Chapter 7

Treatment.--During the first few days following injuries which result in this form of paralysis, it is well to keep the subject inactive, and if much inflammation of the injured structures contiguous to the nerve exists, the application of cold packs is beneficial. Later, as soon as acute inflammation has subsided, vesication of a liberal area around the anteroexternal part of the scapulohumeral joint and over the course of the suprascapular nerve, will stimulate recovery in favorable cases. As a rule, in mild cases, the subject is in a condition to return to work in two or three weeks.

Radial Paralysis.

Described under the titles of "Radial Paralysis" and "Brachial Paralysis," there is to be found in veterinary literature a discussion of conditions which vary in character from the almost insignificant form of paresis to the incurably affected conditions wherein the whole shoulder is completely paralyzed.

When one considers the anatomy of the brachial nerve plexus and the distribution of its various branches, the location of this plexus and its proximity to the first rib, and the inevitable injury it must suffer in fracture of this bone, together with the inaccessibility of the plexus, it is not strange that a correct diagnosis of the various affections of the brachial plexus and the radial nerve is often impossible until several days or weeks have passed. And, in some instances, diagnosis is not established until an autopsy has been performed. Here, too, we fail to find cause for paralysis in some rare instances.

Anatomy.--The radial nerve is a large branch of the brachial plexus and is chiefly derived from the first thoracic root of the plexus and is here situated posterior to the deep brachial artery. It is directed downward and backward under the subscapularis and teres major muscles, rounding the posterior part of the humerus, and passing to the anterior and distal end of the humerus, it finally terminates in the anterior carpal region. The radial nerve supplies branches to the three heads of the triceps brachii, to the common and lateral extensors of the digit and also to the skin covering the forearm.

Etiology and Occurrence.--Nothing definite is known about the cause of some forms of radial paralysis. However, radial paralysis is encountered following injury to the nerve occasioned by its being stretched, as in cases where the triceps brachii is unduly extended in restraining subjects by means of a casting harness. Berns[10] states that in confining horses on an old operating table where it was necessary to draw the affected foot forward twenty-four to thirty-six inches in advance of its fellow, which was secured in a natural vertical position, radial paralysis of a mild form was of frequent occurrence. Country practitioners, in restraining colts by casting with harness or ropes, occasionally observe a form of paresis wherein the radial nerve suffers sufficient injury that there is caused a temporary loss of function of the triceps brachii. Such cases recover within three or four days and are not a true paralysis, but nevertheless constitute conditions wherein normal nerve function is temporarily suspended.

Symptoms.--Immediately subsequent to injuries which involve the radial nerve, there is manifested more or less impairment of function. Remembering the structures supplied by the radial nerve and its branches, one can readily understand that there should occur as Cadiot[11] has stated:

In complete paralysis, the joints of the affected limb with the exception of the shoulder are usually flexed when the horse is resting. In consequence of loss of power in the triceps and anterior brachial muscles, the arm is extended and straightened on the shoulder, the scapulohumeral angle is open, and the elbow depressed. The forearm is flexed on the arm by the contraction of the coracoradialis (biceps brachii), while the metacarpus and phalanges are bent by the action of the posterior antibrachial muscles. The knee is carried in advance, level with, or in front of, a vertical line dropped from the point of the shoulder. The hoof is usually rested on the toe, but when advanced beyond the above mentioned vertical line, it may be placed flat on the ground, the joints then being less markedly bent. When the limb as a whole is flexed, it may be brought into normal position by thrusting back the knee with sufficient force to counteract the action of the flexor muscles.

When made to walk, the animal being unable to exert muscular action with the paralyzed structures, limply carries the member as a whole, and there is shortening of the anterior portion of the stride. There being loss of function of the triceps brachii, it is impossible for the subject to straighten the leg in the normal position for supporting weight; therefore, any attempt to bear weight results in further flexion of the affected member and the animal will fall if the body is not suddenly caught up with the sound leg.

Differential Diagnosis.--In making examination of these cases, one can exclude fracture by absence of crepitation and usually, also, swelling is absent in radial paralysis. In a typical case of radial paralysis, the affected leg can sustain its normal share of weight if placed in position, that is, if the carpal joint is extended in such manner that the leg is positioned as in its normal weight-bearing attitude. In brachial paralysis, whether due to fracture of the first rib or to other serious injury, it is impossible for the subject to support weight with the affected member even when it is passively placed in position.

No difficulty is ordinarily experienced in differentiating radial paralysis from muscular injuries to the triceps; yet, in some cases of "dropped elbow," it is necessary to observe the progress of the case for ten days or two weeks before one can positively establish a diagnosis.

Quoting Merillat[12]: "When, after four weeks, there is no amelioration of the paralysis, the muscles have atrophied, and the patient has become emaciated from pain and discomfort, the diagnosis of brachial paralysis with fracture of the first rib may then be announced."

Prognosis.--When no complete paralysis of the brachial plexus or no fracture of the first rib exists, the majority of cases recover completely in from ten days to six weeks. Some writers claim that recoveries occur in ninety per cent of cases when conditions are favorable.

Treatment.--When incomplete radial paralysis exists, little needs be done except to allow the subject moderate exercise and to provide for its comfort. Local applications, stimulative in character, are beneficial, and the internal administration of strychnin is indicated.

In the cases where weight is not supported without the affected leg being passively placed in position, it is necessary to provide for the subject's comfort in several ways.

Mechanical appliances such as braces of some kind in order to keep the affected leg in a position of carpal extension, constitute the essential part of treatment. The leg is supported in such a manner that flexion of the carpus is impossible. Due regard is given to prevent chafing or pressure necrosis by contact of the skin with the braces--this may be done by bandaging with cotton. The supportive appliance is kept in position for ten days or two weeks. At the end of this time the brace may be removed and the subject given a chance to walk, and improvement, if any exists, will be evident. When there is manifested an amelioration of the condition, moderate daily exercise and massage of the affected parts are helpful.

Should the subject be seriously inconvenienced by the application of a brace or other supportive appliances, it is necessary to employ slings. Further, if weight is supported entirely by the unaffected member, laminitis may supervene if a sling is not used.

Thrombosis of the Brachial Artery.

Thrombosis of the brachial artery or of its principal branches is of very rare occurrence in horses.

Etiology.--Partial or complete obstruction of arteries (brachial or others) occurs as the result of direct injury to the vessel wall from compression and tension of muscles and resultant arteritis; lodging of emboli; and parasitic invasion of vessel walls causing internal arteritis.

Symptomatology.--If sufficient collateral circulation exists to supply the parts with blood, no inconvenience is manifested while the subject is at rest. Where the lumen of the affected vessel is not completely occluded, there may be no manifestation of lameness when the ailing animal is moderately exercised. Consequently, the degree of lameness depends upon the extent of the obstruction to circulation; and, likewise, the course and prognosis depend upon the character and extent of such obstruction.

In severe cases, lameness is markedly increased by causing the animal to travel at a fast pace for only a short distance. There are evinced symptoms of pain, muscular tremors and sudation, but the affected member remains dry and there is a marked difference of temperature between the normal areas and the cool anemic parts. When the subject is allowed to rest, circulation is not taxed, and there is a return to the original and apparently normal condition, only to recur again with exertion. This condition characterizes thrombosis.

Treatment.--In these cases, little if any good directly results from any sort of treatment in the way of medication. Absolute rest is thought to be helpful. Potassium iodid, alkaline agents such as ammonium carbonate and potassium carbonate, have been administered. Circulatory stimulants also have been given, but it is doubtful if any good has come from medication.

Fracture of Humerus.

The shaft of the humerus, protected as it is by heavy muscles, is not frequently fractured; and fractures of its less protected parts, as for example, the head, are complicated in such manner that resultant arthritis soon constitutes the more serious condition.

As a result of falls on frozen ground, kicks or any other form of heavy contusion, the humerus is occasionally broken. It is rarely fractured otherwise. Because of the force of contusions usually required to effect humeral fracture, the manner in which the bone is broken, with respect to direction, is variable. Often oblique fractures exist and occasionally there occurs multiple fracture. In addition to the ordinarily serious nature of the fracture itself, there is always much injury done the adjoining structures.

Symptomatology.--Mixed lameness and manifestation of severe pain characterize this affection. Considerable swelling which increases, in some cases for a week or more, is to be observed. Crepitation is readily detected, if pain and swelling is not too great to prevent passive movement of the member. Where intense pain is not manifested, because of manipulation, one may abduct the extremity and thereby occasion distinct crepitation; but when it is possible to recognize crepitation by holding the hand in contact with the olecranon while the animal is made to walk, this method is to be preferred, if the subject can move without serious difficulty. The pathognomonic symptom here is recognition of crepitation, but this may be very difficult to recognize in fracture of condyles, and in such instances, a careful examination is necessary. Gentle manipulation in a manner that pain is not aggravated will tend to inspire confidence on the part of the subject and relaxation of muscles will enable the operator to detect crepitation.

Course and Prognosis.--Because of the direction of the long axis of the humerus, with relation to the bony column of the extremity, it is obvious that any lateral movement of the leg tends to rotate the shaft of this bone. In fractures of the shaft of the humerus, then, it is apparent that immobilization is very difficult if at all possible.

The proximity to the axillary lymph glands makes for easy dissemination of infection when the contused musculature becomes infected. The adjacent brachial nerve plexus is so very apt to become involved, if not actually injured at the time fracture occurs, that paralysis is a probable complication. Consequently, it is logical to reason that because of the many possible serious complications, such as shock, occasioned by the injury and the distress and pain which this accident produces, recovery must be the exception in fracture of the humerus. However, recoveries do take place and in addition to the reported recoveries by Liautard, Moller, Stockfleth, Lafosse, Frohner and others, we have instances cited by American practitioners where cases resulted in recovery. Thompson[13] reports a good recovery in a 1600-pound mare where there existed an oblique fracture of the humerus. This mare was kept in slings for eight weeks. Walters[14] reports complete recovery in humeral fracture in a foal three days old. The only treatment given was the application of a pitch plaster from the top of the scapula to the radius. The colt was kept in a comfortable box stall and in about four weeks regained use of the leg. Complete recovery eventually resulted. In the experience of the author, recovery has not occurred in humeral fractures.

Treatment.--When animals are not aged and of sufficient value to justify treatment, they are best supported in a sling, if halter broken. If subjects are nervous, wild and unbroken, it is possible to employ the sling, if care is given to train the animal to this manner of restraint. The presence of an attendant for a day or two will reassure such subjects so that even in these cases it may be practicable to employ the sling.

Braces and other mechanical appliances intended to immobilize the parts are not of practical benefit in the horse. Unlike the dog, the horse as yet has not been successfully subjected to tolerating rigid braces for the shoulder and hip.

Everything possible must be done that will make for the patient's comfort. If the subject turns out to be a good self nurse, and the nature of the fracture is such that practical apposition of the broken ends of bone may be maintained, recovery will occur in some cases.

Inflammation of the Elbow. (Arthritis.)

Affections of this articulation other than those which are produced by traumatism are rare. This joint has wide articular surfaces, and securely joined as they are by the heavy medial and lateral ligaments (internal and external lateral ligaments), luxation is practically impossible. When luxation does occur, irreparable injury is usually done. Castagné as quoted by Liautard[15], reports a case of true luxation of the elbow joint in a horse where reduction was effected and complete recovery took place at the end of twenty-five days. This is an unusual case. The average practitioner does not meet with such instances.

Anatomy.--The condyles of the humerus articulate with the glenoid cavities of the radius and a portion of the ulna. Two strong collateral ligaments pass from the distal end of the humerus to the head of the radius. The capsular ligament is a large, loose membrane which encloses the articular portion of the humerus with the radius and ulna and also the radioulnar articulation. It is attached anteriorly to the tendon of the biceps brachii (flexor brachii). The capsule extends downward beneath the origin of these digital flexors. This fact should be remembered in dealing with puncture wounds in the region, lest an error be made in estimating their extent and an open joint be overlooked at the initial examination.

Etiology and Occurrence.--Exclusive of specific or metastatic arthritis, which is seldom observed except in young animals, inflammation of the elbow joint is usually caused by injury. This articulation is not subject to pathologic changes due to concussion or sprains as occasioned by ordinary service, but is frequently injured by contusion from falls, blows from the wagon-pole and kicks. Wounds which affect the elbow joint, then, may be thought of in most cases, as resultant from external violence. They may be contused wounds or penetrant wounds. Sharp shoe-calks afford a means of infliction of penetrant wounds which may occasion open joint and infectious arthritis.

Classification.--A practical manner of classifying inflammation of the elbow is on an etiological basis. Eliminating the forms of elbow inflammation, such as are caused by metastatic infection and other conditions which properly belong to the domain of theory of practice, we may consider this affection under the classification of _contusive wounds_ and _penetrative wounds_.

Symptomatology.--Any injury which is of sufficient violence to occasion inflammation of the elbow causes marked lameness and manifestation of pain. The degree of lameness and distress manifested by the subject, depends upon the nature and extent of the involvement. A contusion suffered as the result of a fall, which occasions a circumscribed inflammation of the structures covering this joint and where little inflammation of the articulating parts exists, marked evidence of pain and lameness might be absent. On the other hand, if a true arthritis is incited, there will be evident distress manifested, such as hurried respiration, accelerated pulse, inappetence, mixed lameness, local evidence of inflammation and particularly marked supersensitiveness of the affected parts. Considering these two extremes of manifested distress and injury, one may readily conclude that in the frequently seen case, wherein contusion has occasioned a moderate degree of injury, prognosis is favorable and recovery ordinarily follows in the course of a few weeks' treatment.

In cases of arthritis due to penetrative wounds (because of the important function of this joint and its large capsule, which when inflamed discharges synovia in a manner that closure of such an open joint is seldom possible) a very grave condition results.

Treatment.--Inflammation of the elbow, such as is frequently seen in general practice where horses are turned out together and exposed to kicks and other injuries, yields to treatment readily, if an open joint does not exist.

Hot packs supported in contact with the elbow and kept around the inflamed articulation for a few days, materially decrease pain and tend to reduce inflammation. The subject must be kept quiet in a comfortable stall and, if necessary, a sling used. Where it is impossible for the animal to support much weight with the injured member the sling should be employed.

As inflammation abates, which it does in the course of from one to three weeks in uncomplicated cases, the subject may be allowed the freedom of a comfortable box stall. Vesication of the parts is in order, and this may be repeated in the course of two weeks, if it is deemed necessary.

Penetrative wounds resulting in open joint are not treated with success as a rule, and because of the handicap under which veterinarians labor, methods of handling such cases, where large, important articulations are affected, are not being rapidly improved. Prognosis is usually unfavorable, and for humane and economic reasons, animals so affected should be destroyed.

Ordinary wounds of the region of the elbow are treated along general lines usually employed. They merit no special consideration, except that it may be mentioned that with such injuries concomitant contusion of the parts occasions injury that does not recover quickly.

Fracture of the Ulna.

Etiology and Occurrence.--Fractures of the ulna in the horse are not common in spite of the exposed position of the olecranon. This bone when broken, is usually fractured by heavy blows and any form of ulnar fracture is serious because of its function and position in relation to the joint capsule. Transverse fractures do not readily unite because of the tension of the triceps muscles, which prevent close approximation of the broken ends of the bone.

Thompson[16], however, reports a case of transverse simple fracture of the ulna in a mare, the result of a kick, in which complete recovery took place. He kept the subject in a sling for six weeks and then allowed six months rest.

Symptomatology.--The position assumed by a horse suffering from a transverse fracture of the ulna, is similar to that in radial paralysis. Crepitation may be detected by manipulating the parts, and in some instances of fracture of the olecranon, there occurs marked displacement of the broken portions of the bone. Lameness is intense and the parts are swollen and supersensitive. The capsular ligament of the elbow joint is usually involved in the injury because fracture of the ulna may directly extend within the capsular ligament. In such cases, there is synovitis, and later arthritis causes a fatal termination.

Treatment.--The impossibility of applying a bandage in any way to practically immobilize these parts in fracture of the ulna, prevents our employing bandages and splints. Therefore, one can do little else than to put the patient in a sling and try to keep it quiet and as nearly comfortable as circumstances allow.

Fracture of the Radius.

Etiology and Occurrence.--From heavy blows received such as kicks, collision with trees or in falls in runaway accidents, the radius is occasionally fractured. In very young foals, fracture of the radius, as well as of the tibia and other bones, results from their being trampled upon by the mother.

Symptomatology.--Excepting in some cases of radial fracture of foals where considerable swelling has taken place, there is no difficulty in readily recognizing this condition. The heavy brachial fascia materially contributes to the support of the radius, and in cases where swelling is marked, crepitation may not be readily detected. In fact, a sub-periosteal fracture may exist for several days or a week or more and then, with subsequent fracture of the periosteum, crepitation and abnormal mobility of the member are to be recognized. In such cases, the subject will bear some weight upon the affected member, but this causes much distress. In one instance the author observed a transverse fracture of the lower third of the radius which was not positively diagnosed until about ten days after injury was inflicted. In this case, without doubt, the subject originally suffered a sub-periosteal fracture of the bone and because the animal was a good self nurse, the brachial fascia supported the radius until the periosteum gave way and the leg dangled. In this instance infection took place and suppuration resulted. It was deemed advisable to destroy this animal.

Prognosis.--In adult animals, radial fracture constitutes a grave condition; generally speaking, prognosis, in such cases, is unfavorable. Because of the leverage afforded by the extremity, immobilization of the radius is difficult. Any sort of mechanical appliance, which will immobilize these parts, is likely to produce pressure-necrosis of the soft structures so contacted. There is occasioned thereby much pain and the subject becomes restive, unmanageable and sometimes the splints are completely deranged because of the animal's struggles, and much additional injury to the leg is done. Occasionally, an otherwise favorable case is thus rendered hopelessly impossible to handle, and the subject must be destroyed several days after treatment has been instituted.

Consequently, unless all conditions are good, and the affected animal a favorable subject, young, of good disposition, and the fracture a simple transverse one, complete recovery is not likely to result from any practical means of handling.