History
A 14-year-old 317-kg (698-lb) Icelandic gelding was evaluated for a small laceration caused by trauma sustained from a kick from a pasture mate. On physical examination, all vital signs were within respective reference limits; however, there was a small hematoma over the left hip joint, a small abrasion on the left side of the neck, and a 1-cm laceration over the lateral aspect of the left elbow joint. The laceration was cleaned and bandaged, and the horse was confined to a stall. Phenylbutazone (4.4 mg/kg [2.0 mg/lb], PO, q 24 h for 3 days) was prescribed.
Three days following initial examination, the horse developed an acute grade 4/5 left forelimb lameness. The horse did not react to pressure applied via hoof testers to the left front hoof. The left elbow joint was slightly swollen, and signs of moderate pain were induced by palpation. Crepitus was not evident in the limb. At that time, the horse was also slightly febrile (39.0°C [102.2°F]; reference range, 37.2° to 38.6°C [99.0° to 101.5°F]). Radiographic views of the left elbow joint and adjacent areas were obtained (Figure 1).
Lateromedial (A) and craniocaudal (B) radiographic views of the left elbow joint of a 14-year-old Icelandic horse evaluated for left forelimb lameness.
Citation: Journal of the American Veterinary Medical Association 233, 6; 10.2460/javma.233.6.873
Determine whether additional imaging studies are required, or make your diagnosis from Figure 1—then turn the page →
Radiographic Findings and Interpretation
A fracture of the humeral epicondyle is evident with a small, sharply marginated fragment displaced slightly caudodistally (Figure 2). Soft tissue swelling and an emphysematous tract leading from the skin wound toward the elbow joint are visible. An additional flexed proximocaudal-distocaudal radiographic view enables visualization of the fracture and localizes it to the lateral epicondyle (Figure 3). A small amount of debris is evident on the skin of the lateral portion of the elbow and may contribute to the irregular lateral margin of the fragment.
Same lateromedial radiographic view as in Figure 1. Notice the small caudally displaced fracture of the lateral humeral epicondyle (white outline) and the soft tissue swelling with emphysematous tract (white arrow).
Citation: Journal of the American Veterinary Medical Association 233, 6; 10.2460/javma.233.6.873
Flexed proximocaudal-distocaudal radiographic view of the left elbow joint. The lateral epicondylar fracture is more noticeable in this view (white arrow).
Citation: Journal of the American Veterinary Medical Association 233, 6; 10.2460/javma.233.6.873
Comments
On the basis of the history and clinical examination and radiographic findings, a diagnosis of a caudodistally displaced lateral humeral epicondylar fracture was made. The possibility of joint sepsis was ruled out on the basis of results of bacterial culture and cytologic examination of aseptically collected synovial fluid. Treatment included distention of the joint with sterile saline (0.9% NaCl) solution, administration of potassium penicillin (22,000 U/kg [10,000 U/lb], IV, q 6 h) and gentamicin sulfate (6.6 mg/kg [3.0 mg/lb], IV, q 24 h) for the skin wound and associated regional cellulitis, flunixin meglumine (1.1 mg/kg [0.5 mg/lb], IV, q 12 h) to decrease the associated inflammation, and ranitidine hydrochloride (6.6 mg/kg, PO, q 8 h) to prevent the formation of gastric ulcers. With conservative treatment of stall rest and administration of anti-inflammatory medications and antimicrobials, the lameness resolved and the horse was discharged in 14 days. On recheck radiography performed 2 and 6 weeks later, the fracture appeared to remain quiescent and without formation of a sequestrum.
Most humeral fractures are incurred by a traumatic event such as a fall or a kick. Any fracture to the humerus may be hard to detect by palpation, and crepitus may not be evident because of the extensive muscle tissue surrounding the bone.1 In another report2 of a lateral humeral epicondylar fracture in a horse, surgical removal of the bone fragment was performed to reduce the risk of degenerative joint disease and sequestrum formation. Septic arthritis was also diagnosed in that horse, making the prognosis slightly more guarded than the horse of the present report. On the basis of the outcome of the horse of this report, conservative treatment appears to be an option for some horses with humeral epicondylar fractures. Removal of the fracture fragment is not always necessary if the wound heals, a draining tract does not remain, and a bony sequestrum does not form.
The flexed proximocaudal-distocaudal radiographic view is useful to further localize the area of the fracture. In the horse of this report, this view helped definitively localize the fracture to the lateral humeral epicondyle. From the lateromedial view, it is impossible to determine whether the lateral or medial aspect of the humerus has been fractured. The flexed proximocaudal-distocaudal view also aids in monitoring fracture healing. New bone formation can be easily visualized by use of this view to help the clinician judge when the fracture is completely healed.
- 1.↑
Whitton RC, Hodgson DR, Rose RJ. Musculoskeletal system. In: Rose RJ, Hodgson DR, eds. Manual of equine practice. 2nd ed. Philadelphia: WB Saunders Co, 2000;95–185.
- 2.↑
Mitchell C, Riley CB. Evaluation and treatment of an adult quarter horse with an unusual fracture of the humerus and septic arthritis. Can Vet J 2002;43:120–122.
