reapplied at any time it should be thought preferable to do so. Of course, this does not constitute an effective means of support if the parts are to be frequently and thoroughly soaked with water, but animals undergoing this sort of treatment are usually kept sheltered.

The same after-care is necessary in such cases as is given in fractures of other bones. Two months after the injury has been done, the application of a blistering ointment to the entire region is of benefit.

Results.—Much depends on the nature of fractures as to the success one may attain in approximating the parts of a broken bone, and in some cases of oblique fracture for instance, complete recovery is impossible, despite the most skillful and painstaking attention given. On the other hand, cases of simple transverse fractures make perfect recoveries in some instances. All fractures are serious, and in every instance the practitioner would best be careful to impress his client with the many difficulties which usually attend the treatment of fracture in horses.

Tendinitis.

Inflammation of the Flexor Tendons.

One of the most common causes of lameness in light harness and saddle horses is tendinitis, and because of the character of the structure of tendons and because of their function, an active inflammation of these parts is always serious.

Being almost inelastic and not well supplied with blood, tendinous tissue is slowly regenerated, and so much time is required for complete recovery to take place in tendinitis, that affected animals seldom fully recover before they are in service or vigorously exercising at will. As a result, complete recovery is delayed or prevented.

The extensor tendons, because of the nature of their function, are very seldom strained; they are often bruised and occasionally divided, but unlike this condition in the flexors, tendinitis of the extensors is of rare occurrence.

For a concise discussion of this subject the most practical classification is one made on a chronological basis and we may then consider tendinitis as acute and chronic.

ACUTE TENDINITIS.

Etiology and Occurrence.—Causes of tendinitis, as in almost all diseases, may be considered under the heads of predisposing and exciting. Among the predisposing causes of tendinitis may be mentioned, faulty conformation. Everything which has to do with increasing the strain upon tendons adds to the probability of their being over-taxed. Long, sloping, pastern bones; disproportionate development of parts, such as a heavy body and small, weak tendons and long hoofs, are the principal factors which usually predispose to tendinous sprains. Degenerative changes which take place in tendons following constitutional diseases such as influenza may also be classed as a predisposing cause.

Excessive strain when put upon tendons in any possible manner, such as is occasioned in running and jumping; making missteps and catching up the weight of the body with one foot, when the force thus thrown upon the supporting structure is great because of momentum gained at a rapid pace, are exciting causes of tendinitis.

Symptomatology.—In all cases of acute tendinitis there is presented a characteristic attitude by the subject. Volar flexion in a sufficient degree to relax the inflamed structures is always evident. The foot may be rested on the toe or placed slightly in advance of the one supporting weight, but the fetlock is always thrown forward. More or less swelling of the inflamed tendons is present. Where the deep flexor (perforans) is involved swelling is marked and with swelling there is present the other symptoms of inflammation—heat and supersensitiveness.

In manipulating tendons for the purpose of detecting supersensitiveness, care must be taken so that no false conclusion be drawn, because of the aversion many horses have to submitting to palpation of the tendons even when they are in a normal condition.

Supporting-leg-lameness is present and varies in degree with the intensity of the pain caused by weight bearing. In many instances, as soon as the subject has traveled a considerable distance, lameness diminishes or discontinues. As soon as the affected animal is permitted to stand long enough to "cool out" there is a return of the lameness, which is then marked.

No difficulty is encountered in making a practical diagnosis in tendinitis; that is, one may fail to readily recognize the extent of the involvement as it affects the superficial flexor tendon, for instance, but this has no practical bearing on the prognosis and treatment, when existing inflammation of the deep flexor is recognized.

The course of each tendon is readily outlined by palpation; all parts are easily manipulated; and with experience one may readily recognize the extent and degree of the inflammation.

Treatment.—In some cases of acute tendinitis, pain is intense and the application of cold packs during this stage is very beneficial in that pain is controlled and inflammation subsides. The extremity may be bandaged with a liberal quantity of absorbent cotton or with woolen material. Ice water is then poured around the bandaged member every fifteen minutes and this should be continued for about forty-eight hours. In some cases this treatment is not necessary for more than twelve hours; at the end of this length of time, pain has subsided and the acute stage of inflammation has passed or its intensity has been diminished.

Following the application of cold packs, the use of a poultice such as some of the sterile, medicated muds, is of marked benefit. The author has made use of tincture of iodin and glycerin in the proportion of one part of iodin to seven parts glycerin, with very satisfactory results. This combination is hygroscopic, anodyne and antiseptic and is easily applied. A liberal quantity is directly applied all around the affected tendons and the leg covered with a heavy layer of cotton, and this is snugly held in position with bandages. The application may be used once or twice daily, or if it is thought necessary, an attendant may pour a quantity of the iodized-glycerin around the leg and under the bandage once daily without removing the cotton and bandage. Needless to say, absolute rest is imperative.

When all evidence of acute inflammation has subsided vesication is indicated. At this stage walking exercise is beneficial and the subject may be allowed the freedom of a paddock.

Some practitioners are partial to the use of the actual cautery in these cases, but it is doubtful if it is necessary to produce such a great degree of counter-irritation in cases where the subject is suffering the first attack of tendinitis.

As has been indicated, ample time should be allowed for recovery and depending upon conditions, it takes from three weeks to six months for complete recovery to become established.

Chronic Tendinitis and Contraction of the Flexor Tendons.

Etiology and Occurrence.—Acute inflammation of the flexor tendons may result in chronic tendinitis. Recurrent attacks in cases where insufficient time is allowed for complete recovery to result, is followed by chronic inflammation and hypertrophy of the tendons. Again, in subjects where conformation is faulty, no amount of care will be sufficient to prevent a recurrence of the inflammation and the condition must become chronic.

Symptomatology.—On visual examination of the subject at rest, one may note the hypertrophied condition of the affected tendons. Their transverse diameter is usually perceptibly increased and in many cases, there is an increase in the antero-posterior diameter. The latter condition causes a bulging of the tendon that is so noticeable, because of the convexity thus formed, it is commonly known as "bowed tendon."



In chronic tendinitis there occurs repeated attacks of inflammation wherein lameness is pronounced and there exists in reality, at such times, acute inflammation of a hypertrophic structure, where at no time does inflammation completely subside. Therefore, in chronic tendinitis there is to be found at times the same conditions which characterize acute inflammation, except that there is usually a variance of symptoms because of the difference in the degree of inflammation and pain.

The diagnosis of contraction of tendons is an easy matter because of the fact that relations between the phalanges are constantly changed with tendinous contraction. If one bears in mind the attachments and function of the digital flexors, no difficulty is encountered in recognizing contraction of either tendon.

Contraction of the superficial digital flexor (perforatus), when uncomplicated, is characterized by volar flexion of the pastern joint. The foot is flat on the ground and the heel is not raised because the superficial flexor tendon does not have its insertion to the distal phalanx (os pedis) and therefore can not affect the position of the foot.

By causing the subject to stand on the affected member, one may outline the course of the flexor tendons by palpation, and in this way recognize any lack of tenseness or contraction of tendons or of the suspensory ligament.



Contraction of the suspensory ligament would cause the pastern joint to assume the same position as is occasioned by contraction of the superficial digital flexor (perforatus) tendon, but when the subject is bearing weight on the affected member, it is easy to determine that no contraction of the suspensory ligament exists, by noting an absence of abnormal tenseness of this structure. And finally, contraction of the suspensory ligament is of rare occurrence.

Contraction of the deep flexor tendon (perforans) causes an elevation of the heel. The foot can not set flat because the insertion of the deep flexor tendon to the solar surface of the distal phalanx (os pedis) causes when the tendon is contracted—a rotation of the distal phalanx on its transverse axis—hence the raised heel. No other tendon has this same effect on the distal phalanx and the condition is correctly diagnosed without difficulty.



Course and Complications.—This condition may exist for years without causing the subject any serious inconvenience, if the affected animal is kept at suitable work. In other instances recurrent attacks of lameness are of such frequent occurrence that the subject is not fit for service. Many affected animals that are kept in service in spite of lameness (and in some instances where no lameness is present), soon become unserviceable because of contraction of the inflamed tendon. This, in fact, is the condition which eventually becomes established in most instances.

Treatment.—Where conformation is not too faulty so that recovery may be expected, good results are obtained by line-firing the tendons and allowing the subject a few months' rest. In some cases median neurectomy is advisable. This is recommended by Breton[25] as being productive of good results even where contraction of tendons exists and tenotomy is done.



By shoeing with high heel-calks considerable strain is taken from the inflamed tendons because of the changed position of the foot which alters the distribution of weight on different parts of the leg. Rubber pads materially diminish concussion and should be made use of when the subject is returned to work, if the character of the work is such as to occasion much concussion.

It is to be remembered, however, that in sprains there occurs fibrillary fracture of soft structures and time is required for regeneration of tissue which has been injured or destroyed. Absolute rest is necessary where inflammation is acute and in sub-acute or chronic tendinitis avoidance of all work which causes irritation to the affected tendons is imperative.



Where contraction of tendons exists surgical treatment is necessary. No good comes from appliances which are calculated to stretch the affected tendons; in fact, they aggravate the inflamed condition and hasten complete loss of function of the affected member. Where there exists no articular or ligamentous diseases which would defeat the purpose, tenotomy is the only remedy for contracted tendons.

Contracted Tendons of Foals.

Etiology and Occurrence.—This condition is occasionally observed and no positive explanation of the reason for its existence can be given. That mal-position en utero causes the metacarpal bones to develop in length so rapidly that the tendons are too short, is an explanation that is offered. Be that as it may, in breeding sections of the country the general practitioner is obliged to handle these cases and successful methods of treatment are essential even though cause is not removable.

Symptomatology.—The superficial flexor tendon (perforatus) alone, is the one usually contracted, and while both flexors are at times involved, this rarely occurs. The condition is usually bilateral.

The degree of contraction varies greatly in different cases. In some, contraction exists to such extent that it is impossible for the colt to stand, and because of continual decubitus where no relief is given, the subject is lost because of gangrenous infection occasioned by bed sores. Otherwise the same symptoms are to be observed in this condition, that exist in contraction of tendons of the mature animal.

Treatment.—Wherever contraction is not too marked and weight is borne with the affected members, and where the feet can be kept on the ground in a nearly normal position, it is possible to correct the condition without doing tenotomy. That is, in cases where the subject is simply "cock-ankled", where volar flexion of the pastern joint exists but the foot is kept flat on the ground, correction is possible without tenotomy.

In such instances the foal must be treated early—before the skin on the anterior pastern region has been badly damaged by knuckling over. It is possible in many cases to stretch the flexor tendons by grasping the colt's foot with one hand, and with the other hand one may push the pastern in the direction of dorsal flexion. This may be tried and when a reasonable amount of force is employed, no harm is done, even though no material benefit results. Some veterinarians claim good results from this treatment alone and direct their clients to repeat the stretching process several times daily.

Whether the tendons are manually stretched or not, splints should be adjusted to the affected members. The legs are padded with cotton and bandages and a suitable splint is applied on either side of the members and securely fixed in position by bandaging.

The splints are kept in position for four or five days and then removed for inspection of the affected parts. If necessary, they are reapplied and left in position for a week; however, this is unnecessary in the average case that is treated in this manner.

Where contraction exists to the extent that the subject can not stand and where no weight is borne by the feet, it is necessary to divide the affected tendons surgically. The same technic is put into practice that is employed in the mature subject but there is much greater chance for a favorable outcome in the foal. Further, if necessary, one may divide with impunity, both tendons on each leg, at the same time. In all cases this operation is done by observing strict aseptic precautions and the legs are, of course, bandaged. If both tendons are divided, splints should be employed and kept in position for ten days or two weeks. Primary union of the small surgical wound of the skin and fascia occurs in forty-eight hours.

The reader is referred to William's "Veterinary Surgical and Obstetrical Operations," for a complete description of this operation.

In veterinary literature there is occasionally described a condition which affects young foals wherein symptoms similar to those of contraction of the flexors are manifested, but upon examination it is found that rupture of the extensor of the digit (extensor pedis) exists. This affection is briefly described by Cadiot but no complete treatise on this condition has been published.

In parts of Canada foals of from one to three days of age are found affected in such manner that more or less interference with the gait is to be seen in those moderately affected. There is, in some subjects, only a slight impediment in locomotion which is occasioned by inability to properly extend the digit. In other subjects, while able to stand and walk, great difficulty is experienced because of volar flexion of the phalanges. The more seriously affected animals are unable to stand and, in most instances, perish because of the effects of prolonged decubitus.

A local enlargement occurs at the anterior carpal region and the mass is somewhat fluctuating, extravasated fluids becoming infected in many instances, and necrosis of the skin and fascia provide means for spontaneous discharge of the contents of the enlargement if it is not opened. The infection when it becomes generalized causes a fatal termination in most cases that are not treated.



Native stock owners of some parts of Canada know this condition as "fish knees" because of the presence of the ruptured end of the extensor tendon which is found coiled in the cavity of the enlargements caused by the ruptured tendon.

Local practitioners have treated the condition by incising the swollen mass and removing the part of tendon contained within such cavities. Treatment has not proved entirely satisfactory in the majority of instances, perhaps because of tardy interference.

In a colt's leg sent the author by Mr. Thomas Millar, M.R.C.V.S., of Asquith, Saskatchewan, a careful dissection of the carpal region revealed the fact that in this case the ruptured extensor tendon was due to injury. The colt may have been trampled upon by its dam in such manner that the tendon was divided. No noticeable evidence of injury to the skin was to be seen on its outer surface, but on the fascial side a cyanotic congested area, which was situated immediately over the site of the ruptured tendon, was very evident.

With the execution of a good surgical technic, the ruptured tendon might be sutured; the wound of the tendon sheath as well as that of the skin carefully united by means of gut sutures, the leg bandaged and immobilized with leather splints and recovery follow in a reasonable percentage of cases so treated. These cases afford an opportunity for the perfection of practical means of treatment by those who frequently meet with this affection.

Rupture of the Flexor Tendons and Suspensory Ligament.

Etiology and Occurrence.—Rupture of the flexor tendons or of the suspensory ligament is of rare occurrence. Frequently, these structures are divided as the result of wounds; but rupture, due to strain, is not frequent.



In some cases in running horses, or in animals that are put to strenuous performances, such as are jumpers, rupture of tendons or of the suspensory ligament takes place. However, more frequently this follows certain debilitating diseases such as influenza or local infectious inflammation of the parts which results in degenerative changes and rupture follows.

The non-elastic suspensory ligament receives some heavy strains during certain attitudes which are taken by horses in hurdle jumping as is explained in detail by Montane and Bourdelle[26] under the description of this ligament. But in spite of the frequent and unusually heavy strains, which these structures receive, complete rupture is not frequently seen.

Symptomatology.—When the anatomy and function of the flexor tendons and suspensory ligament is thoroughly understood, recognition of rupture of either of these structures is easily recognized. When one considers that in rupture, a position directly opposite to that which is seen in contraction in either one of these structures, is assumed, a detailed description of each separate condition is needless repetition.

However, it is pertinent to suggest that rupture of the deep flexor tendon (perforans) allows a turning up of the toe. Whether it be torn loose from its point of attachment or ruptured at some point proximal thereto, the position is the same—heel flat on the ground, toe slightly raised and this raising of the toe varies in degree as the subject moves about.

When the superficial flexor (perforatus) is ruptured there is no change in the position of the foot but the fetlock joint is slightly lowered. The pathognomonic symptom is the lax tendon during weight bearing, which may be felt by palpation of the tendon along its course in the metacarpal region.

With complete rupture of the suspensory ligament there occurs a marked dropping of the fetlock joint and an abnormal amount of weight is then thrown upon the superficial flexor tendon (perforatus), causing it to be markedly tensed. This is readily recognized by palpation. By palpating the suspensory ligament from its proximal portion down to and beyond its bifurcation, while the affected member is supporting weight, it is possible to diagnose rupture of one of its branches.

Prognosis and Treatment.—In rupture of the superficial flexor tendon (perforatus) because of its comparatively less important function, prognosis is favorable and recovery takes place when proper treatment is put into practice.

With rupture of the deep flexor tendon (perforans), especially when it occurs at or near its point of insertion and sometimes following disease, prognosis is unfavorable.

Rupture of the suspensory ligament constitutes a condition which is, as a rule, hopeless, because of the impracticability of treating such cases.

The salient feature which characterizes any practical attempt at treatment of ruptured tendons or other portions of the inhibitory apparatus of the fetlock region, is to retain the phalanges in their normal position for a sufficient length of time that the approximated ends of ruptured tendons or ligaments may unite. The length of time required for this to occur, together with the difficulties encountered in confining the affected extremities in suitable braces or supportive appliances, precludes all possibility of this condition's being practically amenable to treatment when the deep flexor tendon (perforans) and suspensory ligament are simultaneously ruptured. It does not follow, even so, that recovery does not succeed treatment in some of these unfavorable cases.



Affected subjects are kept in slings as long as it seems necessary—until they learn to get up without deranging the braces worn.

Several styles of braces are in use and each has its objections; nevertheless some sort of support to the affected member is necessary and steel braces which are connected with shoes are usually employed.

The principal difficulty which attends the use of braces is pressure-necrosis of the skin which is caused by the constant and firm contact of the metal support. The practitioner's ingenuity is taxed in every case to contrive practical means of padding the exposed parts in order to prevent or minimize necrosis from pressure. This is attempted—with more or less success—by frequent changing of bandages and the local application of such agents as alcohol or witch hazel. Needless to say, the skin must be kept perfectly clean and the dressings free from all irritating substances.



The fact that tendons or ligaments which are ruptured, do not regenerate as readily as in cases where traumatic or surgical division occurs, must not be lost sight of, and prognosis is given in accordance.

Thecitis and Bursitis in the Fetlock Region.

Etiology and Occurrence.—Synovial distension of tendon sheaths and bursae in the region of the fetlock are caused by the same active agencies which produce this condition in other parts. The fetlock region is exposed to more frequent injury than is the carpus and as a consequence is more often affected. The same proportionate amount of irritation affects this part of the leg, owing to strains, as affect the carpus from a similar cause; and synovitis from this cause, is as frequent in one case as in the other. Therefore, it is a natural sequence that the tendon sheaths of the metacarpophalangeal region are frequently distended because of chronic synovitis and thecitis. These inflammations are usually non-infective in character.