24 Emergency Fracture Stabilization

• Objectives for Equine Emergency Fracture Stabilization:

• Describe the initial assessment of a potential fracture patient

• Determine appropriate treatments

• Select the optimal technique for emergency fracture stabilization

• Overview of Equine Emergency Fracture Stabilization:

• Initial assesment

• Emergency Treatments

• Owner/situation

• Horse: systemic and fracture related

• Emergency stabilization of the fracture

• Transportation of the horse

Challenges of Equine Distal Limb Fractures:

• Horses are large and fractious
• Little to no surrounding musculature
• Open fractures are common
• Adequate stabilization is absolutely required prior to transport
• Frequently occur in sub-optimal locations geographically and anatomically

Clinical Presentation:

• Non-weight bearing lameness
• Differentials: Fracture, Septic joint, Hoof abscess, Tendon/Ligament rupture, Solar foreign body penetration
• Associated trauma
• Car accident
• Natural disaster
• Athletic/Sporting accident
• Unknown cause

Initial Assessment:

• Goals:
• Determine the cause of clinical signs
• Stabilize the patient systemically and locally
• Identify and address soft tissue injury: wound/laceration, tendon/ligament rupture
• Make appropriate treatment recommendations: local/on the farm, referral, or euthanasia

Controlling the Environment:

• High stress situation
• Unstable patient
• Anxious owner
• Potential for other authorities & bystanders to add to the confusion
• Veterinarian is in charge, the trained medical expert, and dictates the handling of the patient

Emergency Treatment:

• Stop hemorrhage
• Stabilize obvious fractures
• Thorough physical exam
• Additional considerations include:
• Sedation
• Pain medication
• Antibiotics
• IV fluid therapy

Emergency Treatments to Stop Acute Hemorrhage:

• Apply pressure bandage
• Vessel ligature
• Tourniquet

Emergency Treatments to Stabilize Obvious Fractures:

• Stabilize distal limbs
• Prevents further damage
• Reduces patient anxiety

Recommending Euthanasia depends on:

• Nature of the injury
• Location of the fracture
• Associated soft tissue trauma
• Open & grossly contaminated
• Owner mind set & goals for the animal
• Sentimental value
• Breeding animal
• High level athlete
• Available finances
• Initial stabilization can approach & exceed $1000
• Treatment frequently $5-8000 or more

Emergency Treatments for Pain Management:

• NSAIDs: phenylbutazone(4.4 mg/kg IV), flunixin meglumine (1.1 mg/kg IV)
• Opioids: butorphanol or morphine (0.1mg/kg IV or IM)
• α2 agonists: use sparingly and only when necessary

Emergency Treatments for Sedation/Anti-Anxiety:

• Avoid acepromazine
• α2 agonists: xylazine, detomidine

Emergency Treatment - IV Fluid Therapy

• Assess for hydration and cardiac output
• Resuscitate as necessary with Lactated Ringer's Solution or 0.9% saline

Emergency Treatment - Antibiotics

• Consult with referral center
• Give for open fractures and large wounds
• IV (preferably) and broad spectrum such as; - β-lactam or cephalosporin and an aminoglycoside

Emergency Treatment - Wound Management

• Cover wound & clipping
• General cleaning of the surrounding skin
• Appropriate cleaning/debridement & lavage the wound
• Sterile dressing & bandage

Emergency Treatments - General Anesthesia

• Rarely used as standing transportation always desired
• Indications:
• Horse unable to stand
• Precarious location, ie. emergency rescue situation
• Requires a dedicated equine ambulance & well-trained team
• Constant veterinary attention
• Less than 90 min transport time with police escort

Stabilization of the Fracture:

• Goals:
• Reduce pain & anxiety
• Facilitate partial weight bearing
• Prevent further tissue damage
• Immobilize adjacent joints

Types of Stabilization: Robert Jones Bandage

• Very thick & heavy
• Three, one-inch thick layers of cotton padding, each compressed with brown gauze, then secured with cohesive bandage, bandage 3x the diameter of the limb
• Idea is that the bulk stabilizes the limb
• Provides insufficient stabilization since padding compresses with time & loading
• Modified vs unmodified is confusing

Types of Stabilization: Bandage/Splint Combination

• Method of choice for emergency stabilization
• Relatively fast application & inexpensive
• Materials more readily available such as blankets, towels, bed sheets, and jackets
• Pillows are too bulky and compress too easily
• Splint materials can include:
• PVC pipe section, board, broom handles, +/- metal bars
• Kimzey Leg Saver

Application of the Splint/Bandage:

• Bandage stability is of utmost importance
• Use only enough padding to make the limb a cylinder
• Protects the soft tissues
• Allows uniform pressure distribution of the splint
• Can always add more bandage on top of the splint
• Apply the bandage material as tightly and uniformly as possible
• Excessive padding & inadequate tension in application will allow the fracture to move
• Splint becomes the load-bearing structure
• Apply the splint after the first layer of bandage material
• Must immobilize the joint above and all joints below
• Secure the splint with non-elastic tape, can use duct tape or 2" White athletic tape
• Always extend the splint to the proximal aspect of the adjacent long bone, and always extend the splint to the ground
• Always apply two splints at 90° to each other

Types of Stabilization: Fiberglass Cast

• Better stability than a splint
• Best for unstable fractures or long transportation
• Beware of excessive padding
• Expensive and may not readily available in a field situation
• Requires the horse to stand quietly for 30 min for curing time of the resin
• Layers (in order):
• Wound dressings
• Stockinet
• Cast padding
• Orthopedic felt
• Cast material; 1½ - ½ inch (7-8mm) thick, 4-6 rolls on half limb and 10-12 rolls full limb
• Must incorporate the foot to prevent transmission of force to the fracture
• Can cut a window if concerned about a wound or bone penetration

Specific Applications to the Horse: Front Limb Fracture Regions

• P1, P2, +/- P3, Sesamoid bones, suspensory apparatus breakdown
• MC III & Carpal bones
• Radius, Ulna
• Humerus & Scapula

Specific Applications to the Horse: Hind Limb Fracture Regions

• P1, P2, +/- P3, Sesamoid bones, suspensory apparatus breakdown
• MT III & Tarsal bones
• Tibia
• Femur

Region 1: Phalanges & Sesamoids

• Must align the dorsal cortices
• Removes the lever arm from the fetlock joint
• Use on dorsal and one Lat/Med splint
• Heel wedge may be applied to the foot which gives the horse a toe touching appearance
• Kimzey splint with bandage achieves this

Region 2: MC/MT III, Carpal/Tarsal Bones

• Front limb: One splint lateral and one caudal that extends to the point of the elbow that locks carpus in extension
• Hind Limb: Lateral splint to the level of the stifle joint, may only need to the calcaneus if fracture is in distal MTIII, and plantar splint to the point of the calcaneus

Region 3: Radius and Tibia

• Front Limb: Lateral splint to the level of the withers to prevent abduction of the distal limb & subsequent open fracture, and caudal splint to the point of the elbow
• Rear Limb: Difficult to splint, consider a cast or reciprocal apparatus using a single lateral splint to the level of the coxofemoral joint ideally contoured to the limb where caudal splinting is not possible

Region 3b: Ulna

• Ulnar fracture causes loss of triceps function resulting in classical dropped elbow stance with carpal flexion
• Single caudal splint from the ground to the point of the elbow which locks elbow in extension & allows weight bearing

Region 4: Humerus & Femur

• Cannot be adequately stabilized externally
• Surrounded by adequate musculature to protect the fracture

Transportation:

• Difficult
• Equine ambulances available though expensive to have & maintain
• Rarely an option unless in a horse dense area
• Standard horse & stock trailers are sub-optimal though almost always the only option

Ideal Transportation Equipment:

• Spacious, well-lit interior with horse access from all sides
• Moveable stanchions for support
• Well ventilated, +/- a fan or AC unit & heater
• Loading ramp & non-slip flooring throughout preferably with side and rear loading
• Strong frame to support a winch & harness/sling
• Well stocked & easily accessible medical supplies
• Video camera access to the driver
• Available inflatable air mattress & loading sled

Loading the Horse:

• Get the trailer as close as possible, maybe consider raising the nose of the trailer to lower the rear
• Slowly lead the horse into the trailer since the front of the trailer has the smoothest ride
• Secure a rump bar, a chest bar, & a stall partition that all must be strong enough to allow the horse to lean on

Transporting the Horse:

• Prior recommendation to face the horse forward if a rear fracture & backward if front fracture, thought to relieve stress on the horse during braking, though frequently not practical or possible
• Adequate support bars & careful driving are more important
• Lights on with an assistant to calm the horse & provide any necessary treatments
• Keep the horse untied to allow use of the head for balance
• Travel with reasonable speed and careful driving, speed is not essential if limb is appropriately stabilized
• Support harness is helpful if equipped and tolerated

Unloading the Horse:

• Unload using sound limbs first
• Back the horse off if front fracture
• Walk the horse off if rear fracture preferably through the side loading door
• Adjust trailer nose height or unload onto a platform level with trailer floor
• Mild sedation may be useful during unloading since a nervous horse may jump out

Fracture Treatment:

• May proceed immediately or allow the horse to stabilize overnight depending on location and nature of the injury and disposition of the horse
• In most instances it is best to stabilize, obtain additional imaging, and attempt repair in 12-72 hrs