Laminitis
(Founder, Fever in the feet) |  |
| Traditionally defined as inflammation or edema of the sensitive laminae of the hoof, laminitis is now thought to be a transient ischemia associated with coagulopathy that leads to breakdown and degeneration of the union between the horny and sensitive laminae. In refractory cases, rotation of the pedal bone is a common sequela that may progress to perforation of the sole. The disease is a local manifestation of a more generalized metabolic disturbance, and the hoof problems are
classified as acute, subacute, or chronic. It can develop in the forefeet, all four feet, or occasionally only in the hindfeet. Biomechanical laminitis can be seen in a single foot, usually as a complication of a severe lameness or orthopedic disease in the contralateral limb.
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| Etiology: |
| The most common causes of laminitis are ingestion of excess carbohydrate (grain overload), grazing of lush pastures (especially in ponies), and excess exercise and concussion in an unfit horse. It also may develop secondary to postparturient metritis, endotoxemia, colic and enteritis, or administration of an excess of corticosteroid or some other medicament. The risk is higher in ponies and in horses that are overweight and unfit. Incidence of the acute and subacute forms is
higher whenever there is a flush of new grass. |
| The initial change in acute laminitis is ischemia of the lamellar arterioles and venules. The arterial blood is then shunted to the venous return via the many anastomotic blood vessels in the foot (especially at the coronary band) and bypasses the corium; the result is stagnation of blood and functional congestion and thromboembolism of the capillary beds. Laminar necrosis contributes to rotation. |
| These disturbances in the circulation to the foot, which initially are reversible, probably cause the exhibited pain. However, if the condition becomes protracted and there is chronic hypoxia and a lack of essential sulfur-containing amino acids for the corium, then keratinization slows or stops between the stratum germinativum and the keratogenous zone. The end result, in mild cases, is production of “laminitic rings”; in severe cases, pedal rotation or complete separation of
the hoof from the underlying tissues occurs. The separation of the horny and sensitive laminae is due to ischemia, faulty keratinization, and the constant pull of the deep flexor tendon on the pedal bone, along with the upward push of the toe as the horse stands. There is some support at the back of the pedal bone from the deep digital flexor tendon and the digital cushion; however, these supportive structures may serve as a fulcrum, resulting in pedal bone rotation. If the
separation occurs rapidly, the pedal bone may “sink” within the hoof. In chronic cases, the corona of the pedal bone may penetrate the sole just in front of the frog. The prognosis in severe cases is poor because the changes become irreversible, and secondary infection is common. In subacute and chronic cases, the rotation of the pedal bone occurs relatively slowly. The sole tends to become convex and thicken, and the hoof alters shape to accommodate the new position. |
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| Clinical Findings: |
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In acute laminitis, the horse is depressed and anorectic and stands reluctantly. Resistance to any exercise is marked, and the normal stance is altered in attempts to relieve the weight borne by the affected feet. If forced to walk, the horse shows a slow, crouching, short-striding gait. Each foot, once lifted, is set down as quickly as possible. |
| Usually, heat is apparent in the whole hoof, especially near the coronary band. An exaggerated and bounding pulse can be palpated and may be visible in the digital arteries. Pain can cause muscular trembling, and a fairly uniform tenderness can be detected when pressure is applied to the feet. The pedal bone may rotate during or after the acute stage if efficacious treatment is not given rapidly. Radiographic evidence of rotation can be present as early as the third day. The
visible mucosae are often injected, with increased body temperature (104-106°F [40-41°C]), pulse rate (80-120/min), and respiratory rate (80-100/min). In exceptionally severe cases, for which the prognosis is unfavorable, a blood-stained exudate may seep from the coronary bands. |
| Subacute cases may exhibit any or all of the above clinical signs but to a lesser degree. Often, there is only a mild change in stance, with reluctance to walk and some increased sensitivity to concussion on the soles of the affected feet. There may be no demonstrable heat in the coronary band or increase in digital pulse. The acute and subacute forms of laminitis tend to recur at varying intervals and may develop into the chronic form. |
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Chronic laminitis is characterized by changes in the shape of the hoof and usually follows one or more attacks of the acute form. Bands of irregular horn growth (laminitic rings) may be seen in the hoof, close at the toe and diverging at the heel. The hoof itself becomes narrow and elongated, with the wall almost vertical at the heel and horizontal at the toe. |
| As the condition progresses, the sole becomes thickened and either flattened or somewhat convex in outline. The gait is similar to that already described, and when standing, the body weight is continually shifted from one foot to the other. Radiography reveals rotation and some osteoporosis of the pedal bone. The corona of the bone is forced downward and presses on the horny sole. In severe cases, it may penetrate the sole just in front of the point of the frog. |
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| Diagnosis: |
| In acute and severe laminitis, diagnosis is based on the history (eg, grain overload) and posture of the horse, increased temperature of the hooves, a hard pulse in the digital arteries, and reluctance to move. Mild cases with no visible hoof deformity can be identified via radiography of the affected feet, which show a lack of parallelism on the lateral projection between the hoof wall and cranial face of the third phalanx. Divergence of ≥11° indicates a guarded to unfavorable
prognosis for return to performance. |
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| Treatment: |
| Acute laminitis constitutes a medical emergency because pedal rotation can occur rapidly. Despite prompt therapy, the prognosis is guarded until recovery is complete and it is evident that the hoof architecture is not altered. In acute laminitis, especially in cases of grain overload, mineral oil is indicated; 1 gal. (4 L), PO, acts as a laxative and tends to prevent absorption of toxic material from the GI tract. Purgation should not be done in the acute phase because most
horses tend to be dehydrated. |
| Traditionally, cold packs or ice packs applied to the affected feet have been advocated, but recent evidence suggests that hot packs used early in the course of the disease may be more beneficial. Antihistamines are of doubtful value during acute lameness, but isoxsuprine hydrochloride paste, a peripheral vasodilating agent, may be of value. Heparin (40 u/kg, tid for 3 days) has been used because of the suspected accompanying coagulopathy and thromboembolism;
however, heparin therapy in horses has been associated with RBC clumping which, in a dehydrated animal, could aggravate dynamics of local blood flow in the feet. |
| Flunixin meglumine and phenylbutazone are the preferred anti-inflammatory agents, and meclofenamic acid also has been of value; however, all three may be toxic. These NSAID should be used according to label instructions and, if used in combination, the dosage of each should be reduced accordingly. |
| Phenoxybenzamine hydrochloride (0.66 mg/kg, IV, in 500 mL saline), which is an α-adrenergic blocker that causes vasodilation for up to 24 hr, has been used in severe and acute cases of laminitis. However, it may cause depression and should be avoided in horses in shock. |
| Heart-bar shoes have been used in acute cases in an attempt to diffuse sole pressure and avoid pedal rotation. Because an improperly fitted heart-bar shoe aggravates the pain, correct fitting is essential. |
| Administration of corticosteroids is contraindicated because serious cellular catabolism and inhibition of the immune responses often result in muscular wasting and worsening of the laminitis. Because gram-negative endotoxins due to carbohydrate overload have been implicated in laminitis, it is especially important to preserve the normal immune responses during treatment. |
| Experimentally, a combination vaccine consisting of a killed
Salmonella
mutant bacterin, an endotoxoid, and an aluminum hydroxide adjuvant has been effective in reducing the endotoxin-related complications of laminitis. |
| Digital nerve blocks in the early stages of the disease permit the horse to be walked, which increases the arterial blood flow through the terminal arch. However, nerve blocking and walking are contraindicated once pedal rotation has begun. Because of its value in hoof keratinization, methionine has been used at dosages of 10 mg/lb (22 mg/kg), daily for 1 wk followed by 5 mg/lb for the second week and 2.5 mg/lb for the third. |
| Treatment of chronic laminitis has consisted of attempting to restore the normal alignment of the rotated coffin bone and encouraging frog pressure by lowering the heels, removing excess toe, and protecting the dropped sole. This requires corrective hoof trimming and the use of full leather pads or a heart-bar shoe. Acrylic compounds are useful in conjunction with proper trimming to build up the toe and to protect the sole. The hoof should be trimmed and the shoe reset at 4- to
6-wk intervals. This approach can be successful in selected cases but is expensive, labor intensive, and prolonged. |
| Resection of the separated hoof wall may also be indicated and has been used in acute and chronic cases, particularly those with seedy toe or infection. This surgical procedure carries risk and should follow consultation between the veterinarian and farrier. |
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