480
27
Fractures of the Carpus
C. Wayne McIlwraith
Department of Clinical Sciences, College of Veterinary Medicine & Biomedical Sciences, Colorado State University,
Fort Collins, CO, USA
­Introduction
The carpus is a complex joint consisting of seven bones
within the articulation, all of which can sustain fractures.
In addition, the distal articular surface of the radius is a
major part of the articulation and also sustains fractures.
The motion and biomechanics of the carpal joints are
complicated.8,9,51 Various factors may lead to nonphysio-
logic loading of the carpal bones, including fatigue, poor
conformation (Figure 27.1) or shoeing, and poor racing
surfaces. Such abnormal loading can lead to synovitis,
capsulitis and articular damage, osteochondral chip frag-
mentation, slab fractures of an individual carpal bone, or
collapsing, comminuted fractures of the carpal bones,
which can, in turn, cause instability of the carpus. Horses
that sustain osteochondral chip fractures or ­simple slab
fractures can commonly be treated with arthroscopic
surgery and return to full athletic soundness. Injuries that
cause destabilization within the carpus are also indica-
tions for surgery, but the aim is to restore axial weight‐
bearing ability and to salvage the animal for breeding,
rather than athletic activity.8
­Osteochondral Chip Fractures
(Fragments)
Incidence and Location
Osteochondral chip fractures of the equine carpus are
common in racehorses. In a study of Thoroughbred
racehorses in the UK, it was the third most frequent
musculoskeletal injury for horses in active training, after
tibial stress fracture and fracture of the proximal pha-
lanx.56 In one series published by the author, 580 of 591
horses with osteochondral chip fracture were racehorses
Equine Fracture Repair, Second Edition. Edited by Alan J. Nixon.
© 2020 John Wiley & Sons, Inc. Published 2020 by John Wiley & Sons, Inc.
(including 349 Quarter Horses, 220 Thoroughbreds,
5  Appaloosas, and 6 Standardbreds).45 Standardbreds
are rare in the author’s area, so this is not a true ­reflection
of the overall incidence of osteochondral fragmentation
in Standardbred horses. A series of carpal chip fractures
in Standardbreds has been published more recently.38
The most notable difference between Standardbreds and
other racehorses is that while they are predisposed to
fragmentation of the distal portion of the radial carpal
bone and proximal portion of the third carpal bone,
they  rarely develop fragments in the antebrachiocarpal
joint.38,51 The specific locations of osteochondral
fragments are depicted in Tables  27.1 and 27.2.45
­
The most common location for chip fragmentation was
the distal aspect of the radial carpal bone, as previously
reported.51,52,63 This was followed by the proximal inter-
mediate carpal bone, proximal radial carpal bone, and
distal lateral aspect of the radius. The fractures were
equally distributed between the left and right joints
of  Quarter Horses, but significantly more frequent in
the  right carpus of Thoroughbreds. Previous reports
describe an increased incidence of fractures in the right
forelimb in Thoroughbreds.52,63 There were significantly
more fractures in the right middle carpal joint compared
with the left middle carpal joint, but no significant differ-
ence between the left and right antebrachiocarpal joints.
Significant differences exist between Thoroughbreds
and Quarter Horses in the relative frequency of fracture
location; the proximal intermediate carpal bone was
fractured more frequently in Quarter Horses, and the
proximal third carpal bone was fractured more ­frequently
in Thoroughbreds.
Published incidence data45 do not support earlier
statements that chip fractures are breed related, with
the Thoroughbred being more prone than the Quarter
Horse.63 Carpal chip fractures are very common in
 27  Fractures of the Carpus 481

Table 27.1  Location of carpal chip fractures in carpal joints of 591

racehorses (principally Thoroughbred and Quarter Horse).

Midcarpal (intercarpal) joints (540 joints)

Distal aspect of radial carpal bone 475
Distal aspect of intermediate carpal bone 106
Proximal aspect of third carpal bone 60
641
Antebrachiocarpal (radiocarpal) joints (460 joints)
Proximal aspect of intermediate carpal bone 273
Proximal aspect of radial carpal bone 168
Distal lateral aspect of radius 167
Distal medial aspect of radius 96
Proximal aspect ulnar carpal bone 1
705
Site total 1346
45
Source: McIlwraith et al.

r­acing Quarter Horses.45 Further, our data contrast

with another study in which the third carpal bone was
reported as the most common site in Thoroughbreds,68
but that study included only 57 horses. Previous stud-
ies reported that antebrachiocarpal joint fractures
Figure 27.1  Back‐in‐the‐knee conformation in Thoroughbred were three times more common in the left carpus than
racehorse about to undergo arthroscopic surgery for removal of the right, whereas fractures involving the middle c­ arpal
chip fragmentation. joint were seen twice as frequently in the right ­carpus.51

Table 27.2  Specific location of carpal chip fractures in racing Thoroughbreds and racing Quarter Horses.

Thoroughbreds Quarter Horses

Left Right Left Right

Midcarpal
Distal aspect of radial carpal bone 64 (34.4%) 85 (36.3%) 136 (32.7%) 158 (37.3%)
Distal aspect of intermediate carpal bone 15 (8.1%) 14 (6.0%) 29 (7.0%) 36 (8.4%)
Proximal aspect of third carpal bone 10 (5.4%) 22 (9.4%) 8 (1.9%) 19 (4.5%)
89 121 173 213
Antebrachiocarpal
Distolateral aspect of radius 30 (16.1%) 35 (15.0%) 53 (12.7%) 37 (8.7%)
Distomedial aspect of radius 17 (9.1%) 21 (9.0%) 32 (7.7%) 26 (6.1%)
Proximal aspect of intermediate carpal bone 30 (16.1%) 36 (15.4%) 97 (23.3%) 100 (23.6%)
Proximal aspect of radial carpal bone 20 (10.7%) 21 (8.9%) 60 (14.4%) 48 (11.3%)
Proximal aspect of ulnar carpal bone 0 (0.0%) 0 (0.0%) 1 (0.2%) 0 (0.0%)
97 113 243 211
Total 186 234 416 424

Source: McIlwraith et al.45

482 Part II  Specific Fractures

(A) (B)

(C) (D)

Figure 27.2  Radiographic appearance (A, B) and arthroscopic appearance before (C) and after (D) removal of distal radial carpal bone chip
fragment (arrow) that is barely discernible on preoperative radiographs. Diagnostic arthroscopy was performed because of return of
lameness problems referable to the middle carpal joint after the horse went back into training following lag screw fixation of a sagittal
fracture of the third carpal bone. The case was referred for screw removal (not usually done), but the new intraarticular fragmentation was
the real indication for arthroscopic surgery.

This has been related to stresses induced with counter-

clockwise racing. The author’s data45 indicated that
although there were more fractures in the right middle
carpal joint than the left, there was no difference in frac-
ture ­frequency between antebrachiocarpal joints in
either breed.45 This is interesting when it is considered
that most Quarter Horses do not race through a
turn.  Routinely radiographing both carpal joints and
­arthroscopy of suspicious lesions could mean that more
fragments are being found in the contralateral limb,
­nullifying left‐versus‐right differences.
Clinical Signs
Affected horses present with synovial effusion and
­varying degrees of lameness. In cases of osteochondral
fragmentation with minimal associated damage, the
main clinical sign is that the horse jogs with a wide‐based
stance. Bilateral chip fragments are common, particularly
in the Quarter Horse. Lack of sensitivity has been noted
in the use of radiographs to demonstrate some fragments,
and to determine the amount of associated cartilage dam-
age (Figure 27.2).45

Pathogenesis
It has been suggested that chip fractures are generally a
secondary complication affecting joint margins altered
by osteoarthritis (OA).54 It has been proposed that chip
fractures of the joint margin arise from at least two
­different processes. First, they can arise from fragmen-
tation of the original tissue of the joint margin. This
lesion starts as progressive subchondral bone sclerosis
induced  by repetitive trauma of training and racing,
with ­eventual damage of articular cartilage because of
the noncompliant subchondral bone. Eventually the
sclerotic bone undergoes ischemic necrosis. Second,
fragments can arise within the base of periarticular
osteophytes that form in OA.54 More recently, consider-
able research has recognized that pathologic changes in
the subchondral bone that precede fragmentation are
not simply those of subchondral bone sclerosis. Work at
Colorado State University has shown that microdamage
in the subchondral bone can develop early when horses
are  exercised and trained on the treadmill.30 In addi-
tion, post‐mortem examination of racehorse joints
(­euthanized for catastrophic injury in another limb) has
demonstrated the range of microdamage to include not
only microfractures, but also primary osteocyte death.49
Not only is the mechanical support of the articular
cartilage lost when subchondral bone microdamage
­ hyperextension, extreme speed, poor racing surfaces,
progresses to macrodamage, but cytokine release from
the bone may also potentially influence the state of the
articular cartilage.31
Even more recently, other possible early events leading
to microdamage in exercising horses have been assessed.
Comparison of the mineral components of the carpal
bones, post‐translational modifications of the c­ ollagenous
matrix, and concurrent changes in biomarkers of collagen
(A)
Figure 27.3  (A) Arthroscopic appearance of subchondral bone disease on third carpal bone. It is considered that such disease precedes
osteochondral fragmentation. (B) Diseased wedge of bone associated with a distal lateral radius fracture.
27  Fractures of the Carpus 483
remodeling and bone f­ ormation in radial and third carpal
bone from raced Thoroughbred horses (n = 14) and non-
raced Thoroughbred horses (n = 11)64 showed that while
there is a net increase in bone formation in racehorses,
there is additionally an increase in bone collagen synthe-
sis and remodeling, particularly within the trabecular
regions of the bone. The increase in bone density would
lead to greater stiffness, particularly in the carpal bones,
and failure of the “stiffer” ­cortical bone may result from its
lack of support from the rapidly remodeling and structur-
ally weakened underlying trabecular bone.
It is now generally accepted that microdamage leads to
the clinical osteochondral fragmentation seen in the car-
pus, and observations at arthroscopic surgery confirm
the presence of subchondral bone disease surrounding
and potentially preceding fragmentation (Figure  27.3).
For this reason, the author now prefers using the term
“fragment” rather than “fracture” for the osteochondral
pieces that are created, as they are truly pathologic
­fractures and occur as a consequence of microdamage.
In some instances the lesion appears as a “fresh” fracture
line through an articular surface with no visible sub-
chondral change, but in most instances subchondral
change can be seen arthroscopically, and it certainly
exists at the microscopic level.41
Fatigue of supporting soft tissue structures allowing
faulty conformation, and improper hoof trimming and
shoeing have all been cited as contributing to the develop-
ment of abnormal compression on the dorsal surface of
the carpal bones. In vitro kinematic studies in the carpus
have suggested that the radial carpal bone moves as an
independent unit, and that a concentration of kinetic
energy along the distal and medial aspect of the carpus
(B)
484 Part II  Specific Fractures

during weight‐bearing predisposes the region to injury.38,51 levels35 in synovial fluid of horses with osteochondral
It has been suggested by Bramlage9 that most of the carpal fragments, which reflects an upregulation of the inter-
bones articulate in a way that allows some of the axial load leukin‐1 cascade that has been previously demonstrated
to be transmitted transversely to carpal ligaments, and to promote OA in the horse.21
that the hinge nature of the m ­ iddle carpal joint limits
hyperextension. As a result, injuries to the middle carpal
joint are mostly derived from chronic supraphysiologic Surgery
loads. On the other hand, acute supraphysiologic loads are All osteochondral chip fragments are operated using
more likely to injure the antebrachiocarpal joint, due to its arthroscopic technique, which has been extensively
susceptibility to hyperextension as a rotating joint. Other described elsewhere.42,45 The equine carpal joints have
authors have speculated that the palmar soft tissue struc- been the most frequent locations for arthroscopic surgi-
tures may aid in counteracting carpal hyperextension, and cal procedures. Removal of osteochondral fragments
that jogging Standardbreds for several miles per day could from either carpal joint involves triangulation techniques
condition the palmar ligaments and protect the antebra- using two portals that remain consistent for all fracture
chiocarpal joint from fragmentation. locations. A lateral arthroscopic portal is made between
the extensor carpi radialis tendon and common digital
extensor tendon and their associated sheaths. A medial
Treatment portal is made approximately 5 mm medial to the exten-
sor carpi radialis. These portals are also made halfway
Arthroscopic surgery for the removal of these osteo- between the articular surfaces of the bones. Skin i­ ncisions
chondral fragments is indicated for the immediate relief are made in the appropriate location prior to distention
of clinical signs, and prevention of further development of the joint to avoid any compromise to the extensor
of OA. Carpal chip fragments cause pain by tugging on ­tendon sheaths. The position of the arthroscope and
synovial membrane attachments, induction of synovitis instrument relative to the appropriate lesion is illustrated
from release of debris, and damage to the opposing in Figure  27.4, using the distal radial carpal bone chip
articular surface. These factors can contribute to a fracture as an example. The arthroscope is placed
cycle  of OA which can become self‐perpetuating if through the lateral portal with the lens angled proximally
­surgical intervention is not timely. Other factors enter and the instruments are brought through the medial
into case selection for surgery, particularly the athletic portal.42 Generally, for a fragment on the medial side
ability of the horse and economics. The ideal surgical of  the joint, the arthroscope passes through the lateral
candidate is the proven racehorse that has recently portal and the instruments enter through a medial ­portal.
sustained an osteochondral fragment. Unfortunately,
­
the  “economics of the industry” preclude many horses
undergoing ­surgery. The judicious use of intraarticular
short‐acting corticosteroids can be defended on a one‐
or two‐time basis when it involves either triamcinolone
acetonide (Vetalog™, Zoetis, Parsippany, NJ, USA)23
or  betamethasone esters (Celestone™, Merck & Co.,
Whitehouse Station, NJ, USA).20 However the use of
­6‐alpha‐­methylprednisolone acetate (Depo‐Medrol™,
Zoetis) in the carpal joint with chip fragmentation can
no longer be defended,22 and it is also now recognized
that chip fragmentation of the distal aspect of the radial
carpal bone quickly produces secondary OA, whereas
fragments in the antebrachiocarpal joint are more for-
giving. In any case, repeated injection of corticosteroids
and long‐term continued racing without surgical inter-
vention are very difficult to defend.
The ability of chronic carpal chip fragmentation to
result in progressive OA is not just mechanically based.
Both synovitis and diseased cartilage and bone release
cytokines and other inflammatory mediators that can
Figure 27.4  Diagram illustrating the arthroscopic approach to
cause progression of the disease.35,41 This has mainly remove a fragment from the distal aspect of the radial carpal
been a clinical observation, but has recently been v­ erified bone. Source: McIlwraith et al. 2015.42 Reproduced with
biochemically, with evidence of elevated interleukin‐6 permission of Elsevier.
 27  Fractures of the Carpus 485

(A) (B) (C)

Figure 27.5  Preoperative radiograph (A) and arthroscopic view of direct removal of osteochondral fragment from proximal intermediate
carpal bone, during removal (B) and after debridement (C). Direct removal is preferred with such fragments, because elevation risks the
fragment becoming totally loose.

(A) (B) (C)

Figure 27.6  (A) Flexed lateral to medial radiograph of distal radial carpal bone fragment; (B) arthroscopic view after the fragment has
been elevated before removal, and (C) following completion of debridement.

For lesions on the lateral side of the joint, the ­arthroscope
is placed through the medial portal and the instrument is
positioned through the lateral portal.
A diagnostic arthroscopic examination is always per-
formed first. An egress cannula is placed through the
instrument portal previously made using a #11 scalpel
blade. The egress is then opened to allow flushing of the
joint if visualization is less than optimal. After the view is
cleared, the egress needle is closed and can then be used
to manipulate the fragment and ascertain its mobility.
Alternatively, a probe can be used. The initial diagnostic
examination is done with closed distention (care is
needed to maintain the ingress fluid pressure at a rela-
tively low level, as there is no free flow from the instru-
ment portal at this stage). A complete examination of
each joint can be made through a single arthroscopic
portal; however, the arthroscope may be exchanged
to  the opposite portal if lesions are being removed
from both sides of a joint. Arthroscope and instrument
positioning for removal of fragments in the various
­locations in the carpus have been described extensively
elsewhere.42
Carpal chip fragments can be divided into four categories
and the techniques used for their removal vary accordingly:
1) Recent fragments that are mobile on palpation.
Immediate insertion of the grasping forceps is per-
formed, the ­ fragment is grasped, the forceps are
rotated to free soft tissue attachments (if these are sig-
nificant), and the fragment is removed. The most com-
monly used forceps are 4 × 10 mm cup Ferris–Smith
intervertebral disk rongeurs. Nearly all proximal inter-
mediate carpal bone fragments are removed in this
fashion, as elevation can easily lead to them becoming
loose bodies (Figure 27.5).
2) Fragments with synovial membrane and fibrous
­capsular attachments preventing chip displacement
with initial probing. In this case, a periosteal elevator
is used to separate the fragment from the parent bone
(Figure  27.6). Ideally the fragment should not be
c­ompletely separated, as it then becomes a loose body
and is more difficult to retrieve.
3) Longstanding fragments with early bony r­ eattachment.
These cases are uncommon and in most instances the
486 Part II  Specific Fractures

bone is soft and the fragments are still removed with the middle carpal joint usually signals a poor prognosis,
Ferris–Smith rongeurs. If there is sclerotic bone pre- and is most commonly secondary to chronic distal radial
sent, tapping an elevator with a mallet or using a carpal bone fragmentation (with or without previous
4 mm osteotome may be necessary. Either way, this intraarticular therapy; Figure 27.7). The antebrachiocar-
manipulation is done under arthroscopic visualiza- pal joint is much more forgiving, and chronic fragmenta-
tion, with an assistant striking the osteotome with a tion and spurring can be present without significant
mallet to free the fragment from the parent bone. articular cartilage loss. Removal of osteophytes can be
4) Chip fragments with extensive bone reattachment and done with Ferris–Smith rongeurs (if the bone is relatively
a  bony proliferative response. The bone proliferative soft), but in other instances a motorized burr is more
response usually consists of osteophytes and in many appropriate. These cases are poor surgical ­candidates
instances these can be removed.42 Where these cases and palliative treatment is generally more appropriate.
have proceeded to extensive loss of articular cartilage, the
Once the fragment is removed, the defect is debrided
prognosis is very poor and it is uncommon to do surgery
(see Figures 27.5 and 27.7). Undermined cartilage or flakes
on such cases. There is also a difference between these
of cartilage at the edge of the lesion are removed using a
changes in the middle carpal joint compared to the ante-
bone curette and forceps. Soft defective bone in the base
brachiocarpal joint. Extensive osteophyte formation in
of the defect is commonly recognized and is also curetted.

(A) (B)

(C) (D)

Figure 27.7  (A) Preoperative radiograph showing severe osteophyte formation on distal radial and distal intermediate carpal bones in
a roping horse with chronic change following untreated osteochondral fragmentation. Arthroscopic views (B) before and (C) after removal
of osteophytosis from radial carpal bone, and (D) postoperative radiograph. The extraarticular exostosis is never removed.

(A) (B)
(D) (E)
Figure 27.8  (A) Radiographs and (B) arthroscopic views of grade II fragmentation of the distal aspect of the radial carpal bone before and
(C) after debridement. (D) Grade 4 osteochondral fragmentation of the distal radial carpal bone on initial visualization, and (E) after
removal and debridement of defect.
Kissing lesions are evaluated and only debrided if there
is  separated or defective articular cartilage and bone. A
­simple partial‐thickness defect in the articular cartilage,
with the deeper zone of cartilage firmly attached to sub-
chondral bone, is not an indication for debridement.
Debridement of articular defects is based on our current
knowledge of articular cartilage healing.41,44 While there
is no healing of a partial‐thickness defect, debridement of
that lesion to a full‐thickness defect is considered inap-
propriate because of the poor healing response. Defects
generally heal with fibrocartilage in the base, but fibrous
tissue at the surface. It has also been recognized on fol-
low‐up data that significant articular cartilage loss can be
sustained without compromising the return to athletic
activity.45 To further define how articular cartilage loss
affects the prognosis; four grades of articular damage in
the carpus have been defined:45
Grade 1. Minimal additional cartilage loss (extending
less than 5 mm from edge of defect left by osteochon-
dral fragment; see Figure 27.6).
27  Fractures of the Carpus 487
(C)
Grade 2. Loss of 30% of articular cartilage from the visible
articular surface of affected bone; see Figure 27.8A–C.
Grade 3. Loss of 50% or more of articular cartilage from
the visible surface of the affected bone.
Grade 4. Significant subchondral bone loss with loss
of  cuboidal bone support at the dorsal aspect
(Figure  27.8D–E). Details of arthroscopic technique
and individual differences with carpal fragments asso-
ciated with the various carpal bones are available in
detail elsewhere.42
After debridement, the joint is flushed by opening the
egress cannula and manipulating the tip, both in the area
of the lesion and also to the opposite side of the joint,
where debris will commonly accumulate. Extensive syn-
ovectomy is rarely carried out in carpal joints with chip
fractures. Occasionally, pieces of synovial membrane
are  removed for visualization purposes rather than
­therapeutic reasons. At the completion of irrigation of
the joint, the portals are closed using skin sutures only.
The carpus is bandaged with a sterile nonadhesive
488 Part II  Specific Fractures

­ ressing and adhesive gauze bandage. A full padded leg

d
bandage is then used on the limb during recovery from
anesthesia.

Lag Screw Fixation of Osteochondral Chip

Fractures
Arthroscopically guided screw fixation of large chip frac-
tures can be an alternative to removal in select cases.67
This is based on the premise that reconstruction of artic-
ular surfaces is preferable to creation of a large osseous
defect (grade 4 lesion). Potential candidates should have
a fragment of sufficient size to allow screw insertion, and
have adequate bony structure in the chip to warrant
screw reconstruction. Most chip fractures suitable for
reattachment are repaired with 2.7 mm cortical screws,
although on occasion these may be sufficiently large to
accommodate a 3.5 mm diameter screw. The latter may
be employed in the repair of frontal plane fractures of the
third carpal bone that extend only partway toward the
carpometacarpal joint before exiting to the dorsal sur-
face (so‐called partial slabs). Chip fractures of the dorso-
distal margin of the radial carpal bone, dorsoproximal
margin of the third carpal bone, and the intermediate
facet of the distal radius have been repaired using 2.7 mm
diameter screws in 33 horses.67 Delineation of the frac-
ture margins with needles is performed in a manner sim-
ilar to that described for the repair of larger slab fractures.
Most fractures that are amenable to screw fixation will
exit the bone within the capsular reflection and/or asso-
ciated intercarpal ligaments. This point can be deter-
mined, if necessary by radiographically guided needle
placement. The position for screw placement is defined
by insertion of an 18‐gauge spinal needle, and in most
instances is within the synovial cavity, therefore the drill-
ing process and insertion of implants can be performed
under direct arthroscopic visualization. The 2.7 mm
glide hole is drilled through the fracture fragment to
cross into the parent bone, and a 2 mm drill then used to
complete the thread hole. The hole is then tapped, coun-
tersunk, and an appropriate length screw inserted and
tightened. A radiograph is obtained to confirm appropri-
ate screw length and direction.
Postoperative Care
There are no special requirements for recovery from anes-
thesia following removal of osteochondral chip fragments.
A padded bandage is used for recovery to minimize any
trauma to the carpal joints. At the first bandage change,
a  light bandage of a TelfaTM pad (Kendall, Covidien‐
Medtronic, Minneapolis, MN, USA), a sterile 4 in. Kling
bandage (Kendall), and Elastikon® adhesive tape (Johnson
Figure 27.9  A horse undergoing underwater treadmilling for
rehabilitation following arthroscopic surgery of the carpus.
and Johnson, New Brunswick, NJ, USA) are used. Horses
are placed on phenylbutazone preoperatively, which
is  continued for three to four days postoperatively.
Perioperative antibiotics are not usually administered
unless there is concern about previous and recent intraar-
ticular injection. It has been shown that only 100 Staph
aureus organisms are required to cause infection during
intraarticular injection of an equine joint,27 and if there has
been previous intervention in the joint within two to three
weeks, the use of prophylactic antibiotics is appropriate.
The skin sutures are removed 10–12 days after surgery,
and hand walking for 5 minutes a day commenced. Hand
walking is increased by 5 minutes each week up to
30 minutes a day at 2 months, at which time the horse
may be turned out. Horses recovering from removal of a
fresh single chip fragment can recommence training at
this stage. Rehabilitation using underwater treadmill
exercise has become increasingly popular, and is recom-
mended by the author (Figure 27.9).32 It generally extends
over a 30–45‐day period, and commences 30–45 days
after surgery (some rehabilitation centers prefer not to
start until 60 days). A determination of the validity of
these rehabilitation procedures is currently ongoing.28
The total time from surgery to training varies from two
to four months, depending on the amount of associated
damage to the joint. There is a trend toward earlier
return to full training due to various factors, including a
recognition of the low morbidity of surgery, recognition
of the fact that we are not waiting for cartilage repair, and

the potential for other injuries following a long lay‐up
period.11 Water treadmilling is particularly valuable in
the lay‐up, since it can maintain bone mass to avoid
stress and catastrophic fractures, as well as suspensory
ligament injuries, all of which have been recognized after
coming back from a lay‐up period.28,32
Complications from arthroscopic surgery are rare.
Intraarticular infection is very rare (and usually comes
from a horse losing a bandage or getting the incisions
contaminated soon after surgery). Subcutaneous infec-
tions have occurred (associated with the same factors of
exposure) and these are treated by suture removal.
Synovial effusion (usually low‐viscosity hemorrhagic
fluid) will persist postsurgically when there is extensive
cartilage damage.42 Such cases have been successfully
managed with intraarticular polysulfated glycosamino-
glycan (PSGAG).69 Recent research suggests that the
“normalization” of these joints postoperatively can be
attributed to effectiveness of PSGAG to inhibit acute
synovitis.24 Hyaluronan has also been used to treat per-
sistent joint effusion, and has recently been shown to
have long‐term chondroprotective effects.24
Results of Surgery
Compared to arthrotomy, the benefits of arthroscopic
surgery include increased diagnostic accuracy (and
therefore more definitive treatment of the condition),
less tissue damage and improved cosmetic appearance of
the joint, more complete irrigation of the joint and elimi-
nation of debris, decreased postoperative pain, ability
to  operate multiple joints concurrently, and improved
performance after surgery.42,45 Follow‐up information
­ amount of secondary cartilage damage commonly asso-
has shown that the overall functional ability and cos-
metic appearance of the limbs is excellent.
Postsurgical follow‐up information has been reported
for 445 racehorses (Thoroughbreds and Quarter
Horses).45 After surgery, 303 (68.1%) raced at a level
equal to or better than preinjury level, 49 (11.0%) had
decreased performance or still had problems referable to
the carpus, 23 (5.2%) were retired without returning to
training, 28 (6.3%) sustained another chip fracture, 32
(7.2%) developed other problems, and 10 (2.2%) sus-
tained collapsing slab fractures while racing. There are
no comparative data at the present time to support the
supposition that operated horses are more prone to fur-
ther chip fractures or more severe carpal injuries.
Comparing the results of arthroscopic surgery in our
series of cases with the results of arthrotomy is difficult
because of the variable methods used in the past to assess
success.43 Earlier reports considered return to competi-
tion or starting in one race as a success.36,68 Using these
criteria, the success rate based on our 1987 report would
be 88.6% for Thoroughbreds and 88.8% for Quarter
27  Fractures of the Carpus 489
Horses.45 We believe that return to successful racing at
the same level or higher is a more realistic criterion, and
at least eliminates the variables of the horse’s ability.
When horses were separated into four categories of
articular damage, performance in the two most severely
affected groups was significantly inferior. Successful
return to racing at an equal or better level was found
in  133 of 187 horses with grade 1 damage (71.1%), 108
of  144 horses with grade 2 damage (75%), only 41 of
77 horses with grade 3 damage (53.2%), and 20 of 37 horses
with grade 4 damage (54.1%). The success rate in cases
with grade 1 and grade 2 lesions was significantly greater
than in cases with grade 3 and grade 4 lesions (P < 0.01).45
Refragmentation in grade 3 and grade 4 cases was quite
common, and also osteophytosis and enthesitis on the
dorsal aspect of the carpal bones. Although there have
been no specific follow‐up studies since this initial one
over 20 years ago, a study on palmar carpal osteochondral
fragments in 31 horses also reported on prognosis related
to dorsal carpal bone lesions (using the same grading sys-
tem), demonstrating that 53–54% of horses with grade 3
or grade 4 damage raced successfully.26 This study also
indicated that most horses with palmar carpal debris had
a reduced prognosis compared to earlier studies, where
horses with similar grades of dorsal carpal bone and carti-
lage loss, but without palmar debris, performed better.
The results of surgery were also assessed in relation-
ship to the location of the fracture.45 Only horses with a
single site involved (or the same site bilaterally) could be
included (187 Quarter Horses, 133 Thoroughbreds). The
distal aspect of the radial carpal bone had the poorest
prognosis in Thoroughbreds, which was related to the
ciated with these fragments. The worst prognosis in
Quarter Horses was seen with fragments associated with
the proximal surface of the third carpal bone, followed
by the distal aspect of the radial carpal bone.45
Healing of carpal chip fractures after lag screw stabili-
zation was satisfactory in 26 of 28 horses with available
follow‐up data.67 Of the 28 horses, 23 (82%) returned to
racing, with a mean convalescent time of 10 months; 19
of 28 horses (68%) raced at the same or better level of
competition. Given that the majority of these repaired
fractures would have been grade 4 defects after chip
removal, which has been associated with a 55% return to
racing, screw fixation appears to be a useful technique
for large fractures that would leave a significant articular
defect if removed. It should be recognized, however, that
the delay in return to racing will be longer than after chip
fracture removal.
A retrospective study of 176 Standardbred horses that
had arthroscopic surgery for carpal chip fracture removal
has been published.38 Chip fragmentation of the proxi-
mal third carpal bone and the distal radial carpal bone
490 Part II  Specific Fractures
occurred with equal frequency (49.2% and 49.6%,
­respectively), and chip fractures involving the antebra-
chiocarpal joint were rare.38 Trotters had significantly
more third carpal bone lesions than radial carpal bone
lesions when compared to pacers. Following surgery,
74% of horses had at least one start. Pacers were signifi-
cantly more likely to have at least one start after surgery
than were trotters. However, median earnings per start
significantly decreased after surgery, while median
race  mark significantly increased after surgery. It was
­concluded that the majority of Standardbreds would be
useful racehorses following carpal arthroscopy; however,
most earn less money per start, and many race at a lower
class. There was no data on prognosis relative to location
of fragment or grade of lesion.
Analysis of the surgical findings in 178 Standardbred
horses having diagnostic arthroscopy of the middle car-
pal joint after confirmation of the site of lameness by
intraarticular anesthesia indicated a preponderance of
cartilage, ligamentous, and synovial membrane lesions.37
Carpal osteochondral fragmentation was infrequent. Of
the 270 operated middle carpal joints in the 178 horses,
84 had cartilage erosion on the radial carpal bone and
154 had cartilage erosion of the third carpal bone.
Additionally, 88 had tearing of the medial palmar inter-
carpal ligament (PICL), while osteochondral fragmenta-
tion was identified on only 12 radial carpal and 35 third
carpal bones. This longitudinal study highlights the pre-
ponderance of cartilage and soft tissue injuries compared
to chip fragmentation as a cause of middle carpal joint
lameness in Standardbreds.
­Avulsion Fragments
Associated with Palmar
Intercarpal Ligaments
Introduction and Treatment
Both PICLs connect the proximal and distal row of car-
pal bones, one medially (MPICL) and one laterally
(LPICL). The MPICL runs from the radial carpal bone
to the second and third carpal bones, and, although
described initially as a single entity,40 has since been
recognized as consisting of two branches.53 A medial
branch extends from the palmar aspect of the radial
carpal bone to the palmar fossa of the second carpal
bone, and a lateral branch with the same origin inserts
on the palmar synovial fossa of the third carpal bone.
The dorsal aspect of the MPICL can be evaluated
arthroscopically, but the majority of the ligament is
inaccessible. Visible frayed fibers of the MPICL are
trimmed using a synovial resector or biopsy rongeurs.
While injury to the substance of the MPICL is the
most common problem encountered arthroscopically,40
Figure 27.10  Avulsion fragment associated with medial palmar
intercarpal ligament in middle carpal joint being treated for slab
fracture of a frontal slab fracture involving both radial and
intermediate facets of third carpal bone.
a­ vulsion fragments involving the ­distal attachment to
the third carpal bone are uncommon, but do occur.41
Most of the time these fragments are recognized at
arthroscopy during repair of a frontal slab fracture of
the third carpal bone (most frequently involving both
radial and intermediate ­facets; Figure 27.10).
The LPICL runs from the distal palmar aspect of the
ulnar and intermediate carpal bones to the palmar aspect
of the third and fourth carpal bones. The dorsal aspect of
the LPICL can be examined arthroscopically. Tears of
this ligament occur occasionally, but not nearly as com-
monly as those of the MPICL.42 Most injuries to the
LPICL are avulsion fractures from the ulnar carpal bone
(Figure 27.11). In a study of 37 cases of lateral PICL avul-
sion in horses,5 these avulsion fragments of the LPICL
involved a discrete fragment associated with the liga-
mentous origin on the ulnar carpal bone. Avulsion frag-
ments of the MPICL have only been diagnosed by
arthroscopic examination, compared to avulsion frac-
tures of the LPICL which were evident on radiographs,
were associated with forelimb lameness and clinical
signs referable to the carpus, and were then confirmed
arthroscopically.5 Removal of  avulsion fractures of the
LPICL is done using a ­dorsomedial arthroscope portal
and a dorsolateral instrument portal with the carpus
almost maximally flexed.5,42 For large avulsion frag-
ments, an instrument portal between the common and
lateral digital extensors may be required. Dissection of
the fragment from the body of the ligament can be
accomplished using a curved banana blade or small flat‐
ended periosteal elevator, and is followed by removal
with ethmoid or patella rongeurs (see Figure 27.11).
 27  Fractures of the Carpus 491

(A) (B) (C)

(D) (E) (F) (G)

Figure 27.11  Lateral palmar intercarpal ligament avulsion fracture from the ulnar carpal bone. (A) Dorsolateral to palmaromedial oblique,
(B) dorsal 20° lateral‐palmar medial oblique, and (C) dorsopalmar projections show the varying appearances of the fracture (arrows),
depending on projection. Two fragments are visible in (A) and (C). (D) Arthroscopic images show the pair of fragments (1, 2) associated
with avulsion of the lateral palmar intercarpal ligament (LPICL). (E) Dissection of the fragments. (F) Removal of the fragments with
rongeurs. (G) Fracture bed after fragment removal showing residual intercarpal ligament insertion on the palmar medial corner and
palmar midline portion (arrows) of the ulnar carpal bone.

Avulsion fragments of the MPICL have been removed
on occasion. More commonly they are left in situ, as they
are a minor part of the total joint pathology associated
with collapsing frontal slab fractures of the third carpal
bone that usually involve both radial and intermediate
facets. Beinlich and Nixon5 reported on the outcome
after treatment of 37 horses with avulsion fragments of
the lateral PICL from the ulnar carpal bone; 26 had sur-
gery and 9 were treated conservatively. For those treated
with arthroscopic fragment removal, 20 of 22 horses
(91%) for which follow‐up information was available
returned to work. For the 9 horses treated conservatively,
only 5 returned to work.5 Further, 12 horses having
arthroscopic fragment removal had LPICL avulsion
without concurrent osteochondral fragmentation in the
same or additional joints; follow‐up was available for 9 of
these horses, of which 8 returned to athletic work.
­Osteochondral Fragments
in the Palmar Aspect
of the Carpal Joints
Introduction
Discrete osteochondral fragments from the palmar
aspects of the carpal bones have been recognized and
removed.15,34,42,66 In two case series, involving 10 and
25 horses, it was clear that early diagnosis and removal
of  solitary palmar carpal fragments improved the
­outcome.34,66 A larger series of 31 racehorses with multi-
ple palmar carpal osteochondral fragments and debris
has been reported recently.26 These authors presented
good evidence that debris fragments are typically the
result of extensive pathologic changes in the dorsal
aspect of the joint, and represent a poor prognostic indi-
cator for future athletic performance.26 It is therefore
critical to differentiate between the two types of palmar
fragmentation, since the prognosis for palmar debris is
poor,26 while that following removal of solitary palmar
fragmentation is good.34
Incidence
Small discrete osteochondral fragmentation can
involve any of the palmar surfaces of the carpal bones,
with the radial carpal bone being most frequently
involved.34,42 In a recent description of discrete palmar
carpal fracture in 25 horses, 17 (68%) had fragmenta-
tion involving the antebrachiocarpal joint, 7 (28%) had
fragmentation involving the middle carpal joint, and
1 (4%) had ­fragmentation involving the carpometacar-
pal joint.34 The proximal aspect of the radial carpal
bone  was the most commonly affected site (12 of
492 Part II  Specific Fractures
Figure 27.12  Radiographs of multiple palmar osteochondral
fragments (arrows), recognized following recovery from
anesthesia for colic surgery.
30 fragments), f­ ollowed by the accessory carpal bone (6
of 30). The palmar surfaces of the ulnar and fourth car-
pal bones were involved less frequently. Large partial
slab fractures of the palmarolateral surface of the inter-
mediate carpal bone also occur and are difficult to
access for arthroscopic removal or reattachment.15,34,42
In cases of single palmar fragmentation, they are extru-
sion or compression injuries often associated with
anesthetic recovery (Figure 27.12). All 10 cases reported
by Wilke et al.66 involved the palmaromedial aspect of
the radial carpal bone, and many developed due to
hyperflexion of the carpus during anesthetic recovery.
In the series of cases by Getman et  al.,26 only 7 of 31
cases were considered to be primary lesions involving
the palmar aspect of the carpal bones; in 6 of these
horses the fragments were on the proximal aspect of
the radial carpal bone and 1 was on the proximal aspect
of the third carpal bone. Other cases were considered
to have debris fragments in the palmar pouch second-
ary to more extensive fragmentation in the dorsal
aspect of the joint.
Diagnosis
Clinical signs are referable to the carpal joints, and vary
from acute swelling and progressive lameness with dis-
crete palmar fragmentation, to more insidious lameness
and fibrosis in many instances, where fragmentation is
present in the dorsal compartment of the carpal joint as
well as in the palmar aspect. Definitive diagnosis is made
by radiographic examination.
Treatment
Arthroscopic removal of proximal palmar radial carpal
bone fragments can be done through a palmaromedial
approach to the antebrachiocarpal joint, which gives
access to the palmar perimeter of the radial carpal bone
and caudal aspect of the radius (Figure 27.13).14,34,42,66
The dorsal regions of the antebrachiocarpal joint are
usually examined first, and concurrent damage to
the  articular surface of the radius and proximal
radial  and  intermediate carpal bones is debrided.
The ­arthroscope portal is then made in the distended
palmaromedial outpouching of the antebrachiocarpal
joint.14 An instrument portal is developed adjacent to
the arthroscopic portal, and motorized equipment
used to remove synovial proliferation and provide bet-
ter visualization of the fragment.14,34 Discrete frag-
ments are then removed with straight or upbiting
rongeurs. Palmar fractures that involve the proximal
aspect of both radial and intermediate carpal bones
have also been described.34 Three‐dimensional imag-
ing with computed tomography (CT) provides consid-
erable help in determining the fracture origin site
and  the best approach for removal (Figure  27.14).
The  medial aspect of the proximal perimeter of the
intermediate carpal bone can be visualized using a pal-
maromedial approach to the antebrachiocarpal joint.
Synovial resection often  reveals fragments that have
detached from the i­ ntermediate carpal bone and local-
ize in the radial fossa along the caudal perimeter of the
distal radius (see Figure  27.14). Fragments in other
locations are approached as described,14,34,42 followed
by development of an adjacent instrument portal,
­synovial resection to develop a working space, and
identification and removal of the fragment.
In the series described by Getman,26 palmar osteo-
chondral fragments were removed in only 13 of 31
horses (41.9%). Horses with primary lesions on the dis-
todorsal aspect of the radial carpal bone or dorsal aspect
of the third carpal bone (dorsal compartment) were
more likely to have multiple small palmar fragments
than one or two fragments.26 All horses with slab frac-
tures of the third carpal bone had multiple palmar debris
fragments, and all had a smaller grade of palmar frag-
ments. Horses with the largest dorsal lesions (i.e., grades
2 and 3) were significantly more likely to have the small-
est (grade 1) palmar fragments. Horses with primary
lesions of only the proximal palmar aspect of the radial
carpal bone were significantly more likely to have one
palmar fragment than two or multiple fragments.
 27  Fractures of the Carpus 493

(A) (B)

(C) (D)

Figure 27.13  Palmar fracture of the radial carpal bone in a horse six weeks following recovery from general anesthesia for colic surgery.
(A) Dorsomedial to palmarolateral oblique and (B) lateral to medial radiographs show a large solitary fracture of the palmar aspect of the
radial carpal bone. (C) At surgery the fracture is isolated from synovial attachments and split into two prior to removal. (D) Debrided
fracture bed and the distal medial aspect of the radius after fracture removal. Source: Images courtesy Dr. Alan J. Nixon.

Results evidence of OA, 8 (57%) returned to function after sur-

Results in 10 horses with palmar fracture of the radial
carpal bone suggest that the simple fractures of the pal-
mar perimeter should be removed as soon as they are
identified.66 Cases where the damage was confined to
only the area of the fragment and where the fragment
was removed soon after injury tended to have less OA
and did better after arthroscopic surgery. In a follow‐up
study of 25 horses, 19 (76%) were sound after surgery and
returned to their intended use, 4 (16%) were considered
pasture sound, and 2 were euthanized (because of severe
postoperative OA or long bone fracture during recovery
from anesthesia).34 Of the 14 horses with preoperative
gery. When separated by joint involved, 12 of 17 horses
(71%) with antebrachiocarpal joint fragments and 6 of 7
horses (86%) with middle carpal joint fragments returned
to their previous use.
In the series of 31 cases surgically treated by Getman
et al.,26 multiple palmar fragments were diagnosed in 50%
of the horses. Assessing data from all 31 horses indicated
52% returned to racing, 48% returned to racing and earned
money, and 32% had at least five or more starts. All horses
with multiple fragments had significantly less earnings
per start, and lower performance index values after
­surgery, than those with one fragment. Horses with palmar
494 Part II  Specific Fractures

(A) (B) (C)

(D) (E) (F)

(G) (H)

Figure 27.14  Palmar fractures of the radial and intermediate carpal bones. (A) Dorsopalmar and (B) lateromedial radiographs identify
fractures (arrows) in the palmar aspect of the antebrachiocarpal joint. (C) Preoperative computed tomography shows multiple fractures on
the palmar aspect of the radial carpal bone (white arrows), a fracture bed on the proximal aspect of the intermediate carpal bone (black
arrows), and the displaced large fragment off the intermediate carpal bone located in the radial fossa. (D) The surgical procedure starts
with exploration and debridement of the dorsal compartment of the antebrachiocarpal joint, which is then temporarily closed with towel
clamps, and followed by the palmar medial approach with arthroscope and instrument portals adjacent to each other. (E) Arthroscopic
appearance of cartilage erosion on the dorsal distal aspect of the radius. (F) Palmar fragments being elevated for removal from the radial
carpal bone, and (G,H) intermediate carpal bone. Source: Images courtesy Dr. Alan J. Nixon.

fragments less than 3 mm in diameter were significantly
less likely to return to racing and have five starts or to win
money after surgery compared to horses with larger frag-
ments. The authors concluded the reason for horses with
multiple small fragments having a poorer prognosis was
associated with these being secondary to more severe
damage in the ­dorsal compartment.26 On the other hand,
horses with one or two large palmar fragments usually
had these fragments as primary lesions, and these are the
most appropriate cases for arthroscopic removal.
­Carpal Slab Fractures
Introduction
Slab fractures refer to fractures through an entire carpal
bone (the proximal joint surface to the distal joint sur-
face). They may occur in a frontal or a sagittal plane,
and most commonly involve the third carpal bone. The
radial, intermediate, and fourth carpal bones are less
frequently affected.

Incidence
In a survey of 371 third carpal bone fractures in 313
horses,61 the distribution included 93 frontal plane slab
fractures of the radial facet, 35 large frontal plane slab
fractures involving both radial and intermediate facets,
13 frontal slab fractures of the intermediate facet, and 13
medial corner fractures of the radial facet (considered
partial sagittal slab fractures by this author). Subdivision
of third carpal slab fractures to types 1–8 has been
described,61 but anatomical divisions are better recog-
nized. Frontal slab fractures are commonly differentiated
into displaced or undisplaced, as this has been consid-
ered relevant to surgical management. It is also impor-
tant to distinguish “routine” slab fractures from
“collapsing” slab fractures, where the radial carpal bone
drops into the fracture gap and progressive collapse of
the carpus may be anticipated.19
The radial facet is the most common location for fron-
tal slab fractures of the third carpal bone, and is also the
usual location for sagittal slab fractures. The high inci-
dence of fractures in the radial facet may be related to
the hinge‐like function of the middle carpal joint, which
impacts the radial carpal bone onto the radial facet
of  the third carpal bone during loading of the limb in
the close‐packed extended position.61 Additionally, the
medial location of the radial facet exposes it to larger
forces during exercise, while the intermediate facet is
protected by expansion of the articulation between the
third and fourth carpal bones when the intermediate
carpal bone is loaded against the distal row of carpal
bones.8,9 In another report, frontal slab fractures of the
third carpal bone were reported in 72 Thoroughbreds
and 61 Standardbreds, and 87% of these involved the
radial facet.62 The forelimbs were equally affected in
Standardbreds (35 right, 38 left); however, the right
third carpal bone predominated in Thoroughbreds
(48 right, 34 left). In a survey of the author’s cases, both
Thoroughbreds and Quarter Horses showed a prepon-
derance of slab fractures in the right third carpal bone
(70% and 67.7%, respectively), and this would be con-
sistent with more severe loading of the medial side of
the right carpal joint. In a fourth series of frontal frac-
tures of the third carpal bone, the right forelimb was
affected in 24 of 31 Thoroughbred horses (77.4%).39 The
fractures typically occurred at high speed (racing or
training) and among these 31 horses, intraarticular
corticosteroids had previously been administered in
­ activity is related to the amount of associated articular
20 (64.5%).39 Finally, in a study of catastrophic muscu-
loskeletal injuries in 314 racing Quarter Horses, the
­carpus was fractured in 24% of cases, second only to
fractures of the fetlock region, the latter representing
40% of the overall catastrophic fractures.60 The right
carpus was predominantly affected (67% of the carpal
breakdowns), compared to 17% involving the left carpus
27  Fractures of the Carpus 495
and 17% affecting both carpi. The third carpal bone was
most frequently affected.
Diagnosis
The clinical signs vary from mild to severe non‐weight‐
bearing lameness. Synovial effusion is consistently
­present. A full series of radiographs, including a skyline
view of the third carpal bone, is essential.
Treatment
For the purposes of discussion of repair, slab fractures of
the carpus will be divided into the following categories:
1) Frontal slab fractures of the radial facet of the third
carpal bone
2) Frontal slab fractures of the radial and intermediate
facets of the third carpal bone
3) Sagittal slab fractures of the third carpal bone
4) Combination frontal and sagittal plane fractures of
the third carpal bone
5) Frontal fractures of other carpal bones
6) Comminuted (collapsing slab fractures).
All carpal slab fractures in racehorses are considered to
be surgical candidates, given appropriate economics and
racing ability. Previous statements that undisplaced third
carpal bone slab fractures do not require surgery need
qualification.46 Healing may occur in some cases, but
progressive osteoporosis of the slab fragment and devel-
opment of OA are seen more commonly. In one report,
where undisplaced was defined as a fracture line of less
than 1 mm in width, 12 Standardbreds were treated with
rest and 10 eventually raced; 8 of the 10 raced well.62
However, in the author’s experience, undisplaced frac-
tures with a fracture line of less than 1 mm are uncom-
mon. One report concluded that even incomplete frontal
plane fractures in the radial facet of the third carpal bone
should be repaired by lag screw fixation.59 Radiographic
healing of the fracture was complete by four months in
11 of 16 (69%) of the fractures, and 11 of 13 (85%) of the
affected horses raced again.59 Horses with minimally dis-
placed slab fractures are excellent candidates for surgery.
Frontal slab fractures with some displacement are defi-
nite candidates for surgery, although the outcome is
more variable. Whether the horse can return to athletic
damage, which influences the extent of OA that devel-
ops. When fractures involve both facets, surgery is essen-
tial for restabilization of the fracture.
In this author’s opinion, sagittal slab fractures should
also be repaired by lag screw fixation, and this has now
been confirmed by others.33 While sagittal slabs require
a ­skyline radiograph for demonstration, arthroscopic
496 Part II  Specific Fractures
examination has shown that these slab fractures are
mobile. Conservative management of a series of 12 of
these fractures resulted in return of function in 7.18 The
author has treated cases that had not healed with con-
servative therapy, but later were successfully treated with
lag screw fixation. A case report describes a filly with a
sagittal slab fracture of the medial aspect of the third car-
pal bone treated conservatively with four months’ rest.25
Follow‐up radiographs revealed that OA developed in
the middle carpal joint, and when an attempt was made
to train the filly a chip developed in the antebrachiocar-
pal joint, ending in retirement from racing. More
recently, surgical and nonsurgical management of sagit-
tal slab fractures of the third carpal bone in 32 racehorses
has been reported, and horses treated surgically were
more likely to race after treatment than horses treated
without surgery.33
Surgery
Frontal Slab Fracture of Radial Facet
of the Third Carpal Bone
Surgical repair in all cases uses arthroscopic technique as
described by Richardson,57 with some modifications.42
Surgery is performed with the horse in dorsal recumbency.
A lateral arthroscopic portal and a medial instrument por-
tal are used, and a diagnostic examination of the joint is
performed. The slab fracture is visualized, the fracture line
debrided with a curette, and the fracture site and joint irri-
gated. The carpus is then placed in maximal flexion.
Under arthroscopic visualization, two 18‐gauge needles
are placed into the middle carpal joint medial and lateral
to the fracture slab and adjacent and parallel to the third
carpal bone. A spinal needle is then placed midway
between these two needles, close and parallel to the proxi-
mal articular surface of the third carpal bone, and directed
across the midpoint of the fracture as close to 90° as pos-
sible (Figure 27.15). Another needle is placed in the carpo-
metacarpal joint and a flexed lateral radiograph is obtained.
The needle placement as visualized in the joint determines
the lateromedial site of screw placement (halfway along
the slab). The needle placement on the radiograph dictates
the direction to ensure that it is approximately midway
proximodistal and parallel with the third carpal bone. A
stab incision is made with a #10 scalpel blade and a 4.5 mm
glide hole is drilled through to the fracture line. A 3.2 mm
drill sleeve is inserted and a 3.2 mm hole is drilled into the
parent third carpal bone. The 3.2 mm drill bit should go
close to but not exit the palmar cortex of the third carpal
bone. Drill exit is not damaging, provided that it does not
extend into the palmar carpal ligament, but may deposit
drill swath debris into the palmar joint pouch. The depth
of the hole is measured, tapped, and a screw of appropriate
length selected. Since this is often a blind hole, subtraction
CD ECR
3
4
2
U 1 R
Figure 27.15  Diagram demonstrating position of arthroscope
and placement of needles during fixation of a frontal plane slab
fracture in the third carpal bone under arthroscopic visualization.
CD, common digital extensor tendon; ECR, extensor carpi radialis
tendon; 2,3,4, second, third, and fourth carpal bones; U,I,R, ulnar,
intermediate, and radial carpal bones. Source: McIlwraith et al.
2015.42 Reproduced with permission of Elsevier.
of at least 2 mm for countersinking and 2 mm for fracture
compression is recommended. The 4.5 mm screw is then
placed to compress the fracture (Figure 27.16). The use
of one or two 3.5 mm screws has been described.57
Although there are advantages to the 3.5 mm screw,
including ­limited need to countersink and less promi-
nence of the screw head, the larger, stronger 4.5 mm
screw is preferred, except for smaller slabs (Figure 27.17).
Further radiographs are obtained to verify screw length
and direction. After screw fixation, the arthroscope is
reintroduced to the joint to visualize the fracture reduc-
tion and to remove any additional debris. Sutures are
placed only in the skin incisions.
If stability of the carpus will not be compromised,
removal of the slab fragment is considered when the
fragment is thin, the fracture is comminuted, or there is
a large wedge of fractured bone at the fracture site.
Removal of the slab fragment may be accomplished by
arthrotomy or arthroscopy. The arthroscopic technique
is quite difficult, involving sharp dissection. A curved
blade is necessary to sever the most distal attachments.
Removal is most easily achieved with an arthrotomy
medial to the extensor carpi radialis tendon. Sharp dis-
section is required to sever the joint capsule attachments
to the third carpal bone fracture.
The use of a cannulated Herbert screw has been
described for compression of experimentally created

Figure 27.16  Lag screw fixation of frontal slab fracture involving
radial facet of third carpal bone.
third carpal bone slab fractures (osteotomies),48 and
more recently the use of the Acutrak 2™ (AT) screw
(Acumed, Beaverton, OR, USA) has been reported for
treating frontal slab fractures of the third carpal bone in
horses.29 Like the Herbert screw, the AT screw is cannu-
lated, which facilitates accurate placement over a guide
pin and helps maintain adequate fracture reduction
­during drilling, and screw insertion. The AT screw is a
titanium alloy, cannulated, headless, variable‐pitch, self‐
tapping, taper compression screw. In an in vitro study10
using simulated third carpal bone slab fractures repaired
with either 4.5 mm AO cortical or 4.5 mm AT compres-
sion screws, insertion variables such as drilling torque,
tapping (AO) versus screw insertion (AT) torque, and
maximum screw torque were found to be comparable
between screw types. The mechanical shear testing
­variables recorded for yield and failure were also com-
parable; however, the AO‐repaired constructs had
­significantly greater initial shear stiffness.
Fixation of third carpal bone frontal plane slab fractures
with the AT screw system was reported in 17 racing
Thoroughbreds.29 Of 15 horses that raced before injury,
12 returned to racing. Average days to first start was
349.3 ± 153.9 days. Horses that returned to racing had
more starts after repair (median 6.5 versus 3.5; p = 0.04),
and did not have decreased earnings per start (median
$2432 versus $3061; p = 0.3). The cannulated screw was
accurate to place, prevented the need for countersinking,
decreased the possibility of fragment splitting, and elimi-
nated screw head impingement on dorsal soft tissue while
achieving stable fixation. Possible disadvantages of the
AT  screw system were cited as less potential for initial
27  Fractures of the Carpus 497
fracture fragment compression compared with screws
appropriately placed in lag fashion, the probable difficulty
of removing the screw if required for implant‐related com-
plications, and the necessity of learning a new technique
for inserting the screw type in the dense bone of horses.29
Frontal Slab Fractures of Intermediate
Facet of Third Carpal Bone
These fractures are less frequent, but when encountered
are treated using arthroscopic technique. The technique
is the same as described for radial facet fractures, except
that the arthroscope is placed in the medial portal and
the instruments through the lateral arthroscopic portal.
Care is also needed to avoid damage to the extensor carpi
radialis tendon and its sheath during incision and inser-
tion of drills and guides. A 3.5 mm screw is favored for
these fractures.41
Frontal Slab Fractures of Radial
and Intermediate Facets of Third Carpal
Bone
These frontal fractures involve both the radial and inter-
mediate facets of the third carpal bone (Figure 27.18). If
these fractures are not comminuted and do not involve a
collapsing component, they may be repaired similarly to
radial facet slab fractures.42 The arthroscope is placed
through the lateral portal and the fracture debrided. The
fracture is reduced using carpal flexion. The needles are
placed in the same fashion as previously described, but
two 4.5 mm screws are placed (one through each facet) to
provide sufficient stabilization (Figure 27.19). In general,
these slab fractures occur in a more palmar position than
radial facet slab fractures.
Sagittal Fractures of Third Carpal Bone
Partial slab fractures that enter into the junction between
the second and third carpal bones are removed using
arthroscopic technique. When the sagittal fracture line
parallels the second–third carpal articulation, lag screw
fixation is performed using an oblique 3.5 mm cortical
bone screw. The fracture is defined preoperatively using
a skyline radiograph (Figure 27.20).50 The fracture line
should be seen to traverse the third carpal bone from
the proximal to the distal articular surface on a dorso-
medial‐palmarolateral radiographic projection, to con-
firm it as a sagittal slab fracture and avoid confusion
with other sagittal plane injuries of the third carpal
bone, including subchondral lucencies, corner fractures,
and comminuted fractures.33 The arthroscope is placed
through the lateral portal and the fracture line visual-
ized and ­manipulated so that any loose cartilage and
bone debris is removed (Figure 27.20). A single needle is
placed from the medial side to define the junction of
second and third carpal bones and allow exact positioning
498 Part II  Specific Fractures

(A) (B)

(C) (D)

(E)

Figure 27.17  (A, B) Preoperative radiographs of third carpal frontal slab fracture repaired with 3.5 mm screw. Arthroscopic views
(C) before and (D) after lag screw fixation. (E) Postoperative radiograph.

(A) (B)
(D) (E)
Figure 27.18  (A–D) Radiographs of collapsing frontal slab fracture involving both facets of third carpal bone. (E) Radiograph taken under
anesthesia prior to fixation.
of the cortical bone screw. As a generalization, the
screw is placed immediately alongside the junction of
the second and third carpal bones at the dorsal face, to
provide maximum compression along the fracture line
without incorporating the second–third carpal bone
articulation in the compression fixation. A stab incision
is made to allow identification of the second and third
carpal bone junctions, and a 3.5 mm drill guide placed
equidistant between the proximal and distal borders of
the third ­carpal bone. The drill direction angles in as
near a frontal plane as possible. Intraoperative moni-
toring of placement of the screw is difficult and careful
arthroscopic assessment of the direction of the screw is
critical for compression (Figure 27.20). Following fixa-
tion of the fracture, the joint is lavaged and the skin
portals closed.
27  Fractures of the Carpus 499
(C)
Combination Frontal and Sagittal
Fractures of the Third Carpal Bone
Concurrent frontal and sagittal plane fractures of the
third carpal bone occur predominantly in racehorses.
Most combination or complex fractures of the third
­carpal bone do not result in collapse of the carpus, unless
the frontal plane fracture is substantially d ­isplaced.
Diagnosis usually hinges on identifying a fracture in both
the lateromedial and dorsomedial to  palmarolateral
oblique radiographic projections. Skyline radiographs of
the distal row are vital in further identifying the combina-
tion fracture (Figure 27.21). Sequential repair of the two
fracture planes can return these horses to athletic activity,
provided that the articular surface of the third carpal bone
is relatively intact without additional comminution.
Arthroscopic examination identifies the two fracture
500 Part II  Specific Fractures

planes, and allows debridement of any cartilage and bony
debris from the frontal plane fracture. The carpus is flexed
and the frontal plane fracture reduced and s­ tabilized with
one or two 3.5 or 4.5 mm cortical screws placed in lag
fashion as previously described. The sagittal fracture
remains relatively nondisplaced and is addressed after lag
screw repair of the frontal plane fracture. Repair  of the
sagittal fracture is accomplished with a single 3.5 mm
c­ ortical screw. The placement and direction of the 3.5 mm
screw allow the screw shaft to traverse the third carpal
bone proximal to the screws in the frontal plane fracture
(see Figure 27.21). If the 3.5 mm screw path cannot avoid
the screws stabilizing the frontal plane fracture, a shorter
3.5 mm cortical screw can suffice. Depending on the frac-
ture stabilization, horses are recovered either in a band-
age, or a bandage sleeve cast with the fetlock free to flex.

(A) (B)

(C) (D)

Figure 27.19  Lag screw fixation of collapsing frontal slab fracture involving both facets of third carpal bone. (A) With carpal flexion during
surgery showing displaced fractured portion requiring further reduction distally. (B) Fracture reduced and needles placed; (C) skyline view
of spinal needle centrally; (D) 3.2 mm drill guide placed through glide hole; (E) skyline radiograph after placement of two 4.5 mm cortical
screws in lag fashion. Because of comminution and a gap on the medial side, the screws were placed in the central portion and the lateral
portion of the fracture. (F) Arthroscopic view looking down medial portion of fracture to carpometacarpal joint after debridement. (G)
Lateral portion of fracture in intermediate facet of third carpal bone. (H) Medial portion of fracture after reduction and fixation with loss of
bone due to fragmentation in the proximal aspect creating defect. (I) Arthroscopic view of portion of fracture in intermediate facet after
reduction. (J) Intraoperative radiograph showing fixation of slab fracture.
 27  Fractures of the Carpus 501

(E) (F)

(G) (H)

(I) (J)

Figure 27.19  (Continued)

502 Part II  Specific Fractures

(A) (B)

(C) (D)

(E)

Figure 27.20  (A) Preoperative skyline radiographic view of sagittal slab fracture of third carpal bone. Arthroscopic views of fracture,
(B) before debridement, (C) with spinal needle placed across center of fracture, and (D) after screw fixation. (E) Postoperative radiograph
showing accurate screw placement with screw head adjacent to second–third carpal bone junction.
 27  Fractures of the Carpus 503

(A) (B)

(C)

Figure 27.21  Complex third carpal fracture repair. (A) Preoperative dorsoproximal to dorsodistal skyline radiograph indicates a frontal
(arrowheads) and sagittal plane fracture (arrow) of the third carpal bone. (B) Postoperative skyline and (C) dorsopalmar radiographs show the
fracture repair using two 3.5 mm cortical screws applied in lag fashion to stabilize the frontal plane fracture, and a single 3.5 mm cortical
screw to compress the sagittal plane fracture. The screw inserted to stabilize the sagittal plane fracture is placed immediately proximal to the
two screws in the frontal plane fracture. Source: Images courtesy Dr. Alan Nixon.

Sagittal Slab Fractures of Other Carpal
Bones
Sagittal slab fractures may also occur in the intermediate,
radial, ulna, and fourth carpal bones. These fractures
have generally broken into the adjacent intercarpal artic-
ulation and have been treated by removal of the fragment
using arthroscopic technique.45 Surgical treatment of
sagittal slab fractures of the fourth carpal bone has been
described.3 The results of surgery in these cases were
poor, but presentation of the patients was delayed and
arthrotomy was used. Sagittal fractures may also occur
along with comminuted fractures and/or carpometacar-
pal luxation. In these instances, the fourth carpal ­fracture
is not always specifically addressed.
Frontal Slab Fractures of Other Carpal
Bones
Frontal slab fractures in locations other than the third
carpal bone are uncommon. When they occur, they
­usually involve the radial carpal bone. These fractures
504 Part II  Specific Fractures

(A) (B)

(C) (D)

Figure 27.22  (A, B) Preoperative radiographs and (C) computed tomography of a two‐year‐old racehorse with a palmar fracture (arrows)
of the radial carpal bone. Measurements show anticipated screw length. (D) Arthroscopic view shows the fracture fragment being
aligned and a needle (in left of image) used to plan the lag screw repair. C2, second carpal bone; Crad, radial carpal bone; Fx, fracture
fragment. (E) Postoperative radiographs show the repair using several 3.5 mm cortical screws applied in lag fashion. Source: Images
courtesy Dr. Alan Nixon.

are generally undisplaced or relatively undisplaced, and
can be treated conveniently with lag screw fixation using
arthroscopic technique.42 Both the midcarpal and ante-
brachiocarpal joints are examined arthroscopically using
a lateral portal to assess the amount of joint damage,
remove debris, and ascertain the position of the fracture
line. Needles are placed in both joints, a smooth elevator
or obturator is used to lever the fractured slab into posi-
tion, and one or several 4.5 mm cortical bone screw
placed in lag fashion using the same techniques as
described for radial facet fractures of the third carpal
bone. More palmar variations of frontal slab fracture of
 27  Fractures of the Carpus 505

(E) the radial carpal bone can also occur. There is less bone
for the threaded portion of the lag screw and accurate
placement into the palmar portion of the radial carpal
bone is critical. Very thin palmar slab fractures of
the radial carpal bone can be repaired using 3.5 mm cor-
tical screws placed in a palmar to dorsal orientation
(Figure  27.22). Arthroscopic assessment and visualiza-
tion during screw insertion are accomplished using a
palmaromedial approach.14,42
Frontal slab fractures of the intermediate and fourth
carpal bones have also been described and treated
with  arthrotomy. The results were unsatisfactory.3
Arthroscopically assisted lag screw repair of an interme-
diate carpal bone large palmar frontal fracture allowed
good fracture reduction and stabilization (Figure 27.23).
Similarly, smaller frontal plane partial slab fractures of
the intermediate carpal bone can be reduced under
arthroscopic visualization and repaired using several
3.5 mm cortical screws (Figure 27.24). Preoperative CT
is useful in defining the fracture plane and developing
the plan for lag screw fixation.
Figure 27.22  (Continued)

(A) (B)

Figure 27.23  (A) Preoperative radiographs showing a large palmar slab fracture of the intermediate carpal bone associated with recovery
from general anesthesia. Screw length and trajectory are planned on the preoperative lateromedial radiographs. (B) Postoperative
radiograph showing fracture stabilization using partially threaded 6.5 mm cancellous screws. Source: Images courtesy Dr. Alan Nixon.
506 Part II  Specific Fractures

(A) (B)

(C) (D)

Figure 27.24  (A) Preoperative radiographs and (B) computed tomography showing multiple frontal plane fractures of the intermediate
carpal bone in a Thoroughbred racehorse. (C) Arthroscopic visualization and fracture line debridement are followed by reduction and
stabilization (D) using a curved hemostat to maintain positioning during insertion of 3.5 mm cortical screws in lag fashion. (E, F) Postoperative
radiographs show reduction of both fracture planes. Source: Images courtesy Dr. Alan Nixon.

Comminuted Collapsing Fractures lameness, and frequently palpable instability. The most
The primary indication for surgery in comminuted common radiographic manifestations are an unusually
fractures is to reconstruct bones that have lost their
­ large third carpal slab fracture with collapse of the proxi-
weight‐bearing ability and developed axial instability and mal row of carpal bones into the distal row, or slab fracture
anatomic deformity of the joint. Indicators of instability of multiple bones (Figure  27.25). Carpometacarpal luxa-
include valgus, varus, or palmar deformation, with severe tions (usually with proximal splint fractures and c­arpal

(E)
Figure 27.24  (Continued)
fractures) are another cause of carpal destabilization.
Treatment is undertaken for salvage; return to a­thletic
activity is not expected in these cases.
When there are comminuted fractures of the third car-
pal bone and/or additional fractures causing collapse of
the distal row of carpal bones with instability, arthrode-
sis is needed. Partial carpal arthrodesis leaving the ante-
brachiocarpal joint functional is the best option, if there
is confidence that there is no disease in the antebrachio-
carpal joint and/or no instability. Figure 27.25 illustrates
a case where partial arthrodesis using locking compres-
sion plates (LCPs) was performed. A partial carpal
arthrodesis to repair an unstable comminuted carpal
fracture had been previously described by Auer et  al.2
The use of the LCP system offers improved stability. The
use of partial carpal arthrodesis to preserve antebrachio-
carpal joint mobility has also been described for repair of
a comminuted fourth carpal bone fracture associated
with carpal instability in an Arabian filly.65 This particu-
lar repair was also facilitated with CT d­ ocumentation. T
plates or dynamic compression plates (DCPs) have been
used in the past, with LCPs now ­offering advantages in
stability.
Pancarpal arthrodesis is indicated when there are frac-
tures and instability involving both proximal and distal
row of carpal bones. This technique has been described
using two broad DCP plates.6 More recently, the use of
pancarpal arthrodesis using two LCPs for treatment of a
comminuted ulnar carpal bone fracture associated with
27  Fractures of the Carpus 507
(F)
carpal instability has been reported.12 The filly was main-
tained in a full limb cast for 15 days, followed by a tube
cast for 14 days, and subsequently a full limb bandage
with a caudal splint for 21 days. This resulted in a pas-
ture‐sound filly six months after surgery. For additional
information on carpal arthrodesis, see Chapter 28.
Postoperative Care and Results
Slab fractures treated with arthroscopy are recovered
from anesthesia in a padded bandage and treated as for
other arthroscopic surgeries. External support such as a
sleeve cast is used only when there has been significant
instability within the carpus. When the repair is more
extensive, the use of perioperative antibiotics (broad
spectrum) is also appropriate. All patients receive non-
steroidal anti‐inflammatory agents in the immediate
perioperative period.
Most horses with lag screw fixation of slab fractures
undergo similar exercise and physical therapy protocols
as osteochondral chip fragments. Initiation of walking
exercise depends on the extent of the fracture and confi-
dence in the repair, but often commences four to six
weeks after surgery. In the case of a collapsed or com-
minuted fracture, a cast is usually maintained on the
limb for four to six weeks (Figure 27.26).
There have been two reports with follow‐up data for the
treatment of routine third carpal bone slab fractures.33,52
In one report the race records were obtained for 72
508 Part II  Specific Fractures

(A) (B)

(C) (D)

Figure 27.25  (A–C) Preoperative radiographs of comminuted fractures of distal row of carpal bones, and (D, E) postoperative view
after partial carpal arthrodesis using two broad locking compression plates. Preoperative views were taken on the surgery table
for improved clarity.

Thoroughbreds and 61 Standardbreds.62 However, these
did not generally involve arthroscopic surgery and care
should be taken in extrapolating results. Factors in addi-
tion to the fracture characteristics or the treatment choice
affected outcome.62 Females of both breeds were less
likely to race after injury than males (46% versus 90%). In
Standardbreds, all 38 horses who had raced before the
fracture were able to race again. Prior racing starts were
not related to treatment outcome in Thoroughbreds.
Convalescent time was not correlated with any variable
(including treatment) or related to ­outcome. The percent-
age of Standardbreds racing (77%) was significantly higher

(E)
Figure 27.25  (Continued)
than for Thoroughbreds (65%). Fracture characteristics
were an important determinant of outcome. None of
the  Thoroughbreds treated by screw fixation with frag-
ment thickness >9 mm raced well. None of the four
Thoroughbreds with fragment thickness >7 mm raced
after fragment removal. Horses of both breeds treated by
fragment removal performed similarly to horses treated
by screw fixation, despite increased associated damage
and fracture displacement. Based on their findings, the
authors felt that the optimal range of fragment thickness
for removal was <8 mm for Thoroughbreds and <14 mm
for Standardbreds.62
In another study of 31 Thoroughbred racehorses
­surgically treated for frontal slab fractures of the third
carpal bone, 21 (67.7%) raced at least once after recov-
ery from surgery.39 The mean convalescent time was
9.5 months. Claiming value declined from a mean of
$13 900 to a mean of $6500 (n = 11; P < 0.05), based on
two races before injury and on four races after recov-
ery. The mean finish position was 5.8 ± 3.16 before
injury and 5.8 ± 3.30 after recovery (n = 11). The authors
noted the more serious nature of carpal slab fractures
(compared to osteochondral chip fractures) in that (i)
only 67.7% of the horses raced again compared to 86.0%
of Thoroughbreds with carpal chip fragments;45 and
(ii) the performance level decreased by 50% as judged
by claiming value, whereas 65.9% of Thoroughbreds
with osteochondral chip fractures raced at or better
than their previous performance level.45 Additionally,
27  Fractures of the Carpus 509
Figure 27.26  Use of a sleeve cast for postoperative management
of partial arthrodesis.
horses that did not race after recovery had significantly
larger fractures.39
In the initial description of arthroscopic repair of third
carpal bone slab fractures in horses by Richardson,57
17  horses had follow‐up of six months or longer. Of
these, 10 returned to race successfully. One other horse
was reported to be training soundly and two trained well,
but were retired because of other injuries. One horse was
unable to return to training because of an injury that had
occurred simultaneously with the slab fracture. Two
horses did not recover well enough to train or race, and
one horse was lost to follow‐up. Except for the horses
requiring two screws for repair, the cosmetic appearance
of each carpus was reported to be good, with only a small
swelling over the screw.57
Comminuted fractures can be salvaged if stability can
be gained with internal fixation and postoperative com-
plications can be avoided. Pancarpal arthrodesis has
complications similar to fracture fixation of any long
bone. Additionally, the author has had one horse with
pancarpal arthrodesis later fracture above the plates
while galloping in pasture.
510 Part II  Specific Fractures
­Accessory Carpal Bone
Fractures
Fractures of the accessory carpal bone are not common
when compared to other carpal bone fractures.1 The lim-
ited reports available, however, suggest that these fractures
occur most commonly in horses that race over fences, and
therefore are more frequently seen in the UK. A significant
number are also seen in event horses.16 Vertical (frontal)
fractures occurring through the mid‐portion of the bone
are the most common configuration, and may be single or
slightly comminuted (Figure 27.27). Horizontally oriented
fractures are much less common.13 In a series of 19 acces-
sory carpal bone fractures reported by Barr et al.,4 17 were
vertical with 13 of these being comminuted, 1 was an avul-
sion fracture from the palmar or distal border of the bone,
and 1 was a comminuted fracture at the dorsal articular
surface of the bone. The author has also seen small chip
fragments off the dorsoproximal aspect of the accessory
carpal bone which are located in the palmar pouch of the
antebrachiocarpal joint.
Theories to explain the pathogenesis of vertical frac-
tures in the accessory carpal bone include the bowstring
effect of the ulnaris lateralis, flexor carpi ulnaris, and digi-
tal flexors on the accessory carpal bone when the horse
lands on a partially flexed leg, and also the accessory car-
pal bone being caught in a “nutcracker” between the third
metacarpus and the radius.55 It is logical to assume that
(A)
Figure 27.27  (A) Radiographs of a minimally displaced vertical fracture of the accessory carpal bone in a three‐year‐old Thoroughbred. (B) The
fracture line distracts only along the proximal aspect during flexion. The horse went on to race. Source: Images courtesy Dr. Alan Nixon.
the biomechanical forces associated with the ligamentous
attachments, together with normal movement of the
accessory carpal bone during carpal flexion, are involved.
Diagnosis
Lameness associated with a fracture of the accessory car-
pal bone is usually acute in onset. There is often some
swelling on the palmar aspect of the carpus and the horse
resents partial flexion. Diagnosis is by radiography. The
lateromedial view will demonstrate most fractures, but a
full series should be taken to exclude other concurrent
problems. Dorsoproximal chip fragments of the acces-
sory carpal bone may occur along with vertical fractures
(Figure 27.28). Computed tomography may also be use-
ful in comminuted fractures, where surgical removal of
some or all of the fragments is contemplated.7
Treatment
Chip fractures on the dorsoproximal or palmarodistal
aspect of the accessory carpal bone have been reported
to respond well to either conservative treatment or sur-
gical removal, with return to full athletic function.16
Removal of some dorsoproximal fragments that involve
the antebrachiocarpal joint using arthroscopic technique
is appropriate.42 Distal avulsion fragments are generally
treated conservatively. The author also recommends a
(B)
 27  Fractures of the Carpus 511

(A) (B)

(C) (D)

Figure 27.28  (A) Radiograph of a four‐year‐old‐Thoroughbred with a comminuted fracture of the accessory carpal bone of three months’
duration. A vertical nonarticular fracture (arrowheads) is developing a fibrous union, and a dorsoproximal fracture has separated in the
palmar pouch of the antebrachiocarpal joint (arrow). (B) Postoperative radiograph shows that the intraarticular fracture has been removed
to minimize the degenerative joint disease, and (C, D) tenoscopic images from the severely distended carpal sheath show that the
accessory carpal bone has excoriated the lateral edge of the deep digital flexor tendon (DDFT), resulting in chronic inflammation, adhesion
formation, and synovial hypertrophy. The tendon was debrided, the carpal canal opened by retinacular release, and the intruding fracture
edge smoothed. Source: Images courtesy Dr. Alan Nixon.
512 Part II  Specific Fractures
conservative approach to the treatment of vertical and
horizontal fractures. In the series of 19 accessory carpal
bone fractures described by Barr, all cases were treated
conservatively and, of the 11 cases followed up, all
became sound and 6 returned to competition.4 In 6 cases
radiographed between six months and three years after
the fracture occurred, none showed evidence of bony
union. The usual outcome is a fibrous union, but clinical
soundness will commonly result. There has been a
report of a bony union in a horizontal fracture.13
Although carpal canal syndrome has been reported as a
common sequela to accessory carpal bone fracture,55 it
occurs relatively infrequently in the author’s experience.
If it does exist, it can be treated with a retinaculectomy.
More commonly, displaced frontal plane fractures of
the  accessory carpal bone can result in trauma to the
carpal sheath and contained digital flexor tendons (see
Figure  27.28).47 In a recent description of nine frontal
plane fractures, eight communicated with the carpal
sheath, resulting in carpal tenosynovitis.47 Treatment
consisted of removal of the torn deep digital flexor ten-
don tissue and the intruding fracture fragments and
sharp edges. Various surgical treatments have been
advocated for frontal plane fractures, including lag
screw fixation, bone grafting, and removal.17,58 Anecdotal
experience suggests that the majority of these cases end
up with a fibrous union. The use of ulnar neurectomy
has been described, but there is no data to support that
it changes the overall success rate compared to conserv-
ative healing. Bony union is not necessary for return to
full athletic activity.16
­References
1 Adams, O.R. (1974). Lameness in Horses, 3e.
Philadelphia: Lea & Febiger.
2 Auer, J.A., Taylor, J.R., Watkins, J.P. et al. (1990). Partial
carpal arthrodesis in the horse. VCOT 3: 51–60.
3 Auer, J.A., Watkins, J.P., White, N.A. et al. (1986). Slab
fractures of the fourth and intermediate carpal bones in
five horses. J. Am. Vet. Med. Assoc. 188: 595–601.
4 Barr, A.R., Sinnott, J.A., and Denny, H.R. (1990).
Fractures of the accessory carpal bone in the horse.
Vet. Rec. 126: 432–434.
5 Beinlich, C.P. and Nixon, A.J. (2005). Prevalence and
response to surgical treatment of lateral palmar
intercarpal ligament avulsion in horses: 37 cases
(1990–2001). J. Am. Vet. Med. Assoc. 5: 760–766.
6 Bertone, A.L., Schneider, H.L., Turner, A.S., and
Shoemaker, R.S. (1989). Pancarpal arthrodesis for
treatment of carpal collapse in the adult horse. A report
of two cases. Vet. Surg. 18: 353–359.
Surgery
The only cases of accessory carpal bone fracture that the
author considers appropriate for surgical treatment are
avulsion chip fragments off the proximodorsal aspect of
the accessory carpal bone. These cases are operated
arthroscopically, with the horse in dorsal recum-
bency.14,42 Distention of the antebrachiocarpal joint
results in visible distention of the palmar pouch, and the
arthroscope is inserted in the central portion of the
pouch. If fragments can be recognized by visualization
and manipulation, they are removed (see Figure 27.28).
In some instances, avulsion fragments will be buried
within soft tissue under the synovial membrane, and
their removal is either difficult or impossible. Removal of
proliferative synovial tissue often exposes the fracture
fragment and allows retrieval using a rongeur. A case
report also describes arthroscopically assisted arthrot-
omy to remove multiple comminuted fragments along
the dorsal articulation of the accessory carpal bone with
the radius and ulnar carpal bone.7 OA was prevented,
and the horse was sound for its intended purpose.
Postoperative Care
For conservative management of accessory carpal bone
fractures, the horse is simply confined to a stall. Although
maintaining the horse in a standing position and the
use of external splinting has been described, the author
would limit the treatment to support bandaging and
confinement.
7 Bonilla, A.G. and Santschi, E.M. (2015). Comminuted
fracture of the accessory carpal bone removed via an
arthroscopic‐assisted arthrotomy. Can. Vet. J.
56: 157–161.
8 Bramlage, L.R. (1983). Surgical diseases of the carpus.
Vet. Clin. North Am. Large Anim. Pract. 5: 261–274.
9 Bramlage, L.R. (1988). A clinical perspective of lameness
originating in the carpus. Equine Vet. J.(Suppl 6): 12–18.
10 Bueno, A.C., Galuppo, L.D., Taylor, K.T. et al. (2003).
A biomechanical comparison of headless tapered
variable pitch and AO cortical bone screws for fixation
of a simulated slab fracture in equine third carpal
bones. Vet. Surg. 32: 167–177.
11 Carrier, T.K., Estberg, L., Stover, S.M. et al. (1998).
Association between long periods without high‐speed
workouts and risk of complete humeral or pelvic fracture
in Thoroughbred racehorses: 54 cases (1991–1994).
J. Am. Vet. Med. Assoc. 212: 1582–1587.

12 Carpenter, R.S., Goodrich, L.R., Baxter, G.M. et al.
(2008). Locking compression plates for pancarpal
arthrodesis in a Thoroughbred filly. Vet. Surg.
37: 508–514.
13 Carson, D.M. (1990). The osseous repair of a horizontal
fracture of the accessory carpal bone in a
Thoroughbred racehorse. Equine Vet. Educ. 2: 173–176.
14 Cheetham, J. and Nixon, A.J. (2006). Arthroscopic
approaches to the palmar aspect of the equine carpus.
Vet. Surg. 35: 227–231.
15 Dabareiner, R.M., Sullins, K.E., and Bradley, W. (1993).
Removal of a fracture fragment from the palmar aspect
of the intermediate carpal bone in a horse. J. Am. Vet.
Med. Assoc. 203: 553–554.
16 Dyson, S.J. (1990). Fractures of the accessory carpal
bone. Equine Vet. Educ. 2: 188–190.
17 Easley, K.J. and Schneider, J.E. (1981). Evaluation of a
surgical technique for repair of equine accessory carpal
bone fractures. J. Am. Vet. Med. Assoc. 178: 219–223.
18 Fischer, A.T. and Stover, S.M. (1987). Sagittal fractures
in the third carpal bone in horses: 12 cases. 1977–1985.
J. Am. Vet. Med. Assoc. 191: 106–108.
19 Foerner, J.J. and McIlwraith, C.W. (1990). Orthopedic
surgery in the racehorse. Vet. Clin. North Am. Large
Anim. Pract. 6: 147–177.
20 Foland, J.W., McIlwraith, C.W., Trotter, G.W. et al.
(1994). Effect of betamethasone and exercise on equine
carpal joints with osteochondral fragments. Vet. Surg.
23: 369–376.
21 Frisbie, D.D., Ghivizzani, S.C., Robbins, P.D. et al.
(2002). Treatment of experimental equine osteoarthritis
by an in vivo delivery of the equine interleukin‐1
receptor antagonist gene. Gene Ther. 9: 12–20.
22 Frisbie, D.D., Kawcak, C.E., Baxter, G.M. et al. (1998).
Effects of 6‐α‐methylprednisolone acetate on an in vivo
equine osteochondral exercise model. Am. J. Vet. Res.
59: 1619–1628.
23 Frisbie, D.D., Kawcak, C.W., Trotter, G.W. et al. (1997).
Effects of triamcinolone acetonide on an in vivo
osteochondral fragment exercise model. Equine Vet. J.
29: 349–359.
24 Frisbie, D.D., Kawcak, C.E., Werpy, N.M., and
McIlwraith, C.W. (2009). Evaluation of polysulfated
glycosaminoglycan or sodium hyaluronan administered
intra‐articularly for treatment of horses with
experimentally induced osteoarthritis. Am. J. Vet. Res.
70: 203–209.
25 Gertsen, K.E. and Dawson, H.A. (1976). Sagittal
fracture of the third carpal bone in a horse. J. Am. Vet.
Med. Assoc. 169: 633–635.
26 Getman, L.M., Southwood, L.L., and Richardson, D.W.
(2006). Palmar carpal osteochondral fragments in
racehorses: 31 cases (1994–2004). J. Am. Vet. Med.
Assoc. 228: 1151–1558.
27  Fractures of the Carpus 513
27 Gustafson, S.B., McIlwraith, C.W., and Jones, R.L.
(1989). Comparison of the effect of polysulfated
glycosaminoglycans, corticosteroids and sodium
hyaluronate in the potentiation of a subinfective dose of
Staphylococcus aureus in the midcarpal joint of horses.
Am. J. Vet. Res. 50: 2014–2017.
28 Haussler, K.K. and King, M.R. (2015). Physical
rehabilitation. In: Joint Disease in the Horse, 2e (ed.
C.W. McIlwraith, D.D. Frisbie, C. Kawcak and R. van
Weeren), 243–269. Mosby/Elsevier.
29 Hirsch, J.E., Galuppo, L.D., Graham, L.E. et al. (2007).
Clinical evaluation of a titanium, headless variable‐
pitch tapered cannulated compression screw for repair
of frontal plane slab fractures of the third carpal bone
in Thoroughbred racehorses. Vet. Surg. 36: 178–184.
30 Kawcak, C.E., McIlwraith, C.W., and Norrdin, R.W.
(2000). Clinical effects of exercise on subchondral bone
on carpo‐metacarpophalangeal joints in horses. Am. J.
Vet. Res. 61: 1252–1258.
31 Kawcak, C.E., McIlwraith, C.W., Norrdin, R.W. et al.
(2001). The role of subchondral bone in joint disease: a
review. Equine Vet. J. 33: 120–126.
32 King, M.R., Haussler, K.K., Kawcak, C.E. et al. (2017).
Biomechanical and histologic evaluation of the effects
of underwater treadmill exercise on horses with
experimentally induced osteoarthritis of the middle
carpal joint. Am. J. Vet. Res. 78: 558–569.
33 Kraus, B.M., Ross, M.W., and Boston, R.C. (2005).
Surgical and nonsurgical management of sagittal slab
fractures of the third carpal bone in racehorses: 32 cases
(1991–2001). J. Am. Vet. Med. Assoc. 226: 945–950.
34 Lang, H.M. and Nixon, A.J. (2015). Arthroscopic
removal of discrete palmar carpal osteochondral
fragments in horses: 25 cases (1999–2013). J. Am. Vet.
Med. Assoc. 246: 998–1004.
35 Ley, C., Ekman, S., Elmané, A. et al. (2007).
Interleukin‐6 and tumor necrosis factor in synovial
fluid from horses with carpal joint pathology. J. Vet.
Med. A 54: 346–351.
36 Lindsay, W.A. and Horney, F.D. (1981). Equine carpal
surgery: review of 89 cases and evaluation of return to
function. J. Am. Vet. Med. Assoc. 179: 682–685.
37 Ljungvall, K. and Ronéus, B. (2011). Arthroscopic
surgery of the middle carpal joint in trotting
Standardbreds: findings and outcome. Vet. Comp.
Orthop. Traumatol. 24: 350–353.
38 Lucas, J.M., Ross, M.W., and Richardson, D.W. (1999).
Post‐operative performance of racing Standardbreds
treated arthroscopically for carpal chip fractures: 176
cases (1986–1993). Equine Vet. J. 31: 48–52.
39 Martin, G.S., Haynes, P.F., and McClure, J.R. (1988).
Effect of third carpal slab fracture and repair in racing
performance in Thoroughbred horses: 31 cases
(1977–1984). J. Am. Vet. Med. Assoc. 193: 107–110.
514 Part II  Specific Fractures
40 McIlwraith, C.W. (1992). Tearing of the medial palmar
intercarpal ligament in the equine mid‐carpal joint.
Equine Vet. J. 24: 367–371.
41 McIlwraith, C.W. (2005). From arthroscopy to gene
therapy – 30 years of looking in joints. Milne Lecture.
In: Proceedings of the American Association of Equine
Practitioners, vol. 51, 65–113. Lexington, KY: AAEP.
42 McIlwraith, C.W., Nixon, A.J., and Wright, I.M. (2015).
Diagnostic and Surgical Arthroscopy, 4e. Edinborough:
Mosby/Elsevier.
43 McIlwraith, C.W. and Turner, A.S. (1986). Assessing
success of surgery. Equine Vet. J. 18: 165–166.
44 McIlwraith, C.W. and Vachon, A. (1988). Treatment
of degenerative joint disease. Equine Vet. J.(Suppl 6):
3–11.
45 McIlwraith, C.W., Yovich, J.V., and Martin, G.S. (1987).
Arthroscopic surgery for the treatment of
osteochondral chip fractures in the equine carpus.
J. Am. Vet. Med. Assoc. 191: 531–540.
46 Meagher, D.M. (1974). Joint surgery in the horse: selection
of surgical cases and confirmation of the alternative.
In: Proceedings of the American Association of Equine
Practitioners, vol. 20, 81–88. Lexington, KY: AAEP.
47 Minshall, G.J. and Wright, I.M. (2014). Frontal plane
fractures of the accessory carpal bone and implications
for the carpal sheath of the digital flexor tendons.
Equine Vet. J. 46: 579–584.
48 Murray, R.C., Gaughan, E.M., DeBowes, R.M. et al.
(1998). Biomechanical comparison of the Herbert and
AO cortical bone screws for compression of equine
third carpal bone dorsal plane slab osteotomy. Vet.
Surg. 27: 49–55.
49 Norrdin, R.W., Kawcak, C.E., Capwell, B.A. et al.
(1998). Subchondral bone failure in an equine model of
overload arthrosis. Bone 22: 133–139.
50 Palmer, S.E. (1983). Lag screw fixation of a sagittal
fracture of the third carpal bone in a horse. Vet. Surg.
12: 54–57.
51 Palmer, S.E. (1986). Prevalence of carpal fractures in
Thoroughbred and Standardbred racehorses. J. Am.
Vet. Med. Assoc. 188: 1171–1173.
52 Park, R.D., Morgan, J.P., and O’Brien, T.R. (1970). Chip
fractures in the carpus of the horse: a radiographic
study of their incidence and location. J. Am. Vet. Med.
Assoc. 157: 1305–1311.
53 Phillips, T.J. and Wright, I.M. (1994). Observation on
the anatomy and pathology of the palmar intercarpal
ligaments of the middle carpal joints of Thoroughbred
racehorses. Equine Vet. J. 26: 486–491.
54 Pool, R.R. and Meagher, D.M. (1990). Pathologic
findings and pathogenesis of racetrack injuries. Vet.
Clin. North Am. Large Anim. Pract. 6: 1–30.
55 Radue, P. (1981). Carpal tunnel syndrome due to fracture
of the accessory carpal bone. Equine Pract. 3: 8–17.
56 Ramzan, P.H. and Palmer, L. (2011). Musculoskeletal
injuries in Thoroughbred racehorses: a study of three
large training yards in Newmarket, UK (2005–2007).
Vet. J. 187: 325–329.
57 Richardson, D.W. (1986). Technique for arthroscopic
repair of third carpal bone slab fractures in the horse.
J. Am. Vet. Med. Assoc. 188: 288–291.
58 Roberts, E.J. (1964). Some modern surgical operations
applicable to the horse. Vet. Rec. 76: 75.
59 Rutherford, D.J., Bladon, B., and Rogers, C.W. (2007).
Outcome of lag‐screw treatment of incomplete
fractures of the frontal plane of the radial facet of the
third carpal bone in horses. N. Z. Vet. J. 55: 94–99.
60 Sarrafian, T.L., Case, J.T., Kinde, H. et al. (2012). Fatal
musculoskeletal injuries of Quarter Horse racehorses:
314 cases (1990–2007). J. Am. Vet. Med. Assoc. 241:
935–942.
61 Schneider, R.K., Bramlage, L.R., Gabel, A.A. et al.
(1988). Incidence, location and classification of 371
third carpal bone fractures in 313 horses. Equine Vet.
J.(Suppl 6): 33–42.
62 Stephens, P.R., Richardson, D.W., and Spencer, P.A.
(1988). Slab fractures of the third carpal bone in
Standardbreds and Thoroughbreds. J. Am. Vet. Med.
Assoc. 193: 353–358.
63 Thrall, D.E., Lebel, J.L., and O’Brien, T.R. (1977). A five
year survey of the incidence and location of equine
carpal chip fractures. J. Am. Vet. Med. Assoc. 159:
1366–1368.
64 Tidswell, H.K., Innes, J.F., Avery, N.C. et al. (2008).
High‐intensity exercise induces structural,
compositional and metabolic changes in cuboidal
bones – findings from an equine athlete model. Bone
43: 724–733.
65 Waselau, M., Bertone, A.L., and Green, E.M. (2006).
Computed tomographic documentation of a
comminuted fourth carpal bone fracture associated
with carpal instability treated by partial carpal
arthrodesis in an Arabian filly. Vet. Surg. 35: 618–625.
66 Wilke, M., Nixon, A.J., Malark, J. et al. (2001). Fractures
of the palmar aspect of the carpal bones in horses: 10
cases (1984–2000). J. Am. Vet. Med. Assoc. 219:
801–804.
67 Wright, I.M. and Smith, M.R. (2011). The use of small
(2.7 mm) screws for arthroscopically guided repair of
carpal chip fractures. Equine Vet. J. 43: 270–279.
68 Wyburn, R.S. and Goulden, D.E. (1974). Fractures of
the equine carpus: report on 57 cases. N. Z. Vet. J.
22: 133–142.
69 Yovich, J.V., Trotter, G.W., McIlwraith, C.W., and
Norrdin, R.W. (1987). Effects of polysulfated
glycosaminoglycans on chemical and physical defects
in equine articular cartilage. Am. J. Vet. Res.
48: 1407–1414.