Visiting Vet: Touchy toes

When a dog limps, the cause could be one of several things.

Dogs like this Australian shepherd may get a splinter if they run freely in the woods. — Torsten Simon

Sally, the Australian shepherd, was out with her owner on a nature walk when something happened. One minute she was completely fine, leaping and bounding about. The next, she was lying down, not wanting to move. When her human companion finally coaxed her out of the woods, she was limping badly. “I think she may have a compound fracture of her toe,” her owner said when she phoned me (since I was the veterinarian on emergency call).  A compound fracture, also called an “open fracture,” is when the broken bone punctures the overlying skin. Sometimes the bone visibly protrudes. Other times, it slips back inside after the initial trauma, but the open wound it caused is still apparent.

“Why do you think that?” I asked. It would be unusual for a healthy, young dog to get such a dramatic injury from simply running around. “I can feel something sharp when I try to examine her foot,” the owner replied, ”but she won’t really let me look.”

We scheduled Sally to come in to be evaluated. When she arrived, the wound was obvious, up high in the tissue between her fourth and fifth front toes. She had furry feet, but I could feel a hard, sharp edge just inside the laceration. Sally was a good patient, but it was clearly painful, and when I tried to get better exposure to determine whether I was feeling bone or something else, Sally resisted.

A dog’s toe consists of three small bones called phalanges (singular, phalanx). The standard shorthand is to number them P1, P2, P3. The proximal phalanx, i.e. the one closest to the “wrist,” is P1.  P2 is the middle bone, and P3 the smallest, at the end of the toe where the nail attaches. I examined each bone carefully. P3 and P2 were normal — no pain, no swelling. The wound was over the top of  P1. If that sharp thing was really the end of a broken bone, it would have to be the first phalanx. But, no. I could feel the entire uninterrupted length of P1 and there was no break.

Sally was calm and cooperative, allowing me to shave, prep, and inject the area with local anesthetic. Gently introducing a hemostat into the opening, I clamped onto the end of the sharp thing and gave an exploratory tug. Sally didn’t like that … and the object didn’t move. I widened the opening and pulled harder. The object didn’t budge. Hmmm. Was I completely sure I wasn’t trying to extract one of Sally’s bones? I palpated again. P1, P2, P3. All good. Okay. I gave a touch more local anesthetic, widened the opening even more, took a deep breath and gave a firm, committed yank. Out came a flat slab of wood, about an inch and a quarter long and a third of an inch wide. Ouch. That was one big splinter! I flushed the hole thoroughly with sterile saline, but opted to leave it open to allow for drainage while it healed. Sally bounded off the table gratefully and went home with antibiotics and pain medication.

Then we have Linus, a 6-year-old Labrador retriever who simply woke up one morning with a  painful toe. No known trauma or history of running around in the woods. He just got up one day and wouldn’t put his foot down. Linus was seen first by the veterinarian on emergency call at another practice, and again the next day at my office. Both the emergency vet and I agreed the pain was limited to the area around P3, the third phalanx. The toe was clearly swollen and tender but neither the first doctor nor I could find any underlying cause. There were no palpable fractures, no visible wounds.

Now, Linus is a good boy. Really he is. But he’s not exactly … well … stoic. He let me feel the area very gently, but clipping away the fur for a closer look? Nope. That wasn’t gonna happen with Linus awake. Was it worth anesthetizing the big guy for a more detailed examination? Linus’ dad volunteered his thoughts on the situation. “I do a type of stone sculpture that can leave tiny sharp bits of rock in my work space, “ he said. “I think Linus may have gotten stone splinters in his toe.” Sounded plausible to me. But what should we do about it? Very small foreign bodies, like splinters, bits of glass, miniscule shards of stone, can be hard to locate. Luckily, Mother Nature is smart. She has given the body natural defenses that work to drive out such irritating objects. I suggested soaking the toe in very warm water with Epsom salts twice daily to help draw out any “stone dust” that might be in the toe. I also prescribed oral antibiotics to cover for secondary bacterial infection and anti-inflammatory pain medication. “If he doesn’t improve, we will have to sedate him so I can X-ray the toe and poke around surgically if needed,” I concluded.

When dogs suddenly start limping, owners often assume there is “something stuck in their paw.” More often than not, the owners are wrong. Sure, sometimes a burr gets stuck between the toes, or a thorn in the pad. But more commonly, that limping pup has a strain, sprain, or bruise. Linus was all better in a few days, without our ever having proved the cause. Maybe he had slipped on the ice and banged it, like when you stub your toe hard. But I suspect his owner had the diagnosis right. I think Linus walked through those tiny stone splinters on the floor and one or more got embedded in his foot. In Sally’s case, her owner’s presumptive diagnosis of a compound toe fracture was wrong, but her mom was correct that there was something sharp and hard and pokey in there. Two big dogs. Two different pain thresholds. Two acutely painful paws. One caused by a giant hunk of wood, the other by miniscule shards of stone.