Emergency Management of Equine Orthopedic Injuries


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Emergency Management of Equine Orthopedic Injuries

  1. 1. EMERGENCY MANAGEMENTOFEQUINE ORTHOPEDICINJURIES “Field First-Aid& Emergency Transport” Dane M. Tatarniuk, DVM December 10th, 2013 Equine Musculoskeletal First-Aid Overview: - Considerations for management of orthopedic emergencies - Classification of fractures - Forms of external stabilization for transport from thefield to hospital setting Communication/History: - Things to identify during your history: o What type of injury is sustained? o Is it known how the injury occurred? o Is it known when the injury occurred? o How lame is the horse? Weight bearing? o Is there any ongoing bleeding? - Maintain composure, keep the owner calm, speak directly - If horse is lame, keep it confined - Verbalize a clear estimate of how much time it will take for you to arrive - Ask the owner to organize hooking-up a trailer, if referral to your hospital is a potential outcome - Give owner any specific recommendations for immediate management (ie, bandaging wound, give phenylbutazone, etc.) based on the information you have available Supplies to consider bringing in the vet-truck: - Sedatives, IV anesthetics (ketamine), antibiotics, pain medication, radiograph machine, ultrasound machine, clippers, surgical instruments & suture, bandaging material, splinting material, cast material, euthanasia solution On-farm Examination: - Assess status of the horse? o QAR, BAR, weight bearing, recumbent, painful, anxious/stressed, adequately restrained, etc. - Assess environment? o In pasture/stall/barn, electricity present, horse trailer available, how did horse injure itself, etc. - Maintain safety of those involved (owners, assistants, bystanders) o Sedate if necessary - Physical exam 1
  2. 2. - - o HR often elevated (60+ bpm) with fractures, less commonly elevated with lacerations o Systemic compromise – not very common but look for signs of shock, neurological symptoms, etc.  Hypovolemic shock – HR, mucus membranes, CRT  Can measure systemic lactate if you have hand-held meter in truck  Give hypertonic saline followed by isotonic crystalloids, stop ongoing bleeding  Certain fractures can lacerate large arteries Illiac artery from pelvic fracture Femoral/Popliteal artery from femoral/proximal tibia fracture Abdominal trauma -> splenic rupture -> hemoabdomen o Don‟t miss a colic – horses can thrash around and lacerate/fracture themselves due to gastrointestinal pain. Musculoskeletal exam o Where is the injury – instability, swelling, laceration present, what anatomical structures are in the area, contamination present, etc. Formulate a plan o Further diagnostics (x-ray, synoviocentesis, etc.) needed? o Discussion with owner regarding injury, prognosis for return to athletic function, potential complications, estimate of cost incurred  If unsure, contact referral hospital for further clarification o Management  On-farm therapy (ie, laceration repair)  On-farm stabilization of injury for referral (ie, splinting)  Euthanasia Differentials for non-weight bearing lameness: - Fracture(s) - Foot abscess - Cellulitis - Septic synovial structure(s) o Joint, tendon sheath, bursa - Solar puncture - Lacerated tendon(s) Clinical features of fractures: - Visualization of displaced, open fracture - Instability on flexion/extension/palpation - Crepitus + swelling - Pain 2
  3. 3. - If not non-weight bearing lame, significant (grade 3+) lameness - Avoid performing nerve blocks, as horse may place excessive weight/force on limb, which can lead to further displacement of fracture and damage to soft tissues Avoid moving horse around until fracture is stabilized Avoid: - Challenges of Fracture Repair: - Size: o It takes a significant force to break a horse bone  Soft tissue damage is common o Implants placed must be strong enough to withstand forces applied  Most bone plates are manufactured for humans o Horses are not graceful during anesthetic recovery  Risk of bending or breaking plate, or re-fracturing limb during anesthetic recovery o Secondary complications can occur from compensation  Overload other limbs -> laminitis  Prolonged recumbancy -> myopathy, neuropathy, sores - Cost / Management: o If the fracture is amendable to internal fixation repair, the cost is usually significant ($3000 to $10000) and hospitalization is prolonged due to aftercare. Prognosis for fracture repair: - With surgical repair, some fractures have poor prognosis, while others have excellent prognosis - Depends on many variables: o What bone is fractured o Configuration of fracture o Open vs. Closed o Duration of fracture o Soft tissue or vascular damage o Articular vs. non-articular o Purpose of horse  Athlete vs. pasture sound pet o Age, breed, weight of horse - If unsure, best option is to contact referral center and speak to an surgical specialist Fracture Classification: 1. Complete vs. Incomplete 2. Displaced vs. Non-displaced 3. Open vs. Closed 3
  4. 4. a) Type 1 – Less than 1cm skin perforated by sharp piece of bone; little contamination& skin damage. b) Type 2 – Larger skin laceration, but minimal loss of soft tissue, minimal bone exposure & minimal contamination c) Type 3 – Extensive laceration, massive skin defect, gross contamination evident 4. Configuration – Transverse, oblique, spiral, comminuted, avulsion 5. Location – Bone(s) & Limb – Diaphysis, epiphysis, metaphysis, physis Goals of Fracture Stabilization: 1. Prevention of damage to neurovascular structures 2. Keeping fractured bone from penetrating skin and becoming an open fracture 3. Protect an open fracture from contamination through skin opening 4. Stabilize the limb to relieve patient anxiety and minimize further fracture displacement 5. Minimize further damage to the ends of bone (& soft tissue) Restraint & Analgesia for Fracture Stabilization: - Want to restrain the painful & anxious horse for proper placement of bandage/splint - Don‟t want to increase incoordination or ataxia - Options o Alpha-2 agonists  Xylazine, romifidine, detomidine o Acepromazine  No analgesia  May be contra-indicated in hemodynamically unstable patient due to induced hypotension o Butorphanol  Only in combination with alpha-2 agonist, otherwise will be excitatory  Decent analgesia - If horse is still painful following administration of NSAID and sedation, can add other opioid o ie, Morphine (0.1 mg/kg intramuscular, TID) o Use judgment – don‟t want to make them feel „too‟ good on the limb -> more weight bearing, less protection Splints: - Characteristics: o Economical o Can be applied in a field setting, on a standing horse o Neutralizes forces on the fracture 4
  5. 5. - o Does not impede the horse from moving Materials: o Bandage  Sheet or roll cotton, combine  Brown gauze, vetwrap, Elasticon o Splint  PVC pipe, wood, hockey stick, broom handle, metal bar o Cast  Cast over the bandage = bandage cast o Pre-made splints  „Kimzey Leg Saver‟ splints available Biomechanical Forces: - Some specific considerations: o Extensor muscles can abduct the limb o Suspensory apparatus  Instead of flexion at the fetlock joint, bending forces will be placed at the fracture site (in distal limb fractures) Need to keep fetlock angle neutral (straight) during stabilization o Reciprocal apparatus  Fractures of the tibia & tarsus can be displaced by flexion of the stifle  Can‟t necessary prevent stifle flexion with splinting, but can minimize amount of flexion that occurs Splinting Methodology: - Splinting is based on the biomechanical forces imparted on the fracture, as well as ability to counter-act those forces - Therefore, different fractured bones require different types of splints: 5
  6. 6. Area Forelimb Phalanx Metacarpus Radius Calcaneus Humerus Hindlimb Phalanx Metatarsus Tarsus, Tibia Stifle, Femur Splint Dorsal Lateral & Palmar Lateral to withers, palmar to elbow Palmar to elbow None Plantar Lateral, Plantar Lateral up to tuber coxae, plantar None Recumbent Horse: - Utilize sedation - If horse very unsafe, consider IV anesthetics (ketamine) - Stabilize the limb in routine fashion - Can slide horse onto tarp and then move tarp into trailer Transport in Trailer: - Think about momentum when you brake - If forelimb fracture, face the horse backwards, so hind-end is at the front of the trailer - If hindlimb fracture, face the horse forwards, as normal Conclusions: - At some point in your equine career, you will have to manage an orthopedic (fracture) emergency. - The best you can do is to be prepared to recognize and diagnose the injury, stabilize the fracture, communicate to the owner the prognosis of the injury, and ensure safe transportation of the horse to a hospital setting. 6