Management of Congenital and Acquired Flexural Limb ...

Management of Congenital and Acquired FlexuralLimb Deformities

Stephen B. Adams, DVM, MS and Elizabeth M. Santschi, DVM

Flexural limb deformities in foals are a common orthopedic problem. Deformities of the metacar-pophalangeal and distal interphalangeal joints can be mild to severe and no single treatment regimeis always successful. Analgesia, balanced nutrition, oxytetracycline administration, limb splintage,and surgical transection of flexor tendons or accessory ligaments may be required for successfultreatment. Many congenital flexural limb deformities can be treated successfully without surgery.Acquired flexural limb deformities often require surgical intervention in addition to medical treat-ment. Deformities of the distal interphalangeal joint may be treated surgically by desmotomy of theaccessory ligament of the deep digital flexor tendon or by deep digital flexor tenotomy. Desmotomyof the accessory ligament of the superficial digital flexor tendon, desmotomy of the accessory ligamentof the deep digital flexor tendon, superficial digital flexor tenotomy, or a combination of theseprocedures in addition to aggressive medical therapy is often required for successful correction ofmetacarpophalangeal flexural deformities. Author’s addresses: Department of Veterinary ClinicalSciences, School of Veterinary Medicine, Purdue University, West Lafayette, IN 47907-1248 (Adams);and University of Wisconsin, School of Veterinary Medicine, 2015 Linden Dr., West Madison, WI53706 (Santschi). © 2000 AAEP.

Introduction

In foals restriction of a joint in a flexed position orthe inability to extend a joint completely is termed aflexural limb deformity. Flexural limb deformitiesmay be congenital or acquired. In some affectedfoals, in addition to the superficial and deep digitalflexor musculotendon units and their accessory lig-aments, the suspensory ligament, joint capsules,and collateral ligaments prevent normal extensionof the joints. Malformed bones occasionally occurwith congenital flexural deformities and rarely occurwith acquired deformities. In utero malposition,genetic predisposition, poor nutrition, and exposureto teratogens have been suggested as causes of con-genital flexural limb deformities. Acquired flexural

limb deformities may be caused by nutritional im-balances, rapid growth, and trauma.1 Lameness inthe affected limbs may precede some acquired flex-ural limb deformities, suggesting that pain may pre-dispose foals to develop flexural limb deformities.Congenital flexural limb deformities most commonlyinvolve the carpus, metacarpophalangeal, or meta-tarsophalangeal (fetlock) joints. Acquired flexurallimb deformities usually occur in the distal inter-phalangeal joint of the forelimbs, or the metacarpo-phalangeal joints.1,2

Congenital Flexural Deformities

Congenital flexural deformities usually involve thecarpal or fetlock joints and range in severity frommild flexion of one joint to severe flexion of several

AAEP PROCEEDINGS / Vol. 46 / 2000 117

IN DEPTH: LIMB DEFORMITIES

NOTES

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Proceedings of the Annual Convention of the AAEP 2000

joints. Although foals with severe distal limb flex-ural deformities may respond to treatment, foalswith severe flexion of the carpus (palmar angle 90°or less) or congenital arthrogryposis are unlikely toimprove and often are euthanatized.

Medical TreatmentWhen examining a neonatal foal affected with flex-ural limb deformities, it is important to determine ifthe foal can stand without assistance. If the foalcan stand, specific therapy for flexural limb deformi-ties is often unnecessary (Fig. 1). The foal shouldhave controlled exercise such as turn out in a smallpaddock with the mare for 1 h daily. The goals ofcontrolled exercise are to help lengthen or stretchthe palmar or plantar soft tissues (musculotendonunits, ligaments, joint capsules) while protecting thelimbs from overuse. Progress towards normal limbextension should be monitored daily. Some foalscan bear weight on the limb with fetlock joint knuck-led forward (flexed). As a result, the extensor ten-dons become taut and the flexor tendons are lax.

In these instances the limb should be splinted toextend the fetlock joint and load the flexor tendons.

If the foal cannot stand, splinting the limb inextension is necessary to allow the foal’s body weightto load and stretch the tendons and palmar softtissues. Splints should be applied carefully as theycan easily cause pressure sores due to the fragility ofthe integument and the pressure that is sometimesnecessary to extend the limb. Any strong, lightmaterial is suitable for a splint, however, polyvinyl-chloride (PVC) pipe is readily available and easilycut and shaped to the required size. For neonates,4-inch diameter thick-walled pipe, cut longitudi-nally into thirds or halves, is appropriate. Theends of the splint are padded with roll cotton coveredwith elastic tape. When applying a splint, the limbis bandaged amply, and the splint is positioned overthis bandage on the palmar or plantar aspect of thelimb. The splints are left on for a maximum ofeight h. If re-application of the splints is necessary,the limb should be unsplinted for several hours be-fore the splints are applied again.

A straight splint should be used if the deformity issevere. When the deformity improves, a bend canbe placed in the splint at the level of the fetlock jointto further extend this joint. PVC splints can bebent easily by notching each side of the splint andheating it over a flame (Fig. 2). Cooling the splintwith cold water will hasten hardening of the splintin the bent position. The use of splints should bediscontinued when joint angles approach normaland the foal can stand unassisted. At this point,controlled exercise will usually result in completecorrection of the deformity.

Corrective shoeing in foals with congenital flex-ural deformities is usually limited to applying toeextensions. Toe extensions are most valuable incases of distal interphalangeal joint flexural defor-mities. Toe extensions can be difficult to keep onthe foal’s foot, and hoof acrylic and aluminum plates

Fig. 1. This foal could stand and walk unassisted. The defor-mity resolved after 2 weeks of controlled exercise. (Reprintedfrom Adams SB, Santschi EM. Management of flexural limbdeformities in young horses. Equine Pract 1999;21:9–16 withpermission from the publisher.)

Fig. 2. Splints can be made from thick walled PVC plastic drain-age pipe that is cut in half longitudinally. This foal splint isbeing made from 4-inch diameter pipe and has been notched oneach side and heated to bend it at the level of the fetlock joint.

118 2000 / Vol. 46 / AAEP PROCEEDINGS




are often used in such instances. Commercialglue-on shoes are also available.

Intravenous administration of oxytetracyclinemay be useful in treating foals with congenital flex-ural deformities to relax flexor musculotendonunits.3,4 The most commonly used dose of oxytet-racycline for neonatal foals is 2–3 g given slowlyintravenously once a day until the limbs are in aposition where the foal can bear weight withoutassistance. Improvement is frequently observedafter a single treatment but up to three consecutivedays of treatment may be needed. This dose ofoxytetracycline far exceeds the dose recommendedfor treatment of bacterial infections, but appearssafe for healthy foals.5 Oxytetracycline should beused cautiously in sick foals, particularly those withrenal compromise, as the drug can be nephrotoxic.Fetlock deformities are the most refractory to treat-ment, and early treatment is indicated. Oxytetra-cycline appears to be most efficacious if used in thefirst few days of life, but it may be useful in olderfoals. Splints are often used in conjunction withoxytetracycline administration (Fig. 3).

Nonsteroidal anti-inflammatory drugs should beused in the treatment of flexural deformities be-cause the limbs are often painful from stretching thepalmar soft tissues. These drugs may cause ulcers,although ketoprofen may be less ulcerogenic thaneither phenylbutazone or flunixin meglumine. Re-ducing limb pain and promoting exercise will aidrecovery.

Surgical TreatmentSurgery to transect restrictive ligaments, tendons,or joint capsules is often not necessary for treatmentof foals with congenital flexural deformities, andshould be reserved for foals that fail to respond toother therapy. However, palmar carpal joint cap-sule transection may be needed for foals with severeflexural limb deformities of the carpus.6 Tenotomyof the ulnaris lateralis and flexor carpi ulnaris 2 cm

proximal to the accessory carpal bone has been ad-vocated for treatment of carpal flexural deformitiesin foals that can stand to nurse.7 Transection offlexor tendons or the suspensory ligament in ani-mals intended to be used as athletes is not recom-mended. Arthrodesis may be the treatment ofchoice for animals with severe fetlock deformitieswith marked flexion and abnormally shaped bones.This procedure can result in a pasture sound animal.8

Ruptured extensor tendons may occasionally leadto flexural limb deformities. More commonly, how-ever, ruptured extensor tendons occur secondary toflexural deformities. Usually extensor tendon rup-tures do not require specific therapy. If foals withruptured extensor tendons have difficulty placingthe foot in extension, a firm half-limb support ban-dage can be used to stabilize the fetlock joint andallow ambulation.

Acquired Flexural Limb Deformities

Acquired flexural deformities usually occur in thedistal interphalangeal joints of the forelimbs or themetacarpophalangeal joints. These deformities oc-cur uncommonly in the metatarsophalangeal andcarpal joints.

Distal Interphalangeal JointAcquired flexural deformities of the distal interpha-langeal joint usually occur in foals 6 weeks to 8months of age. Affected foals are often rapidlygrowing and nursing heavily lactating mares.Flexural deformity causes the angle formed by thedorsal hoof wall and the ground under the sole of thehoof (hoof-ground angle) to increase. This defor-mity may occur rapidly over 3 to 5 days so that theheel of the hoof raises off the ground causing the foalto “walk on its toes.” With more slowly developingdeformities the heel maintains contact with theground and grows excessively long. Over 2 to 3months the heel may grow to a length equal to thetoe of the hoof. Hooves with this deformity have

Fig. 3. (A) Congenital fetlock flexural limb deformity in the rear limbs. (B) Same foal 48 h later following 2 doses of oxytetracyclineand application of splints. (Reprinted from Adams SB, Santschi EM. Management of flexural limb deformities in young horses.Equine Pract 1999;21:9–16 with permission from the publisher.)





been termed club feet or boxy feet (Fig. 4). Thecoronary band may appear prominent in horses withclub feet. Deformity of the dorsal hoof wall withdishing and distraction of the sensitive and insensi-tive laminae may occur in long standing disease andlead to seedy toe and toe abscesses. Because oste-itis and remodeling of the distal phalanx can alsooccur, radiographs of the foot should be taken aspart of the clinical evaluation.

Medical TreatmentBalanced nutrition should be ensured for all affectedfoals. Energy intake should be reduced when muchhigher than minimal requirements, particularly inrapidly growing foals. In foals with mild flexuraldeformities the heels can be lowered with a rasp ifthey are long and in contact with the ground.When the toes of the hoof are worn, bruised, de-formed, or very short, a plastic acrylic cap (Techno-vit, Jorgensen Laboratories, Inc.) or glue-on shoescan be applied to the foot for protection. Extending

the toe with the acrylic or with glue-on shoes canincrease tension on the deep digital flexor tendonduring break-over and help to lengthen the muscu-lotendinous unit. Foals with flexural deformities ofthe distal interphalangeal joint that occur rapidlymay also benefit from the administration of oxytet-racycline to relax the deep digital flexor musculoten-don units. Foals should be walked several timesdaily. Pain may contribute to development of flex-ural deformities and stretching of the shortenedmusculotendon units during correction of the flex-ural limb deformity may be painful, so non-steroidalanti-inflammatory drugs should be administered.

In foals that do not respond to this approach tomedical therapy an alternative to surgery is to trimthe feet to a near normal shape and apply glue onshoes with raised heels. This relaxes the deep dig-ital flexor tendon and allows the weight-bearing loadto be shifted to the entire solar surface of the foot.Several resets of the shoes may be necessary andsuccess is variable. We generally prefer to surgi-cally correct nonresponsive flexural deformities ofthe distal interphalangeal joint.

Surgical TreatmentThe severity of the flexural deformity determinesthe surgical procedure necessary for correction.Guidelines for selecting either inferior check liga-ment desmotomy or deep digital flexor tenotomybased upon the hoof-ground angle are given in Fig-ure 5. These are general recommendations andthere are exceptions.

Desmotomy of the accessory ligament of the deepdigital flexor tendon (inferior check ligament desmo-tomy) is the treatment of choice in foals with thehoof-ground angle 90° or less that do not respond in10 days to conservative therapy (Fig. 6). This sur-gery is relatively easy, very effective for mild flex-

Fig. 4. This mild acquired flexural limb deformity of the distalinterphalangeal joint resulted in a long heel and prominent dor-sal coronary area. This deformity is often called a boxy foot orclub foot. (Reprinted from Adams SB, Santschi EM. Manage-ment of flexural limb deformities in young horses. Equine Pract1999;21:9–16 with permission from the publisher.)

Fig. 5. Guidelines for surgical treatment of flexural deformitiesof the distal interphalangeal joint based upon hoof-ground angle.ICLD 5 inferior check ligament desmotomy; DDFT 5 deep digitalflexor tenotomy.





ural deformities, and often corrects the deformityimmediately. Some owners are reluctant to autho-rize surgery in foals intended for sale because of thepotential to decrease value. The alternative to sur-gery is long term corrective shoeing, analgesics ad-ministration, and physical therapy, all of which canbe time consuming, expensive, and may not be suc-cessful. Descriptions of the surgical technique fordesmotomy of the accessory ligament of the deepdigital flexor tendon are found in most equine sur-gery textbooks. In some foals two to three days ofexercise are needed after surgery to relax or stretchother restrictive soft tissues and thereby to correctthe flexural deformity.9

Desmotomy of the accessory ligament of thedeep digital flexor tendon may be successful insome horses where the hoof-ground angle isgreater than 90° but less than approximately 115°and where marked hoof wall deformity and remod-eling of the distal phalanx have not oc-curred.1,2,9,10 In questionable cases, desmotomycan be performed first, and deep distal flexor te-

notomy later if correction is insufficient followingthe first procedure (Fig. 7). Horses with hoof-ground angles of 115° or greater usually requirea deep digital flexor tenotomy. Tenotomy of thedeep digital flexor tendon can be performed atthe level of the middle of the metacarpus or atthe level of the pastern joint. Tenotomy in themid-metacarpal region is simple to perform anddoes not require entering a tendon sheath. Ex-cessive scarring at the mid-metacarpal incisionsite has been described as an undesirable compli-cation, but in our experience this is a minor prob-lem if the operated limb is effectively bandagedand exercise is limited to walking for 3 weeks aftersurgery. Correction of the flexural deformitymay take several days due to restriction of exten-sion by joint capsule, ligaments, and periarticulartissues. Pain may be marked and analgesicsshould be administered in the postoperative pe-riod. Elevation of the toe of the hoof from theground during weight bearing is uncommon, but ifthis instability does occur, a heel extension should

Fig. 6. (A) Flexural deformity of the distal interphalangeal joint with a hoof-ground angle of 75° in a 5-month-old foal. (B) The samefoal 7 days after desmotomy of the accessory ligament of the deep digital flexor tendon and lowering of the heel with a rasp. (Re-printed from Adams SB, Santschi EM. Management of flexural limb deformities in young horses. Equine Pract 1999;21:9–16 withpermission from the publisher.)





be placed on the hoof. Many horses can be usedfor riding following tenotomy of the deep digitalflexor tendon.

Younger foals with severe chronic flexural limbdeformities of the distal interphalangeal joint re-sulting in weight bearing on the dorsal surface of thehoof wall have an unfavorable prognosis. Teno-tomy of the deep digital flexor tendon may be per-formed, but the success rate is variable due tocontraction and fibrosis of joint capsule and liga-ments and marked deformity of the distal phalanxand hoof wall (Fig. 8).

Metacarpophalangeal Joint

Acquired metacarpophalangeal (fetlock) joint flex-ural limb deformities occur most commonly in rap-idly growing horses 10 to 18 months of age and areoften bilateral.11 The angle of the affected jointincreases from a normal angle of about 140° (mea-

sured from the dorsal surface of the limb) to 180°and greater.

Three structures support the fetlock joint when it isin the normal weight-bearing position: the deep dig-ital flexor tendon, the superficial digital flexor tendon,and the suspensory ligament. Metacarpophalangealjoint flexural deformities are often caused primarily bya shortened superficial digital flexor musculotendi-nous unit relative to the skeletal column. Althoughthe superficial digital flexor musculotendinous unitmay initiate the flexural limb deformity, the deep dig-ital flexor musculotendinous unit may shorten second-arily and contribute to the deformity. In some horseswith marked flexural deformity of the metacarpopha-langeal joint, the suspensory ligament may be taut.One, two, or all three structures may be involved inflexural limb deformities of the metacarpophalangealjoints, making treatment of these flexural limb defor-mities challenging.

Fig. 7. (A) The flexural deformities of the distal interphalangeal joints of both forelimbs in this Quarter Horse colt were approxi-mately 115° and did not improve with desmotomy of the accessory ligament of the deep digital flexor tendon. Tenotomy of the deepdigital flexor tendons was then performed at the mid-metacarpal level. (B) Six months after surgery the alignment of the joints isnearly normal. There is minimal scar tissue and near normal appearance of the flexor tendons. (Reprinted from Adams SB,Santschi EM. Management of flexural limb deformities in young horses. Equine Pract 1999;21:9–16 with permission from thepublisher.)





The severity of the deformity may be classifiedinto three grades.11 Horses with mild deformitieshave upright metacarpophalangeal joints thatrarely flex greater than 180°. The flexor tendonsand suspensory ligament are loaded during weightbearing. Horses with moderate deformities haveflexion of the metacarpophalangeal joints past 180°while standing so that the fetlock joints are forwardof the hoof. However, when these horses walk ortrot, the metacarpophalangeal joints may extend toa position caudal to the hoof. Severely affectedhorses have metacarpophalangeal joints which areflexed past 180° at all times. These horses are saidto be “knuckled over.” When the metacarpophalan-geal joint flexes greater than 180°, the extensor ten-dons support the fetlock from further flexion andstand out prominently on the dorsal surface of thelimb. No stress is placed on the flexor tendons orsuspensory ligament (Fig. 9).

Fig. 8. The severe flexural limb deformities of the distal inter-phalangeal joints in the forelimbs of this foal were of severalmonths duration. No improvement was made after tenotomy ofthe deep digital flexor tendons. (Reprinted from Adams SB,Santschi EM. Management of flexural limb deformities inyoung horses. Equine Pract 1999;21:9–16 with permission fromthe publisher.)

Fig. 9. Moderate flexural deformity of the metacarpophalangealjoints in a 2-year-old Saddlebred filly. Note the prominent ex-tensor tendons which have become taut to prevent the horse fromknuckling over. (Reprinted from Adams SB, Santschi EM.Management of flexural limb deformities in young horses.Equine Pract 1999;21:9–16 with permission from the publisher.)

Fig. 10. The flexor tendons and suspensory ligament should bepalpated for tautness while forcing the fetlock into maximal ex-tension by pushing back with the opposite hand. The tauteststructure is usually the first one released at surgery.





Medical TreatmentSplints and corrective shoes may be successful intreating horses with mild flexural deformities of themetacarpophalangeal joint. A balanced diet shouldbe ensured and non-steroidal anti-inflammatory drugsshould be administered to reduce pain.1 Physicaltherapy, consisting of manual stretching of theflexor musculotendon units by extending the footand metacarpophalangeal joint can be done two tothree times daily. In most horses a corrective shoewith a 1–2 cm toe extension and a 2–3 cm heelelevation will be beneficial. The elevated heel shoereduces tension on the deep digital flexor musculo-tendinous unit which may allow the fetlock joint toresume a more normal position. Hoof angle hasvery little influence on the tension in the superficialdigital flexor tendon.12

Splints that position the metacarpophalangealjoint caudal to the hoof and force the horse’s weightonto the flexor tendons during weight bearing can behelpful. Splints can be made of 6-inch diameter,thick-walled PVC pipe split in half longitudinallyand cut to the proper length. A bend may be put inthe splint to conform it to the fetlock joint.

Surgical TreatmentSurgical treatment is indicated for mild flexural de-formities when no response to medical therapy isnoted after 10–14 d. Surgery should be consideredimmediately for treatment of chronic deformities inwhich the fetlock angle is always greater than 180°.

Selection of the best surgical procedure or combina-tion of procedures to correct metacarpophalangealjoint flexural deformities can be difficult becausemore than one structure supporting the fetlock mayprevent normal extension of the joint. The clini-cian should determine which structures prevent re-turn of the fetlock to a normal position by palpatingthe suspensory ligament and the flexor tendons justabove the fetlock with the horse bearing weight andthe fetlock firmly pushed palmarally into extension(Fig. 10). At this time the angle of the fetlock atmaximal extension is determined. In all but themost severe deformities, one or both of the tendonsare the most taut during palpation.

Guidelines for selection of surgical treatment formetacarpophalangeal joint flexural deformities aregiven in Figure 11. Flexural deformities less than180° during forced extension usually respond to in-ferior or superior check ligament desmotomy.13

The inferior check ligament is transected when thedeep digital flexor tendon is the most taut structureduring palpation and the superior check ligament istransected when the superficial digital flexor tendonis most taut or both tendons seem to be equally taut.Splints may help maintain the fetlock in a normalposition but are often not needed.

When the fetlock angle during forced extension isapproximately 180°, surgical transection of both theinferior and superior check ligaments is recom-mended followed by postoperative splintage. Se-vere flexural deformities greater than 180° usually

Fig. 11. Guidelines for surgical treatment of flexural deformities of the metacarpophalangeal joints based upon maximal extensionof the joint during weight bearing. ICLD 5 inferior check ligament desmotomy; SCLD 5 superior check ligament desmotomy;SDFT 5 superficial digital flexor tenotomy.





require desmotomy of both check ligaments or infe-rior check ligament desmotomy plus tenotomy of thesuperficial flexor tendon (Fig. 12). Very rarely thesuspensory ligament will require transection. Thegoal of all surgical procedures is to get the fetlock ina position less than 180° so flexor structures areloaded during weight bearing. Postoperative splint-ing will be helpful in maintaining the fetlock joint in aproper position. Splints may need to be applied for3 to 14 days depending on the progress. All horsesundergoing surgery should receive postoperative an-algesics.

Prognosis

The prognosis for young horses with mild and mod-erate flexural deformities of the distal interphalan-geal joint is good for athletic use. Horses requiringdesmotomy of the accessory ligament of the deepdigital flexor tendon may race successfully.14,15

Horses requiring tenotomy of the deep digital flexortendon for resolution of the flexural limb deformitycan often be used for light pleasure riding.1

The prognosis for horses with mild or moderate ac-quired flexural deformities of the metacarpophalan-geal joint depends on the response to therapy and maybe fair for pleasure riding. It is often difficult to suc-cessfully correct severe metacarpophalangeal jointflexural deformities and relapse may occur in horseswhich initially seem to respond to treatment.11

References1. Adams SB, Santschi EM. Management of flexural limb de-

formities in young horses. Equine Pract 1999;21:9–16.2. Auer JA. Flexural deformities. In: Auer JA, ed. Equine

Surgery. Philadelphia: WB Saunders Company, 1992:957–971.

3. Lokai MD, Meyer RJ. Preliminary observations on oxytet-racycline treatment of congenital flexural deformities in foals.Mod Vet Pract 1985;66:237–239.

4. Madison JB, Garber JL, Rice B, et al. Effect of oxytetracy-cline on metacarpophalangeal and distal interphalangealjoint angles in new born foals. J Am Vet Med Assoc 1994;204:240–249.

5. Wright AK, Petrie L, Papich MG, et al. Effect of high-doseoxytetracycline on renal parameters in neonatal foals, in Pro-ceedings. 38th Ann Conv Am Assoc Equin Practnr 1993;297–298.

6. Wagner PC. Flexural deformity of the carpus. In: WhiteNA, Moore JN, eds. Current practice in equine surgery.Philadelphia: JB Lippincott, 1990:480–482.

7. Vasey JR, Pascoe RR, Hazard GH, et al. Surgical manage-ment of carpal flexural deformity in foals. Vet Surg 1995;24:452.

8. Whitehair KJ, Adams SB, Toombs JP, et al. Arthrodesis forcongenital flexural deformity of the metacarpophalangealand metatarsophalangeal joints. Vet Surg 1992;22:228–233.

9. McIlwraith CW, Fessler JF. Evaluation of inferior checkligament desmotomy for treatment of acquired flexor tendoncontracture in the horse. J Am Vet Med Assoc 1978;172:293–298.

10. Fackelman GE, Auer JA, Orsini J, et al. Surgical treatmentof severe flexural deformity of the distal interphalangeal jointin young horses. J Am Vet Med Assoc 1983;182:949–952.

11. Wagner PC, Saines MH, Watrous BJ, et al. Management ofacquired flexural deformity of the metacarpophalangeal jointin Equidae. J Am Vet Med Assoc 1985;187:915–918.

12. Thompson KN, Chung TK, Silverman M. The influence oftoe angle on strain characteristics of the deep digital flexortendon, superficial flexor tendon, suspensory ligament, andhoof wall. Equine Athlete 1992;5:1–6.

13. Blackwell RB. Response of acquired flexural deformity ofthe metacarpophalangeal joint to desmotomy of the inferiorcheck ligament, in Proceedings. 28th Ann Conv Am AssocEquine Practnr 1982;107–111.

14. Stick JA, Nickels FA, Williams MA. Long-term effects ofdesmotomy of the accessory ligament of the deep digital flexormuscle in Standardbreds: 23 cases (1979–1989). J Am VetMed Assoc 1992;200:1131–1132.

15. Wagner PC, Grant BD, Kaneps AJ, et al. Long-term resultsof desmotomy of the accessory ligament of the deep digitalflexor tendon (distal check ligament) in horses. J Am VetMed Assoc 1985;187:1351–1353.

Fig. 12. (A) An 18-month-old filly with moderate flexural limb deformities in which the fetlock joints could be forced into extensionto about 180°. (B) Ten days after inferior and superior check ligament desmotomies on both forelimb the flexural deformities haveimproved so angles of approximately 165° are present in both forelimbs. The filly could walk without knuckling for short periods oftime but required splints periodically to maintain the angle less than 180°.





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