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Flashcards in Soft Tissue Trauma Deck (91)
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What conditions present true veterinary emergencies?

- Respiratory distress
- Neurological abnormalities
- Bleeding from body orifices
- Rapid, progressive abdominal distension
- Dystocia
- Collapse
- Extreme pain
- Fractures
- Severe wounds
- Urinary obstruction
- Persistent vomiting
- Toxin ingestion


Outline the advice that should be given to an owner in case of a veterinary emergency

- Encourage bringing to practice ASAP
- Need to protect the spine (lift gently on rigid board)
- Place in confined space if suspect fracture to minimise movement
- Direct pressure on active haemorrhage
- Calm owner before transport, ensure know the route


Outline the criteria for a P1 (top priority) emergency case

- History of head or spinal trauma
- History consistent with internal injuries
- Life threatening haemorrhage (chest, abdomen worst)
- Cardiorespiratory compromise
- Diagnose based on history, observation and physical examination
- Re-assess -cardiovascular function can deterioratem, CNS signs may become more obvious


What action is required for a P1/top priority emergency case?

Immediate action, high risk of death


Outline the criteria for P2 emergency cases

- Do not move, need stabilisation prior to moving e.g. fracture, tendon rupture/laceration, joint instability, vascular or neurological damage
- Esp. important for large animals


Outline the criteria for P3 emergency cases

- Require urgent attention, but may not be immediately life threatening
- Synovial involvement (can wait 24-48hrs)
- Bony involvement
- Contaminated wounds


Outline the criteria for P4 emergency cases

- Delayed action
- Do not require emergency treatment or urgent action
- Must rule out all previous problems, be prepared to evaluate findings and diagnosis
- Explain to owner what to look for in case of deterioration


In an emergency case, outline the initial assessment of the patient

- If lame, assess degree, appearance of limb may not match up with degree of lameness
- Conformation/gross abnormalities
- Location and discharge from wound
- Degree of blood loss
- Contamination


Outline what should be investigated in the physical examination of an emergency case

- Presence/absence of crepitus
- Degree of contamination
- Soft tissue involvement
- Bony involvement
- Swellings and effusions


List and justify the diagnostic tests that should be included in the assessment of an emergency case

- Radiogrpahy esp. traumatic injury, abdo and thoracic, assess cardioresp., diaphragm, bladder, pelvis
- Ultrasonography (AFAST, assess effusion, haemorrhage, bladder trauma)
- Synoviocentesis if synovial involvement
- PCV/TP to assess blood loss later in disease progression
- Assessment of other body system function using haematology, biochem, urinalysis esp. if may need surgery
- +/- MRI, CT, gamma scintigraphy


Identify the key features of first aid for acute trauma/wounds

- Control haemorrhage
- Control pain
- Reduce contamination
- Bandaging wounds
- Wound closure
- Splinting of fractures/tendon injuries


How can haemorrahge be controlled in acute trauma/wounds?

- Pressure (bandage or manual)
- Tourniquet
- Ligatures for large vessels


What are the components of analgesia in acute trauma/wound cases?

- +/-Opioids (NOT cattle/ruminants)
- Splinting/bandaging to prevent movement of limbs
- +/- sedation


List the NSAIDs that can be used in trauma cases for dogs

- Robenacoxib
- Meloxicam
- Carprofen


List the NSAIDs that can be used in trauma cases for cats

- Robenacoxib
- Meloxicam
- Ketoprofen


List the NSAIDs that can be used in trauma cases for horses

- Flunixin meglumine
- Meloxicam
- Ketoprofen


List the NSAIDs that can be used in trauma cases for cattle

- Ketoprofen
- Meloxicam


What conditions would containdicate the use of NSAIDs in an acute trauma/wound case?

- Hypovolaemia
- Severe haemorrhage
- Renal/liver compromise


List the opioids that can be used in acute trauma/wounds in dogs

- Methadone
- Buprenorphine
- Fentanyl


List the opioids that can be used in acute trauma/wounds in cats

- Methadone
- Buprenorphine


List the opioids that can be used in acute trauma/wounds in horses

- Butorphanol
- Buprenorphine
- Morphine


What is a potential complication when using opioids in horses?

- Can lead to excitation, combine with alpha 2 agonist to reduce this
- Pethidine will lead to horse becoming completely uncontrollable


What are the potential risks when using opioids in acute trauma/wound cases?

- Respiratory depression
- Bradycardia
- NB: Do not let this stop you using them!


How can wound contamination be reduced in an emergency case?

- Gross decontamination
- Clipping
- Lavage
- Antiseptics
- Debridement
- KY jelly in wound


List the different categories of wound closure, and identify the factors that underlie the decision making process

- Primary closure, delayed primary closure, delayed secondary closure, second intention healing
- Depends on contamination, ability to appose wound edges, degree of dead space below


Briefly outline splinting of fractures in emergency cases

- Depends on region, in SA, proximal limb fractures difficult to splint
- Splint the joints above and below
- Open fractures must be splinted
- Robert Jones adequate for distal limb fractures
- Do not pull exposed tissue back through skin


What are the main functions of applying bandages in acute trauma/wound cases?

- Reduces fluid accumulation
- Reduces contamination
- Reduces movement
- Prevents dehydration


What are the potential consequences of incorrect bandaging?

- Tissue maceration and infection
- Continued contamination
- Sloughing of new epithelialisation
- Continued pain for the patient
- Impairment of vascular supply


What are the key client considerations in decisions regarding equine wounds?

- Prognosis for athletic function
- Prognosis for pasture soundness
- Cost
- Duration of box rest
- Time out of work
- Amount of nursing required


Which equine injuries carry a poor prognosis for recovery?

- Compound, open fractures with significant contamination of soft tissue
- Complete fractures involving the femur, humerus and tibia
- Complete lacerations of SDFT, DDFT, SL
- Complete laceration of SDFT, DDFT and distal sesamoidean ligaments


What are the 2 broad categories of soft tissue injuries?

- Percutaneous
- Overstrain


What is the key determinant of prognosis for percutaneous soft tissue injuries?

Location and degree of damage


In which locations do percutaneous injuries carry a worse prognosis?

Palmar/platar aspect injuries worse, more difficult to heal


How do overstrain soft tissue injuries occur?

- Overload leading to breakdown of structure
- Can be acute onset overload or chronic condition


Compare the incidence of chronic and acute overstrain soft tissue injuries and briefly explain this

- acute onset overload: overwhelm tensile strength
- Chronic: more common, microdamage progressing to degree where structure breaks down in one event


Which tendons are most commonly affected by soft tissue injury in horses?

- SDFT (esp. race horses)


Which tendons are most commonly affected by soft tissue injury in dogs?

Tendons of achilles and biceps brachii


Which ligaments are most commonly affected by soft tissue injury in horses?

- Suspensory ligament (proximal suspensory desmitits, esp. dressage)
- Suspensory branch desmitits


Which ligaments are most commonly affected by soft tissue injury in dogs?

- Cruciate stifle ligaments
- Collateral ligaments


Which questions are relevant to the investigation of a horse with suspected tendon or ligament disease>

- Duration of problem?
- Onset, and signs at onset?
- Exacerbation of problem?
- Presenting signs?
- Response to treatment?


Outline the clinical evaluation of a horse with suspected tendon or ligament disease

- Evaluate stance/posture
- Palpate limbs with animal standing for swelling, heat, pain on palpation
- Lift limb and palpate when soft tissue relaxed
- Lift contralateral limb
- Check ROM


What injury is indicated by hyperextension of the fetlock in a horse (sunken fetlock)?

Marked injury of suspensory apparatus/suspensory ligament


What commonly occurs in the contralateral limb following recovery from soft tissue injury, and explain why?

- Both limbs will have experienced same stresses/forces throughout life, when one is injured, likely that the other also has subclinical disease
- Will likely suffer strain/rupture once back in exercise


What injury is indicated in a horse with a sunken fetlock where the toe is also off the ground?

SDFT and DDFT dysfunction


What injury is indicated in a horse with a collapsed fetlock and toe off the ground?

SDFT, DDFT, SL dysfunction


What injury is indicated in a horse with knuckling that is not a result of neurological condition?

Extensor tendon dysfunction


Which imaging modalities are of use with non-emergency soft tissue injuries

- Ultrasound
- Radiography
- Arthroscopy/tenoscopy/bursography


What are the advantages of ultrasonography in the investigation of soft tissue injuries?

- Good for soft tissue assessment
- Good for bony surface assessment e.g. for avulsions
- Quick and easy
- portable unit
- GA not needed
- Oedema of soft tissue injury provides excellent contrast


What are the weaknesses of ultrasonography in the investigation of soft tissue injuries?

- Expensive equipment
- Experience in interpretation needed
- 2D images obtained


Justify the use of radiography in the investigation of soft tissue injuries

- Primary soft tissue injury may have bony involvement e.g. avulsion injury, esp. with suspensory ligament
- Allows assessment of joint angles


Justify the use of MRI in the investigation of soft tissue injuries

- Distal limb especially useful
- Fast evaluation of of acute injuries


What are the most common indications for use of arthroscopy, tenoscopy or bursography in the investigation of soft tissue injuries?

- More chronic management
- Or acute cases with wounds that may have resulted in septic processes in joint


When should ultrasonography of soft tissue injuries be carried out and why?

- Repeat ~7 days after injury in order for fibres to become more destroyed by proteinases, macrophages, more oedema will be present allowing better contrast
- Allows assessment of full extent and progression of damage


What ultrasonographic features may change with soft tissue injury?

- Echogenicity
- Cross sectional area
- Fibre alignment
- Margins of the structure
- Shape of the structure
- Location of the structure


What soft tissue injury is most likely to cause the following clinical signs?
Heat and pain on palpation of the palmar metacarpal region of the equine limb, bowed appearance of the palmar metacarpus, vascular engorgement, lameness

Superficial digital flexor tendonitis


What may be found on palpation of the metacarpal region of a limb with SDF tendonitis?

- Thickened SDFT
- Soft swelling of the SDFT (change in texture, more spongy)
- Pain on gentle pinching


Describe the common ultrasound findings in a case of superficial digital flexor tendonitis

- Core lesions most common
- Transverse: loss of normal echogenicity depending on stage of disease, increased cross sectional area
- Longitudinal: loss of normal parallel fibre alignment, and lesions of mixed echogenicity, shorter fibres


Compare the echogenicity of acute, subacute and chronic superficial digital flexor tendonitis lesions

- Acute: anechoic (filled with blood)
-Subacute: hypoechoic
- Chronic: hyperechoic areas


Give the approximate severity, time out of training and prognosis for return to racing for an SDFT lesion where the total lesion CSA/total tendon CSA = 0-15%

- Mild severity
- 10 months out of training
- 63% prognosis for return to racing


Give the approximate severity, time out of training and prognosis for return to racing for an SDFT lesion where the total lesion CSA/total tendon CSA = 16-25%

- Moderate severity
- 11 months out of training
- 30% prognosis for return to racing


Give the approximate severity, time out of training and prognosis for return to racing for an SDFT lesion where the total lesion CSA/total tendon CSA = >25%

- Severe
- 18 months out of training
- 23% prognosis return to racing


Outline the value of ultrasonography in monitoring the progression of SDFT injury

- Used for management of re-initiation of training and intensity
- re-scan before increasing/changing exercise
- Re-scan every 2-3 months and before any change in exercise
- If >10% increase in CSA, reduce exercise level


Compare the occurrence of particular tendon injuries depending on the work done by the horse

- SDFT rupture more common in racehorses
- Suspensory ligament rupture more common in dressage or show jumpers


Describe the normal ultrasonographic appearance of the suspensory ligament

Heterogenous due to presence of ligamentous fibres, muscle fibres and fat


Describe the diagnosis of proximal suspensory ligament desmitis in the hindlimb of a horse

- Rare to palpate swelling/heat as is deep to other soft tissue structures and surrounded by fascia
- Pain on deep palpation
- Diagnostic analgesia and imaging findings (ultrasound +/- MRI)
- Usually present with lameness, uni or bi lateral


Describe the diagnosis of proximal suspensory ligament desmitits in the forelimb

- Radiography may indicate small zone of sclerosis, indicating origin lesion of suspensory ligament
- Ultrasound


Discuss the prognosis for proximal suspensory desmitis

- Forelimb: good
- Hindlimb: acute desmitis reasonable prognosis
- Chronic: poor, improves with treatment


List the treatment options for chronic suspensory desmitis

- Extracorporeal shockwave therapy
- Fasciotomy and neurectomy


What signs would be seen with suspensory branch desmitits in the horse?

- Palpable pain
- Peri-ligamentous heat
- Peri-ligamentous and ligamentous swelling
- Variable lameness


Outline the diagnosis of suspensory branch desmitis in the horse

- History, physical examination
- Ultrasonography (most useful), MRI (possible, usually not needed)


What commonly develops with chronic suspensory branch demitis?

Peri-ligamentous fibrosis


Describe the method for, and typical ultrasonographic appearance with suspensory branch desmitits

- Brnaches are on lateral and medial aspects of the limb, image these directly
- Distorted, disrupted appearance
- Central anechoic region
- In longitudinal view will see areas of disruption and hyperechogenicity


For which conditions is extracorporeal shockwave therapy particularly useful?

Enthesious problems (where tendons/ligaments inert onto bone)


Discuss the prognosis of suspensory branch demitis

- Reasonable, but recurrence common
- Chronic desmitis carries worse prognosis
- PRP and stem cell treatment may improve prognosis


What conditions would the following signs be suggestive of?
Swelling in proximal metacarpal region, pain on palpation, heat, vessel engorgement, lameness variable, acute onset lameness usually with fetlock flexural deformity

- Desmitis of the ALDDFT
- Desmitis of the SDFT
- Distinguish by distribution of swelling - ALDDFT more proximal, SDFT causes bowing


Describe the ultrasonographic appearance of desmitis of the ALDDFT

- Increased CSA
- Loss of normal fibre pattern
- Loss of normal contour


Which tendon is the one most commonly injured within the digital flexor tendon sheath?



What are the 2 types of tenosynovitis of the digital flexor tendon sheath?

- Primary (usually associated with some kind of injury)
- Or secondary


Which structures run through the digital flexor tendon sheath that commonly cause secondary tenosynovitis and how does this occur?

- Pathology of soft tissue structures running through the sheath leads to inflammation of sheath
- Superficial digital flexor tendon
- Deep digital flexor tendon
- Manica flexoria
- Palmar annular ligament


What are the functions of tenoscopy?

- Diagnostic value
- Therapeutic value


What are the key features in the treatment of tenosynovitis of the digital flexor tendon sheath?

- Intrasynovial anti-inflammatories e.g. steroids, hyaluronic acid
- Tenoscopy


Discuss lesions of the DDFT that occur further distally in the foot (diagnosis and treatment)

- Increasingly recognised as a cause of lameness
- Impossible to use ultrasound through the keratinised hoof wall - MRI required
- Treatment options: rest, farriery, intrabursal/intraarticular medications
- Bursoscopy


What emergency treatment should be used where flexor tendon dysfunction is suspected?

Bandage limb and apply palmar or dorsal splint, or Kimsey splint


What emergency treatment should be used where extensor tendon dysfunction is suspected?

Bandage and dorsal splint


Outline the emergency treatment of all tendon/ligament injuries

- Stabilise limb, restore biomechanical function by creating alignment of single bony column and reduce pressure on soft tissues
- Local wound care
- Antibiotics and anti-inflammatories


Briefly describe the characteristics of healed tendons

- Stiffer than normal tendons as tendons fibrose rather than regenerate
- Less efficient energy store leading to poorer performance due to limited elastic energy storage


Outline the acute phase treatment of tendon/ligament injury in the horse

- Physical therapy: cold, compression, rest
- Medical: NSAID analgesia e.g. phenylbutazone and anti-inflamm, steroids controversial (can be used short term to reduce initial inflammation)


Outline the subacute phase treatment of tendon/ligament injury in the horse

- Fibroplasia phase
- Mobilisation: early and progressive, train tenocytes back to normality, passive manipulation if on box rest, mobilisation from 7-14 days onwards ideally
- Monitor with ultrasonography (CSA, fibre pattern)


Outline the chronic phase treatment of tendon/ligament injury in the horse

- Remodelling
- Controlled ascending excercise
- Ultrasonographic monitoring


Outline some examples of treatment options for tendinitis

- Stem cells (mesenchymal stem cells), must be used in acute phases
- Platelet rich plasma - provides biological scaffold as well as containing cytokines, proinflamm growth factors etc. that may promote healing


Outline how tendonitis can be prevented

- Maximise quality of tendon prior to skeletal immaturity (tendon training of immature horses)
- Reduce degeneration after skeletal maturity (avoid tendon training)
- Reduce risk factors for tendonitis (decreased speed, fatigue, jumping, weight, improve ground surface, shoeing)
- Detect tendonitis early with ultrasound and structure training around this