Introduction
Phalangeal fractures in cattle can be divided by etiology into those that are pathological (ie, secondary to normal physiologic stressors applied to weakened bone) or nonpathological (ie, secondary to supraphysiologic stressors, most often trauma, applied to normal bone). In our experience, pathological fractures of the proximal and middle phalanges are uncommon and are usually associated with septic physitis in juvenile bovines or occasionally wound-induced phalangeal osteomyelitis. Nonpathological fractures of the proximal and middle phalanxes are rarely reported. In cattle, fractures of the distal phalanx are most commonly pathological and associated with septic pedal osteitis secondary to advanced sole ulcers, toe ulcers, white line disease, or septic arthritis of the distal interphalangeal joint.1,2,3,4,5,6,7,8 Less commonly, fractures of the distal phalanx occur secondary to impaired mineralization, as has been reported with fluorosis.9 Avascular necrosis of the apex of the distal phalanx may develop as a complication of laminitis and result in pathological fracture.8 Nonpathological fractures of the distal phalanx in cattle are well characterized and described in textbooks.10,11,12
Pathological phalangeal fractures that are associated with infection typically have gross evidence of local inflammation, and draining tracts are frequently present to direct clinicians toward radiographic imaging in animals of high value. For most pathological phalangeal fractures, removal of the infected bone, whether by digit amputation or debridement of affected tissue, is the foundation of treatment.4,5 Therapy to restore the affected digit, although possible, is associated with a guarded prognosis and considerable expense.13
Nonpathological phalangeal fractures are seldom associated with substantial swelling, have less evidence of crepitus than most other types of lower limb fractures, and are associated with varying degrees of lameness owing to the animal’s ability to transfer weight from the affected digit to the adjacent unaffected (sound) digit. Thus, diagnosis of nonpathological fractures in cattle can be challenging. The veterinary literature contains little data about the outcome for cattle with nonpathological (traumatic) phalangeal fractures. The literature that is available is limited to descriptions of fractures of the distal phalanx,14 fractures of the extensor process or flexor tubercle of the distal phalanx,15,16 and 2 reports17,18 regarding management of comminuted fracture of the proximal phalanx.
In cattle, application of a hoof block to the adjacent unaffected digit is commonly used to manage painful conditions of the affected digit. However, the effectiveness of hoof block application for the treatment of phalangeal fractures in nondairy cattle has not been reported. The objective of the study reported here was to characterize the history, clinical findings, and outcomes for cattle with nonpathological phalangeal fracture that were examined and treated at a veterinary teaching hospital. We hypothesized that application of a hoof block to the adjacent unaffected digit, with or without a distal limb cast, would be an acceptable means for treatment of phalangeal fractures in beef and performance (rodeo) cattle.
Materials and Methods
Case selection criteria
Medical records of the Oklahoma State University Boren Veterinary Medical Teaching Hospital were searched to identify cattle that were treated for phalangeal fractures between May 2004 and May 2020. Search terms used included phalan*, P1, P2, P3, pastern, coffin bone, and fracture. To be included in the study, a bovine had to have a radiographically confirmed fracture of the proximal, middle, or distal phalanx. Cattle were excluded from the study if the phalangeal fracture was deemed pathological in nature secondary to a septic process, such as a penetrating wound, physitis, or deep digital sepsis.
Medical records review
For each study-eligible animal, data collected included signalment (breed, age, reproductive status, intended use), body weight, and body condition. Other information collected included history, results of physical and orthopedic examinations (including lameness score), radiographic findings, treatment, and outcome. Increased heat was noted if the affected digit was subjectively warmer than the unaffected digits, and increased swelling was noted if the affected digit or adjacent soft tissue was subjectively larger than the unaffected digits. Pain was assessed by the application of hoof testers or percussion to the sole of the hoof and was noted if those procedures resulted in a withdrawal response of the affected limb. Abnormal foot placement was recorded if the animal stood or walked with the affected limb abducted to reduce weight bearing on a lateral digit, adducted to reduce weight bearing on a medial digit, or placed cranially to reduce weight bearing on the heel region. Lameness was scored on a scale of 1 to 5 as described,19 where a lameness score of 2 was considered mild lameness (ie, animal assumes an arched-back posture while walking) and a score of 5 was considered severely lame (inability or extreme reluctance to bear weight on at least 1 limb). Follow-up information was obtained from the medical record or via telephone communication with the owner 4 months to 16 years following discharge of the patient from the teaching hospital.
Statistical analysis
Descriptive statistics (mean ± SD, median, and range) were generated by use of a commercially available spreadsheet program (Excel; Microsoft Corp). A Fisher exact test20 was used to compare the breed distribution between bucking and nonbucking stock within fracture groups.
Results
Cattle
Thirty-four cattle with a phalangeal fracture were treated at the veterinary teaching hospital during the observation period. Seventeen cattle were subsequently excluded from the study owing to a presumptive diagnosis of a phalangeal fracture without radiographic confirmation (n = 6) or a phalangeal fracture in the presence of a septic process (ie, pathological phalangeal fracture; 11). Thus, only 17 cattle were included in the study. The study population included 5 bucking bulls, 2 Hereford bulls, 1 Hereford cow, 2 Angus cows, 1 Angus bull, 2 Maine-Anjou cows, 1 Milking Shorthorn cow, 1 Holstein cow, 1 Brahman bull, and 1 crossbred beef cow. At the initial examination for the phalangeal fracture, the study population had a mean ± SD age of 3.7 ± 1.6 years (range, 1 to 7 years) and weight of 657 ± 164 kg (range, 408 to 1,088 kg; Table 1).
Descriptive data for 17 cattle with nonpathological phalangeal fractures that were treated at a veterinary teaching hospital between May 2004 to May 2020.
Variable | No. of animals | Mean ± SD | Median (range) |
---|---|---|---|
Age (y) | 17 | 3.7 ± 1.6 | 3.4 (1–7) |
Body weight (kg) | 12 | 657 ± 164 | 641 (408–1,088) |
Body condition score* | 9 | 4.8 ± 0.9 | 5 (3–5) |
Duration of clinical signs (d) | 14 | — | 9 (0–91) |
Duration of first hospital stay (d) | 17 | — | 0 (0–17) |
Lameness score† | 11 | 4 ± 0.8 | 4 (2–5) |
No. of visits | 17 | 2 ± 1 | 1 (1–4) |
Scored on a scale of 1 to 9, where 1 is emaciated and 9 is morbidly obese.
Scored on a scale of 1 to 5, where 1 is normal (not lame) and 5 is severe, 3-legged lameness.
Patient history
The history and physical examination findings were unavailable for 1 bucking bull. The phalangeal fracture occurred while the animal was on pasture and unobserved (n = 10), following a bull fight (2), while bucking (1), or at an unknown time (4; Supplementary Table S1). Six animals were administered antimicrobials (products and doses not recorded) by the owner prior to presentation at the teaching hospital.
Physical examination findings
All fractures were closed with no evidence of skin or hoof wall penetration, and there was no radiographic evidence of gas associated with any of the fractures. For the 16 cattle for which physical examination findings were available, the most common findings included lameness (n = 14), swelling of the affected digit (11), abnormal foot placement (6), heat (6), and signs of pain when the affected digit was compressed with hoof testers (5) or percussed (3). A lameness score was recorded for 11 animals; 1, 1, 6, and 3 animals were assigned a lameness score of 2, 3, 4, and 5, respectively.
Diagnosis
Ultrasonography was used to make a preliminary diagnosis of distal phalanx fracture prior to radiographic evaluation in 2 animals. Among the 17 study cattle, 7 animals had 8 distal phalanx fractures and 10 animals had 11 proximal phalanx fractures. One cow had a fracture of the medial distal phalanx of both forelimbs. One cow had a fracture of the proximal phalanx of both digits of the right forelimb. One cow had a fracture of the medial proximal phalanx and metatarsal bone of the left hind limb. Fracture of a middle phalanx was not identified in any of the cattle.
All 11 proximal phalanx fractures and 1 of the 8 distal phalanx fractures were described as comminuted. A lameness score was assigned to 7 of the 11 animals with comminuted phalangeal fractures (1 cow had 2 comminuted proximal phalangeal fractures); 1, 3, and 3 animals were assigned a lameness score of 3, 4, and 5, respectively. The remaining 7 distal phalanx fractures were described as noncomminuted. A lameness score was assigned to 4 of the 6 animals with noncomminuted phalangeal fractures (1 animal had 2 noncomminuted distal phalangeal fractures); 1 and 3 animals were assigned a lameness score of 2 and 4, respectively. All fractures were intra-articular in nature. All 11 proximal phalanx fractures (Figures 1 and 2) involved the proximal interphalangeal joint (PIPJ), with 2 proximal phalanx fractures also involving the metacarpophalangeal joint. Seven of 8 distal phalanx fractures were transverse midbody fractures that extended from the solar margin to the center of the distal interphalangeal joint. The remaining distal phalanx fracture was comminuted with transverse and oblique fractures. Four of the 5 bucking bulls had a chronic fracture of the proximal phalanx as determined by radiographic evidence of callus formation at the fracture site during the initial examination. Bucking bulls were overrepresented in the group of animals with proximal phalanx fractures (P = 0.04).
Treatment
Interventions included foot trimming, hoof block placement, distraction of the limb to facilitate fracture reduction, and distal limb cast application. Five animals were administered analgesia as necessary during hospitalization. Analgesics administered included meloxicam (n = 4), flunixin meglumine (1), gabapentin (1), and morphine (1). Of the 17 cattle evaluated, 15 had a hoof block applied with adhesive to the unaffected digit of the affected foot, and 7 were additionally treated with placement of a distal limb cast (Supplementary Table S1). For a bucking bull with a chronic (64-day history of lameness) fracture of the lateral proximal phalanx of the right hind limb, treatment was limited to foot trimming, with the hoof of the medial digit left approximately 7.5 mm longer than the hoof of the affected digit to reduce weight bearing on the fractured digit. The hoof of the affected digit was trimmed by use of trimmers and a grinder to reduce solar contact with the ground and decrease the breakover point. Hoof blocks were composed of either wood or plastic (Easy Bloc; Demotec), with a reduced breakover point to help prevent flexor tendon laxity. Distal limb casts were composed of fiberglass, encased the entire foot, and extended to the level of the proximal metacarpus or metatarsus. The number of casts applied per animal varied from 1 (n = 5 animals), to 2 (1 animal), to 3 (1 animal). The cow with a fractured metatarsal bone in addition to a fractured lateral proximal phalanx of the left hind limb was treated with a transfixation pin cast. For the 8 animals that were treated with casts, the duration of cast immobilization ranged from 4 to 16 weeks (median, 6 weeks; mean, 7.3 weeks), and hoof blocks were maintained on the unaffected digit for 4 weeks after cast removal. All owners were advised to confine the animal to a stall or pen after hospital discharge.
Outcome
Sixteen of the 17 animals survived to hospital discharge. The cow with comminuted fractures of the proximal phalanx of both digits of the right forelimb was euthanized immediately after diagnosis. Follow-up information was obtained from the medical record for 3 animals, with follow-up times ranging from 4 months to 4 years after initial examination. The owners of 12 animals were contacted by telephone, and follow-up information was obtained for 9 of those animals.
Follow-up information was available for 3 of the 5 bucking bulls examined. Two bulls returned to performance bucking (including performing at the National Finals Rodeo), and 1 was used successfully as a breeding bull. However, 2 of those 3 bulls had some residual lameness.
One Angus bull with fracture of the lateral distal phalanx of the right forelimb successfully returned to the breeding herd. A Milking Shorthorn cow with fracture of both medial distal phalanges of the forelimbs returned to full milk production and was culled 3 years later because of reproductive issues. A Brahman bull with fracture of the lateral proximal phalanx of the left forelimb had complete resolution of lameness and was sold as a successful breeding sire. An Angus cow with fracture of the lateral proximal phalanx of the left hind limb successfully returned to the breeding herd with mild residual lameness. A Maine-Anjou cow with concurrent fracture of the lateral proximal phalanx and the third metatarsal bone remained within the breeding herd for at least 5 years following initial presentation. A Hereford bull with fracture of the lateral distal phalanx of the right forelimb was lame for 3 months after hospital discharge and was culled. That was the only animal of the present study that was treated for a phalangeal fracture and subsequently culled because of lameness associated with that fracture.
The time spent in the herd following hospital discharge ranged from 3 months to 6 years. The outcome was considered favorable for 3 of the 5 animals with distal phalanx fractures and a known outcome. All 5 of those animals were treated with the application of a hoof block to the unaffected digit of the affected foot, and 1 had a distal limb cast applied in addition to the hoof block. That animal was the Hereford bull that was culled after 3 months because of unresolved lameness. The outcome was considered favorable for 6 of the 8 animals with proximal phalanx fractures and a known outcome. Among the 6 animals with a favorable outcome, 2 (both bucking bulls with chronic fractures) were treated with only the placement of a hoof blook on the unaffected digit of the affected foot, 3 were treated with a distal limb cast in addition to the hoof block, and 1 with a concurrent fracture of the third metatarsal bone was treated with a transfixation pin cast in addition to the hoof block. The 2 animals with proximal phalanx fractures that had an unfavorable outcome included the aforementioned bucking bull that underwent foot trimming only and the Hereford cow with fractures of both proximal phalanges of the right forelimb that was euthanized immediately after diagnosis.
Discussion
All cattle with nonpathological phalangeal fractures evaluated in the present study had moderate to marked lameness at initial presentation to the teaching hospital. Of the 7 animals with distal phalanx fractures, 3 had a favorable outcome (ie, returned to function or remained productive in the herd) following treatment by the application of a hoof block to the unaffected digit of the affected foot only; the outcome was unknown for 2 others and unfavorable for the remaining 2, of which 1 was treated with both a hoof block and distal limb cast. Three of the 4 animals with acute fracture of the proximal phalanx had favorable outcomes following the application of a hoof block and distal limb cast; the remaining animal was euthanized immediately after diagnosis. The prognosis for return to function was less clear for animals with chronic fracture of the proximal phalanx. Of the 7 animals with chronic (≥ 14 days) or unknown duration of lameness and proximal phalanx fracture, 2 had a favorable outcome following treatment with a hoof block only, 1 had a favorable outcome and 3 had an unknown outcome following application of a hoof block and distal limb cast, and 1 had an unfavorable outcome following hoof trimming only.
For the cattle with phalangeal fractures evaluated in the present study, the most common clinical signs were marked lameness and abnormal foot placement, which were consistent with findings reported in other studies.14,16,17 Differential diagnoses for severe digital lameness in cattle include subsolar abscess, sole ulcer, synovial sepsis, interdigital necrobacillosis, digital dermatitis, and fracture.21 For patients with distal phalanx fractures specifically, the other primary differential diagnoses are subsolar abscess and sole bruise, wherein severe lameness is present with little to no swelling above the hoof capsule. Heat and swelling of the affected digit were inconsistent findings in the cattle of the present retrospective study, although that might have been a reflection of negative reporting. Many of the phalangeal fractures assessed in the present study appeared to be chronic on the basis of history of lameness or radiographic evidence of callus formation at the fracture site, and it is possible that the heat and swelling of acute inflammation may have abated by the time the animal was initially examined at the teaching hospital. The elicitation of signs of pain during application of hoof testers or percussion of the hoof was also an inconsistent finding for the cattle of the present study. This was in contrast to a report16 of cattle with fractures involving the extensor process of the distal phalanx, in which a localized pain response was consistently elicited. In dairy heifers and cows with fractures of a distal phalanx, the application of hoof testers to the affected hoof consistently elicited signs of pain in animals with recent onset of lameness, but signs of pain were elicited less consistently in animals with chronic lameness.14 The chronicity of lameness for the cattle of the present study was most likely the reason many of the study subjects did not have signs of pain when hoof testers were applied to the affected foot. For patients in which lameness arising from a foot is still suspected despite a negative response to the application of hoof testers, the use of a 4-point nerve block or regional IV perfusion of a local anesthetic22 may be useful for localizing the lameness.23
Fluid distension of the joint was not reported for any of the cattle of the present study, which was in contrast to findings of a review of horses with distal phalanx fractures.24 Although the lack of joint effusion for the cattle of this study may reflect a lack of reporting rather than a true absence, cattle have thicker skin than horses, which may hinder the detection of mild joint effusion.25
Definitive diagnosis of closed phalangeal fractures is most readily achieved with radiographic examination. At our teaching hospital, diagnostic imaging is limited for most cattle examined for lameness and when an obvious source is not identified owing to their limited financial value as commercial production animals. Consequently, the incidence of phalangeal fractures in cattle is likely underreported. Of the 5 bucking bulls included in the present study, only 1 was reportedly bucking at the time when the phalangeal fracture occurred. For the remaining 4 bucking bulls, the duration of lameness was unknown but was a minimum of 2 weeks, and all 4 bulls had evidence of callus formation at the fracture site. Ultrasonography can be used to identify phalangeal fractures and has been described in hydrated bovine specimens obtained from a slaughterhouse26; however, its use is limited to assessment of the bony surface and for evaluation of the progression of callus formation.27 Furthermore, in our clinical experience, ultrasonographic imaging of the distal phalanx through the sole of mature beef cattle is difficult without markedly thinning the sole, which may put the animal at risk of developing osteitis and subsequent pathological fracture.3,7 Further investigation into the relative thickness and moisture content of the solar tissue, and hence ability to acquire diagnostic ultrasound images, is warranted for beef cattle.
In racehorses, phalangeal fractures occur most commonly in conjunction with repetitive stress injury, leading to predictable locations and configurations.28 Repetitive stress injury may contribute to the development of proximal phalanx fractures in performance bucking bulls because that type of animal was overrepresented in the present study. For cattle maintained on pasture, phalangeal fractures likely result from a supraphysiologic loading event, such as stepping on uneven ground, mounting behavior, or kicking at a hard surface.
Neither a sex nor age predilection was identified in association with either proximal or distal phalangeal fractures for the cattle of the present study. Those findings were in contrast to results of radiographic study29 of foot disorders in cattle, in which the majority (32/40 [80%]) of phalangeal fractures occurred in male animals and 28 of 40 (70%) affected animals were ≥ 4 years.
In the present study, a forelimb was affected in 6 of the 7 cattle with distal phalanx fractures, which might be associated with the fact that, for cattle, the forelimbs bear a greater proportion of the animal’s weight than do the hind limbs.30 Five of the 8 distal phalanx fractures assessed in this study occurred in the right forelimb. In free-ranging cattle, distal phalanx fractures have been reported to be more common in the medial digit of a forelimb.10 For the 7 cattle with distal phalangeal fracture of the present study, the fracture occurred in a lateral digit (5 fractures) of all 5 beef cattle and a medial digit (3 fractures) of the 2 dairy cows. The reasons for that disparity remain unknown but may be associated with differences in the housing and activity of beef and dairy cattle. In a case series report14 of 16 dairy heifers and cows with distal phalanx fractures, a medial forelimb digit was affected in all 16 animals, with 8 animals sustaining bilateral fracture of the medial digit. Only 1 of the 2 dairy cows evaluated in the present study had a distal phalanx fracture of the medial digit in both forelimbs.
For the 10 cattle with 11 proximal phalanx fractures evaluated in the present study, 6 of the fractured digits occurred in a forelimb and 5 occurred in a hind limb. Five of the 10 cattle with proximal phalanx fractures were bucking bulls, and the lack of predilection for proximal phalangeal fractures that occurred in forelimbs versus hind limbs may have been associated with the activity of these animals. Presumably, the hooves of both the forelimbs and hind limbs of bucking bulls sustain large ground reaction forces during bucking events. In the present study, all hind limb proximal phalanx fractures occurred in the lateral digit. A similar predilection for fractures of the lateral digit in the hindlimb has been reported in housed cattle with distal phalanx fractures.31 These findings may be explained by the fact that, in cattle, the lateral digit of the hind limb is larger and bears more weight than the medial digit.10
The middle phalanx was not fractured in any of the cattle of the present study. Middle phalanx fractures are rare in cattle,10 perhaps because the middle phalanx is smaller and less mobile than the proximal phalanx and does not sustain the direct ground reaction force received by the distal phalanx. One report29 from India described middle phalanx fractures in 7 bovids, but it was unclear whether the affected animals were cattle or other bovidae. That study28 also appeared to include animals with nonpathological and pathological (ie, animals with concurrent or underlying septic processes) fractures.
In the present study, all 16 cattle with phalangeal fractures that received treatment were managed conservatively. Phalangeal fractures that are managed conservatively may require 6 to 12 months to achieve bony union, with union progressing from the solar margin to the articular surface in fractures of the distal phalanx.11 Conservative treatment is appropriate for most cattle with phalangeal fractures, and the use of adhesive to apply a hoof block to the unaffected adjacent digit may result in immediate resolution of lameness.14,16 The distal phalanx is encased within the hoof capsule, which generally provides sufficient protection and stability to the bone such that cast application may not be necessary. The protection provided by the hoof capsule may also be the reason fractures of the distal phalanx are less likely to be comminuted than are fractures of the proximal phalanx. In the present study, 6 of the 10 animals with proximal phalanx fractures were managed by the application of a distal limb cast in addition to a hoof block. We believe that the addition of a distal limb cast is indicated for proximal phalanx fractures in cattle for several reasons. Compared with fractures of the distal phalanx, fractures of the proximal phalanx are more likely to be comminuted, and casting provides stability and protection of fracture fragments to promote healing. Additionally, the proximal interdigital ligaments limit independent movement of the proximal phalanges; thus, stabilization of both the medial and lateral proximal phalanges is necessary to minimize the mobility of the fracture fragments. Transfixation pin casts have been used as an alternative to distal limb casts for stabilization of proximal phalanx fractures in cattle.18 A transfixation pin cast was used to stabilize a proximal phalanx fracture in 1 animal of the present study; this animal remained in the breeding herd at follow-up obtained 5 years later.
Only 5 of the 17 cattle evaluated in the present study received analgesic medications. In our clinical experience, simply alleviating weight bearing on the affected digit provides substantial pain relief. Analgesics were administered in accordance with the attending clinician’s preference. Owing to the retrospective nature of this study, the reasons for the lack of analgesic administration were unknown. Additionally, most animals of the present study that received analgesia were examined during the latter half of the study period, and the provision of analgesics to those animals may have reflected changing attitudes toward analgesia in food animals.
The outcome was known for 13 of the 17 animals evaluated in the present study and was favorable for 9. The large proportion of animals with favorable outcomes in the present study was in agreement with findings of other studies involving cattle with phalangeal fractures. In 1 report,14 follow-up was performed for a cow with bilateral medial distal phalanx fractures for 18 months, at which time the hooves of the medial digits were 1.5 cm longer at the toe than the hooves of the adjacent lateral digits. The authors postulated that the overgrowth of hoof at the toes of the fractured digits may have resulted from a reduction of wear from a lack of weight-bearing owing to the application of a hoof block on the adjacent digit.14 A bull with a distal phalanx fracture and large osteolytic lesion that underwent surgical debridement and an autogenous cancellous bone graft was intermittently non–weight-bearing and abducted the limb for 5 months after surgery.23 However, that aberrant behavior resolved coincident with radiographic evidence of fracture healing, and the bull resumed breeding cows in a pasture environment.23 The effect of healed phalangeal fractures on the weight-bearing dynamics and hoof horn growth of cattle requires further investigation. Only 1 animal of the present study was euthanized immediately following diagnosis; that cow had severely comminuted fractures of both the medial and lateral proximal phalanges of the right hind limb. Although the reason for euthanasia was not recorded in the medical record, it could be speculated that the cost of treatment, which would likely include a transfixation pin cast, may have exceeded the financial value of the animal.
Limitations of the present study were those typical of retrospective studies and included missing information in the medical records, particularly with respect to the clinical findings at hospital presentation, detailed treatments (eg, wiring of digits in flexion), and owner recall bias. Results of the present study suggested that the outcome for cattle with nonpathological fracture of a proximal or distal phalanx can be good with the application of a hoof block to the unaffected adjacent digit to minimize weight bearing on the fractured digit while it heals. Cattle with proximal phalanx fractures may benefit from the application of a hoof block in combination with a distal limb cast to help stabilize the fracture. Issues that warrant further investigation include other treatments and management strategies that may affect the outcome in cattle with nonpathological phalangeal fractures and the role of repetitive stress injury in the development of traumatic long bone fractures in performance bucking bulls.
Supplementary Materials
Supplementary materials are posted online at the journal website: avmajournals.avma.org
Acknowledgments
The authors declare that there were no conflicts of interest.
The authors thank Dr. Jared Taylor for assistance with statistical analysis.
References
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