Knee Injury

[KsKingBee]

Sorry Casportpony. You had sent me a link to this thread and for some reason it brought me to page one, without the option to continue to page 2 & 3, so I didn't know those pages existed. So I posted something that didn't really apply after I hit "submit" and pages 2 & 3 came up. Then I tried to cancel my post, but it wouldn't let me. It said I couldn't cancel, and I couldn't just edit and repost a blank comment, so I posted a single digit and hoped no one would notice.

No such luck Sydney, now you have to answer to the CaSportPony.

 

[Sydney Acres]

Quote:
Welllll ---

It's really hard for me to interpret from pictures, without seeing, feeling, manipulating and smelling it myself, but I'll stick my toe in the water (since everybody has popcorn, after all

).

The first pictures look like the lesion is below the joint, not in it. The picture where the joint is disarticulated looks like the articular cartilage was not inflammed, and there is a clear glistening of what I assume is normal joint fluid. The surrounding area does look a little thickened, which I assume is inflammation moving upwards from the lesion and surrounding the joint, but hasn't invaded into the protective joint capsule yet. It appears that the swelling started distinctly below the hock joint (the knee is the next one up the leg, and points towards the head when flexed, whereas the hock, the equivalent to our ankle, points towards the tail when flexed), with the greatest amount of inflammation on the back of the leg, with progressively thinning areas of swelling wrapping mostly around the outside, but somewhat also around the inside of the leg, the extending upwards toward the joint as well.

The description of the center of the swelling being hard and crunchy means that either bony tissue is involved, or there is some kind of crystal formation, or mineralization of soft tissue, or some combination of those. Other things that I would consider are the lack of a distinct tubular bone structure, very inflammed/thickened connective tissue outside the bone (probably either the (normally) thin periosteum that surrounds the outside of the mineralized bone, or the ends of tendons that were attached to the bone in that location), the level of pain the bird showed (laying down instead of limping), and the sudden change in the birds condition from being disabled to being really sick. That bone, focally, was really compromised and desperately remodeling with a huge amount of disorganized bone tissue, instead of healing with a strong, functional bony structure. That kind of bone growth is kind of like rapidly building something with styrofoam instead of slowly creating steel. The repair takes up more space and isn't nearly as strong. That rarely happens with a fracture. I suppose it could if the animal was forced to use the leg with an unstable fracture, where the broken bone ends aren't held together and they rub against each other with each step. But typically you would have a bird that suddenly went down, before the extreme bony swelling had a chance to develop, and you would first see soft tissue swelling from the trauma and maybe be able to detect the instability. A green stick fracture shouldn't have that level of instability, so the bony callous that it develops shouldn't be that exuberant, and the inflammation shouldn't be so extreme. And there should still be an obvious strong bony "pipe" that the new mineralization is adhering to and trying to repair. So to my eyes, this doesn't look like a typical green stick fracture, although I can't be sure from just pictures.

The two things that first come to mind that would cause this level of disorganized bony proliferation are a bone infection (bacterial or fungal are most common), or bone cancer. Depending on where you live, fungal infections may be common, can seat anywhere on a bone, and will look exactly like this. Bacterial infections can get into bone through injury and a tiny penetrating wound that might never be seen, or can land focally on a bone after traveling through the blood. An injury that would cause a green stick fracture plus a tiny penetrating wound leading to bone infection would be a double whammy. These types of infections don't look like typical abscesses, don't form pus, and rarely smell bad. This bird is a little young for cancer, but realistically, they have pediatric oncology wards for a reason. Youngsters get cancer too, unfortunately, and bone cancer typically causes first lytic resorption of bone tissue, then desperate disorganized attempts at repairing of the bone, ending in severe focal pain, then obvious illness. So either infection or cancer could look exactly like this. Gout could potentially also cause this, but the location is weird, the progression isn't right, and the response would be extreme for just a few uric acid crystals. This level of gout typically would take a very long time to develop, and should not be painful enough outside of a joint to create these symptoms. I could see this level of inflammation if gout settled in a tendon, but that shouldn't trigger this kind of bony remodeling. A "slipped tendon" causes some obvious abnormal angulation of the leg at the hock joint, and may cause some local soft tissue inflammation and swelling, but would have no reason to cause bony remodeling to this extent. Something had to be destroying bony tissue to justify this kind of a response.

Or at least that's my best guess, based just on pictures and a few symptoms. I could be wrong.

If the dissected area was saved, you could send it in for a biopsy. That would likely give you a more definitively answer.

 

[ChickenTDuck1234321]

Hello!

Okay, what you have here looks to me to be sequelae of the earlier infection! So when a bird gets sick with a systemic infection (meaning the pathogen has reached the bloodstream), there are some common lesions we see in the veterinary world. In birds you see three lesions following a bacterial or viral insult: hepatomegaly (enlarged liver), splenomegaly (enlarged spleen), and swollen joints. Since we cannot see the spleen or liver, this is what we probably have to work with on this bird.

This is not medical advice, but I would quarantine the bird, monitor for changes in appetite/water intake, and just make the bird as happy as possible! If I had to guess what you're dealing with based on respiratory signs is most likely a fowl cholera (P. multocida), colibacillosis (E. coli), Mycoplasmosis (Mycoplasma spp.), etc. If more of your flock gets sick, please do not hesitate to shoot me a PM. I can help you and your veterinary professional to the best of my ability.

Have a great day,

Luke

 

[ChickenTDuck1234321]

I agree with the fungal, to a degree, however, neurologic signs would be more apparent. I will admit, I just jumped into the thread not reading every page. Also, the bird if given radiographs will possibly have some opacities at the proximal aspect of the lung parenchyma. Fungal infections start proximal in the lungs and develop heterophilic growths as they progress towards the distal aspect of the lung parenchyma..
Oncogenic growths in this region are extremely uncommon. I have not seen one to date in the diagnostic lab or the field. This does not mean it can't happen.
Depending on where the bird lives, reovirus has been showing its ugly face a lot through the midwest USA all the way to Virginia. This would cause a slipped tendon; some also claim heart attacks (ruptured aorta). Personally, this is a very real possibility. Reovirus is triggered when the bird is stressed, and BOOM you have abnormal gait. I tend to see this as a bilateral problem though, so it is lower on my differentials.

I stand by this is most likely sequelae from a previous respiratory infection gone septicemic. I am assuming it is a heterophilic abscess that will take time to break down. I have seen these take weeks to months to break down.

I would strongly advise to not cut into this unless they are culling the bird or if the bird has no improvement. Their is a lot of vasculature there, and birds need all the blood they can get. If this will be removed, use a lidocaine ring block and sterile surgical instruments. Scalpels are cheap.

Luke

 

[Sydney Acres]

Hello Dr. Luke,
I don't mean to be a witch here, but clearly you have not represented your profession well in this situation. You have neither read the history of the illness, nor looked over most of the information provided. You have no business giving medical advice in this situation, which you are doing despite the claim that you are not giving any.. You clearly have not evaluated the most critical part of the thread, or you would not be recommending that this bird be quarantined, monitored, and "made as happy as possible" AFTER IT HAS BEEN CULLED AND ITS LEG HAS BEEN DISSECTED TO SHOW US THE LESION. Did you think you were looking at a backyard surgery and didn't notice that the rest of the bird wasn't attached??? Your cavalier declarations of medical differentials are ridiculous in this situation -- you are not addressing an audience of other veterinarians who understand all the medical terms that you are using, or appreciate your attempt at elevating your assumed status by using such language. You come off as arrogant, callous, and clueless. I can only hope that you are a new grad who hasn't yet learned that such behavior is offensive, and will later mature into a caring professional, one that is willing to share some hard-earned knowledge with compassion and humility.

And while the textbooks do teach that fungal infections are systemic, with both respiratory and neurologic involvement, there are many cases of isolated lesions, regardless of the fungal organism involved. You may "not have seen one to date," but I have seen several. However, I suspect that I have been around a few decades longer than you. With age, you will find that patients don't always read the book, and that many individual illnesses don't match their description.

 

[ChickenTDuck1234321]

I am sorry, I was sent this in a private message to jump in. Don't mean to disagree with your medicine, and I will say my realm of expertise is working in large scale commercial turkey, broiler, and pheasant operations. This is not in my realm. I just like backyard stuff. I value your experience. Medicine is not black and white, and a discussion gets further than calling me arrogant and questioning my experience. I read through the history of everything after I posted. You have some great points, but just because I disagree doesn't mean that it was a simple issue. I used the language I did, because I suspected you were a veterinarian. You used a lot of pathology jargon.
I will politely remove myself from this conversation and wish you the best. I am not one to argue over the internet or resort to name calling. I apologize for my response being perceived as crass. Have a great week. If you would like to talk; I openly invite you to PM or phone call.

 

[Birdrain92]

LuxbwinDVM did you come up to South Dakota State University and talk to Dr. Daly's Vet 103 and 109 class?

 

[Birdrain92]

Oops. Never mind, it was a different vet from Sioux Falls, SD that said there was a Poultry Vet in Sioux Falls.

 

[Argus]

Disagree with your medicine? Good lord. You don't even have to read the words, just look at the pictures. The bird has obviously been dissected and its quarantining days are over.

 

[Sydney Acres]

I am sorry, I was sent this in a private message to jump in. Don't mean to disagree with your medicine, and I will say my realm of expertise is working in large scale commercial turkey, broiler, and pheasant operations. This is not in my realm. I just like backyard stuff. I value your experience. Medicine is not black and white, and a discussion gets further than calling me arrogant and questioning my experience. I read through the history of everything after I posted. You have some great points, but just because I disagree doesn't mean that it was a simple issue. I used the language I did, because I suspected you were a veterinarian. You used a lot of pathology jargon.
I will politely remove myself from this conversation and wish you the best. I am not one to argue over the internet or resort to name calling. I apologize for my response being perceived as crass. Have a great week. If you would like to talk; I openly invite you to PM or phone call.

@luxbwinDVM I appreciate your apology. My objection to your posts is not that you disagree with my medicine, especially because we don't really disagree. We both believe this is most likely due to an infection. The details of how we view this will of course be different -- your experience is geared towards the relative uniformity of production medicine and flock health, whereas mine is focused on the uniqueness with which every patient tries to rewrite the book, so I rarely eliminate any possible differentials until I have proof of a correct diagnosis. Of course you're going to rule out fungal infections because all the fungal infections you see are systemic -- your patients are all subjected to the genetics and stresses of factory farming. We approach medicine from very different angles, and yet came to essentially the same conclusion, even though the final details were a little different. Your focused approach compared to my wider list of differentials is most definitely not why I posted such a strongly worded response.

So here's the issues I have with your posts. With the exception of situations like this, I go to great lengths to not confirm my profession. Some people suspect I am a veterinarian, but I do not want readers to interpret what I write as professional advice. The code of ethics in veterinary medicine requires that a doctor/patient/client relationship exists before professional advice can be given, and there are good reasons for that requirement. Without the benefit of a physical exam, the veterinarian is completely dependent on the accuracy of the owner's description of the situation. Pictures can help, but are a poor substitute for the huge spectrum of information that can be obtained from the in-person exam, interpreted not by an inexperienced and often frightened owner, but by the full range of senses of an experienced veterinarian, fully trained to interpret what s/he is seeing/feeling/smelling/sensing. Without the benefit of the in-person exam, even the best veterinarian is significantly more likely to draw the wrong conclusion. Knowing that I will always have incomplete information online, I do not want a reader to consider my words more accurate because of my profession. When I'm online, I'm intentionally just some anonymous person. If I am believed because I have a reputation for thoughtful interpretation of the information that is provided, then that's fine. That should be no different for a veterinarian than for an experienced poultry keeper or someone with a degree in poultry science. But when a person provides advice while displaying his/her credentials, that's different. Many readers assume that the online advice given by a veterinarian is more accurate than what is given by a non-DVM, not realizing that the veterinarian is unable to utilize his/her most important tool, the physical exam, while online. So giving online advice while displaying the degree is somewhat misleading, and not really ethical, regardless of your good intentions. Claiming that your advice is not professional advice is irrelevant, as no one will believe you when you're actively flying the DVM flag. Everyone knows that you're just saying that to wiggle out of liability if you're wrong. Stating that "this is not medical advice," and then giving medical advice, fools no one when you are simultaneously stating that you are a veterinarian.

But enough with the ethics lesson. Here's the bigger issue. If you're going to proudly display your credentials, at least don't embarrass your profession by being rushed, careless, unprepared, or insensitive to the feelings of those who might be reading what you wrote. There was absolutely no excuse for you blurting out recommendations without reading the information provided. If you don't have the time to find out what's going on, then you don't have the time to interpret what you haven't yet found out . Everyone reading your post knew that the bird was already dead and dissected, and for you to recommend that the owner should "make it as happy as possible" was just horrible. Really, as your colleague I just cringed with embarrassment that my profession was being represented in this manner. What if this bird was someone's beloved pet? What if the owner posted these pictures because s/he has a strong scientific curiosity, but inside is grieving for the loss of a precious family member right now? How do you think your comments would make such a person feel? It would have been terrible if anyone had made such a comment, but for a veterinarian to make such a mistake is just unacceptable. I'm sorry if you thought I was harsh, which I was, but you're not talking to your commercial employer who has hundreds or thousands or millions of birds kept on a for-profit basis. You're talking to people who care about the well-being of each of their individual animals, whether they are treasured pets or carefully nurtured livestock intended for the table. Such insensitivity can be very hurtful to the person who has just had to make a difficult decision.

Regarding the medicalese, are you defending that by claiming that you were just talking to me? "I used the language I did, because I suspected you were a veterinarian." Did you think that I was the only one that was going to be reading your comment? Did you think that I was the owner of the bird and needed medical management advice? It just doesn't make sense. No, I wasn't personally offended by the terminology -- I understood it. But using THAT MUCH medical terminology in a public forum, where most readers would have no more reason to understand it than you and I would have to understand the terminology of astrophysics or jet mechanics, is just plain arrogant. Maybe it wasn't intentionally so on your part, as someone who only deals with commercial producers has a reasonable expectation that his/her clients would at least have a basic understanding of poultry medicine. But you weren't posting to your commercial clients. You were posting to the general public. A few people will understand what you wrote, a few people will get out their medical dictionaries to see what the heck you're talking about, but lots of people don't like being talked to like this and are offended. Most people will think that a doctor who isn't considerate enough to translate this into English is just a jerk, many will be annoyed, and some will feel belittled for not being able to understand it. It's just not the right thing to do. I didn't comment on your apparent lack of experience based on the medical information that you provided. I love working with new grads, as they usually instantly remember more medical information than I ever learned (even if they don't always yet know how to apply it -- that's why I mentor those that will come after me). I commented because it appears that you have not yet enjoyed the harsh reality of working with the public. It is wonderful and fun and challenging, and never boring, but the life experience of doing so teaches us some rules. Don't give advice if you don't know the situation. Don't ever be careless when reviewing the medical record, or the current symptoms. Don't try to communicate using words that the person you're talking to won't understand -- you're usually excused if a few slip out here and there, but when it's more than 5% of the conversation it becomes obvious that you're just not trying, which makes the person think that you really don't care if they understand what you're saying or not. And never, ever, give management advice that involves making someone's dead pet "as happy a possible" unless your client wants to discuss the afterlife!!

With all that being said, I would like to ask you to continue to post on BYC. You have vast knowledge of poultry disease that few people possess, including most veterinarians. I may feel that your differentials are a bit too focused, either because you lack experience outside the commercial field, or because your knowledge base is much greater than mine regarding infectious disease so you can rule out more differentials with confidence -- probably a combination of the two circumstances. But that doesn't matter. I may not feel that it is appropriate for you to advertise your profession while giving advice online, but that is not my decision to make, and I respect your right to disagree. What is undeniable is that you have a huge amount to contribute to people looking for information, and what you are able to contribute is information that can sometimes be difficult to find in other ways. You would be an invaluable addition to the BYC community. I would just ask that you recognize that you are writing to a different type of poultry owner here than you are at work, and be sensitive to that difference.