Practical guide of arthrocentesis in the horse

p r a c t i c a l

g u i d e

o f

Lameness is a usual problem both in sport and leisure horses. The aetiology of this problem can be very varied but in most cases it is due to alterations in joints, periarticular tissues and other synovial structures. A good knowledge of the anatomy of all these structures is therefore essential in the veterinary clinical approach.

This Practical Guide of Arthrocentesis in the horse provides all the necessary information about joints as well as the appropriate resources to reach an accurate diagnosis and be able to perform the necessary therapeutic punctures.

High-quality drawings and clear and concrete texts make this book an indispensable resource in equine clinical practice.

ARTHROCENTESIS IN THE

Miguel Gimeno Domínguez Jesús Laborda Val Julio Gil García Javier Nuviala Ortín

HORSE

Arthrocentesis in the horse

Practical guide of

ARTHROCENTESIS IN THE

HORSE

III

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Warning Veterinary science is constantly evolving, as are pharmacology and the other sciences.

Inevitably, it is therefore the responsibility of the veterinary clinician to determine and verify the dosage, the method of administration, the duration of treatment and any possible contraindications to the treatments given to each individual patient, based on his or her professional experience. Neither the publisher nor the author can be held liable for any damage or harm caused to people, animals or properties resulting from the correct or incorrect application of the information contained in this book.

This book has been published originally in spanish under the tittle: Guía práctica de artrocentesis en el caballo. © 2002 Text and photographies: Miguel Gimeno Domínguez, Jesús Laborda Val, Julio Gil García y Javier Nuviala Ortín.

For this english edition: © 2012 Grupo Asís Biomedia, S.L. Plaza Antonio Beltrán Martínez nº 1, planta 8 - letra I (Centro empresarial El Trovador) 50002 Zaragoza - Spain Design and layout: Servet editorial - Grupo Asís Biomedia, S.L. www.grupoasis.com Printed in Spain

Practical guide of Arthrocentesis in the Horse

Authors: Miguel Gimeno Domínguez Jesús Laborda Val Julio Gil García Javier Nuviala Ortín

Collaborators: Ignacio Guarda Ricardo Olivares Pérez-Montt We are grateful to D. Ángel Hernando Barrado for his help in the writing of this work.

Authors Miguel Gimeno Domínguez Professor of Anatomy Faculty of Veterinary Medicine University of Zaragoza

Jesús Laborda Val Professor of Anatomy Faculty of Veterinary Medicine University of Zaragoza

Julio Gil García Professor of Anatomy Faculty of Veterinary Medicine University of Zaragoza

Javier Nuviala Ortín Graduate in Veterinary Medicine Faculty of Veterinary Medicine University of Zaragoza

Collaborators: Dr. Ignacio Guarda Dr. Ricardo Olivares Pérez-Muntt

3

Forelimb

Table of contents Overview 1. Overview of the limbs of the horse

Forelimb 2. Visible and palpable bony prominences of the forelimb 3. Subcutaneous bursae of the forelimb 4. Shoulder joint 4.1. Arthrocentesis of the shoulder joint 4.2. Puncture of the subtendinous infraspinatus bursa 4.3. Puncture of the intertubercular or bicipital bursa 5. Elbow joint 5.1. Arthrocentesis of the elbow joint 5.2. Puncture of the olecranon bursa (subcutaneous olecranon bursa) 6. Carpal joints 6.1. Arthrocentesis of carpal joints 7. Joints of the digit 8. Metacarpophalangeal joint or fetlock joint 8.1. Arthrocentesis of the metacarpophalangeal joint or fetlock joint 9. Proximal interphalangeal joint or pastern joint 9.1. Arthrocentesis of the proximal interphalangeal joint or pastern joint 10. Distal interphalangeal joint of coffin joint 10.1. Arthrocentesis of the distal interphalangeal joint or coffin joint 10.2. Puncture of the navicular or podotrochlear bursa

4

Arthrocentesis in the horse

Hindlimb 11. Visible and palpable bony prominences of the hindlimb 12. Subcutaneous bursae of the hindlimb 13. Hip joint 13.1. Arthrocentesis of the hip joint 13.2. Puncture of the trochanteric bursa 14. Stifle joint 14.1. Femorotibial joint 14.2. Arthrocentesis of the stifle joint 14.3. Puncture of the lateral cavity of the femorotibial joint 14.4. Puncture of the medial cavity of the femorotibial joint 14.5. Puncture of the femoropatellar joint 15. Foot joints 15.1. Arthrocentesis of the tarsal joint 15.2. Puncture of the distal intertarsal joint 15.3. Puncture of the tarsometatarsal joint 15.4. Puncture of the subtendinous bursa of the medial tendon of the tibialis cranialis muscle or “cunean� bursa

5

Forelimb

6. Carpal joints The carpus is the proximal end of the autopodium (hand), and is formed by eight bones that have three articular planes:

Hand

• Radiocarpal or antebrachiocarpal joint, between the distal ends of the radius and ulna and the proximal carpal row.

• Intercarpal joints, between the proximal and distal carpal rows.

• Carpometacarpal joint, between the distal carpal row and the metacarpus.

Synovial cavities

The joint cavity is divided into three compartments, one between the distal ends of the radius and ulna and the proximal carpal row, one between the proximal and distal carpal rows, and the third one between the distal carpal row and the proximal end of the metacarpus. The proximal one is independent, but the middle and distal ones are often connected with each other.

Retinacula

The fibrous membrane of the dorsal or cranial carpal surface is very thick and resistant, and covers the tendons of the extensor muscles of the carpus and digit, thus forming the extensor retinaculum of the carpus. The palmar fibrous membrane adapts to the palmar surface of the carpus and forms the cranial aspect of the carpal tunnel. The flexor retinaculum is a fibrous band, independent from the joint capsule, which joins the accessory bone to the medial carpal bones (radial carpal and second carpal). The carpal tunnel is a space bounded laterally by the accessory bone, cranially by the fibrous membrane of the joint

Carpal tunnel

capsule of the carpus, and caudally and medially by the flexor retinaculum.

Carpal ligaments: Styloid processes

• Lateral collateral ligament. It consists of two parts: one superficial and the other deep. The deep one joins the lateral styloid process (ulna) to the ulnar carpal, fourth carpal and metacarpal III bones. The superficial one connects the lateral styloid process (ulna) with the head of the metacarpal IV bone.

• Medial collateral ligament. It also has two parts: one superficial and the other deep. The deep one joins the medial styloid process (radius) to the radial carpal, second carpal and metacarpal III bones. The superficial one connects the medial styloid process (radius) with the head of the metacarpal II bone.

6

Arthrocentesis in the horse

1

5

6

4

2

3 3

4

1 2

5

Right carpus.

Medial view.

Left carpus.

Proximal view of the proximal row.

1. Accessory carpal bone.

1. Carpal tunnel.

2. Radial carpal bone.

2. Flexor retinaculum.

3. Third carpal bone.

3. Accessory bone.

4. Second carpal bone.

4. Ulnar carpal bone.

5. First carpal bone.

5. Intermediate carpal bone.

6. Radial carpal bone.

1 8

7

6

9 7 8

5 3

Right carpus.

Lateral view.

Left carpus.

Distal view of the distal row.

6. Ulnar carpal bone.

7. Second carpal bone.

7. Intermediate carpal bone.

8. Third carpal bone.

8. Fourth carpal bone.

9. Fourth carpal bone.

View of the right forelimb. The accessory bone has been removed.

7

Forelimb

Ligaments of the accessory carpal bone

Ligaments of the accessory carpal bone: they join this bone to the neighbouring bones: ulna, ulnar carpal, fourth carpal and metacarpal bones:

• Accesorioulnar ligament.

• Accesoriocarpoulnar ligament.

• Accesorioquartal ligament.

• Accesoriometacarpal ligament.

The small metacarpals II and IV articulate palmarly with the metacarpal III. The articular surfaces are facets located on the palmar aspect of the metacarpal III and on the cranial aspect of the metacarpals II and IV. The interosseous spaces between the small and large metacarpals are occupied by the dorsal and palmar metacarpal ligaments. In many horses aged between 3 and 5 years, the metacarpal ligaments undergo inflammation, especially the ligament between the metacarpal II and III bones, which gives rise to a painful swelling; after a time, the inflammation subsides and a small raised area remains due to the exostosis formed by irritation of the periosteum.

Exostosis

Movements: the normal position of the carpal joint is the extension position. The movements are exclusively extension and flexion. The movement is performed mainly between the proximal row and the radius, and a little less between the two carpal rows. The movement between the distal row and the metacarpus is virtually nonexistent. During hyperextension of the hand, such as in rapid motion, the cranial edges of the carpal bones approach each other and may break into become fragments inside the joint (“chip fractures”).

Chip fractures

8

Arthrocentesis in the horse

3

Right carpus. Lateral view.

1. Superficial part of the lateral collateral ligament.

2. Deep part of the lateral collateral ligament.

7 4 1

3. Accesorioulnar ligament.

4. Accesoriocarpoulnar ligament.

5

5. Accesorioquartal ligament.

7 6

6. Accesoriometacarpal ligament.

2

7

7. Intercarpal ligaments.

8. Intermetacarpal ligament.

8

9

Forelimb

6.1 Arthrocentesis of carpal joints For a perfect analgesia of the carpal joint, two punctures have to be carried out, a proximal one for the antebrachiocarpal or carpo-radial cavity, and a distal one for the intercarpal and carpometacarpal cavities.

Proximal puncture of the carpus

The antebrachiocarpal or carpo-radial joint must be injected with the carpus flexed, in order to expand the space between the radius and the proximal carpal row. The injection site is a small depression which can be located either lateral or medial to the tendon of the extensor carpi radialis muscle. If the lateral puncture is chosen, care should be taken not to perforate the tendon of the extensor digitalis communis muscle. As the surfaces of the carpal bones form an angle with the horizontal, it is advisable to direct the needle in a proximal direction in order not to damage the articular cartilage. A 20 G x 1 inch needle (25 x 0.9 mm) can be used, injecting 10 ml of anaesthetic.

Distal puncture of the carpus

The intercarpal and carpometacarpal joints can be anaesthetised by two different routes. One is similar to that described for the carpo-radial joint with the carpus flexed, the needle being placed between the proximal and distal rows of the carpal bones. The other one is on the palmar aspect, and can be done taking advantage of the palmar recess of the joint cavity, the needle being placed distal and lateral to the accessory bone. During this puncture the horse’s carpus must be in extension (the horse must be standing). In both cases, a 20 G x 1 inch needle (25 x 0.9 mm) can be used, injecting 10 to 15 ml of anaesthetic.

10

Arthrocentesis in the horse

1 Dorsal proximal arthrocentesis of carpus.

2 Palmar proximal arthrocentesis of carpus.

3 Distal arthrocentesis of carpus.

1

2

3

1

2

3

11

Forelimb

7. Joints of the digit All the ligaments of the digit are located on the aspect that is palmar or caudal to the axis of rotation of the joints: metacarpophalangeal, proximal interphalangeal and distal interphalangeal joints.

All the ligaments of the digit prevent extension

This arrangement of the ligaments of the digit prevents hyperextension; moreover, due to the position of the collateral ligaments (they are attached caudally to the axis of rotation), rotation cannot be performed. The only way of rotating the digit is by forcing this movement when it is flexed.

8. Metacarpophalangeal joint or fetlock joint Formed by the joint between the metacarpus and the proximal phalanx and the joint between the metacarpus and the palmar proximal sesamoid bones.

The joint cavity is shared by the two joints. It has dorsal and palmar recesses, the palmar one extending proximally and reaching the level of the small metacarpal bones.

Dorsal and palmar synovial recesses

Ligaments of the metacarpophalangeal joint: • Lateral collateral ligament: it connects the tuberosities of the distal end of the metacarpus with the tuberosities of the proximal end of the first phalanx. • Medial collateral ligament: it joins the tuberosities of the distal end of the metacarpus to the tuberosities of the proximal end of the first phalanx.

Ligaments of the metacarposesamoidal joint: • Intersesamoid ligament: a very resistant membrane joining the axial or flexor surfaces of the palmar proximal sesamoid bones. The tendons of the flexor digitalis superficialis and flexor digitalis profundus muscles slide over this ligament.

12

Arthrocentesis in the horse

1

1

Right fetlock 4

1. Distal carpal row.

2. Tendon of extensor digitalis communis muscle.

2

3. Interosseus medius muscle (suspensory ligament).

3

4. Metacarpal III.

5

5. Distal check ligament (metacarpal head of flexor digitalis profundus muscle).

6. Distal sesamoid ligaments.

7. First phalanx (pastern).

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6 6

7

2

Right fetlock

3

1. Metacarpal IV.

2

1 4

2. Metacarpal III. 3. Proximal sesamoid.

4. Lateral collateral sesamoid ligament.

5. Lateral collateral ligament.

3

4

6. Short lateral sesamoid ligament.

5

Palmar synovial recesses of the digit.

1. Metacarpophalangeal or fetlock synovial recess.

2. Proximal interphalangeal synovial recess.

7. First phalanx (pastern).

6 7

3. Distal interphalangeal synovial recess.

4. Navicular or podotrochlear bursa.

13

p r a c t i c a l

g u i d e

o f

Lameness is a usual problem both in sport and leisure horses. The aetiology of this problem can be very varied but in most cases it is due to alterations in joints, periarticular tissues and other synovial structures. A good knowledge of the anatomy of all these structures is therefore essential in the veterinary clinical approach.

This Practical Guide of Arthrocentesis in the horse provides all the necessary information about joints as well as the appropriate resources to reach an accurate diagnosis and be able to perform the necessary therapeutic punctures.

High-quality drawings and clear and concrete texts make this book an indispensable resource in equine clinical practice.

ARTHROCENTESIS IN THE

Miguel Gimeno Domínguez Jesús Laborda Val Julio Gil García Javier Nuviala Ortín

HORSE