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A 17-month-old Holstein heifer was presented for persistent enlargement above the right hind fetlock of 1-month’s duration. Diffuse plantar soft tissue swelling was present on the radiographs and ultrasonography revealed the presence of multiple porcupine quill extremities embedded in the subcutaneous tissue within the flexor tendon sheath wall. Surgical removal was performed.
Diagnostic échographique de la présence de pics de porc-épic dans la gaine des tendons fléchisseurs chez une taure. Une taure âgée de 17 mois a été présentée pour l’évaluation d’une inflammation persistante de la gaine des tendons fléchisseurs du membre postérieur droit. La radiographie indiquait une atteinte non spécifique des tissus mous. L’échographie a permis de mettre en évidence la présence d’extrémités de pics de porc-épic au sein du tissu sous-cutané réactionnel ainsi que dans le fascia plantaire de la gaine des tendons fléchisseurs des doigts. Les corps étrangers ont été retirés chirurgicalement.
(Traduit par les auteurs)
A 17-month-old heifer was referred to the Veterinary Hospital for a persistent enlarged flexor tendon sheath on the right hind limb of 1-month’s duration. The anamnesis revealed the heifer had been injured by porcupine quills in this area 1 mo ago. Quills were removed by the owner several hours after the initial injury and penicillin procaine (Depocillin; Intervet Canada, Whitby, Ontario), 20 000 IU/kg body weight (BW), IM was administered for 5 d.
On admission, the heifer was alert and responsive; no lameness was noticed. Upon initial examination, rectal temperature (38.4°C), heart rate (68 beats/min), and respiratory rate (48 breaths/min) were within normal limits. Swelling was obvious on the lateral aspect of the flexor tendon sheath. Superficial and deep palpations of the tendons did not elicit a pain response. Dorso-plantar and latero-medial radiographs were taken to start limb evaluation (Figure 1). No bone reaction was visible. A moderate to severe soft tissue swelling was present on the proximo-plantar aspect of the fetlock. No air was present within the tissue. Ultrasonography of the flexor tendon sheath was performed thereafter. Several puncture wounds were detected after clipping the hairs. A real-time linear array scanner at a transducer frequency of 7.5 MHz was used and both transverse and longitudinal images were stored (Figure 2). Ultrasonography of the tendons and the tendon sheath revealed deep penetration of multiple bilinear hyperechoic structures of various lengths enclosed in a hypoechoic cavity within subcutaneous tissue and the plantar tendon sheath wall. The deep and superficial flexor tendons appeared homogeneous within the medial and lateral sheath and no effusion was present around them.
Based on the history and the presence of multiple linear foreign structures within the tendon sheath, a diagnosis of reactional inflammation of the subcutaneous and peritendinous tissue due to the migration of porcupine quills was made. Treatment consisted of surgical removal of the multiple foreign bodies. Surgery was performed under sedation with xylazine (Rompun 20 mg/mL injectable; Bayer Healthcare, Bayer, Toronto, Ontario), 0.05 mg/kg BW, IV and locoregional anesthesia provided by a sacro-coccigeal epidural injection of 30 mg of morphine (Sulfate de morphine injection USP, 10 mg/mL; Sandoz, Boucherville, Québec) diluted in 30 mL of lidocaine 2% (Lurocaine; Vetoquinol Canada, Lavaltrie, Québec). The heifer was positioned in left lateral recumbency on a tilt table with the affected limb uppermost. An 8-cm longitudinal skin incision was performed axially over the distal third of the metatarsus. A lateral and medial blunt subcutaneous dissection facilitated the exposure of the medial and lateral portions of the sheath. Per-operative ultrasonography with the scanner inserted in a sterile glove allowed location of 6 superficially and 2 deeply inserted quills within the sheath. A stab incision was performed over each superficial foreign body and it was grasped and extracted. The surrounding tissue appeared inflamed but no exudate was evident around the foreign bodies. The 2 deeply located quills were approached with a medial approach but only 1 could be removed. The last quill was left in place after several attempts to grasp it. The length of the quills ranged between 7 and 30 mm (Figure 3). The wound was flushed with 1 g of cefazolin (Cefazolin for injection USP 1 g; Novopharm, Toronto, Ontario) diluted in 1 L of sterile saline 0.9% and sutured routinely.
Sodium ampicillin (Ampicillin sodium for Injection USP; Novopharm), 10 mg/kg BW, IV, TID was administered preoperatively and continued for the following 5 d. Ketoprofen (Anafen injection 100 mg/mL; Mérial Canada, Baie d’Urfé, Québec) 3 mg/kg, IV was administered preoperatively and 2 administrations of phenylbutazone (Phenylbutazone tablets 1 g; Dominion Veterinary Laboratories, Winnipeg, Manitoba), 4.5 mg/kg BW, PO every other day were given during the postoperative period to limit swelling and pain. Cold hydrotherapy was initiated 48 h after the surgery once daily. No lameness was noticed during the immediate post-operative period even if a slight swelling persisted over the surgical site. The heifer was discharged from the hospital 6 d after surgery.
Hydrotherapy was continued for 1 mo after discharge and complete resolution of the swelling occurred after 20 d. One year after the injury, the heifer has calved and is in lactation in the herd. No difference exists between the 2 hind limbs and no episode of lameness has been reported since discharge.
Ultrasonographic findings in this heifer were consistent with those reported previously in a dog (1). The backward pointing barbs of quills induce a forward migration deeper into the tissue leading to synovial cavity or organ infection (1–3). Swelling over the flexor tendon sheath in cattle is mainly associated with septic tenosynovitis which induces a severe non-weight bearing lameness (4). Ultrasonography is a noninvasive useful complementary technique, and as such, is important for evaluation of inflammation within soft tissue, and lameness in horses. Lesions of the digital flexor tendon sheath have been described ultrasonographically in cattle (5). Tenosynovitis induced hypoechoic to hyperechoic effusion in the tendon sheath associated with loss of the striated pattern of the tendons on the longitudinal images. In this case, we observed an absence of effusion and both flexor tendons retained their normal ultrasonographic structure.
Migrating quills are uncommon foreign bodies in cattle. Ultrasonography was clearly indicated in this case as the quills were not visible on radiography. It is surprising that the heifer was not lame at presentation with this severe inflammatory reaction around the quills within the tendon sheath. This could have been due to the absence of tendon injury and to the localization of the quills in the subcutaneous tissue, being in the tendon sheath but outside the synovial cavity. Cattle are known as having remarkable ability to localize infection. This may explain the moderate migration of the quills in the time between the initial trauma and surgical removal.
One had to be left deep within the tendon sheath during surgery. Tenoscopic removal was envisaged but the owner elected to have conservative management. It is surprising that no lameness has been reported since the surgery as further migration of the quill could ultimately have injured the tendon. We do not know if the quill is still at the same location as there has been no follow-up ultrasonographic examination. However, even though 1 quill remained within the tissue, surgical removal was necessary to reduce the amount of swelling associated with the foreign bodies. CVJ
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