Hello everyone,
I have been a member for many years and it's been a while since I needed the group for advice.  Krystle (23 year old morgan mare) is having acute laminitis in all 4 feet with rotation in front and some sinking in hinds.  I filled in as much of her case history as I could quickly (I never updated it with the transition from Yahoo groups) and posted her current x-rays in order to post for some advice.  She had a number of issues the last month that led to the laminitis including left front sole bruising from mud under a pad, followed by left hind lameness that discovered a coffin bone fracture (honestly not sure that is new and causing her pain or the laminitis started earlier than detected was causing her the pain).  She has had allergies that redeveloped this fall (hives and asthma) and had some dex in order to be able to keep exercising (she is an FEI dressage horse).  I have not done an insulin test since spring because she was on the dex and am waiting for one to come back now that was pulled yesterday. 

I took her to a vet clinic on 12/23 because I was worried with the holidays that I wouldn't be able to get a farrier (mine is away) and she would go downhill too fast.  They started her on metformin immediately, ice for 4 days until I asked them to stop that, NSAIDs, a big soft mat in her stall and heavy bedding.  They do not want to touch her feet (she has shoes on all 4 and leather pads on 3) because they think even pulling the shoes off will cause damage and don't think she should be barefoot. I of course asked them about triming and alignment as well as reducing the NSAIDs, to which they said no.  She is not laying down at all.   They are also suggesting tenotomy ASAP as a "last ditch lifesaving effort".  They do not want to do the de-rotational shoeing at the same time though (the vet has done it many times without immediately doing the feet).  My local vet I use for performance agrees with the tenotomy (as long as the de-rotational shoeing is done).  My main vet is very hesitant for her to get the tenotomy, and I know from my involvement with this group that it is not recommended, but with two respected vets saying it is her only chance at survival, I am very conflicted.

Could someone take a look at her x-rays and give me some advice?  They will be taking some more today or tomorrow to see if the rotation and sinking is slowing down or continuing.  My gut from years in this group says to take her home and get mechanical changes to her feet, but am worried about getting a farrier with the holiday, and I am worried that there are multiple causes and this is just not a "typical" high-insulin case and thus will not be resolved with diet, trimming and rest alone

Thanks,
Angie
  
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Angie
Rhode Island, 2006
Krystle's Case History: https://ecir.groups.io/g/CaseHistory/files/Angie%20and%20Krystle
Krystle's photos: https://ecir.groups.io/g/CaseHistory/album?id=282722

 

 

Hi Angie

I am glad you are back here. I'm sorry you have to come back under these circumstances. You have done great things with your mares over the years. https://www.ecirhorse.org/assets/documents/ECIR-Success-Stories-Angie.Krt

If she were under my care, I would search for a hoof pro, set up an appointment, and bring her home. I have dealt with a lot of vets over the years, high end or otherwise, either personally and/or watching how other equines have been treated. It honestly drives me bonkers. Please ask them to show you how successfully their treatments have been for immediate relief and long-term recovery.

You already know about NSAIDs and Tenotomy. The rads show some evidence of previous laminitis, I believe, in the ripple of the hoof wall at the coronet band. IMO, you are not in the Tenotomy as "last ditch life-saving" category. The area that I hope we see more clarification on is the LH CB fracture, but I may not be viewing  correctly. More views might be helpful but I bow to Dr Kellon and Lavinia.

You may remember that Dex is not generally advised for EMS equines with high insulin. Did she seem to get through that okay? Was any lameness or even slight changes seen at the same time?

I'd also pull an ACTH if not already done.

Later today, when I am at my desk top, I can see if we have your old yahoo CH, retrieved when Yahoo shut us down.

Hang in there. Keep breathing. Hug your horse. You are in the right place to help Krystle.
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Nancy C in NH
ECIR Moderator 2003
ECIR Group Inc. President 2021-2022

ECIR Group NEW Case History site open to Early Adopters.

HOW TO SEARCH THE ARCHIVES: https://ecir.groups.io/g/main/wiki/1993

Thanks Nancy! 

Unfortunately with her last bout of allergies (2019) we could not find anything to take away her acute hives except for Dex, so she had quite a bit of it over the course of that year with no issues observed. (She routinely gets ACTH and Insulin tested at least a couple of times a year).  No issues with Dex then probably gave me a false sense of security now, and I should have thought more about it when she had to abruptly stop exercise when the lamenesses came up. 

She has had one confirmed and one other possible laminitic event, the first in 2017 when she was on stall rest for an injury, which resolved quickly,  and another a couple of springs ago which again resolved quickly. 

I have asked them to get some better views to look at the possible fracture today or tomorrow so I'll post those when I get them. Hopefully I'll get back the ACTH and Insulin today. I upped her Prascend in the spring from 1 to 1.5 when her ACTH was a little high. I'll find that test later and post it. 

Thank you so much for the support. 

Angie
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Angie
Rhode Island, 2006
Krystle's Case History: https://ecir.groups.io/g/CaseHistory/files/Angie%20and%20Krystle
Krystle's photos: https://ecir.groups.io/g/CaseHistory/album?id=282722

 

 

I agree with everything Nancy said. I want to mention that a very capable trimmer/farrier can make  a cast (not using casting material necessarily but using a fiberglass formulation) for the CB fracture, if that is what you have. I understand the fracture can show improvements in 5-6 weeks. I have no personal experience with a fracture but learned about CB casts from my trimmer who has done it with good results. The head farrier at the UCDavis vet hospital also fashioned casts for CB fractures.

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Cass, Sonoma Co., CA 2012
ECIR Group Moderator
Cayuse and Diamond Case History Folder                
Cayuse Photos                Diamond Photos

Hi Angie,

I took a quick look at the radiographs. There is no bony column rotation on any of the feet but there is some capsular rotation on the fronts.This means that the hoof lamellar zone increases as you travel from top to bottom. The fix is getting the trim corrected to back up the toes and set the breakover further back, in line with where the bony column dictates it should be. Hinds have a slightly broken back HPA.There is some degree of sinking on all four. As Nancy mentioned, there is evidence of laminitis in the wrinkles of the hoof wall just below the coronary band. Soles are a bit thin, which goes along with the sinking.

Unless I'm missing something, the only thing I see on the LH in that lateral view is a possible bit of bone that might be missing from the top edge of the extensor process. There doesn't appear to be any evidence of a fragment floating around anywhere. I would like to hear what Dr. Kellon sees, if she's available.

Agree with Nancy's assessment that there is no evidence that there is any need for "last-ditch efforts" to salvage Krystle at this point. Actually, compared to many of the cases seen here, the situation looks fairly simple to correct. Trim needs to be addressed immediately as the issues there are only compounding the damage. I would recommend pulling the shoes, correcting the trim then booting and padding her for comfort. Insulin, glucose and ACTH results will also be needed to help diagnose what is causing the problem.

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Lavinia, George Too, Calvin (PPID) and Dinky (PPID/IR)
Nappi, George and Dante Over the Bridge
Jan 05, RI
Moderator ECIR

Re: Radiographs

RF DP: The sidebone is active and can cause pain at this stage
RH LAT: The outline of the extensor process looks a little odd but I don't see a fragment either. It's probably caused by that small bone spur - early coffin joint arthritis. There is a thickened horn-lamellar zone (HLZ) indicating chronic lamellar thickening a gas or fluid pocket close to ground level. Fracture cannot be diagnosed on this view but if the horse is lame enough to consider fraction I would take more views and if negative it's probably an abscess, possibly that collection at the toe.
LF LAT: Slight true rotation, thickened HLZ.
LF  DP: Sidebone active.
RF LAT: Mild true rotation, separation at the white line, part gas/air, part dirt filled

I would get those shoes off ASAP and do a realigning trim, balanced mediolateral, then put the horse in boots and pads. You want to do this as close to when the   films were taken as possible. I agree there is no indication for tenotomy. The metformin was a good idea, ice not, NSAIDs and shoes not IMO.
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Eleanor in PA

www.drkellon.com  BOGO 2 for 1 Course Sale Through End of January
EC Owner 2001
The first step to wisdom is "I don't know."

Thank you everyone.  I apologize, I had not added the view where the fracture was diagnosed in the left hind - it is a line/crack in the middle of the bone. I have put it up now - it was from 12-15.  They didn't get any views of that today so I will try to get another one soon.  I also added X-rays from today - from the measurements the vet said only real change was  maybe a degree or two more rotation in the right front, but otherwise the same.    They put some padding on top of her leather pads you can see on the X-ray because they had trouble cutting them out with the shoe on (and of course didn't want to take it off).  She does seem more comfortable since they have put that in, but that could just be because they stopped the ice on my request at the same time.   

I also got the metabolic panel back today (drawn yesterday after 5 days of metformin.  I don't have a starting value.)  They sent it to Antech (not Cornell):
ACTH - 83 pg/mL
Insulin - 28 uU/mL  (Ref 0-42 uU/mL)
Glucose - 80 mg/dL (ref 70-120 mg/dL)

I am bringing her home tomorrow.  Right now the soonest I can get a farrier out is Tuesday (Lavinia  do you have any RI local ideas for me?  I also sent you an e-mail last night).  What boots does the group recommend, and what padding do you put in them (after the trim)?

Dr. Kellon, what do you mean by the sidebones are "active"?  She has had them forever, first x-ray was when she was 8 or 9 years old, and they haven't caused her any trouble.  Do they come into play with the laminitis, and is there anything that can be done to minimize that pain?

Could I get a recommendation for stopping or weaning her off the NSAIDs?  They have her on 1 bute twice a day and acetaminophen twice a day (not sure dose).  She has been on the bute for 2.5 weeks (was on it for the suspected fracture) and the tylenol for 7 days.

Thanks everyone for your help - I feel better already!

Angie

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Angie
Rhode Island, 2006
Krystle's Case History: https://ecir.groups.io/g/CaseHistory/files/Angie%20and%20Krystle
Krystle's photos: https://ecir.groups.io/g/CaseHistory/album?id=282722

 

 

Hi Angie

I was expecting your insulin to be much higher.  I think this is good news. Getting the PPID under control will also add help there, IMO.

The new padding (interesting set up) if it is helping would be because it is unloading the hoof wall and taking the pressure off the junction between the wall and the lamina, relieving pull/pressure from the periphery of the foot.

Using recovery boots like Soft Ride or Easy Care Rx would be my first go to. You or your trimmer may need to rasp the break over back. Krystle will tell you what works. Better movement, sighing, relaxed eye, licking and chewing.

I would start without wedge or elevated frog pads in the boots. Just start with pads to fit within the hoof wall, to support the sole. I used cut up anti-fatigue mats. Others will have recommendations.
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Nancy C in NH
ECIR Moderator 2003
ECIR Group Inc. President 2021-2022

ECIR Group NEW Case History site open to Early Adopters.

HOW TO SEARCH THE ARCHIVES: https://ecir.groups.io/g/main/wiki/1993

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Ellen
Pal & Savvy
N. Alabama
Aug 2013
Case History