Videos 1 and 2 Digital flexor tendon sheath: previous injury to the palmar aspect of the palmar annular ligament and the sheath wall Transverse (Video 1) and longitudinal (Video 2) sections of the palmar aspect of the left fore digital flexor tendon sheath at the level of the fetlock joint. This horse had sustained an injury while hunting some months previously and had demonstrated an intermittent lameness since that time.
There are several focal areas of increased echogenicity, surrounded by well defined anechoic areas. These abnormal areas are located at different depths to each other: within the subcutaneous tissue, within the tendon sheath wall, within the paratenon of the superficial digital flexor tendon (SDFT), and on the palmar aspect of the SDFT itself. There appears to be mild disruption of the palmar aspect of the SDFT in the region of one of these abnormal ultrasonographic areas. Dynamic ultrasonographical assessment allows: the location of the foreign bodies to be more accurately defined, indicates the presence of ill defined acoustic shadows from some of these areas, and also allows a more accurate interpretation of the tendon margins to be made (which is often also easier in longitudinal section than in transverse section). There are no significant abnormalities of the deep digital flexor tendon, the palmar aspect of the proximal sesamoid bones, and the intersesamoidean ligament. A normal manica flexoria is also visible in transverse section.
Surgical removal confirmed these focal echogenic structures to be blackthorns encapsulated within pockets of fluid (represented by the surrounding areas of decreased echogenicity). The mild disruption to the palmar aspect of the SDFT was also confirmed. Ultrasonography was used at the time of surgery to aid in the location of the foreign bodies and to help direct the surgical procedure.
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Video 3 Hock: blunt, traumatic injury of the lateral digital extensor tendon Transverse section of the cranial aspect of the left hock, centered over the lateral digital extensor tendon (LaDET). This horse had been involved in a fall and had subsequently developed a marked effusion of the LaDET sheath.
There is moderate–severe disruption of the fiber pattern of the LaDET, particularly on its medial aspect. As expected, there is more synovial fluid evident within the distal aspect of the tendon sheath compared to further proximally. There is associated synovial proliferation, thickening of the synovial lining and the mesotenon. The underlying distocranial aspect of the tibia and the lateral trochlear ridge of the talus, with its overlying articular cartilage, are normal in appearance.
The horse was treated conservatively with rest, controlled exercise, and non-steroidal anti-inflammatory medication in the short term. The effusion has decreased (but by no means resolved) and the horse has remained sound with increasing exercise. There has been ultrasonographical improvement in the appearance of the LaDET.
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Video 4 Hock: kick injury to the sustentaculum tali, involving the tarsal sheath Transverse section of the medial aspect of the right hock. This horse presented with a 3-week history of a moderate lameness and a draining wound on the medial aspect of the hock.
There is a significant effusion of the tarsal sheath with thickening of the synovial lining and mesotenon. The fluid is largely anechoic in nature. There is fragmentation of the sustentaculum tali adjacent to the deep digital flexor tendon (DDFT). The wound tract can be traced from the fragmented bone to the skin surface. The ability to follow a wound tract ultrasonographically is not only useful from a diagnostic view point but can also be used to aid surgical debridement. Debridement of the wound tract and the damaged sustentaculum tali was performed and there was a small communicating tract with the tarsal sheath which was flushed tenoscopically. There was no evidence of damage to the DDFT.
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Video 5 Superficial digital flexor tendon: traumatic kick injury Transverse section of the palmar aspect of the left fore metacarpus. This horse presented with a severe kick wound to the distal third of the palmar metacarpus and was non-weightbearing lame on initial assessment.
At the proximal and distal aspect of the superficial digital flexor tendon (SDFT), the tendon is enlarged with a generalized reduction in its echogenicity. At the level of the wound there appears to be a complete loss of the medial aspect of the SDFT. There are multiple small, focal and very echogenic artifacts at the level of the wound and also within the digital flexor tendon sheath (DFTS). These artifacts are caused by the presence of air and result in acoustic shadowing. In these types of cases, care must always be taken not to misinterpret the loss of image quality (due to the presence of air and the subsequent acoustic shadowing) as severe tendon damage. In this case digital palpation confirmed severe disruption to the SDFT.
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Video 6 Digital flexor tendon sheath: previous penetrating injury involving the superficial digital flexor tendon and the sheath wall Transverse section of the palmar aspect of the right fore digital flexor tendon sheath (DFTS) at the level of the fetlock joint. This horse had sustained a wound to the palmar aspect of the left fore DFTS a few weeks previously. There had been associated effusion of the DFTS, a moderate but intermittent lameness, and an intermittently draining wound since that time. Repeat synoviocentesis of the DFTS, performed on several different occasions since the original injury, had not been consistent with infection and there had been no communication with the wound on distension of the DFTS with sterile saline.
An acoustic shadow from the skin surface is present in the first frame of the video and is caused by part of the wound. There is thickening of the tissues between the skin surface and the superficial digital flexor tendon (SDFT). The plica is evident with effusion of the DFTS on either side of this. Medial to the plica there is an area of increased echogenicity situated between the palmar wall of the DFTS and the palmar aspect of the SDFT. This tissue is of mixed echogenicity, and creates an acoustic shadow. There is apparent disruption of the palmar surface of the SDFT, but as in Video 5, it is important not to over-interpret areas of ultrasonographic “cut-off” as tissue damage. The thickened tissue can be traced ultrasonographically to the wound on the surface of the skin. Surgery confirmed the presence of an abscess within the thickened tissue present ultrasonographically. This tissue had formed an adhesion between the wound, the palmar DFTS wall, and the palmar aspect of the SDFT. This infected tissue had been walled off such that there was no associated infection of the DFTS. Surgery also confirmed a small longitudinal tear in the palmar aspect of the SFDT in the region of the adhesion.
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Video 7 Digital flexor tendon sheath: penetrating injury involving the superficial digital flexor tendon and the sheath Transverse section of the plantar aspect of the digital flexor tendon sheath (DFTS). This horse had sustained a penetrating injury to the plantar aspect of the DFTS and presented with a moderate hind limb lameness. Ultrasonographically there is a moderate amount of subcutaneous thickening, effusion of the DFTS, and thickening of the synovial lining on the plantar aspect of the superficial digital flexor tendon (SDFT). There is a linear tract of reduced echogenicity extending from the plantar to the dorsal aspects of the SDFT, which is consistent with a penetrating injury. Synoviocentesis confirmed sepsis of the DFTS. Surgical exploration confirmed that the penetrating injury had been caused by a blackthorn.
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The Superficial Digital Flexor Tendon (SDFT)
Video 8 Superficial digital flexor tendon: severe acute injury and re-injury lesions Transverse section of a severely damaged superficial digital flexor tendon (SDFT). The tendon is grossly enlarged and is of mixed and irregular echogenicity. There is no normal fiber pattern present and the appearance of the tendon in this video is sometimes described as having an “open-weave” pattern. The outline of the tendon is not well defined throughout the duration of the video. Distally, there is the indication of a “halo” or ring of decreased echogenicity (giving a “donut” type of appearance), within the center of the tendon. This represents a re-injury lesion.
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Video 9 Superficial digital flexor tendon: acute injury and re-injury lesions Transverse section of the superficial digital flexor tendon (SDFT). This tendon had initially been injured approximately 1 year before this ultrasonographical examination was performed. The old (“healed”) tendon lesion is evident at the start of the video where there is a large central area of the tendon that is of increased echogenicity and of an abnormal fiber pattern, typical of a chronic injury. Further distally there are several small anechoic core lesions present within the center of the “healed” lesion. Further distally still there is a “halo” (ring of decreased echogenicity) present around the “healed” lesion giving a “donut” type of appearance. At the distal aspect of the tendon, just proximal to the level of the fetlock joint and within the digital flexor tendon sheath there is a large anechoic tendon lesion in the central and palmar aspect of the tendon, representing an acute lesion. This horse has re-injured the SDFT, at the distal junction between the initial tendon injury and the normal tendon distal to it. This junction is often the site of re-injury. The area of decreased echogenicity within the DDFT at the start of the video is due to the distal attachment of the accessory ligament of the DDFT and is normal.
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The Hind Limb Suspensory Apparatus
Video 10 Hind limb proximal suspensory ligament: normal Longitudinal section of a normal hind limb proximal suspensory ligament. The dorsal and plantar borders of the ligament are clearly defined and there is a good fiber pattern of the ligament at its origin. There is a large anechoic oval structure present on the plantaroproximal aspect of the ligament which is a blood vessel. Blood vessels can cause edge artifacts (which are not that pronounced in this case), which can make ultrasonographical interpretation of the ligament difficult. Dynamic ultrasonography allows the probe angle to be constantly changed in order to evaluate the ligament as fully as possible, thereby reducing the “real effect” of these artifacts as much as possible. The plantaroproximal aspect of the third metatarsal bone is smooth in outline and echogenicity.
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Video 11 Hind limb proximal suspensory ligament: abnormal Longitudinal section of a right hind proximal suspensory ligament. There is a significant loss in the longitudinal fiber pattern (reduction in the echogenicity) of the origin of the ligament as well as significant disruption and irregularity of the plantaroproximal aspect of the third metatarsal bone.
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Video 12 Hind limb suspensory branch: abnormal Transverse section of the lateral suspensory branch of the left hind limb. There is a loss in the fiber pattern of the axial (or deeper) aspect of the ligament as well as irregularity of the ligament–bone interface at the insertion of the ligament onto the lateral proximal sesamoid bone. There is also some thickening of the subcutaneous tissue overlying the suspensory branch.
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Video 13 Hind limb suspensory branch: abnormal Longitudinal section of the lateral suspensory branch of the right hind limb. There is mild irregularity and mild fragmentation of the lateral proximal sesamoid bone at the insertion of the ligament onto the bone. There is associated loss in the longitudinal fiber pattern of the ligament at the site of this irregularity. The changes in this video are mild and in similar cases the significance of these findings should be interpreted in light of the clinical and diagnostic findings. This video highlights the importance of examining the entire width of the ligament as the plantar aspect of the ligament is more affected than the dorsal aspect, which is often the case.
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Video 14 Oblique distal sesamoidean ligament: abnormal Transverse section of the lateral oblique distal sesamoidean ligament (ODSL). The video starts over the distal aspect of the lateral suspensory branch, which appears normal, and the lateral attachment of the palmar annular ligament onto the lateral proximal sesamoid bone, which is demonstrating some mild irregularity. Distally, there is moderate damage to the lateral ODSL. The ligament is of mixed echogenicity, with some small focal areas of significantly increased echogenicity as well as more diffuse areas of reduced echogenicity. There are focal areas within the ODSL which represent fragmentation of the lateral proximal sesamoid bone at the attachment of the ligament onto the bone.
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Video 15 Oblique distal sesamoidean ligament: abnormal Transverse section of the medial oblique distal sesamoidean ligament (ODSL) of the left hind limb. There is a focal area of decreased echogenicity on the dorsal aspect of the ligament but there is no apparent disruption to the bone–ligament interface.
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