Comeback from withers injury

An unusual injury to the withers casts doubt on the future of an easygoing gelding.
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The first call Michelle Hofstra got about Nigel in the spring of 2008 wasn't too troubling. The 4-year-old Quarter Horse was being leased by a local 4-H family, and they just wanted to give her a heads-up about a minor problem.

A horse with a withers injury may be reluctant to move his neck up and down or from side to side. Photo © EQUUS

A horse with a withers injury may be reluctant to move his neck up and down or from side to side. Photo © EQUUS

"They told me that he looked a little bit colicky," she recalls, "and that they had already called the veterinarian, who was coming out later that day." After examining Nigel, the veterinarian said that it didn't seem like colic as much as a very mild case of the painful muscle disorder commonly called tying up. He gave the gelding a shot of Banamine, which seemed to make him feel better.

But when she received a second call, Hofstra began to worry. The morning after that veterinary visit, Nigel didn't seem to be in any obvious pain, but he'd developed several strange patterns of movement. For one, he wouldn't lower his head without adopting a very awkward stance. "If he tried to put his head down," she says, "he would pull his hind legs next to his forefeet." His walk was also affected: "They told me he would walk forward willingly, but he was very reluctant to turn in either direction. When he did turn, he used his back legs only to face the new direction. He'd pivot around his front legs, just like a turn on the forehand."

Hofstra's first instinct was to head to the farm immediately to see Nigel herself, but that wasn't an option: "We were in the middle of a huge and very scary equine rhinopneumonitis [equine0 herpesvirus type-1] outbreak in the area," she says, "and a horse who was at the farm with Nigel had been at the farm where the outbreak had started. [Nigel's current home] was on a voluntary quarantine, and I had horses at home I didn't want to put at risk." Another veterinary visit wasn't an option either; the local university referral clinic was now also quarantined, accepting no new horses and sending field veterinarians only to emergencies and suspected cases of rhino, a contagious respiratory disease that in rare instances can cause potentially fatal neurological complications.

After a discussion with their regular veterinarian and Hofstra by phone, it was decided that Nigel's caretakers would keep a careful watch on him at home. That option seemed safe enough for the short term. The gelding was eating and drinking, and he did not have a fever or any other signs of illness that might point to rhinopneumonitis. Nor did his odd gait seem to indicate a neurological problem---he was perfectly coordinated, and his balance and reflexes were normal. He didn't have the classic stance or painful signs of laminitis, nor did he have the darkened urine from muscle damage associated with tying up. Rather, Nigel's difficulties in lifting his head and turning seemed to be more biomechanical in nature. Most likely, some sort of injury had left him with an unusual stiff lameness---one that was going to have to wait for a full diagnostic workup.

The veterinarian prescribed phenyl-butazone and advised the caretakers on other ways they could make Nigel comfortable. "They began putting his hay and water up at shoulder height so he didn't have to lower his head, and they kept him in a small pen so he wouldn't get harassed by other horses if he didn't want to move," says Hofstra. "They called me each day with updates and said he never really seemed distressed. He was also starting to improve, very slightly. They also sent?me pictures. I felt better but was still very worried."

After nearly three weeks, the rhino outbreak subsided, and community quarantines were lifted. Nigel's caretakers immediately scheduled an appointment with a veterinarian from the University of Saskatchewan in Saskatoon, and Hofstra drove out to?finally get a firsthand look at her horse. "He was just as they described," she says. "He would turn by moving his back legs around his front, and he?was refusing to lower his head."

Looking carefully over Nigel, Hofstra noticed a change that flipped on a light bulb in her head: "The area around his withers looked different, like it was swollen, and on one side more than the other."

The difference in his withers profile was subtle, but significant. While searching the Internet for clues to Nigel's condition, Hofstra had read about cases of broken withers. A horse's thoracic?vertebrae, which serve as attachment points for the ribs, also feature a line of finlike projections, called spinous processes, on the top of each bone. These projections rise just behind the neck to form the upward curve of the withers, and they serve as attachment points for many of the ligaments of the shoulders and neck.

Fractures and other injuries to the spinous processes are fairly rare in horses, but when they occur they can cause signs like Nigel's---an unwillingness to raise and lower the head and trouble turning. "I remember saying, ?I think he broke his withers,' and every-one looking at me like I was nuts," Hofstra says. "And it does sound like a very crazy thing for a horse to do."

But when the field veterinarian gave Nigel a full physical exam, Hofstra's theory seemed less far-fetched. The gelding's withers were indeed swollen, especially on the left side. The most telling detail, however, was the gelding's reaction to having that area touched: "Nigel is very, very mellow and stoic," says Hofstra, "but the moment the veterinarian touched his withers, he lashed out and kicked the wall. Hard."

Clearly, Nigel's problem originated in his withers, but radiographs would be needed to make a more specific?diagnosis, and the specialized equipment needed to get clear images of?that part of the body was available?only at the university. The following?day, Hofstra came to load Nigel for a?trip to the clinic.

Busted flat
The x-rays of Nigel's withers were as dramatic as any the veterinarians had ever seen. "The spinous processes of eight of his vertebrae were fractured, and many of them had moved out of place," says Rebeccah Stewart, DVM, who was still a veterinary student at?the time. Most of the fractures were comminuted, meaning that the bone was not just broken, but crushed. Two of the processes were displaced, shifted off to the left side.

"It was amazing to me---and all of us, I think---that he was still standing and eating and drinking," says Stewart. "It's like someone who had broken their back but was standing in front of you having a conversation."

Nigel was far from normal, however. He was still very stiff and lame at the walk, refused to turn unless he could pivot around his front legs and was?extremely reluctant to move his head from right to left or up and down. He had swelling over the top and along both sides of his withers, and by carefully palpating the area, the veterinarians could feel an abnormal, hard?lump---a little less than an inch long---on the left side. That lump was the end of one of the displaced processes.

Stewart, who was assigned to Nigel's case and would eventually write a paper?about it for a veterinary journal, had heard about horses breaking their withers but never imagined how dramatic it could be: "I think they mentioned it briefly in veterinary school but didn't dwell on it because it is so rare. You never expect to see one."

The veterinary team discussed treatment options with Hofstra. Simple fractures of the spinous processes are often left to heal on their own as the horse rests. In Nigel's case, however, the veterinarians took a closer look at all of the fragments and displaced bone. Had any appeared inclined to shift position or impinge on (come in contact with) each other, they might have considered surgery to remove, reduce or surgically stabilize the bone fragments together. But none of the fragments in Nigel's withers appeared to be mobile---the strong muscles and ligaments surrounding the withers were uninjured and were stabilizing the area.

"The fractures didn't involve the?lower portion of the vertebrae or the?mobile joints between them," says Stewart. "If he had broken his vertebral column, he would have been in a much more serious situation." So the plan was to keep Nigel as still and quiet as possible for a few weeks while the bone fragments knit together in their current positions. If the bones didn't heal properly, the veterinarians would reconsider what to try next.

Nigel returned to Hofstra's farm and was put on strict stall rest. "He was in a 12- by 15-foot pen, with elevated water and hay," she says. He was also put on a low-dose regimen of bute for a week to control the pain, but Nigel continued to act more comfortable than anyone would expect of a horse with eight shattered bones. "He was very content in his pen," Hofstra says. "He could lie down and get up and seemed happy to watch the goings-on around the farm."

Eventually, Nigel began dropping his head lower, even after the bute was discontinued, and his unusual feet-forward stance became less pronounced, but he did continue to pivot on the forehand when he turned. After eight weeks of stall rest, he was given clearance to be turned out in a small pasture with a quiet companion. "He got more active as he felt better," says Hofstra. "He lowered his head more and more, until he was back to grazing and, eventually, he was jogging and loping on his own in the field."

Slow progress
Nearly three months after their first visit to the university clinic, Hofstra shipped Nigel in for a follow-up exam and radiographs. The gelding was now sound at the walk and trot, with no visible swelling over his withers. He had also begun to turn normally, if slowly. Hofstra had also noticed that Nigel didn't seem to spread his forelegs very wide as he grazed, and he didn't roll all the way over. Instead, he'd wallow in the summer dust on one side, then rise to lie down again on his other side.

The swelling over the withers?was gone, but the normal ridge that occurs there had taken on a slightly "flattened" profile. The bony lump on the left side was still present, and Nigel flinched when it was touched. Radiographs revealed new bone growth at every fracture site. Nigel's body?was indeed attempting to heal his bones and was doing a good enough?job to allow him to move without pain?in his pasture.

No one could foresee yet whether Nigel could ever be ridden again. "[The veterinarians] didn't want to give me any sort of prediction, and I understand why," Hofstra says. But she had already thought through that possibility and had a plan in place: "I decided that if he couldn't be ridden, I'd teach him to drive." The veterinary team recommended continuing the quiet pasture rest before making any decisions about the horse's long-term future.

Nigel continued to improve over the coming weeks, and by September, Hofstra was confident---and curious---enough to cautiously mount the gelding bareback. "The first few times, we just stood there," she says. "Then we'd take a short walk until he'd stretch his head down and seem tired. By the end of that first week, we were able to walk for about five minutes."

Throughout the winter, Hofstra?continued to ride Nigel bareback for?longer periods of time. That spring,?one year after the injury occurred,?she placed a saddle on his back to see how the change in the shape of the withers would affect its fit. "I was?really surprised that it didn't change things at all," she says. "The very top of his withers is flat, but the saddle isn't resting on that area." Now working fully tacked, Nigel was making progress toward becoming a fully functional riding horse again.

"For a long time, he wasn't comfortable turning through corners," Hofstra says. "We would trot or lope down a straightaway, then go through the corners very slowly at a walk. By March, though, he was trotting through corners, and he continued to improve." The gelding never stumbled or seemed in any way uncoordinated or weak.

That summer, a friend called Hofstra, looking for a child's mount. She sent Nigel on a test visit, fully disclosing what the gelding had been through. It turned out to be a perfect match.

Back on track
Nigel made his final visit to Saskatoon two years after the accident. By then he showed no signs of lameness or stiffness at all. He was able to roll completely over, and he could bend his neck right and left as well as raise and lower it.

Radiographs showed that the bone fragments had knitted together completely, and the alignment of the most badly damaged spinous processes had actually improved. Hofstra noted that the gelding tended to carry his head a bit higher than he did before the accident, but not to an extent that would be noticeable to anyone who hadn't known him for years.

"This case always reminds me of how capable the body is of healing itself," says Stewart. "We've come leaps and bounds in veterinary medicine?over time; we can fix so much with plates and pins. But the body itself is an amazing healing tool. If you give it enough time, it can repair all sorts of damage. Science has yet to completely replicate that."

No one will ever know for sure exactly how Nigel injured himself, but Hofstra and Stewart agree on the most likely scenario. "My best guess is that he reared up and went over while playing," says Hofstra. "Our paddocks can be pretty icy, even in the spring, and he must have just gone up and slipped. That's the only way I can imagine him?injuring himself there and only there."

Stewart concurs. Accidents where the horse rears and falls backward onto a hard surface are the most common cause of withers injuries. "A roll onto something like a rock would have?damaged the skin," she says. "I can't imagine any way he did this other than blunt-force trauma as he landed on?his withers."

Nigel was eventually sold to another family, and he now spends his days teaching a new generation of riders.?"I'll always kept track of him," says Hofstra. "I love to hear that he's doing so well and making so many people happy. He's just a great horse."

This article first appeared in EQUUS issue #431.

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