Homeopathic treatment of a Post-traumatic Infection of Bone in a Horse, by Sarah Stieg, DVM, MRCVS

First printed in the Journal of the American Holistic Veterinary Medical Association (JAHVMA), Vol 31, Winter, pp31-34. Reproduced with kind permission from JAHVMA.

Introduction:

Post-traumatic infections of bone or infectious osteitis can be a serious sequela in severe distal limb injuries of the horse. The keystone of conventional therapy is aggressive antibiotic therapy, combined with the necessary removal of any dead sequestered bone.1,2 Blood supply to the injured bone is crucial to control acute infection and to generate productive periosteal proliferation. Periosteal proliferation will not attach to avascular infected bone. It is advised that antibiotics will not be able to clear the local infection until the avascular sequestrum is removed, due to the limited penetration of antibiotics into necrotic bone.2 The only exception to leave a sequestrum in place is to temporarily provide necessary stability to the fractured bone.1 Resolution is imperative due to the potential of bacteria invading the vascular bone and ultimately the medullary cavity, establishing osteomyelitis.1,2 In the case presented here, when the patient did not respond effectively to antibiotic therapy alone and was scheduled for surgical intervention, homeopathic treatment was instituted and provided complete resolution of the sequestrum as well as the horse’s lameness.

Signalment: 

4 year old Ex-Racing Thoroughbred Chestnut Gelding

Presenting Complaint:

Traumatic injury to the right knee, including a sequestrum in the distal radius.

Prior History:

The patient was a 4 year old ex-racing Thoroughbred chestnut gelding, who was pulled from the track due to a severe bout of colitis and subsequent laminitis treated at the North Carolina State University College of Veterinary Medicine (NCSU CVM) Equine andhttp://pivh.org/wp-admin/post-new.php Farm Animal Veterinary Center a year and a half prior. The patient was adopted post hospital stay by a local veterinarian. He was sound upon adoption and gradually returned to very light work.

Current Condition:

The patient was kicked in the right knee out in pasture on approximately 10/08/08, 16 days prior to presentation. The region of the knee was initially very hot and swollen, and the patient was American Association of Equine Practitioners (AAEP) lameness grade 3-4 lame. Several days after this injury, a draining track developed on the medial side of the right knee with yellow-white opaque discharge. The knee was radiographed approximately 10 (Figure 1) and 16 (Figure 2) days post injury and a sequestrum (2x1cm) was observed on the medial aspect of the right distal radius. Considerable soft tissue swelling was present.

Figure 1 & 2 updated

Figure 1: Day 10 (10/17/08) DP Right Radius/Carpus
Figure 2: Day 16 (10/23/08) DP Right Radius/Carpus

 

The patient was treated by the referring veterinarian with flunixin meglumine and trimethoprim/sulfa antibiotic (TMS) and had the affected limb bandaged with track-wraps for support on both front limbs. While the knee was still swollen, the injury was not currently draining, and there was a small scab over the drainage site. The equine surgery faculty at the NCSU CVM Equine and Farm Animal Veterinary Center recommended that the sequestrum be removed in one to two weeks from time of presentation. The owner was concerned about finances and possible complications of surgery. She elected a conservative approach, to include stall rest and a homeopathic workup and to re-assess in two weeks.

Relevant Homeopathic Symptoms:

To begin a homeopathic case workup the relevant symptoms (general and characteristic) are listed and associated homeopathic rubrics (e.g. a symptom label with the corresponding group of homeopathic remedies that are indicated to affect or relieve that symptom) are examined in order to analyze the case. The patient’s relevant general symptoms include the formation of an infected sequestrum from a traumatic injury and the type of discharge present (opaque yellow-white). The characteristic symptom in this case was the tendency toward suppression of an adequate healing response. This was indicated by the lack of response to medication and current stagnation of the injury (scabbing over of drainage tract, unresolved infection and swelling), and the previous history of hospitalization for colitis with subsequent development of laminitis. The symptom chart (Figure 3) lists the relevant symptoms of this case and demonstrates the translation of symptoms to the corresponding homeopathic rubrics.

JAHVMA - Sarah Stieg - Symptom progress chart Fig.3Figure 3: Symptom Translation to Homeopathic Rubric Chart.

Symptom Analysis Using Rubrics From Boger Boenninghausen’s Repertorya:

The remedy analysis (Figure 4 and Figure 5 utilizing Radar software)b aids remedy selection by indicating how strongly a remedy is represented for all the symptoms selected. The remedies are listed in order of the intensity of the indication for the symptoms listed. The colored boxes represent the intensity (grade) of the remedy in a rubric, which is indicated from the lowest grade 1 (lightest shade) to the highest grade 4 (darkest shade).

Fig. 4 Homeopathic Analysis

Figure 4: Homeopathic Analysis 1 using symptoms & correlating rubrics from Fig. 3.

Fig. 5 Homeopathic Analysis

Figure 5: Homeopathic Analysis 2 using symptoms & correlating rubrics from Fig. 3.

Differential Discussion of the Most Highly Indicated Remedies:

(from the Homeopathic analyses of Figure 4 and Figure 5)

1)   Silica terra (sil.)

Sil. is known extensively for suppurative processes, promoting suppuration, ripening abscesses, and resolving stubborn fistulous openings, as well as having a strong affinity for bone. In the Sil. patient every injury is known to suppurate.3 Sil. will produce an inflammatory response around any fibrinous nidus and hasten the process of suppurating it out.4 While abscessation surrounding a nidus or foreign body can be painful, Sil. patients are noted for being mild and having a yielding disposition. The common causations of illness in the Sil. patient are: injury and strains; the ill effects of vaccination, suppression; overwork, mental and physical.

2)   Calcarea carbonica (calc.)

The chief action of Calc. is found within the vegetative sphere of the patient, and has a strong affinity for impaired nutrition, the glands, skin and bone.3 Calc. is noted for concentrating and contracting abscesses, specifically indicated for deep abscesses to be reabsorbed when suppuration and discharge may be dangerous due to anatomic location; as opposed to Sil. or Hep. which hasten suppuration.4 In this case, while there is a deep suppurative process occurring surrounding a nidus of bone, it has already created a fistulous track that has been previously draining on the surface. This description does not match that of Calc. as accurately as that of Silica.

3)   Hepar sulphuris calcareum (hep.)

Hep. also has a marked tendency to suppuration and abscesses surrounding foreign bodies, including the necrosis and suppuration of bone.4 However, the lesions of the Hep. patient tend to be those of great sensitivity to the patient, even to the slightest touch, and can manifest this oversensitivity in extreme irritability.3,4 The patient did not display any sensitivity around the injury while being handled or radiographed, and was exceptionally cooperative to the ongoing care of his injury as noted by his owner and stable manager, thus matching the description of Silica more accurately.

Remedy and Potency Selection:

Sil. was selected due to fitting the symptoms of the entire case, e.g. the nature of the abscess, the fistulous tract, the location of bone, and the previous extensive history (potential causation) of suppression. Regarding potency, the patient was a young horse of high vitality. While the injury was acute, the process of suppuration and lack of continued reaction to reabsorb this lesion indicated that there was a chronic disease process or susceptibility underlying this patient’s response. A single dose of a 1M potency would have been the preferred prescription, however due to the short window of opportunity to treat this case, a higher potency was unavailable at that time. The only potency readily available was a 30c. Because this potency was much lower than the patient’s vitality and age indicated, the owner was instructed to repeat the remedy once a day for 3 days.

Remedy Prescription: Day 17 (10/24/08)Sil. 30c SID for 3 days.

Update: Day 30 (11/06/08) – 2 weeks post remedy.

Approximately two to three days after the remedy was given, the area around the sequestrum (region of knee) began to swell and resumed discharging. This reaction continued for approximately three days. The patient was now sound at the walk and the trot. There was no longer any draining track or discharge – just a very small scab. Repeated radial radiographs (Figure 6) were taken to check progress. To correctly evaluate the remedy response and determine a plan of action, each symptom of the patient was re-evaluated post remedy administration with the associated progress report to determine if the case was effectively moving in a curative direction (Figure 7).

JAHVMA - Sarah Stieg Fig 6, Day 30 (11.06.08) DP Right Radius Carpus

 

 

 

 

 

 

 

 

 

 

Figure 6: Day 30 (11/06/08) DP Right Radius/Carpus

JAHVMA - Sarah Stieg - Symptom progress chart Fig 7Figure 7: Symptom with correlating progress summary chart.

The equine surgery faculty at the NCSU CVM Equine and Farm Animal Veterinary Center still recommended surgical removal at this time. The owner was concerned about the boney callous formation, the possibility of it remaining and causing a blemish, making the patient difficult to sell, etc. Alternatively she was concerned about surgical intervention and the possibility of creating more of a problem by the risks associated with exposing his cortex to an outside infection. The owner elected to stay with homeopathy and give the patient more time to heal.

Action: No Remedy given, the patient is continuing to improve. Wait and recheck.

Update: 4.5 months Post injury (2/15/09) – 3.5 months Post Remedy

The patient recovered smoothly throughout the rest of November and remained sound since. Repeat radiographs were taken by the referring veterinarian 4 weeks earlier, approximately 3.5 months post injury (Figure 8 and Figure 9). The radiographs appreciated a radiolucency at the previous site of the sequestrum indicating resolution of the sequestrum. No visible or palpable callus or scar remained from the injury. The horse was put into training at the beginning of February and was subsequently performing well. Each original symptom of the patient was re-evaluated with the current progress report to determine if the case was effectively moving in a curative direction (Figure 10).

Figures 8 & 9

Figure 8: 3.5 Months (01/13/09) DP Right Radius/Carpus
Figure 9: 3.5 Months (01/13/09) DLPMO Right Radius/Carpus

 

JAHVMA - Sarah Stieg - Symptom progress chart Fig.10

Figure 10: Symptom with correlating progress summary chart.

Action: No remedy needed, the patient is clinically sound and sequestrum has been resolved.

Update: 1 – 3 years post injury (October 2011 last contact)

The patient has remained sound and has continued to perform well. No further radiographs were taken. He entered training and is currently competing on the local hunter/jumper circuit on the flat and over fences.

Case Discussion:

The patient displayed a curative response to the selected remedy Sil. The re-swelling of the knee and the re-emergence of discharge from the fistulous tract two to three days post remedy were both crucial signs that the remedy was acting on the patient. In a curative homeopathic response where underlying chronic disease is suspected, the patient will begin to show a noticeable reaction (called a counteraction)5 to the remedy between days two to five post-remedy administration. This can manifest as an aggravation in the patient’s symptoms and can be distinguished from the continuation of the patient’s disease process by the simultaneous improvement of the patient’s well-being.5 In this case, the re-emergence of the inflammatory response was necessary to resolve the injury from the previous deficient reaction of the patient. At the same time, the patient transitioned over this period from AAEP Grade 3-4 lameness to complete soundness at the walk and the trot. The repeat radiographs demonstrated that the previous deficient response had been re-ignited and the sequestrum site was now healing. No further remedy was needed in this case, as the symptoms continued to improve. If resolution of the patient’s symptoms had plateaued or re-emerged without any new symptoms to indicate another remedy was needed, then a higher potency of a single dose Sil. would have been administered to resolve the case. Classical homeopathy for this patient demonstrated a minimally invasive and cost effective treatment avenue to resolve this potentially very serious sequelae to a traumatic limb injury.

References:

  1. Bramlage, L.R. Treatment of Posttraumatic Infections of Bone. AAEP Proceedings. 1998; 9 (44): 172-175.
  2. Stashak, T.S. Adam’s Lameness in Horses, 5th Lippincott, Williams, & Wilkins. Baltimore, MD, USA. 2002: 428-430.
  3. Murphy, R. Nature’s Materia Medica. Lotus Health Institute. Blacksburg, VA, USA. 2006.
  4. Kent, J.T. Materia Medica of Homeopathic Remedies. Homeopathic Book Service. Sittlingbourne, Kent, Norway. 2005.
  5. Pitcairn, Richard. Prescription Evaluation Section. Professional Course in Veterinary Homeopathy. ANHC Education Programs. Sedona, AZ, USA. 2008: Sec. 3.1.

Footnote:

a)   Boger, C.M. Boger Boenninghausen’s Characteristics & Repertory with Word Index. B. Jain Publishers (P) Ltd. New Delhi, India. 2008.

b)   Radar Repertory Program, Release 10.5.002. Archibel Homeopathic Software. Assesse, Belgium. 2009.

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