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Equine fracture management and repair

Description
Assessment of the patient




Emergency Status

  • All equine fractures are potential emergencies until assessment proves otherwise.
  • Determine if horse is in shock from blood loss or pain.
  • Assess fracture site for vascularity, ruptured vessels, contusion.
  • Assess type of fracture, simple, compound, comminuted, multiple, epiphyseal and severity, long-bone, or chip fracture; immediate radiography may help.
  • Assess horse's personality and tolerance for pain and therapy. Horses who cannot tolerate pain and will not tolerate attempted treatment of the convalescent period may not be candidates for treatment.





    Emergency Treatment




    Treat for shock and anxiety.

  • Be careful using sedatives that reduce pain but allow excessive weight bearing on fractured limb. Tranquilizers may also increse the risk of shock if blood loss is a problem. Pain can cause severe shock in the horse and should be treated.



    Minimize soft tissue trauma.

  • Handle fracture as little as possible.
  • Restrain or tranquilize to prevent excessive use of fractured limb.
  • Apply splints to protect soft tissue and prevent fracture and movement or skin puncture by the fracture fragments.



    Immobilization

  • Immobilization should be attempted for fractures below the distalradius to prevent soft tissue trauma and bone displacement. Do not apply splints or bandages to the limb with fractures of the radius or tibia unless a body splint is used to prevent abduction of the leg and subsequent soft tissue damage.
  • Prevent horse from using limb if damage from compression is occurring.



    Splints (emergency coaptation)

  • Pillow and broom stick - make sure there is adequate padding under any type of rigid splint.
  • Robert-Jones - Apply large amounts of cotton to cushion the fracture.






    Aplying a Robert-Jones bandage (Source: www.tlaer.org)




    Management of compound fractures

  • Prevent simple fractures from becoming compound.
  • Protect exposed ends of bones during restraint or transport.
  • Surgical prep around fracture site and damaged skin to prevent further contamination to skin puncture after splint application.



    Wound management

  • Debride necrotic tissue and debris using aseptic technique.
  • Flush with saline with antibiotic (penicillin).
  • Wrap with sterile bandage.
  • Protect wound from further trauma by adequate coaptation.





    Transport


    Do not move horse until fracture has been assessed and emergency treatment has been administered. Owners should be advised to keep horse quiet and not moved until the fracture can be examined by a veterinarian.
  • Bring trailer to horse; move as little as possible.
  • Support slings can be provided in the trailer; do not try to support the entire horse's weight in a sling, only assist the horse.
  • Someone riding in the trailer with the horse may help calm the horse and provide a way to indicate an emergency during transport. The trailer must be suitable for human transport, otherwise this can be very dangerous.
  • Large vans with horses riding backwards for front limb fractures are best and require less balancing by the horse during transport than a small horse trailer.





    < Fracture repair in the horse




    Special Considerations

    In bones without a blood supply from muscle or ligament attachment to the periosteum (metacarpus, metatarsus), fracture healing is inhibited, especially with increased soft tissue trauma.
    The weight of the horse is supported by a bone that is 1/10 the size of the same bone size to weight ratio in the dog or man. The dynamic structure of the bone size to weight ratio in the dog or man. The dynamic structure of the bone allows for this weight support; therefore, when excessive load is applied to the bone the result is an explosion with multiple fractures. This is especially common in the femur, tibia, humerus, radius, metatarsus and metacarpus, and second phalanx.
    The horse is an animal of flight and will not always tolerate a cumbersome fixation apparatus or body support in the form of a sling. Internal fixation should be the goal of all fracture repair in the horse with external devices kept to a minimum.
    Compound fractures have a much poorer prognosis than simple fractures, especially in those bones that have a poor blood supply due to a lack of soft tissue attachment to the periosteum.
    Foals have a better prognosis than adult horses due to size and the rapid bone turnover and remodeling.



    Types of Fractures

  • Rapid load or explosion fractures due to maximal compression-tension, torque application. Usually occurs from limb malplacement during work, kicking a solid object, foot placement during panic situation, twisting leg or foot which is fixed on the ground, rapid uncontrolled standing after recovery from anesthesia.
  • Compression fractures, due to rapid maximal loading - usually chip fractures in knee or fetlock due to hyperextension.
  • Fatigue fractures - bone fatigues like metal fatigues from constant submaximal loading during exercise or racing. Lines of maximal stress will start to separate. Examples include distal metacarpal condylar fractures, sagittal P1 fracture (screwdriver fracture), saucer fracture (buck skins).
  • Shear fractures - due to application of a force which acts perpendicular to stress (friction or bone union); examples include P3 extensor process fractures, accessory carpal bone fractures, or epiphyseal fractures, and may include avulsion fractures at joint capsule attachments.




    Methods of Fracture Repair


    Coaptation - cast application usually is required. A less rigid apparatus will not support horse's weight.
  • Must enclose the foot.
  • Must be applied to just below carpus or just below elbow to provide adequate reduction and support. Most fractures even of the first and second phalanx must have full limb cast to just below the elbow or stifle to prevent compression.
  • Cast padding is kept to a minimum to reduce movement in the limb, which can lead to friction scores.
  • Is best for transverse or epiphyseal fractures, especially in younger animals.
  • Cast must extend from the foot to include a joint above the fracture site.

    Thomas splint

  • Distal or mid-shaft tibia, poor response
  • Distal radius - poor response.
  • Difficult to maintain
  • Foot must be wired or glued to the foot plate.
  • Large horses usually need to be partially rested in a sling.

    Kirschner-Ehmer - KE apparatus (Transverse pinning)
  • Third metacarpal or metatarsal fracture, especially comminuted for multiple fractures requiring protection from compression.
  • Radius (works best in tractable horses).
  • Tibial shaft or proximal epiphyseal fractures.
  • Hard to keep stable due to loosening of the transverse pins.
  • May aid fixation in combination with a plate or lag screw.
  • Phalangeal fractures with stabilization from common to a special shoe.

    Lag screws fixation
  • Third carpal slab fracture (> 6 mm thickness).
  • Third metacarpal --- metatarsal condylar fracture.
  • Basilar sesamoid fracture base > 6 mm thickness.
  • First, second, and third sagittal phalanx fractures.
  • Second and fourth metacarpal --- metatarsal fractures with distal segment removal.
  • Lag screw fixation of long bone fractures in horses requires additional methods of support (plates, cast, K.E.).

    Bone plate fixation
  • All long bone fractures (difficult in humerus and femur).
  • Pastern fusion with or without P2 fractures.
  • Scapula.
  • Mandible and maxilla.
  • Exact application of plates with compression is required for maintaining plate without bending or eventual breakage due to metal fatigue. Two plates are required in a long bone fracture in the horse.
  • Application should be completed with minimal soft tissue damage and extra periosteal application to allow as little damage to blood supply as possible.

    Intermedullary pinning
  • Little use in horse except in femur and humerus of the foal. Curvature of bone may cause breakage of cortex when pin is placed in bone.
  • Have been used for carpal and tarsal fusion.
  • Rush pins can be helpful in the young horse and lightweight horse.

    Pasture or stall rest
  • Humerus: must have minimal displacement. Horse must be able to support weight in opposite limb, have common sense about resting, lying down and care of the limb.
  • Check for radial nerve paralysis; may be severed by fracture of the humerus.
  • Pelvis - acetabular fracture.
  • Mandible - vertical ramus fracture.
  • Third phalanx fracture.
  • Sesamoid fracture (undisplaced).
  • Thoracic spine.
  • Navicular fracture.

    Special repair
  • Traction - counter traction apparatus for reduction and fixation of fractures. Uses transverse pinning or a metal splint in combination with transverse pinning.
  • Electric potential induced healing via piezoelectric effect. This is not a substitute for rigid fixation but may be helpful in non-unions.
  • Electromagnetic induced healing - experimental. Appears to help stimulate bone production when normal periosteal production is not present.
  • Bone grafts - autogenous cancellous grafts from the ilium sternum, or rib or frozen homoeogous cortical grafts. Cortical grafts require absolute rigid fixation.





    Complications of fracture repairR


    Pressure sores
  • Cast too tight (pressure sore), cutting off blood supply.
  • Cast too loose (friction sore), producing ulcers.
  • Cast applied with leg in traction - pressure sores occur just distal to joint prominences where rubbing occurs after limb relaxation.
  • Can erode through tendons and ligaments or through joints, causing incurable problem.
    Rx: best cure for cast sore is a new, properly fitted cast.

    Laminitis
  • Breakdown of the lamina due to excessive weight bearing on contralateral limb. Usually occurs in contralateral front limb.
  • Preventive shoe and pad should be applied.
    Rx: Treatment is based on support of the foot with shoe and pad and stall padding maintenance. Attempt some weight reduction.

    Limb Breakdown
  • Excessive weight bearing on the contralateral limb produces a bowing of limb at joints - stretching of the collateral ligaments tendons.
  • Becomes worse with time.
  • Occurs in horses that won't lie down and won't accept relief with a sling.
    Rx: Support limb with wraps from the initiation of fracture treatment. Attempt slinging the horse or repairing cast to allow more weight support on fractured limb. Attempt weight reduction.

    Stress diarrhea
    Due to excessive pain, lack of proper nutrition due to inability to ambulate, salmonellosis due to stress is most common problem.
    Rx: Treat symptomatically. Attempt to reduce pain.

    Decubital sores
    Constant or prolonged recumbency produces sores, ulcers, over the tuber coxae, hip, lateral tuberosity of humerus and over the hocks, and carpus.
    Rx: Padding of the prominences; increase the stall bedding; topical ointment application with antibacterials to aid in healing ulcers; decubital sores won't totally heal until pressure is removed.

    Psychologic sequela
  • Rejection of coaptation as soon as upon awakening from recovery. Horses fight or reject casts or can injure themselves by hitting contralateral limb or luxating a proximal joint due to weight of the case.
  • Rejection of sling or support. Only 25% of horses truly accept a sling for prolonged support. Arabians are best at adapting with Thoroughbreds the worst at accepting a sling.
  • Psychological depression and fatalism. Horses mentally quit after periods of prolonged fracture convalescence. Sling, coaptation, and pain all can cause a severe depression and giving up attitude. Rx: Psychological disease needs therapy. Horses should be carefully screened to avoid a lengthy, expensive repair in a horse that will not accept a sling or pain. Nursing care of these horses can make the difference between success and failure during the long convalescent period.

    Horses undergoing prolonged convalescence from fracture repair should have nursing care to avoid boredom and to prevent breakdown disease, which can lead to a psychological problem.
  • Constant grooming.
  • Rearranging sling and support padding.
  • A pet; goat, chicken, donkey.
  • Changing sequence - remove from sling at times during day.
  • Place in high activity stall so activity will prevent boredom.
  • Hand feeding and treats.

    Foot contracture and fracture disease
  • Foot contracture is hard to avoid and can be aided by corrective shoeing after fracture repair and improved weight bearing.
  • Fracture disease (stiff joints due to prolonged immobilization) does not normally occur in horses due to lack of muscle mass below the stifle and elbow. Joint laxity can occur with prolonged coaptation.
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