Introduction

Orthopedic injuries to client-owned animals are common presentations in companion animal practice. The causes of orthopedic injuries seen by veterinarians include falls, accidents, developmental diseases, and animal abuse. A thorough history and complete physical examination by the veterinarian are important keys when determining the cause and extent of the injuries to the pet. The age, sex, and breed of the animal are important factors used to help diagnose orthopedic injuries to an animal. Canine hip dysplasia, fragmented coronoid process, Legg-Calve-Perthes (LCP) disease, osteochondrosis, panosteitis, and ununited anconeal process are common developmental orthopedic conditions that can be associated with breed or age.

In this case, the original cause of the injury and initial radiographic diagnosis of LCP disease were later determined to be incorrect. Additional information and answers to follow-up questions provided by the owner during subsequent veterinary visits determined that animal and domestic abuse had occurred. Veterinarians should be aware of the possibility of animal abuse when presented with history and physical examination findings that suggest abuse. It is equally important that the history, clinical presentation, examination, and diagnostic imaging be critically evaluated during each patient visit to ensure that the diagnosis is consistent with all relevant information available to the veterinarian.

The purpose of this case report is to demonstrate the importance of a thorough and complete history and physical examination each time an animal is examined by a veterinarian and to understand their connection to animal and domestic abuse. The report will assist veterinarians in understanding how to recognize the signs of abuse and provide the appropriate information to be able to report suspected abuse. The report also highlights the connection between domestic violence and animal abuse.

Case Report

A 1 yr old castrated male shih tzu presented to the University of Georgia’s College of Veterinary Medicine veterinary teaching hospital with an acute right rear limb lameness and hyphema in his right eye. The owner was not present when the injury occurred, and the roommate stated that he had seen the dog fall off the bed several hours prior to presentation and was non-weight bearing after the fall. The owner was not sure how the dog’s eye was injured but suspected that it was either because of the fall or a recent tumble attributed to the slick flooring at the home. On physical examination, the dog was normotensive with a body condition score of 4 out of 9 (lean). The dog was painful on palpation of the right rear limb and was non-weight bearing on the affected leg. An ophthalmologic examination of the right eye revealed a 1 × 1 mm superficial corneal ulcer, blood in the anterior chamber, and scleral injection. Intraocular pressure was 23 mm Hg (reference range 15–25 mm Hg). A mild swelling of the periocular soft tissue of the right eye was noted.

The dog was sedated for radiographs, and the radiographic interpretation was consistent with a diagnosis of avascular necrosis of the right femoral neck with resultant fracture and possible avascular necrosis of the left femoral neck (Figure 1). The dog was sent home with carprofen (2.2 mg/kg [1 mg/lb] per os [PO] q 12 hr) for 14 days and instructions for cage rest until the owner could afford the recommended femoral head and neck excision surgery. A neomycin/polymixin sulfates/bacitracin zinc ophthalmic ointment was prescribed q 12 hr for 7 days to treat the corneal ulcer.

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The dog presented for an examination 3 days later for evaluation of the previously diagnosed corneal ulcer. The corneal ulcer was unchanged, and the intraocular pressure was 18 mm Hg.

Eleven days later, the dog presented with a history of an ulcerated and bleeding lesion on the tongue. The owner’s roommate stated that he had seen blood on the rawhide chew toy that the dog had been given the evening before while the owner was working. On physical examination, the dog was partially weight bearing on his right rear leg, a small amount of blood in the anterior chamber of the right eye remained, and a full-thickness, 6 mm puncture wound in the center of the rostral third of the tongue was seen. The previously noted corneal ulcer was resolved. Clindamycin (10 mg/kg [22 mg/lb] PO q 12 hr) and tramadol (3.0 mg/kg [1.3 mg/lb] PO q 12 hr) were prescribed for 10 days, and the previously prescribed carprofen was continued.

The dog presented 6 days later, 20 days after the initial examination, with an acute left rear limb lameness and a reluctance to stand. The owner had been warned that a similar injury could occur to the left rear limb because LCP disease can be a bilateral problem, and that early radiographic changes associated with LCP were noted at the left femoral neck. The owner reported that she was gone overnight, and when she returned the following morning, the roommate notified her that the dog was now dragging his left rear leg. Physical examination revealed a healing ulcer on the tongue, partial weight bearing on the right rear leg, and a small amount of bruising of the dorsal conjunctiva of the right eye. A neurological examination was normal. The dog was painful on palpation of the caudal lumbar vertebrae. Radiographs indicated the presence of a left distal femur Salter-Harris type II fracture (Figure 2); a chronic, nondisplaced, and healing right pubic fracture; a chronic right femoral neck transverse fracture; and a healing right zygomatic arch transverse fracture (Figure 3).

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Surgical repair of the left distal femoral fracture was accomplished with open reduction and internal fixation using three 0.62 Kirschner wires. A femoral head and neck excision was performed on the right rear leg (Figure 4).

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Discussion

Traumatic fractures are common presentations in a veterinary hospital with falls, jumping, and vehicular impact being the most common causes of long bone fractures in small animal practice.¹ LCP is defined as the avascular necrosis of the proximal femoral epiphysis and is primarily seen in miniature breeds of dogs between 4 and 12 mo of age.² The dog in this case report had both a long bone fracture and what was initially diagnosed as LCP. The radiographic interpretation of the injury, although reported as LCP, did not have many of the typical changes seen with LCP. The femoral neck remnant was longer than expected, and the femoral head was more radiodense and smoother than would be expected with LCP. The left femoral neck had radiographic changes that were not normal and could be supportive of the original diagnosis. The history and signalment can be important sources of information when trying to determine the cause and potential treatment options when presented with a patient with one or more orthopedic injuries.

On initial presentation, the dog in this report had a right rear limb lameness that appeared acutely after reportedly jumping off an elevated bed at the owner’s home. The dog’s signalment (age and breed) supported the initial radiographic diagnosis of LCP, and radiographic changes in the contralateral limb seemed to provide additional evidence supporting the diagnosis. The owner did state that she did not see the injury occur and returned home to find the dog non-weight bearing. The owner’s roommate reported that he witnessed the dog jump off the bed and injure himself. When questioned about the injury to the dog’s eye, the owner reported that she thought it had occurred during the fall or when he slipped on the flooring in her apartment. Due to financial limitations, the dog was initially sent home with instructions to cage rest the dog and administer the prescribed medication to help control the pain associated with the documented injury. The owner was warned that a similar injury could occur acutely to the left rear leg.

The dog presented 20 days after the initial presentation with an acute lameness of the left rear limb that was suspected to be an LCP-associated fracture of the left femoral head and neck. The dog was reported to be confined to a crate during the day except to be allowed outside for 5 min supervised periods three to four times each day. The owner was not home when the new injury occurred. The roommate was home at the time of the injury. Radiographs revealed a left distal femur Salter-Harris type II fracture and a healing right zygomatic arch transverse fracture.

Because of the nature and type of the injuries diagnosed during this and previous visits, the veterinarian asked the pet owner additional questions relating to the time and nature of the injuries. The owner stated that each injury occurred during her overnight employment, and that she had not been present when any of the injuries occurred. According to the owner, the only person that had been present at the time of each of the dog’s injuries was her unemployed roommate. The owner also stated that she and the male roommate had had a previous romantic relationship but were no longer living as a couple.

The veterinarians involved with the case told the owner that they were required to report the suspected abuse because of the nature of the injuries that occurred during the strict cage confinement, and they suspected that the dog had been physically abused by her roommate because he was present at the time of the injuries. The owner stated that she understood the veterinarians’ decision, and the owner admitted, when questioned by the veterinarian, that the roommate had previously been abusive to her on at least one occasion.

Additional diagnostic tests may be warranted in some instances of suspected animal abuse cases. Abdominal and thoracic imaging may be helpful to identify additional trauma when indicated to determine if other coincidental injuries are present. The nature of the injuries involving multiple limbs provided enough information to suspect abuse in this case, but additional imaging identified additional injuries. In this instance, skull radiographs were obtained at the time of the left rear lameness and identified a healing fracture of the right zygomatic arch. This fracture may have resulted in the hyphema of the right eye that was present on initial presentation. The discovery of the zygomatic arch fracture confirmed the veterinarians’ decision to report the suspected abuse.

The overall incidence of animal abuse can be difficult to determine, but up to 90% of 1,000 small animal veterinary practitioners in the United Kingdom acknowledged that nonaccidental injuries had been seen at their veterinary hospital, and 48% of the practitioners suspected that the injuries they have seen would be defined as animal abuse.³ Factors that raised the suspicion included the nature of the injuries, implication of a particular person, behavior of the pet or owner, features of the history, and socioeconomic status of the owners. In this case, suspicion arose because of the nature of the injuries, the history, and the implication of the roommate, who was the only person present each time the dog was injured.

Interestingly, the behavior of the dog in this case was consistently friendly; he sought attention, showed no fear of strangers regardless of the injury on presentation, and did not draw suspicion as an abuse patient.

The connection between animal abuse and domestic violence is well documented, with up to 41% of the men who were arrested for domestic violence admitting to having committed at least one act of animal abuse since the age of 18 versus 1.5% of men in the general population.^4,5 In one survey, 71% of domestic violence victims reported that their abuser also targeted their animals.⁶ A connection between domestic violence and animal abuse was also demonstrated in this case. It is somewhat surprising that the pet owner admitted to the veterinarians that she was a victim of domestic violence. One study showed that 92% of women who admitted to being victims of either verbal or physical abuse stated that they had been unwilling to discuss the animal abuse with their veterinarian.⁷ In this case, it was unclear after discussions with the owner whether she ever suspected or knew if her roommate had physically abused her dog.

Most veterinarians surveyed recognized the link between human and animal abuse and felt that they should intervene in some way when confronted with either.⁸ A majority of those surveyed requested more resources be made available to them so that they could handle the cases more effectively, and they also stated that they had not reported animal abuse cases because of the lack of resources and training.⁹ In this case, with permission from the owner, the veterinarians and staff were able to contact members of the owner’s family who were able to provide the physical and emotional support she required at the time. The owner’s family assisted in the removal of both the owner and the pet from the apartment that the owner shared with the suspected abuser. The local police department was contacted by the mother of the owner to assist in the prosecution of the suspected abuser. Assistance was also provided by Project Safe^a, a community-based organization dedicated to the prevention of domestic abuse and ensuring the safety of those who are abused.

A veterinarian should be able recognize nonaccidental injuries in the animals they see and be prepared to report suspected animal abuse cases. Legal and financial fears have been identified as potential reasons veterinarians are hesitant to report suspected animal abuse cases, and veterinary practice acts vary from state to state, often causing confusion as to their reporting responsibilities or immunity.¹⁰ The American Veterinary Medical Association’s Model Veterinary Practice Act provides immunity from liability for reporting animal abuse cases to the proper authorities.¹¹ Twelve states currently have mandatory abuse reporting laws, and only 13 states have no abuse reporting laws. The remaining states provide civil or criminal immunity for good faith reporting of animal abuse.¹² Victims of domestic violence often delay seeking help because they cannot safely leave their pets at home or bring them with them.¹³ In this instance, the dog was admitted to the hospital prior to surgery. The owner stated that she appreciated the help that the hospital provided her and that it gave her a feeling of relief to know that her dog was safe after she returned home to her family. The recovery time at the hospital allowed the owner to seek support without the added concern of the welfare of her dog.

Conclusion

This case presented several concerns that are not uncommon in veterinary medicine: animal abuse and the reporting of suspected abuse. Although not initially recognized as animal cruelty, subsequent patient visits helped the veterinarians involved with the case to determine that the injuries diagnosed did not seem accidental or developmental. Once animal abuse was suspected, the veterinarians worked to aid both the owner and the pet. The complete medical record documented the physical examination and history findings that supported the suspected abuse.

Veterinarians collect valuable, medically relevant evidence when they conduct thorough physical examinations, run appropriate laboratory tests, and perform necropsies, all of which allow veterinarians to play important roles as expert witnesses when animal cruelty cases go to trial.¹⁴ The role of the veterinarian in suspected cruelty cases is to report these cases and to document their findings. Although the original diagnosis of the case turned out to be wrong, the complete medical record proved to be invaluable when the animal abuse was recognized. The burden of proof, or the concern for the success of prosecution, is not the responsibility of the veterinarian. Failure to report suspicious cases in a timely manner can result in additional dangers to those abused. In this case, the original delay in recognition of the abuse resulted in additional injuries to the pet. The individual patient visits in this case were not suggestive of animal abuse, but collectively, the patient visits were determined not to be coincidental, and abuse was suspected. Fortunately, the owner returned after each injury to the pet to the same veterinary hospital, and the veterinarians were able to review the medical records associated with each visit. If the owner had elected to seek care at multiple veterinary hospitals, the injuries caused by the abuse may have been missed, and the owner and pet would have remained in danger.

Additional training and resources on recognizing and reporting animal cruelty is necessary to allow practicing veterinarians to become comfortable when reporting suspected animal abuse cases. A quick online query on how to report animal abuse found that the Department of Agriculture and Society for the Prevention of Cruelty to Animals in the veterinarians’ state provided recommendations on how to recognize and report suspected cases of animal abuse or cruelty in the state that the veterinarians practiced in. Because reporting requirements and methods vary among states, it is important for veterinarians to become familiar with the laws and regulations of their respective state. The American Veterinary Medical Association can serve as a resource for the reporting requirements of each state.

Veterinary students are less likely to be exposed to animal cruelty and abuse cases during their training, so an additional focus should be incorporated into the curriculum to better prepare veterinary graduates to recognize animal abuse cases and to reinforce the connection between animal abuse and domestic violence. The veterinarians in this case were fortunate to have had prior knowledge of the steps involved to report the suspected abuse because of their previous experiences with Project Safe. It would be beneficial for all veterinarians to familiarize themselves with the process involved and community assets available to prepare for cases like the one in this report. Many communities have social service agencies like Project Safe that can help with reporting suspected abuse cases as well as provide recommendations to assist victims of domestic violence, allowing for the protection of those victims, their families, and their pets.

At the time of suture removal and orthopedic recheck, the owner reported that she was safe and that the dog was doing well in their new home. The owner thanked everyone associated with her case. Although the veterinarian involved was interviewed by the local police department, he is not aware of any prosecution of the suspected abuser.