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Summary

Elbow hygroma is a pathological process that begins as a local inflammation over the lateral aspect of the olecranon and ends as an unsightly fluid-filled cavity surrounded by dense fibrous connective tissue. Conventional surgery to remove a hygroma has a poor cosmetic and functional prognosis. If hygromas had a good medical or surgical prognosis, they would not become chronic. In practice, even after surgery, hygromas usually become chronic lesions, often developing a dehisced incision line, infection, purulent fistulas and ulceration, mainly because the primary cause of local trauma is difficult to control.

Traumeel® is an anti-homotoxic preparation for injection or topical use with regenerative, anti-exudative and anti-inflammatory proprieties. As an alternative to proposed surgery for hygroma in a dog, this case report describes the outcome of Traumeel® injection into the cavity via acupoint SI08-Xiaohai (Small Sea), plus topical application over the area and minimal bandaging to reduce local trauma. As assessed clinically by resorption of the fibrous connective tissue capsule around the cavity and complete cosmetic and functional rehabilitation of the elbow joint, the case resolved successfully after 10 intrabursal injections of Traumeel®.

KEYWORDS
Homeopuncture, Homotoxicology, Hygroma, Elbow, Inflammation, Dog, Canine, Physiotherapy, Traumeel

Definitions:
(1) Homeopunctureis a medical concept that combines homeopathy and acupuncture, in which one or more relevant homeopathic remedies are injected at acupoints relevant to the patient’s overall condition.

(2) Homotoxicology is a medical concept developed in Germany by Dr. H. Reckeweg; it is based on the principle that all manifestations of health and disease involve the transformation of identifiable chemical compounds within the body. Homotoxicology regards the pathogenesis and progression of disease through the action that toxic substances (homotoxins) have in living beings. For example, tissue changes and compounds generated by a trauma episode can be considered as homotoxins that cause and maintain disease. Treatment of disease by the principles of homotoxicology involves the use of anti-homotoxic preparations.

(3) Anti-homotoxic preparations usually consist of a complex of homeopathic remedies relevant to the patient’s overall conditionthat stimulate the body to produce the necessary defensive responses to eliminate identified homotoxins.

INTRODUCTION
An elbow hygroma / olecranon bursitis is a fluid-filled cavity surrounded by dense fibrous connective tissue that occurs over the lateral side of the olecranon [2]. It is a pseudocyst rather than a true cyst because it has no epithelial or synovial lining [1]. Hygroma development in young dogs can be prevented by adequate protection of the bony prominence; usually this means provision of a padded rest area and not allowing the young dog to lie on hard surfaces, until a natural protective callus forms in the skin over the olecranon.

An elbow hygroma develops secondarily to repeated trauma or excessive pressure over the area, resulting in ischemia to soft tissues over bone, cellular necrosis and the formation of a fibrous tissue capsule around the fluid-filled cavity. Hygromas are sterile and painless initially, unless they become infected secondarily, or form fistulas. They vary in size becoming larger and thicker with repeated trauma. They calcify rarely [1].

The first indication of a hygroma is the presence of inflammation and oedema without cavity formation. Covering the part with a loose padded bandage for 2-3 weeks allows the tissues to heal without cavitation. The floor of the dog's normal resting area should be padded also. In time, a naturally protective callus (tyloma) forms [5].

Hygromas occur mostly in large breeds, especially young dogs between 6 and 18 months old, before a protective callus forms. Hygromas also can develop in older animals that present with arthralgia or orthopaedic pain in other joints, causing excessive pressure over the elbow when lying in sternal recumbency [2]. Many elbow hygromas are of cosmetic importance only and need no treatment. Many are small and painless and remain for life [5].

Veterinary literature has little information on the management of hygromas. Primary treatment consists of removing the repeated trauma. Conventional treatment consists of establishing drainage, excision or both. Total and partial excision and cortiocosteroid injection have been advocated but these procedures may be harmful; corticosteroid instillation is not needed and cannot be recommended [5].

Small early hygromas can be treated by repeated surgical aspiration and application of a protective bandage. The contents are aspirated weekly with careful aseptic precautions. Success is unlikely if fluid remains after 3 or 4 treatments. [5]. Even if the hygroma is small, repeated surgical aspiration or needle drainage per se is unsuccessful in long-standing hygromas, in which the wall of the cavity is thick and rigid. Indeed, such treatment may induce complications, like introduction of bacteria and secondary infection.

Surgical drainage and protective bandaging is the recommended treatment for hygromas in which the capsule is thick and rigid. Surgical excision, including partial excision, is contraindicated in order to avoid preparation surgical procedures over the bony prominence and the risk of wound breakdown [5].

Although one should avoid surgery in most cases [2, 5] development of secondary infection in the cavity is an indication for surgical drainage, followed by padding the elbow for 4 weeks to protect its pressure point and prevent trauma, tearing of the incision line and ulceration. Adequate antibiotic therapy is recommended.

CLINICAL CASE
Clinical History and Procedures: According to the owner, a 12 year-old, circa 35kg, mixed-breed, neutered male dog began to develop a large, warm, painless swelling over the left elbow joint, measuring circa 7cm x 5cm in early July 2006 (Fig. 1). The cause was unknown but probably was due to trauma over the elbow during walking outside with the owners. Repeated pressure over the elbow when lying down on hard surfaces during the following days intensified the inflammatory reaction; the swelling grew larger each day until stabilization. The swelling remained stable in size and appearance over the 5 next weeks. Pain became progressively worse on manipulation of the swelling, and when performing joint movements such as rising up and lying down. The animal started to lick the area constantly.

Course with topical (external) treatment: On August 22, the animal was taken for veterinary evaluation to a colleague in another practice because of intense pain over the elbow and an ulcerated swelling with a fistula over the medial side, from which a purulent sanguineous fluid drained heavily. Two radiographs of the left elbow joint (medio-lateral and cranio-caudal) showed an oval extra-articular formation, caudo-dorsal to the olecranon tuber. As the fistula had a septic discharge, the initial medical approach was to apply a protective bandage over the area, to be changed every 3 days, plus a course of oral antibiotic for 3 weeks. The owner was given a poor prognosis for this treatment and was told that surgery might be needed if the swelling and fistula had not healed, or if infection and intense pain were to remain after the end of the initial 3 weeks of treatment.

On September 13, after the end of the initial course of treatment, the swelling was as large as before and was warm but painless. The inner fibrous capsule protruded over the fistula (Fig. 2) with a continuous sero-sanguinous discharge. The owner applied a bandage, which was changed daily to prevent infection, trauma and licking over the area.

From September 22, painful signs under palpation of the elbow region began to develop and the owners started to apply a gel containing an anti-inflammatory substance (NSAID) over the swelling. On September 29, impaired walking began with lameness of the left forelimb; palpation and manipulation of the area induced intense pain reaction.

Course of anti-homotoxic therapy:
Subcutaneous injection therapy: In an attempt to avoid surgery (as suggested by the other veterinarian), the owners asked me to for a second opinion. It was decided to start treatment using anti-homotoxic medication, consisting of an initial subcutaneous (SC) injection of 2ml of Traumeel®, an anti-homotoxic preparation used to treat inflammatory or irritative processes associated with trauma and degenerative condition. This injection was repeated after 7 days. Simultaneously the owners continued to apply the NSAID-gel over the area.

Change to topical injections into the hygroma: Two weeks after the initial subcutaneous injections, the swelling, heat and local pain showed no improvement and the fistula had a sero-sanguinous discharge. As the initial subcutaneous Traumeel® injections had failed, the next clinical option was to give the same preparation into the hygroma cavity.

The procedure consisted of injecting of 1ml of Traumeel® through the existing fistula, using a 26G, 0.5’ hypodermic needle. At its surface, the fistula coincided with the location of acupoint SI08-Xiaohai (Small Sea). Among the Shu-Antique Points of the SI Meridian, SI08 is the He-Sea point, one of whose functions is to distribute Weiqi (Defensive Energy) to the surrounding tissues.

To limit the risk of contaminating the interior of the hygroma, the area was prepared surgically before each injection. The injections were given in 10 sessions between October 18 and December 27, 2006, with an interval of 7-10 days between injections. During this time, local application of the initial NSAID-gel was replaced with Traumeel® homeopathic gel, three times a day. An elbow pad also was applied over the area to protect it from trauma. Follow-up assessments occurred at weeks 5 and 8 after the last (10th) Traumeel® injection.

Results
Ten parameters were considered in the evaluation of the treatment: (1) dimensions of the swelling; (2) presence and evolution of fistula; (3) volume of transudate inside the hygroma; (4) volume and characteristics of the drained transudate; (5) ability to palpate typical bone formations of the elbow joint; (6) ability to palpate the fibrous capsule under the skin; (7) signs of local pain on palpation; (8) signs of local pain on mobilization of the elbow joint; (9) signs of local pain when weight-bearing; (10) lameness of the affected limb.

The dog’s clinical condition improved progressively during the 10 weeks of treatment with intrabursal injection of Traumeel via SI08 (Fig. 3, Fig. 4 and Fig. 5) until final resolution at 8 weeks after the 10th injection.

At evaluation #1, 7 days after intrabursal injection #1, the general size (1) of the hygroma was smaller. There was a significant decrease of transudate inside (3). The fistula (2) had not changed significantly and the fibrous protrusion was still present. Although still sero-sanguinous, the volume discharged (4) was significantly less. The inner fibrous tissue (6) was palpated through the skin, representing almost all of the volume inside the swelling. The swelling prevented palpation of local bone features (5) - distal humeral lateral and medial epicondyles, proximal ulnar lateral and medial coronoid processes and the olecranon tuber. For the first 3 days after injection, signs of pain (7, 8, 9) improved but increased again on days 4 and 5; spontaneous pain recurred on day 7. Lameness of the left forelimb (10) was still present.

After injection #2, closure of the initial fistula occurred, but an erythematous area was present proximal to the fistula. This latter area developed another fistula, much smaller than the first.

After injection #3, it was possible to palpate the lateral epicondyle and lateral coronoid process of the elbow. This indicated that resorption of the fibrous capsule was occurring from its distal to proximal end, in an ascendant direction, becoming concentrated over the medial aspect of the left forelimb, over the olecranon tuber.

After injection #4, the most significant improvement related to signs of local pain; local palpation was possible without pain and the dog showed no pain on rising up or lying down on the ground. Lameness was moderate.

During the following treatments, the volume of discharge became residual and the second fistula healed.

After 10 treatments the animal was considered to be rehabilitated successfully and the hygroma resolved. The parameters established to determine clinical success were as stated above. The original swelling, fistula and inflammatory reaction could not be seen, or detected on palpation. It was possible to palpate all local bony edges and the animal showed no signs of local pain of any kind. The left forelimb lameness had resolved and the protective elbow pad was removed.

After injection #10, an oral form of Traumeel® was prescribed 3 times daily. The dog was reassessed 5 weeks later. At that time the fibrous capsule was a small (0.5cm X 0.5cm), compact, marble-like, non-adherent subcutaneous lesion over the local soft tissues of the elbow.

The last follow-up evaluation was performed 8 weeks after the 10th (last) Traumeel® injection. The subcutaneous fibrous capsule could not be detected on palpation. All medication was suspended and the case was considered to have resolved successfully.

DISCUSSION
Elbow hygroma / olecranon bursitis has an unfavourable prognosis when treated surgically or by conventional (allopathic) veterinary practice. A small hygroma, with minimal fibrosis and minimal or no protective callus, is the best indications for successful surgery [1, 3]. However, surgery usually is delayed until the hygroma becomes bigger, infected or develops a fibrous cavity. Although surgery should be avoided if possible [3, 5], development of a fibrous capsule or infection may necessitate it. Indeed, surgery is the only conventional approach available in chronic cases due to secondary infection, the presence of a fibrous inner capsule, or fistula formation. In these cases, surgery can vary from a simple drainage of small-sized swellings, to complete surgical excision in larger, fibrotic ones.

During radical surgery to excise a hygroma, the naturally protective callus (tyloma) is removed. Post-operative complications in larger hygromas are very common due to the scarcity of local skin tissue, which very often requires flaps for skin closure. Postoperative management often is complicated; incisions often dehisce, local ulceration and secondary infection are common, bandages are difficult to maintain and recurrence is common. Wounds that dehisce seldom heal [3]. These complications contribute to high rates of hygroma recurrence because articular stabilization of the elbow, necessary to a good cicatrisation process, is difficult to achieve. Therefore, conventional surgery and medicine in canine olecranon bursitis results in a very low number of successful outcomes. The dog usually suffers negative cosmetic and functional consequences that very often compromise its quality of life.

Instead of radical excision, surgical placement of a Penrose Drain is preferable because it allows preservation of the protective callus. However, drains should not be used in ulcerated hygromas [3]. This case had been infected and later ulcerated. Therefore, according to conventional theory, it could not had been approached other than by surgical removal of the protective callus and excision of the protective fibrous capsule, followed by placement of drainage tubes for at least 2-4 weeks. These radical procedures would have meant a very poor prognosis for this dog.

In the principles of biological and homotoxicological veterinary medicine, elbow hygroma / olecranon bursitis is due to a noxious physical agent (“exogenous homotoxic affection”), which is the repeated trauma over the elbow. Elbow hygroma / olecranon bursitis is placed over the left side of the Biological Division and represents a humoral reaction phase of the embryologic cavodermal mesenchyme. Illness in this Phase corresponds to the excretion phase in the Six-Phase-Table of Homotoxicoses. This phase is marked by an exudative reaction, which promotes the elimination of toxins from the organism. Because intracellular enzymatic systems are still intact, it is possible to stimulate the organism with a homeopathic simillimum that induces a therapeutic, non-threatening chemical intoxication to which the body raises antidotal responses to essentially cure the case.

[In his opus magnum (Organon), Hahnemann mentions the simillimum: "the cure is effected only by opposing a simillimum to a simillimum" – meaning “like cures like”. The “simillimum” is the most perfectly fitting homeopathic remedy for a certain constitution. As homeopathy tries to follow the “Law of Similars”, only one remedy is supposed to be best. When a remedy is not exactly the simillimum, it is usually called just a "similar". In some forms of homeopathy, as in the use of Traumeel® in this case, preparation combinations of therapeutic herbal and inorganic agents are used simultaneously in homeopathic potencies.]

According to the principles of anti-homotoxic medicine, different components of the anti-homotoxic preparation activate bodily defence systems in different ways. In this context, the immunological bystander reaction represents an anti-homotoxic theory of inflammatory illness [4]. It is based on the use of anti-homotoxic preparations with substance combinations in the range of low and medium homeopathic potencies (D1-D14) for low dose antigen reaction stimulation.

Traumeel® was selected as the anti-homotoxic preparation suitable for this clinical case. It is a valuable preparation, chosen for the therapeutic properties of its homeotherapeutic kernel that cover the different reactions of the pathological findings presented by the dog.

The combined effect (Bürgi’s effect) of the herbal and inorganic factors in Traumeel® offers the following therapeutic properties:

The presence of low and medium potencies in the injectable and oral preparations (D2-D8) stimulates the body’s main defence system on the basis of the immunological bystander reaction, which determines its main regenerative, anti-exudative and anti-inflammatory properties.

The homeopuncture concept: Homeopuncture refers to the intradermal (ID) or subcutaneous (SC) injection of one or more homeopathic remedies into relevant acupuncture points, to induce a desired therapeutic response. Two main question arise: for a given therapeutic purpose, which remedy to inject? and at which acupuncture points?

Intrabursal Traumeel® injection at a local acupuncture point, SI08-Xiaohai (Small Sea), was chosen to treat this dog. Traumeel is an anti-homotoxic preparation with anti-exudative, anti-inflammatory and regenerative tissue proprieties. SI08 is located where the fistula had formed at the centre of the hygroma in a depression between the medial epicondyle of the humerus and the olecranon (Fig. 2).

The purpose of the treatment was to remove stagnation, excess, and local pain, and to re-establish normal Qi flow in the affected Meridian (SI) at the area where the trauma had occurred. Instead of a dry needling acupuncture protocol, a subcutaneous (SC) injection of Traumeel® anti-homotoxic preparation, or combined but independent use of both methods, it was decided to combine both techniques simultaneously. The therapeutic protocol was to insert a hypodermic needle at SI08 (for its local acupoint functions), and to combine it with intrabursal injection (via that needle) of Traumeel® anti-homotoxic preparation (for its local regenerative, anti-exudative and anti-inflammatory properties).

This procedure controlled the inflammatory process, promoted local tissue regeneration and controlled local pain, which allowed for complete functional and cosmetic rehabilitation of the elbow joint. This approach allowed successful treatment using only one needle (hypodermic needle) per treatment, a reduced dose of anti-homotoxic preparation (half the doses injected SC), as well as a reduced time per treatment session.

Cases of canine elbow hygroma / olecranon bursitis treated exclusively with conventional surgery or allopathic veterinary medicine have a poor cosmetic and functional prognosis. Conventional treatments, such as aseptic needle drainage, surgical insertion of a Penrose Drain and bandaging, are successful only if repeated trauma ceases; that rarely is achievable.

Depending on how long the condition remains untreated, or its recurrence, calcification of parts of the fibrous capsule can occur. This would represent a negative evolution along Reckweg’s table of Six Phases. However, we expected that treatment with homeopuncture would have a very good prognosis, based on classification of the disease as an early stage on Reckweg’s Table and the therapeutic properties of Traumeel®, the anti-homotoxic preparation selected. These expectations were fulfilled by the successful results obtained - complete cosmetic and functional rehabilitation of the dog.

As elbow hygroma / olecranon bursitis is a humoral exudative inflammatory condition, with no intracellular enzymatic implications, it allowed this restricted local approach (intrabursal injection of Traumeel® via SI08) to be successful, without the need for an elaborate protocol, or administration techniques difficult to perform by the practitioner and painful for the dog.

CONCLUSIONS
Generally, if a fibrous-encapsulated cavity has formed, conservative treatment is unsuccessful [1]. However, in this dog, with a well established fibrous cavity, previous purulent infection, fistula and ulceration, and with persisting trauma (the dog still lying down on the elbow), the hygroma healed completely without surgery using intrabursal injection of Traumeel® via SI08, local topical application of Traumeel® gel and minimal protection around the elbow. As a local technique, intrabursal injection at SI08 allowed better results from smaller doses of Traumeel® than were used previously by subcutaneous injection.

In this particular case of canine elbow hygroma, Traumeel® injection at acupoint SI08-Xiaohai:
(a) gave an excellent result as regards cosmetic and functional outcome,
(b) gave considerable advantages to the animal’s quality of life and
(c) was economically affordable for owners.

Therefore, Traumeel® intrabursal injection therapy at an acupoint on or very near a hygroma, plus topical use of Traumeel® (followed later by oral use), plus minimal bandaging to protect the area may be considered an efficient and promising alternative option to surgical drainage or more radical and dangerous surgical excision.

ACKNOWLEDGEMENTS: The original report was published in German in BTM; I thank BTM for permission to re-present the report in English. I thank Drs. Sagiv Ben Yakir BSc, DVM, MRCVS (Israeli Veterinary Institute for Holistic Medicine) and Phil Rogers MVB, MRCVS (Dublin, Ireland) for constructive criticism of, and help in editing, the English version of the manuscript.

REFERENCES
[1] BELLAH, J. R., “Surgical Management of Specific Skin Disorders” in SLATTER, D. (Ed.), Textbook of Small Animal Surgery, 2nd Ed., Vol. I, W. B. Saunders Company, USA, 1993, p 350.
[2] BIRNESSER, H. et al, “El Medicamento Homeopático Traumeel Comparado con AINES en el Tratamiento Sintomático de Epicondilitis”, in Medicina Biológica, 2005; 18 (3): 91-97.
[3] HEDLUND, C. S., “Surgery of the Integumentary System” in FOSSUM, T. W. (Ed.), Small Animal Surgery, 2nd Ed., Mosby Inc., USA, 2002, p 192-193.
[4] HEINE, H. Neurogene Entzündung als Basis chronischer Schmerzen. Beziehungen zur antihomotoxischen Therapie. 1997, Vortag 31. Med. Woche Baden-Baden, 01.11.97b (Biol. Medizin).
[5] JOHNSTON D. E. (1985) Bursitis / Tendinitis. In: Textbook of Small Animal Orthopaedics, C. D. Newton and D. M. Nunamaker (Eds.); WWW: International Veterinary Information Service (www.ivis.org), Ithaca, New York, USA, www.ivis.org/special_books/ortho/chapter_70/IVIS.pdf
[6] PRÄG, M., “Inyecciones de Traumeel en Tendinites de Inserción de la Musculatura”, in Medicina Biológica, 2006; 19 (1): 14-16.
[7] SMIT, A., “Detoxificación y Drenaje”, in Medicina Biológica, 2004; 17 (1): 19-27.
[8] SMIT, A., “Tratamiento de las Enfermedades Musculoesqueléticas”, in Medicina Biológica, 2004; 17 (2): 53-60.

Fig. 1 – Appearance and dimensions of the initial swelling.

Fig. 2 – Medial aspect of the elbow joint. The protrusion of the fibrous tissue can be observed coming out through the fistula.

Fig 3 – Progression of the bursitis (initial phase)

Fig 4 – Progression of the bursitis (during treatment)

Fig 5 – Progression of the bursitis (final appearance)