Journal of Equine Veterinary Science 32 (2012) 222-230

Journal of Equine Veterinary Science

journal homepage: www.j-evs.com

Clinical Technique

Procedure for the Transrectal and Transcutaneous Ultrasonographic

Diagnosis of Pelvic Fractures in the Horse
Wade T. Walker DVM, Natasha M. Werpy DVM, DACVR, Laurie R. Goodrich DVM, PhD, DACVS
Gail Holmes Equine Orthopaedic Research Center, Colorado State University, Fort Collins, CO

a r t i c l e i n f o a b s t r a c t

Article history: Recent advancements in the quality and availability of imaging modalities have allowed
Received 1 June 2011 clinicians to diagnose fractures in horses with hindlimb lameness. Many imaging
Received in revised form modalities aid in the diagnosis of pelvic fractures, including radiography, nuclear scin-
29 August 2011
tigraphy, computed tomography, and ultrasonography. Ultrasonography is an appropriate
Accepted 8 September 2011
Available online 29 October 2011
initial diagnostic tool when a pelvic fracture is suspected. The use of ultrasonography
minimizes many of the risks and complications associated with the radiographic, scin-
tigraphic, and computed tomographic evaluation of pelvic fractures, and is readily
Keywords:
Diagnostic
available to equine practitioners. This manuscript provides a detailed description of
Equine a complete transrectal and transcutaneous ultrasonographic examination of the equine
Fracture pelvis. The described method has been effective in the diagnosis of pelvic fractures in
Pelvis a series of eight cases. Transrectal ultrasonography was found effective in revealing
Ultrasound fractures of the ischiatic table, acetabulum, pubis, and ilium. Transcutaneous ultraso-
nography effectively identified fractures of the ilium, acetabular rim, femoral neck,
greater trochanter, and a capital physeal fracture with a subluxated femoral head.
Ó 2012 Elsevier Inc. All rights reserved.

1. Introduction lameness, gluteal muscle atrophy, as well as crepitation

and muscle spasm on palpation are often indicative of
In horses, hindlimb lameness caused by pelvic fractures pelvic injury [5-7]. Asymmetry of the pelvic canal, crep-
is far more common than previously appreciated. Early itus, hematomas, as well as the pubic bone, ventral
retrospective studies report that 4.4% of all hindlimb lame- sacroiliac joint, and internal surface of the ilium can all be
ness was a result of pelvic fractures [1]. More recent studies evaluated by rectal palpation. Abnormalities on rectal
performed on Thoroughbreds have demonstrated a much palpation may suggest the presence of a pelvic fracture
higher frequency of hindlimb lameness resulting from [5-8].
pelvic fractures than reported by original studies [2-4]. Various techniques for the radiographic evaluation of
Recent recognition of the incidence and implications of the equine pelvis have been described [9-11]. Radiographic
pelvic fractures in the horse have facilitated advancements imaging is performed under general anesthesia to obtain
in their diagnosis. a ventrodorsal projection to evaluate pelvic symmetry
Pelvic fractures can have a nonspecific clinical followed by an oblique image with the affected side down
presentation [5]. Soft tissue swelling, unilateral hindlimb [9-11]. This protocol has proven to be 70% effective in
confirming the diagnosis of pelvic fractures [10]. However,
anesthetizing a horse with a pelvic fracture may illicit
W.T.W. is currently at Arizona Equine Medical and Surgical Centre, complications such as fracture displacement which could
1685 S. Gilbert Rd., Gilbert, AZ 85296. potentially lacerate the internal iliac vessels [12]. Because
Corresponding author at: Natasha M. Werpy, DVM, DACVR, Gail
Holmes Equine Orthopaedic Research Center, Colorado State University,
of the risks associated with obtaining radiographs under
300 W. Drake Rd., Fort Collins, CO 80523-1678. general anesthesia, many clinicians are hesitant to use this
E-mail address: [email protected] (N.M. Werpy). technique when a pelvic fracture is suspected.

0737-0806/$ - see front matter Ó 2012 Elsevier Inc. All rights reserved.
doi:10.1016/j.jevs.2011.09.067
 W.T. Walker et al. / Journal of Equine Veterinary Science 32 (2012) 222-230 223

Standing ventrodorsal, ventrodorsal oblique, lateral, and 2. Methods and Materials

lateral oblique radiographic techniques of the equine pelvis
have been described [13-15]. These methods avoid the A thorough clinical and ultrasonographic examination
associated risk of fracture displacement with general was performed on eight horses admitted to the Colorado
anesthesia and offer visualization of the caudal pelvis and State University Veterinary Teaching Hospital for suspected
cranial acetabular rim [13]. Pelvic radiography in the pelvic fractures from 2005 to 2008. The subsequently
standing horse may decrease the associated risks of reported technique for the transrectal and transcutaneous
recumbency; however, these techniques require high ultrasonographic diagnosis of pelvic fractures was used on
exposure tubes and antiscatter equipment [13-15]. Addi- 10 horses with no history of hindlimb lameness. Normal
tionally, the unwillingness of horses in pain to stand square (Figs.1-4) and pathologic ultrasonographic images (Figs. 5-9)
often complicates standing techniques [15]. oriented with cranial to the left and caudal to the right are
Detection of pelvic fractures using nuclear scintigraphy included. Ultrasonographic results were confirmed with
has been described [16-20]. Nuclear scintigraphy can be clinical examination, radiography, nuclear scintigraphy, or
effective for diagnosing fractures of the tuber coxae, tuber postmortem findings (Table 1).
ischii, greater trochanter, and third trochanter [19-21]. In
addition, it has been used to identify bone remodeling 2.1. Clinical Examination
of the ilial body, which could be a precursor to cata-
strophic failure [17-19]. A study suggests that nuclear After performing a thorough physical and lameness
scintigraphy is unreliable for diagnosing pubic bone examination, the pelvis was visually and manually exam-
fractures because of radiopharmaceutical uptake in the ined to evaluate external symmetry. The tuber sacrale,
urinary bladder [19]. Furthermore, nuclear scintigraphy tuber coxae, and tuber ischii were physically manipulated
does not reveal detail of the fracture configuration and is bilaterally to elicit pain or crepitus. Other areas of the pelvis
complicated by pelvic asymmetry, muscle atrophy, and such as the region of the coxofemoral joint and ventral
motion [19]. pelvis were palpated for heat, pain, and hematomas.
Computed tomography has been recently described in Patient preparation included intravenous administration of
the diagnosis of pelvic fractures in two fillies [22]. This can 0.02-mg/kg detomidine hydrochloride (Pfizer Animal
be an effective diagnostic aid in young horses and poten- Health, Exton, PA), evacuation of feces from the rectum, and
tially ponies or other small breed horses; however, general an intrarectal infusion of 60-mL 2% lidocaine via an
anesthesia is required, and computed tomography is only extension set. A rectal examination was then performed to
available at a select number of referral veterinary assess internal symmetry, pain, crepitus, callus, and the
hospitals. presence of hematomas in the pelvic canal.
Ultrasonography of the equine pelvis has been validated
using computed tomography, magnetic resonance imaging, 2.2. Approach to Transrectal Ultrasonographic Examination
and frozen sections [23]. This modality has proven to be an
effective method for the diagnosis of pelvic fractures [3, For the ultrasonographer’s safety, the transrectal
24-27] and coxofemoral subluxation in horses [28]. examination was performed before the transcutaneous
Owing to the risks associated with recumbent radiographic examination while the horse was sedated. A 7.5-10-MHz
techniques and the inability to perform this technique in linear rectal transducer was used transrectally to evaluate
the field, clinical examination followed by ultrasonographic the osseous integrity of the pelvic canal. Orientation of the
imaging of the pelvis is an effective and inexpensive way probe alternated between transverse and longitudinal
for equine practitioners to diagnose pelvic fractures direction to perform a thorough transrectal examination
[23-27]. Furthermore, the relatively noninvasive technique (Fig. 1A). During the examination, the probe was advanced
of pelvic ultrasonography is useful to monitor the slightly less than one probe length with each change of
progression of pelvic fractures, determine prognosis, and direction to ensure that the entire osseous surface of the
prescribe therapeutic modalities [6,26]. pelvis was imaged. To assess the ischiatic table, the probe
Recently, transcutaneous and transrectal ultrasono- was placed midsagitally on the most caudal margin of the
graphic examinations have been deemed appropriate ischium. The probe was advanced laterad (away from
diagnostic procedures to precede radiographic examina- midline) along the caudal border of the ischiatic arch until
tions when a pelvic fracture is suspected [29]. Studies have the ischiatic tuberosity was reached. From the ischiatic
described the normal ultrasonographic appearance of the tuberosity, the probe was swept craniomediad (toward
pelvis [23-25] and the abnormal ultrasonographic findings midline) until the pelvic symphysis was reached one probe
associated with the diagnosis of pelvic fractures [25,26]. A length cranial to the lesser ischiatic arch. The probe was
detailed description of the transrectal ultrasonographic advanced laterad along the concave dorsal surface of the
diagnosis of pelvic fractures has yet to be described. The ischiatic table until the lesser ischiatic notch was reached at
purpose of this study is to describe a thorough ultrasono- the most lateral margin of the ischium. From the dorsal
graphic examination of the bony structures of the pelvis. In border of the lesser ischiatic notch, the probe was returned
addition, the subsequently described technique was used craniomediad reaching the pelvic symphysis two probe
along with other diagnostic aids and postmortem confir- lengths cranial to the lesser ischiatic arch. The probe was
mation to effectively diagnose pelvic fractures in eight advanced laterad to image the caudal border of the obtu-
horses. The signalment, clinical examination findings, rator foramen until the ischiatic spine was reached.
ultrasonographic findings, and results of other diagnostic Advancing the probe craniomediad allowed for the
imaging modalities in these horses are presented. remaining ischiatic and pubic borders of the obturator
224 W.T. Walker et al. / Journal of Equine Veterinary Science 32 (2012) 222-230

Fig. 1. Internal structures of the equine pelvis (A), including the pelvic symphysis (1), ischiatic table (2), tuber ischii (3), ischiatic arch (4), lesser ischiatic notch (5),
obturator foramen (6), ischiatic spine (7), pubic bone (8), acetabulum (9), body of the ilium (10), wing of the ilium (11), tuber sacrale (12), and tuber coxae (13).
Normal transverse transrectal image (B) of the pelvic symphysis on midline (arrow) and axial aspect of the ischiatic tables (arrowheads). Normal sagittal
transrectal image of the caudal border of the obturator foramen (C) consisting of the soft tissues within the obturator foramen (arrowhead) and cranial ischium
(arrows). Normal sagittal transrectal image of the pubic bone (D, arrows) and soft tissues within the obturator foramen (arrowhead).

foramen to be imaged until the pelvic symphysis was the probe in the left hand. After proper orientation of the
reached on midline. The aforementioned examination was probe was achieved, the probe was advanced dorsad to
repeated on the contralateral hemipelvis for comparison of examine the medial surface of the ilial body between the
symmetry and echogenicity. borders of the greater sciatic notch and arcuate line of the
The acetabulum, ilium, and sacrum were examined ilium. As the probe continued dorsomediad along the body
transrectally by placing the probe at the most cranial aspect of the ilium, the ventral aspect sacroiliac joint was exam-
of the pelvic symphysis and advancing the probe laterad ined. From this point, the ventral sacrum was examined,
over the pubic bone to the level of the acetabulum (Fig. 2A). including the ventral sacral foramina and the promontory
When examining the medial aspect of the left ilium and of the sacrum at midline (Fig. 3A). The aforementioned
ventral sacrum, the probe was in the right hand; exami- examination was repeated on the contralateral hemipelvis
nation of the contralateral structures was performed with for comparison of symmetry and echogenicity.

Fig. 2. Internal structures of the equine pelvis visualized from the medial aspect (A), including the ischiatic table (1), pubic bone (2), arcuate line of the ilium (3),
ischiatic spine (4), and the medial surface of the ilium (5). Normal sagittal transrectal image of the medial surface of the acetabulum (B, arrows) and obturator
vessels (arrowheads). Normal sagittal transrectal image of the medial surface of the body of the ilium (C, arrows) between the greater sciatic notch and arcuate
line of the ilium.
 W.T. Walker et al. / Journal of Equine Veterinary Science 32 (2012) 222-230 225

Fig. 3. Ventral view of the equine pelvis (A), including the tuber ischii (1), ischiatic table (2), obturator foramen (3), acetabulum (4), pubic bone (5), ventral sacral
foramina (6), promontory of the sacrum (7), ventral sacroiliac joint (8), and the wing of the sacrum (9). Normal transverse transrectal image of the sacroiliac joint
(B, accent), including the ventral surface of the ilium (arrowheads) and the ventral sacrum (arrows). Normal sagittal transrectal image of a ventral sacral foramina
(C), including the ventral sacral nerve root (arrows), a branch of the caudal gluteal artery within the nerve root (accent), and the ventral aspect of the sacrum
(arrowheads).

2.3. Approach to Transcutaneous Ultrasonographic neck, and greater trochanter of the femur. The probe was
Examination moved further caudad to image the lateral aspect of the
ischium along the caudal portions of the lesser ischiatic
A transcutaneous ultrasonographic examination was notch. At the most caudal aspect of the pelvis, the tuber
then performed similar to those previously described ischii was palpated and imaged with the probe in a vertical
[23,25] (Fig. 4A). A 3-5-MHz curvilinear transducer was orientation. The aforementioned examination was
used alternating between transverse and longitudinal repeated on the contralateral hemipelvis for comparison of
orientation to better visualize the osseous structures of the symmetry and echogenicity.
pelvis transcutaneously. The tuber sacrale was imaged from
its most dorsal margin craniolaterad over the concave crest 3. Results
of the ilium to the tuber coxae (Fig. 4A). The probe was
swept caudodistad across the gluteal surface of the ilial 3.1. Normal Transrectal Ultrasonographic Findings
wing between its most lateral and medial margins until
reaching the body of the ilium. From the caudal ilium, the The pelvic symphysis was identified with the probe in
probe was advanced caudad to view the dorsal aspect of the transverse orientation, midsagittally as a thin linear hypo-
acetabulum, the coxofemoral joint, as well as the head, echoic region separated by the hyperechoic osseous

Fig. 4. Structures of the normal pelvis evaluated with transcutaneous ultrasonography (A), including the wing of the ilium (1), tuber coxae (2), body of the ilium
(3), acetabular rim (4), coxofemoral joint (5), greater trochanter of the femur (6), and the tuber ischii (7). Normal longitudinal transcutaneous image the tuber
sacrale (B, arrow) and the iliac crest (arrowheads). Normal transcutaneous image of the coxofemoral joint (C, accent), acetabular rim (arrows), and greater
trochanter (arrowheads) with the probe directed dorsoventrally.
226 W.T. Walker et al. / Journal of Equine Veterinary Science 32 (2012) 222-230

Fig. 5. Transverse transrectal image of case 2 demonstrating the pelvic

symphysis (accent), normal section of ischium (arrowhead), and a callus on
the ischium due to a previous fracture (arrows). See Figure 1B for normal
ultrasonographic appearance.

structures of the ischiatic table (Fig. 1B). The ischiatic table

was identified as a smooth concave hyperechoic line. This
line led to a rough hyperechoic convex surface near the
lateral margin of the caudal ischium representing the tuber
ischii. The dorsal margin of the lesser ischiatic notch was
delineated by a smooth transition of hyperechogenicity
into an area of mixed echogenicity representing the over-
lying musculature.
The obturator foramen was easily identified with the
probe in sagittal orientation as an area of mixed echoge- Fig. 7. Gross (A) and dorsoventral transcutaneous image (B) of case 4
demonstrating a greater trochanteric and capital physeal fracture and
nicity surrounded by the ischiatic and pubic margins of the
a subluxated coxofemoral joint. The acetabular rim (arrow), femoral head
obturator foramen. These margins were identified as (accent), and greater trochanter (arrowheads) are all imaged with the probe
a smooth convex hyperechoic line (Fig. 1C). The pubic bone in longitudinal orientation. The femoral head is subluxated and there is
was identified in sagittal orientation as a smooth hyper- a step fracture on the femoral neck. See Figure 4C for normal ultrasono-
graphic appearance.
echoic line that did not span the entire length of the probe
(Fig. 1D). As the probe was moved laterad on the body of
the pubic bone, the length of the pubic bone widened until Two hypoechoic circular structures in the obturator groove
reaching the medial surface of the acetabulum. The medial on the medial aspect of the acetabulum were consistently
surface of the acetabulum was identified in sagittal orien- identified with the probe in sagittal orientation repre-
tation as a smooth and wide hyperechoic line between the senting the obturator artery and vein (Fig. 2B). The obtu-
region of the pubic bone and ischial spine. We found that rator nerve also occupies this region but could not be
the medial surface of the acetabulum was wider than the imaged consistently.
margins of the probe and required sweeping the probe in Dorsolateral to the acetabulum, the medial surface of
a cranial to caudal manner to examine its entire surface. the body of the ilium was visualized with the probe in
sagittal orientation. This congruent hyperechoic line
between the greater sciatic notch and arcuate line of the
ilium was imaged within the length of the probe (Fig. 2C).
The ventral aspect of the sacroiliac joint was imaged as
a hypoechoic gap between the hyperechoic wing of the
ilium and the sacrum [23] (Fig. 3B). The ventral sacral
foramina were identified in sagittal orientation as half-
circles of mixed echogenicity perpendicular to the plane
of imaging (Fig. 3C). The promontory of the sacrum was
identified midsagittally in transverse orientation as
a convex hyperechoic prominence.

3.2. Normal Transcutaneous Ultrasonographic Findings

The tuber sacrale was identified as a smooth hyper-

echoic prominence (Fig. 4B), and the tuber coxae was
Fig. 6. Sagittal transrectal image of case 2 at the medial aspect of the
acetabulum demonstrating displacement of the obturator vessels (arrow-
identified as a hyperechoic convex line at the craniolateral
heads) and extensive callus (arrows). See Figure 2B for normal ultrasono- aspect of the pelvis. The crest of the ilium was imaged with
graphic appearance. the probe in longitudinal orientation as a smooth concave
 W.T. Walker et al. / Journal of Equine Veterinary Science 32 (2012) 222-230 227

Fig. 8. Sagittal transrectal image of case 5 demonstrating an ischial step

fracture. The fracture (arrows) is displaced from the ischium (arrowheads).

hyperechoic line spanning the region between the tuber Fig. 9. Transverse transcutaneous image of case 7 with two displaced
sacrale and tuber coxae. The gluteal surface of the ilial wing fragments on the wing of the ilium (arrows). See Figure 4B for normal
ultrasonographic appearance. Image courtesy of Dr. Myra Barrett.
was identified as a smooth concave hyperechoic line
(Fig. 4B). The lateral and medial margins of the ilial wing
narrowed caudal in direction until the body of the ilium were only identified on the transcutaneous examination
was imaged as a narrow convex hyperechoic line viewed (Fig. 7B). Fractures of the ischium (Fig. 8), pubis, and ilium
entirely within the length of the probe in transverse were only diagnosed using transrectal ultrasonography.
orientation. Caudal to this, the body of the ilium widened Pelvic fractures were highly suspicious using transrectal
until the acetabular rim was identified as a small convex ultrasonography in six of eight cases and were confirmed
hyperechoic line (Fig. 4C). The coxofemoral joint was with other diagnostic aids. Two cases were diagnosed with
identified as a small hypoechoic line in apposition to the transcutaneous ultrasonographic examination and were
hyperechoic lines of acetabular rim and head of the femur negative on transrectal examination. Bony proliferation
(Fig. 4C). The femoral neck was identified as a smooth and irregularities of the acetabular rim and greater
hyperechoic line extending dorsad and superficially until trochanter were diagnosed only on transcutaneous exam-
a large hyperechoic prominence was imaged representing ination (Fig. 7B). Although case 7 did not receive a trans-
the greater trochanter. The lateral aspect of the caudal rectal ultrasonographic examination because of his small
ischium at the lesser ischiatic notch was identified as size, an ilial wing fracture (Fig. 9) was diagnosed on the
a smooth hyperechoic line. The tuber ischii was identified transcutaneous examination. Recumbent ventrodorsal
as a smooth hyperechoic prominence at the origins of the radiographs indicated that there was no further involve-
caudal thigh muscles. ment of the pelvis in this case.
In this series of cases, transrectal ultrasonographic
3.3. Ultrasonographic Diagnosis of Pelvic Fractures examination of the pelvis was an effective diagnostic aid in
revealing fractures of the pubis, acetabulum, ischium, and
Seven horses referred to the Colorado State University internal ilium (Table 1). Transcutaneous ultrasonographic
Veterinary Teaching Hospital for a suspected pelvic fracture examination of the pelvis effectively identified fractures of
received a complete ultrasonographic examination. Trans- the body of the ilium, femoral neck, and greater trochanter,
cutaneous ultrasonography was performed on one addi- as well as bony proliferation on the acetabular rim and
tional horse without a transrectal examination because of a subluxated femoral head.
his young age and because a fracture was readily diagnosed
on transcutaneous examination. Fractures were identified 4. Discussion
in three cases on both transrectal and transcutaneous
examinations. Fractures of the ischium and pubis were only In the present case series, case 5 and 8 had fractures of
identified on the transrectal examination (Fig. 5). Trans- ischium, pubis, and ilium that were diagnosed with trans-
rectal ultrasonographic examination of the acetabulum rectal ultrasonography and could not be detected with the
indicated a high suspicion of fracture that was verified with transcutaneous approach. Other studies support that
other diagnostic aids (Fig. 6, Table 1). Bony proliferation of transrectal ultrasonography is diagnostic for ischial and
the acetabular rim was evident on transcutaneous ultra- pubic bone fractures [26,29].
sonographic examinations where acetabular fractures were Performing a thorough clinical and lameness examina-
highly suspicious transrectally in all cases except horse 8. tion followed by a transrectal and transcutaneous ultraso-
The acetabular fracture in this case was acute. We were not nographic examination has been shown to be effective for
able to differentiate between articular fracture or the diagnosis of pelvic fractures [26,29]. Our results support
osteoarthritis in the coxofemoral joint on transcutaneous work from two other studies [26,29] that demonstrate the
ultrasonography without transrectal ultrasonographic reliability of transrectal and transcutaneous ultrasono-
examination. A femoral fracture and femoral subluxation graphic examinations in the evaluation of pelvic fractures.
Table 1

228
Signalment, transrectal, and transcutaneous ultrasonographic findings, results of other diagnostic aids, and final diagnosis of eight horses presenting for a suspected pelvic fracture

Horse Age Sex Breed Physical Ultrasonographic Findings Additional Diagnostics Diagnosis Diagnostic Aid Leading
to Diagnosis
Transrectal Transcutaneous

1 25 MC QH 4/5 left hind lame, stifle Negative Ill-defined irregularities Ventrodorsal: L greater Fracture of the left Radiographs,
effusion, quadriceps of L greater trochanter avulsion greater trochanter ultrasonography was
atrophy, tuber coxae trochanter and and L cranial and osteoarthritis of only suggestive of
pain acetabular rim acetabulum bony the coxofemoral a fracture
changes joint
2 2 FI TB 4/5 left hind lame, pain Misshapen L Bony proliferation of Ventrodorsal: L Fracture of the left Radiographs,
and swelling over L acetabulum with the L acetabular rim acetabular fracture acetabulum and ultrasound was only
coxofemoral joint extensive callus with osteophytes, ischium suggestive of
extending to the bony callus and fractures
ischium fractured L puboiliac

W.T. Walker et al. / Journal of Equine Veterinary Science 32 (2012) 222-230

junction
3 1 FI QH 5/5 right hind lame Proliferative bony Bony proliferation of Findings from R stifle Fracture of the right Ultrasound
with gluteal atrophy callus on R ischiatic the R acetabular rim radiographs were ischiatic table
and pain table negative
4 1 MI QH 5/5 right hind lame Negative R coxofemoral joint and Findings from R stifle Fracture of the right Ultrasound and
with stifle swelling femoral head radiographs were greater trochanter necropsy
and toed out stance visualized within negative, standing and capital physis
with elevated R hock acetabulum but not pelvic radiographs with a femoral head
continuous with not diagnostic due to subluxation
femoral neck and overexposure,
greater trochanter capital physeal
fracture confirmed at
necropsy
5 17 MC TB 5/5 left hind lame with Multiple step fractures Negative Rectal palpation was Fracture of the left Ultrasound
abduction and ataxia in L ischium and severely painful with ischium and pubis
at walk pubis with multiple crepitus on the floor
hematomas, of the pubis;
irregularities in body abdominocentesis
of ilium revealed
hemoabdomen; R
stifle radiographs
were negative
6 4 months MI QH 5/5 right hind lame Irregular step in medial Bony proliferation of Ventrodorsal: Fracture of the right Ultrasound and
with swelling and margin of R the R acetabular rim caudolateral pubis and radiographs
pain on R acetabulum displacement of R acetabulum
coxofemoral joint pubis at iliopubic
with toed out stance physis and irregular
R dorsal acetabular
rim
7 2 months MI QH 5/5 right hind lame Not performed due to Step fractures on the Ventrodorsal: non Fracture of the right Ultrasonography and
with swelling and age and diagnosis lateral aspect of the R displaced fractures of ilial body radiographs
pain ventrolateral to with other ilium just distal to the caudal R ilial
the tuber coxae modalities the tuber coxae body
8 17 FI QH 5/5 left hind lame with Fracture of the L pubic None Nuclear scintigraphy: Fracture of the left Ultrasonography,
a palpable mass bone and focal uptake at the L pubic bone and nuclear scintigraphy
medial to the L acetabulum with pubic bone acetabulum was only suggestive
acetabulum displaced iliac of a fracture
vessels and a large
hematoma
 W.T. Walker et al. / Journal of Equine Veterinary Science 32 (2012) 222-230 229

In one study [26], initial transrectal ultrasonographic As with any rectal examination, the potential compli-
examinations effectively diagnosed pelvic fractures in cation of a rectal tear exists. Sedation and a transrectal
seven of nine cases. The two cases in that study which were infusion of 60-mL 2% lidocaine via an extension set will
negative revealed pelvic fractures on a follow-up trans- enhance the comfort of the patient, limit resistance, and
rectal ultrasonographic examination [26]. Another study decrease peristalsis and straining. Although we did not
[29] demonstrated that the ultrasonographic yield for the find it necessary, the administration of an antispasmotic
diagnosis of pelvic fractures was approximately the same as may be beneficial in horses that are straining against the
a radiographic examination (73%). In this study, five frac- examiner. Using these precautions, the authors feel that
tures were diagnosed by ultrasonography and not by transrectal ultrasonography is safer than general anes-
radiography. All fractures were suspected with ultraso- thesia because it eliminates the risk of fracture displace-
nography but three were confirmed with radiography. This ment to the patient and avoids repeated exposure of the
study reported that radiography better characterized three staff to radiation.
fractures that were diagnosed using ultrasonography [29]. Although the present ultrasonographic technique
In this study, only five of nine acetabular fractures were successfully diagnosed or confirmed the diagnosis of pelvic
definitively diagnosed with ultrasonography, although fractures in this case series, several limitations exist. We
fractures were suspected in the other four cases. The describe a specific technique that has been found to be
authors could not definitively diagnose acetabular fractures useful in a limited number of cases. Previous studies have
using transrectal ultrasonography in the four other cases. used ultrasound to effectively diagnose pelvic fractures in
However, this modality suggested the presence of an far more cases [26,29]; however, a thorough verbal and
acetabular fracture in all of the cases with acetabular pictoral description of the approach was not included.
pathology [29]. Acetabular rim fractures can be diagnosed Several approaches can be used as long as the entire bony
with the probe directed dorsoventrally and oriented surface of the pelvis is visualized. Only 25% of horses
parallel to the longitudinal surface of the ilial body [28,29]. included in our case series were <1 year of age; however,
Furthermore, a novel ultrasonographic technique which 37% [8]-42% [5] of pelvic fractures occur in horses <1 year
images the coxofemoral joint during weight-bearing and of age. Transrectal ultrasonography can be dangerous in
noneweight-bearing stance can be used to diagnose cox- this demographic because of their small size and flighty
ofemoral joint subluxation [28]. Transcutaneous ultraso- nature. Additionally, radiographs and nuclear scintigraphy
nographic examination of the acetabulum in our case series can be complicated by the presence of open physes. If
effectively revealed bony changes in the acetabular rim in available, computed tomography can be an effective alter-
four cases where pathologic change was present. In case 8, native for the diagnosis of pelvic fractures in young horses;
transcutaneous ultrasonographic examination did not however, this modality requires general anesthesia [22].
reveal acetabular rim changes, although an acetabular Finally, although offered to owners, pelvic radiography
fracture was diagnosed transrectally. The acute nature of under general anesthesia was only performed in 50% of the
this fracture may have resulted in the discrepancy between presented cases. Because of the small number of cases and
transcutaneous and transrectal ultrasonographic findings, the lack of consistency in diagnostic approach, direct
as bony changes on the acetabular rim were not yet comparisons between the efficacy of ultrasonography and
present. other diagnostic aids could not be made.
Similar to ultrasonographic studies elsewhere on the
horse, ultrasonography requires familiarity with the
machine, an in-depth understanding of equine pelvic 5. Conclusion
anatomy, and experience to achieve competency. Having
a dry gross specimen of the equine pelvis available can aid Transrectal and transcutaneous ultrasonographic
in the recognition of normal anatomy [6]. It is important to examination of the pelvis can be an effective, sensitive, and
compare one side of the hemipelvis with its contralateral inexpensive modality for the diagnosis of pelvic fractures in
counterpart to evaluate bilateral symmetry [6], which can the horse [24-28] and is most useful in concert with other
be of assistance when diagnosing less apparent lesions. diagnostic aids. Transrectal and transcutaneous ultrasono-
It is imperative that transrectal and transcutaneous graphic examination has been deemed an appropriate
ultrasonographic examinations are performed and include initial imaging examination following a clinical and lame-
all bony surfaces of the pelvis when a pelvic fracture is ness examination when a pelvic fracture is suspected [29].
suspected. One case report discussed a false-negative This study describes a detailed transrectal and trans-
transcutaneous ultrasonographic pelvic examination cutaneous ultrasonographic technique for the diagnosis of
where the greater trochanter blocked visualization of pelvic fractures and presents figures of both the normal and
a craniolateral ischial fracture. However, transrectal ultra- pathologic appearance of the pelvis. In addition to a valu-
sonography was not performed in this case leading to many able aid in the diagnosis of pelvic fractures, this modality
other diagnostic tests at the owners’ expense [30]. In provides an effective way to monitor the progression of
another study, transrectal ultrasonography was not per- pelvic fractures, determine prognosis, and recommend
formed because the horse was negative to rectal palpation. specific therapeutic modalities [6,26]. Ultrasound is readily
A pelvic fracture was later diagnosed on a follow-up available to equine practitioners and can be a helpful aid for
transrectal ultrasonographic examination [26]. These diagnosing pelvic fractures in the field where high-power
examples highlight the importance of performing a thor- X-ray equipment, computed tomography, or nuclear scin-
ough transrectal and transcutaneous ultrasonographic tigraphy are not available. When ultrasonographic findings
examination [26]. are unclear or the ultrasonographer is uncomfortable with
230 W.T. Walker et al. / Journal of Equine Veterinary Science 32 (2012) 222-230

the findings, radiography, nuclear scintigraphy, and [15] Talbot AM, Barrett EL, Driver AJ, Barr FJ, Barr ARS. How to perform
standing lateral oblique radiographs of the equine pelvis. Proc Am
computed tomography can be used effectively.
Assoc Equine Pract 2006;52:613-6.
[16] Lamb CR, Koblick PD. Scintigraphic evaluation of skeletal disease
and its applications to the horse. Vet Radiol 1988;29:16-27.
Acknowledgments [17] Hornof WJ, Stover SM, Koblick PD, Arthur RM. Oblique views of the
ilium and the scintigraphic appearance of stress fractures of the
The authors thank Dr. Anna D. Fails and Heather Miller ilium. Equine Vet J 1996;28:355-8.
[18] Shepherd MC, Meehan J. The European Thoroughbred. In:
for their artistic contributions. Dyson SJ, Martinelli MJ, Pilsworth RC, Twardock AR, editors.
Equine scintigraphy. Newmarket, UK: Equine Veterinary Journal
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