Pe OECD y eg Oe ur taag sin) Je yaleTABLE OF CONTENTS PART 1: JOINT INJECTION Introduction and Uses Preparation ofthe Site .. Management of the Horse .. General Technique Injection Strategies Complications Coffin .. 4 Dorsal, Perpendicular Dorsal, Parallel Lateral wicular Bursa astern Dorsal... Palmar/Plantar ....... Fetlock Palmar/Plantar Pouch Collateral Sesamoidean Dorsal Digital Synovial Sheath Corpus... Dorsal Lateral 6 7 8 8 10 10 12 4 16 18 20 220 a 24 26 28 30 34 34 36 Elbow Lateral Caudal Shoulder . Bicipital Bursa Distal Proximal Hock Tarsometatarsa Distal Interarsal Tibiotarsal . stifle Z Femoropatellar, Cranial Femoropatellar Lateral Femorotibial, Lateral & Medial Femorotibial, Medial Compartment, Medial Outpouching Hip Sacroiliac Joint Cervical Facet Joint Temporomandibular Joint References, PART 2: REGIONAL NERVE BLOCKS Introduction and Uses in of the Site Prepara Management of the Horse General Technique Forelimb Nerve Blocks Hindlimb Nerve Blocks Injection Strategies Complications Forelimb Nerve Blocks Palmar Digital Nerve Pastern Semi-Ring, Abaxial Sesamoid Low Palmar About the Authors ma 78 78 80 80 RES High Palmar Lateral Palmar . E Median, Ulnar, and Medial . Cutaneous Antebrachial Hindlimb Nerve Blocks High Plantar 3 Tibial and Peroneal (Fibular) Other Nerve Blocks Maxillary Infraorbital Mandibular Mental Pudendal References gee sobs Seb b BBe 2 S2e BRE 100 100 102 104 106 108 110Dedicated to special friends who have helped along the way Gordon Brumbaugh, DVM, PhD G. Kent Carter, DVM. Mike Coker, CF], DVM. Fred DeGraves, DVM, PhD Ron Genovese, VMD Charles Graham, DVM Ger Kelly, MVB David Hanselka, DVM Charles W. Raker, VMD Michael Schramme, Dr.med.vet Leon Scrutchfield, DVM. Fred Schmidt, DVM. Harry Werner, VMD Musteations by Felecia Paras, Biomedical Visuals ‘The authors wish to thank G, Kent Carter, DVM (College Station, Texas) for his help and encouragement inthe preparation of this publication. pea | Lk ee signed and Published by Veterinary Learning Systems, 780 Township Line Rd, Yardley, PA 19067 Copyright ©2007 by Veterinary Learning Systems a division of MediMesia USA All ight teserved. Printed inthe USA. ARR RAA AA AR ARPA AAAKey DECC ed Eas any 6 Carpus oa 9 Coffin BUNT 11 Sacroiliac Joint etfs INJECTIONINTRODUCTION AND USES Arthrocentesis, a procedure used to administer drugs or collect synovial fluid, is a valuable technique for localizing pain during a lameness examination and for treating horses with joint disease. Improvements in the efficacy of intraarticularly admin- istered medications and in surgical techniques used to treat horses with joint disease have placed increased importance on intraarticular analge- sia to precisely localize the site of pain during lameness examination. Al- though many clinicians may be reluc- tant to perform arthrocentesis because they fear introducing sepsis or caus- ing injury, the procedure is rarely associated with complications when performed properly. Using arthrocentesis to localize the site of lameness involves relatively lit tle expense, and the results are usual- ly straightforward and easily inter- preted. To perform arthrocentesis, however, a thorough working know!- edge of joint anatomy, an apprecia- tion of aseptic technique, and skill in restraining horses are required. Practical Applications of Arthrocentesis Some practical applications of arthrocentesis in horses are to: + Administer medication, such as so- dium hyaluronate, corticosteroids, antibiotics, or polysulfated glyco- saminoglycans * Verify or negate intraarticular pain as the cause of lameness. Intraar- ticular anesthesia is more precise than regional anesthesia in localiz~ ing pain. * Collect synovial fuid for examina- tion. Analysis of synovial fluid can range from gross inspection of the fluid to sophisticated examinations that include cultures to identify pathogens, physical or chemical tests, or microscopic examination using a light or electron micro- scope.!? ‘+ Administer a radiographic contrast medium or electrolyte solution to determine, by radiographic or visual examination, whether a syn- vial structure communicates with a nearby wound. * Provide both entry and exit portals in joints requiring lavage.“* The most common of these apy cations of arthrocentesis is to admin- ister a local anesthetic solution into the joint. Mepivacaine hydrochloride is the local anesthetic agent preferred by most clinicians because, compared with lidocaine hydrochloride, itis rel- atively nonirritating to tissue and induces relatively long-acting intraar- ticular anesthesia (about 90 minutes). A long duration of anesthesia is ad- vantageous when multiple sites of Jameness are being investigated. Intraarticular Versus Regional Anesthesia Intraarticular anesthesia is often more precise and useful than regional anesthesia in establishing diagnostic information for several reasons. The location and distribution of sensory nerves in horses vary consid- erably; therefore, the clinician cannot be certain, after administering region- al anesthesia, that a specific area has been anesthetized (i, blocked) Testing the efficacy of a regional nerve block by testing for lack of skin th a pointed instrument, sensation such as a toothpick, ballpoint pen, or car key, is questionable because it ver- ifies only that the skin has been desensitized. The clinician cannot be certain, therefore, that after adminis- tering regional anesthesia, a joint hasbeen blocked. Direct instillation of a local anesthetic agent into a joint, on the other hand, leaves little or no doubt that intraarticular structures are anesthetized. A regional nerve block may not adequately localize the source of pain responsible for lameness. In addition to desensitizing articular structures, a successful regional nerve block desensitizes a multitude of extraartic: ular structures, such as ligaments, tendons, tendon sheaths, subcuta- neous tissue, and extraarticular bone. Intraarticular anesthesia is more useful than regional anesthesia when the clinician attempts to establish the significance of multiple clinical or radiographic findings on a limb of a horse. An excellent and common example is a horse that has radio. graphic evidence not only of disease of the fetlock joint but also of extra- articular disease of the proximal sesamoid bones and proliferative and degenerative changes of the pastern joint. The use of regional anesthesia in this horse does not allow pain to be selectively localized so that the contri- bution of each lesion to lameness can be accurately assessed. Without pre- cise assessment of the contribution of each lesion to lameness, selecting an ideal therapy and establishing an accurate prognosis are difficult. Regional nerve blocks occasionally create temporary gait abnormalities, which can cause injury by interfering with proprioception, For example, blocking the superficial and deep per- oneal nerves and the tibial nerve in the gaskin region can cause a horse to stumble because the horse lacks pro- prioception in the blocked limb. Extensive subcutaneous adminis- tration of local anesthetic solution can cause subcutaneous inflamma- ion, swelling, and even skin necrosis. Many horses resent a regional block more than a joint block because a regional block often requires multi- ple injections, A regional nerve block does not allow the examiner the opportunity to examine synovial fluid of a joint suspected to be the source of lame- ness, Examination of synovial fluid, both grossly and microscopically, may provide “one more piece” to the diagnostic puzzle. Even though instillation of a local anesthetic solution into a joint or bursa is more precise than regional anesthesia in pinpointing the site of pain, diffusion of local anesthetic solution from some joints or bursae into surrounding joints or adjacent nerves may make interpretation of the effects of intrasynovial administration of local anesthetic solution difficult. For instance, local anesthetic solution injected into the tarsometatarsal joint may result in perineural anesthesia of the dorsal metatarsal and plantar metatarsal nerves.’ The plantar meta- tarsal nerves are often desensitized t0 diagnose disease of the proximal por- tion of the suspensory ligament, Anesthesia of the coffin joint also anesthetizes the navicular apparatus’ and the toe region of the sole." Anes- thesia of the navicular bursa also anesthetizes the toe region of the sole PREPARATION OF THE SITE Most clinicians clip or shave the hair at the site of arthrocentesis, but we prefer not to unless the hair makes identification of landmarks difficult The presence of hair does not appear to inhibit the ability of an antiseptic soap to effectively reduce bacteria to an acceptable concentration for arthrocentesis.” The site of arthro- centesis should be thoroughly scrubbed with an antiseptic soap,such as polyhydroxydine solution (Xenodine), povidone-iodine (Beta dine), or chlorhexidine (Nolvasan), for a total contact time of 7 minutes or longer. The last application of antiseptic soap should not be rinsed until the clinician is ready to insert the needle. At that time, the area should be liberally sprayed or wiped with 70% isopropyl alcohol until itis free of soap. Excess alcohol should be wiped away with a sterile gauze sponge or a gloved hand. If a rel- atively large-bore (e.g., 18-gauge) needle is to be used, subcutaneous injection of a small amount of local anesthetic solution using a small- bore (e.g., 25-gauge) needle may help diminish resentment by the horse when the large-bore needle is inserted, MANAGEMENT OF THE HORSE Methods of restraining the horse for arthrocentesis vary with the antici- pated and actual behavior of the horse, the availability of experienced help, the environment, and the spe- cific joint to be entered. The clinician should anticipate problems rather than assume that the procedure will be trouble free. An experienced assistant should control the horse by using a lead shank and nose twitch. Usually, a needle-shy horse is identified as such because of its well-established history of behav- jor. A truly dangerous horse poses a risk to both the clinician and itself, By changing the environment, the veteri- narian can usually provide conditions suitable for work on a dangerous horse. A slow, quiet approach is best. Some clinicians prefer restraining a fractious horse in a stock to minimize personal risk, but a stock can be a danger to the horse. Chemical restraint, achieved by ad- ministering acetylpromazine, xyla- zine, detomidine, or detomidine or xylazine in combination with mor- phine or butorphanol, can help con- trol horses that cannot be handled by physical restraint alone. Tranquiliza~ tion or sedation of @ lame horse may not affect the grade of lameness. Ifthe joint is injected with a local anesthetic solution, the effects of which last longer than those of the sedative, the horse can be examined after the effects of sedation have dissipated. Performing arthrocentesis in a poor environment can potentially complicate the procedure and in- crease the risk of error or injury. The environment in which the procedure is to be performed should be inspect- ed carefully. A dusty area increases the likelihood of introducing an infection, and a crowded area, filled with distractions, such as people, equipment, extraneous noise, and other horses, increases the likelihood. that an accident will occur GENERAL TECHNIQUE The single most important factor for successful placement of a needle within a joint is an accurate apprecia- tion of relevant anatomy. If the clini- cian infrequently performs arthro- centesis of a particular joint, the anatomy of the region of that joint should be reviewed. The clinician should strive for performance that is quick and successful at the outset because multiple attempts at arthro- centesis increase the likelihood of failure as well as injury to both the horse and the clinician, Adequate preparation helps prevent or mini- mize most problems. The joint and the site of entry determine the position of the clinicianrelative to the horse and whether the injection is performed with the limb bearing weight or held. The bore and length of the needle depend on the particular joint being injected and the size of the horse. Handling the shaft of the needle and palpating the site of injection may be necessary to ensure proper insertion; therefore, sterile gloves should be worn to reduce the risk of bacterial contamination. To begin the procedure, the joint and surrounding structures within the scrubbed area are palpated to identify the landmarks. The needle is inserted with a quick thrust through the skin, The needle should be insert- ed without the syringe attached. A syringe can act as a lever, and sudden movement by the horse may cause the needle to damage tissue. To avoid broken needles, only disposable nee- dles that are reasonably flexible should be used. A needle longer than the length required to enter the joint is more likely to bend than break when stress is applied. The depth of needle penetration varies with the joint. To penetrate the carpal, tibiotarsal, and fetlock joints, the needle is inserted relatively super- ficially, but to penetrate the coffin, pastern, and elbow joints and the medial and lateral compartments of the femorotibial joint, the needle may need to be inserted 1 to 1.5 inches, depending on the size of the horse and the approach used. Because clini- cians do not always enter the joint space with the initial thrust, the nee- dle sometimes must be redirected; if possible, it should be redirected with- out being withdrawn back through the skin Experience helps the clini- cian identify underlying tissue by its texture as the needle penetrates. The most accurate indication of successful arthrocentesis is the pres- ence of synovial fluid exiting the nee- dle. Unfortunately, the clinician can place a needle correctly within a joint without being able to see or aspirate synovial fluid. The reasons for this are: Some joints normally contain a very small volume of synovial fluid e.g» distal joints of the tarsus); the needle opening may be against syn- ovial villi or cartilage; aspiration may have pulled villi into the needle open- ing: a chronically inflamed joint may contain a less than normal amount of synovial fluid; hypertrophied villi and joint capsular thickening caused by chronic inflammation may have reduced the volume of the damaged joint; or the needle may have become plugged with tissue. After the needle is situated correct: ly within the joint, the syringe is attached to either inject medication or aspirate fluid. In some cases, the degree of resistance to pressure on the plunger of the syringe during injec: tion may be the only way to deter- mine if the joint was entered. If the needle is placed correctly, resistance to injection is slight, but for some joints, such as the shoulder joint, lack of resistance to pressure on the plunger Fibrous capsule Synovial fluid ilageof the syringe is not a good indication that the joint has been entered. Syringes that lock onto the needle hub should be avoided because sud- den motion may require that the syringe be detached quickly from the needle to prevent the needle from being pulled out or to prevent the syringe from acting as a lever, which may either result in injury to the horse or break the shaft of the need. ‘A needle should not be inserted through inflamed tissue into a joint. Inflammation may be the result of @ recent wound, subcutaneous infection, dermatitis, recent local cautery, or application of a counterirritant. Many joints can be entered using an alterna- tive approach remote from the site of inflammation, Specific, step-by-step details of the injection techniques for 16 different joints, two bursae, and a tendon sheath are discussed and illustrated in the pages that follow. For each joint or bursa, we have listed an approximate needle size. The amount of local anes- thetic solution instilled into a joint arbitrary, but we have stated a volume of fluid that can reasonably be inject- ed. For many joints, several approach- es for arthrocentesis are described. Being able to insert a needle into a joint at several sites is often necessary because a wound or infection in one area may necessitate that the joint be entered in another area, Sometimes an ingress and egress portal for lavage of the joint must be established. Also, wwe have assigned a degree of difficulty to each approach to the joint, bursa, or tendon sheath based on a scale of 1 to 3, with 1 indicating the lowest degree of difficulty with which the joint or bursa is entered. Occasionally, a clinician experiences problems resulting ftom arthrocente- sis, These problems must be resolved promptly and thoroughly because they can quickly lead to serious problems. For instance, certain bacteria, when introduced into a joint, can rapidly cause irreparable damage. The two most common serious complications of arthrocentesis are a broken needle and a postinjection reaction. Following are the immediate and follow-up steps the clinician should take when presented with one of these complications. Broken Needles ‘The likelihood of breaking a needle in a joint is low, and properly restrain- ing the horse and using flexible, dspos- able needles can farther reduce the risk. Joints that are considered high risk in terms.of broken needles—the hip, shoulder, and to some extent, the fe- moropatellar joint—should be injected or aspirated using a spinal needle because spinal needles are particularly flexible and usually bend to accommo- ate stress, rather than break. Ifa needle does bend, it should be removed slowly, following the curve of its bend. Even though needles usually break at skin level, broken needles are usually diffi calt to retrieve. Unless a needle appears to be readily accessible, itis best extract- ed while the horse is anesthetized. Gen- eral anesthesia allows for more careful exploration and manipulation. Radio- ‘graphic examination of projections tak= en at multiple angles, ultrasonography, or fluoroscopy may help identify the exact location of the needle. Arthro~ scopic retrieval ofthe needle and assess- ‘ment of the joint may be necessary. After the needle has been retrieved, the joint should be copiously lavaged.with a sterile, balanced, polyionic solution because the joint must now be considered contaminated. The degree of damage and the appearance of the internal environment of the joint determine the extent of aftercare. Postinjection Reactions Horses that suffer from a postin. jection reaction can be difficult to manage because distinguishing between a local drug reaction and early infection caused by contamina- tion is often impossible. Early signs of either problem include heat, pain. swelling, and lameness. In either case, the interval between the injection and the onset of clinical signs may be sim- ilar and, therefore, cannot be used to determine whether the inflammation is caused by infection. In either case analysis of synovial fluid reveals inflammation of the joint, but deter- mining whether the inflammation is caused by sepsis is ofien not possible unless bacteria can be isolated. It is prudent to assume that a painful joint is infected, and, there- fore, the horse should be treated accordingly. Initially, treatment should consist of copious lavage of the joint with a sterile, balanced, polyionic solution. This can often be accomplished, depending on the joint and the temperament of the horse, with the horse sedated rather than anesthetized. Lavage is performed as follows, regardless of whether the horse is sedated or anesthetized: 1. Prepare the skin over the joint for aseptic insertion of needles or catheters. 2. Use large-bore (ie. 16-gauge or greater) needles or catheters for most joints. 3. If the procedure is to be performed with the horse standing, distend the joint with an appropriate, ster- ile, local anesthetic solution, Allow enough time for the anesthetic solution to anesthetize the joint. 4. With the first needle in position and the joint distended with fluid, insert a second needle into the joint at another site, Lavage the joint with copious amounts of fluid. Distend the joint maximally two to three times during the lavage.‘* Distension allows the cleansing fluid to circulate into the deep crevices and folds of synovial tissue. If the procedure is performed with the horse anes- thetized, lavaging the joint using arthroscopic cannulas may be bene- ficial because the joint can be visually examined and a large quantity of flu- ic can be forced through the joint. 5. Administer an appropriate antib otic directly into the joint at the end of lavage. 6. Systemically administer an appro- priate antibiotic. 7. Administer regional antimicrobial perfusion of the affected region of the limb, if possible and appropriate. 8. Confine the horse and support the joint with a suitable bandage (if the area can be bandaged). ‘The decision to repeat joint lavage and the duration of antimicrobial therapy depend on: ‘+ The clinical appearance of the joint and the horse's response to treat- ment. + Isolation and identification of a causative agent. ‘+ ‘The wishes of the owner or trainer. Medication Rules A possible third complication is related not to health problems but to medication rules for competition horses. Keep in mind that some med- ications are detectable and, therefore, could create a problem for the owner or trainer ifthe horse is tested. nYel Neate eu Extensor of the distal phalanx Middle phalanx Navicular bone Distal phalanx‘The coffin joint (P2-P3, distal interphalangeal or coronopedal joint) is most easily entered with a needle, using a dorsal approach, with the limb bearing weight. Consequently, the dor- sal approach may be more dangerous than the lateral approach in which the foot is hed. Insert the needle into the dorsal pouch of the joint at the point where the pastern meets the proximal edge of the coronet. For most horses, this point is approximately 0.3 10.25 inch above the edge of the hoof wal, approximately 0.75 inch lateral or medial to an imaginary line drawn vertically through the center of the phalangeal bones. Direct the needle perpendicular to the bearing surface of the foot. The size of the foot determines the depth of penetration, but generally this depth is about 1 to 1.5 inches. The procedure can be performed withthe foot held, Iu itis generally easier to accomplish with the limb bearing weight. Smoval fluid usually appears inthe needle hub, but accuracy of needle placement can also be ascertained by ease of injection. After injection, the syringe may refll when pressure on the plunger is released. ‘The coffin joint may communicate directly wit the digital lexor tendon sheath in some foals. Although the coffin joint and navicular bursa do not have anatomic coma tion, a substance of low molecular weight, such as a Jocal anesthetic solution, may dif= fuse from the coffin joint into the navicular bone and bursa. Consequenty, anesthesia of the coffin joint also causes anesthesia ofthe navicular apparatus. Administration of a small volume (eg, 6 mL) of local anesthetic solution into the coffin joint anesthetizes branches ofthe palmar digital nerves, resulting in anesthesia ofthe toe region ofthe sol.” Admin istration of a large volume (¢., 10 mL) of local anesthetic solution into the caffin joint anesthetizs additional branches so the heel region ofthe sole also becomes anesthetized. Palpate the proximal edge ofthe coronet, approximately 0.75 inch lateral tothe dorsal longitudinal midline ofthe paste. Insert the needle into the joint by directing the needle perpendicular tothe bearing surface ofthe foo, through the coronet, ‘on or slighty medial or lateral tothe dorsal, longitudinal midline of the pastem, toa depth of approximately 1 10 1.5 inches.DORSAL, PARALLEL Extensor process of the distal phalanx Middle phalanx Navicular bone Distal phalanxNeedle: 1 inch (2.54 cm), 20 to 22 gauge a Volume: 4 to 6 h of the coffin joint can be entered by ins the needle through the .00f, parallel to the bearing surface The dorsal po coronary band, just above the proximal edge 0 of the foot or perpendicular to the slope of the pastern on the dorsal midline. Insert the needle until the dorsal aspect of the middle phalanx is encountered. The depth of pene tation is less than 0.5 inch, The procedure is most easily performed with the limb bear- ing weight and consequently may be more dangerous than the lateral approach, in which the foot is held. Applying a nose twitch to the horse Synovial fluid usually appears in the needle hub, bu also be determined by ease of injection and return of injected fluid back into the syringe increases the safety of the procedure. racy of needle placement can when pressure on the plunger is released. Insert the needle parallel to the bearing surface ofthe foot or perpendicular to the slope of the pastern, through the coronary band, until the dorsal aspect ‘of the middle phalanx is encountered, phalanx.fe Middle phalanx: Joint capsule, Canilage of the foot‘The coffin joint can also be entered from the lateral aspect ofthe joint. Insert a L-inch, 20- to 22-gauge needle through the skin, just above the palpable, proximal edge of the lat- cral cartilage of the foot, approximately midway between the dorsal and palmar/plantar aspects of the middle phalanx. Angle the needle downward toward the medial aspect of the bearing surface of the foot. The procedure can be performed with the limb in either the ‘weight-bearing or non-weight-bearing position. The depth of successful penetration is Fh, We find this technique to be apparently les discomforting to the horse than the dorsal approaches. Using the lateral approach to the coffin joint, the navicular bursa or digital tendon sheath can be inadvertently entered.* The likelihood of entering either of thi vial structures increases if the needle is insert usualy Jes than palmar/plantar to the recommended site of insertion. Using a needle no longer than 1 inch may decrease the likelihood of entering the navicular bursa or digital tendon sheath. Performing the procedure with the limb in a weight-bearing position may also decrease the likelihood of inadvertently entering the navicular bursa or digital tendon sheath, but the procedure is more safely performed with the limb in a non-weight-bearing position Ah Palpate the proximal edge o the lateral Inset the needle at a downward angle, cartilage ofthe foot, approximately midway aiming toward the mecial aspect of the bhetween the dorsal and palmarfplentar bearing surface othe foot. aspects ofthe middle phalar