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Cardinio

Cardinio. Cardino. 9yo Holsteiner , eventing LF lameness, acute onset 6mo previous rDVM 2.5/5 lame LF Positive carpal flexion Intercarpal and proximal suspensory blocks US PSD, medial lobe Scintigraphy WNL Tx Stall rest IA corticosteroids Shock wave Refractory.

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Cardinio

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  1. Cardinio

  2. Cardino • 9yo Holsteiner, eventing • LF lameness, acute onset 6mo previous • rDVM • 2.5/5 lame LF • Positive carpal flexion • Intercarpal and proximal suspensory blocks • US • PSD, medial lobe • Scintigraphy • WNL • Tx • Stall rest • IA corticosteroids • Shock wave • Refractory

  3. Lameness evaluation • Moderate III/V LF lameness at baseline trot • Hard and soft surface • Positive carpal flexion • Regional anesthesia

  4. MRI examination (3/17/11) left right

  5. MRI examination (3/17/11) left right

  6. MRI examination (3/17/11) left right

  7. AL-DDFT • The AL-DDFT originates from the thick fibrous tissue on the palmaraspect of the carpus and joins the DDFT at the proximal third of the metacarpus • Continuation of the palmar carpal ligament with additional fibers originating from the palmar aspect of the third and fourth carpal bones. • Fibrous bundles course from the AL-DDFT to the SDFT • may predispose to adhesions in horses with severe desmitis of the al ddft or tendonitits of the sdft • In some limbs there are fiber bundles between the lateral aspects of the AL-DDFT and the DDFT (verified by dissection and MRI- Dyson 2010) • No bundles were seen in any limbs between the medial aspects of AL-DDFT and either the DDFT or the SDFT • Differentiation between abaxial adhesions between the SDFT and the AL-DDFT and the flexor retinaculum or the palmar neurovascular structures may be difficult.

  8. The AL-DDFT is loaded and prevents overstretching of DDFT by passively carrying the load during maximal extension of the coffin and fetlock joints • when the MCP joint angle reaches 240°, the AL-SDFT, AL-DDFT and SL support the fetlock joint as much as the SDF and DDF muscles. • While standing, the AL-DDFT functions as part of the stay apparatus • The AL-DDFT has a low modulus of elasticity (most inelastic component of the deep digital flexor muscle/tendon unit) and a moderate strength to rupture • the DDFT has a high modulus of elasticity and more than 3 times the strength to rupture

  9. Age-related changes in the mechanical properties of the AL-DDFT have been described and failure forces of the AL-DDFT in older horses were significantly lower than in younger horses • Degenerative changes predispose to injury, commonly in middle-aged and older horses, resulting in acute onset of lameness with localized soft tissue swelling, heat and pain on palpation • common in ponies , Warmbloods and general purpose riding horses • Thoroughbreds relatively underrepresented.

  10. Prognosis may be guarded • With rest and rehabilitation, the reported prognosis for return to work varies from 16%-75% • 75% when treated with desmotomy (WSU, 3.2011) • recurrence is high • Injuries to the AL-DDFT may have concurrent tendonitis of the SDFT or adhesions between AL-DDFT and DDFT or SDFT • Decreased prognosis • Adhesions to adjacent structures can form during healing • treat to minimize adhesion formation or consider surgical resection.

  11. Nagy and Dyson, 2010 • Describe MR characteristics of AL-DDFT in sound horses • Excluded one limb b/c AL-DDFT larger and had higher signal intensity than expected • Three other limbs excluded b/c CSA too large based on clinical experience • The AL-DDFT usually had intermediate signal intensity compared with flexor tendons or the collagenous part of the suspensory ligament, with or without higher signal intensity bands • Collagen bundles of the AL-DDFT are more loosely arranged and more obliquely oriented compared with the DDFT • may account for its higher signal intensity. • The margins of the AL-DDFT often could not be clearly seen because of the similar signal intensity of the surrounding connective tissue, especially medially. Slight irregularity of the margins was seen occasionally, but moderate or severe irregularity was not recorded in any horses. This suggests that more than slight irregularity of the margins may be of clinical significance.

  12. AL-DDFT

  13. Treatment for Proximal Suspensory Injuries • Prolonged R&R • PRP/BM • Neurectomy

  14. Blocks • PD often worsens • Low 4-pt may diffuse • Medial approach to lateral palmar • Decreases risk of blocking middle carpal or carpal canal • IA MC improves 60% horses

  15. Imaging • Radiography • Rarely avulsions or palmar cortical stress fx • Scintigraphy • 25% sensitivity in pool phase as diagnosed by US • 12% sensitivity in bone phase as diagnosed by US • Use when pain larger than expected

  16. Treatment • Acute • 90% return with 3mo R&R • Chronic • Shock wave • 53% back to full work at 6mo • Desmoplasty • 75-43% • Bone marrow, stem cell • Neurectomy • Ulnar • Lateral palmar • DBLP

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