Chapter 10

In the handling of open joint capsules where the perforation of the capsular ligament is small and discharge of synovia does not immediately follow, there is presented a problem which is difficult to decide upon and that is the manner in which such wounds are to be handled. One hesitates to enlarge such openings to drain or irrigate the capsule when there is no proof that serious trouble will follow because of infectious material which has probably been introduced at the time the wound was inflicted. It is especially difficult to decide upon the manner of handling such cases where the tarsal joint is wounded, although one hesitates to invade any joint to the extent of incising its capsule, unless there is urgent need of so doing.

Frost[19] offers the following suggestion in such instances:

The treatment recommended by us for open joints, in which we wish to prevent ankylosis, is, first, to shave all hair from the area surrounding the wound, following with a thorough cleansing of the skin and disinfection of the wound, and then to inject a twenty per cent Lugol's solution in glycerin into the wound. This should be repeated two or three times a day, each time enough of the solution being injected to fill the joint capsule, thereby securing the flushing effect. As this solution does not cause irritation to the tissue and yet is a strong antiseptic, it serves to shorten the period of congestion and inflammation and to overcome the infection without causing a destruction of the secreting membrane until the external wound has had time to heal. The injection of this solution seems to retard the excessive secretion of synovia. The larger the joint capsule and the smaller the external wound, the longer our antiseptic will remain in contact with the inflamed tissues as the glycerin, being thick, does not flow through a small opening.

After-care.--Following the initial cleansing and treatment of open joint, subsequent dressing is necessary as frequently as conditions demand. If the parts are badly infected and profuse discharge of pus exists a daily change of dressings is necessary. In the average instance, however, semi-weekly treatments are sufficient. And in many instances where one is obliged to travel a considerable distance to handle the affected animal one weekly dressing of the wound will suffice after the second treatment.

The same general plan of treatment concerning the subject's comfort that has been previously mentioned in arthritis, is carried out here. A further and detailed consideration of the subject of handling of open joints follows.[20]

* * * Such wounds may be classified in two general groups as follows: First, wounds in which the trauma has exposed the articulation to view, and second, those the result of punctures, in which the external wound is small and free drainage is lacking.

Wounds in which the articulation is exposed to view have drainage either all ready provided for, or it is established without hesitancy surgically. With free drainage thus established there is little or no chance for the adjacent tissues to become infiltrated with infected wound discharge. This prevents an extension of the injury and the establishment of a good field for the growth of anaerobic bacteria.

Open joints caused by punctures, unless the puncture is aseptic, produce a swelling which is more painful than is the open wound which exposes the joint to view. Especially is this true if the puncture is of small diameter, allowing the tissues to partially close the opening immediately after the wound has been made. Where drainage is lacking there follows an exudation which congests the tissues surrounding the injury and all factors favoring germ growth are present. It is perhaps advisable to establish good drainage in such cases as soon as a diagnosis is made.

It is not always an easy matter to recognize an open-joint, when first made, but twelve to twenty-four hours later there is no cause for doubt. The condition is then a very painful one; lameness is excessive; there is rise in temperature; acceleration of the pulse and manipulation or palpation of the region affected, occasions great pain.

The treatment of open joints must be varied to suit the disposition of the animal, the nature and location of the injury, the length of time intervening between the infliction of the wound and the first attention given, and the surroundings in which the patient is kept.

In each and every case in which there exists an open wound the surface surrounding the wound is cleansed thoroughly, the hair is shaved if possible, and the margin of the wound is curretted and cleansed thoroughly with antiseptic solutions.

If there is evidence that the articulation contains infective material, it is washed out with copious quantities of peroxide of hydrogen--usually as much as six or eight ounces. This is followed by injection of an ounce or two of tincture of iodin. Even though the joint appears to be clean some tincture of iodin is used, as it checks the secretion of synovia and is, in every way, beneficial. Care is taken to apply the iodin also to the surface immediately surrounding the wound. The entire wound is then covered with a dusting powder composed of zinc oxide, boric acid, exsiccated alum, phenol and camphor.

This powder is used in abundance and the wound is then covered with a heavy layer of absorbent cotton and well bandaged. This bandage is not disturbed for at least three days and may be left in place for a week. In cases in which it is necessary to keep the dressing on for a week, or in cases where the patient is, through necessity, kept in quarters that are wet or unclean, the first bandage is covered with a layer of oakum which has been saturated in oil of tar and this in turn is held in place by means of several layers of bandages. The bandages are also saturated with oil of tar.

In from one to two months wounds so treated, unless they are foot-wounds, will be ready to dress without being bandaged. It is ordinarily unnecessary to dress foot-wounds oftener than every second week after the discharge of synovia has ceased. When the wound has filled with granulation, a protective dressing is applied which is rendered water proof by the use of bandages covered with oil of tar. The patient can now be turned out for a month or six weeks without disturbing the dressing. After the removal of the bandages, the only treatment necessary is an occasional application of some mildly antiseptic ointment.

Except in nail pricks of the foot, occasioned by punctures, a five per cent tincture of iodin is injected into open joints, if the wound remains sufficiently open, and this treatment is continued so long as there is a discharge of synovia. Surgical drainage is established if it is considered practicable and the remainder of the treatment is about the same as for wounds which are open.

Open joints occur in horses at pasture and are sometimes not discovered until several days or a week after the injury, and in some instances the wounds are filled with maggots. The only difference in the treatment of these cases is that more time and care is taken in cleansing the wound, more curetting is necessary, and after cleansing the wound with peroxide of hydrogen, the joint is thoroughly washed out with equal parts of tincture of iodin and chloroform. This is followed by the injection of a quantity of seventy-five percent alcohol and the wound is dressed and bandaged as already described. At each subsequent dressing of infected wounds so treated less suppuration is noticed and the synovial discharge usually ceases in from one to two months.

About _ninety percent of all cases of open joint make complete recoveries_, about four per cent partially recover and six per cent are fatal. Among the fatal cases are the open joints with complications as severed tendons, those occasioned by calk wounds in horses that are stabled, and nail punctures of the feet. The following report of twelve favorable cases is taken from a record of sixty-two cases. The favorable ones are reported, chiefly because there are now enough reports on record of such cases which have terminated fatally.

Case 1.--A gray gelding used as a saddle pony received a horizontal wire cut laying completely bare the scapulohumeral articulation. The margins of the wound were cleansed as heretofore described, a drainage was provided surgically, tincture of iodin was injected and the wound was covered with equal parts of boric acid and exsiccated alum. The horse was kept tied and a diluted tincture of iodin was injected into the wound once daily and the powder applied often enough to keep the wound covered. The case made a complete recovery and the pony was again in service within sixty days.

Case 2.--A twelve-hundred-pound bay mare with an open carpal joint. The wound was an open one about two and one-half inches in length, and made transversely and when the member was flexed the articular surface of the carpal bones were presented to view. An ounce of tincture of iodin was injected into this joint after having cleansed the margin of the wound and the mare was cross-tied in a single stall to keep her from lying down. The owner was instructed to keep the outside of the wound powdered with air slaked lime and a very unfavorable prognosis was given.

I heard nothing further from this case until fifty-nine days from the date of the injury, when I met the owner driving this mare to a buggy. The wound had healed by first intention and at that time so little cicatrix remained that it was difficult to find it.

Case 3.--A brown mare with an open fetlock joint due to a spike-nail puncture. Lameness was excessive, and joint greatly swollen. Tincture of iodin was injected into the wound and towels dipped in hot antiseptic solutions were applied for several hours daily until the acute stage had passed. Later the mare was turned out to pasture and a vesicant was applied once or twice a month until recovery was complete which was in about six months.

Case 4.--A four-year-old bay mare having a wire-cut which opened the tarsus joint was treated as heretofore described. The wound was kept bandaged for about two weeks and later it was dressed without being bandaged. In ninety days she had completely recovered.

Case 5.--A twelve-year-old mare with an open fetlock joint due to a puncture wound. The margins of the wound were cleansed and the external wound enlarged to facilitate drainage. Tincture of iodin was injected; the wound was bandaged and dressed for a month in the manner heretofore described, when all discharge had stopped. A vesicant was applied; the mare was put to pasture and within sixty days from the date of the injury she was being driven on short trips.

Case 6.--A two-year-old brown gelding with a wire-cut on the left front foot. The wound extended down through the sole and opened the navicular joint. This colt was very wild and it was necessary to tie it down each time the wound was dressed. The wound was dressed weekly for a month and less frequently thereafter. It was handled eight times; the last dressing was left in place until worn out. Six months later the colt was practically well, a very little lameness being shown when walking on frozen ground.

Case 7.--A seven-year-old saddle-horse weighing eleven hundred and fifty pounds received a wound of the tarsus, laying bare the articular surfaces of a part of the joint. It was impossible to keep this wound bandaged because of the restless disposition of the subject. Injections of a dilute tincture of iodin were employed every second or third day for a month and the wound was kept covered with the antiseptic dusting powder referred to heretofore. In five months complete recovery had taken place, with the exception of a stubborn skin disturbance which was successfully treated six months after the wound was inflicted. The horse is still in use and is absolutely free from lameness.

Case 8.--A two-year-old brown gelding with a wire-wound opening the scapulohumeral joint. This wound was large enough to expose to view the articular portion of the humerus. The same treatment as that given case No. one was instituted and in ninety days the colt was practically well.

Case 9.--A three-year-old bay filly was found at pasture with one fore foot badly injured. The owner intended to destroy her, but a neighbor prevailed upon him to have her treated. Apparently the wound was of about a week's standing and in a very bad condition, filled with maggots and dirt. Both the navicular and coronary articulations were open. This wound was cleansed in the usual manner and the owner cared for the case the balance of the time because the distance from my office was too great to give her personal attention. She made an almost complete recovery in five months.

Case 10.--At two-year-old mule with an open navicular joint due to a barbed wire wound. Usual care was given this case and in five months recovery was complete and little scar is to be seen. This case received seven treatments.

Case 11.--An eighteen-months-old colt at pasture was found down and unable to rise without help. In addition to several wounds of lesser importance there was a large wound on the inner side of the elbow, the joint was open and the entire leg was greatly swollen and in a state of acute infectious inflammation. The colt could not walk, its temperature was 105°, pulse was rapid and respiration was a little hurried. After advising the owner to put the poor animal out of its misery I left the place. Four days later the owner came to my office and asked if he could borrow some old shears to "trim off some loose hide from that colt." He left the colt in the pasture and all the care it received was the regular application of a proprietary dusting powder. It made a complete recovery.

Case 12.--A family mare, heavy in foal, received a vertical wound of the fetlock joint inflicted by a disc-harrow. The _cul-de-sac_ of the ligament of this joint was opened freely. The wound was dressed in the usual manner and again three days later when no suppuration had taken place. Four days later the patient gave birth to a colt and suckled it right along through her convalescence. This wound healed by first intention and seventy-nine days from the date of the injury the mare was driven to town, two and one-half miles distant, and showed but little lameness.

Phalangeal Exostosis (Ringbone)

This term is applied to exostoses involving the first and second phalanges (suffraginis and corona), regardless of their size, extent or location. It is a misnomer, in a sense, and the veterinarian is frequently obliged to spend considerable time with his clients in order to convince them that a spherodial exostosis of the proximal phalanx, in certain cases, is in reality "ringbone," even though there exists no exostosis which completely encircles the affected bone.

Etiology and Occurrence.--Exostosis of the first and second phalanges is usually due to some form of injury, whether it be a contusion, a lacerated wound which damages the periosteum, or periostititis and osteitis incited by concussions of locomotion, or ligamentous strain. Practically the only exception is in the rachitic form of ringbone which affects young animals.

There are predisposing causes that merit consideration, chief among which is the normal conformation of the coronet joint. This proclivity is constant; the normal interphalangeal articulation is an incomplete ginglymoid joint and while its dorso-volar diameter is great, this in no wise compensates for its disproportionately narrow transverse diameter. The pivotal strain which is sometimes thrown upon this articulation when an animal turns on one foot, as well as the tension which is put on the collateral ligaments when the inner or the outer quarter of the foot rests in a depression of the road surface, tends to detach the insertion of these ligaments or to cause fibrillary fractures of their substance.

Short, upright, pasterns receive greater concussion during fast travel on hard roads than do the longer more sloping and well formed extremities. Those who are advocates of the theory that this type of osteitis with its complications has its origin in the articular portion of the joint, claim that the upright pastern constitutes an important tendency toward ringbone. Howbeit, ringbone is an active, serious and frequent cause of lameness and it affects animals of all ages and occurs under various conditions. Horses having good conformation and kept at work wherein no great amount of strain is put upon these parts, are occasionally victims of this affection.

Classification.--The arrangement employed by Moller[21] is intensely practical and logical. He considers ringbone as _articular_, _periarticular_, _rachitic_ and _traumatic_. A mode of classification that is common and in a practical way, good, is, high and low ringbone. When prognosis is considered, for instance, it is very convenient to state that the chances for recovery are much better in high ringbone than in low ringbone. The classification of Möller will be followed here.

Symptomatology.--In all forms of incipient ringbone except rachitic, the first manifestation of its existence, or of injury to the ligaments in the region of the pastern joint which causes periostitis, or affections of the articular portions of the proximal inter-phalangeal joint, is lameness. Lameness which typifies ringbone is of the supporting-leg variety and by compelling the subject to step from side to side, marked flinching is observed, especially in periarticular ringbone; causing the affected animal to turn abruptly on the diseased member, using it as a pivot, likewise accentuates the manifestation. In fact, many subjects that exhibit no evidence of locomotory impediment while walking or trotting in a straight line on a smooth road surface, will manifest the characteristic form of lameness from ringbone when the aforementioned side to side movement is performed.

When the manner in which pain is occasioned is considered, it will be understood why lameness is intermittent in the early stages of this affection and may even be unnoticed by the driver. An animal may travel on a smooth road without giving evidence of any inconvenience, but as soon as a rough and irregular pavement or road surface is reached, will limp. As the subject is driven farther on level streets the lameness may disappear. This intermittent type of lameness may continue until there is developed a large exostosis, or until articular involvement causes so much distress during locomotion that lameness is constant. On the other hand, resolution may occur during the stage of periosteal inflammation, or, an exostosis forms which causes no interference with function.

Before there is evidence of an exostosis, diagnosis of ringbone is not easy, for it is then a problem of detecting the presence of a ligamentous sprain, periostitis, or osteitis. The diagnostician should take note of local manifestations of hypersensitiveness, or heat if such exist, and, in addition, other conditions must be excluded before definite conclusions are possible.

In _articular_ ringbone as soon as there is developed an exostosis, it occupies a position on the dorsal (anterior) part of the articulation and extends around the sides of the joint.

_Periarticular_ ringbone is characterized by exostoses which are situated on the sides of the phalanges and not extending around to the anterior part of the joint. This type of ringbone as well as the articular may occur "high" or "low."

With the _traumatic_ form of ringbone, all consequences, as to the size and form the exostosis is to assume, depend upon the nature and extent of the injury.

_Rachitic_ ringbone is frequently observed in some sections of the country and does not ordinarily cause much if any lameness. It is a disease of colts and may affect one or all of the phalanges at the same time. As the subject advances in age there is more or less diminution in the size of the enlargements.

Treatment.--Rest is essential in the treatment of ringbone. If diagnosed during its incipiency, remedial measures such as are usually employed to treat sprains, are indicated and later the parts should be blistered. When an exostosis has developed puncture firing is the remedy _par excellence_. Not that this method of treatment is infallible, for to any thinking one who takes into consideration the pathological anatomy of this condition, it is evident that no manner of treatment is beneficial in some cases. If the exostosis is so situated that it does not mechanically interfere with function, and is not so large that it may inhibit flexion and extension, and where the articular portions of the joint are not eroded, good results attend the use of the actual cautery.

In firing, after having anesthetized the extremity, and prepared the surgical area, the cautery is deeply inserted in numerous places, taking care, however, not to open the joint. The parts are immediately covered with aseptic absorbent cotton and this dressing is left in position for forty-eight hours and if perchance there is evidence of synovial discharge, the parts are again aseptically dressed in order to prevent infection of the articulation. If, as is the case usually, no perforation of the joint capsule exists, the openings made by the cautery have been closed by the coagulation of serum and there is then little chance of infection causing trouble, even though the member is left unbandaged.

In several instances, the author has treated ringbone by this method where the periarticular type existed and lameness was marked, and in three weeks the subjects were in service and not lame--this, in one instance in a valuable polo pony where the subject continued in service for more than a year without any evidence of recurrence of the lameness. The production of a deep-seated and acute inflammation with the actual cautery is preferable to any sort of counter-irritation which may be produced by vesicants.

There is no occasion for any difference in the treatment of either of the first three classes of ringbone, but in the rachitic type where treatment is given, the application of a vesicant is all that is required. In most instances treatment is not necessary.

The affected animals require a month to three months' time for recovery to take place in the average favorable cases of ringbone.