March 2021

In today’s VETgirl online veterinary continuing education blog, Dr. Kathryn M. Slaughter-Mehfoud, DVM, MPH reviews emergency field treatment of equine limb fractures. If you are about to see a horse with a fractured limb, here’s what you need to know! She is currently an equine surgical resident at University of Illinois.

Emergency Field Treatment of Equine Limb Fractures

By Kathryn M. Slaughter-Mehfoud, DVM, MPH

Equine limb fractures are not only extremely painful to the patient, but are also quite traumatizing for the owner. The veterinarian must execute emergency management firmly, calmly, and with sensitivity to the traumatized owner and spectators. It is imperative horses sustaining limb fractures have adequate sedation, bandaging and stabilization, and pain management prior to transportation to a surgical facility.

The main goal for initial management of limb fractures is to decrease further trauma to the fracture site. Sedation is required to safely allow examination and appropriate bandaging and stabilization of the limb. Horses respond frantically and violently to the acute loss of not being able to bear weight on a limb. Their hysterical reaction can further damage the limb, eliminating any chance of surgical treatment. Most horses don’t stand still for bandaging and stabilization of a fractured limb. Thus, a potent, long-lasting sedative regimen must be implemented. A long-lasting alpha-2 agonist, such as detomidine, combined with an opioid, such as butorphanol, is preferred. When applying first aid to equine limb fractures, this is not the time to be conservative with your sedation protocol. These horses are extremely anxious and in severe pain, thus a higher dose of sedation is needed to combat their readiness to override the sedation. For a typical 500 kg horse, I recommend 10 mg butorphanol and 5 mg detomidine intravenously to provide adequate sedation for initial management. If it isn’t possible to administer sedation intravenously safely, intramuscularly is the second choice for route of administration.

Examination, Diagnosis, and Communication
Once the horse is sufficiently sedated, an examination of the fractured limb should be completed. Severe swelling is likely to be present, which may hinder the veterinarian’s ability to palpate and assess the extent of the fracture. For a prompt diagnosis, radiographs should be performed in the field, allowing discussion with the referral hospital and the owner before pursuing further treatment. It is essential to have a blunt conversation with the owner and the referral hospital in regards to prognosis, future athletic use, and financial costs. If the owner doesn’t wish to pursue surgical treatment due to a poor prognosis, loss of athletic use, or financial constraints, the horse should be immediately humanely euthanized. It is inhumane to keep a horse alive with a limb fracture and transport it to a surgical facility, knowing the horse will be euthanized just hours later. If the owner desires to continue further treatment, the limb should be appropriately bandaged and stabilized prior to transportation to a surgical facility.

Wound Management, Bandaging, and Stabilization
Open fractures require more initial wound management than closed fractures. With open fractures, the wound should be clipped and gently cleaned with saline before applying a bandage. A tetanus toxoid should be given intramuscularly, and injectable broad-spectrum antimicrobials should be administered.

Bandaging and stabilization of the fractured limb should include the joints proximal and distal to the fracture site. The most common bandaging techniques for stabilization of limb fractures include: a Robert Jones bandage, splints, and a bandage cast. A Robert Jones bandage contains multiple layers of alternating cotton and elastic gauze. Each layer of cotton and elastic gauze should be applied very tightly. An appropriately applied Robert Jones bandage usually makes the veterinarian sweat during application. After a Robert Jones bandage has been applied to the limb, one to two splints (depending on the fracture) should be used to further stabilize the limb.

Splints can be applied cranially, caudally, and laterally. Splints are abundantly secured in place with either two-inch white tape or duct tape. It’s important to apply enough tape to the splinted bandage to ensure the splint doesn’t slip out of place, potentially causing further damage to the fracture site. Ideally, splints are pre-constructed from PVC and are stocked in ambulatory vehicles for emergency use. However, creativity during an emergency saves lives. Metal rods, twitches, fence boards, wooden fence posts, and broom handles can all be used as a splint for stabilization of the limb.

Considering common supplies located in most ambulatory vehicles, the Robert Jones bandage with splints is the most practical stabilization method in the field. However, a bandage cast is superior for stabilization if casting material is available. For a bandage cast, two layers of alternating cotton and elastic gauze are first applied, followed by approximately three layers of fiberglass (casting) tape. The casting tape should incorporate the heel. A bandage cast is preferred if the horse is being transported a long distance.

Equine Limb Fractures
Fractures of the distal limb, including the proximal, middle, and distal phalanges, as well as the distal metacarpal/metatarsal bone (cannon bone) should be bandaged and stabilized in a straight line. Using a wedge, the heels should be lifted to aid in creating a straight line for stabilization. For these distal limb fractures, the bandage and splints or bandage cast should include the heels and extend to the proximal aspect of the cannon bone. A cast or splint should never end at the mid-diaphysis. If using splints, the splints should be placed dorsally and laterally for forelimb fractures. For hindlimb fractures, a splint should be placed on the plantar aspect of the limb.

Fractures of the cannon bone should be bandaged and stabilized from the hoof to the elbow or stifle. The bandage or bandage cast should be applied with the limb in a neutral position. Splints should be applied to the caudal and lateral aspects of the limb. For forelimb fractures, the caudal and lateral splints should extend from the hoof to the elbow. For hindlimb fractures, the caudal splint should be applied from the hoof to the point of the hock and the lateral splint from the hoof to the stifle.

Fractures of the radius and tibia can be challenging to properly bandage and stabilize due to regional large muscle mass and the risk of a closed fracture becoming an open fracture on the medial aspect of the limb. Bandaging and stabilization should extend from the hoof to the elbow or stifle joint. For radius fractures, a caudal splint should be applied from the hoof to the elbow and an additional splint should be applied laterally from the hoof to the point of the shoulder. For tibia fractures, a splint should be applied laterally from the hoof to the point of the hip.

Fractures of the ulna results in the breakdown of the triceps apparatus. Consequently, the carpus is held in flexion. Bandaging and stabilization with a caudal splint should extend from the hoof to the elbow.

Once the fracture is bandaged and stabilized, systemic anti-inflammatory/analgesics should be administered. Minimizing inflammation is critical to increase perfusion of the fractured limb, which will increase the prognosis for surgical repair. A nonsteroidal anti-inflammatory drug, such as intravenous phenylbutazone at the 4.4 mg/kg dose, is recommended.

Ultimately, the equine field practitioner plays a vital role in contributing to the horse’s chance for survival. Properly bandaged and stabilized limbs prior to transportation is imperative. In proximal limb fractures, catastrophic hemorrhage is of concern due to potential laceration of major blood vessels from fractured ends. With distal limb fractures, stretching of vessels from improperly immobilized limbs can lead to severe vascular damage. Correct bandaging and stabilization during initial emergency treatment can be the defining factor for not only whether the horse is a good candidate for surgical repair, but also whether the horse ultimately survives.

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