It was the type of Facebook post that makes you stop scrolling. Late last summer, Ruth Sobeck, DVM, posted a photo on her page of a horse’s hind hoof with a large nail protruding from it. Accompanying the photo was a simple question from Sobeck, “Would you remove this nail if you found it in your horse’s hoof?”
A veterinarian with a solo practice in Palos Verdes, California, Sobeck often uses her Facebook page to share experiences and pose questions to her friends and clients. Within hours, the post about the nail had more than 50 replies. Some people said they’d pull out the nail and soak the hoof, then monitor the horse for a few days, calling the veterinarian or farrier if significant lameness developed. A few offered anecdotes of having done just that successfully. Other people had the opposite reaction, and stated emphatically that they’d never pull a nail from a hoof and that they’d call the veterinarian immediately.
As the virtual conversation continued, Sobeck popped back into the comments briefly, promising an update soon. A few hours later, she posted a radiograph that showed the nail had penetrated to the coffin bone, the major bone within the hoof. Then the horse’s owner appeared in the thread and posted pictures of her mare in surgery, having the nail removed.
That Facebook post and the responses to it not only captured a “teachable moment” that Sobeck could capitalize on, but also told the story of how an owner’s ability to overcome her instincts may have saved her horse’s life.
The hoof that sparked the discussion belongs to a 24-year-old Thoroughbred mare named Raye. She’s owned by Valerie Nestrick, DVM, a small-animal veterinarian who was given the mare four years ago by her trainer, Kim Glaza.
“Kim owned her first and used her for teaching advanced riders,” says Nestrick. “Raye can be challenging, but Kim told me she was ready to take care of a novice rider so she gave her to me. Like she is about most things, Kim was right.” Raye came to live with Nestrick’s other horse, a gelding named Evan, in her backyard paddock in the suburb of Lomita. The pair worked together as part of the Los Angeles County Sheriff’s Department Mounted Posse, in which Nestrick is a Reserve Deputy; they also explored trails and continued regular rides and lessons with Glaza.
On a Monday in early September last year, Nestrick trailered both her horses to the city equestrian park. “Kim was going to ride Raye and I was going to ride Evan,” she says. All seemed well until Glaza mounted up and walked a short distance with Raye.
“She immediately got off and said, ‘Something doesn’t feel right’,” recalls Nestrick. “She went straight to the left hind hoof and picked it up. That’s the first time we saw the nail.”
Both women were astonished. “Raye wasn’t lame,” says Nestrick. “Nothing about the way she was walking gave me any indication that there was a large nail stuck in her hind hoof.”
Nestrick says her first, nearly overwhelming, instinct was to remove the nail. “When you see a nail sticking out of your horse’s foot, your brain immediately tells you to grab it and pull it out,” she says. “And it’s not a little urge. It’s a huge ‘danger, danger’ type of alarm that goes off mentally.”
Nestrick, however, remembered a warning she’d gotten previously from Sobeck, a personal friend as well as Raye’s regular veterinarian, about not removing nails found in hooves. “I knew I’d heard from Ruth to leave the nail alone,” Nestrick says, “so I resisted all my instincts and gave her a call.”
Sobeck’s admonition to never pull a nail from a hoof stems from the uncertainty that comes with these types of injuries. “The trouble with any object in the hoof is you don’t know where or how deep into the foot it has gone,” says Sobeck. “And once you’ve pulled the nail out, there’s really no good way to know.” Identifying the structures involved in such an injury is important to determining the level or type of treatment the hoof needs; without that information, there’s a much higher risk of potentially devastating complications.
“Let’s say you have what looks like a small wound from a nail you removed,” says Sobeck. “You could pour antiseptic in it and the horse might seem fine. The wound might even start to close up on the surface. But if the nail breached some critical structures and infection set in deep inside the wound, you could find the horse down and in pain two days later. There could be significant damage to a bone or tendon, and now you’re that far behind on that case.”
With the nail or object still in place, however, a veterinarian can take a radiograph; a metal object will show up clearly, revealing the location and depth of the wound, as well as the structures that might be involved. The appropriate treatment may be as simple as pulling out the nail or it may involve surgery. Diagnostic imaging, done while the object is still in place, helps the veterinarian decide how to proceed.
Of course, not every pulled nail has a bad outcome, but successes can give horse owners a false sense of security, says Sobeck. “It’s like when people give Banamine to a colicky horse without checking with the veterinarian first. It may have always been fine before, but that one time when it’s not fine, it can make the situation so much worse. To save money on a veterinary call, you could wind up costing yourself thousands more or even losing the horse. I never want to waste a client’s money, but in my mind, it’s not worth the risk.”
An inside look
Sobeck asked Nestrick a key question over the phone: Would walking Raye cause the nail to drive further into the hoof? The answer was “no,” so Sobeck told her it was OK to trailer the mare back home for treatment. She would meet them there.
“One of the big concerns with anything that penetrates the sole is that walking on it will drive it deeper,” says Sobeck. “In those cases, you need to get creative and use blocks of wood or bandages to keep the object from coming into contact with the ground. The nail in Raye’s hoof was already below the level of the shoe, so she wouldn’t be putting any pressure on it with each step. That’s why it was OK to put her back on the trailer.”
The ride home gave Nestrick time to consider where and even when Raye may have stepped on the nail. “She had been seen by the farrier four days earlier, so I know for sure she didn’t have it then,” she says. “I hadn’t ridden her since, and she hadn’t left home until I loaded her up on the trailer to go to Kim’s. I suppose she could have stepped on it in the 50 yards or so we rode at the park, but that doesn’t seem likely. She must have picked it up at my place, which is hard to explain.” There had been no recent construction on Nestrick’s farm, and in the 27 years she’d kept horses there, she’d never had trouble with a rogue nail before.
Sobeck met Nestrick when she arrived and began her examination of Raye. “In my mind, the nail didn’t look like it was in a good place,” says Sobeck. “It was in the middle third of the hoof, the area that includes the navicular bursa. That’s the area I’m most concerned about because an infection there can be very destructive and difficult to treat.”
A series of radiographs showed even more reason for concern: The nail had entered the sole at a horizontal angle, looking like it ran parallel with the ground, but the x-rays re-vealed it actually took a sharp 90 degree turn upward inside the foot, heading directly for and possibly even touching the coffin bone.
Sobeck didn’t hesitate in recommending a referral to a surgical clinic. “I told Val that if it were my horse I’d take her to a clinic, because that’s the complete truth,” says Sobeck. As Nestrick loaded Raye back onto the trailer, Sobeck called ahead to Chino Valley Equine Hospital to let the staff know to expect the pair.
A surgical solution
At the veterinary clinic, Andreas Klohnen, DVM, took over Raye’s case. “I used Dr. Sobeck’s radiographs,” he says. “They had been taken only a few hours previously and were quiet clear, so there was no need to take them again.”
On the images, Klohnen noticed a dark shadow on the coffin bone, suggesting the nail tip was indeed touching and had damaged the bone. “It looked like it had been there for some time and a bit of infection had begun,” he says. A slight digital pulse and heat in the foot confirmed an infection in the early stages. The nail head was also near where the deep flexor tendon attaches to the bone, but there didn’t appear to be damage to that area.
“It was very interesting that this mare wasn’t lame,” says Klohnen. “Why wasn’t she when other horses would have been toe-touching, fracture-like lame? It’s an abscess-like sensation that causes the intense pain, so perhaps any fluid was somehow running through the tract out of the hoof and not building up. Or perhaps she’s just very stoic. She was a bit off, but not nearly as lame as I would have expected her to be.”
Raye was quickly prepped for surgery. With the mare unconscious and on the surgical table, Klohnen began to work. “Cutting into the hoof with a blade is extremely difficult,” he says. “So, after we scrubbed the hoof the best as we could, we used a cautery unit to actually just burn through the hoof sole and into the tissue. It’s cauterizing as it’s cutting, so it also limits the amount of bleeding.”
Klohnen left the nail in place and cut a large oval around it as he worked deeper into the hoof. “By leaving it in place, you can make sure you are going exactly along the route the nail took,” he says, “and that you go as deep as necessary. You are also cleaning and debriding the area as you go.” Once the entire tract had been widened, the nail fell free.
Because the nail had reached the coffin bone, Klohnen then used an instrument called a curette to scrape away at its surface. “We gently clean the bone until the surface is nice and white with no signs of injured or infected bone,” he says. He also visually confirmed that the flexor tendon had not been compromised or injured by the nail.
Once that was done, Klohnen flushed the tract repeatedly with sterile saline solution. “If the nail hadn’t reached the bone, we may have flushed the wound with Betadine,” he says. “But that is too harsh for bone, so we used large amounts of saline instead.” The clinicians then packed the cleaned wound with gauze soaked in a triple antibiotic solution and bandaged the entire hoof before bringing Raye out of anesthesia.
Nestrick watched the entire surgery from an overhead viewing area. “My experience with small animals made me just knowledgeable enough to really worry,” she says. “But the practice owner came in and assured me she was fine. I was expecting her to be really lame when she recovered, but she wasn’t. She was walking around on that hoof like nothing had happened.”
Raye stayed at the clinic for the next 10 days, finishing a course of systemic antibiotics and receiving anti-inflammatory medications. The bandage on her hoof and the packing inside the wound were changed daily. “The wound needs to heal from the inside out,” explains Klohnen. “So we watch as the depths fill in with nice, pink granulation tissue. And we pack less and less in as needed.”
Once back home, Nestrick took over caring for Raye’s healing hoof, which was sometimes logistically challenging. But Raye never took a lame step. “It can take months for a hoof to heal completely,” explains Sobeck. “Even after the wound itself fills in, it has to shrink and dry and harden. Then it goes through primary cornification, where it turns into the type of tissue you find on the horse’s sole. Then it enters the final stage, where that tissue hardens. We will keep her with a pad under the shoe for a long time for all of that to happen.”
The promising outlook for Raye is a direct result from Nestrick’s remembering and heeding Sobeck’s warning to not remove nails found in hooves and to seek immediate veterinary attention.
“If she had pulled the nail and said, ‘Let’s just see what happens,’ things probably would have gone much differently,” says Klohnen. “I suspect that over the next 48 to 72 hours, the infection would have started raging and the mare would have become painfully lame. Then we would still have had to do all the same things in regard to surgery and aftercare, but it would have been much harder and much more expensive with less chance of a favorable outcome.”
In the end, Sobeck’s Facebook post about Raye’s hoof had nearly 250 comments and 20 shares with many of those who had said they’d pull the nail reversing their position when they learned more about the risks. “This is something I’m always going to be warning people about,” says Sobeck, “and obviously there are still people that need to hear it: Don’t pull the nail out. Call your veterinarian.
This article first appeared in EQUUS issue #472, January 2017.