Post-surgical knuckling in cats – care and prospects for recovery – a case study

Ginger just before his accident

Ginger just before his accident with his mom

Our one and a half year old male cat Ginger has just recovered from a compound fracture of his right femur and complications following corrective surgery. I feel Ginger’s story might be a useful case study in post effective operative care for cats with nerve damage.

About five months ago, we come home from work one evening to find poor Ginger dragging his right hind leg behind him, as if it were paralyzed. We realized immediately that he had had a major accident (a fall or collision with a vehicle), and summoned our country vet for help the following morning. He examined Ginger and took an X-Ray of the affected leg, which confirmed a compound femoral fracture. The vet suggested immediate corrective surgery, to insert a pin into the broken section of his leg to stabilize it, and to help the bones fuse in as straight a manner as possible. Ginger was operated on that evening under general anesthesia (administered via injection), and the pin inserted successfully. We were issued with painkillers and an oral antibiotic to be given to him for the next two weeks, and were asked to bring him for several progress checks over the next three weeks.

His first three days after surgery was simply scary. He awoke from his anesthesia all right, but the pain seemed to set in quickly. He screamed, went into fits of frantic limping in apparent agony, and finally hid in a dark corner of the house refusing to interact with anyone. We tried our best to comfort him, giving him his food and medicines diligently, which he took after some fuss.

After about three days, the pain seemed to subside, and Ginger slowly recovered his appetite and crawled about the house. We kept him indoors (Ginger was not neutered at the time and it was a battle to prevent him from dashing out) and took him to the vet every few days for the next three weeks for checkups. He gradually improved in his ability to walk – albeit with a pronounced limp. At the end of the three weeks, he was taken into surgery once again, and the pin removed. We also realized that his chances of survival would improve if his mating drive were reduced, so we had him neutered the same day.

Here is when the most intriguing problem arose. When Ginger awoke after the surgery for pin removal and neutering, the paw in his affected leg was folded in. He was, to use the common term, “knuckling”. We were devastated. We realized immediately that his sciatic nerve would have been damaged during the pin removal process, or the anesthetization. Our vet was reluctant to admit that something during the surgical procedure caused this nerve damage. He admitted it was nerve damage after testing for sensation; Ginger had no surface pain sensation right up to the mid-region of his lower leg (tibia), and no deep pain sensation in any of the toes in this leg. But our vet was adamant that it might have been caused by the fracture itself and that we hadn’t noticed it because he hadn’t tried to use his affected foot before the pin was removed. This was observationally false; however we didn’t quarrel with this explanation, and focused on treatment. We were told that there was little to do, except to perform a regime of physiotherapy, and to protect the knuckling leg from injury by covering it up “with a sock”. Worse, we were told that it might be an idea to amputate the affected leg from high up in the femur, in a couple of months, or else we would have to see the cat die of gangrene setting in through wounds in the affected paw that would arise due to his knuckling.

There were other complications that set in at this point; that I will gloss over since they are a digression from the knuckling problem. Ginger had got a coliform infection that had affected his digestive and urinary tract, that got so bad that we had to take him to the top city vet to treat effectively. Unlike our country vet, our city vet was able to identify the existence of antibiotic resistant bacteria (resistant to amoxicillin and some other cephalosporins). It was successfully cured with a ten-day regime of co-trimoxazole.

Getting back to the knuckling problem, the cloth socks we used to protect Ginger’s affected paw were slipping off constantly, and he was getting infected wounds on the top of his paws, that were now dragging against the ground. We tried plasters and a plastic splint, but this was worse – the whole assembly simply tore off his body hair, and exposed his foot for further physical damage. It had been three weeks since his second operation to remove the pin, and there was not the slightest improvement in his knuckling.

We then heard of 3M Micropore tape being useful for stabilising wounded limbs of pets from a website. After a bit of thought, Ginger’s (human) mom hit upon a way to make a “shoe” for a knuckling cat. The below pictures illustrate how to make this shoe. Basically, you make a small pocket of gauze that is bound together by the Micropore tape. This pocket must be just big enough cover the affected paw and half the foot. The pocket must be slipped on to the foot and be bound to the foot with a further round of Micropore tape to prevent it slipping off. Two important characteristics of this shoe design are:

  1. The inside must be lined with gauze so that the shoe doesn’t stick to the fur and damage the skin. The shoe should simply slip out when you cut the fastening.
  2. The affected paw must be stretched straight (not knuckling) before tightening the shoe gently, allowing for ample blood supply, but not so loose that it slips forward and out, or the paw knuckles.

We changed Ginger’s shoe once a day, for good measure (to allow for aeration and to prevent dirt gathering and causing infection from the residual wounds in his paw, a legacy of the initial knuckling).

By the time we had devised this shoe, we had switched vets permanently to the city vet (one Dr. Chandika from Pet Vet). He seemed a very savvy vet with a broader perspective of cases like this, and gave us some practical tips on physiotherapy such as brushing the affected leg gently from top to toe to encourage sensation (this is an interesting topic, I shall return to it in a moment). He also dared to suggest that although Ginger had no deep pain in all the toes in his bad foot, he still might recover from his knuckling given a few more months, provided we put the protective shoe and kept his paw straight/flat.

We did a new shoe for Ginger every day for the next three months. We did some gentle physiotherapy daily, bending his paw and joints, and brushing his joints and toes with a comb. Once in a while we’d let him loose without the shoe, to see if he’d stop knuckling. Initially he’d knuckle immediately, but as the months went by, he only knuckled when he got excited and ran fast. We’d put the shoe back on. After about four months of the use of this shoe and some regular massaging, he simply stopped knuckling one fine day. He has not been knuckling for the past two weeks, running up trees at lightning speed. He still has a residual limp in the affected leg, and he still can’t exercise full control over the paw (such as extending his claws fully). But he is now sans knuckling, and has effective use of this leg. No more shoes for Ginger. It was a slow but amazing recovery, considering that immediately after the nerve damage, his leg had atrophied to skin and bone. He now has gained back almost all his muscle and fur.

That is the story. The lessons we learnt were:

  1. We have all heard that the mammalian nervous system has the power to regenerate (especially when the endoneurial tubes are intact and only the axon fibres are damaged) or even completely re-innovate for short distances. But what we realised is that this takes a very long time, and we must not loose hope. The popular notion that if a cat can’t stop knuckling after a couple of months, or if it lacks deep pain sensation in all its affected toes, that it’s unlikely to recover use of its leg, is simply false. One or two months are simply not enough; one must give it six months at least.
  2. Never amputate your cat’s leg just because it’s knuckling and injuring its toes. Care for it, make it a snug-fitting protective/corrective shoe, and give it a chance to recover for several months, and hopefully it will stop knuckling. A three laggard cat might be able to survive with dignity if cared for properly, but a four-legged cat with one paw having some minor residual inflexibility is a predicament that is an order of magnitude better.
  3. Internally pinning fractures carries some serious risks. Make sure to go to a well-known, experienced city vet who speaks to you about all the risks and how they plan to mitigate them.

Let us return to that city vet’s advice about brushing the leg. He suggested the established hypothesis that stimulating the nerve endings encourages growth. I believed him (there is ample literature on this subject), and as a student of philosophy of mind, I could also see another potential benefit. This benefit involves the concept of a “body image” in the brain. Neuroscientists and philosophers of repute such as Antonio Demasio, V.S. Ramachandran and Thomas Metzinger all speak of a decoupling between the actual limbs and the “phantom limb” that we “feel” moving in our subjective minds. Our brains have a physical architecture where the body is mapped in the brain, and movements can be felt based on communication with the “body map” portion of the brain. So if for example I have my hand amputated, and have a rubber hand, I might be able to activate the “hand” in my mind via the rubber hand. Alternate communication pathways being established between the “body map” of the hand in my brain, and the rubber hand, can trick the brain into “owning” the rubber hand. Visual input can be an alternate communication pathway to the body map in the brain. By simply looking at someone stroke my rubber hand, I could actually begin to feel sensation in my rubber fingers.

Ginger today - 07 Aug 2014

Ginger today – 07 Aug 2014

I feel that an intact body image helped Ginger in his healing. Although there was no direct nervous signalling from his paw, he was able to retain his mental integrity of the full leg through alternate signalling, through visual input during those stroking sessions. If nothing else, it helped him to feel the paw as an integral part of his body, and prevented him from rejecting it as a “foreign body”. There are many reports of cats mangling their own paws when they loose nerve supply. I am hypothesising that this didn’t happen with Ginger because we used a comb (and our fingers) to regularly rub him down the leg up to his toes, while he watched.

Whether this last hypothesis proves to be true or false (I welcome comment), Ginger recovered from his knuckling and lack of deep pain sensation in his toes, after over five months of gentle physiotherapy and the use of a home-made replaceable “shoe”. So if your cat is knuckling after surgery, don’t loose hope, get cracking and make her a shoe…

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11 Responses to Post-surgical knuckling in cats – care and prospects for recovery – a case study

  1. Sanja says:

    Thank you, thank you so much! We are in exact same situation right now! Our one year old cat Miju broke her femur and after the surgery she was left with same bended paw and no deep sense of feel in her toes. I was looking for some help and the answers and I found your story. I do brush, touch and massage her right hind foot, there is a small sore on her paw already, but she is licking and cleaning it regularly and showing me she didn’t forget about her injured limb.

    • Sanja, stick with Miju and she will recover more or less fully over several months. Nerve damage reverses very slowly, but surely. Wish Miju as speedy a recovery as she possibly could! PS: Ginger even got back his ability to extend/retract his claws, after about 8 months. He’s fully recovered.

  2. Mimsey says:

    Thank you so much for your story! I have EXHAUSTED the Internet trying to find out why our 13 week old kitty is knuckling after surgery on her fractured femur. Also why is she holding her leg after surgery EXACTLY like she did after injury, before surgery? Vet says it’s all normal and will heal with time. I feel so helpless! Thank you for your story and tips!

    • Sanja says:

      Dear Mimsey, just be patient and everything is going to be well again! I am happy to report that our Miju recovered completely! After I read the original story and followed the advice Ruwan gave us, our cat was on her way to pretty fast recovery. I used a special bandage, elastic and breathable..which sticks to itself. I found it at the pet store, with cute paw print. It was much faster and easier to make a little booty that way. Of course, not to loose, not to tight. I would never leave it longer than 8-9 hours at the time, just in case. She wore it for about 3 weeks, of and on like that. I would massage her foot or brushed it and I would try always to correct it into the right position by applying the pressure: straightened paw- pressed lightly to the surface! It was like a miracle when Miju started walking on her paw again, but that was not the end of our journey. She started biting it and was serious about eating a different parts of that poor leg! we had to wrap that leg at times, to prevent that, but she ate the fur and the leg was bare in different places. Well, that stopped too in a few weeks, as she gained back some of the feeling in her paw. We are very happy now and 4 surgeries and painful complications after her broken femur are behind us. We wish you the same!

  3. Nilu says:

    Mimsey, its just a matter of time before your kitty recovers. We can totally relate to your feelings, as we’ve gone through it ourselves. That is exactly why we wanted to share Ginger’s story. Hope you kitty get well in time. We wish her the best!

  4. Sarah Champion says:

    My 4 year cat is in a similar situation in that, after a saddle thrombosis, his right hock is paralysed and causing him to knuckle too. It’s 5 weeks since it happened and my vet is pressurising me to amputate the whole leg! I’m very reluctant because a) he has a major heart condition so there’s a huge risk and b) the leg is still warm and an earlier injury from his knuckling, HAS healed. At present, in bandaging him daily with Vetrap and have ordered a specialist sock with built in protection. His quality of life is not impaired in any way. He plays happily with his brother, jumps up on things as usual and just adjusts his leg under him when he’s sitting or eating.

    My vet has told me that because he has no deep pain sensation, there is little chance of any recovery now and that the animal physio I’m using is a waste of time! This story has given me hope and the courage to go back to the vet and insist that my cat needs more time.

    • Hello Sarah, firstly so sorry to hear your Kitty got so sick. A cursory glance online tells us that most cats who survive a ST episode “regain normal limb function within several months”. They require a great deal of nursing care until they’re fully mobile. So it seems that as long as you have the determination to help your cat along for 4 to 6 months, his knuckling would stop. Protect her, keep her foot straight with the aid of a bandage/shoe until she stops knuckling. Don’t amputate unless your Pet shows obvious necrosis or pain, just continue her bandage for a few months and see if she improves. You can always go for a drastic measure if there is no progress, after six months. Best of luck to you and your cat… lots of love from GINGER.

  5. Stacey says:

    Hi , I have no idea if you’ll even see this but I’m going to give it a shot. I foster for 3 animal rescue groups here in central Texas and I recently took in a 10 mo old kitty that was a Stray and hit by a car. Broken tail and pelvis. Tail had to be amputated and had surgery for the broken pelvis which was replaced with a metal plate. It’s 2mo post op and he’s been “knuckling ” the entire time. Surgeon says it will correct on its own after some time ( not sure what length of time he means by this ) but it’s not improving. Took him for acupuncture last week and was recommended to have a few more treatments. Today I noticed a bald spot on his paw where he knuckles and just drags it when walking. I’m curious about the “boot” you made from tape . Can you provide pics? Or any other specialty that may be able to help ? I’ve been flexing his food a few times a day I guess in my way trying to do some type of therapy. I look forward to hearing from you. I have videos if you’d like to see him. I think I know the “tape ” you refer to its stretchy and breathable. The kind you get on your arm after getting a blood draw? From your story and posts below it sounds like this whole case was over a years time ? Did she ever try to chew off the shoe? And again , thank you for your time.

    • Hello Stacey, sorry for the super late reply, I’ve been snowed under with work and got a chance to read your comment this morning. Let me try to answer your questions.

      1. Pics – the best I’ve got are the ones in the blog story, its a case of making a small rectangular case with the tape and folding it on to the paw with a bit more tape.
      2. Other tips – the idea is to make a small case that can be easily removed by cutting, without taping the paw like a bandage. They tend to be upset by the tape being stuck to them, and worse its harder to remove it. If its properly done, you would likely have to only change it once a day.
      3. Yes its the type tape used for patching after blood draw. 3M Micropore Tape.
      4. Time to recover – the knuckling stopped after about 5 months. Complete mastery of the disabled leg came after a couple of months more.
      5. Chewing the shoe – yes every night we put the shoe, and he pulled it off by the following night, We replaced before he pulled the whole thing off.

      I think the bottom line is to encase the paw and foot comfortably with thin but sturdy bandage that is easy to replace.

      Hope kitty will recover… give him lots of good food, vitamins and love.

  6. D J says:

    Such patience! Ginger’s loved, AlriGht. You’ve helped, immensely! Thanks!!

  7. Sanja says:

    We solved our problem in about a month.
    I would put a little paw in the correct position and I would wrap it in that breathable soft, sticky on booth sides bandage- i got it at the pet pharmacy section at the pet store- they have them in super cute designs and prints!
    I estimate our cat wore it 4 hours a day average.
    I also stimulated and massaged that little foot whenever possible.
    I am physical therapist actually- and that was my first animal patient.
    She made a full recovery and I wish for everyone else to do the same!

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