Approach to Equine Fracture Management PDF

APPROACH TO FRACTURES IN THE HORSE ALISON PRUTTON BVSC SFHEA MRCVS Acknowledgement: Dr Elaine Horan LEARNING OBJECTIVES Construct a differential diagnosis list based on clinical presentations associated with common fractures in the horse and choose appropriate...

APPROACH TO FRACTURES IN THE HORSE ALISON PRUTTON BVSC SFHEA MRCVS Acknowledgement: Dr Elaine Horan LEARNING OBJECTIVES Construct a differential diagnosis list based on clinical presentations associated with common fractures in the horse and choose appropriate diagnostics Determine appropriate medical (and surgical) interventions in the management and treatment of common fractures in the horse Determine appropriate prognosis for common fractures in the horse 2 COMMON FRACTURES IN THE HORSE Distal Phalanx fractures Limb Fractures Pelvic Fractures 3 FRACTURE DIAGNOSIS History Acutely lame Evidence of trauma? Traumatic Kick, impact, fall, RTA Stress Non-physiological loading 4 C L I N I C A L E X A M I N AT I O N Consider safety – assess the situation and environment Cardiovascular status External or internal haemorrhage? Dehydration? Palpate legs thoroughly: Visual assessment from front, back and sides Swellings Assess posture Wounds Look for swelling Digital pulses? Asymmetry Foreign body in sole? Degree of lameness Hoof testers May be non-weight bearing Pain on palpation Not always! Range of motion Crepitus? 5 T Y P I C A L C L I N I C A L P R E S E N TAT I O N Severe lameness… BUT lameness CAN be low grade May have: Heat, pain & swelling +/- Wound +/- Crepitus +/- Limb instability Pelvic asymmetry (External points of reference = TC, TS, TI) Abnormal limb positioning Ataxia? 6 DIAGNOSIS - IMAGING Radiography Most useful Be aware of lag period Hairline/Non-Displaced fractures often not visible initially Multiple views Before or after splinting? Ultrasonography Assess surface of bone only Useful for pelvic fractures 7 DIAGNOSIS – ADVANCED IMAGING Nuclear Scintigraphy Can assess areas which are not possible to radiograph Highlights areas of increased bone turnover Useful for pelvic fractures Computed Tomography Particularly useful for skull (standing) & cervical vertebrae (GA) Limbs - clearer 3D picture prior to surgery (GA) Magnetic Resonance Imaging Distal limb if diagnosis unclear 8 CRITERIA FOR HUMANE EUTHANASIA When would immediate humane destruction be required in a fracture case? 9  BEVA GUIDELINES A Guide to Best Practice for Veterinary Surgeons When Considering Euthanasia on Humane Grounds: Where Horses are Insured Under an All Risks of Mortality Insurance Policy https://www.beva.org.uk/Portals/0/Documents/ResourcesForVets/Humane%20Destruction.pdf 10 BEVA GUIDELINES SUMMARY Fractures warranting immediate destruction: 1. Multiple tarsal/carpal bone fractures 2. Compound (open) long bone fractures 3. Adult humeral/radial/tibial/femoral displaced fractures 4. Pelvic fractures if horse recumbent 5. Pastern fracture – if comminuted, no intact strut 11 PROGNOSIS Dependant on region affected/f# location Proximal limb f#s worse? Size of horse Prognosis worse with increasing size Fracture configuration Transverse, oblique, spiral etc Articular versus non-articular Degenerative joint disease risk Closed versus open/compound Degree of contamination Non-displaced fractures versus displaced Simple versus severely comminuted Regional soft tissue damage Fracture or luxation? Consult with surgical specialists early on to help plan & optimise care, and set client expectations 12  DECISION MAKING AND MANAGEMENT IN THE FIELD Aims: Relief of pain and anxiety Stabilisation* Analgesia Facilitate repair and/or healing Stabilisation* Control haemorrhage Control wound infection Prevent additional tissue damage Establish a diagnosis Not always possible in first instance Referral required? Surgical options available? Financial limitations? > Move to optimal facilities for care and investigation 13  FRACTURE MANAGEMENT IN THE FIELD Sedation Xylazine or detomidine Relaxation, not ataxia Analgesia/Anti-inflammatory (ensure f# stabilisation) Butorphanol, morphine NSAIDs Wound management Clip, clean debride Antibiotic therapy (open f#) Tetanus prophylaxis Stabilisation: treatment/analgesia and reduction of anxiety and for safe transport to referral centre IV fluid therapy if required Transport to referral centre for surgery if appropriate 14  T R A N S P O R TAT I O N O F T H E H O R S E Apply appropriate support first Move horse a minimum distance Use low loading ramp if possible Forelimb fracture → travel facing backwards? Hindlimb fracture → travel facing forwards? Relative freedom of head & neck Horse ambulances Low loading/shallow front & rear ramps or turntable stall Central stall (smoothest ride) Supporting harness available – pros/cons Non-slip surfaces CCTV Care when handling, esp loading/unloading Wright, 2017 15 D I S TA L P H A L A N X F R A C T U R E S 16 PEDAL BONE FRACTURES Acute, moderate to severe lameness Warm hoof Generally, only Increased digital pulse in acute stage +/- Positive to hoof testers +/- DIP joint synovitis (palpable effusion) if articular 17 DIAGNOSIS - RADIOGRAPHY Dorsoproximal palmarodistal oblique (“Upright Pedal View”) 18 F R A C T U R E C L A S S I F I C AT I O N TYPE Description I Abaxial non-articular fracture II Abaxial articular fracture III Axial and peri-axial articular fracture IV Extensor process fracture V Multifragment (comminuted) articular fracture VI Solar margin fracture 19 PROGNOSIS Type I & VI – fair to good Type II & III- fair Dependant on degree of displacement of articular surface Type IV Small fragments- good prognosis Large fragments- guarded prognosis Type V- Multi-fragment (comminuted) articular fracture Poorer prognosis Secondary osteoarthritis 20 T R E AT M E N T Usually Conservative management Box rest ~2-4 months NSAIDs in acute stage Remedial farriery: Hoof cast Bar shoe Sole packing Surgical fixation rarely required Can stabilise an articular fracture Lag screw 21 LIMB FRACTURES 22  L I M B F R A C T U R E S - R E G I O N A L I M M O B I L I S AT I O N Regional considerations But no single technique that is optimal for all fractures within each region Proximal hindlimb factures IV Proximal forelimb fractures Crus (tibia) fractures IV III III Forearm fractures Mid-hindlimb fractures II II Mid-forelimb fractures Distal hindlimb fractures I I Distal forelimb fractures 23 P R I N C I P L E S O F T E M P O R A RY I M M O B I L I S AT I O N Objectives: Neutralisation of distracting forces Relief of pain and anxiety Application of counter pressure Protection of soft tissues Do not delay Incorporate articulations proximal and distal to the fracture where possible 2 splints used at 90o can form a stable column for horses to bear a moderate amount of weight Inappropriately applied splints can cause more harm than good 24 F R A C T U R E S TA B I L I S AT I O N Robert Jones bandages Splints Splinted Robert Jones Bandage Dorsal splint and heel wedge Kimsey Leg-saver Splint Palmar/plantar board splint Casts Bandage casts Compression boots 25 ROBERT JONES BANDAGES ~3 x diameter of limb Parallel sided tube Progressively tighter Wide conforming gauze compresses cotton wool layers Elasticated bandage to finish Distal limb (ground to proximal Full Limb bandage (ground to elbow) MC3/MT3) bandage material material requirements: requirements: ~3 rolls cotton wool ~6-8 rolls cotton wool ~10-12 rolls conforming gauze ~18-20 rolls of gauze ~4 rolls of elasticated bandage ~8-10 rolls if elasticated bandage Modified Robert Jones bandage – similar but less bulk Less effective for immobilisation but will provide counter pressure and stable base for the application of externally applied rigid splints. Better tolerated in HLs. 26 SPLINTS Wood cut to size 1/3 circumference PVC pipe cut to size Applied over RJB or modified RJB Dead space filled so splint is perpendicular to ground & leg is cushioned Commercial splints available (Eg, Kimsey Leg-Saver Splint) 27 Wright, 2017  BANDAGE CASTS & CASTS Bandage Casts Fibreglass casting tape can be applied over a distal limb bandage (modified RJB) to provide 2- dimensional immobilization. Less bulk than RJB Well-tolerated Once cured, foot can be enclosed with a further roll of fiberglass tape Casts Wright, 2017 Best immobilization/stabilization and counter pressure of all temporary immobilization techniques Fibreglass tape impregnated with water-activated polyurethane resin Resin activated by dipping in tepid water (21-25oC) Keep wet during curing to assist in bonding Conforming bandage underneath Inner conforming later of cast material (plaster of paris) under approx. 6 layers of fibreglass tape Padding with cast felt/foam at proximal margin 28 COMPRESSION BOOTS Circumferential distal limb support Fetlock angle of ~135o to support limb in a neutral (weight bearing) position Ski boot clips Foam lining Robust and long lasting Expensive 29 I M M O B I L I S AT I O N O F Z O N E I I I 30  ZONE I FORELIMB Distal extremity to distal third of third metacarpal bone Fractures of P1 and P2 and proximal sesamoid bones Splinting: Aim to eliminate bending forces at fetlock by straightening limb Align bones in a column “dorsal cortical alignment” Appropriate immobilisation Splint on dorsal aspect extending from toe to proximal metacarpus Include heel wedge Kimzey Leg Saver Splint Doesn’t provide mediolateral stability so do not use for MCIII condylar f#s Monkey Splint – same concept as dorsal splint + heel wedge But support inadequate – not recommended Compression boots – good circumferential support. Doesn’t use DCA, instead supports limb in a neutral position Palmar board splint – occasionally useful 31 ZONE I - HINDLIMB P1, P2, PSB’s Similar principles – align boney column and protect plantar soft tissues But: caudal splint placed Align solar surface of foot with bones of digit and metatarsus ‘Plantar board splint’ - Also useful for stabilising horses with suspensory apparatus disruption Modified Kimzey Leg Saver Splint sometimes used RJB or bandage cast sometimes used 32 E XC E P T I O N : M E TA C A R PA L / M E TATA R S A L CONDYLAR FRACTURES Don’t follow usual ‘rules’ for zone 1 Most common training & racing longbones f#s worldwide. Lateral = more common than medial Can disarm lat collat lig of MCP joint leading to luxation & open f# Non-displaced lateral condylar fractures in which fracture line clearly communicates with lateral cortex: Relatively stable > Good prognosis Non- displaced medial condylar fractures OR lateral condylar fractures which spiral into medial component: More unstable > Potential for catastrophic complete fracture Communicate the risk to owner Dorsal cortical alignment is not suitable Options: Medial and lateral splints to carpus over RJB (solar surface flat on floor) To counteract risk of medial or lateral displacement Compression boots are suitable Bandage cast or casts are suitable 33 34 ZONE II II II I I 35  ZONE II - FORELIMB Fractures of the third metacarpal bone (diaphysis or proximal epiphysis), carpal bones, distal radius, carpal luxations Immobilisation: Robert jones bandage from the ground surface to as far proximal as possible (elbow) With lateral and caudal rigid splints applied Alternative = lateral and cranial Tube/sleeve cast can be used Diameter of bandage 3 times diameter of leg Splints applied on top of bandage, applied with duct (Palmer, 2012) tape or tensoplast 36 ZONE II - HINDLIMB Middle and proximal Third metatarsal bone (+/- tarsal bone fractures?) Immobilize with: Robert jones bandage Caudal splint from point of hock to ground Lateral splint Tarsal bone f# and tarsal luxations = more Zone 3 (extended lateral splint required in addition) (Palmer, 2012) 37 SPLINT BONE FRACTURES How would you immobilize this fracture? 38 ZONE III III III II II I I 39 ZONE III - FORELIMB Fractures of the mid to proximal radius Muscles become abductors of the limb rather than effectors of extension or flexion Stabilise : Full limb Robert Jones Bandage Caudal splint to elbow Extended lateral splint from the ground to the level of the withers Morgan and Galuppo 2021 40 41 ZONE III - HINDLIMB Fractures of tarsus and tibia Difficult to immobilize Reciprocal apparatus Abnormal limb abduction Immobilize Robert Jones Bandage Extended lateral splint to hip Prevent abduction and rotation Tarsal luxation/subluxation: Cast If only light conforming bandage required: Pressage (Morgan and Galuppo 2021) (Palmer, 2012) 42 ZONE IV IV IV III III II II I I 43 ZONE IV- FORELIMB (Humerus), ulna (olecranon) or neck of scapula Fractures of this region disable the triceps apparatus making it impossible for the horse to fix the carpus Not splinted at fracture site Stabilised by fixing carpus in extension Full leg (light) bandage to minimise pendulum effect Caudal splint to elbow previously described, but dorsal splint better tolerated (also less bulk) Proximal antebrachium to distal metacarpus Gives greater control of limb and assists with balance Some fractures do not benefit from temporary immobilisation (supraglenoid tubercle) Can assist protration of limb using a rope around the pastern 44 ZONE IV HINDLIMB Femur or pelvis NOT possible to stabilise with bandage or splints Weight of any bandage would act as a pendulum 45 P E LV I C F R A C T U R E S 46 P E LV I C F R A C T U R E Assess asymmetry of the pelvis Stress or traumatic Degree of lameness varies 47 P E LV I C F R A C T U R E Ilial wing f# Tuber coxae f# Ilial shaft f# 48 TYPES Tuber Coxae f# ‘Knocked down hip’ May be displaced Iliac Wing f# Most common (stress fx TB) May have ventral displacement of tuber sacrale Muscle wastage Iliac Shaft f# Very painful Marked asymmetry – tuber coxae *Damage to iliac arteries 49 P E LV I C F R A C T U R E Diagnosis Palpation per rectum Ultrasonography- if non-displaced/minimal callus can be difficult to detect, hypoechoic areas near bone Nuclear Scintigraphy – most sensitive Radiography? Treatment Conservative Cross tie to reduce risk of f# displacement Prognosis Dependent on region affected and displacement Survival rate 50-70% Fracture tuber coxae > Good Involve ilial shaft or acetabulum > Poor px for return to athletic career 50 REFERENCES Morgan, J.M. and Galuppo, L.D., 2021. Fracture Stabilization and Management in the Field. Management of Emergency Cases on the Farm, An Issue of Veterinary Clinics of North America: Equine Practice, E-Book, 37(2), p.293. Wright, I.M., 2017. Racecourse fracture management. Part 1: Incidence and principles. Equine Veterinary Education, 29(7), pp.391-400. Wright, I.M., 2017. Racecourse fracture management. Part 2: Techniques for temporary immobilisation and transport. Equine Veterinary Education, 29(8), pp.440-451. Wright, I.M., 2017. Racecourse fracture management. Part 3: Emergency care of specific fractures. Equine Veterinary Education, 29(9), pp.500-515. 51