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ORTHOPEDIC: LAMENESS

A Comparison of Five Techniques for Injection of the Navicular Bursa in the Horse
Jane C. Boswell, MA, Vet MB, Cert VA, Cert ES (Orth), MRCVS; Michael C. Schramme, Dr Vet Med, Cert EO, Dipl. ECVS, MRCVS; Kostas Hamhougias, DVM, MRCVS; Katrina Toulson, B Vet Med, MRCVS; and Mina Viitanen, DVM, MRCVS

Injection of the navicular bursa is most reliably achieved by inserting a needle through the skin 1 cm proximal to the coronary band, midway between the heel bulbs and advancing it in the sagittal plane of the foot towards the navicular position. Authors Address: The Equine Referral Hospital, Royal Veterinary College, Hawkshead Lane, North Mymms, Hateld, Hertfordshire AL9 7TA. UK 1999 AAEP.

1.

Introduction

Numerous different techniques for injection of the navicular bursa have been described, but there is little conformity among these descriptions. The aim of this study was to evaluate ve different techniques for injection of the navicular bursa and to assess which technique was most consistently successful.
2. Materials and Methods

B. Distal Palmar Approach Parallel with the Sole (DPPS)2 (Fig. 2)

The needle was inserted midway between the heel bulbs, immediately proximal to the coronary band and advanced dorsally in the sagittal plane, parallel with the solar surface of the foot.

C.

Proximal Palmar Approach (PP30)3 (Fig. 3)

The literature was reviewed and techniques for injection of the navicular bursa were categorized into ve different approaches.
A. Distal Palmar Approach Parallel with the Coronary Band (DPPCB)1 (Fig. 1)

The needle was inserted into the hollow of the heel and advanced dorsally in the sagittal plane, at an angle of 30 to the horizontal.

D.

Lateral Approach (L45)4 (Fig. 4)

The needle was inserted midway between the heel bulbs, immediately proximal to the coronary band and advanced dorsally in the sagittal plane, parallel with the coronary band.

The needle was inserted proximal to the lateral cartilage of the third phalanx, between the second phalanx and deep digital exor tendon and advanced distally at an angle of 45 in the frontal plane.

NOTES

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Fig. 1. Technique 1: Distal palmar approach parallel with the coronary band (DPPCB).

Fig. 2. Technique 2: sole (DPPS).

Distal palmar approach parallel with the

Fig. 4. Technique 4:

Lateral approach (L45).

Fig. 3. Technique 3:

Proximal palmar approach (PP30).

E. Distal Palmar Approach to the Navicular Position (DPNP)5 (Fig. 5)

The navicular position was dened as a point on the lateral or medial aspect of the hoof wall, 1 cm distal to the coronary band and midway between the most dorsal and most palmar aspect of the coronary band as viewed from lateral or medial. A radi154 1999 9 Vol. 45 9 AAEP PROCEEDINGS

opaque marker was attached to the lateral hoof wall to mark this point. The needle was inserted midway between the heel bulbs, proximal to the coronary band and advanced along the sagittal plane of the foot towards the bisecting point between the sagittal plane and the long axis of the navicular bone. The long axis of the navicular bone was assumed to be the connecting line between the navicular position points on the lateral and medial hoof walls. Five inexperienced practitioners performed each approach on ve cadaver forelimbs. In order to ascertain conformity with the description of the techniques, radiopaque markers were applied to the dorsal hoof wall and coronary band, and radiographs were taken after needle placement. Once the needle was inserted in accordance with the relevant description, 3 ml meglumine diatrizoatea was injected and another radiograph was taken. The presence of contrast medium in the navicular bursa only was interpreted as a successful injection. The navicular position was marked with a radiopaque marker on the hoof wall of a forefoot in 10 standing horses to assess whether the landmarks for the navicular position as dened in the cadaver

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ORTHOPEDIC: LAMENESS

Fig. 6. A lateromedial radiograph of the foot of a standing horse shows the position of the navicular position marked by a radiopaque marker 1 cm below the level of the coronary band and midway between the most dorsal and most palmar aspects of the coronary band.

technique was between 2.3 and 5.75 times more likely than the other techniques to result in successful injection of the navicular bursa in the hands of an inexperienced practitioner. A Kruskal-Wallis test showed there was no signicant difference between the ve techniques in the number of times that the needle had to be inserted to conform with the relevant description of the approach ( p 0.08).
4.
Fig. 5. Technique 5: Distal palmar approach to the navicular position (DPNP).

Discussion

limbs could be applied to the live horse. Radiographs were taken to assess the position of the marker. The data were analyzed using Cochran-Q, Fischers Exact post hoc and Kruskal-Wallis tests, p values 0.05 were considered signicant.
3. Results

The results for successful injection of the navicular bursa in the hands of inexperienced practitioners were 4/25 (16%) for the DPPCB technique, 8/25 (32%) for the DPPS technique, 8/25 (32%) for the PP30 technique, 10/25 (40%) for the L45 technique, and 23/25 (92%) for the DPNP technique. Radiographs demonstrated that the radiopaque marker used in the DPNP technique was superimposed, at least partly, on the navicular bone in all limbs, in both the cadaver specimens and in the live horses (Fig. 6). Analysis of these results suggested a highly signicant difference between these techniques ( p 1 106) and that the results obtained with the DPNP technique differed signicantly from those of the other 4 techniques ( p 0.0002). The DPNP

The position of the navicular bone was highly predictable as a point 1 cm below the coronary band, halfway between the most dorsal and most palmar aspect of the coronary band. The use of this point as a landmark for injection of the navicular bursa allowed a high degree of accuracy and reliability of needle placement, irrespective of the foot conformation. The DPNP technique was superior to the other injection techniques evaluated. These ndings have been supported by the authors experiences in clinical cases. In the other techniques, strict adherence to published guidelines may result in erroneous needle placement.
References and Footnotes
1. Scrutcheld, W. Injection of the navicular bursa. The Southwestern Veterinarian 1977;30:161. 2. Wheat JD, and Jones K. Selected techniques of regional anaesthesia. Vet Clin North Am. Large Anim Pract 1981;3:220. 3. Bishop HW. A Clinical Review. Navicular Disease. Journal of the Royal Army Veterinary Corps. 1960;31:6164. 4. Grant BD. Bursal Injections. Proceedings 42nd Annual Convention of American Association of Equine Practitioners 1996; 42:6468. 5. Verschooten F, Desmet P, Peremans K et al. Navicular disease in the horse: the effect of controlled intrabursal corticoid injection. Errata. J Equine Vet Sci 1991;11:18. 370, Schering Health Care Limited, Burgess Hill, West Sussex, England. AAEP PROCEEDINGS 9 Vol. 45 / 1999 155
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