Riley gets referred (or, why I have insurance)

Fasten your seatbelts, it's going to be a bumpy ride.

Bette Davis

Also a long ride. This could easily be two posts...

Riley started his two months of stall rest on July 3. Did I ever tell you why he's laid up? Well, the initial diagnosis was pedal osteitis in the right front hoof, caused by bruising, which was caused by repeated concussion and thin soles. My local vet recommended two months of stall rest.

In good faith (sort of), I followed my vet's advice. I say sort of, because I had her send x-rays to another vet at a nearby clinic. This vet concurred with my vet, but they both admitted it wasn't a "cut and dried" diagnosis. Two weeks into the stall rest regimen, I felt restless.

• Why wasn't the left foot, which is actually the clubbier foot, bruised/inflamed?
• If it was chronic bruising, why did he alternate between perfectly sound and very lame?
• What if this was not the right diagnosis?
• What if there was/is infection? Could Riley lose more bone during this rest?

Do you know where I'm going with this? Those who know me will not be surprised to hear about my little self-referral...

Riley's road trip
Off to the clinic we go. A really, really good clinic. I chose it because a) it's renowned for lameness, b) it has a standing MRI machine, and c) they have already consulted on Riley's x-rays this spring.

Here's a rundown of what happened...

• I meet the vet and hand him Riley's history -- a one page bulleted list of the sequence of events/significant stuff.. The assistant accepts it without comment, and I sense they won't read it right away, or maybe at all.
• Lameness evaluation. Riley is trotted on macadam, after 3 weeks of stall rest. He moves out with loft and energy, almost a passage. I think he looks beautiful, but even I could tell he was NQR. The vet rates him a 1/2 to 1 on his right front. He blocks the heel, and notes 90% improvement.
  
  The heel? Wait! His injury/problem is at the toe.
  
  The focus of the exam now turns to his heel. I want to call time out bring us back on task, but of course that would be offensive. I just watch everything unfold.


• X-rays. More radiographs are taken. The vet initially tells me he sees nothing to explain the lameness. As we talk, he moves the slider back and forth (making the picture darker and lighter). I notice him looking more closely at the picture, but he says nothing for 30 full seconds. He points to the navicular bone. "You know, there actually is some sclerotic bone there." (He had seen this when I sent him x-rays in March, but it didn't concern him then.) I explain that Riley has been sound except for two weeklong bouts of three legged lameness -- how would this be caused by the navicular bone? The vet responds that if tendons/ligaments are involved this is quite possible. He seems to have found his answer. I feel at a loss.
• What about the toe???? Next he pulls up the x-ray that depicts the pedal bone loss. It shows a small shark bite out of the inside edge of the bone. Radiographs just don't offer much useful information about what is causing it. I ask about other diagnostic tools.
  
  He says, "Do you have insurance?"
  
  "Yes."
  
  We settle on an MRI, to be done after lunch.
  
• Lunch. Based on the vet's assessment so far, Riley may have navicular unsoundness at age 3. I knew I had to get through lunch, and the rest of the exam, with some sort of composure. Have you heard the psychological buzzword compartmentalizing (walling off your emotions)? Mentally I shove the whole morning into a box and slam the lid.
• Post-lunch MRI. This procedure takes over an hour but reveals new info. I overhear the vet conferring with a colleague, who is saying "it's osteomyelitis, it's just that there's no infection." That would be Riley," I thought. I resist the urge to eavesdrop further and keep walking.
  

The conference and diagnosis
Twenty minutes later, the vet calls me over from the waiting area -- my notes are in his hand, and he waves them at me. "I read your history," he said, "and I think we can put this all together."

He feels that the pedal osteitis is caused by bruising, but he thinks it was a traumatic bruise, like landing on a rock at speed. The severe inflammation compromised the bone--blood flow to the bone is reduced, and it dies. The bruise itself got better, but some bone was lost. The vet called the second occurrence of extreme lameness a "flareup."

What about the navicular bone? The heel? According to the vet, the heel pain/lameness is likely to be "compensation pain," as Riley adjusted his movement to avoid pressure at the toe (where the bruise is). He said that the MRI showed some navicular bursitis which he again says is likely to be from compensation.

The treatment
Horses can lose up to 1/4 of their pedal bone with no ill effects, and Riley is nowhere near that. But the necrotic bone could break off or otherwise mess things up -- it needs to go. The vet recommends a standing procedure to debride/scrape out the dead pedal bone. Though invasive, it is not an enormously complex procedure, and he feels Riley will likely be fine afterward. The scary thing is that the scraping exposes the pedal bone. It takes 7-10 days for new tissue to cover it, and 2-3 months to recovery. But he will recover.

It ain't over yet
We trailer poor Riley, our groggy charge, back home. Frankly he doesn't look too good, but he has been sedated for hours. He hasn't eaten since 10am, and probably has had very little to drink. Coming off the trailer he seems subdued and clammy, so I hand walk him for a half hour before putting him into his stall. The vet gave the okay to give him his hay at home. He eats, drinks about 1/4 of a bucket of water. He looks totally spent and starts dozing.

8pm
The barn manager calls. She found him lying down and groaning. She said that he is "not himself," and earlier he had seemed gimpy on both front feet (which are now shoeless). I pelter her with questions. He has pooped three times since 3:30 and drunk a lot of water. Gut sounds on one side, but not the other. As she talks to me, he gets up and shakes. He looks a little brighter, and starts interacting with his neighbor. I say I'll come out and have a look. She will meet me at the barn. I want to hold off on Banamine until I can see how he is moving -- he shouldn't be outright lame, and I want to see how severe it is.

Twenty minutes later, I arrive to find Riley looking tired but comfortable. I hand walk him a bit, and he poops. The foot ouchiness isn't outside normal limits. The manager gives him his banamine shot and says she'll call me at 7am with a report.

7am today, Tuesday
All is well in Rileyville. He's back to normal, perky and bright. Praise Allah.

So now, I await the doctor's call. He is concerned that a big surgical facility will want to redo all of the diagnostics, and he thinks it's overkill. He will do some checking to help me find a vet to do the procedure.