Six cases of comminuted fracture of the accessory carpal bone where dorsoproximal fragments within the palmar antebrachiocarpal joint were removed by arthroscopy in the standing horse.

Six cases of comminuted fracture of the accessory carpal bone where dorsoproximal fragments within the palmar antebrachiocarpal joint were removed by arthroscopy in the standing horse. | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); Skip to main content Preprints Collections Wiley Open Research IET Open Research Ecological Society of Japan All Collections About About Authorea FAQs Contact Us Quick Search anywhere Search for preprint articles, keywords, etc. Search Search ADVANCED SEARCH SCROLL This is a preprint and has not been peer reviewed. Data may be preliminary. 13 March 2026 V1 Latest version Share on Six cases of comminuted fracture of the accessory carpal bone where dorsoproximal fragments within the palmar antebrachiocarpal joint were removed by arthroscopy in the standing horse. Authors : Kathy Duncan [email protected] , Andrea Cardona Miranda 0009-0005-7666-8087 , and Bryan O’Meara Authors Info & Affiliations https://doi.org/10.22541/au.177341073.38524242/v1 147 views 66 downloads Contents Abstract Supplementary Material Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract Background: Accessory carpal bone fractures in the horse often result in a fracture configuration described as frontal plane, complete fractures, with dorsoproximal fragmentation. Conservative management of accessory carpal bone fracture type has been associated with good outcomes. Horses that do not return to soundness are highly likely to develop osteoarthritis of the carpal joints, carpal sheath pathology, or both. The removal of these fragments to ameliorate osteoarthritis is reported in the literature. Objective: To describe a novel technique to remove dorsoproximal accessory carpal bone fracture fragments from the palmar aspect of the antebrachiocarpal joint in the standing horse. Study design: Retrospective case series of six horses that underwent standing carpal arthroscopy between 2016 and 2025. Methods: Six horses with comminuted accessory carpal bone fractures underwent standing arthroscopic removal of dorsoproximal osteochondral fragments within the palmar antebrachiocarpal joint. The antebrachiocarpal joint was anaesthetised and the subcutaneous tissue infiltrated using mepivacaine hydrochloride. A suction punch forceps and a soft tissue motorised ablator were used to dissect the soft tissue attachments. A motorised bone burr was used to remove or debulk the fragments. Results: All horses recovered well from surgery and were stabled for 3 months. In all six cases, the fracture healed by fibrous union. 5 of 6 horses returned to athleticism, often within 12 months from injury; one horse was retired for breeding purposes. Main limitations: Retrospective nature of study, small sample size, varying degrees of pathology present. Conclusions: This is a novel technique that may be suitable in selected cases of accessory carpal bone fracture to ameliorate antebrachiocarpal joint osteoarthritis. Performing the surgery standing negated the need for general anaesthesia. The described technique may encourage surgeons to adopt standing removal of fragments earlier in the healing process which may improve the outcome in horses with this fracture configuration. Six cases of comminuted fracture of the accessory carpal bone where dorsoproximal fragments within the palmar antebrachiocarpal joint were removed by arthroscopy in the standing horse. Kathy Duncan BSc(Hons) BVMS Dip. ECVS MRCVS , Heath Equine Veterinary Practice, Cholmondeley, Cheshire, UK Andrea Cardona Miranda, DVM, Cert AVP (EM), Equicall, Kent, UK Bryan O’Meara MVB MVM Cert ES(Orth) Dip. ECVS MRCVS , RCVS and European Specialist in Equine Surgery , Bryan O’ Meara Veterinary Consultancy, Newbury, Berkshire, UK Keywords : Horse, Accessory Carpal Bone Fracture, Arthroscopy, Standing. Summary: Background: Accessory carpal bone (ACB) fractures in the horse often result in frontal plane, complete fractures, with dorsoproximal fragmentation. Horses that do not return to soundness can develop osteoarthritis of the carpal joints and carpal sheath pathology. The removal of these fragments to ameliorate osteoarthritis has been reported. • Objective: To describe a standing surgical technique to remove dorsoproximal ACB fracture fragments from the palmar aspect of the antebrachiocarpal joint. • Study design: Retrospective case series of six horses that underwent standing carpal arthroscopy between 2016 and 2025. • Methods: Six horses underwent standing arthroscopic removal of dorsoproximal osteochondral fragments within the palmar antebrachiocarpal joint. The antebrachiocarpal joint and the subcutaneous tissue were anaesthetised. A suction punch forceps and a soft tissue motorised ablator were used to dissect the soft tissue attachments. A motorised bone burr was used to remove or debulk the fragments. • Results: All horses were stabled for 3 months. All fractures healed by fibrous union. 5 of 6 horses returned to athleticism, most within 12 months from injury. • Limitations: Retrospective study, small sample size, varying degrees of pathology. • Conclusions: This technique may encourage surgeons to adopt standing removal of fragments earlier in the healing process in specific ACB fracture cases. INTRODUCTION Accessory carpal bone (ACB) fractures account for 2% of all carpal fractures (Barr et al. 1990). They can occur in all breeds although they are more common in jumping horses (Dyson, 1990; Launois et al. 2002). Fractures usually take place in a vertical plane along the groove formed by the long tendon of the ulnaris lateralis muscle and they can be simple or comminuted in nature (Barr et al., 1990; Easley and Schneider, 1981; Kawcak, 2020; Ross, 2011; Wyburn and Goulden, 1974). This is supported by a cadaveric study in which the ACB was subjected to varying loads; in all eight specimens, bone damage occurred in a vertical plane (Reuter et al., 2024). Although rare, a horizontal configuration has also been reported (Carson, 1990; Roberts, 1964). In cases where the fracture is comminuted, there is typically a dorsoproximal fragment involving the antebrachiocarpal joint (Figure 1). There are three mechanisms by which the ACB can fracture: external trauma, soft tissue avulsion and the so-called “nutcracker” effect (Munroe and Cauvin, 1997; Ross, 2011; Minshall and Wright, 2014). Avulsion fractures occur when excessive tensile forces exerted by the palmar ligamentous attachments lead to a fragment being pulled away from the ACB as a result of abnormal loading of the bone during exercise (Fürst and Jackson, 2022; Rijkenhuizen and Németh, 1994). This intense loading may be due to different factors, such as overextension of the limb or asynchronous contraction of the extensor and flexor carpi ulnaris muscles (de Preux et al. 2022; Rijkenhuizen and Németh, 1994; Wilke et al. 2001). On the other hand, the nutcracker effect describes a compressive mechanism in which the ACB is crushed between the radius and the third metacarpal bone, typically in jumping horses during landing or after a fall with a flexed limb. This direct compression is believed to contribute to its characteristic fracture configuration. While these mechanisms differ—one involving tensile forces and the other compressive forces—both ultimately result in structural failure of the ACB under extreme mechanical stress (Fürst and Jackson, 2022; Rijkenhuizen and Németh, 1994). Articular fractures of the dorsoproximal aspect of the ACB have been managed both conservatively and surgically (Munroe and Cauvin, 1997). Conservative methods generally consist of bandaging or casting for a set duration followed by an initial 3-month period of box confinement and then 3 to 9 months of pasture turnout (Minshall & Wright, 2014; Ross, 2011; Ruggles, 2019;). Various surgical techniques have been used to treat comminuted ACB fractures, including comminuted simple open fragment removal (Munroe & Cauvin, 1997), arthroscopic fragment removal with debridement of displaced fractures in the antebrachiocarpal joint or carpal sheath (Bonilla & Santschi, 2015; Minshall and Wright, 2014), and bone grafting and fracture fixation (Easley & Schneider, 1981; Rijkenhuizen & Németh, 1994), including lag screw and dynamic or locking compression plate (LCP) placement (de Preux et al., 2021; Easley & Schneider, 1981; Rijkenhuizen & Németh, 1994; Ruggles, 2019). The reported prognosis for different treatment approaches is variable in the literature. Still, when there is dorsoproximal fragmentation of the ACB, in the author’s experience, and as stated by Fürst and Jackson 2022 and Aßmann et al., 2023, osteoarthritis of the antebrachiocarpal joint occurs, worsening the prognosis to return to full athletic function. Additionally, loose fragments can rotate axially and cause carpal sheath pathology (Radue, 1981), and secondary damage to the deep digital flexor tendon and other surrounding soft tissue structures (Minshall and Wright, 2014). Therefore, surgical removal of loose fragments is recommended in athletic horses. The mortality rate of horses undergoing general anaesthesia is approximately one in three hundred (Dugdale and Taylor 2016; Arndt et al., 2020; Loomes and Louro 2022). In addition, general anaesthesia in horses carries other multiple risks such as musculoskeletal injuries at both induction and recovery phases, damage to the airway secondary to tracheal intubation or post-anaesthetic myopathies or neuropathies (Deutsch and Taylor, 2021). Therefore, there is a trend towards performing procedures on the standing sedated horse to avoid the risk of general anaesthesia (Bonomelli and Garcia Bonilla 2022). This case series describes a novel technique to remove dorsoproximal accessory carpal bone fracture fragments from the palmar aspect of the antebrachiocarpal joint in the standing horse. CASE HISTORY: Six horses (2 mares, 3 geldings and 1 stallion, aged between 2 and 13 years old) presented with acute signs of lameness in the forelimb following a traumatic event. 5 cases were lame in the left forelimb and 1 case in the right forelimb. Radiographic examination revealed accessory carpal bone fractures with dorsoproximal comminution. Conservative treatment was initially elected in all cases. There was no evidence of pre-existing carpal pathology in any of the horses prior to the traumatic event. CLINICAL FINDINGS Follow up radiographs were taken 1-3 months after the injury in all 6 cases. These revealed antebrachiocarpal joint space narrowing, sclerosis and/or osteophytosis in all horses, indicative of early osteoarthritis of the joint. DIAGNOSIS: ACB fracture with dorsoproximal fragmentation triggering osteoarthritis of the radiocarpal joint. Surgical technique: All animals were administered perioperative phenylbutazone (4.4mg/kg) intravenously (IV) and broad-spectrum antimicrobials (regimen depended on each case and practice protocol) and placed in stocks. Sedation was achieved with detomidine hydrochloride (0.01-0.02mg/kg IV) and butorphanol tartrate (0.01-0.04mg/kg IV), where an initial bolus was given, followed by a continuous rate infusion (CRI) and additional boluses were given as necessary. Preoperative radiographs were taken and skin staples were used to aid the localization of the loose bone fragment. Following aseptic preparation of the affected limb, a sterile vet wrap ( 3M , Minnesota, USA) was placed proximal and distal to the surgery site, including the foot, and also on the full length of the contralateral limb. Higher quantity draping methods such as those used under general anaesthetic limb arthroscopy, were avoided so as to prevent reducing access or visibility of the limb. Palpation and visibility of local landmarks were deemed vital for accurate positioning of the arthroscopic portals. Local anaesthetic (mepivacaine hydrochloride) was infiltrated subcutaneously and 20mls were injected intra-articularly into the antebrachiocarpal joint. A bale of shavings ( Bedmax , Northumberland, England) was draped using a large sterile drape ( Buster ®, Maine, USA) and positioned in front of the hind limbs to ensure the surgeon’s safety. The surgeon was seated on a stool lateral to the affected limb. A drape (1m x 1m) was secured using a number of clamps to the surgeon’s gown and served as an extension of the surgeon’s gown to ensure the surgeon’s limbs did not contaminate the arthroscopic paraphernalia. The arthroscopic camera, light source and fluid line were attached to the surgical table and the surgeon’s gown. The surgeon’s lap was used to place the arthroscope during the creation of the portals and as required (Figure 2). The arthroscopic tower was positioned beside the neck of the horse (Figure 3). An arthroscopic portal was created using a no.11 scalpel blade into the antebrachiocarpal joint. This portal is ideally located proximal to the ACB, on its most dorsal edge, and proximal to the fragment. An instrument portal was then located distally but portals were used interchangeably as required. The arthroscopic fluid levels should be maintained as low as possible (40-50mmHg) to maintain good visibility but to avoid subcutaneous extravasation. A soft tissue ablator and suction punch forceps were used to detach the soft tissue attachments from the fragments. An arthroscopic bone burr was used to reduce fragment’s size to where they could be removed using Ferris-Smith rongeurs. The fracture site was debrided with a loop curette/angled spoon in most cases. Intraoperative radiographs were carried out to ensure that all the osteochondral fragments were extracted. The joint was flushed and the arthroscopic portals were opposed using a 3-metric nylon suture (Ethilon ®, Henry Schein, New York, USA) in a simple interrupted pattern. The limbs were then bandaged in a sterile dressing. Throughout the procedure, as with many standing orthopaedic surgeries, the nomination of a person responsible for timely positioning of a deep bucket on the floor or behind stocks is advised to help maintain sterility. Postoperative management: All six horses went through the same period of rehabilitation after surgery. Strict box rest was carried out for 3 months, with full limb bandages for the first two weeks, those being changed every 2-3 days or as necessary. Oral NSAIDs were given for up to 30 days postoperatively, according to the needs of the horse. Sutures were removed in aseptic fashion 10-14 days after the procedure. Short periods of hand-grazing (5-10 minutes) were permitted after suture removal depending on the horse’s temperament. In 6-12 weeks after the surgery, medication of the antebrachiocarpal joint with Triamcinolone Acetonide and Hyaluronic Acid was performed. Further joint medications were recommended according to the degree of osteoarthritis and, in some cases, the carpal sheath was also medicated. Twelve weeks postoperatively, small pen turnout was introduced and gradually increased until returning to their usual turnout routine over the following months. Walking exercise was gradually returned after three months from injury. Riding exercise was gradually introduced from six months, depending on the individual horse’s comfort levels. The horses that went back into graduated ridden exercise did so from 6-9 months from injury. All owners were advised to expect the horse would be out of full work for a full calendar year. Case six is an exception, which returned to elite jumping exercise at eight months after surgery. OUTCOME: Outcome information was obtained with consequent follow-ups and telephone conversations with either the owners, trainers or referring veterinary surgeons. None of the horses had complications in the postoperative period. In all six cases, the ACB fracture healed by fibrous union. Five of the six horses (83%) were considered sound and returned to their intended use within a year of surgery. One was a two-year-old Thoroughbred filly who successfully raced for three more years, even winning over 6 furlongs 11 months post-surgery. Another was a seven-year-old polo pony gelding who played for two more years at the same level. The third was a three-year-old Warmblood gelding who was broken in and pursued a riding career, with no evidence of lameness on the affected limb. The fourth case was a thirteen-year-old Thoroughbred gelding returned to a riding school and was used for general purposes, and lastly an elite showjumper who returned to jumping 1.45m after 8 months. The remaining horse, a Warmblood mare, was retired for breeding purposes after the surgery. However, the horse had shown limited potential as a younger animal. DISCUSSION: The complexities of managing ACB fractures have led to ongoing debates between conservative and surgical approaches. Whilst conservative management has been associated with positive outcomes (Barr et al. 1990; Carson, 1990; Dyson, 1990; Accorroni et al. 2025), there is a considerable body of evidence suggesting that malunion and delayed fracture healing are common complications (Aßmann et al. 2023; Barr et al. 1990; de Preux et al. 2022; Dyson, 1990; Easley and Schenider, 1981; Fürst and Jackson, 2022; Minshall and Wright 2014). In a series of 10 horses described by Wilke et al. (2001) the prognosis for return to function was considered poor, with 6 horses being euthanized. Only 3 of the horses returned to work, all of which underwent arthroscopic removal of intra-articular fragments, suggesting that such surgical treatment may improve the prognosis. In contrast, a recent study reported the successful conservative management of two horses with displaced frontal plane fractures of the ACB (Accorroni et al., 2025). Both horses, a flat racing Thoroughbred and a show jumper, returned to athletic competitions in 9 and 12 months respectively. Regardless of the treatment, when there is dorsoproximal fragmentation of the ACB, in the author’s experience, and as stated by Fürst and Jackson 2022 and Aßmann et al., 2023, osteoarthritis of the antebrachiocarpal joint occurs, worsening the prognosis to return to full athletic function. The loose fragments can also cause carpal tunnel syndrome (Radue, 1981), and secondary damage to the deep digital flexor tendon and surrounding soft tissue structures (Minshall and Wright, 2014). Similarly it is the authors’ impression that the development of osteoarthritis within the middle carpal joint is less common and is often associated with significant fragmentation of the accessory carpal bone adjacent to the palmar aspect of the middle carpal joint. The horses in this study fractured the accessory carpal bone as a result of a single traumatic event. Owners reported jumping accidents, hyper flexion of the carpus (‘nut cracker effect’) and one horse had a rotational fall with a show jumping pole caught between the radius and metacarpal region of the limb. All horses were unilaterally lame on presentation with effusion of the antebrachiocarpal joint. The complex anatomy regarding soft tissue attachments and bony interfaces in this area (Minshall and Wright 2014, Davern et al. 2019), provides us with an additional challenge when trying to offer a prognosis following both conservative management and surgical intervention. All horses were presented for surgical treatment within 3 months of injury and showed osteoarthritic changes on their preoperative radiographs. The variability in duration between accident and presentation for surgery did not seem to equate to worse degrees of osteoarthritic changes in the joint, and therefore outcome. This case cohort all presented with a dorsoproximal osteochondral fragment, and a degree of comminution which formed the basis of the development of the surgical procedure. To simplify the preoperative variabilities of pathology, we chose to focus on the attempted removal of the dorsoproximal fragment, and other fragments in this dorsoproximal region. Over zealous removal of ACB fragments involving the palmar aspect of the middle carpal joint may be detrimental to limb function in the author’s opinion. The variability in comminution and exact location of fracture lines was not fully investigated as routine radiography was the main preoperative imaging modality. Ultrasonographic examination of the carpus was performed to assess potential injury of the surrounding soft tissues within the carpal sheath and to help determine fragment location however ultrasonography was not performed in all cases and its requirement was dependent on the clinical presentation. Advanced imaging modalities, such as computed tomography (CT) and magnetic resonance imaging (MRI) requiring general anaesthesia is contraindicated because of the risk of further displacement of fragments or rotation of fragments causing disruption to the digital flexor tendons. Standing cone beam computed tomography may be valuable to perform in the standing horse and would allow for more detailed fracture characterisation and for guiding the surgeon with regards surgical planning (Hagenbach et al. 2024). MRI of the accessory carpal bone in the standing horse is potentially achievable and was performed in one horse in this study; however, imaging the affected area is often challenging due to the inherent limitations of MRI in the standing horse (Nagy and Dyson, 2011; Lin et al. 2025). The use of advanced imaging to assist surgical planning has also been described by De Preux et al. (2022), who reported successful fixation of a multifragmentary ACB fracture in a mature horse using computer-assisted orthopaedic surgery (CAOS). All horses had a positive surgical outcome, with the fracture healing by fibrous non-union. A significant limitation of the study was the small number of horses and their varied athletic uses. As a result, it was not possible to compare their athletic performance, as the demands ranged from an elite show jumper to horses used for general riding. In spite of these limitations, this case series described a novel surgical technique in the standing horse that may be considered for ACB fractures with dorsoproximal fragmentation (both frontal or comminuted) where there is the potential for the development of osteoarthritic change in the antebrachiocarpal joint. The primary goal is to reduce the long term severity of osteoarthritis in the carpus, thus improving the horse’s chance of returning to normal athletic activity. The description of this technique may encourage surgeons to consider removal of these fragments as a standing procedure, which could improve outcomes for horses with these fracture configurations. References: Aßmann, A.D., Fürst, A. E. and Bischofberger, A.S. (2023) Standing osteosynthesis of an accessory carpal bone fracture in a Warmblood mare with a 6-hole 3.5 talonavicular fusion plate and 3.5mm screws. Equine Veterinary Education. 35, e398-e405. Arndt, S., Hopster, K., Sill, V., Rohn, K. and Kästner, S.B.R. 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Wyburn, R. and Goulden, N.B. (1974) Fractures of the equine carpus: a report on 57 cases. New Zealand Veterinary Journal . 22, 133–142. Supplementary Material File (figures acb paper eve submission (1).docx) Download 788.55 KB File (table acb paper eve submission.docx) Download 9.35 KB Information & Authors Information Version history V1 Version 1 13 March 2026 Copyright This work is licensed under a Non Exclusive No Reuse License. Keywords accessory carpal bone fracture arthroscopy horse standing Authors Affiliations Kathy Duncan [email protected] Heath Equine Veterinary Practice View all articles by this author Andrea Cardona Miranda 0009-0005-7666-8087 Equicall View all articles by this author Bryan O’Meara Bryan O’ Meara Veterinary Consultancy View all articles by this author Metrics & Citations Metrics Article Usage 147 views 66 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation Kathy Duncan, Andrea Cardona Miranda, Bryan O’Meara. Six cases of comminuted fracture of the accessory carpal bone where dorsoproximal fragments within the palmar antebrachiocarpal joint were removed by arthroscopy in the standing horse.. Authorea . 13 March 2026. DOI: https://doi.org/10.22541/au.177341073.38524242/v1 If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Simply select your manager software from the list below and click Download. For more information or tips please see 'Downloading to a citation manager' in the Help menu . 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