Minimising serious fractures of the racehorse fetlock - risk reducing of catastrophic fractures associated with the fetlock joint
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By VA Colgate, PHL Ramzan & CM Marr
Minimising serious fractures of the racehorse fetlock
In March 2020, a symposium was held in Newmarket, UK, aiming to devise measures which could be used internationally to reduce the risk of catastrophic fracture associated with the fetlock joint. The meeting was supported by the Gerald Leigh Charitable Trust, the Beaufort Cottage Charitable Trust and the Jockey Club with additional contributions from a number of industry stakeholders. On the first day a panel of international experts made up of academic professors, Chris Whitton (Melbourne, Australia), Sue Stover (Davis, California), Chris Kawcak (Colorado), Tim Parkin (Glasgow) and Peter Muir (Wisconsin); experienced racehorse clinicians, Ryan Carpenter (Santa Anita) and Peter Ramzan (Newmarket); imaging experts, Sarah Powell (Newmarket) and Mathieu Spriet (Davis, California); and vets with experience in racing regulatory bodies, Scott Palmer (New York) and Chris Riggs (Hong Kong) joined forces to discuss risk assessment protocols, particularly those based on imaging features which might indicate increased risk of imminent fracture. This was followed by a wider discussion with a diverse invited audience of veterinary and industry stakeholders on how our current knowledge of fracture pathophysiology and risk factors for injury could be used to target risk assessment protocols. A report of the workshop outcomes was recently published in Equine Veterinary Journal.
The importance of risk reduction
With the ethics of the racing industry now in the public spotlight, there is recognition that together veterinary and horseracing professionals must strive to realise an improvement in equine injury rates. Intervention through risk profiling programmes, primarily based on training and racing metrics, has a proven track record; and the success of a racing risk management program in New York gives evidence that intervention can and will be successful.
The fetlock of the thoroughbred racehorse is subjected to very great loads during fast work and racing, and over the course of a training career this can result in cumulative changes in the bone underlying the articular cartilage (‘subchondral’ bone) that causes lameness and may in some circumstances lead to fracture. Fracture propagation involving the bones of the fetlock (cannon, pastern or proximal sesamoid bones) during fast work or racing can have catastrophic consequences, and while serious musculoskeletal injuries are a rare event when measured against race starts, there are obviously welfare and public interest imperatives to reduce the risk to racehorses even further. The dilemma that faces researchers and clinicians is that ‘fatigue’ injuries of the subchondral bone at some sites within the fetlock can be tolerated by many racehorses in training while others develop pathology that tips over into serious fracture. Differentiating horses at imminent risk of raceday fracture from those that are ‘safe’ to run has not proven particularly easy based on clinical grounds to date, and advances in diagnostic imaging offer great promise.
Profiling to inform risk assessment
Risk profiling examines the nature and levels of threat faced by an individual and seeks to define the likelihood of adverse events occurring. Catastrophic fracture is usually the end result of repetitive loading, but currently there are no techniques that can accurately determine that a bone is becoming fatigued until some degree of structural failure has actually occurred. However, diagnostic imaging has clear potential to provide information about pathological changes which indicate the early stages of structural damage.
Previous research has identified a plethora of epidemiological factors associated with increased risk of serious catastrophic musculoskeletal injury on the racetrack. These can be distilled into race, horse and management-related risk factors that could be combined in statistical models to enable identification of individual horses that may be at increased risk of injury.
In North America, the Equine Injury Database compiles fatal and non-fatal injury information for thoroughbred racing in North America. Since 2009, equine fatalities are down 23%; and important risk factors for injury have been identified, and this work has driven ongoing improvement.
The problem with all statistics-based models created so far for prediction of racehorse injury is that they have limited predictive ability due to the low prevalence of racetrack catastrophic events. If an event is very rare, and a predictive tool is not entirely accurate, many horses will be incorrectly flagged up as at increased risk. At the Newmarket Fetlock workshop, Prof Tim Parkin shared his work on a model which was based on data from over 2 million race starts and almost 4 million workout starts. Despite the large amount of data used to formulate the model, Tim Parkin suggested that if we had to choose between two horses starting in a race, this model would only correctly identify the horse about to sustain a fracture 65% of the time. Furthermore, the low prevalence of catastrophic injury means it will always be difficult to predict, regardless of which diagnostic procedure is employed.
Where do the solutions lie?
A radiograph showing a racing thoroughbred’s fetlock joint. The arrow points to a linear radiolucency in the parasagittal groove of the lower cannon bone—a finding that is frequently detectable before progression to serious injury.
One possible strategy to overcome the inherent challenge of predicting a rare event involves serial testing. Essentially with this approach, a sequence of tests is carried out to refine sub-populations of interest and thus improve the predictive ability of the specific tests applied. An additional consideration in the design of any such practical profiling system would have to be the ability to speedily come to a decision. For example, starting with a model based on racing and training metrics such as number of starts and length of lay-off periods, as well as information about the risk associated with any particular track or racing jurisdiction, entries could be screened to separate those that are not considered to be at increased risk of injury from a smaller sub-group of horses that warrant further evaluation and will progress to Phase 2. The second phase of screening would be something relatively simple. Although not yet available, there is hope that blood tests for bone biomarkers or genetic profiles could be used to further distil horses into a second sub-group. This second sub-group might then be subjected to more detailed veterinary examination, and from that a third sub-group, involving a very small and manageable number of horses flagged as potentially at increased risk, would undergo advanced imaging. The results of such diagnostic imaging would then allow vets to make evidence-based decisions on whether or not there is sufficient concern to prompt withdrawal of an individual from a specific race from a health and welfare perspective. Of course there are other considerations which limit the feasibility of such a system, including availability of diagnostic equipment and whether or not imaging can be quickly and safely performed without use of sedation or other drugs, which are prohibited near to a race start.
Diagnostic techniques for fetlock injury risk profiling
Currently there is no clear consensus on the interpretation of images from all diagnostic imaging modalities, and important areas of uncertainty exist. Although a range of imaging modalities are available, each has its own strengths and weaknesses, and advances in technology currently outstrip our accumulation of published evidence on which to base interpretation of the images obtained.
Interpretation is easy when the imaging modality shows an unequivocal fracture such as a short fissure in a cannon bone. Here the decision is simple: the horse has a fracture and must stop exercising. Many cases, however, demonstrate less clearly defined changes that may be associated with bone fatigue injury.
Currently radiography remains the most important imaging modality in fetlock bone risk assessment. With wide availability and the knowledge gained by more advanced imaging techniques refining the most appropriate projections to use; radiography represents a relatively untapped resource that through education of primary care vets could immediately have a profound impact on injury mitigation. The most suitable projection with which to detect prodromal condylar fracture pathology in the equine distal limb is the flexed dorsopalmar (forelimb) or plantarodorsal (hindlimb) projection. On this projection, focal radiolucency in the parasagittal groove, whether well or poorly defined, with or without increased radio-opacity in the surrounding bone, should be considered representative of fracture pathology unless evidence from other diagnostic imaging modalities demonstrates otherwise.
Computed Tomography (CT) excels at identification of structural changes and is better than radiography at showing very small fissures in the bone. However, additional research is needed to determine specific criteria for interpretation of the significance of small lesions in the parasagittal groove with respect to imminent risk of serious injury. There are good indications that fissure lesion size and proximal sesamoid bone volumetric measurements have the potential to be useful criteria for prediction of condylar and proximal sesamoid bone fractures respectively. With technological advancement, it is likely that CT will be more widely used in quantitative risk analysis in the future.
Magnetic Resonance Imaging (MRI) has the ability to detect alterations in the fluid content of bones, which allows assessment of acute, active changes. Indeed standing, low-field MRI has been shown to be capable of detecting bone abnormalities not readily identifiable on radiography and has been successfully used for injury mitigation in racehorse practice for some time. However, when used for evaluation of cartilage and subchondral bone lesions, there is a relatively high likelihood of false positive results.
PET is the most recent advance in diagnostic imaging. It is being developed in California and, when combined with CT, provides information on bone activity and structure. In these three images of the same fetlock, from different aspects, the orange spots indicate increased activity in the proximal sesamoid bone, which is a potential precursor to more serious injury.
Image courtesy of Dr M. Spriet, University of California, Davis.
