PART 2: HEALING BEGINS

In the immediate aftermath of Arteiro’s accident, our main task was dealing with the long-term consequences of his injuries.

Iwent to see Arteiro 10 days after the entrapment. Wendee had told me that he had been put on anti-inflammatories and kept in his stall to mitigate any more damage to the leg. Dr. Ahern had saved the gelding’s life, but we weren’t sure what the long-term consequences of the accident might be. When I got there, Arteiro was a 4 out of 5 on the lameness scale, ranging from 0 (no observable unsoundness) to 5 (non-weight bearing). He still had significant swelling in the affected limb---his pastern was twice the diameter it was supposed to be. He also had a large, superficial wound on the inside of the joint. It was an abrasion, almost as if he had been burned by the friction of the stall bars. When horses exert force against a stationary object, it can damage the blood flow in the tissues. At first, the trauma can look mild, but then the skin begins to slough off.

Wendee had been keeping the wound clean and bandaged, so it was healing well, but it was still very large. There was also a large defect in that hoof---a four-centimeter horizontal crack just below the coronary band on the outside of the hoof ---that would have to grow out.

The good news was Arteiro had full range of motion and allowed me to flex the limb, so I was hopeful there wasn’t a fracture. And that was indeed the case: His radiographs looked remarkably normal for what he’d been through. The damage seemed to be limited to soft tissues. I had a strong suspicion that ligaments were involved, but there was still too much swelling and skin disruption associated with the wound to get a good ultrasound image. That would have to wait.

I also discovered something unexpected during that first visit: Arterio had a heart murmur, an irregularity in the sound his heart made with each beat. The murmur was a grade 2 out of 6, so relatively lowgrade, but persistent. I had listened to his heart in exams before the accident, so I knew this was a new development.

I wondered whether his struggles to free himself from the bars had damaged a valve or led to a cardiac overload. We know that, in times of great physical stress, dogs and people can rupture the chordae tendineae---little fibrous vines that pull valves closed.

This new murmur was not life threatening, but if it worsened, it might have some relevance to Arteiro’s future athleticism. At the time, it didn’t warrant transporting him to see a cardiac specialist, so Wendee and I agreed to just monitor the situation.

I recommended that we continue with stall rest and anti-inflammatories for another three weeks. We did, however, switch Arteiro to a topical anti-inflammatory to prevent the renal and gastrointestinal side effects that can occur with the long-term use of systemic non-steroidal anti-inflammatory drugs.

We also decided to introduce a little hand walking ---just five minutes a day on a flat surface to promote blood flow.

RECOVERY, ONE STEP AT A TIME

I came back in mid-May to perform an ultrasound of the injured leg. The wound had healed enough to allow contact of the probe to the injured area. Ultrasound revealed disruption of the fibers in the lateral oblique distal sesamoidean ligament, which is part of the suspensory apparatus supporting the pastern joint.

Arteiro was walking sound at this point, but remained 2 out of 5 on the lameness scale at the trot. Wendee and I discussed various options like platelet rich plasma (PRP) and shockwave therapy but decided to continue with the more conservative approach that seemed to be serving him well.

We still didn’t know what other damage Arteiro might have---to what extent he may have hurt his back or his hip in the struggle to free himself. Normally, once we’ve ruled out a fracture, we’d “block” the nerves serving each area in a limb to pinpoint the source of lameness. Arteiro, though, was a bit needlephobic and hind-limb foot-shy so we were unable to safely block his hind end in the field.

With all of that in mind, we decided to start intravenous injections of sodium hyaluronate to support

healing processes not only in the pastern and coffin joints, but in any other articular areas elsewhere in his body that were recovering.

We sought to take a holistic approach, working to preserve Arteiro’s soundness while addressing the needs of the entire horse.

No matter the injury you’re dealing with, you’ve got this “golden hour”--a window which can actually last days or weeks---to modulate the body’s inflammatory reaction and minimize the negative impact of inflammation. We wanted to make sure we’d done all we could in that time.

Wendee is a fantastic, attentive owner. I knew she’d take care of Arteiro’s mind as well as his body and notice immediately if something wasn’t going well.

STEADY PROGRESS

In mid-June, Wendee called to report that Arteiro had had three episodes of locking stifle, but I assured her that these were not an emergency and instead likely reflected weakness from the gelding’s prolonged stall rest. I came back in July, a little more than three months after the injury. Arteiro was still 2 out of 5 on the lameness scale, but there was significantly less swelling in his right hind leg and the ultrasound showed good fiber organization in the healing ligament. His pastern wound was almost healed and the defect in his hoof continued to grow down toward the ground. We increased his daily handwalking sessions to 30 minutes each. I was very happy with how well he was doing.

Three months later, I paid Arteiro another visit. He was only 1 out of 5 on the lameness scale, which was fantastic to see. His hoof defect was growing out and the ultrasound showed that his soft tissue injuries were still healing well. We took radiographs and the images showed only minor changes in the pastern bones---a tiny bit of bone remodeling that looked like his body was trying to stabilize the joint by laying down extra bone. If the joint had been seriously compromised, I believe we would have seen more of a reaction and the beginnings of significant pastern- or coffin-joint osteoarthritis.

Those radiographs and his degree of soundness reassured me that Arteiro would continue to heal well. Periodic follow-up visits and calls with Wendee have confirmed his progress and he has slowly been brought back into work. He’s at risk of pastern- and coffin-joint arthritis later in life, and we are going to continue to monitor his heart murmur, but he is doing fabulously considering the amount of trauma he experienced.

WHAT WENT RIGHT

From a veterinary standpoint, a few key factors made this a success story. One contributor to Arteiro’s fairly speedy convalescence is his age. He was only 4 years old when this happened and like young kids, younger horses can bounce back

We sought to take a holistic approach, working to preserve Arteiro’s soundess while addressing the needs of the entire horse.

from trauma a bit easier than older ones. I think this is one reason we didn’t see significant damage to his withers, neck, pelvis or back. If there was damage, it healed during his convalescence.

But maybe the biggest factor in Arteiro’s recovery was the consistency in his care and Wendee’s willingness to stick with the rehabilitation plan. In that “golden hour” after a trauma I mentioned, you need to develop a plan for treating the entire horse over the coming weeks. Rehabilitation plans for horses are similar to those designed in human medicine---the best outcomes result from carefully controlled movement plans. In most situations, shutting a horse up in a stall is not the best thing, but neither is turning them out in a field.

One lesson everyone can learn from Arteiro’s accident and recovery is that even if the horse seems fine after an incident, get a veterinarian involved in a long-term way. After a fall or other trauma, some horses act pretty normal, but that doesn’t mean they are okay. We lose too many horses too early to advanced arthritis, and I honestly believe many of those cases are related to traumas that weren’t carefully managed years earlier.

I’d also emphasize that the care required is not difficult or expensive, but it does require coordination, persistence and patience. In this case, the plan called for judicious use of anti-inflammatory medications and lots of rest, with just enough activity to preserve range of motion.

Wendee was amazing in managing the process. She kept Arteiro’s mind busy while supporting his body’s effort to heal and didn’t deviate from the plan. She’s probably the biggest factor in his recovery.