VETERINARY TOPICS
Champagne Photography
Evidence suggests standing MRI is preemptive screening tool to identify fracture risk in fetlock joint
T
HE FETLOCK joint is the
most common site of cata-
strophic fracture in the Thor-
oughbred racehorse in the U.S.,
United Kingdom, and Hong Kong,
and a reduction in the occurrence
of fractures in this location would
have a significant impact on the
number of Thoroughbred racehorses
lost to fractures during training and
racing.
The fetlock joint is also frequently
affected by degenerative conditions
that lead to reduced performance
and often result in premature retire-
ment. While epidemiologic studies
have identified risk factors for frac-
ture formation, practical screening
tools to identify the at-risk horse,
before a fracture or irreversible joint
degeneration occurs, are limited.
Recent developments in standing
magnetic resonance imaging, or
MRI, offer the potential for just such
screening.
A bone adapts to the demands of
training and racing by a process
known as bone modeling.
Trainers and owners are most fa-
miliar with this process when deal-
ing with bucked shins.
The process of bone modeling
has a similar effect at many loca-
tions throughout the equine “in train-
ing” skeleton in addition to the shins.
It also occurs in the tibia, shoulder
(humerus), pelvis (hips), and the
fetlock. It is well known that bone
increases its size and mass in re-
sponse to exercise and that these
changes are essential if bone is to
tolerate the physical demands of
training and racing.
During normal exercise, bone
density increases by bone model-
30 THOROUGHBRED TIMES March 26, 2011
Benefits of MRI
ing as the bone is stressed dur-
ing work. Bone is first removed
(absorbed) and then it is replaced
with more dense bone. In some
horses, excess training can cause
Trabecular bone
the rate of bone removal (absorp-
tion) to exceed the rate of bone re-
placement, a process known as
non-adaptive bone modeling. This
abnormal condition weakens the
bone and causes it to become more
susceptible to fracture.
More specifically, if this process
goes undetected, the continued stress
of intense exercise on a bone that
is already weakened may lead to
stress fracture and ultimately cata-
strophic fracture. Identifying those
➤ the joint, these changes do not cause
Figure 2
Figure 1
➤ many years. In one postmortem
horses that have non-adaptive bone
modeling is the challenge of
trainers and veterinarians that di-
rect these horses. For reasons iden-
tified below, this condition is more
difficult to identify than is imme-
diately apparent.
Fetlock issues
In the fetlock, the effect of train-
ing and bone modeling occurs in
the subchondral bone layer at the
back part of the cannon bone just
beneath the sesamoids (Figure 1).
The subchondral bone layer is the
bone just below the cartilage layer.
This deep (extra-articular or out-
side the joint) location of subchon-
dral bone makes the identification
of non-adaptive bone modeling dif-
ficult to recognize by conventional
means such as radiographs or ul-
trasound (Figure 2).
Because these changes are deep
within the bone and are not inside
an increase in joint fluid produc-
tion (joint swelling) or produce re-
liable changes on radiographs. If
identified early, the same training
JOHN G. PELOSO, D.V.M.
practices that minimize the effects
of bucked shins can also minimize
the effects of non-adaptive bone
modeling in the subchondral bone
of the fetlock.
Disease of the subchondral bone
of the fetlock has been recognized
in Thoroughbred racehorses for
➤
study, 67% of all horses had gross
evidence of injury to the subchon-
dral bone in at least one fetlock.
The pathologic change that occurs
in the subchondral bone of the fet-
lock is termed palmar osteochon-
dral disease (POD). This condition
has been diagnosed for several years
Figure 3
using a bone scan (Figure 3), which
identifies the problem by showing
an “increased uptake of radiophar- ure 5), to excessive thickening or
maceutical at the back of the fet- hardening called sclerosis (Figure
lock joint,” indicating an active 6). In the more advanced cases there
problem. A bone scan cannot dif- is extensive subchondral bone loss,
ferentiate the spectrum of disease which eventually leads to thinning
or a secondary collapse of the over-
or the exact anatomic changes that
have occurred in that bone (Figure lying articular cartilage layer (Fig-
4). ure 7).
Current thinking suggests that Thinning and destruction of the
POD progresses from a mild thick- cartilage layer creates joint pain,
ening of the subchondral bone (Fig- and eventually significant degen-
Images courtesy of Elizabeth J. Davidson, DVM, Diplomate ACVS
Early subchondral Subchondral
Normal changes lucency
Maladaptive
microdamage Subchondral
and sclerosis lucency
Figure 4

The two MRI images (above) are from a normal horse that has
yet to begin training
➤
Figure 5
erative arthritis. In this model, the
initial stages of the disease are in
the bone only, are visible by stand-
ing MRI, and are potentially re-
versible. In the later stages of the
disease, the subchondral bone be-
comes necrotic and can no longer
provide structural support to the ar-
ticular cartilage layer positioned
above. This causes the cartilage
layer to collapse (Figure 7) much
like a sinkhole that forms when rock
dissolves from beneath the land sur-
face. The ultimate consequence of
this articular cartilage layer collapse
is endstage joint disease and the
premature end to a racing career.
Identifying the problem
The question is how horses with
this problem can be identified, know-
ing that it is difficult to recognize
in its early stages while recogniz-
ing that the disease is most treat-
able if discovered early.
The following clues should in-
crease suspicions. Playing the odds,
subchondral bone modeling is re-
sponsible for 66% of all lameness
in the fetlock, so horsemen in doubt
should assume the fetlock is the
problem.
Greater attention should be paid
to changes in personality and train-
ing behavior. Are they:
• Horses that were previously
happy in the barn, that cleaned up
their grain, and enjoyed going to
the racetrack, but now seem an-
noyed, do not finish up at mealtime,
and are sour when going out to gal-
lop in the morning?
• Horses that do not travel as
smoothly as they did previously or
have become very “choppy”?
• Horses that are now tying up
but they did not do so previously?
An acute lameness after racing
or breezing that resolves after two
to three days of rest is often a clin-
ical red flag.
The lameness can appear subtle
because of its evenness: It can occur
in both front fetlocks, or both hind
or all four fetlocks. This symmetry
can cause the lameness to linger
and cause a history of poor per-
formance for weeks to months. Fi-
nally, exercise riders that report “the
horse just doesn’t feel right” are
some subtle, nondescript symptoms
➤
that might be helpful.
Typical at-risk horses have some
of the following clinical character-
istics:
• In the early stages of the dis-
ease, because the condition is out-
side the joint (subchondral), some
of the reliable parts of a lameness
diagnosis are not present;
• The lameness is mild, there is
no joint pressure or filling, and flex-
ion tests and radiographs are neg-
ative; and/or
• When performing diagnostic
blocks, fetlock joint anesthesia is
negative but a low four-point nerve
block is positive.
The later stages of the disease are
easier to identify because there is
significant articular cartilage in-
volvement. Now there is more joint
➤
▼ medicine.
➤ general anesthesia is particularly
Figure 6
fluid pressure, a more prominent
lameness, a positive response to
both fetlock joint anesthesia and a
low four-point diagnostic nerve
block, and fetlock flexion tests, ra-
diographs, and a bone scan are pos-
itive. In other words, some of the
components of end-stage joint dis-
ease are present.
To get maximum value from a
fetlock MRI, it is imperative the site
To view a video of a horse
undergoing a standing
MRI examination, access
www.hallmarq.net
of pain be localized to the fetlock
using either a low four-point nerve
block or fetlock joint anesthesia.
MRI may be indicated where other
diagnostic imaging methods such
as radiology, ultrasound, and bone
scan have provided vague findings,
when more detail is required for a
known disease process, as an aid to
treatment or management proto-
cols, or to monitor healing.
Knowledge of the horse’s lame-
ness and medication history is es-
sential when decisions are to be
made regarding future serious works
and racing schedules.
Specific training and clinical de-
tails (timing of recent fast works, a
24-hour history of acute lameness
that resolved) should be exchanged
between the trainer, the racetrack
veterinarian, and the veterinarian
acquiring and interpreting the MRI
images with the goal of maximiz-
ing the likelihood of a successful
examination.
Use of MRI
MRI uses magnetism and ra-
diofrequency waves to create an
image. It creates many tissue im-
ages because it “slices” the fetlock
in three planes—left to right, top to
bottom, and front to back—thereby
providing three different perspec-
tives of the same problem.
Specifically, the hydrogen atoms
(in water and fat) in tissues are iden-
tified in the image with a similar
clarity that the radioactive agent is
identified on a bone scan. For exam-
ple, the edema in the latent condyle
fracture in Figure 8 shows up as a
clear white line against the black
bone background. Recognizing the
role that edema plays in disease and
the ability of MRI to distinguish
water and fat, it is obvious why MRI
plays such a prominent role in human
Because MRI gives useful infor-
mation about both bone structure
and bone chemistry, it can be used
to detect bone injury in the early
stages of disease, well before it can
be identified on X-rays.
The availability of MRI systems
for imaging horses under standing
sedation and without the need for
beneficial for horses in training as
trainers and owners are very reluc-
tant to anesthetize horses for a lame-
ness diagnosis, especially during
the racing season. Anesthetic death,
a poor recovery from anesthesia, or
recovery from general anesthesia
on a limb with a hidden orthopedic
fracture (see Figure 8) are all legit-
imate reasons for concern.
So, is standing MRI the preemp-
tive screening tool to identify frac-
ture risk in the racehorse fetlock
joint?
A postmortem study by veteri-
narian Dr. Tim Parkin of the Uni-
versity of Glasgow demonstrated
that, at a slice location just outside
the middle ridge of the cannon bone
(Figure 6 at white arrowhead), an
VETERINARY TOPICS
increase in subchondral bone den-
sity greater than 1.6 centimeters
correctly identified 90% of cannon
bones that fractured. These types
of measurements can be developed
to screen the at-risk horse with the
goal of preventing fracture forma-
tion. An MRI examination can be
performed on horses under stand-
ing sedation so that POD can be de-
tected early in the disease process.
Figures 4 to 8 demonstrate the
progression of subchondral disease,
and the ability of the standing MRI
to distinguish the range of changes
associated with POD. This could
prevent the progression of subchon-
dral damage toward end-stage joint
disease (Figure 7) or catastrophic
fracture (Figure 8) by modifying
the training and racing program.
Ongoing debate exists in the U.S.
over the value of standing MRI in
equine lameness diagnostics. Sup-
porters of high field MRI empha-
size the fact that the stronger magnet
produces a higher resolution image.
Yet in applications such as race-
horse fetlock bone screening, where
the lower resolution of standing
MRI still produces diagnostically
valuable images, the ability to scan
without general anesthesia is a real
benefit.
Of available imaging modalities,
a bone scan (nuclear scintigraphy)
produces the lowest resolution
image, yet the role that a bone scan
plays in lameness diagnostics is not
contested. It is interesting to note
that in the United Kingdom, Eu-
rope, and Dubai the realities of sub-
chondral bone disease in the
Thoroughbred fetlock are routinely
being monitored using the stand-
ing Hallmarq MRI system (three in
Newmarket, one in Ireland, two in
France, and one in Dubai) where
➤ reversible if recognized early. The
➤
Figure 7
THOROUGHBRED TIMES March 26, 2011
an average of 2.4 fetlock examina-
tions are performed per site per
month.
The MRI images presented in this
article were all done in the stand-
ing sedated Thoroughbred horse in
various stages of training using the
Hallmarq MRI system. The cases
progress from early in the course
of subchondral bone disease (Fig-
ure 5), to end-stage joint disease
(Figure 7), and early stages of frac-
ture formation (Figure 8).
➤
➤
Figure 8
The fetlock joint is the most com-
mon site for fracture formation in
the Thoroughbred racehorse. Good
evidence exists to show that these
conditions develop deep to the car-
tilage layer in the subchondral bone
due to a silent process known as
non-adaptive bone modeling.
The condition has two hard re-
alities: It is difficult to identify in
its early stages yet its effects are
tools available for disease identi-
fication, namely clinical examina-
tion, radiology, ultrasonography,
or a bone scan, are not sensitive
indicators for the spectrum of this
condition.
MRI is identified as the imag-
ing modality of choice for stress-
fracture detection in human
medicine. MRI can also provide
diagnostically valuable images in
the standing patient so the risks of
general anesthesia are avoided.
Racing jurisdictions in the United
Kingdom, Europe, and Dubai are
currently using this technique for
early fracture identification.
Therefore, when answering the
question, “Is standing MRI the pre-
emptive screening tool to identify
fracture risk in the racehorse fet-
lock joint?” evidence suggests the
answer is yes.
John G. Peloso, D.V.M., is founder, owner,
and partner of Equine Medical Center of Ocala
in Ocala. For more information, please visit
www.emcOcala.com.
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