Fractures in The Horse (VetBooks - Ir)

Fractures in the Horse
Fractures in the Horse
Edited by
Ian Wright
Newmarket Equine Hospital,
Newmarket, UK
This edition first published in 2022
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Library of Congress Cataloging-in-Publication Data

Names: Wright, Ian M., editor.
Title: Fractures in the horse / edited by Ian Wright.
Description: First edition. | Hoboken, NJ : Wiley-Blackwell, 2022. |
Includes bibliographical references and index.
Identifiers: LCCN 2021046306 (print) | LCCN 2021046307 (ebook) | ISBN
9781119431770 (cloth) | ISBN 9781119431763 (adobe pdf) | ISBN
9781119431756 (epub)
Subjects: MESH: Fractures, Bone–veterinary | Horses–injuries
Classification: LCC SF951 (print) | LCC SF951 (ebook) | NLM SF 951 | DDC
636.1/08971–dc23
LC record available at https://lccn.loc.gov/2021046306
LC ebook record available at https://lccn.loc.gov/2021046307
Cover Design: Wiley
Set in 9.5/12.5pt STIXTwoText by Straive, Pondicherry, India
10 9 8 7 6 5 4 3 2 1
For Alice, Grace and Gaynor
vii
Contents
Preface xxxiii
List of Contributors xxxv
1 Introduction 1
I.M. Wright
Historical Review 1
The Ancient World 1
Middle Ages/Mediaeval Period 2
The Renaissance/Reformation 2
The Enlightenment and Industrial Revolution 2
The Twentieth and Twenty-first Centuries 4
The Future 6
References 7
2 Bone Structure and Function 11

C.M. Riggs and A.E. Goodship
Introduction 11
Bone Architecture 11
Cellular Components 12
Bone Formation 13
Vascular Supply 14
Innervation 14
Microstructure 15
Ultrastructure 17
Organic Component 18
Inorganic Component 19
Mineralization 19
Function 20
Tissue (Material) Properties 20
Structural (Whole Bone) Properties 23
Adaptation 24
Stress Protection 25
Conclusions 25
References 26
3 Pathophysiology of Fractures 29
J.L. Pye and S.M. Stover
Material Features of Bone Failure 29
Loading Modes 30
Locally Acting Loading Modes 30
Globally Acting Loading Modes and Resulting Fracture Configurations 30
viii Contents
Tension 30
Compression 31
Torsion 31
Bending 32
Shear 34
Combined Loading 34
Relationships Between Location and Morphology 35
The Mechanical Behaviour of Bone 35
Structural Properties and the Load–Deformation Curve 36
Material Properties and the Stress–Strain Curve 36
The Role of Geometry 37
Viscoelasticity 39
Monotonic and Repetitive Stress Fractures 40
Classifications of Fractures 43
Fracture Topography 43
Completeness 45
Complexity 45
Displacement 45
Contamination 45
Articular Involvement 45
Other Factors 46
References 46
4 Fracture Epidemiology 55
T.D.H. Parkin
State of Knowledge 55
Geographic, Discipline and Horse Level Incidence 55
Incidence of Fractures Sustained During Competition 55
Thoroughbred Racing 55
Quarter Horse Racing 57
Endurance Riding 57
Eventing 57
Incidence of Fractures Sustained During Training 57
Thoroughbred Training 57
Showjumping Training 58
Measures of Fracture Incidence in Other Horses 58
Risk Factors, Predisposing Factors and Evidence 59
Risk Factors Associated with Training Regimens 59
The Importance of Detailed Information About Horses Under Investigation 61
Predictability and Potential for Effective Screening 62
References 63
5 Imaging Fractures 67
S.M. Puchalski and G.J. Minshall
Introduction 67
Image Quality 67
Image Interpretation 68
Negative Studies 68
Radiography 69
General Principles 69
Technical Considerations 70
Projections 70
Artefacts and Other Misleading Features 71
Contents ix
Limitations 72
Principles of Interpretation 72
Fracture Types 72
Monotonic Fractures 72
Stress Fractures 72
Articular Fractures 73
Fissure Fractures 73
Avulsion Fractures 73
Compression Fractures 73
Accompanying Features 73
Soft Tissue Swelling 73
Presence of Gas Lucency 73
Monitoring Fracture Healing 74
Ultrasonography 74
Transducers 74
Artefacts and Other Misleading Features 75
Limitations 75
Entheses 76
Secondary Features 76
Nuclear Scintigraphy 76
Time of Evaluation 79
Patient Preparation 79
Image Acquisition 79
Image Quality 81
Descriptors 81
Quantitative Assessment 81
Qualitative Assessment 82
Clinical Indications 82
Limitations 82
Dorsal Cortex of the Third Metacarpal Bone 82
Enostosis-like Lesions 82
Computed Tomography 84
Artefacts 85
Limitations 86
Magnetic Resonance Imaging 87
Limitations 88
x Contents
ositron Emission Tomography

P 91
References 91
6 Bone Healing 97
C.E. Kawcak
Introduction and Principles 97
Phases of Bone Healing 98
Cellular and Humeral Influences on Bone Healing 101
Mechanical Influences on Bone Healing 103
Monitoring Bone Healing 104
Healing of Stress Fractures 105
Healing of Incomplete Fractures 106
Healing of Complete Non-displaced Fractures 106
Healing of Displaced Fractures 106
Healing of Reduced and Repaired Fractures 106
Healing of Repaired But Non-reduced and/or Unstable Fractures 107
Effects of Internal Fixation on Bone Healing 107
Effects of External Fixation on Bone Healing 107
Intrinsic Factors That Affect Healing 108
Exogenous Factors That Influence Fracture Healing 108
Pharmacologic Influences 108
Non-steroidal Anti-inflammatory Drugs 108
Bisphosphonates 108
Antimicrobials 109
Biological Techniques 109
Bone Grafts 110
Synthetic Bone Substitutes 110
Exogenous Devices 111
Conclusions 111
References 112
7 Triage and Emergency Care 117

I.M. Wright and J. Daglish
Introduction 117
Racecourse Fractures 117
Insurance 119
Clinical Assessment 119
Clinical Features of Specific Fractures 122
Distal Phalanx 122
Navicular Bone 122
Middle Phalanx 122
Proximal Phalanx 122
Distal Condyles of the Third Metacarpal and Metatarsal Bones 123
Forelimb Proximal Sesamoid Bones 123
Transverse and Oblique Fractures of the Diaphysis of the Third Metacarpal and Metatarsal Bones 124
Cuboidal Bones of the Carpus 124
Carpal Subluxation and Collapsing Carpal Fractures 124
Radius 125
Ulna 125
Humerus 125
Scapula 126
Tarsus 127
Contents xi
Tarsal Luxation and Subluxation 127

Tibia 127
Stifle Joints 127
Femur 128
Pelvis 128
Sedation 130
Analgesia 131
Radiography 132
Ultrasonography 133
Wounds 133
Principles of Temporary Immobilization 133
Techniques for Temporary Immobilization 134
Robert Jones Bandages 134
Splinted Robert Jones Bandages 135
Bandage Cast 136
Casts 136
Compression Boots 137
Dorsal Splint 139
Flexion Splints 140
Palmar/Plantar Splint 141
Recommended Emergency Support 141
Distal Phalanx and Navicular Bone 141
Middle Phalanx 141
Proximal Phalanx 141
Distal Condyles of the Third Metacarpal/Metatarsal Bones 141
Proximal Sesamoid Bones 142
Diaphyseal Fractures of the Third Metacarpal/Metatarsal Bones 142
Fractures of the Carpus 143
Fractures of the Radial Diaphysis 143
Ulnar Fractures 143
Fractures of the Humerus and Scapula 143
Fractures of the Tarsus 144
Tibial Fractures 144
Fractures Involving the Stifle Joints, Femur and Pelvic Girdle 144
Transport 144
Ambulances 146
Nursing and Supportive Care 146
References 148
8 Surgical Equipment, Implants and Techniques for Fracture Repair 153

J.A. Auer
Principles 153
Anatomic Fracture Reduction 153
Stable Internal Fixation 153
Preservation of Blood Supply 153
Early, Active Mobilization 153
Pre-operative Planning and Approach to Bone 154
Instruments and Implants 154
Equipment for Internal Fixation 155
Depuy Synthes Instruments 155
Power Drill 155
Large Fragment Set 155
xii Contents
Drill Bits 155

Double Drill Guide 156
Universal Drill Guide 156
Special Drill Guides for Plate Application 156
Drill Guides for Locking Head Screws 157
Countersink 157
Depth Gauge 158
T-Handle 158
Tap 158
Screwdrivers 158
Torque-Limiting Devices 158
Tension Device 159
Push–Pull Device 159
Plate Bending Press 159
Bone Clamps 160
Additional Instruments 160
Screw Types, Sizes and Techniques 160
Cortex Screws 161
Self-tapping Cortex Screws 161
Screws Inserted in Lag Technique 161
Position Screws 164
Plate Screws 164
Cancellous Screws 164
Cannulated Screws 165
Locking Head Screws 165
Headless Screws 165
Screw Removal 165
Intact Screws 165
Stripped Hexagonal Screw Head 166
Broken Screws 166
Plates 167
Dynamic Compression Plates 167
Locking Compression Plates 169
Principles of Plate Fixation 169
Plate Functions and Applications 170
Neutralization Plates 170
Compression Plate 170
Buttress Plates 171
Application of a Dynamic Compression Plate 171
Application of a Locking Compression Plate 171
Human Femoral Locking Compression Plates 174
Veterinary T-LCP 174
Human Distal Femoral Locking Compression Plates 174
Compact 2.4 UniLOCK System 175
Variable-angle Locking Compression Plates 175
Limited Contact Dynamic Compression Plates 176
Dynamic Condylar Screw and Dynamic Hip Screw Implant Systems 176
One-third Tubular Plates 177
Leg Lengthening Plates 177
Intramedullary Implants 177
Steinmann Pins 177
Contents xiii
Stacked Pin Fixation 179

Rush Pins 179
Interlocking Intramedullary Nails 180
Wire and Cable 181
Orthopaedic (Cerclage) Wire 181
Cables 181
Reduction Devices 181
Fragment Distractor 181
Aiming Devices 182
Equine Aiming Device 182
Notes 183
References 183
9 Pre-operative Planning and Preparation 187

C. Lischer, K. Mählmann, and C.E. Kawcak
Introduction 187
Detailed Plan of the Surgical Procedure 190
Assessment and Understanding of the Fracture Configuration and Plan for Fixation 190
Access to the Surgical Site 190
Positioning the Horse and Limbs 190
Anticipated Methods for Reduction 192
Fixation 192
Imaging 192
Wound Closure 193
Bandaging and External Coaptation 193
Laminitis Prophylaxis 193
Recovery from Anaesthesia 193
Instruments, Implants and Disposable Items 193
Personnel 194
Imaging Modalities 194
Radiography 194
Fluoroscopy 194
Arthroscopy 195
Endoscopy 195
Preparation of the Operating Room 195
Floor Plan 195
Preparation of the Patient 196
Peri-operative Antimicrobials 196
Pain Management 197
Strategies for Complications 197
Equipment 198
Failure to Effect Reduction 198
Technical Errors During Implant Insertion 198
Anaesthetic Crisis 198
Complication During Recovery 198
Sign Out 198
Recovery 198
Open Fractures 198
Emergency Management 199
Use of Antimicrobials 199
xiv Contents
Debridement and Lavage 199

Soft Tissue Closure 201
Fracture Stabilization 201
Prognosis 201
eferences 201
R
10 Anaesthesia and Analgesia 207

E. Vettorato and F. Corletto
Abbreviations 207
Pre-operative Evaluation and Consideration 207
Pre-operative Analgesia 209
Induction of Anaesthesia 211
Maintenance of Anaesthesia and Intra-operative Analgesia 213
Peripheral Nerve Blocks 215
Monitoring and Cardiovascular Support 216
Head and Tail Rope Techniques 219
Deflating Air Pillow 219
Large Animal Vertical Lift 220
Sling Recovery 220
Pool Recovery System 222
Tilt Table 223
Other Potential Complications 224
Anaesthesia of Foals 226
References 228
11 Intra-operative Complications 235

C. Lischer and K. Mählmann
T echnical Errors 235
Fracture Reduction 235
Splitting Bone Fragments 236
Implant Location 237
Inadvertent Screw Contact 237
Screws in Joints 237
Screws in the Fracture Plane 238
Screw-induced Malalignment 238
Growth Plates 238
Screw Length 239
Locking Implants 239
Screw Breakage and Damage 240
Instrument Breakage 240
Inability to Tighten or Stripping of Screws 241
Asepsis and Prevention of Surgical Site Infection 241
Preparation of the Surgical Field and Draping 241
Prevention of Airborne Contamination 242
Handling of Implants and Instruments 242
Intra-operative Wound Irrigation 242
Operating Room 243
Intra-operative Imaging 243
Glove Perforation 243
Communication 243
References 244
Contents xv
12 Standing Fracture Repair 249

R.J. Payne and T.P. Barnett
Development and Philosophy 249
Indications and Contra-indications 250
Case Selection 250
Facilities and Equipment 251
Pre-operative Preparation, Sedation and Local Anaesthesia 251
Operative Technique 253
Post-operative Care 255
Post-operative Bandaging and Immobilization 255
Medical Management 256
General Nursing Care 256
Rest, Review and Return to Training 256
Summary 257
References 257
13 External Coaptation 259

I.M. Wright
Introduction 259
Casts 259
Materials and Construction 260
Application 263
Monitoring and Maintenance 268
Removal 270
Transfixation Casts 271
Equipment and Construction 272
Results 275
External Skeletal Fixation Devices 276
Distal Limb ESFD 277
Application 277
Results 278
Other External Fixation Devices 278
References 279
14 Post-operative Complications 283

Construct Instability 283
Screw Loosening 283
Infection 284
Risk Factors 285
Implant Associated Biofilm 285
Prevention 285
Diagnosis 285
Clinical Evaluation 286
Cytological Analysis and Microbiological Culture 286
Laboratory Parameters 287
Diagnostic Imaging 287
Treatment 288
Drainage and Debridement 288
Implant Removal or Replacement 289
Antimicrobial Treatment 289
xvi Contents
Supporting Limb Laminitis 294

Risk Factors 294
Pathophysiology 294
Clinical Signs 295
Radiography 295
Prevention and Treatment 295
Pain Management 295
Podiatry 297
Reducing Effective Body Weight 298
Changes in Bedding 298
Medication 298
Cryotherapy 299
Limb Deformities 299
Post-operative Colic 299
References 299
15 Convalescence and Rehabilitation 311

M.R. King, S.A. Johnson, and J. Daglish
Introduction 311
Rehabilitation Goals 311
General Considerations 311
Inflammatory Phase 313
Reparative Phase 313
Remodelling Phase 313
Musculoskeletal Comorbidities 313
Pain Modulation 313
Cryotherapy 313
Heat Therapy 314
Transcutaneous Electrical Nerve Stimulation 315
Physiotherapeutic Modalities 315
Neuromuscular Electrical Stimulation 315
Pulsed Electromagnetic Field Therapy 316
Whole Body Vibration Therapy 317
Therapeutic Ultrasound 318
Laser Therapy 318
Physiotherapeutic Exercise 319
Proprioceptive Facilitation Techniques 319
Aquatic Therapy 321
Targeted Physical Therapy 322
Injury-specific Exercises 322
Core-specific Exercises 323
Outcome Measures 324
Goniometry 324
Pressure Algometry 324
Summary 324
Notes 325
References 325
16 Fractures of the Distal Phalanx 331

D.W. Richardson
Anatomy 331
Fracture Types 331
Incidence and Causation 333
Contents xvii
linical Features and Presentation 333

C
Imaging and Diagnosis 334
Acute Fracture Management 335
Treatment Options and Recommendations 335
Specific Management Techniques 336
Type 1 (Non-articular Wing) Fractures 336
Type 2 (Articular Wing) Fractures 336
CT-Guided Lag Screw Fixation 337
Post-operative Care and Convalescence 340
Type 3 (Mid-sagittal) Fractures 341
Screw Size 341
Screw Position 341
Screw Number 342
Lag Screw Fixation Technique 342
Type 4 (Extensor Process) Fractures 346
Fragment Removal 346
Repair 346
Type 5 (Complex and Transverse) Fractures 347
Type 6 (Solar Margin) Fractures 347
Type 7 Fractures 348
Results 348
References 348
17 Fractures of the Navicular Bone 351

M.R.W. Smith
Anatomy 351
Fracture Incidence and Aetiology 351
Parasagittal Fractures 351
Transverse Fractures 352
Frontal Plane Fractures 352
Fractures of the Sloping Border 352
Distal Border Fragments 352
Bipartite and Tripartite Bones 353
Parasagittal Fractures 353
Presentation and Diagnosis 353
Conservative Management 355
Surgical Repair 355
Pre-operative Planning 357
Surgical Preparation 357
Computed Tomographic Imaging 357
Surgical Technique 357
Outcome 361
Complications 361
Palmar/Plantar Digital Neurectomy 362
References 362
18 Fractures of the Middle Phalanx 365

J.P. Watkins and K.G. Glass
Anatomy 365
Fracture Types 365
Osteochondral Chip Fractures of the Proximal Articular Surface 366
xviii Contents

Clinical Features and Presentation 366
Techniques for Treatment 366
Results 368
Axial Fractures 369
Results 369
Fractures of the Palmar/Plantar Eminences 370
Proximal Interphalangeal Arthrodesis 372
Results 376
Comminuted Fractures 377
Results 383
Fractures of the Distal Articular Surface 385
References 386
19 Fractures of the Proximal Phalanx 389

M.R.W. Smith
Anatomy 389
Fracture Types 389
Fragmentation of the Dorsoproximal Articular Margin 390
Short Incomplete Parasagittal Fractures 390
Long Incomplete Parasagittal Fractures 390
Complete Parasagittal Fractures 390
Dorsal (Frontal) Fractures 392
Fractures of the Palmar/Plantar Processes 393
Fragmentation of the Distal Articular Margin 394
Distal Articular Fractures 394
Salter–Harris Fractures 394
Epidemiology 395
Contents xix
Aetiopathogenesis 396
Surgical Repair – Dorsal Screw Configuration 400
Surgical Repair – Triangular Screw Configuration 401
Standing Fracture Repair 402
Moderately Comminuted Fractures 403
Minimally Invasive Repair 403
Open Reduction and Internal Fixation 404
Highly Comminuted Fractures 405
Long Frontal Plane Fractures 406
Short Dorsoproximal Dorsal (Frontal) Plane Fractures 407
Distal Joint Fractures 408
Results 408
Long Frontal Plane Fractures 410
Short Dorsoproximal Dorsal (Frontal) Plane Fractures 410
References 411
20 Fractures of the Proximal Sesamoid Bones 415

L.R. Bramlage and I.M. Wright
Anatomy 415
Aetiology 417
Incidence 417
Classification 417
Apical Fractures 419
Incidence and Location 419
Diagnosis 419
Treatment 420
Results 421
Abaxial Fractures 421
Diagnosis 422
Treatment 423
Results 426
Uniaxial Mid-body Fractures 426
Diagnosis 426
Treatment 427
Lag Screw Fixation 427
xx Contents
Transfixation/Hemi-circumferential Wire 430

Autologous Cancellous Bone Grafts 432
Results 432
Basilar Fractures 432
Diagnosis 433
Repair 433
Results of Repair 434
Removal of Articular Fragments 434
Results with Removal 434
Non-articular Basilar Fragments 434
Results 434
Sagittal/Axial Fractures 434
Fractures Caused by External Trauma 435
Destabilizing Fractures of the Proximal Sesamoid Bones 435
Diagnosis 435
First Aid 436
Treatment 436
Arthrodesis of the Metacarpo/Metatarsophalangeal Joint 436
Complications 440
Results 440
References 441
21 Fractures of the Distal Condyles of the Third Metacarpal

and Third Metatarsal Bones 445
I.M. Wright
A natomy 445
Fracture Types 446
Fractures of the Palmar/Plantar Subchondral Bone 449
Bicortical Incomplete Fractures 449
Complete Non-displaced Fractures 450
Displaced Fractures of the Lateral Condyles 450
Propagating Fractures 450
Complex Fractures 450
Displaced Fractures of the Lateral Condyle 454
Concurrent Lesions 457
Incomplete Fractures 458
Displaced Fractures 458
Contents xxi

Anaesthesia for Repair 459
Pre-operative Planning and Preparation 459
Variations in Technique 462
Fracture Healing 463
Complications 463
Implant Removal 464
Displaced Fractures of the Lateral Condyle 465
CT-directed Minimally Invasive Repair 470
Percutaneous Repair 471
Open Lateral Approach 471
Plate Fixation 476
Standing Repair 478
Complications 478
Implant Removal 479
Complex and Complicated Fractures 479
Results 479
Displaced Fractures 480
Concurrent Lesions and Complications 480
References 480
22 Diaphyseal Fractures of the Third Metacarpal and Third Metatarsal Bones 485
C. Lischer and C. Klaus
Anatomy and Biomechanical Considerations 485
Fracture Types 485
Incidence and Aetiology 486
Dorsal Cortical Stress Fractures 486
Diagnosis 487
Treatment 487
Incomplete Longitudinal Fractures 488
Diagnosis 488
Treatment 489
Avulsion Fractures Associated with the Origin of the Suspensory Ligament 489
Diagnosis 489
Treatment 489
Transverse Stress Fracture of the Distal Diaphysis 490
Diagnosis 490
xxii Contents
Treatment 490
Complete Diaphyseal Fractures 491
Diagnosis 491
Treatment 492
References 499
23 Fractures of the Second and Fourth Metacarpal and Metatarsal Bones 501
D.W. Richardson and K.F. Ortved
Anatomy 501
Fracture Types 501
Treatment 502
Proximal Fractures 502
Surgical Debridement 503
Internal Fixation 504
Ostectomy of Mt4 505
Mid-Diaphyseal Fractures 506
Surgical Management 507
Distal Fractures 509
References 510
24 Fractures of the Carpus 511

C.W. McIlwraith
Anatomy 511
Osteochondral Chip Fractures (Fragments) of the Dorsal Articular Margins 512
Clinical Signs 513
Pathogenesis 513
Treatment 515
Surgery 515
Results 519
Arthroscopic Surgery for the Repair of Carpal Chip Fractures 520
Avulsion Fragments Associated with the Palmar Intercarpal Ligaments 521
Osteochondral Fragments in the Palmar Compartments of the Carpal Joints 521
Incidence and Diagnosis 522
Treatment 522
Results 523
Carpal Slab Fractures 523
Incidence 523
Diagnosis 524
Treatment 524
Surgery 526
Frontal Plane Slab Fracture of the Radial Facet of the Third Carpal Bone 526
Frontal Plane Slab Fractures of the Intermediate Facet of the Third Carpal Bone 529
Frontal Plane Slab Fractures of Radial and Intermediate Facets of the Third Carpal Bone 529
Comminuted Collapsing Fractures 530
Sagittal Fractures of the Third Carpal Bone 534
Contents xxiii
Sagittal Slab Fractures of Other Carpal Bones 535

Frontal Plane Slab Fractures of Other Carpal Bones 535
Post-operative Care and Results 536
Accessory Carpal Bone Fractures 538
Diagnosis 539
Treatment 540
References 540
25 Fractures of the Radius 545

A.J. Ruggles
Anatomy 545
Fracture Types and Causation 545
Imaging and Diagnostics 546
Fissure Fractures 547
Repair of Simple Diaphyseal Fractures 547
Implant Selection 547
Surgical Techniques 549
Physeal Fractures 550
Proximal Radius 551
Distal Radius 551
Post-operative Management 553
Results 554
References 554
26 Fractures of the Ulna 557

I.M. Wright
Anatomy 557
Incidence 558
Aetiology 558
Fracture Types and Classification 558
Clinical Signs 562
Radiography and Radiology 563
Emergency Care 563
Conservative Treatment 565
Fracture Repair 566
Principles and Surgical Approach 566
Locking Compression Plate Repair 569
Fixation of the Ulna to the Radius in Foals 570
Repair of Apophyseal Avulsion (Type 1a) Fractures 571
Repair of Salter–Harris Type II (Type 1b) Fractures 571
Simple Humero-ulnar Articular (Type 2) Fractures 572
Fractures Commencing at or Distal to the Radio-ulnar Articulation (Type 5 Fractures) 574
Comminuted (Type 4) Fractures 575
Open Fractures 579
Repair with Wire 579
Fractures with Cubital Luxation 580
xxiv Contents
ost-operative Care and Convalescence 580

P
Results 581
Apophyseal Avulsions 581
Salter–Harris Type II Fractures 581
Proximal Non-articular (Type 3) Fractures 582
Simple Humero-ulnar Articular Fractures 582
Comminuted Articular Fractures 582
Fractures Commencing at or Distal to the Radio-ulnar Articulation 582
Open Fractures 582
References 583
27 Fractures of the Humerus 585

Anatomy 585
Fractures of the Greater Tubercle 586
Non-surgical Treatment 588
Surgical Treatment 588
Results 590
Fractures of the Deltoid Tuberosity 590
Treatment and Results 590
Stress Fractures 591
Clinical Features and Diagnosis 591
Treatment and Results 593
Diaphyseal Fractures 595
Conservative Management 597
Surgical Management 598
Results 600
References 600
28 Fractures of the Scapula 603

Anatomy 603
Fracture Types 603
Radiography 604
Ultrasonography 605
Treatment 605
Contents xxv
Supraglenoid Tubercle Fractures 605

Complete Fractures of the Scapular Neck or Body 607
Fractures of the Scapular Spine 607
eferences 610
R
29 Fractures of the Tarsus 611

I.M. Wright
Anatomy 611
Fractures of the Tarsal Bones 613
Fractures of the Medial Malleolus of the Tibia 613
Fractures of the Lateral Malleolus of the Tibia 615
Fractures of the Distal Intermediate Ridge of the Tibia 618
Sagittal Fractures of the Talus 618
Fractures of the Trochlear Ridges of the Talus 619
Fractures of the Medial Tubercles of the Talus 621
Other Fractures of the Talus 621
Fractures of the Calcaneus 621
Fractures of the Central Tarsal Bone 628
Fractures of the Third Tarsal Bone 631
Fractures of the Proximal Third Metatarsal Bone 635
Other Tarsal Fractures 636
References 637
30 Fractures of the Tibia 641

Anatomy 641
Fracture Types 641
Radiography 647
Treatment 648
Proximal Physeal Fractures 648
Distal Physeal Fractures 654
Fractures of the Tibial Tuberosity 654
Stress Fractures 661
Fractures of the Medial Eminence 661
Caudal Cruciate Avulsion Fractures 662
References 662
31 Fractures of the Patella 665

K.F. Ortved and I.M. Wright
Anatomy 665
Fracture Types 666
Radiography 667
xxvi Contents
Ultrasonography 667
Treatment 667
Subtotal Patellectomy and Removal
of Intra-Articular Fragments 668
Repair of Parasagittal Fractures 673
Transverse Fractures 675
Extra-articular Fragmentation 677
References 677
32 Fractures of the Femur 679

Anatomy 679
Proximal (Capital) Physeal Fracture 679
Results 683
Results 688
Distal Physeal Fractures 688
Results 691
Fractures of the Third Trochanter 691
Results 692
Fractures of the Supracondylar Tuberosity/Gastrocnemius Muscle Avulsion 692
Results 693
Fractures of the Trochlear Ridges 693
Fractures of the Femoral Condyles 693
Contents xxvii
vulsion Fractures of the Cranial Cruciate Ligament 694

A
References 694
33 Fractures of the Pelvis 697

R.C. Pilsworth and P.H.L. Ramzan
Anatomy and Biomechanics 697
Fracture Types, Incidence
and Causation 698
Fractures of the Tuber Coxae 699
Fractures of the Iliac Wing 700
Fractures of the Iliac Shaft 700
Fractures of the Ischium 700
Pubic Fractures 701
Risk Factors Associated with Pelvic Fractures 701
Age 701
Sex 701
Track Surface 701
Other Risk Factors 702
Ultrasonography 702
Scintigraphy 705
Radiography 706
Displaced Open Fractures 707
Delayed Emergence of the Parent Fracture Bed 708
Iliac Wing Fractures 709
Case Selection and Management 709
Pain Control 709
Prevention of Displacement 710
Prevention of Pleuropneumonia 710
Prevention of Laminitis 710
Prevention of Colic 710
Potential of Problems with Parturition 711
Prevention of Injury on Return to Training 711
Results 711
Iliac Wing 712
Iliac Shaft 712
Tuber Coxae 712
Tuber Ischium 712
Ventral Pelvis and Acetabulum 713
References 713
34 Fractures of the Vertebrae and Sacrum 715

F. Rossignol
Introduction 715
Fractures of the Axial Dens with Atlantoaxial Subluxation 715
Anatomy 715
xxviii Contents

Ventral Atlantoaxial Fusion Using an LCP 718
Other Techniques 718
Results 718
Atlantoaxial Subluxation 719
Dorsal Laminectomy 719
Results 719
Complete Ventral Luxation
of the Axis 720
Fractures of the Atlas 720
Fractures of the Axis 721
Fractures of Cervical Vertebrae 3 to 7 722
Anatomy 722
Fracture Types, Incidences and Causation 722
Plate Fixation 726
Dorsal Laminectomy 730
Results 731
Fractures of Thoracolumbar Vertebrae 732
Anatomy 732
Fractures Types, Incidence and Causation 732
Surgical Stabilization in Foals 733
Fractures of the Spinous Processes 733
Fractures of the Sacrum 734
Anatomy 734
Technique and Results 735
Fractures of the Coccygeal Vertebrae 735
References 735
35 Fractures of the Ribs 739

D.G. Levine
Anatomy 739
Fracture Types 739
Contents xxix
I ncidence and Causation 739

Conservative Treatment 741
Foals 741
Adults 742
Fracture Fixation 742
Approach 742
Plating 743
Nylon Cable (Zip Tie) 744
Securos Cranial Cruciate Ligament Repair System™ and Similar Suturing Techniques 744
Pins and Wires 745
Results 745
References 746
36 Fractures of the Head 747

A.E. Fürst
Introduction 747
Anatomy 747
Cerebral Cranium 747
Visceral Cranium 747
Mandible 748
Clinical Signs 749
Clinical Examination 749
Treatment Principles 749
Pre-operative Management 749
Surgical Considerations 750
Post-operative Management 750
Complications 751
Fractures of the Cerebral Skull 751
Examination 751
Clinical Signs 751
Acute Treatment and Medical Management 751
Surgical Treatment 753
Prognosis 753
Fractures of the Facial Skull 753
Surgical Approach 755
Reduction 755
Fixation 756
Fragment Interdigitation 756
Polydioxanone Sutures 756
Orthopaedic (Cerclage) Wire Sutures 756
Rosettes (FlapFix) 756
Plates 757
Skin Closure 757
Fractures of Incisive, Frontal, Nasal and Maxillary Bones 758
Orbital Fractures 759
Outer Parts of the Orbit 759
Inner Part of the Orbit 762
Fractures of the Mandible 762
xxx Contents
Surgical Planning and Preparation 764

Wound Management 764
Intraoral Wire 764
Cable Fixation 765
Screws and/or Plates 765
U-shaped Splint 767
Polymethylmethacrylic Compounds 768
External Fixators 768
Pinless Fixator 769
Individual Fracture Locations and Configurations 769
Pars Incisiva 769
Symphysis of the Mandible in Young Horses 769
Premaxilla 769
Interdental Space 771
Unstable Bilateral Fractures of the Pars Incisiva 771
Fractures of the Interdental Space and Pars Molaris 771
Vertical Ramus 774
Fractures of the Hyoid Apparatus 776
References 777
37 Fractures in Foals 779

A.J. Ruggles
Introduction 779
Anatomy 779
Salter–Harris Fracture Definitions 780
Pathophysiology of Physeal Fractures 780
Common Physeal Fracture Locations in the Horse 781
Considerations in the Management of Orthopaedic Injury in the Foal 782
Instability 782
Biomechanical Considerations 782
Fracture Reduction and Load Sharing 782
Implant Selection 783
Prevention of Angular Deformities 783
Analgesia and Medical Management 783
External Coaptation 784
Nursing Care 784
Fractures of the Distal Phalanx 784
Fractures of the Proximal and Middle Phalanges 785
Fractures of the Proximal Sesamoid Bones 785
Fractures of the Mid and Distal Third Metacarpal and Metatarsal Bones 792
Casts and Transfixation Casts 794
Internal Fixation 794
Prognosis 794
Fractures of the Proximal Metacarpus and Metatarsus 795
Fractures of the Cuboidal Bones of the Carpus and Tarsus 795
Radial Fractures 798
Fractures of the Ulna 799
Humeral Fractures 804
Fractures of the Scapula 804
Contents xxxi
alcaneal Fractures 804

C
Tibial Fractures 804
Femoral Fractures 806
Pelvic Fractures 807
Guidelines for Implant Removal 807
Indications 807
Risks 807
Timing 807
Techniques 808
Post-operative Management and Complications 808
References 809
Index 811
xxxiii
Preface
Fractures in the Horse was conceived in the hiatus between tive includes my parents, grandparents and extended
the first and second editions of Equine Fracture Repair in family who worked tirelessly to provide an education and
an attempt to fill the void and to provide a contemporane- Trinity College, Cambridge, which opened my mind.
ous text. It was undertaken with the realization that it Alasdair Steele-Bodger, Donald Steven, Robert Walker
would represent a recorded time point in perceived knowl- and John Hickman gave early inspiration. Hugh Davies
edge. Authors were invited on a best available basis because taught me much about people, horses and their complex
of their collective experience, not simply to provide litera- inter-relationships. John Houlton grafted in some surgi-
ture summaries. The discerning reader will recognize dif- cal skills, Les Gray kept me grounded and Wayne
fering approaches and opinions: this is important. No McIlwraith introduced me to the wonderful world of
chapter provides the definitive account on the subject; all arthroscopy. I have been blessed by working for great
continue to evolve. However, understanding the principles owners, trainers and referring veterinary surgeons; it
on which causation, diagnosis and management are made would be invidious to name individuals, but I am par-
is critical. The book should also provide a source of refer- ticularly grateful to those who had faith in me in the
ences for those who wish to delve further into particular early stages of my career. Colleagues at Newmarket
knowledge pools. It has been written in the hope that it will Equine Hospital have supported, questioned and debated
spawn subsequent editions which, in turn, will improve to good effect, while the imaging, anaesthesia and thea-
the care of horses with or at risk of fracture. tre teams have provided services that I have yet to see
I am extremely grateful to the authors who gave their bettered. My cases have been cared for by dedicated sta-
time, shared their knowledge and to varying degrees ble staff and a stream of interns. Emma Yeates has jug-
ignored, tolerated or responded to my attempts to motivate, gled the book, PA duties and day-to-day running of the
cajole or beg into action. hospital for which there can never be sufficient thanks.
The debts of gratitude to other who have led, taught, Finally, nothing would have been possible without the
inspired and motivated me is long and while not exhaus- love and support of Gaynor.
xxxv
List of Contributors
J. A. Auer S. A. Johnson
University of Zurich College of Veterinary Medicine and Biomedical Sciences
Zurich Colorado State University
Switzerland Fort Collins
CO
T. P. Barnett USA
Rossdales Equine Hospital
Newmarket C. E. Kawcak
UK Veterinary Teaching Hospital
Colorado State University
L. R. Bramlage Fort Collings
Rood and Riddle Equine Hospital CO
Lexington USA
KY
USA M. R. King
College of Veterinary Medicine and Biomedical Sciences
F. Corletto Colorado State University
Newmarket Equine Hospital Fort Collins
Newmarket CO
UK USA
J. Daglish C. Klaus
Newmarket Equine Hospital Freie Universität
Newmarket Berlin
UK Germany
A. E. Fürst D. G. Levine
University of Zurich School of Veterinary Medicine
Zurich University of Pennsylvania
Switzerland Philadelphia
PA
K. G. Glass USA
Veterinary Medicine and Biomedical Sciences
Texas A&M University C. Lischer
College Station Freie Universität
TX Berlin
USA Germany
A. E. Goodship K. Mählmann
Royal Veterinary College Freie Universität
London Berlin
UK Germany
xxxvi List of Contributors
C. W. McIlwraith D. W. Richardson
Colorado State University School of Veterinary Medicine
Fort Collings University of Pennsylvania
CO Philadelphia
USA PA
USA
G. J. Minshall
Newmarket Equine Hospital C. M. Riggs
Newmarket The Hong Kong Jockey Club
UK Sha Tin
Hong Kong
K. F. Ortved
School of Veterinary Medicine F. Rossignol
University of Pennsylvania Equine Clinic of Grosbois
Philadelphia Boissy
PA France
USA
A. J. Ruggles
T. D. H. Parkin Rood and Riddle Equine Hospital
Bristol Veterinary School Lexington
University of Bristol KY
Bristol USA
UK
M. R. W. Smith
R. J. Payne Newmarket Equine Hospital
Rossdales Equine Hospital Newmarket
Newmarket UK
UK
S. M. Stover
R. C. Pilsworth UC Davis School of Veterinary Medicine
Newmarket Equine Hospital University of California
Newmarket Davis
UK CA
USA
S. M. Puchalski
Puchalski Equine Inc E. Vettorato
Petaluma Newmarket Equine Hospital
CA Newmarket
USA UK
J. L. Pye J. P. Watkins
UC Davis School of Veterinary Medicine Veterinary Medicine and Biomedical Sciences
University of California Texas A&M University
Davis College Station
CA TX
USA USA
P. H. L. Ramzan I. M. Wright
Rossdales Equine Practice Newmarket Equine Hospital
Newmarket Newmarket
UK UK
1
Introduction
I.M. Wright
Newmarket Equine Hospital, Newmarket, UK
Over the course of the last 50 years, the concept of fractures fractures by the ancient Syrian, Egyptian, Persian and Greek
in horses has emerged from an association with inevitable civilizations, although in the latter Xenophen (380 BCE)
euthanasia to an expectation, in many cases, for restoration described ‘Rules for the Choice, Management and Training
of full athletic function. This has been the result of major of Horses’ and Aristotle (333 BCE) in ‘The History of
developments in understanding pathogenesis, imaging, Animals’ introduced the concept of gaits. An ancient Greek
anaesthesia, internal fixation, pharmacology and mini- treatise called the Mulomedicina Chironis has been ascribed
mally invasive surgical techniques. However, although pre- to a healer Chiron. There is evidence that this was a real
vious progress was slow, there were inklings of latent person circa 700 BCE, but confusion is produced by later
knowledge. This should not be surprising: in 1722 W. elevation to the mythologic status of centaur.
Gibson [cited in 1] wrote, ‘As the general use and service of In paleopathologic investigations, three healed metacar-
horses has rendered them more worth the notice and regard pal bone fractures dating from the Iron Age (800 BCE–43
of mankind than any other of the brute creatures; so there CE) have been found in different parts of Europe [3]. These
has in most ages of the world been a more than ordinary included a compound fracture of what was considered most
care taken, not only to model and fit them for their respec- likely a working mare buried in a human cemetery of the
tive services, but also of their breed and preservation.’ fourth to seventh century BCE at Sindos, Greek Macedonia.
The bone was markedly distorted but the animal is thought
to have survived for at least three to four years after the
H
istorical Review injury, and it was suggested that this lame mare may have
pulled her ‘loving owner’s’ cart to the grave before being sac-
The following review makes no claim to be comprehensive rificed and laid next to him [4]. A rib fracture in a horse from
but aims to be sufficiently representative to illustrate the the Roman Imperial period (27 BCE–284 CE) was found at a
temporal recognition, development of understanding, site near Seinstedt, Germany [5]. The same group reported a
diagnosis and treatment of fractures in horses. ‘neatly healed’ fractured third metatarsal bone in a horse
from the Iron Age sacrificial site of Skeddemosse, Sweden [6],
and a fractured metacarpus from a similar period was found
The Ancient World
in a horse at Tiel-Passewaaij, the Netherlands [7].
Fractures have occurred in wild (non-domesticated) ani- According to Harcourt [cited in 8], an archeologic study
mals throughout their evolution. It has been suggested that of the Roman site of Tripontium, England, found a healed
horses were initially domesticated in the late Neolithic fractured humerus in a horse although there was no evi-
period: first for food and later for transportation and war [2]. dence to indicate intervention. The paucity of healed frac-
Domestication of Equidae introduced new environments tures in large animals was considered direct evidence of
and circumstances particularly as horses were used for the associated bad prognoses [3]. No archeologic evidence
work, often were ascribed special value (both economic and of therapeutic intervention during this period has been
emotional) and played important cultural roles in human found [7, 9]. The possibility had been suggested in a healed
civilization. There is a dearth of documentation of equine metacarpal of an Iron Age horse from Manching [10].
Fractures in the Horse, First Edition. Edited by Ian Wright.

© 2022 John Wiley & Sons Ltd. Published 2022 by John Wiley & Sons Ltd.
2 Introduction
However, the specimen had a complicated fracture that binding a fractured metacarpus in a horse suspended in a
healed with ‘distortion of the bone and development of an sling is illustrated in Mending the fractured metacarpal of the
enormous callus’, which appears to make this tenuous. horse (1390) from Libro de menescalcia e de albeyteria et fisica
The writings of Hippocrates (considered the father of med- de las bestias (a Spanish text from the Middle Ages) and in the
icine) in the fourth to fifth century BCE included a text fifteenth-century work of Johan Alvares de salami Ella’s. A
‘De Fracturis’, which is the first known treatise devoted to the fractured pelvis from the fourteenth to sixteenth century
subject. The Hippiatrika, a text compiled in the fifth or sixth was recovered from the Cumanian settlement of Karcag-
century CE, was a compilation of extracts of Greek technical Organdaszentmiklós, Hungary. The fracture involved the
literature on the care and healing of horses. This included a ilial shaft and was displaced, but there was sufficient adjacent
contribution from Apsyrtus, a ‘well-known horse specialist’ new bone to suggest that this was of multiple months’ dura-
from the fourth century CE [10], who was of the opinion that tion during which period the horse was considered to have
‘all fractures below the knee have a good chance of healing’. been ‘immobilized’ [13].
Later manuscripts published as Hippiatria (1531) or
Hippiatrica (1543) also cite Apsyrtus treating fractures below
The Renaissance/Reformation
the knee with splints and bandages with cures expected in
about 40 days (which must question the diagnosis), while From a medical/scientific perspective, the Middle Ages may
fractures above the knee were considered incurable [11]. be considered to have ended with the introduction of mechan-
The Romans appeared to document little in veterinary ical printing at the end of the fifteenth century. ‘Proprytes and
medicine until the end of their Western empire when the medicynes of hors’ was thought to be first printed in 1497 or
Byzantine Publius Vegetius (circa 450–500 CE) recognized 1498. This was followed by ‘Medicines for Horses’ somewhere
that diseases of the horse were similar to those suffered by between 1510 and 1560. There are no ascribed authors to
men. Vegetius is often considered the first to have docu- either. However, such texts made little comment on trauma-
mented hippiatric beliefs and practices. These were almost tology, concentrating on remedies, topical applications, blood-
certainly preceded but records are lacking. letting and similar (now considered illogical) insults [1].
Equine fractures were mentioned by a French author Rusius
in 1559 and Thomas Blundeville, an English mathematician
Middle Ages/Mediaeval Period
(who invented the protractor), in The fower chiefyst offices
Throughout the Middle Ages (circa 500–1500 CE), horses belonging to Horsemanshippe published in 1565 described
continued to play a major role in warfare with increasing fractures as a form of ‘evil’ that, in common with wounds and
numbers employed in agriculture and transport. In the ulcers, causes a ‘loosening or division of the unity’ [14].
early Middle Ages, Western medicine in general was domi- Gervase Markham made comment on veterinary matters in
nated by religious (Christian) doctrine; science in the cur- books commencing with ‘A Discourse of Horsemanshippe’ in
rently accepted sense was neither considered nor applied. 1593. This was followed by Thomas De Grey’s ‘The Compleat
Further discussion on fractures is found in republications Horse-man and Expert Farrier’ in 1639 and ‘The Anatomy of a
of the ancient works of Chiron the Centaur (circa 400 CE) Horse’ by A. Snape in 1674.
and Vegetius Ranatus (450–500 CE). The latter was trans-
lated from Latin to English in 1748 as ‘Distempers of
The Enlightenment and Industrial Revolution
Horses’ and includes a chapter (two pages) on fractures.
Open limb fractures were recognized as ‘almost incurable’. Reference to anaesthesia and analgesia (albeit not in such
For closed fractures, bandages, splints and slings were rec- terms) occurs in a series of experiments in the 1650s and
ommended. The latter fitted so that the horse ‘may not 1660s when animals were injected with a solution of opium
touch the ground with his foot, lest the fracture should [A H Machle 1998 cited in 1].
move to and fro in a lamentable manner’. Vengetius The concept of musculoskeletal biomechanics appears in
Ranatus instructed that the horse must not be allowed to print in the mid-seventeenth century when individuals like
stand on the fractured limb for 40 days ‘for that is the time the physician Giovanni Alfonso Benelli (1608–1679) applied
when things that are broken, or torn asunder, or disjoined, the concepts of physics and mechanics, thus viewing bones
are consolidated’ [11]. and joints as levers. Further reference is made in ‘The
The Mamluks, who ruled Egypt and Syria between 1250 Compleat Horseman’ [15], a 1702 translation by Sir William
and 1517, are thought to have used orthopaedic bandages Hope of ‘Le Parfait Marschal’ by Jacques de Solleysel. Of
containing resins from Boswellia plants and pitch from cedar note is the absence, to this time, of veterinarians. Solleysel is
and tannűb trees to heal broken bones in horses [12]. There is said to have combined riding school training with veterinary
also iconographic evidence of care of horses with fractures: practice (largely performed by farriers). It was not until 1762
Historical Revie 3
that Claude Bourgelat founded the first veterinary college in Fitzwygram (1869) [20] described bone structure, as far as
Lyon. W. Gibson in ‘The Farriers New Guide’ published in it was understood, and gave a rudimentary classification of
London in 1722 noted that although broken bones might be fractures. The following paragraphs provide a summary that
corrected, a horse that had a fracture ‘with a large wound in endured. ‘In the human subject, the treatment of broken
the flesh’ was unlikely to recover satisfactorily. In 1766, von bones is comparatively easy, because the patient can be
Suid described a sling system designed to prevent horses placed without difficulty or opposition on his part on his back
from lying down and reported healing of 10 horses with frac- in bed, the position most favourable for relieving the broken
tures of distal bones. limb of all weight and pressure. Whilst in this position splints
Youatt (1843) in the ‘Fractures’ chapter of ‘The Horse’ [16] and other restraints can be conveniently imposed, and the
stated that ‘Accidents of this description are not of frequent patient is blessed with sense enough to induce him to submit
occurrence but when they do happen it is not always that the to such restraints and to remain quiet. In the horse, we have
mischief can be repaired: occasionally, however and much none of these advantages. We cannot without hurtful vio-
more frequently than is generally imagined, the life of a val- lence throw the animal on his back, nor can we by any per-
uable animal might be saved if the owner, or the veterinary suasion induce him voluntarily to remain in that position.
surgeon would take a little trouble’ [17]. This concept was Hence fractures of important bones are generally incurable.
reinforced by Williams (1893) [18] who noted that ‘a ridicu- In most cases therefore of such injuries it is better to have the
lous idea has prevailed amongst horsemen that fractured animal destroyed at once. Again the horse is an animal,
bones never unite. This is incorrect . . . provided that frac- whose value as a general rule consists in his power of loco-
tured ends can be kept at rest.’ Both authors placed great motion. In man on the other hand the surgeon, though he
emphasis on the use of slings, but splints of green wood [16] may not be able to make a perfect cure, is often well content,
and leather [18] are also described. if he can produce such re-union of the bones, as may enable
Clater’s ‘Every Man His Own Farrier’ (1853) [19] sug- the patient, in case of broken leg for instance, to walk about.
gested that ‘a horse is often condemned without cause, on A horse is of no value, unless he can walk, trot and gallop
account of fracture of the bones of the fore-legs: either the sound and level. An exception however to this general rule
practitioner dislikes the trouble of the case, or the proprie- occurs in the case of valuable brood mares or stallions.’
tor is loath to make the proper remuneration. There is but Fitzwygram [20] also understood the concepts of mono-
one circumstance that would justify the abandonment of a tonic and fatigue (cumulative stress/strain imbalance) frac-
horse with fractured leg, and that is it being a compound tures, and described fractures caused either by violence to
fracture, i.e. the integument and muscular parts being lac- the bone or from excessive strain. Diagnosis was entirely
erated; then, indeed the case is hopeless. The cure of a frac- clinical. Treatment objectives were reported as ‘setting’, i.e.
ture of the pastern or the shank bone may be undertaken the bringing together of the broken ends and when the
with a fair prospect of success. All that is to be done is to bones were ‘thus adjusted . . . to keep them in their place’,
cut the hair closely from the parts; to bring, – and as gently which was described as ‘a very difficult matter and needs
as may be, – the divided edges of the bone in apposition; to expertise and ingenuity’ which is equally applicable today.
retain them there by a pitch plaister; and then to bind on Splints padded with tow (flax or hemp), bandages and strips
splints, which shall reach a considerable way above and of adhesive plaster were described. The starch bandage,
below the injured part. This should be done in the box in which had been in human use since Roman times (reported
which it is intended that the horse should remain. He by Celsus in 30 CE), was considered particularly useful and
should be bled, and a dose of physic should be given to could be stiffened with an external wooden splint. It was also
keep down inflammation, and then he should be left to suggested that in some cases the horse may be slung with a
himself. He will take care of his broken leg; he will not view of taking the weight off the part affected.
press upon it for many a day; and not at all, until he can do In 1884, Smith [21] reported sling management of horse,
so without much pain: and, in many more cases than some which was non-weight-bearing on a hindlimb and which
have imagined, the fractured bone will unite, and the horse subsequently (at post-mortem) was found to have an axial
will do well. A sling should rarely, I would say almost never, fracture of the lateral condyle of the femur. The first surgi-
be used. The sad excoriations, and other inconveniences cal repair of an equine fracture appears to be in 1891 when
occasioned by the long use of a sling, have, more than any- Prieur [cited in 22] referred to repair of an equine jaw frac-
thing else, brought the treatment of fractures into disre- ture with a drilled wire suture in Cairo, Egypt.
pute. The horse does not like pain, and will generally take Around 1800, William Eton [23] described the creation
all the care of his injured limb that we could wish him to of a gypsum (calcium sulphate) plaster mould to immobi-
take. Fractures of the hind extremities are more serious lize fractured legs that he had observed in Turkey. First
affairs, and should be undertaken with caution.’ documented use in man is attributed to a Dutch surgeon
4 Introduction
Antonius Mathijsen in 1852 and it was adopted into mili- Salter and Harris [30] described a classification of growth
tary service in the 1850s during the Crimean War by a plate fractures in children. Its applicability to horses was
Russian surgeon Nikolai Pirogor (1810–1881). The earliest soon recognized, and its adoption into veterinary orthopae-
reference to attempted use of plaster of Paris in horses was dics was rapid and enduring.
in 1872 [24], although it was not recommended. However, Internal fixation of fractures was first reported by Lambotte
in 1883 plaster of Paris splints were described as a success- in 1913 [cited in 31]. Techniques for active repair of fractures
ful method of fracture management [25]. in horses appeared in the first half of the twentieth century,
Near the end of the century, one of the first identifiable but progress was slow. Roberts [cited in 17] concluded that
movements to reduce the incidence of fractures in horses intramedullary pins were impractical in horses because of
was the 1889 formation of the Horse Accident Prevention fragment rotation and implant bending. Problems associated
Society (Slippery Roads), which campaigned against asphalt with plates available at this time included bending at screw
road surfaces. holes and shearing of screws. These issues were addressed by
the combined mathematical, physical, engineering and med-
ical collaboration in establishing the Arbeitsgemeinschaft fűr
The Twentieth and Twenty-first Centuries
Osteosynthesfragen (AO) group in 1958. This was translated
The Farm Vet published by an anonymous veterinarian in in the United States into the Association for the Study of
1914 noted that ‘chloroform can be used to render animals Internal Fixation (ASIF). The terms are synonymous, inter-
insensible and relaxes muscles which oppose the necessary changeable and sometimes used concurrently (AO/ASIF).
extension of limbs in order to get fractured bones in apposi- Central to the early AO goals were accurate anatomic recon-
tion’. Horses are noted as ‘the worst subjects for fractures struction, fracture compression, rigidity of fixation and pres-
and sheep the best. Horses must be able to work sound. ervation of blood supply [32]. This promoted primary bone
Sheep and cattle need only to put on sufficient flesh to bring healing, a concept first published in 1947 [33]. In 1968, an
them to the block.’ osteotomized third metacarpal bone was repaired in vivo
In 1905, Wotley Axe [26] commented on the emergency with a human plate [22]. AOVET was founded in 1969, and
care of equine fractures; ‘if an ambulance cart can be pro- in the following year a report documented the repair of dia-
cured without much delay, it would be desirable to convey physeal fractures of third metatarsal bones in two ponies
him at once where he may be required to go’ and that ‘it using primordial compression plates and cortical screws [34].
should be kept in mind that the success of treatment is greatly Initial progress was slow. In a well-documented seven-hour
facilitated by the speedy readjustment of the broken bone’. marathon surgery in 1972, a third metacarpal lateral condy-
Potential limitations of temperament were also recognized; ‘a lar fracture was repaired in Derby winner Mill Reef. The
horse’s highest intelligence fails to realise the advantage of owner was charged £25 000 [35] (which equated to approxi-
that perfect quiet upon which the surgeon sets so much store, mately £330 000 in 2020). As interest increased, an exponen-
in guarding against an extension of the injury and in bringing tial growth in the publication of papers on equine fractures
about its reparation. The moment the fracture is suspected followed (Figure 1.1). The first Manual of Internal Fixation in
every means should be adopted at once to restrain the ani- the Horse was published in 1982 [36]. Development of an
mals movements and to provide as far as possible against any equine fracture documentation system was attempted [37],
undue use or disturbance of the injured limb.’ but the discipline progressed too quickly for this to be viable.
Röentgen discovered X-rays in 1895 and the potential of In 1996, Alan Nixon edited the multi-author ‘Equine Fracture
radiographic diagnosis in horses was first recognized as Repair’ [38], which provided an excellent state of knowledge
early as 1927 [27]. Radiographs produced on photographic summary for the time. A second edition was planned 10 years
films were first documented in equine fracture evaluation later but did not reach fruition until 2020 [39]. In the interim,
in 1950 [28]: until this time diagnosis was entirely clini- ‘AO Principles of Equine Osteosynthesis’ was published in
cal [20]. Radiographic diagnosis came to public attention 2000 [40]. The rapid relief of pain that follows a stable frac-
in 1966 with the diagnosis of a distal phalangeal fracture in ture repair is remarkable and, in addition to preventing
champion steeplechaser Arkle. secondary, and often life-limiting clinical problems such as
The 1962 publication of the eponymous ‘Lameness in overload laminitis, has made a major contribution to animal
Horses’ [29] signalled the arrival of the speciality. It also welfare. On a personal basis, this remains one of the greatest
provided a series of radiographic images of equine frac- motivating forces.
tures and recommended specific treatments including suit- Implants used in equine fracture repair have also evolved;
ability for fragment removal. Although at this time the while cortical bone screws have been a consistent mainstay
desirability for reconstruction was recognized, techniques throughout, plate design has increased in sophistication.
and suitable equipment were not yet available. In 1963, The originally used dynamic compression plate (DCP) [41]
Historical Revie 5
45
40
35
30
Number of papers
25
20
15
10
0
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
Repair and Vet
Figure 1.1 Number of papers on equine fractures published in the veterinary literature between 1945 and 2016. Source: Data from
PubMed (https://www.ncbi.nlh.gov/pubmed/).
remains in use. Although not identified in horses, stress Use of resin-bonded fibreglass to create casts for horse
protection and remodelling osteoporosis were associated limbs was reported in 1963 [52], and use of fibreglass to
with DCP application in man and this led to development reinforce plaster of Paris casts was first documented in 1966 in
of first the limited contact dynamic compression plate (LC- treating people [53]. Equine use of an experimental tape was
DCP) and subsequently the locking compression plate reported in 1971 [54], and its material advantages were docu-
(LCP) [42]. mented in 1973 [55]. Subsequent commercial development of
Safe and effective adaptation of AO/ASIF techniques fibreglass casting materials suitable for use in horses [56–59]
relied on developments in anaesthesia, operating theatre enhanced acute support before surgery and recovery from
and table design, asepsis, evolution of suture material, general anaesthesia. It has also permitted more protracted
medication, cast materials and imaging. Fracture repair immobilization of fractures that are not amenable to recon-
under general anaesthesia is almost always optimal. struction or to augment or protect constructs. Severely com-
Justification for standing techniques was based on historic minuted and/or complex fractures can also be managed with
mortality risk data [43]. Development of anaesthesia train- transfixation casts used alone or in conjunction with selective
ing programmes, improvements in pharmacology and cen- internal fixation [60, 61]. These techniques have now replaced
tralized hospital experience have subsequently resulted in external fixation devices for distal limb fractures [42, 62].
significantly reduced risk [44]. Distal limb amputations with replacement prostheses
Understanding the importance of soft tissues in success- have been documented [63], but complication rates are high,
ful fracture management has been an important although longevity is usually limited and the ethics are questionable.
less well-documented concept [45–47]. Refinements have Other prosthetic techniques have also not made a significant
occurred and prognoses improved by the use of minimally impact in equine orthopaedics [64]. Nonetheless, veterinar-
invasive surgical techniques, principally arthroscopy first ians have always been capable of lateral thought and have
in removing articular fracture fragments [48] and more been prepared to try alternative approaches. Plato’s adage
recently in guiding reduction and repair [49, 50]. Minimally that ‘necessity is the mother of invention’ is readily applica-
invasive plate application has also been adopted into clini- ble to equine fracture management. Examples include
cal practice [51]. Accurate three-dimensional imaging and standing fracture repair, long-term suspension of horses
the repeatability/predictability of work/fatigue fractures [65, 66] and relief of load on fractured bones or limb seg-
have also permitted percutaneous repair with consequent ments [61, 62, 67–71]. Attempts to hasten bone healing
preservation of soft tissue. (Chapter 6) have largely been unfruitful.
6 Introduction
Nuclear medicine (scintigraphy) was adopted into equine T

he Future
orthopaedics in the 1980s [72]. Determination of increased
metabolic activity in bone allowed identification of sus- Ethereal debate centred on the question of ‘what is a frac-
pected fractures in areas of limited imaging capability or in ture?’ is anticipated. The dictionary definition of ‘being
some cases in advance of identifiable (usually radio- broken, of a crack, division or split’ [90] is clear, but at what
graphic) morphologic changes [73]. level? Division of a bone into two or more pieces is indis-
After nearly a century of interpreting radiographic infor- putable and all would agree that incomplete fissures in cor-
mation on photographic film, digital imaging became the tical or subchondral compacta are fractures. But should
norm and with it substantially more information on bone disrupted trabeculae in spongiosa be similarly classified?
structure and fracture identification. However, radiographs Do some enostoses represent fractures in trabecular
are two-dimensional assessments of a three-dimensional bone [91]? Are the recently adopted terms of ‘bone failure’,
object with superimposition of other structures. They are ‘bone bruising’ and ‘fatigue failure’ manifestations of frac-
therefore limited in assessing the geometry of fractures tures at a microscopic level?
that are not simple and uniplanar. Introduction of com- If the veterinary profession wishes to retain its role as
puted tomography (CT) in the last decade provided three- guardians of animal welfare, then future endeavours will
dimensional radiographic information and has been a need to include measures targeting prevention or reduc-
great step forward resulting in the re-classification of many tion of fracture incidence in horse sports, particularly rac-
fractures from incomplete to complete, uniplanar to spiral ing. Elements of society have and will continue to question
and simple to comminuted. Confident identification of whether use of horses for competitive sport is ethical and,
fractures has not only directed optimal management but rather more directly, whether ‘horseracing is too danger-
has also permitted minimally invasive repair. ous?’ [92]. In some countries, animals are also gradually
Ex vivo (post-mortem) use of CT and magnetic resonance moving from the legal status of chattel to sentient beings:
imaging (MRI) to evaluate equine fractures was reported in with that will come rights and this may herald a change in
1995 [74]. Both produce sectional multiplanar images, but society’s attitudes. The veterinary profession is best posi-
these are based on different information sources. CT relies on tioned to provide objective guidance. Suggestions that with
tissue attenuation of X-rays; MRI principally maps the pres- the right insight nearly every catastrophic fracture in flat
ence of hydrogen atoms (particularly in water and fat), and racehorses could be foretold [93] are not justifiable.
structural information of the skeleton is inferred from However, the prevention of some work/stress-related frac-
this [75]. CT identification of a two-dimensional radiographi- tures through conditioning and training methods, surface
cally occult fracture was reported in 1999 [76], and in 2001 design and maintenance [94] and potentially from genetic
Tucker and Sande [77] identified the potential for CT to better studies [95] appears feasible goals. Robust epidemiological
delineate fracture orientation and assist in surgical planning studies should identify risk factors, enable change to be
in horses. Subsequent development and adoption of mobile rational and, if both are correct, reduction in work-related
in-theatre units made this a reality, and CT is currently con- (stress) fractures is a reasonable expectation. Unfortunately,
sidered the gold standard in assessing and directing repair of epidemiologic evidence thus far is inconsistent [96].
equine fractures. In vivo diagnostic use of MRI for the evalua- Previously heralded mineral-based dietary influences
tion of equine fractures started to appear in 2010 [78] with appear unlikely to contribute [97]. Screening of horses in
subsequent contributions to understanding pathogenesis [79], training or monitoring at-risk individuals by biomarkers as
surgical planning [80] and risk assessment [81]. yet appears to lack sensitivity and specificity [98].
Inherent surgical limitations are now recognized in vet- Assessment by diagnostic imaging is an attractive concept
erinary medicine [82]. Those who regularly deal with but remains unproven [95, 99–104]. Longitudinal studies,
equine fracture repair understand the importance of team of which there are few in man [105], are a laudable goal [95]
work, attention to detail, communication and planning. but unlikely to be practical in equine athletes.
The ideas crystallized in the publications of Atul Notwithstanding the above, monotonic fractures that
Gawande [83–85] are as relevant to equine surgeons as result from trauma will continue to present and challenge
their human counterparts. An international World Health veterinarians. The potential for survival, humane preserva-
Organisation (WHO) study demonstrated that adoption of tion of life and return to useful function continues to pro-
a surgical checklist reduced human post-operative morbid- gress proximally in the horse’s limb. Development of CT
ity and mortality by 36% and 48%, respectively [86]. equipment that will allow three-dimensional evaluation of
Multiple subsequent studies have upheld these findings in the proximal appendicular and axial skeleton appears close
man, and similar results have been reported in veterinary to the horizon. Variable angle LCPs (VA-LCP) are now in
anaesthesia [87] and small animal surgery [88, 89]. production for man and should soon join the veterinary
Reference 7
surgeons’ armamentarium [42]. Refinements such as the It has been stated that orthopaedic surgery may be
addition of hard carbon film to improve drill efficiency and reduced to three key factors: knowledge, understanding
reduce bone temperature may become the norm [106]. and accuracy [111]. Publications (hopefully this included)
Further development of biodegradable plates and screws is add to the body of corporate knowledge. Competent equine
anticipated together with drug, osteoconductive and oste- fracture repair requires a trained and experienced team
oinductive coatings to implants [42, 107, 108]. Customized including imagers, surgeons, anaesthetists, theatre techni-
implants made using 3D printing technology are also an cians and nurses. Accuracy is aided by technology but
enticing prospect but access to adequate technological requires discipline, training and experience. Understanding
knowledge and appropriate materials is unlikely to be is a never-ending personal challenge. Technical errors are
widespread in equine surgery. Computer-assisted surgery inevitable when even ‘simple’ fractures are repaired by
in horses is in its infancy [109, 110] but will not be a substi- inexperienced personnel. Technology aside, size, behav-
tute for anatomic knowledge or surgical skill. There is little iour and temperament will always be challenges to equine
current evidence to support clinical application of cellular, fracture management. However, if the rate of progress seen
growth factor or cell signalling molecules in improving the in the last 50 years continues, then many of these will be
rate or quality of fracture healing [42]. However, in com- met and current limitations will be confined to historical
mon with other regenerative disciplines, targeted nuclear perspective.
manipulation appears rational and holds promise.
R
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10 Introduction
academic institution in North America. Vet. Surg. 47: bone morphologic changes associated with catastrophic
1052–1065. proximal sesamoid bone fracture in Thoroughbred
90 Onions, C.T. (1973). The Shorter Oxford English racehorses? Equine Vet. J. 51: 123–130.
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lesions in the long bones of 10 horses scintigraphic and Med. Sci. 81: 593–597.
radiographic features. Equine Vet. J. 30: 35–42. 103 Spriet, M., Espinosa-Mur, P., Cissell, D.D. et al. (2019).
92 Campbell, M.L.H. (2013). When does use become abuse F-sodium fluoride positron emission tomography of the
in equestrian sport? Equine Vet. Educ. 25: 489–492. racing Thoroughbred fetlock: validation and comparison
93 Riggs, C.M. (2012). Chronicle of a death foretold. Equine with other imaging modalities in nine horses. Equine
Vet. J. 44: 631–632. Vet. J. 51: 375–383.
94 Symons, J.E., Hawkins, D.A., Fyhrie, D.P. et al. (2017). 104 Denoix, J.M. and Coudry, V. (2020). Clinical insights:
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95 Colgate, V.A., Group, F., and Marr, C.M. (2020). 105 Rizzone, K.H., Ackerman, K.E., Roos, K.G. et al. (2017).
Science-in-brief: risk assessment for reducing injuries of The epidemiology of stress fractures in collegiate
the fetlock bones in Thoroughbred racehorses. Equine student-athletes, 2004-2005 through 2013-2014
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96 Clegg, P.D. (2011). Review article: HBLB’S advances in 106 Gasiorowski, J.C., Richardson, D.W., Boston, R.C., and
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97 Currey, J.D., Foreman, J., Laketić, I. et al. (1997). Effects 107 Field, J.R., Hearn, T.C., and Arighi, M. (1993).
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11
Bone Structure and Function

C.M. Riggs1 and A.E. Goodship2
1
The Hong Kong Jockey Club, Sha Tin, Hong Kong
2
Royal Veterinary College, London, UK
I ntroduction The cells of individual bones express a genetic blueprint

that governs their overall shape at an early stage of embryo-
The skeleton is an extraordinary organ that has evolved to genesis. For instance, the developing femur of an embry-
optimize its structure to functional demands. The strength onic mouse transplanted in utero to the spleen still goes on
and rigidity of its individual components, bones, maintain to form a bone that with minimal mechanical environment
the body’’s form, provide a series of interconnected levers is still recognizable as a basic femur (Figure 2.1)
upon which forces generated by muscles can act to effect (John Chalmers, personal communication). The macro-
movement and locomotion and afford physical protection scopic architecture of each bone has evolved to meet func-
to vital internal organs. In addition, it serves as a reservoir tional demands that vary between different species and
for essential minerals, houses haematopoietic tissue, con- different anatomical locations in the same species. However,
tributes to acid–base balance, serves as a fat repository, long bones, which make up the majority of the appendicu-
sequesters certain toxins (heavy metals) from the circulation lar skeleton, share a fundamentally similar blueprint. The
and acts as an endocrine organ with released hormones majority of bones comprise a tubular shaft (the diaphysis),
having systemic effects. Furthermore, it is dynamic. Some optimized to use minimal mass for the greatest strength in
of its component parts undergo structural adaptation in resisting bending and twisting. The diaphysis flares at each
response to the variation in the loads they experience end, the metaphyses, to form a more bulbous terminus, the
throughout life, while others, principally those evolved for epiphysis, with broad, sculptured end surfaces that articu-
primary protective functions such as the skull, maintain a late with adjacent bones. The epiphyses are optimized, to
similar architecture irrespective of changes in load. The resist compressive loading and reducing pressure and
architecture of bone from molecular composition to shape impact loading on articular surfaces. The cortex of the dia-
and size of whole bones is maintained by cellular mecha- physis and outer shell of the epiphysis is formed of cortical
nisms that effect modelling, remodelling and repair on an bone that appears solid and has an apparent density (vol-
ongoing basis and have the capacity to form large segments ume fraction [Vf ] = volume of bone matrix per unit volume
of new tissue to fill defects created by injury. of tissue) of approximately 90%. The medulla of the diaphy-
This chapter focuses on the features of a bone that are sis is filled with marrow that is comprised predominantly of
essential to its mechanical functions. adipocytes. The cortex steadily thins as it flares towards the
epiphysis while the medulla becomes filled with cancellous
(trabecular) bone, which becomes progressively more dense
B
one Architecture (Vf ) towards the articular surface. The cortical shell may be
less than a millimetre thick below articular cartilage and is
The skeleton is comprised of a set of bones that together directly supported by the underlying cancellous bone across
form the axial skeleton, including the skull, ossicles, hyoid, the entire joint surface. The trabeculae within the epiphysis
vertebrae, ribs and sacrum and the appendicular skeleton, are generally arranged in arrays that transmit load from the
which includes the limb bones. joint surface to the cortex as it thickens towards the

12 Bone Structure and Function
(a) Osteoblasts synthesize the organic component of bone

matrix, which they secrete as osteoid. They also play an
active role in the mineralization of osteoid and moderate the
extent to which it mineralizes. Osteoblasts are derived from
the mesenchymal cell line. Undifferentiated mesenchymal
cells are directed down the osteoprogenitor line under the
influence of fibroblast growth factor, microRNAs and con-
(b) nexin, which stimulate the transcription of bone morphoge-
netic proteins (BMPs) and expression of the Wingless Wnt
signalling pathway. Cells differentiate through stages during
which they proliferate before developing into mature osteo-
blasts that express genes for various proteins, such as
alkaline phosphatase (ALP), osteocalcin (OCN), bone sialo-
protein (BSP) and collagen. Fully differentiated osteoblasts
are relatively large cuboidal cells that form a single layer on
bone surfaces. They have well-developed rough endoplas-
mic reticulum and Golgi apparatus, consistent with their
Figure 2.1 Normal femur of an embryonic mouse (a) and one
that was transplanted in utero to the spleen (b).
role in matrix synthesis. Osteoid is composed predominantly
of type I collagen with traces of type II, V and other minor
structural collagens, which are embedded in a ground sub-
iaphysis. Spaces between the trabeculae are filled with
d
stance of water and a wide range of non-collagenous
blood and lymphatic vessels, nerve fibres, adipocytes and
proteins including proteoglycans and glycosylated proteins.
haematopoietic tissue.
The majority of osteoblasts undergo apoptosis (programmed
Cuboidal bones of the carpus and tarsus, the distal pha-
cell death) after they have made their contribution to new
lanx, navicular bone, proximal sesamoid bones and patella,
bone formation, but a significant proportion remain to form
share a different structural template, which consists of a
bone surface lining cells, covering the newly formed sur-
thin cortical shell that encloses a network of cancellous
faces, or become embedded in the matrix they generate to
bone throughout the medulla. The relative density of can-
form a dense network of residual osteocytes.
cellous bone varies between different regions of individual
Bone surface lining cells reflect a quiescent form of oste-
bones depending on their loading history [1–3].
oblasts. They form the cellular layer of periosteum and
A soft tissue layer, the periosteum, covers the majority of
endosteum and are capable of de-differentiating back into
the outer surface of most bones. Periosteum is absent where
osteoblasts. They play an important role in ‘containing’
articular cartilage and ligamentous insertions are present. The
(forming a membrane around) cellular activity during
periosteum is comprised of two layers: an outer fibrous sheath
bone remodelling and may, under certain circumstances,
and an inner, cellular sheet frequently referred to as the cam-
protect bone against osteoclastic resorption.
bium layer that is highly vascularized. The cambium layer is
Osteocytes embedded in bone matrix reside within small
abundant in osteoprogenitor cells, which, combined with its
cavities called lacunae. They are densely and evenly distrib-
rich blood supply, make it important in fracture healing. The
uted throughout healthy lamellar bone and constitute the
inner (medullary or endosteal) surface of a bone is lined with
vast majority of the cell population. Bone can remain physi-
endosteum, which is comprised of a thin membrane, only
cally intact and serve a functional mechanical role without
10–40 μm thick, consisting of connective tissue and a few lay-
viable osteocytes although it is in effect necrotic. Osteocytes
ers of cells. The endosteum also contains osteoprogenitor cells
have numerous physiological functions, one of which is to
and has an important function in fracture healing.
moderate matrix mineral content: necrotic bone can become
The medulla of long bones is filled with haematopoietic
hypermineralized and thus relatively brittle. Each cell has
tissue and fat. The proportion occupied by either tissue
numerous long, slender cytoplasmic projections that grow
shifts towards fat in older animals. It contains osteogenic
from the cell membrane during its transition from osteoblast
stem cells, and the fat may play an important role in bone
to osteocyte. These lie within minute canals called canali-
biomechanics and absorption of impact loads [4].
culi. Projections of adjacent osteocytes and smaller projec-
tions from bone lining cells and osteoblasts on bone surfaces
Cellular Components
contact each other and communicate via gap junctions. This
Healthy bone is highly cellular with four dedicated cell types effectively creates an interconnected syncytium throughout
responsible for different functions associated with its forma- the bone. A small volume of extracellular fluid is contained
tion, maintenance, functional adaptation and homeostasis. within the lacunae and canaliculi, and the flow of this fluid
Bone Architectur 13
or the small electrical current it generates may be integral to e.g. the third metacarpal bone, have effectively reached
physiological mechanisms for the detection of mechanical their adult length by the time of parturition and retain little
strain. There is increasing evidence that osteocytes play the growth cartilage in weight-bearing locations (Figure 2.2).
pivotal role in bone metabolism and homeostasis, through Growth cartilage at the physis and around the epiphysis is
the detection of deformation and microdamage and initia- eventually replaced by bone, at which stage the skeleton is
tion and modulation of the cellular response to these events. considered to be mature. In the horse, this occurs relatively
Osteoclasts are large multinucleate cells that resorb early in bones of the distal limb (e.g. 6 months in the third
bone. Osteoclasts share a haematopoietic stem-cell precur- metacarpal bone) and considerably later in bones of the
sor with cells of the monocyte/macrophage family. Stem proximal limb (e.g. 24–36 months in the humerus). The
cells are recruited from the circulation and undergo differ- previous location of the physis remains visible grossly and
entiation into pre-osteoclasts and, subsequently, active radiologically for many years as a roughening on the peri-
osteoclasts under the influence of several factors, including osteal surface of the bone and as a transverse linear radi-
macrophage colony-stimulating factor (M-CSF) and recep- opacity termed the ‘physeal scar’.
tor activator of nuclear factor kappa-B ligand (RANKL), Cuboidal bones of the carpus and tarsus ossify in the last
which are secreted by osteoprogenitor cells, osteoblasts two months of gestation. In normal foals, over 80% of the
and osteocytes [5]. During the activation of bone resorp- cartilage anlage has been replaced by bone at the time of
tion, bone lining cells first lift off the bone surface, thereby birth [6]. The extent of ossification may be significantly
allowing osteoclasts access to the matrix. The osteoclast less in foals born prematurely or those that are dysmature
membrane seals to the bone surface around the margin of or suffering hypothyroidism. The majority of cuboidal
its contact, and the membrane within the enclosed area bones ossify from a single centre and grow centrifugally.
develops a ruffled structure. Osteoclasts secrete protons However, the third tarsal bone has two centres located in
and enzymes, such as tartrate-resistant acid phosphatase the body of the bone and dorsally. The point where the two
(TRAP), cathepsin K and matrix metalloproteinase-9 ossifying fronts meet represents a line of potential weak-
(MMP-9) into the sealed compartment to dissolve the min- ness in foals in which the ossification process is retarded at
eral and digest the organic component. Resorption of the birth.
matrix creates a pit in the bone surface, which is referred to
as a Howship’’s lacuna.
Bone Formation
Long bones of the appendicular skeleton form in the
embryo as cartilage rudiments that are invaded by blood
vessels and bone cells. Centres of ossification form within
the anlage and progressively replace the cartilage model.
Ossification usually begins at foci in the mid-diaphysis and
then the epiphyses. As a rigid tissue, bone can only grow or
change shape through appositional growth, involving the
addition or resorption of tissue at existing surfaces. The
presence of articular cartilage at the ends of long bones
prevents longitudinal growth, as new bone cannot be
deposited at these surfaces. Conversely, cartilage expands
by interstitial growth. Retention of a transverse section of
growth cartilage, the physis, at a point where the fronts of
diaphyseal and epiphyseal ossification centres meet per-
mits the continued growth of the bone along its long axis.
In addition, a layer of growth cartilage is retained between
the epiphyseal centre of ossification and overlying articular
cartilage to facilitate radial expansion of the epiphysis dur-
ing growth. By the time of birth, functional loading neces-
sitates that the proportion of cartilage remaining in the
weight-bearing locations of the skeleton is relatively low.
Figure 2.2 Third metatarsal bones from a neonatal Thoroughbred
In precocial animals that undergo locomotion immediately foal (left) and that of adult Thoroughbred. Note the similar length
after birth, such as the horse, bones of the distal limb, of the two bones.
Vascular Supply bone in Volkmann’s canals, which are generally orientated

perpendicular to the long axis of the bone. These branch at
Both cortical and cancellous bone are highly vascularized: it
right angles to give rise to smaller vessels that are contained
is estimated that around 10% of cardiac output is directed to
with Haversian canals that lie in the centre of osteons and
bone [7]. Arterial supply is through three major sources: (i)
are usually parallel to the long axis of the bone. Osteons, and
a nutrient artery that enters the medulla through a foramen
hence vessels within them, branch regularly, thereby pro-
in the diaphysis, (ii) periosteal arterioles that directly pene-
viding an intricate network of vessels perfusing cortical
trate the cortex throughout the diaphysis and (iii) metaphy-
bone: osteocytes in healthy bone reside within 300 μm of a
seal arteries that typically penetrate the bone at or adjacent
capillary. The anastomosing network between medullary
to the point of insertion of the joint capsule (Figure 2.3).
and periosteal blood supplies gives cortical bone a dual
Dense cell populations within cortical bone require sub-
blood supply. This is important following injury or surgery,
stantial blood supply to sustain high demands for oxygen
when one or other of the supplies may be disrupted.
and nutrients and to remove waste products associated with
Disruption to blood supply and the subsequent effects on
normal metabolism and homeostatic processes. Cortical
oxygen tension have a profound effect on bone cell activity.
bone is perfused by a combination of arterial blood supplied
Hypoxia has been shown in vitro to increase the number,
from the main nutrient artery in addition to smaller arteries
size and bone-resorbing activity of osteoclasts and inhibit
in the periosteum. The nutrient artery ramifies within the
the bone-forming activity of osteoblasts [7]. Conversely,
medulla and anastomoses with metaphyseal vessels. Under
when oxygen tension is above normal, osteoclast function
normal conditions, the medullary circulation provides ves-
is suppressed and osteoblast activity increased.
sels that perfuse the inner 80% of the cortex. Arterioles that
originate from periosteal vessels supply the outer shell of the
Innervation
cortex although they have the capacity to supply a much
greater proportion of the bone following injury. Blood flow is Bone is densely innervated, although the precise nature and
predominantly centrifugal. Capillaries pass through cortical role of the nervous system in bone function is still being
Endosteal
vessels
Epiphysis
Metaphysis
Diaphysis
Periosteal vessels
Tendon
Muscular vessels
Figure 2.3 Diagrammatic illustration of blood supply to a long bone of the appendicular skeleton. Arterial supply has three sources:
(i) nutrient artery, which passes through the cortex into the medulla in the mid-diaphyseal region via a nutrient foramen, (ii) periosteal
arteries, which supply the outer circumference of the cortex, and (iii) metaphyseal vessels, which supply the epiphyseal and
metaphyseal regions. All three networks share anastomoses.
Bone Architectur 15
unravelled. The periosteum is richly supplied with sensory

fibres and both sensory and sympathetic fibres are present
on the surface of trabeculae in epiphyseal and metaphyseal
bone. In cortical bone, nerve fibres are located within
Haversian and Volkmann’s canals. Direct contact between
nerve fibres and osteocytes has been demonstrated.
The morphology and molecular phenotype of sensory
neurons that innervate periosteum and the medullary cav-
ity is consistent with a role in nociception. However, the
precise mechanisms behind sensation of pain derived from
bone are poorly understood [8].
There is increasing evidence that the nervous system plays
a role in controlling the activity of bone cells and their
homeostatic functions [9]. The mechanisms are not under- Figure 2.4 Microradiograph of a 100 μm thick, undecalcified
stood but may relate to direct effects of signalling molecules section of cortical bone from the proximal diaphysis of the
humerus of a two-year-old Thoroughbred racehorse that had
in nerve fibres through receptors expressed by bone cells, suffered a catastrophic fracture. Different grey levels reflect
indirectly via the effects of neuromediators on bone blood mineral density of the matrix. Note lightly mineralized
flow or through regulation of cytokines expressed by cells of periosteal new bone to the right (dark grey), moderately
the immune system. There is some evidence that the nerv- mineralized ‘young’ secondary osteons (variable densities of
grey) and most densely mineralized primary bone (which
ous system may play a central role in the adaptation of bone appears almost white).
to changes in its mechanical environment, mediated by the
dense network of periosteal and endosteal nerve fibres.
Conversely, collagen fibres in lamellar bone are laid
down in a highly organized fashion around a plexus of
blood vessels. Organic matrix is deposited as thin sheets, or
Microstructure
lamellae, each approximately 5 μm thick. The orientation
Bone matrix is a two-phase composite consisting of an of collagen fibres is largely parallel within each lamella
organic component, which is synthesized and secreted by and may be the same or vary between successive lamellae.
osteoblasts, and mineral. The matrix of lamellar bone makes Osteocytes are present in lower density than woven bone,
up more than 90% of its volume, the rest being cells, cell pro- but are more evenly distributed and are of consistent size
cesses and blood vessels. and orientation. Lamellar bone may be deposited around
The matrix undergoes mineralization as soon as it is secreted part or the entire outer circumference and inner endosteal
and reaches 70–80% of its final mineral density (around 65% surface of a bone (circumferential lamellar bone) or may
dry weight) within approximately three weeks. Remaining form as concentric lamellae within the small tubular subu-
water within the matrix is then progressively substituted by nits of osteons (Figure 2.5). Osteons are formed during the
mineral over the ensuing months or years, resulting in the primary growth of bone around a small central Haversian
steady increase in mineral density of the bone as it ages. This is canal that contains neurovascular components. Lamellar
easily appreciated on microradiographs in which the relative bone has superior mechanical properties to woven bone
age of different areas of the cross-section of the bone can be but is formed more slowly.
determined by their radiopacity (Figure 2.4). Regulation of A combination of these different matrix organizations is
mineral volume fraction varies between and within bones and found in a microstructure that is common in long bones of
influences material properties such as stiffness and toughness, the distal limbs of horses and other animals that have
which have important functional consequences. evolved to ambulate soon after birth. Woven bone is depos-
The principal structural component of the organic phase ited at the periosteal surface to form waves or folds that
is type I collagen whose fibres are configured to form one grow out radially several hundred micrometres before
of several different microstructures. branching out circumferentially. Adjacent folds meet to
Woven bone describes a microstructure that is associated form bridges or domes that enclose a small volume of peri-
with relatively loosely packed, large diameter collagen fibres osteal soft tissue, which usually includes several blood
that are orientated haphazardly within the matrix. It has a vessels. Lamellar bone then forms on the interior surface
high density of osteocytes, which vary in size, orientation and of the woven bone, replacing the soft tissue, to form pri-
distribution. It mineralizes rapidly although relatively une- mary osteons that are elongated around the circumference
venly. Woven bone is formed relatively quickly and is usually of the bone and which often contain multiple vessels and
present in bone undergoing rapid expansion (e.g. embryos associated canals (Figure 2.6). This microstructure is
and neonates) or in fracture callus. It is relatively weak. referred to as laminar or plexiform bone and it reflects an
Figure 2.5 Composite photomicrograph of a transverse section through the lateral margin of the cortex from the mid-diaphysis of
the third metacarpal bone from a two-year-old Thoroughbred racehorse. Fluorescent dyes administered systemically to the horse at
different times before it died demarcate the mineralization front at the time of administration. Several different bone microstructures
are present: (i) circumferential lamellar bone (top left), (ii) Plexiform bone and primary osteons (top right) and (iii) secondary osteons
at different stages of formation (bottom half of image). Periosteal surface to the top and palmar to the left. Field width is
approximately 10 mm.
Figure 2.7 The geometric properties of bone can be modified

through the coordinated action of osteoblasts and osteoclasts,
which deposit (red areas in the diagram) and resorb (grey areas)
bone at existing surfaces to alter the overall geometry of the
bone. This process is called modelling.
Figure 2.6 Diagrammatic illustration of plexiform bone, based on mass around the circumference of the shaft (Figure 2.7).
the histological appearance of a transverse section through the Both processes are termed modelling and occur during
cortex of the third metacarpal bone from a neonatal Thoroughbred.
growth and as a response to changes in the bone’s mechan-
Plexiform bone develops around a woven bone template (light
shade). Buds of woven bone (dark shade) grow radially outwards for ical environment.
approximately 300 μm from the periosteal surface before Groups of osteoclasts may be recruited to foci on the sur-
expanding circumferentially to join with neighbouring radial struts, face of or within the bone matrix and stimulated to resorb
thereby forming a three-dimensional mesh of successive layers of
tissue, either as surface layers or as tunnels through the
bone linked by radial struts. The spaces that remain within the
network fill more slowly with lamellar bone to form primary matrix. In the latter case, osteoclasts cut tubes, ‘resorption
osteons. Source: Riggs and Evans [10]. Reproduced with permission canals’ approximately 250 μm in diameter, through the
of John Wiley & Sons. bone. The canals are typically orientated parallel to the
long axis of the bone, extend over several millimetres and
evolutionary compromise whereby the rate of bone apposi- may branch several times (Figure 2.8). Under normal cir-
tion is accelerated with little detriment to material cumstances, osteoclasts and osteoblasts work in synchrony,
properties [11]. the latter following the resorptive front, forming fresh
Accretion of new bone at periosteal and/or endosteal matrix on the recently ‘cut’ surface. Osteoid is deposited as
surfaces can increase the thickness, overall diameter and sheets, lamellae, in which collagen fibres are aligned in
mass of the bone. Alternatively, accretion at one surface parallel (Figure 2.5). Successive lamellae, between which
and simultaneous resorption at another can alter the geo- the alignment of collagen fibres relative to the long axis of
metric properties of the bone, increasing its overall diame- the bone may vary, form layers on the surface of bone or
ter for a similar mass of tissue or redistributing a similar around the inner circumference of the resorption canals
Bone Architectur 17
relate to mineral homeostasis: resorption of bone provides a

rapid supply of calcium ions from the skeleton to meet
systemic metabolic requirements. More recently, focus has
shifted to the role of remodelling in maintaining the struc-
tural integrity of bone as a load-bearing tissue: it is a mecha-
nism whereby damaged matrix can be removed and replaced
with fresh, healthy tissue [12, 13]. A large proportion of
researchers interested in the effects of loading on bone sup-
port the concept of microdamage as a common phenome-
non. Minute cracks (micrometres in length) in bone matrix,
regularly illustrated in publications and frequently associated
with previous loading, are purported to represent localized
damage as a consequence of loading [14, 15]. In addition,
there is growing support for the hypothesis that damage to
the matrix induces apoptosis of surrounding osteocytes,
which in turn acts as a stimulus for localized recruitment and
activation of osteoclasts [16]. This provides an elegant physi-
ological mechanism whereby remodelling is specifically
targeted to repair damage at varying scales of magnitude:
bone that contains cracks is removed and replaced with
healthy tissue. However, this hypothesis is not universally
accepted and some argue that, in most cases, ‘microdamage’
is no more than an artefact created by the techniques used to
study it and that there is no evidence that remodelling is
Figure 2.8 Diagrammatic representation of an isolated directly coupled to damage [17]. Boyde has provided evidence
secondary osteon complex in longitudinal (left) and transverse
sections, illustrating its branching course and different stages of from clinical material from a number of species, including
development. The branch to the right illustrates a group of the horse, to illustrate that when they do occur, microcracks
mobilized osteoclasts that are resorbing bone in a coordinated can be effectively managed physiologically and mechanically
manner to form a tunnel. Osteoblasts follow secrete successive through alternative means that include bonding cracks by
layers of osteoid on the walls of the tunnel, progressively filling
it in to form a secondary osteon. Source: Riggs and Evans [10]. filling them with mineral-rich matrix and ‘bandaging’ tra-
Reproduced with permission of John Wiley & Sons. beculae with surface new bone [17]. It is not inconceivable
that both mechanisms of repair occur, the balance being
determined by the loading environment.
until only a small central hole that contains blood vessels Remodelling also provides a mechanism through which
and lymphatics (the Haversian canal) remains. The result- bone can be ‘fine-tuned’ so that its microstructure, as well
ant structure is called a secondary osteon. This process, as macrostructure, is modified to best match prevailing
whereby osteoclasts are activated and bone is resorbed and mechanical demands: a form of ‘microadaptation’. For
subsequently replaced at the same location with fresh tis- instance, primary bone in the caudal cortex of the equine
sue, is called remodelling, and the functional unit of cells radius, which contains predominantly longitudinally ori-
that performs it is referred to as a basic multicellular unit entated collagen fibres, is largely remodelled within the
(BMU). The deepest margin of resorption, where new bone first two to three years of life and replaced with secondary
abuts pre-existing tissue, is called the reversal line and is osteons containing predominantly transversely orientated
demarcated by a line of cement, a thin layer of amorphous fibres, which are more suited to resist the compressive
matrix that joins fresh bone to old. This is an important strains that predominate at this location [18].
structural feature in relation to a bone’s ability to resist
fatigue as it acts to ‘capture’ small cracks that may develop
Ultrastructure
within bone and so prevent their further extension.
Remodelled bone, containing a high proportion of second- Bone matrix is a composite of organic and inorganic com-
ary osteons, is typically weaker and less stiff than the primary ponents. The primary structural protein, type I collagen, is
tissue that it replaced. This begs the question of the func- common to many other connective tissues. Collagen
tional (evolutionary) value of remodelling. For many years, makes a significant contribution to the toughness and
the primary physiological role of remodelling was thought to strength of bone. The process of mineralization and
c omplex interaction of mineral crystals and collagen composed of around 1000 amino acids, are transcribed and
within its matrix give bone its unique composite strength bind intracellularly to form a triple helix with N-(amino)-and
and stiffness. C-(carboxy)-terminal non-helical propeptides on the end of
each procollagen chain. Procollagen is secreted via secretory
Organic Component granules into the extracellular space, where it undergoes fur-
Type I collagen is present in bone in the form of relatively long ther modification that includes cleavage of the N- and
fibres. The manner in which these fibres are deposited, their C-terminal propeptides by procollagen peptidase to form tro-
orientation relative to each other and their pattern of miner- pocollagen. The resultant molecule is approximately 300 nm in
alization determine the bone’s microstructure and material length and is relatively rigid. Excision of the terminal propep-
properties. The relatively small amounts of type III and V col- tides allows the molecules to polymerize into fibrils, which are
lagens that are also present in the organic matrix modulate stabilized by covalent cross-links between hydroxylysine and
the structure of the fibrils formed by type I collagen. lysine residues. Chains of tropocollagen molecules pack
Approximately 10% of osteoid consists of non-collagenous together side by side to form fibrils. Adjacent molecules are
proteins, including osteocalcin, osteonectin, osteopontin, precisely staggered by roughly quarter of their length (67 nm)
fibronectin and bone sialoprotein II, BMPs, growth factors relative to each other, and collinear molecules are separated by
and an array of proteoglycans and glycosaminoglycans [19]. a gap of approximately 40 nm. Consequently, there is a peri-
These molecules serve important functions in cell commu- odic pattern with zones in the fibrils where there are gaps
nication, which influence formation and resorption, in within the cross-section and areas where there are not
determining bonds within and between collagen fibres, (Figure 2.9). This produces a striated effect that can be seen in
which influence the spatial organization of the extracellular electron micrographs of stained collagen fibrils. Each gap in
matrix, and in the mineralization process. the fibril is surrounded by around six tropocollagen molecules
Type I collagen is formed through a combination of intra- and forms a cavity approximately 1.4 nm wide and 40 nm long.
and extracellular processes. Three polypeptide chains, each Although it is easier to visualize the structure as linear arrays
Collagen
300 nm
Molecule
15 nm
α2 helix
α1 helices
Collagen
Microfibrils
cross-links
Collagen
Fibrils
D-spacing: ~67 nm
80 – 100 nm
Multiple microns
Figure 2.9 Model of hierarchical structure of collagen fibrils. Three helical (two α1 and one α2) collagen molecules form a triple helix
300 nm long; these are assembled into a fibril containing a staggered array of helices with 40 nm gap between C and N termini of
collinear helices. Gaps are aligned across the width of fibrils. Alongside each 40 nm wide ‘gap zone’ (white) is a zone 27 nm wide in
which no gaps exist. Source: Schwarcz et al. [20]. Licensed under CC BY 4.0.
Bone Architectur 19
of tropocollagen, there is evidence that the molecules inside (a) (b)

the fibril are actually twisted into a complex 3D structure [21]. 3 3
There is evidence that difference in the quality of the 2 2
collagenous matrix accounts for some of the variation in 1 1
bone strength that is widely noted. Collagen molecules
undergo a large number of complex post-translational
modifications, both within and outside the cell, which
Collagen
require action of several different enzymatic and non- triple helix
enzymatic processes. These are carefully orchestrated and
when disrupted can have profound effects on the struc-
tural properties of bone. Furthermore, racemization and
isomerization reactions are age-related changes that
Mineral in
occur spontaneously and result in conformational modifi- gap zone
cations within the molecules that alter their physical
properties.
Gap zone
Inorganic Component
The principal inorganic components of bone are phosphate
and calcium ions, which nucleate to form apatite crystals
(nanocrystals), most commonly hydroxyapatite represented
by the chemical formula Ca10(PO4)6(OH)2. Significant
amounts of bicarbonate, sodium, potassium, citrate, mag- Figure 2.10 Schematic diagram showing progressive steps in
nesium, carbonate, fluorite, zinc, barium, and strontium are the mineralization of collagen molecules in a single fibril,
assuming that most mineral in bone is intrafibrillar. (a) Early
also present. Infrared spectrometry shows the presence of
mineralization in gap zones; (b) further mineralization extends
different apatite molecules and carbonate substituting for into adjacent overlap zones. Source: Landis et al. [23].
both PO4 and OH in many cases [22]. Reproduced with permission of Elsevier.
The precise form that the inorganic phase takes and its
location relative to the collagen fibrils are poorly under-
stood. Whether mineral forms within fibrils, outside them Mineralization
or a combination of the two remains contentious. There is
evidence that mineral is initially deposited in the gaps Mineralization of osteoid involves an interaction of processes
within fibrils (between collinear collagen molecules) by a that either promote or inhibit deposition. Initial nucleation
process of heterogeneous nucleation – a surface-catalyzed of mineral may be enhanced by the formation or exposure of
or assisted nucleation process. However, there are those nucleators and by the removal or modification of inhibitors.
who argue that the data and the structural restraints However, details of the mechanisms involved and the loca-
imposed by collagen within the fibrils do not support or per- tion in, on or around the fibrils remain subjects of contro-
mit such an arrangement. Similarly, the morphology of the versy. Many believe that specific atomic groups located in the
crystals is not universally accepted. There is evidence that gap zones of collagen fibrils are arranged in such a way as to
mineral is deposited as needle-like crystals, whereas others induce heterogeneous nucleation of hydroxyapatite [24].
argue that it is really in the form of flakes or plates, which These nuclei subsequently expand by addition of further
appear as needles when viewed from side on. There is gen- inorganic ions, so giving rise to crystals. Certain factors,
eral agreement though that the crystals are anisotropic: principally non-collagenous proteins, have been shown to
they are elongated along their crystallographic c-axis, which promote or inhibit mineralization. For example, phospho-
is aligned parallel with the collagen fibrils. Schwarcz proteins, such as bone sialoprotein, bind calcium and thereby
et al. [20] have recently proposed a model whereby mineral act as mineral nucleators. Conversely, proteoglycans may
that is not in the form of apatite initially forms in the gap inhibit the process by masking critical zones or occupying
zones of fibrils. It then extends out into the extra-fibrillar essential spaces within fibrils, thereby reducing diffusion,
space where apatite crystals form sheets or lamellae that chemical interaction and sequestration of calcium ions.
partially wrap around the fibrils (Figure 2.10). Several min- The role of matrix vesicles as initiators is also contentious.
eral lamellae may form around a single fibril, and lamellae These small (20–200 nm) spherical bodies are derived from
surrounding one fibril and those of adjacent fibrils bind osteoblasts. They are found in osteoid and are often associated
firmly together through strong bonds. with small crystals of calcium phosphate. They are bound by
a lipid membrane, which has a composition that is different to Tissue (Material) Properties
that of the parent cell. They are enriched in tissue non-specific
When a load is applied to a material, it will deform. The load
alkaline phosphatase (TNAP), nucleotide pyrophosphatase
can be standardized per unit area, termed stress, and deforma-
phosphodiesterase annexins among other factors that are
tion quantified as change in length in relation to its original
known to promote mineral deposition. Calcium ions are also
length, termed strain. The relationship between stress and
concentrated within the vesicles. While it is generally accepted
strain reflects the stiffness, or Young’s modulus, of the mate-
that matrix vesicles play a role in initiating bone mineraliza-
rial (Figure 2.11). A material that deforms little as the stress is
tion, its exact nature and extent is controversial.
increased has a relatively high Young’s modulus and is
In most healthy adult bones, the mineral fraction (propor-
termed stiff, whereas one that has a low modulus is termed
tion of dry weight accounted for by mineral) is between 60
compliant or flexible. Many materials, including bone, behave
and 70%. Fractions in this range engender material proper-
in an elastic manner, deforming proportionally in relation to
ties that provide an optimal compromise between strength,
stress and recoiling to their original shape when the stress is
stiffness and toughness. Osteoblasts and osteocytes limit the
removed (Figure 2.11). However, as the magnitudes of stress,
ultimate extent of matrix mineralization through the adjust-
and hence strain, rise, the distracting forces acting within the
ment of extracellular ion concentrations [25, 26]. Loss of
material increase. If the stress is so great as to strain the mate-
these cells, for instance in osteonecrosis, is associated with
rial to a point where the internal forces exceed a critical limit,
hypermineralization, which can have profound effects on
it causes damage. This is referred to as the yield point, and if
material properties causing bone to become brittle.
this is exceeded the structure will undergo plastic deforma-
tion and remain permanently deformed when the load is
removed (Figure 2.12). If the stress is increased beyond the
Function yield point, then the material will continue to strain to a point
where it fails completely, termed its ultimate strain
Mineralization of bone matrix makes it appropriately stiff
(Figure 2.13). The stress applied to reach this point defines the
and strong to fulfil its primary roles. The physical nature of
ultimate strength of the material. The degree of strain that a
its primary functions means that the mechanical properties
material can undergo between starting to yield and failure
of bone as a material (tissue) and structure (whole bone) are
largely determines its energy absorbing capacity. A material
critical. A vast body of literature documents the mechanical
that fails quickly after reaching its yield point absorbs little
properties of bone from many different species. The degree
energy and is termed brittle. Conversely, one that undergoes
of matrix mineralization, variation in matrix organization
significant plastic deformation absorbs relatively more energy
(microstructure), porosity and orientation of collagen fibres
and is termed tough (Figure 2.14).
within the matrix all significantly influence the strength,
Bone is a complex material, and there are many factors
stiffness and toughness of bone. A brief review of mechani-
that affect its mechanical properties. It is a composite made
cal terminology follows to assist readers less familiar with
of two different phases: collagen fibres and mineral crystals.
these terms to understand the concepts that follow.
The organic phase is relatively compliant, while the mineral
Stress
X
y
Elastic Modulus
Object deformed within its elastic limit

(strain = x/y × 100)
Strain
Figure 2.11 Graphical and schematic illustrations of the relationship between stress imposed on an object by a tensile load and
deformation of the object.
Functio 21
Yield point
Stress
Strain
Permanent deformation Object deformed beyond its
elastic limit – plastic deformation
deformation of the object beyond its yield point.
Ultimate strength
Ultimate
stress
Stress
Strain Ultimate
strain
deformation of the object beyond its ultimate strength.
endows rigidity. Variation in mineral content has a pro- vibrations depends on the mass of the atoms at either end of
found effect on the modulus and stiffness of bone but is less the bond. For example, an H−H bond vibrates at a higher
associated with strength [27]. Conversely, the organic com- frequency than an O−O bond. The frequency of vibration is
ponent of bone is more related to its strength. The impact of characteristic of specific chemical bonds and can be used to
this is apparent from studies that used radiation to disrupt analyze the chemistry of samples.
collagen in bone samples. Bone density measurements Laser light of a specific wavelength, in bone 830 nm, can be
remained the same with varying levels of collagen damage, used to ‘excite’ molecules, i.e. heat them up. The laser light
but bone strength varied significantly in proportion to the travelling through the matrix and hitting a molecule is scat-
level of collagen damage (Figure 2.15) [28]. tered. Most of it is unchanged, but some loses energy when
Recently, there has been increasing focus of attention on exciting chemical bonds and changes colour – this is called
subtle variation in the organic phase of bone and its impact on Raman scattering. One million photons of light are required
the tissue’s material properties. The Raman spectral signature to obtain one Raman photon. Plotting the intensity of the scat-
of bone provides information on the chemistry of both the tered light (or energy absorbed by the sample) against the col-
mineral and organic phases of bone matrix, which in turn are our of scattered light gives a Raman spectrum, which shows
related to its material properties. Bonds within molecules of a which bonds are vibrating within the molecules of the matrix.
material vibrate, just like a stretching spring: this form of The spectral signatures of bones with matrices of different
molecular motion is manifest as heat. The frequency of these composition in both healthy individuals and subjects with or
which makes it suitable for transmission of sound but brittle,

(ii) bone in the antler of deer has a low level of minerali-
zation, making it tough and suitable for fighting, and (iii)
locomotor long bones have mid-range mineralization [29].
Raman spectroscopy is sufficiently sensitive and precise
to demonstrate subtle differences in matrix chemical com-
position within an individual bone. For instance, in a
Stress weight-bearing bone of the appendicular skeleton, such as
the third metacarpal of the horse, the material properties
are uniquely and site specifically adapted at the molecular
level to optimize function. The mid-diaphysis is most
highly mineralized, which results in maximum stiffness to
resist bending forces yet allows flexural strains for energy
efficient locomotion. Conversely, bone matrix in the meta-
physeal and epiphyseal regions, which are loaded more in
Strain compression, has lower levels of mineralization, making
the material more compliant and so better suited to absorp-
Figure 2.14 Schematic to illustrate the effects of the tion of peak and shock loads, thereby protecting the articu-
mechanical properties of a material on its ability to absorb
lar cartilage and associated structures. The changes in
energy before failing. The dotted line represents a material that
behaves in a brittle manner whereas the red line represents a chemistry have been shown to be at the millimetre level of
tough material, which undergoes much greater plastic spatial resolution [30].
deformation before failing. The shaded areas under the graphs At a larger scale, in all except woven bone the collagen is
represent the energy absorbed to failure.
deposited in regular arrays in the form of sheets, lamellae,
in which the fibres are aligned in parallel. The orientation
Effect of radiation on bone of fibres relative to the long axis of the bone can vary
mechanical properties between lamellae and has a significant effect on the way
the bone responds to stress. The lamellae may be laid down
100
Young’s in one of several different arrangements (microstructures),
modulus which are also associated with different mechanical prop-
80 erties [10]. In young, fast growing, animals, lamellar and
Property as % of controls
woven bone are often deposited in combination to form

Bending regularly repeating layers (e.g. plexiform bone), combining
60 strength
the benefits of the rapid formation of woven bone with the
superior material properties of lamellar bone.
40 Bone contains many holes (porosities) at various differ-
ent scales, from canaliculi (sub-micrometres), through
Haversian canals (tens of micrometres) to resorption
20 Impact
Work to
energy canals (hundreds of micrometres). Holes reduce the den-
fracture
sity (Vf ) of the material, weakening it, and potentially act as
0 stress risers. However, they can also stop cracks by blunt-
None 17 kGy 30 kGy 95 kGy ing the tip of the crack if it enters the hole [31]. Remodelling
Radiation dose creates a temporary porosity between the temporal phases
Figure 2.15 Effects of progressive radiation damage to the of resorption and new bone formation, and the secondary
organic phase of bone on its overall mechanical properties. osteon that is created effectively acts as an embedded ‘fibre’
Source: Based on Currey et al. [28]. of new bone within the matrix that is only bound to the
surrounding structure by a relatively weak cement line.
suspected of having disease/degenerative conditions can be The secondary osteon contains bone that is younger and,
identified from the magnitude and width of the spectral therefore, less densely mineralized than the surrounding
peaks. For instance, differences in chemical composition of tissue. Consequently, remodelled bone is generally less
the matrix from bones with widely differing functional roles strong or stiff than primary bone, but the reduced mineral
can be identified and related to their mechanical needs, e.g. content and more ‘fibrous’ structure make it more compli-
(i) the tympanic bulla has a high mineral to collagen ratio, ant and tougher than the primary tissue [31].
Functio 23
Composite materials, for example fibreglass, often sus-

tain damage in the form of microcracks when deformed Compression
beyond their point of yield. Cracks typically form either
Tension
within the stiffer phase or at the interface between the
stiffer and more compliant phases. The formation of
increasing numbers of microcracks due to repetitive load-
ing is associated with a progressive decline in the stiffness
of the material [32]. There is substantial evidence that in Neutral axis
many cases bone behaves in a similar manner. Cyclical
loading of bone specimens at relatively high strains in vitro Figure 2.16 Eccentric compressive loading on bones of the
results in a progressive reduction in their elastic modulus, appendicular skeleton results in bending forces, with one cortex
which is associated with increase in the density of microcracks in tension and the opposite in compression. Stress magnitude
throughout the sample [33]. Similarly, experiments that increases linearly with distance from the axis about which the
object bends (the neutral axis).
result in bones being overloaded in vivo result in a rise in
the density and size of microcracks, which is demonstrable
when the bones are subsequently examined post-mortem for by differences in their geometric properties. These can
[32]. Bone is remarkably good at absorbing microdamage vary greatly, particularly in animals subject to different
without significant detriment to its mechanical properties: exercise. In galloping Thoroughbreds, strain gauges bonded
the two phases and the numerous small holes (e.g. lacunae, to the dorsal cortices of third metacarpal bones demon-
Harversian canals and secondary osteons) deflect and/or strated significant variation in the maximum extent of
‘retain’ cracks at varying scales, preventing their extension deformation (peak strain magnitude) between different
to dangerous lengths. Short cracks remain inherently sta- animals. Peak strains measured in young, exercise naive
ble, while those exceeding a critical (>100–300 μm) horses were 1.5–2 times higher than those recorded in
length [31] are able to ‘punch through’ the natural crack older animals, which had been in training for a prolonged
arrestors and grow. There is mathematical and experi- period [36]. The difference was accounted for by a signifi-
mental evidence to suggest that small microcracks may cant variation in the geometric properties of the bones
actually increase the fatigue life of bone by absorbing between the two groups [37].
strain energy and redistributing stress [34]. Indeed, the Most bones of the appendicular skeleton of quadrupeds
ability to sustain and absorb damage without a significant are loaded in axial compression due to gravity. However,
increase in risk of failure is a critical feature of bone, and the principal load is frequently applied eccentrically, result-
microcracks may not be entirely detrimental to its ing in a bending moment, which is often exaggerated by
mechanical function. the pull of musculature. Loads due to bending result in a
The material properties of bone are strain-rate depend- stress gradient across the bone, with one side loaded in
ent. Most importantly, as the rate of loading rises above a compression and the other tension (Figure 2.16). The fur-
critical threshold, bone behaves in a more brittle man- ther the mass of the structure is from its neutral axis (the
ner [35]. This may be clinically significant in areas of high axis about which it bends), the greater ‘leverage’ the mate-
impact loading, which are more common in the distal limb rial has to resist the loads and the stronger and stiffer the
of the horse. bone is in that plane. In a situation where loads are unpre-
dictable and an object may be subject to bending forces in
any plane, a hollow cylinder provides the most mechani-
Structural (Whole Bone) Properties
cally effective distribution of mass. If one plane is loaded
The degree of deformation that a structure, such as a whole more heavily and more frequently than another, then
bone, undergoes when loaded will be determined by the eccentric distribution of mass around the circumference of
magnitude and nature of the load, the geometric properties the cylinder will offer optimum resistance to the predomi-
of the structure (its mass and the distribution of that mass nant loads while also providing support in other planes
around the axis of loading) and the mechanical properties (Figure 2.17).
of the material from which it is made. Load is transmitted between bones at joints. Typically,
There is relatively little diversity in the material proper- bones flare at their ends, providing a wider surface area at
ties of cortical bone from similar bones between different the articulation and reducing stress on the load-bearing
individuals of the same species or even between species. structures: hyaline articular cartilage, mineralized articu-
Numerous studies have shown that most variations in the lar cartilage, subchondral bone and deeper metaphyseal
mechanical properties of whole bones are largely accounted bone. A framework of cancellous bone supports the entire
mechano-sensitive mechanism. The interconnected net-

work of osteocytes and bone surface lining cells are well
placed to sense deformation, fluid flux, etc., and there is
good evidence that these cells are the drivers for adaptive
modelling [40]. Numerous experiments have been under-
taken in an attempt to determine the precise mechanical
stimulus that activates a modelling response and the bio-
logical objective of that response [40]. Intuitively, mainte-
nance of peak strain magnitude within certain limits
during routine activity would be a sensible objective, and
there is evidence to support this. The concept of a
Figure 2.17 Line drawing illustrating the stress intensity (colour
density) either side of the neutral axis at the mid-diaphysis of a thermostat-like mechanism ‘The Mechanostat’, switching
bone which is loaded in bending. Bone modelling can alter the either bone resorption or formation on or off in response
geometric properties of the bone to place the tissue at the to decreased or increased peak bone strains, was champi-
optimal location to resist bending stresses.
oned by Harold Frost [41]. In all probability, there are
likely to be a number of strain-related drivers that impact
joint surface and transmits the load to the diaphyseal cor- the balance of cellular activity [42].
tex. The relatively fine trabeculae forming the cancellous While the physiological response to a change in the mechan-
network provide a compliant structure more capable of ical environment is rapid [43] and effected after relatively few
absorbing impact loads than dense cortical bone. Fat and cycles of loading [44], the architectural response may take
other soft tissues in the spaces between trabeculae may also weeks or months to complete. Consequently, in the event of a
play an important role in damping these loads. In modera- sudden increase in physical activity, high bone strains associ-
tion, localized fracture of individual trabeculae may be ated with that activity persist for some time. This indicates the
another physiological mechanism of mitigating loads that importance of ‘training’ in developing bone structure that suits
could be more damaging to other tissues. needs: much as the cardiovascular system can be prepared for
optimal athletic performance, then so can the skeleton. Ideal
training of racehorses involves exercise programmes that are
A
daptation designed to stimulate an appropriate remodelling response
without causing excessive damage [45].
There are many examples in mammalian biology of spe- An adaptive mechanism can only respond to strains that
cific architectural features of bones that are ideally suited the bone can detect. It cannot empower the bone to resist
to their mechanical environment. It is generally accepted extraordinarily high strains (monotonic overload) associated
that while the basic form of each bone is genetically pre- with an accident. The risk of failure due to supraphysiologi-
programmed, the shape, mass and fine structural features cal loads can be mitigated by the inclusion of a margin of
of bones of the appendicular skeleton are ultimately deter- safety to any response: greater bone mass means stronger
mined by a proactive response of bone cells to their bones, less likely to fracture. However, the formation of bone,
mechanical environment [38, 39]. Increase in cyclical and, more critically, carrying an unnecessarily heavy skele-
bone strains due to raised levels of activity encourages ton, is metabolically costly and in its own right potentially
bone formation. Conversely, disuse results in net resorp- disadvantageous, particularly in animals that rely on flight
tion. In addition, a change of activity that results in altered for survival. The safety factor built into any adaptive response
loading on the bone (a change in principal strain direc- of bone is, presumably, under genetic control. Horses ‘coded’
tion) stimulates a modelling response that redistributes with light bones will have a potential speed advantage but
the mass of bone about its central axis to achieve a struc- may be more prone to accumulate fatigue damage and conse-
ture that is better suited to resist the new strains. For quently suffer fractures. This area of skeletal physiology will
instance, exercise at a fast gallop in the horse is associated inevitably receive increasing attention in the future [46, 47].
with a shift in the neutral axis of the third metacarpal There is good evidence that cancellous bone is also mod-
bone [36] and, presumably, this is the drive for the model- elled in response to changes in loading. Experimentally, the
ling response that occurs in this bone while young horses volume fraction of subchondral bone in the palmar aspect of
first adapt to fast work. Stress itself is not directly measur- the third metacarpal bone increases in response to raised lev-
able, so the consequence of loading, strain or effects asso- els of treadmill work [48]. There is some evidence that an
ciated with strain, such as fluid flow or change in electrical increased density of subchondral bone in animals subject to
fields throughout the tissue, must be at the root of any increased physical activity may occur as a consequence of a
Conclusion 25
response to fracture of trabecular struts [49]. It is arguable Loss of bone at specific sites within one skeletal element
whether this can be termed ‘adaptive’ or, in fact, represents a is also seen following application of orthopaedic implants,
healing response to pathology, whatever the initiating cause. both in fracture fixation and joint replacement. After a
Increased density is associated with reduced compliance, and fracture, the limb is functionally impaired, which reduces
this may have negative consequences for tissues, such as hya- loading and consequent bone strain. When a fixation
line and calcified articular cartilage, sandwiched between the device is used to stabilize the fragments, the loading close
subchondral bone and point of load [49–51]. to the fracture site is further diminished because the
implant provides a shared load path. Strain gauge studies,
in conjunction with both internal and external fixation
S
tress Protection techniques, have confirmed the reduction in functional
bone strain. Application of a dynamic compression plate
While new bone is deposited to strengthen bones in (DCP) to the dorsal cortex of the sheep radius resulted in a
response to increased functional loading, it may be resorbed 30% reduction in strain beneath the plate [59].
when the prevailing loads and resultant strains are reduced. The reduction in the functional strain initiates a bone
For instance, when the forelimbs of dogs are immobilized resorption response, and the use of rigid internal fixation
by a cast, the medullary cavities of bones in that limb plates is associated with both modelling and remodelling
increase in diameter due to net endosteal surface resorp- changes. This has been documented as localized increase
tion [52]. This loss of bone mass is reversed with rein porosity in the cortex underlying a compression plate
introduction of normal activity, demonstrating the dynamic together with resorption of bone at the endosteal sur-
nature of mechanically related bone modelling. face [60]. The effect on intracortical porosity was shown to
Functional adaptation to mechanical conditions may be be temporary [61] and was reduced following redesign of
localized to a single bone or even to a specific site within a the plates to redistribute pressure on the periosteal surface.
bone. Experimentally, external fixators used to reduce the Conventional fixation plates applied tightly to the bone
strain environment of the tarsus of sheep induced reduced surface compress the periosteal blood vessels. It appears
bone mineral content of the os calcis [53]. Similarly, appli- that the intracortical effects are due to vascular compro-
cation of a rigid external fixator to the intact ovine tibial mise, as the use of redesigned plates with lower contact
diaphysis resulted in 50% reduction in normal functional (LC-DCP) reduced intracortical porosity [62].
strain magnitudes, which was associated with a progres- Endosteal resorption results from reduced mechanical
sive time-related reduction in bone mineral content [54]. loading attributed to the loss of functional activity and the
Removal of all loads on the diaphysis of the ulna in chick- load sharing between the bone and the plate. In prelimi-
ens resulted in predictable loss of bone mass, but this was nary studies, it was shown that a plate incorporating a
reduced or prevented by application of only very short peri- spring section applied under tension to an intact bone did
ods of cyclical load via pins that transfixed the bone. As few not induce strain protection under the spring section when
as four cycles of osteogenic strain applied once per day were compared with a standard DCP plate [63].
sufficient to maintain the pre-isolation bone mass [44]. Rubin
et al. [55] subsequently observed a distinct strain energy com-
ponent in bone in the 20–30 Hz frequency range, which they
hypothesized, arose directly from muscular action. In the C
onclusions
same avian model, others demonstrated that loss of bone
mass in isolated ulnas could be prevented through sub- Bone is a remarkable tissue that has evolved to optimize
physiological levels of deformation applied at a specific fre- its composition and structure to meet functional needs.
quency of 30 Hz [56]. Frequency analysis of in vivo strain data The overall mass, geometric properties and structural com-
from a range of different species and anatomical sites (weight- ponents, at varying levels of scale, are constantly refined
bearing and non-weight-bearing) revealed that the highest through cellular processes of modelling and remodelling to
strains (>1000 microstrain) occur relatively few times a day, maintain optimal mechanical support with minimal tissue
while lower magnitude strains (<10 microstrain) occur many mass in the face of varying demands throughout an ani-
thousands of times per day [57]. This suggests that the pre- mal’s life. Healthy bone is densely populated with cells that
dominant contribution to the strain history of a bone arises are maintained by a rich blood supply. Just like any other
from activities not necessarily associated with vigorous loco- tissues, bone cells are liable to disruption and death follow-
motion. Furthermore, the application of induced electrical ing insult. However, bone is able to repair through removal
fields at 15, 75, and 150 Hz was found to inhibit the loss of and replacement of damaged matrix or, when necessary,
bone mass seen in isolated avian ulnas [58]. through regeneration to fill voids.
R
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29
Pathophysiology of Fractures
J.L. Pye and S.M. Stover
UC Davis School of Veterinary Medicine, University of California, Davis, CA, USA
Material Features of Bone Failure Haversian canals make up the osteons of the Haversian sys-
tem in compact bone [17]. Primary osteons are the first to
Bones are composite structures of heterogeneous materials be laid down during bone formation and growth. During
that have unique capacities to resist structural failure, self- postnatal growth, increase in long bone diameter is achieved
repair, and adapt to changes in mechanical usage [1–4]. through periosteal formation of woven bone that provides
The hierarchical composite structure of bone results in the structure for the formation of primary osteons or cir-
structural properties that are greater than that of the indi- cumferential lamellae. Throughout life, there is continual
vidual components. Mechanisms of failure are related to replacement of bone through remodelling. Bone tissues are
the hierarchical structures and components, although the resorbed and replaced with secondary osteons [18, 19].
roles that specific microstructural constituents play in Secondary osteons can be recognized by the presence of
crack initiation, propagation and final unstable fracture are peripheral cement lines, an approximately 2 μm thick,
incompletely understood [5, 6]. collagen-deficient region at their outer boundary [17, 20].
Bone is a biphasic composite comprised of organic and Cement lines are formed by osteoblasts at the time of transi-
inorganic components, and water in approximate volumet- tion from bone resorption to formation [21–23].
ric proportions of 35, 40, and 25% respectively [7]. The Mineralization and crystallinity are closely metabolically
inorganic component is primarily crystalline hydroxyapa- regulated and modulated to optimize mineral homeostasis
tite [Ca3(PO4)2]3Ca(OH)2. The organic matrix is comprised and mechanical function. Bone tissue matrix is not fully
mainly of type I collagen. The degree of mineralization saturated with mineral. Higher mineralization increases
confers strength and stiffness [8–10], and the collagen the load required to initiate cracks, but enhances propaga-
phase contributes ductility and overall toughness [11, 12]. tion of cracks because the structure is less able to dissipate
On the nanoscale level, type I collagen fibres consisting energy [5]. Excessive mineralization increases brittleness
of staggered collagen molecules are reinforced by and susceptibility to microcracks at lower levels of defor-
hydroxyapatite crystals [13–16]. Type I collagen is a triple mation [24, 25]. Conversely, low mineralization weakens
helix containing three chains of amino acids that are cross- the bone and increases fragility [16, 25].
linked by hydrogen bonds to form tropocollagen molecules. Collagen does not contribute significantly to matrix
Staggered arrays of multiple tropocollagen molecules are strength and stiffness but is critical to toughness, the
covalently bonded together to form a collagen fibril. Fibril energy required to cause failure [11]. Collagen comprises
arrays twist into individual collagen fibres. Hydroxyapatite >90% of the organic component of bone and is largely
crystals assemble in gaps between collagen fibrils, result- responsible for its viscoelastic properties [7]. Collagen has
ing in mineralization of fibrils as the bone forms and increased stiffness with increased loading rate, while the
matures (Figure 3.1). Collagen fibre organization varies mineral phase is largely unaffected [26]. Higher loading
from random in rapidly formed woven bone to highly rates therefore reduce bone compliance at the microstruc-
organized in lamellar bone. tural level, resulting in increased brittleness and a reduc-
Haversian systems are present in compact bone to pro- tion in fracture resistance [26]. This rate-dependent change
vide vascularization to osteocytes embedded in bone matrix. in fracture toughness results in a transition from ductile to
Concentric lamellae that surround a central blood vessel in brittle behaviour [27–30].

30 Pathophysiology of Fractures
Haversian Concentric Figure 3.1 Schematic illustration of bone

Canal Cement Line Lamellae microstructure showing major osteonal
Secondary components.
Osteocyte
Osteon
Blood
vessel
Collagen
Fibril
Mineral
Crystal
Loading Modes to single axis loading in tension, compression, shear, bend-

ing, torsion or combined loading of a homogeneous struc-
The biomechanical response of bone to loading is depend- ture with isotropic material properties (Figure 3.2). Such
ent on its geometry and material composition, and the analyses provide insight into the circumstances that led to
loading environment. Loading characteristics include the bone fracture, but may not accurately reflect the in vivo
direction, rate, magnitude, frequency and duration of loading conditions.
applied loads. Loads may be applied locally (e.g. at the tips Bone is an anisotropic material, meaning its mechanical
of microcracks) or globally (e.g. in the far-field, acting on properties depend on the direction of the applied forces. In
the whole bone). general, because of the structure and orientation of osteons,
compact bone is strongest in axial compression, weaker in
tension and weakest in shear. As a result, fractures usually
Locally Acting Loading Modes propagate along tension and shear planes. Shear planes run
Compact bone invariably contains microcracks, and an at approximately 45° angles from compressive and tensile
understanding of the modes of fracture must take into stresses. Fractures will also follow the path of least resist-
account their presence [31, 32]. The direction of crack ance. Therefore, fracture lines or cracks will often be
propagation within the bone and the microstructure of the diverted around heavily buttressed areas. Likewise, frac-
bone material have profound influences on fracture resist- tures may terminate at suture lines or pre-existing cracks as
ance. Transverse cracking, where the crack must course these dissipate fracture energy more efficiently.
through longitudinally oriented osteons, is tougher than Classic loading modes and fracture configurations are
longitudinal cracking, where the crack splits osteons along readily applicable to long bones, and diaphyseal fractures
the longitudinal axis of the bone [33, 34]. The process of are mostly used to illustrate these concepts. They are also
bone remodelling increases resistance to crack propagation recognized in some types of epiphyseal [37], proximal sesa-
by adding secondary osteons and cement lines throughout moid [38] and carpal cuboidal bone fractures [39, 40] in
the structure and by reorganizing osteons and trabeculae horses. However, these loading modes and associated frac-
along directions of high stresses. ture configurations are currently not well understood in
relation to a number of other common equine sites, such as
distal phalangeal, distal sesamoidean and tarsal cuboidal
Globally Acting Loading Modes and Resulting
bone fractures.
Fracture Configurations
During normal daily activity, forces and moments are Tension
applied to whole bone structures in various directions Tensile loading occurs when equal and opposite loads are
simultaneously [35]. Loading conditions are often simplified applied to distract the ends of a bone. Maximum tensile
Loading Mode 31
Loading Bending/
Tension Compression Bending Torsion
mode Compression Shear
Transverse Oblique Transverse + Larger Spiral Longitudinal

Oblique Butterfly
(Butterfly)
Fracture
Configuration
Figure 3.2 Common fracture configurations and simplified causative forces illustrated on diagrams of the dorsal surface of the third
metacarpal bone. Source: Modified from Morgan and Bouxsein [36].
stress occurs on a plane perpendicular to the direction of Torsion

applied load. The structure lengthens and narrows, and Torsional loading occurs when opposite moments (rota-
subsequently fails as a result of debonding at cement lines tional forces) are applied to the ends of a bone, such that
and osteonal pull out to result in a transverse fracture con- the bone twists around the longitudinal axis. Fracture sur-
figuration (Figure 3.3). Long bones are not well adapted to faces produced by torsional loads are helical, creating a
resist uniaxial tensile loads, which are not common during fracture that circles or spirals around the shaft. Torsional
normal physiological activities. loading induces shear stresses in planes parallel and per-
pendicular to the longitudinal axis. The magnitude of
Compression shear stresses increases proportionally with increasing
Compressive loading occurs when equal and opposite distance from the central axis of rotation (typically the
loads are applied to push the ends of the bone closer longitudinal axis of the bone). Tensile and compressive
together. Axial compression causes the bone to shorten and stresses are also induced, orientated approximately 45°
widen. Because bone material is weakest in shear and the from the shear direction. The fracture originates where
plane of maximum shear stress is offset 45° from the axis of shear stress is greatest on the periphery of the bone and
loading, diaphyseal fractures due to longitudinal compres- then propagates due to tensile stresses distracting bone
sion have an oblique configuration (Figure 3.4) [41]. fragments along a spiral configuration until the fracture
in vivo, oblique fractures often result from a combina- ends are approximately parallel or above one another
tion of compression, bending and/or torsion forces that (Figure 3.5). The fracture becomes complete when a longi-
cause the bone to break diagonally to the long axis. The tudinal fissure occurs, connecting the proximal and distal
fracture morphology reflects the predominate type of ends of the spiral crack.
load. If compression forces are predominant, a short It must be recognized that this classic spiral fracture pat-
oblique configuration will occur. If bending forces are tern occurs when an isotropic and homogeneous prismatic
predominant, the fracture will have a transverse compo- cylinder is loaded in pure torsion. As such, it is rarely seen
nent, with or without a butterfly fragment. Long oblique in vivo, because of the asymmetric geometry of equine long
fractures, which are often difficult to differentiate from bones, the forces exerted on those bones by soft tissues,
spiral fractures, are common when torsion is the predom- regional variations in predominant collagen fibre orienta-
inant force. tion and other material characteristics within the bone.
Figure 3.3 Tensile loads cause the bone to elongate and narrow. Failure occurs due to tensile forces perpendicular to a transverse
plane. Tension from the suspensory ligament and distal sesamoidean ligaments influenced the transverse configuration of the
mid-body proximal sesamoid bone fracture shown. Source: Dr Ryan Carpenter.
Figure 3.4 Compressive loads cause the bone to shorten and widen. Failure occurs along the plane of maximum shear stress,
oriented approximately 45° from the axis of compressive loading. An incomplete dorsal cortical stress fracture of the third metacarpal
bone illustrates a fracture due predominantly to compressive loading and shear failure. Source (inset): Based on O’Brien et al. [41].
Bending Failure is initiated on the tensile (convex) side of the

When a bending load is applied, compressive stress is bone because bone material is weaker in tension than com-
induced on the concave side and tensile stress is induced pression. Tensile failure causes transverse crack propaga-
on the convex side of the deforming bone. Bending cretion until compressive stresses on the concave side of the
ates a longitudinally oriented plane, called the neutral bone induce failure in shear at 45° to the longitudinal axis
axis, where neither compressive nor tensile stresses are of the bone. Failure along the plane of highest shear stress
present. The greater the distance from the neutral axis, drives the fracture line in oblique directions, producing an
the larger the tensile or compressive stress. This has oblique fracture face or a butterfly fragment (failure in two
implications for internal fracture fixation, as implants shear planes at right angles to one another) on the com-
(such as intramedullary nails) that are positioned at the pressive side of the bone (Figure 3.6). When the contribu-
neutral axis are exposed to lower levels of bending (and tion of the compressive loading component is substantial, a
torsional) strain compared to implants placed away from larger butterfly fragment will result.
the neutral axis (such as bone plates and external There are several modes by which bending deformation
fixators) [42]. is induced. Axial compression of a curved bone (e.g.
Loading Mode 33
~ 45° spiral Principal

fracture tensile stress
Shear stress
Figure 3.5 Shear stresses arising from torsional loading result in tensile and compressive forces at ~45° to the plane of shear. The
fracture propagates perpendicular to the principal tensile stress in a spiral configuration relative to the longitudinal axis (A). The
fracture becomes complete when the proximal and distal ends of the spiral are connected by a longitudinal fissure. This humeral
fracture in a four-month-old Arabian foal provides an example of a spiral/long oblique fracture occurring predominantly due to
torsional forces. Source: Dr Scott Katzman.
Figure 3.6 Bending creates tensile and compressive loads on different sides of the bone. Failure occurs first on the side under
tension resulting in a transverse distraction fracture. The fracture then propagates on the side under compression in an oblique
configuration, with or without a butterfly fragment, illustrated by a Salter–Harris type II fracture of the proximal tibial physis in a
10-day-old foal and a mid-diaphyseal butterfly fracture of the third metatarsal bone in a foal. Source: Drs. Susan Stover and Larry
Galuppo).
Stress Three-Point Bending Four-Point Bending
Stress
Distance Between Load Supports Distance Between Load Supports
Figure 3.7 Three-point bending configurations have a central load point at the location of highest bending moment (stress) on a
bone supported near its ends. Four-point bending configurations have two inner load points between two outer support points to
produce a constant bending moment between the two inner supports. Source: Lopez [43] Reproduce with permission of Elsevier.
Figure 3.8 A shear force is an external force acting on an object or surface parallel to the slope or plane in which the surface lies.
Cyclic shear loading of an interface between regions of different subchondral bone densities in the distal condyles of the third
metacarpal bone predisposes to condylar fracture in Thoroughbred racehorses. Source: Dr Ryan Carpenter.
radius) and external forces applied to the side of a long Shear

bone both induce bending. in vitro, bending can be A shear force is one that is applied parallel to a surface or
induced through three-point and four-point bending section through a bone, causing a tendency for surfaces or
(Figure 3.7), and cantilever bending (where one end of a sections to slide past one another (Figure 3.8). Shear load-
beam is fixed and a force is applied to the free end). ing is distinct from shear stresses and strains induced by
Bending can also occur during axial compression second- other loading conditions discussed earlier [44]. Bone is
ary to specimen buckling. Bone fracture from four-point disproportionately weaker in shear than in tension or
bending is uncommon in clinical settings, but is useful compression [45–47].
experimentally as it creates a uniform bending moment
between two central load points. This avoids concentrat- Combined Loading
ing stress under the central load fixture of three-point The in vivo environment is more complex than uniaxial
bending and thus potential failure due to artefactual loading. Bone geometry, gait, muscle forces, ground sur-
stress concentration. face conditions and disease processes all influence bone
The Mechanical Behaviour of Bon 35
stresses generated by both external and internal loads. long oblique configurations due to a combination of com-
Ideally, experimental studies should recreate physiologi- pressive and torsional forces placed on the limb during
cal loading conditions. Combined loading circumstances axial loading [54, 55, 57, 59].
can be achieved by multiaxial loading (e.g. compression Cyclic shear loading plays an important role in the for-
and torsion) and/or applying loads at soft tissue attach- mation of third metacarpal (MCIII) or metatarsal (MTIII)
ment sites. condylar fractures [60, 61]. During high-speed locomotion,
load is concentrated on the palmar aspect of the distal con-
dyles of MCIII and adaptive modelling leads to increased
elationships Between Location
R density of the subchondral bone [62]. Bone forming the
and Morphology sagittal ridge, which is not directly loaded during locomo-
tion, remains of relatively lower density [63]. The resulting
Fracture configurations in a clinical setting are often not variation in bone density between the two condyles and the
easily categorized into the classic patterns because clinical sagittal ridge creates a stiffness gradient, leading to concen-
fractures occur under complex, multidirectional loading tration of shear force at the interface of the regions of dif-
conditions at high strain rates and are influenced by local ferent densities at the parasagittal groove, where increased
bone quality and surrounding soft tissues. However, an shear strain will result in fatigue damage [62]. Continued
understanding of the predominant biomechanical forces cyclic shear loading of the condyle leads to the propagation
involved in fracture generation in different parts of the of a single dominant crack until structural failure
skeleton is crucial to executing a successful repair and occurs [60].
formulating strategies to reduce the risks of repair Pure compression fractures are uncommon in
complications. horses [44]. Fractures that involve significant compressive
Mid-body fractures of the proximal sesamoid bones pro- forces can occur in the cervical vertebrae as a result of
vide a good (albeit simplified) example of the relationship trauma, such as falls or impact into a fixed object [64–66].
between transverse fracture configuration, location and Dorsal cortical stress fractures of the third metacarpal bone
morphology. The proximal sesamoid bones are composed can also be related to compression [43]. During fast-gaited
of dense trabecular bone [48], and are subjected to high exercise, the dorsal cortex of the third metacarpal bone is
tensile loads exerted proximally and distally by the suspen- subjected to greater compressive forces than the rest of the
sory and distal sesamoidean ligaments, respectively [49, cortex [67]. Consequently, dorsal cortical stress fractures
50]. Complete, mid-body fractures of the proximal sesa- have a short oblique configuration, typically propagating in
moid bones typically have a transverse orientation, attrib- a palmaroproximal to dorsodistal direction [68].
utable to longitudinally directed tensile forces [51].
Short oblique and butterfly fractures generally result
from bending forces, which cause tensile loading on the The Mechanical Behaviour of Bone
convex side and compressive loading on the concave side of
the bone. The radius is particularly susceptible to side- When externally applied forces (loads) act on an object, it
impact loads like kick injuries, typically resulting in com- will undergo deformation (i.e. changes in dimensions).
minuted fractures in adult horses [52, 53]. Simple fractures Forces expressed relative to the areas of application are
are less common, but when they do occur the configura- termed stresses, and deformations caused by these stresses
tion is usually either short oblique or butterfly, with the and expressed as a proportion of the original dimensions
base of the butterfly fragment on the same side of the bone are called strains.
as the impact [53]. In one ex vivo study mimicking kicking The mechanical behaviour of a bone organ (e.g. a
injuries in intact radii and tibiae, most oblique fractures humerus) is related to its structural properties (dependent
also had a second divergent fissure which may have on size/shape/geometry, etc.) and material properties (the
extended into a butterfly fracture if the impact velocity had bone tissue that it is made of, which is independent of
been higher [53]. shape/geometry, etc.). When testing the structural proper-
Long oblique and spiral fracture configurations occur in ties of bone, the relationship between load and displace-
the diaphyses of the femur, [54–56], tibia [37, 57] and ment is represented by the load–deformation curve. When
humerus [58]. Traumatic diaphyseal fractures of the proxi- testing material properties, load and displacement are
mal long bones in adult horses are often severely commi- recorded as stress and strain. In other words, for the bone
nuted due to substantial energy release at the time of the organ as a whole, the deformation is a function of the load
fracture [54–56]. However, in foals, diaphyseal fractures of applied. Within the bone material, the strain is a function
the femur, tibia and humerus commonly occur in spiral or of the stress induced [42]. The International Organization
for Standardization (ISO) and the American Society of curve. The yield, ultimate and failure strengths of a struc-
Testing and Materials (ASTM) develop and maintain stand- ture correspond to the yield, ultimate and failure load
ards for testing materials and structures in different points on the load–deformation curve. The ultimate and
industries. failure strength are usually similar in bone but may be dif-
ferent in other materials. Work to fracture (energy absorbed
to failure) of a structure is analogous to the material prop-
Structural Properties and the Load–
erty of toughness and is represented by the area under the
Deformation Curve
load–displacement curve.
The load–deformation curve (Figure 3.9) is useful for
determining the mechanical properties of whole struc-
Material Properties and the Stress–Strain
tures, such as an entire bone, or a bone-implant construct
Curve
in fracture repair [35].
The initial curved portion is known as the toe region, Material properties are determined using a standardized
where low load invokes relatively large deformation, which bone specimen and the results of tests are represented
reflects the uncrimping of collagen fibres in highly colla- graphically on a stress–strain curve. The stress–strain curve
genous tissues. The linear portion of the curve is called the is analogous to a load–deformation curve for bone struc-
elastic region, where the object maintains the capacity to tural properties, with the distinction of being normalized
return to its original shape once the load is removed. If to load distribution and specimen geometry.
loading continues through the elastic region to the yield Stress (σ) is the force (F) divided by the area (A) of the
point, then the structure incurs damage. The plastic region surface that the force acts on (Figure 3.10a). Forces directed
of the curve follows the yield point, wherein the material is perpendicular to a planar surface are called normal forces,
no longer capable of returning to its original configuration and forces directed parallel to a planar surface are called
when the load is removed. In the plastic region, the struc- shear forces. When a force acts perpendicular (normal) to
ture deforms to a greater extent for a given load than in the the surface of an object, it exerts a normal stress. When a
elastic region. If the load continues to increase, the struc- force acts parallel to the surface of an object, it exerts a
ture will eventually fail. In a clinical setting, the failure shear stress. The units of stress are force over area, and the
point for bone is the load at which it fractures, but in an most common unit is the pascal (Pa), which is equal to 1 N
experimental setting the failure point for a specific biome- over 1 m2 (N/m2). The pascal is a very small unit, therefore
chanical test may be defined by the investigator. The ulti- physiological stresses are more commonly expressed in
mate load prior to failure is referred to as the ultimate megapascals (MPa) (1 MPa is equal to 1 000 000 Pa).
strength of the material. The failure point of bone typically Strain (ε) is a change in dimension that develops within a
coincides with peak load, as bones have limited ability to material in response to stress, divided by the original dimen-
deform plastically. The stiffness of the structure is indicated sion (Figure 3.10b). Strain may be normal (i.e. a change in
by the slope of the elastic region of the load–displacement length or width) or shear (i.e. a change in shape). Normal
Failure Figure 3.9 Representative load–deformation

s
curve for a whole bone.

es
Point
iffn
St
Ultimate
Load
Yield
Point
Axial or Torsional
Load
Toe
Region
Elastic Plastic
(Yield Energy) (Failure Energy)
Deformation
Linear or Angular Deformation
(a) (b) (c)
F1 F2 F3
L
F3 A
A a
F2
∆L
σ = F/A ε = ∆L/L
Figure 3.10 Diagrammatic representations of stresses and strains. (a) A force directed perpendicular to a surface (i.e. a normal force)
is described as a compressive (F1) or tensile (F2) force depending on its direction. A force acting parallel to a surface (F3) is called a
shear force. Stress (σ) is defined as force (F) divided by the cross-sectional area (A) of the surface to which it is applied (σ = F/A). (b)
Strain (ε) is defined as a change in dimension divided by the original dimension (ε = ΔL/L). (c) Shear strain is the amount of angular
deformation (a) of a right angle lying in the plane of interest in a material, which is expressed in radians (γ). Source: Modified from
Morgan and Bouxsein [36].
strain refers to the length (or width) of a structure divided Stress–strain curves demonstrate that compact and tra-
by its original length (or width) and is therefore dimension- becular bone have significantly different material proper-
less but commonly measured in units of microstrain (με), so ties influenced by porosity (or apparent density). Compact
that a strain of 0.01 (1%) would be 10 000 microstrain. For bone has higher apparent density than trabecular bone
reference, maximum strains in the third metacarpal bones and withstands high compressive stress but will fail at
of Thoroughbred racehorses galloping at racing speeds of strains exceeding 2% [35, 71]. Trabecular bone is porous
16 m/s have been measured in the range of 3250–5670 με and can therefore absorb a significant amount of energy
(0.3–0.6%) [69]. Shear strain is the amount of angular defor- and tolerate up to 30% strain prior to failure [35, 47]. The
mation from a right angle lying in the plane of interest in a strength and stiffness of trabecular bone vary with appar-
sample (Figure 3.10c). Shear strain is expressed in radians ent density but are generally less than that of compact
(γ) or degrees (1 rad = 57.3°). bone (Figure 3.12).
Change in one dimension is accompanied by a change in
a perpendicular dimension. The relative amount of change
The Role of Geometry
in perpendicular dimensions is represented by Poisson’s
ratio. For example, in a tensile test, lengthening of a struc- Bone geometry markedly influences structural mechanical
ture is accompanied by a narrowing of the width. The quo- properties. Axial stiffness, which is the resistance of bone
tient of strains in longitudinal and transverse directions is to deformation during loading in tension or compression,
called Poisson’s ratio (ν), defined as ν = −(ΔW/W)/(ΔL/L). is proportional to the cross-sectional area, while bending
It is a measure of how loading in the longitudinal direction and torsional stiffness depend on how the bone material is
(axially) affects the structure transversely (laterally). distributed around the axis of bending or torque. Material
Typically, axial tension results in transverse contraction, most distant from the neutral axis has the largest effect on
while axial compression results in transverse bulging. resisting bending and torque loads. Two geometric proper-
Poisson’s ratio for bone typically has values between 0.2 ties, the area moment of inertia and the polar moment of
and 0.5 (average: 0.3) [70]. inertia, quantify the contribution of geometry to a particu-
As in the load–deformation curve, once the yield point is lar bone’s resistance to bending and torsion, respectively.
exceeded, increased applied stress results in permanent Application of a load at a distance from the centre of a
deformation of the material. Permanent deformation bone induces a bending moment. The bending moment is
occurs in the plastic region of the curve, which extends a product of the magnitude of the force applied and the
from the yield point to the failure point. Ductility is a meas- length of the moment arm about which the force is applied.
ure of the ability of a material to deform plastically prior to Moment arm length is the perpendicular distance from the
failure, and brittleness is the opposite of ductility. The total line of action of the force to an axis of rotation. A longer
area under the stress–strain curve (Figure 3.11) is a meas- moment arm increases the bending effect of the force
ure of the energy absorbed to failure or toughness. applied.
Figure 3.11 Example of a stress–strain curve of

Ultimate a bone sample. Source: Modified from Lopez [43].
r)
ea
Stress Failure
or us
Sh
Point
g’s ul
oun Mod
(Y
Yield
Normal or Shear
Point
Stress (σ)
Toe
Region
Elastic Plastic
(Yield Strain (Failure Strain
Energy Density) Energy Density)
Strain (ε)
Normal or Shear
Compact Bone (P = 1.85g/cm3) F
Neutral Axis
150
Stress (MPa)
100 Moment
Arm
50 Higher Density Trabecular Bone (P = 0.9g/cm3)
Area Moment
of Inertia
Lower Density Trabecular Bone (P = 0.3g/cm3)
5 10 15 20
Strain (%) Elastic Modulus
Figure 3.12 Compressive stress–strain behaviour of one

compact and two trabecular bone samples demonstrating the
influence of apparent density (P) on the material properties of
bone. Compact bone is more dense than trabecular bone and
exhibits greater stiffness and strength under compressive
F
loading, but tolerates minimal strain before failure. Trabecular
bone is porous with a low resistance to compressive stress but is
capable of enduring much higher strains than compact bone. Figure 3.13 Factors influencing the deformation of bone
Source: Modified from Keaveny and Hayes [72]. subjected to a bending force include the magnitude of the
bending moment (a product of the force applied (F) and the
length of the moment arm), the elastic modulus of the bone
The amount a bone will deform under a bending force is material, and the area moment of inertia about a neutral axis.
related to the magnitude of the bending moment, the elas-
tic modulus of the bone material and the area moment of Factors that affect bone strength and stiffness in torsion
inertia (I) about the neutral axis (Figure 3.13). The area are similar to those that operate in bending: the applied
moment of inertia is defined as the capacity of a cross- torque (force applied to induce a rotation), the length of the
section to resist bending. For any given bending moment, bone, the shear modulus and the polar moment of inertia
bone deformation can be reduced by decreasing moment (J) about the torsional axis. The polar moment of inertia is
arm length, increasing stiffness of the bone (i.e. larger elas- defined as the moment of inertia with respect to an axis
tic modulus) or increasing the area moment of inertia. perpendicular to the plane of the area. The shear stress
c reated in a bone when loaded under torsion is inversely to the combination of elastic and viscous behaviour where
related to the polar moment of inertia. Thus, in a bone with the applied stress results in an instantaneous elastic strain
a high polar moment of inertia, the same torque will result followed by a viscous, time-dependent strain. In other
in smaller shear stress than in a bone with a lower polar words, a viscoelastic material will return to its original
moment of inertia. shape after a deforming force has been removed (i.e. it will
The area moment of inertia and the polar moment of show an elastic response) even though it will take time to
inertia are proportional to the fourth power of the radius do so (i.e. it will have a viscous component to this response).
for circular cross-sections (Figure 3.14). For example, if the If a mechanical stress is imposed on a viscoelastic mate-
diaphysis of the bone is considered a hollow cylinder [73–75], rial and held constant, then the resultant strain will
small increases in bone diameter will result in exponen- increase with time, a phenomenon known as creep
tially greater bending and torsional strengths. Periosteal (Figure 3.15a). If a constant strain is imposed on a viscoe-
callus will contribute substantially more to the bending lastic material, then the induced stress will lower with time
and torsional stiffness of a bone than endosteal callus, as (stress relaxation) (Figure 3.15b). Viscoelastic materials
the new bone material is located further away from the dia- also display hysteresis, which is the tendency for materials
physeal (neutral) axis. Similarly, a small amount of com- to exhibit different mechanical behaviour based on whether
pact bone loss near the marrow cavity may have a relatively a load is being applied or removed (Figure 3.15c). When a
small effect on overall bending and torsional rigidity. viscoelastic material is loaded and unloaded, the unloading
Although helpful in fostering a conceptual understand- curve is different from the loading curve. The difference
ing, assumptions of cylindrical or elliptical geometry between the two curves represents the amount of energy
underestimate the complexity of bone structure [76]. that is dissipated or lost during loading. A key factor in
Experimentally, finite-element (FE) modelling, wherein these phenomena is the movement and redistribution of
geometry and material properties are obtained from quanti- fluid through pores in the viscoelastic biologic tissue [42].
tative computed tomography (QCT), is used to generate 3D An important characteristic of viscoelastic materials
models that more accurately predict the structural response such as bone is strain rate sensitivity, which means that the
of bones with irregular and variable cross-sectional charac- stress–strain behaviour of the material depends on the rate
teristics to different loading conditions [77, 78]. at which it is loaded (Figure 3.16). Strain rate is the speed
or velocity at which a change in dimension (deformation)
of a material occurs. The unit quantity for strain rate is
Viscoelasticity
inverse time, typically seconds (denoted s−1 or 1/s). As
Viscoelastic materials exhibit both viscous and elastic char- strain rate increases, the stiffness and ultimate strength of
acteristics when loaded. Elasticity is the tendency of solid the bone increase. The energy absorbing capacity of bone
materials to return to their original shape after a deforming also increases with increasing strain rate until a critical
force is removed. Viscosity is a measure of a fluid’s resist- velocity is reached, beyond which this capacity decreases.
ance to flow (i.e. a viscous fluid will resist motion). Bone is The critical strain rate is reported to occur at approximately
a viscoelastic material because it contains water that can be 10−1 to 100/s and represents a transition in the behaviour of
displaced through the organic matrix. Viscoelasticity refers the bone from pseudo-ductile to brittle [29, 30, 82]. Once
the critical velocity is reached, the bone becomes increas-
ingly brittle, resulting in lower strain to failure, lower
energy absorbing capacity and reduced fracture tough-
ness [26, 82, 83].
The relationship between gait and strain rate is roughly
Area Moment of Inertia
Ro π linear such that the highest strains are experienced at the
I= (Ro4 – R4i )
4 fastest gaits [84]. Strain rates experienced by horses at walk
to canter gaits (2–10 m/s) in vivo are in the range of 1.3–
Ri Polar Moment of Inertia 8.3 × 10−2/s [81]. At a gallop, horses regularly achieve a
π velocity of 1.5 × 10−1/s [84], and in the dorsal aspect of the
J = (Ro4 – R4i )
2
third metacarpal bone of Thoroughbred racehorses strain
rates as high as 3 × 10−1/s can be estimated for racing
speeds (16–18 m/s) [69, 79]. These are within the range at
which bones undergo brittle deformation; however, the
Figure 3.14 Formulae for the area moment of inertia and the
polar moment of inertia for a hollow cylindrical cross-section. relationship between strain rate and catastrophic fracture
Source: Modified from Morgan and Bouxsein [36]. risk is not straightforward. Whether or not a fracture will
(a) Creep (b) Stress Relaxation (c) Hysteresis

Stress
Strain
Loading
Stress
Strain
Stress
Unloading
Time Time Strain
Figure 3.15 Behaviour of viscoelastic materials. (a) Creep is an increase in strain under constant stress over time. (b) Stress
relaxation is a decrease in stress under constant strain over time. (c) Hysteresis refers to the loss of energy with cyclic loading.
600
onotonic and Repetitive Stress
M
Very High Strain Rate (103 s–1)
Fractures
500
Fractures can occur as a result of a single extreme load or

400 smaller repeated loads. A monotonic fracture occurs when
Higher Strain Rate (100 s–1)
Stress (MPa)
a single extreme load deforms the bone beyond its ultimate

300 limit, resulting in complete and sudden failure [85].
Examples include a fall over a fence during jump racing or
200 cross country, or an accident during recovery from general
anaesthesia [85, 86]. Stress fractures are the result of repet-
Low Strain Rate (10–3 s–1) itive loads, caused by a few repetitions of a high load or by
100
multiple repetitions of lower loads. The vast majority of
bone injuries in racehorses are due to repeated high-
0.5 1.0 1.5 2.0 2.5 3.0
intensity loading, which results in weakening of the bone
Strain (%)
and subsequent failure [85, 87–89].
Experimentally, loading conditions are simulated by
Figure 3.16 The mechanical behaviour of bone is strongly monotonic (single cycle to failure or quasi-static tests) and
dependent on strain rate. High strain rates lead to higher yield cyclic loading. Materials that fail from repeated cyclic load-
strength and stiffness in cortical bone, but also increased brittleness
and reduced fracture toughness. However, strain rates measured on ing are typically viewed as failing secondary to fatigue [90].
the dorsal metacarpus of Thoroughbred racehorses are intermediate The ‘fatigue life’ refers to the number of load cycles that
(i.e. between low and high strain rates), ranging from ~10−2/s at a can be sustained at a given load before catastrophic failure
walk to ~10−1/s at a gallop [69, 79, 80]; and physiological strains are occurs [87]. The in vitro fatigue life of bone is related to the
less than 0.6%. Thus, strain-rate-related effects in vivo are likely
lower than those observed in ex vivo studies. Very high strain rates magnitude of the applied load as well as the geometry and
(~103/s) are expected for impact speeds as might occur in a violent material properties of the loaded structure [85, 87]. The
collision. Source: Modified from Davies et al. [81]. fatigue life can be deduced from the S–N curve that depicts
the relationship between the applied stress (S) and the
occur likely depends on the interaction of strain rate with number of loading cycles before failure (N) (Figure 3.17).
several other factors including the direction of loading, At high loads, a relatively low number of cycles will induce
number of load cycles, magnitude of strain and the pres- failure, whereas at lower loads the bone endures a greater
ence of pre-existing fatigue microdamage [80]. number of cycles before failure. The fatigue limit of a
Monotonic and Repetitive Stress Fracture 41
120 8
Kpeak
7
a0
6
80
KR(MPa - m½)
K0
Stress (MPa)
5 Crack Growth Initiation Point
3
40
2
0 0
50 000 100 000 9 10 11 12
Cycles to Failure (N) Crack length (mm)
Figure 3.17 An idealized S–N curve for cortical bone illustrates Figure 3.18 Example of a rising R-curve (KR vs. crack length)
the relationship between load magnitude (stress) and cycles to for transverse crack growth in a third metacarpal specimen from
failure. Larger loads have a disproportionately larger effect on a horse. KR: crack growth resistance; K0: crack growth initiation
reducing fatigue life than smaller loads. Source: Modified from toughness; Kpeak: peak stress intensity factor; and a0: initial crack
Kawcak et al. [89]. length. Source: Based on Yeni and Norman [105].
equine bone under static and dynamic loading condi-

aterial is the stress level at which the material can endure
m tions [26, 104] (Figure 3.18).
an infinite number of loading cycles without failure. The Rising R-curve behaviour is predominantly the result of
fatigue limit can be determined from the stress plateau in extrinsic toughening mechanisms including crack bridging
the S–N curve. When loaded below the stress plateau, the by uncracked ligaments and intact collagen fibrils, crack
material has infinite fatigue life. Bone does not exhibit a deflection along the cement lines and microcracking in the
fatigue limit [10, 91–93]; however, an endurance limit has crack wake, which redistributes stress from the tip [105–
been characterized for bone, which is defined as the stress 110] (Figure 3.19). These mechanisms depend on specific
amplitude at which the material can sustain a defined microstructural features, which in turn vary with orienta-
number of cycles [94, 95]. tion [113]. The marked anisotropy in fracture toughness, in
Cyclic loading of bone results in formation of cracks at that bone is easier to split than break, can be related to the
micro- and ultrastructural levels [96]. Most cracks stop relative contributions of these mechanisms [114]. Lower
enlarging after reaching a certain length because cracks toughness is observed in the longitudinal orientation
interact with microstructural features that retard their where cracks can propagate along cement lines, which pro-
propagation [97]. This observation is supported by studies vide a path of relatively low resistance. Crack bridging
that have demonstrated an increase in crack density but appears to be the prominent source of toughening in the
not length, with continued loading [2, 98, 99]. However, longitudinal orientation [114]. Crack bridging refers to
excessive accumulation of microdamage reduces bone unbroken regions that span the crack in the wake of the
stiffness and ultimate strength, increasing the risk of cata- crack tip and act to resist crack opening [109]. The highest
strophic fracture [85, 92, 100]. toughness is observed in the transverse orientation, where
Paradoxically, the process of microcrack formation can cracks encounter osteonal boundaries. Crack deflection
also increase resistance to crack propagation (toughness) around cement lines is the extrinsic mechanism that
and catastrophic failure [85]. Energy is released when the increases toughness most substantially in the transverse
bone material yields, marking the onset of plastic deforma- orientation [113]. The degree to which bone can employ
tion. If the amount of energy released is less than the microcracking and other extrinsic toughening mechanisms
energy required to form the initial crack, the damage will to disperse energy ultimately determines the brittleness or
arrest. Otherwise, the crack will continue to spread, and toughness of the specimen [115].
more cracks will form [99, 101]. The stable (subcritical) Pre-existing fatigue damage reduces the capacity of com-
cracking that precedes outright fracture is best character- pact bone to exploit microcracking to reduce stress intensity
ized by the rising resistance curve (R-curve), where frac- at the crack tip [116]. This is because a significant proportion
ture resistance actually increases with crack extension [28, of available microcrack ‘sites’ are used up [117]. There is also
102, 103]. Rising R-curve behaviour has been reported in the risk that beyond a certain density of microcracks, the
(a) Crack Deflection (b) Crack Bridging
Osteon Collagen
Fibrils
(c) Uncracked Ligament Bridging (d) Microcracking
Uncracked Ligament
Bridges Microcracks
Figure 3.19 Schematic illustrations of some toughening mechanisms possible in cortical bone. (a) Crack deflection by osteons, (b)
crack bridging by collagen fibres, (c) uncracked ligament bridging and (d) diffuse microcracking. Source: Ritchie [102]; Ager et al. [111];
Launey et al. [112].
risk of catastrophic fracture increases [118]. Reduced stiff- horses [130]. Living bone not only has the ability to change
ness of bone secondary to fatigue damage exacerbates the its shape and volume to reflect the mechanical loads it
risk of fracture because there is increased deformation of the must support (modelling) but can also replace damaged or
bone in response to a given load [91, 100, 118, 119]. in vitro, fatigued bone with new bone (remodelling). Remodelling
multiplication and coalescence of microcracks under con- involves resorption of bone by osteoclasts and replacement
tinued stress results in the eventual formation of a macro- by osteoblasts in a highly orchestrated and controlled series
scopic fissure and potentially catastrophic failure [120]. of events. Remodelling has an important role in enhancing
The bones of racehorses in training are subjected to high the fatigue life of bone by replacing material that has accu-
loads, resulting in a relatively high risk of damage until mulated microdamage with new, healthy tissue [131]. The
bone stiffness is increased through adaptive mecha- extent of fatigue damage at any one time is a balance
nisms [85]. Adaptive modelling refers to changes in bone between the rate of accumulation of microdamage and the
shape and internal structure in response to mechanical rate of repair [85, 132].
forces placed on the bone, according to Wolff’s law [121]. Microcrack formation plays a role in initiating the
New bone formation in response to repeated loading remodelling process [133, 134]. Damaged bone can be
improves biomechanical properties and increases fatigue resorbed rapidly; however, bone deposition takes longer.
life [122–126]. An excellent example of adaptation to load Remodelling to remove fatigued bone increases porosity
is the increase in cortical thickness and bone volume frac- during the initial phase of bone resorption, and this
tion in the metacarpal bones of Thoroughbred racehorses decreases stiffness [135]. A focus of damage that initiates
in response to training [127–129]. intense remodelling can induce transient focal osteopenia
The acquisition of damage with cyclic loading alone may and predispose to the development of a clinical
not be sufficient to result in complete fracture in living fracture [135]. Sites of transient osteopenia include stress
Classifications of Fracture 43
fractures and subchondral stress remodelling. The majority Table 3.1 Predictable sites of stress fractures and stress
of catastrophic fractures in racehorses are secondary to remodelling.
pre-existing stress fractures or subchondral bone stress
remodelling [136–140]. Bone/joint Anatomical region References
Criteria for the identification of stress fractures in
Scapula Distal aspect of the spine [140]
Thoroughbred racehorses have been determined from epi-
[145]
demiological and histopathological studies. As previously
Humerus Caudoproximal [146]
summarized [85] these include:
Craniodistal [144, 147]
1) Absence of specific trauma, but association with Medial diaphyseal [148, 149]
repetitive, high strain loading (e.g. intense race train- Caudodistal
ing) [69, 141]. Carpus Dorsomedial third carpal bone [150]
2) A high degree of morphologic consistency and tendency Radial carpal bone [151]
to occur in certain predilection sites [142–144]. Intermediate carpal bone [89]
Common sites for stress remodelling and stress frac- Third Mid-diaphyseal and [152]
tures in Thoroughbred racehorses are presented in metacarpal supracondylar [60]
Table 3.1. Parasagittal groove [153]
3) Microdamage is chronic and occurs on a progressive Proximal palmar [154]
scale. There is often long-standing pathology at the frac- Dorsal cortex [69]
ture margins, and incomplete fractures are regularly Distal condyle [155]
identified at the same locations where complete frac- Proximal Palmar flexor region [38]
tures commonly occur [19, 143, 167–169]. sesamoid Medial sesamoid abaxial [156]
mid-body subchondral bone
Proximal Sagittal groove [157]
phalanx
Classifications of Fractures [158]
Pelvis Ilial wing [159]
Fracture classification systems have been developed in Pubis [137]
order to better direct treatment and prognostication and to [160]
provide information on biomechanical factors that pro- [161]
mote fracture and therefore could be useful in preven- [162]
tion [170]. The topography, configuration and complexity Tibia Distomedial [163]
of the fracture should be described in a thorough but con- Caudoproximal [164]
cise manner. Fracture description should include the Caudal diaphyseal [148]
‘what’, ‘where’ and ‘significance’ of the finding. For exam- Proximolateral under the head
of the fibula
ple, a typical fracture of the scapula in racehorses may be
described as ‘a complete, displaced, closed, oblique frac- Tarsus Dorsolateral third tarsal bone [165]
[166]
ture (what) at the level of the distal end of the spine (where),
separating the bone into a large proximal fragment and a Lumbar spine L5–L6 vertebral junction [136]
smaller distal fragment (significance)’ [170]. Features of
fractures and qualifiers of features are provided in Table 3.2.
typically caused by a combination of compressive, shear
and bending forces [176]. The proximal ulnar physis is not
involved in the formation of a joint and is therefore termed
Fracture Topography
an apophysis. The Salter–Harris classification system is
The bone involved and the location within the bone should therefore not completely applicable to fractures of the
be described as per Table 3.2. Fractures distal to the carpus/ proximal ulnar physis, and a specific type 1–5 scheme is
tarsus have a more favourable prognosis, primarily due to applied [178].
the capacity to supplement internal fixation with external The most common physeal fracture in horses is a Salter–
coaptation [172], but are still associated with challenges Harris type II [175]. These have been reported in the third
including poor soft tissue coverage [173]. metacarpal and metatarsal distal physes, distal femoral
Physeal fractures generally occur in foals and yearlings, physis and proximal tibial physis [175–177]. Physeal frac-
and may be classified according to the Salter–Harris type tures of the proximal tibia have a typical pattern of type II
I–V scheme [174–176] (Figure 3.20). Physeal fractures are with a lateral metaphyseal corner [179]. Type IV injuries
Table 3.2 Features and qualifiers of features applicable to fracture description.
Feature Qualifier Description
Location Epiphysis Fracture involves the end of a long bone

Physis Fracture involves an open physisa
Metaphysis Fracture involves a region of the bone adjacent to the physis
on the side closest to the diaphysis
Diaphysis Fracture involves the central region of a long bone
Direction For example, proximodorsal to Direction(s) of the fracture line(s) is (are) described from
distopalmar proximal to distal unless the direction of propagation is known
(e.g. MCIII/MTIII condylar fractures progress from distal to
proximal)
Plane For example, transverse, oblique, Orientation of the predominant fracture line
longitudinal, sagittal and dorsal
Configuration Transverse Fracture courses perpendicular to the longitudinal axis of the
bone
Longitudinal Fracture courses parallel to the longitudinal axis of the bone
Oblique Fracture courses along a flat plane obliquely through the bone
(i.e. not parallel to a transverse or longitudinal plane)
Spiral Fracture has a spiral component
Butterfly Fracture has transverse and oblique components
Extent Complete Fracture courses completely through the bone, dividing it into
two or more separate fragments
Incomplete Fracture does not course completely through the bone
Displacement Nondisplaced Fracture fragments remain in anatomic apposition
Displaced Fracture fragments separated, angulated or overriding, and no
longer in anatomic apposition
Complexity Simple One fracture line dividing the bone into two separate
fragmentsb
Intermediate May have one or two sizeable bony fragments (e.g. complete
mid-diaphyseal metacarpal/metatarsal fracture with a
butterfly component)
Complex Multiple fracture lines and 3 bony fragments or greater
comminution
Joint involvement Non-articular The fracture does not extend through an articular surface
Articular The fracture courses through an articular surface
Contamination Closed The skin overlying the fractured bone is intact and not
penetrated by the injury
Open The skin has a wound over the fracture that introduces
contamination and increases the risk of infectionc
Other Avulsion A fracture fragment that distracted from the parent bone by
tension through a soft tissue (tendon and ligament)
attachment
Slab A biarticular fracture with the fracture plane perpendicular to
the articular surfaces of the parent bone
Condylar Fracture involves a condyle
a
Physeal fractures are further described according to the Salter–Harris classification scheme.
b
One or two minor bone chips do not change the definition of a fracture as simple.
c
Open fractures are further classified according to [171].
Source: Stover [170]. Reproduced with permission of Sage Publication.
Classifications of Fracture 45
tend to be unstable and many require internal fixa- acute stage [185]. Taking multiple radiographic projections
tion [180]. Bridging of the physis during internal fixation (for example, as recommended in the diagnosis of third tar-
of physeal fractures should be avoided if possible as it may sal bone slab fractures) or repeating radiographs in
result in premature closure and subsequent development 5–10 days may help to confirm clinical suspicion of a non-
of angular limb deformity [180]. Type V injuries are rare, displaced or minimally displaced fracture. The use of addi-
and are often not initially radiographically detectable, but tional imaging modalities such as ultrasound (particularly
manifest as a progressive angular limb deformity [176]. for pelvic and scapular fractures), nuclear scintigraphy (for
incomplete fractures of the proximal portions of the limbs
and axial skeleton), computed tomography and magnetic
Completeness
resonance imaging (standing systems likely to be preferred
A complete fracture occurs when a bone is separated into in most cases) if available and applicable may help to iden-
two or more parts. Complete fractures may divide a bone tify and better characterize displacement [147].
into individual segments, or a fragment of bone can be
completely separated from the parent bone. An incomplete
Contamination
fracture typically involves only one cortical or subchondral
compacta without propagating to another cortical or artic- A closed fracture is one in which the skin is intact over the
ular surface. Additional subcategories of incomplete frac- fracture site, and an open fracture is one in which the skin
tures include fissure fractures, where a crack extends into is disrupted. However, intact skin that has been extensively
but not through one cortex (seen commonly in the tibia bruised or stretched becomes less of a barrier to bacterial
and radius), and greenstick fractures, where the cortex invasion. Open fractures carry a significantly poorer prog-
loaded in tension fractures and the opposing cortex bends, nosis than those that are closed [172, 182, 186]. In one
such as those occasionally seen in the middle of the meta- study, closed fractures were 4.2 times more likely to remain
carpal/metatarsal diaphysis in foals [181]. uninfected and horses were 4.6 times more likely to leave
the hospital following internal fixation than open frac-
tures [187]. A follow-up retrospective study from the same
Complexity
institution did not find an association between open frac-
Fracture complexity must be considered when formulating tures and surgical site infection; however, the authors pos-
treatment options and prognosis. In adult horses, recon- tulate that a relationship may have been missed due to the
struction of a complex fracture should not be attempted inclusion of fewer open fracture cases in the more recent
unless there is at least 180° of the cortex available to sup- study [188]. In human traumatology, open fractures are
port axial weight bearing and load sharing with any subdivided into types I–III based on the length of skin
implants [180]. Cortical discontinuity or comminution opening and soft tissue damage [171]. Most equine open
results in a gap at the fracture site such that there is no fractures are type I (skin laceration <1 cm) or type II (larger
fracture compression with applied axial loads. A fracture skin laceration, but little tissue loss). Type III is defined as
gap promotes cyclic bending or torsion of the implant with an open fracture with extensive lacerations, massive skin
the fulcrum at the level of the fracture and results in even- defects and gross contamination [180]. The majority of
tual failure of the implants [180]. Many complex long bone horses that sustain type III open fractures are euthanized
fractures that are not considered repairable in the adult without an attempt at repair [180].
horse are repairable in the foal because of lower body
weight and propensity for rapid healing [172, 181–184]
Articular Involvement
(Chapter 37).
Articular involvement often influences treatment deci-
sions and can affect prognosis depending on the location of
Displacement
the fracture. Disrupted articular congruity can predispose
The distinction between non-displaced, minimally dis- to development of osteoarthritis and reduce the prognosis
placed and displaced fractures is often arbitrary and can be for return to athletic activity. For example, conservative
difficult to define radiographically. Complete oblique and management of all but the smallest supraglenoid tubercle
spiral fractures of the proximal long bones (humerus, fractures typically results in residual lameness secondary
radius, femur and tibia) can displace markedly due to the to osteoarthritis of the shoulder joint [189]. In other ana-
forces placed on the fragments by associated large mus- tomic locations, articular involvement does not appear to
cles [180]. Non-displaced or minimally displaced fracture be as detrimental. For example, 98% of horses that sustain
lines may not be obvious on radiographs obtained in the an incomplete fracture of the proximal aspect of the third
I II III IV V
Figure 3.20 Salter–Harris physeal injury classification. Type I injuries are confined to the physis. Type II injuries traverse along the
physis and then exit into the metaphysis. Type III and IV injuries involve the epiphysis and adjacent articulation. Type III injuries are
restricted to the epiphysis and physis, while type IV injuries cross into the metaphysis. Type V injuries are compression fractures of the
physis with little or no displacement. Source: Modified from Richardson et al. [177].
metacarpal bone return to athletic function, even though Pathologic fractures occur through abnormal or diseased
these fractures typically involve the carpometacarpal bones at lower loads than those that would cause fracture
joint [190]. in healthy bones. Among the more common examples of
conditions that predispose to complete fracture are neopla-
sia (e.g. osteosarcoma, lymphosarcoma and chondrosar-
Other Factors
coma) and osteomyelitis [193–196]. Regionally, in
Involvement of additional bones can substantially impact California, a silicate-associated systemic osteoporosis syn-
prognosis. For example, an axial proximal sesamoid frac- drome known as ‘bone fragility’ manifests with pathologic
ture occurring concurrently with a displaced lateral condy- fractures [197]. Most affected horses have concurrent pul-
lar fracture is associated with a poor prognosis for return to monary silicosis and a history of exposure to soil contain-
athletic function [177]. Disruption of vasculature supplying cytotoxic silica dioxide crystals [198, 199]. Horses with
ing the fracture site can slow or prevent healing or lead to pituitary pars intermedia dysfunction (PPID) or chronic
avascular necrosis precluding the possibility of salvage. hyperglucocorticoidism are also susceptible to pathologic
Examples include transection of the popliteal artery in fractures [200]. Fractures associated with a pre-existing
femoral fractures [191] and thrombosis of palmar/plantar stress fracture or subchondral stress remodelling are also
digital arteries in acute fetlock breakdown injuries [192]. considered pathologic fractures.
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55
Fracture Epidemiology
T.D.H. Parkin
Bristol Veterinary School, University of Bristol, Bristol, UK
State of Knowledge genuinely reflect differences in outcome, but it is also the

case that the same outcome (in particular fatal injury)
In the last 20 or 30 years, epidemiology research groups, has been referred to in several different ways by different
around the world, have focussed efforts on addressing one authors. For example, authors have referred to a fatal injury
of the primary welfare concerns associated with equine as a ‘catastrophic injury’ or a ‘fatal musculoskeletal injury’.
sports, i.e. how to minimize the risk of injury in horses I have retained the original terminology used when refer-
competing for human pleasure. Most sports-horse-related encing individual papers, but readers should be aware that
injuries that result in euthanasia affect the musculoskeletal all three definitions relate to the same outcome.
system, in particular the bony structures of the distal limb.
For this reason, the majority of work has focussed on iden-
tification of risk factors and preventive measures to miti- eographic, Discipline and Horse
G
gate such injuries. Equine fractures that have been the Level Incidence
subject of epidemiological analyses are predominantly
non-traumatic and related to exercise, principally during The measure of incidence used in different studies largely
racing and training but also in other forms of equestrian depends on the focus of the study. For example, studies that
competition. There is a dearth of published information on focus on competition (in the main racing) ideally quote fig-
the epidemiology of fractures in the non-sports horse. As a ures that describe the number of fractures as ‘X’ per 1000
result, the majority of this chapter focuses on work con- starts, whereas those that focus on training need to describe
ducted in competition horses. the number of fractures as ‘X’ per 100 horse years or months
The chapter is structured to firstly describe the relative at risk. The success of interventions cannot genuinely be
incidence of different fracture types in different disciplines assessed unless appropriate measures of pre-intervention
or horse populations in different geographical locations in risk are used. A small reduction in the number of fractures
both racing (competition) and training. Secondly, it sum- or injuries at a particular racecourse/racing jurisdiction/
marizes work conducted on the identification of risk fac- yard/competition venue should not be regarded as good evi-
tors for different types of fracture, in competition and dence of effective intervention unless the number of starts/
during training. In recent years, research in this field has horse months at risk at that location is also reported.
attempted to better predict which horses are most likely to
sustain a fracture. In other words, we have moved from the
Incidence of Fractures Sustained During
identification of risk factors to trying to identify the ‘at-risk’
Competition
horse. A description of how these efforts are proceeding is
included. The chapter concludes with a short commentary Thoroughbred Racing
on predictability and the potential for pre-fracture screen- A number of epidemiological studies of racehorse injury or
ing methods that could be employed in order to minimize fatality have identified the structures or tissues affected.
the risk of injury in equine athletes. Some of these studies have relied upon racecourse veterinary
It is worth noting that over the years different case def- reports [1–6] or clinical records [7, 8], whereas others have
initions have been used for studies in this area which initiated or used post-mortem examinations to ensure accurate

56 Fracture Epidemiology
fracture classification [9–13]. The cost of racecourse post- 1996 and 1998, referred to ‘sesamoid/fetlock’ at 0.52 per
mortem programmes often restricts their implementation, 1000 starts, ‘cannon/splint’ at 0.46 per 1000 starts and
but recent work suggests that, provided these are accurate ‘carpal/accessory carpal’ at 0.36 per 1000 starts as the most
and use precise case definitions, they are invaluable [14]. At common locations [1]. However, this study also reported a
the very least, it is important that racecourse veterinary sur- significant number of fractures at ‘unknown sites’ (1.42
geons, reporting to injury databases, attempt to identify per 1000 starts), and it was this, in part, that prompted a
which bone is fractured. As the majority of fatal fractures sus- further study that aimed to accurately describe the
tained during racing are associated with the metacar- anatomical location of all fatal distal limb fractures
pophalangeal joint [3, 4, 6, 7, 10, 11], this can often simply occurring in Thoroughbred racing in the UK between 1999
involve opening the joint from the dorsal aspect to confirm and 2006 [10]. Overall, the incidence of fatal distal limb
which and how many bones are involved. fracture per 1000 starts was 0.38 on turf flat, 0.72 on all-
weather flat, 0.93 in hurdle races, 1.37 in races over
Thoroughbred Racing in North America Studies of races held steeplechase fences and 2.17 in national hunt flat races
at New York racecourses between 1983 and 1985 reported (introductory races for horses that are being prepared for
2.1 fractures per 1000 starts on dirt tracks and 1.1 per 1000 jump racing and which have not previously run in flat
starts on turf tracks [15]. In Kentucky, between 1992 and races). The frequency of the most common types of fatal
1993, 1.4 catastrophic injuries per 1000 starts were distal limb fractures in different types of race in GB were
reported [16]. The majority of these injuries affected bones also calculated: fractures of the lateral condyle of the third
in the forelimb. In 1990, the California Horse Racing Board metacarpal bone were most common in jump racing (0.28
(CHRB) requested that the California Veterinary Diagnostic per 1000 starts in hurdle and 0.96 per 1000 starts in national
Laboratory System carry out post-mortem examination of hunt flat racing), proximal phalangeal fractures were most
all horses that die at racetracks under the jurisdiction of common in turf flat racing (0.16 per 1000 starts) and biaxial
the CHRB. Subsequently, the risk of fatal fracture on these proximal sesamoid fractures were most common in all-
tracks during the 1990s was reported as 1.5 per 1000 weather flat racing (0.39 per 1000 starts) [10].
starts [17, 18]. Recent data recorded by British Horseracing Authority
More recently, the Jockey Club in the North America ini- veterinary officers reported an overall incidence of fatality
tiated the routine collection of (fatal) injury data from in flat racing of 0.76 per 1000 starts between 2000 and
North American racetracks, known as the Equine Injury 2013 [4]. It also estimated that in flat racing the incidence
Database (EID). Currently, racetracks that stage 96% of all of fracture (and fatal fracture) of the third metacarpal or
race starts in North America contribute to the database. metatarsal bone (Mc/Mt3) was 0.30 (0.19) per 1000 starts,
Between January 2009 and December 2014, there were 2.0 the pelvis 0.26 (0.08) per 1000 starts, the proximal phalanx
fatal and non-fatal fractures per 1000 starts on reporting 0.21 (0.12) per 1000 starts and the proximal sesamoid bones
racetracks [19]. Annual statistics relating to the risk of fatal 0.07 (0.05) per 1000 starts. These figures include all flat
injury are supplied by the Jockey Club, which in the last races on turf and all-weather surfaces, and it was noted
four years have shown a significant reduction in the risk of that the overall risk of bone injury (of which 94% were
fatal injury from 1.89 per 1000 starts (2014) to 1.61 per 1000 described as fractures or possible fractures) on all-weather
starts (2017) [20]. The majority of these injuries involve a surfaces was 1.5 per 1000 starts compared to 1.24 per 1000
distal limb fracture, so it is fair to assume that the figure of starts on turf. In a follow-up study, the same authors calcu-
2.0 fractures per 1000 starts reported between 2009 and lated that the risk of fatal or non-fatal distal limb fracture
2014 [19] will have dropped by a few decimal points since in all-weather flat racing was 0.95 per 1000 starts [5]. In
that time. All in all, there has been a 20% drop in the inci- national hunt flat races between 2000 and 2013, the inci-
dence of equine fatal injury during racing in North America dence of fracture (and fatal fracture) that included Mc/
between 2009 and 2017. On the assumption that the num- Mt3 was 1.03 (0.88) per 1000 starts and the pelvis was 0.42
ber of starts had remained constant, this is equivalent to (0.22) per 1000 starts [3].
approximately 150 fewer horses dying on North American
racetracks in 2017 compared with 2009. Thoroughbred Racing in Other Countries Recent work from
Australia estimated the risk of fatality in flat racing in New
Thoroughbred Racing in the UK Between 1987 and 1993, South Wales and the Australian Capital Territory [6].
reports indicated that catastrophic fractures occurred with Overall, the incidence of musculoskeletal fatality was 0.52
frequencies of 0.33 per 1000 flat, 1.4 per 1000 hurdle and per 1000 starts with a fracture risk of 0.35 per 1000 starts.
2.3 per 1000 steeplechase racing starts [2]. The sites of Euthanasia following proximal sesamoid bone fracture had
fractures recorded by racecourse veterinarians, between an incidence of 0.07 per 1000 starts with fetlock as the
Geographic, Discipline and Horse Level Incidenc 57
reported site in 0.06 per 1000 starts. Obviously, utilizing the of cases from a single region, in the 2007–2008 season, there
term fetlock does not identify which bone was fractured, were 4.2 fractures per 1000 starts [24]. One horse was subject
and it is likely that some of ‘fetlock’ fractures were also to euthanasia at the ride following a fracture resulting in an
fractures of the proximal sesamoid bones. A study in estimate of 0.35 fatal fractures per 1000 starts. However,
Victoria between 1989 and 2004 reported the risk of fatality given the fact that this was a single fatality, this estimate
as 0.44 per 1000 flat race starts and 8.3 per 1000 jump race should be treated with caution. Interestingly, the anatomical
starts [13]. This study further described the risk of locations predominantly affected closely mirror those of the
‘catastrophic limb injury’ as 0.32 per 1000 starts in flat Thoroughbred racing on turf with the lateral condyles of
racing and 5.7 per 1000 starts in jump racing. Mc3 (37%: 14 of 38) and the proximal phalanx (21%: 8 of 38)
A recent review of many years of work by the Japan being the two most common sites of fracture [24].
Racing Association demonstrates the value of monitoring
data over a prolonged period and also highlights significant Eventing
differences in the risk of fatal fracture in Thoroughbred There is limited information available about the risk of frac-
racing around the world [7]. In 1980, the incidence of fracture and types of fracture sustained by eventing horses [25,
ture (fatal and non-fatal) during racing was approximately 26]. Two reports indicate that fractures are relatively rare,
23 per 1000 starts, whereas the latest figures presented whether in competition or during training, particularly in
show a significant decrease to 14 per 1000 starts in 2001. comparison to soft tissue injuries. Neither study attempts to
The risk of fracture while racing on turf was reported as a quantify risk, in terms of numbers of fractures per 1000
14-year (1987–2000) average of 17.7 per 1000 starts and on starts during, in particular, the cross-country phase.
dirt as 19 per 1000 starts. A 10-year average of fatal fracture
(euthanasia following a fracture) during racing (1985–
Incidence of Fractures Sustained During
1994) was reported at 3.2 per 1000 starts.
Training
Work from Hong Kong focussed on proximal limb, and
pelvic fractures (only) reported no significant difference in Thoroughbred Training
risk between dirt (0.27 per 1000 starts) and turf (0.31 per Far fewer studies have been conducted to investigate the
1000 starts) tracks [8]. Fractures during racing that resulted risk of, or risk factors for, fracture during training com-
in euthanasia had an incidence of 0.08 per 1000 starts; all pared to racing. This is due to the ready availability of data
of which occurred on turf. from racing in contrast to the need to design robust studies
and data collection protocols and to recruit trainers who
Quarter Horse Racing are willing to participate.
In comparison to Thoroughbreds, little epidemiological Additionally, studies of horses in training lack an obvious
research has been conducted in Quarter Horse racing denominator, as with ‘per 1000 starts’ in racing which also
[21–23]. All of the information comes from the work con- complicates attempts to examine risk of fracture away from
ducted through the CHRB Post-mortem Program. Even the racecourse. It might be optimal to quantify risk per
though full post-mortems were conducted, the predomi- training events at different speeds, but that level of detail is
nant fracture site was described as the fetlock (0.76 per rare and it is more common to simply report fracture rates
1000 starts) followed by the carpus (0.48 per 1000 starts), by the number of horse months. This also has the advantage
vertebra (0.14 per 1000 starts) and scapula (0.13 per 1000 that one can directly compare different trainers with differ-
starts) [21]. The work demonstrates some clear differences ent numbers of horses in training for different periods of
in fractures resulting in euthanasia from Thoroughbreds: time. An inconsistency that does arise concerns the defini-
fractures of the Mc/Mt3 condyles and humerus are more tion of a ‘day at risk’. A horse on box rest is generally
common in Thoroughbreds, whereas carpal, vertebral (par- regarded as not being at risk of a training-related fracture.
ticularly lumbar) and scapula fractures are more common in But, is a horse at risk when it is walking and trotting, cantering
Quarter Horses [22, 23]. The authors hypothesized that dif- or only when doing galloping speed exercise? Similarly, at
ferences may be due to inherent breed characteristics such how much greater risk is a horse that is galloping compared
as conformation or limb geometry affecting locomotor bio- to when cantering? Such questions complicate markedly
mechanics and, as they compete in races of very different the investigation of training fracture risk.
distances, there are also consequent differences in speed. The majority of training-related work has been con-
ducted in the UK [27–29]. The first study included details
Endurance Riding of 1178 horses providing almost 13 000 horse months in
There is very little epidemiological information relating to flat race training. Using total months in training as the
fractures sustained during endurance rides. In a small series denominator, the incidence of non-traumatic fractures
was estimated at 0.94 per 100 horse months [27]. It is and 25% in three-year olds. With a mean of 95 days lost per
important to note that this estimate excludes 22% of frac- two-year-old fracture case and 115 days lost per three-year-
tures in the same population that occurred during racing. old fracture case.
The most common sites of fracture were Mc3 (20%), ilium Further evidence of the impact of fracture on training is
(16%) and tibia (14%). The respective estimates of inci- provided in a retrospective study of veterinary records from
dence rate were 0.22 per 100 horse months (Mc3) and 0.16 three training yards in Newmarket [32]. Over the period of
per 100 horse months (pelvis and tibia). study, an average of 332 horses were in training, and 50
A similar study of horses in jump race training collected tibial stress fractures, 35 proximal phalangeal fractures and
information on almost 9500 horse months (1119 horses) [29]. 27 carpal fractures were recorded. Average annual injury
The incidence rate estimate for fracture in these horses was rates (musculoskeletal injuries in general) were similar
0.6 per 100 horse months, i.e. lower than that of their flat between the three yards (between 23 and 26%). However,
race counterparts. However, when comparing the incidence there were significant differences in the types of fracture
rates for the two groups during racing (18.7 fractures per 100 seen in different yards with proximal phalangeal fractures
horse months in flat racing and 27.6 per 100 horse months in being up to three times more common in one yard com-
jump racing), the reverse is true. Although exposed to a sig- pared with the other two, and tibial stress fractures being
nificantly greater risk of fracture during racing, horses in more than twice as common in one of the other yards.
jump race training are at reduced risk compared with flat These studies demonstrate how important it is to accu-
racehorses. This may reflect the relative infrequency of rately record detailed information about the occurrence
jumping during training, the reduced speed (compared to and impact of fractures during training as well as racing in
flat racehorses) or a combination of these factors. order to clearly identify the level of risk to which horses are
A large study from New Zealand followed 1571 horses exposed. Without this, it is impossible to assess the impact
during 3333 training preparations over 392 290 training of intervention. The fact that there were significant yard-
days [30]. A total of 55 fractures were recorded, and the level differences in both studies also show how important
authors estimated that the incidence rate for first occur- it is, where possible, to conduct studies at the individual
rence fracture-related lameness was 0.14 (95% confidence trainer level. There are almost certainly unique trainer
interval 0.1–0.18) per 1000 training days, and for second characteristics that increase or decrease the risk of fracture
occurrence it was 0.16 (95% confidence interval 0.08–0.3) or injury more generally. If data are collected and investi-
per 1000 training days. The first incidence rate equates to gated as a whole from a number of trainers and not inter-
0.43 fractures per 100 horse months, suggesting that there rogated for individuals, subtle important differences will
are significant differences in the rate of fracture in be lost and interventions will be less effective. That said,
Thoroughbreds being trained in different parts of the there also has to be a consideration of statistical power and,
world. It is important to remember that such differences for some less frequent outcomes, it is often an unavoidable
could be due to different gene pools as well as differences necessity to collect data from multiple trainers.
in how horses are trained and raced.
Quantifying the number of days lost from training has Showjumping Training
been the focus of a few studies, providing valuable informa- One significant international study used the concept of
tion about the medium-to longer-term impact of fractures. days lost to training to describe problems associated with
In one study data from seven UK training yards reported elite showjumping horses [33]. The authors note that only
incidence rates for two- and three-year-old horses sepa- 6% of available training days were lost – far fewer than
rately [31]. Stress fracture incidence rates were similar for comparative estimates from Thoroughbreds. It perhaps
two- and three-year olds at 1.48 and 1.43 per 100 horse says something in itself, about the prevalence of fracture,
months, respectively, but the incidence of fatal fracture was that the word is not used in the paper. Clearly, injuries as a
almost twice as high in three-year olds compared with two- whole and in particular fractures are far less common in
year olds (0.3 and 0.17 per 100 horse months, respectively). the elite showjumper. The best approximation of the
The most common fracture site seen in both two-and three- impact of fractures comes from the estimate that 22% of the
year olds was the pelvis with cumulative incidences of 3% 2357 (from a total of 39 028 horse days at risk) days lost
and 5% in two-and three-year olds, respectively. Overall, of were due to an acute orthopaedic injury. This equates to
52 601 days available for training in two-year olds and only 1.3% of all available training days.
29 369 days available for three-year olds, 27% of two-year-
old days (14 091 days) and 22% of three-year-old days Measures of Fracture Incidence in Other Horses
(6324 days) were lost from training. Of the total days lost Reports of fracture incidence rates in other breeds or non-
from training, fractures accounted for 18% in two-year olds sports horses are few and far between. There is some work
Risk Factors, Predisposing Factors and Evidenc 59
that describes differences in the type and configuration of so they will continue to be reported, even if their impact
carpal bone fractures in Thoroughbreds compared with and usefulness are limited.
Standardbreds (and Quarter Horses). However, this work is
based on veterinary records of horses admitted to a particu-
Risk Factors Associated with Training
lar referral hospital in the USA and does not provide any
Regimens
denominator data from which it may be possible to pro-
duce estimates of incidence [34]. A more recent study A major focus of work to identify, in particular modifiable,
based on 356 Standardbred racehorses, providing 8961 risk factors has been the association between training regi-
horse months at risk, does provide some estimates of inci- mens and the risk of fracture in either racing or training. Early
dence risk for a number of different types of fracture [35]. studies in the USA reported that the total distance accumu-
The authors calculated that the most common fracture lated during a two-month period was associated with the risk
types in this population were those affecting the proximal of catastrophic musculoskeletal injury [39], and that risk was
sesamoid bones (0.32 per 100 horse months), followed by greatest within a 30-day period of above average high-intensity
proximal phalangeal fractures (0.28 per 100 horse months) exercise [42]. In these studies, a period of high-intensity exer-
and both pelvic and Mc/Mt3 fractures (0.16 per 100 horse cise was defined as a 60-day period, where the average daily
months). In comparison to Thoroughbreds in training, it high-speed distance accumulated was in the top 25th percen-
appears that the incidence of pelvic fracture is similar; tile of daily high-speed exercise distances across the popula-
proximal sesamoid bone and proximal phalangeal fraction. The authors estimated that this level of high-speed
tures are more common in Standardbreds; and fractures of exercise equated to approximately 25 furlongs (5000 m) per
Mc/Mt3 are marginally more common in Thoroughbreds. 30-day period or approximately six furlongs per week.
Away from sports horses, some work has focussed on the Further studies from California investigated risk factors
geriatric horse [36–38]. This indicates that lameness is a sig- for suspensory apparatus failure and fractures of the Mc3
nificant problem in the older horse, and is the primary rea- condyles [43] and scapula [44]. A longer interval since the
son for euthanasia. However, fractures are not of particular last 60+-day period without a race and the distance exer-
concern, and the authors suggest that this is, at least in part, cised in the last month (suspensory apparatus failure) or
due to changes in management and reduced exercise levels. two months (Mc3) were associated with an increased risk.
For every extra day since the last 60+-day lay-up, the odds
of condylar fracture increased by 0.3%. The odds of suspen-
isk Factors, Predisposing Factors
R sory apparatus failure remained level for up to 120 days
and Evidence since the last 60+-day lay-up, but increased thereafter: 3.4
times for periods between 121 and 214 days since the last
All but a very few epidemiological studies that have sought 60+-day lay-up and 5.9 times for periods greater than
to identify risk factors for fracture have been conducted in 320 days since the last 60+-day lay-up. For every extra fur-
Thoroughbreds, and from these a large number of different long exercised at fast pace, the odds of both outcomes
risk factors have been shown to be associated with various increased by 4% [43]. Most significantly, the work on scap-
different fracture outcomes. Some risk factors have been ular fractures, although limited somewhat by a lack of sta-
identified in one or two studies only, and others are clearly tistical power, demonstrated that a tapering off of the total
not modifiable. For this reason, the primary focus of this distance in the month prior to fracture (compared with the
section is on the more commonly identified risk factors and preceding month) was seen more frequently in horses with
those that have the potential to be altered by way of care- fractures compared to control horses [44].
fully designed interventions. A range of exercise-related risk factors were demon-
Gender is a good example of a risk factor for fracture that strated by the same group when investigating proximal
has been commonly identified as being important [18, 19, sesamoid bone fractures [45]. For example, compared with
39–41]. However, it is obviously unrealistic to expect male horses that died or were subject to euthanasia for other rea-
or female horses to be prevented from racing, or indeed sons, horses that had sustained proximal sesamoid bone
entire males to be gelded purely to reduce the risk of frac- fracture(s) were more likely to have spent a greater time in
ture when racing. However, such findings do have value in active training and racing, completed more exercise events,
that they may provide insight into the pathogenesis of a exercised further during their whole career and had higher
particular injury type. From an analytical point of view, it exercise intensities in the 12 months prior to fracture.
is also important to include such risk factors in multivari- Similar work conducted in the UK has identified associa-
able models to account for the potential confounding effect tions between the risk of fracture in training or racing and
that they may have on other risk factors within the model, exercise distance over relatively short time periods [28, 46].
Horses that trained over more than 220 furlongs (44 km) at more specifically the subchondral bone of this region has
canter speed and 30 furlongs (6 km) at gallop speed, in a been shown to undergo an adaptive response to high-speed
30-day period were at the highest risk of fracture [46]. exercise [60]. The bones of the horses which were doing no
More specifically, the risk of pelvic or tibial stress fracture high-speed exercise in the observational epidemiological
increased with increasing distance cantered up to a maxi- studies are therefore unlikely to have adapted to the loads
mum at around 250 furlongs (50 km) per 30-day period [28]. that they would experience under racing conditions, thus
Importantly, the associations with the gallop distance cor- exposing them to increased risk of fracture [54, 55].
respond very closely with those reported in California (six In the final multivariable models produced for catastrophic
furlongs per week) [42]. Even though the case definitions distal limb fracture and lateral condylar fracture, the best-
and the populations studied were quite different, the fact fitting form of the variable relating to the distance galloped in
that these results concur is regarded as evidence of a true training indicated that the risk was highest for horses doing
causal effect and provides greater confidence when offer- no fast work. For horses doing between 4 and 10 furlongs of
ing advice on optimal training distances at different speeds. fast work per week, the risk was reduced, and thereafter the
The association between average fast-pace distance and level of risk did not alter [54, 55]. Only a few high load cycles
musculoskeletal injury has also been demonstrated in have been demonstrated as sufficient to induce an osteogenic
studies from Australia [47, 48]. In the first of these, two- response in avian ulnas [61]. By extrapolation, relatively
year-old horses that had a greater percentage of fast work short distances of gallop work during training may be ade-
days during their first fast work preparation were more quate to stimulate adaptation and be protective against frac-
likely to sustain musculoskeletal injury that ended the ture during racing. Alongside the previous work suggesting
training preparation. The average distance trained at an optimal six to seven furlongs of fast work per week, these
speeds greater than or equal to 800 m/min was also posi- findings may contribute to the formulation of training regi-
tively associated with musculoskeletal injury [47]. The sec- mens specifically designed to reduce the risk of fracture.
ond study investigated fatalities in flat racing and An important caveat to these conclusions is that infer-
demonstrated that the high-speed distance accumulated ring causality is difficult, and it is possible that the associa-
during the period 31–60 days prior to a race start was most tions between the absence of fast exercise and increased
important in determining the likelihood of fatality [48]. In risk of fracture are an example of effect rather than cause.
a parallel study of fatalities in jump racing, the total num- In other words, horses that are suffering sub-clinical injury
ber of career starts and having started more than once in are unable to train to the same extent as the rest of the pop-
the period 14 days prior to the case race were both associ- ulation, and it is the sub-clinical injury itself and not the
ated with an increased likelihood of fatality [49]. Although reduced exercise that increases the likelihood of fracture.
these studies used a broader case definition of ‘fatality’, it At this point in epidemiological investigations, it becomes
was previously reported that the majority were due to mus- necessary to either design intervention studies that pro-
culoskeletal injury [13]. It is therefore most likely that this spectively examine the impact of a training modification
result is due to the effect of exercise as identified in the that is designed to minimize the risk of fracture (for exam-
studies conducted in the USA and the UK. The moderate ple in this case to ensure all horses do at least some fast
differences in hazard periods between these studies may be work) or to encourage more comprehensive recording of
due to the broader case definition or to local differences in veterinary and treatment records of horses in training so
the racing population and racing and training practices. that existing (sub-) clinical injury can be accounted for dur-
All of these studies provide good evidence of an association ing the model building process [62].
between increased amounts of high-speed exercise and risk Another important aspect of an effective training regimen
of severe musculoskeletal injury and/or fracture that support are rest periods and correct management of return from rest.
the hypothesis that horses doing large amounts of fast exer- In the racehorse, some work has demonstrated that inap-
cise accumulate (sub-clinical or clinical) bone damage that propriate rest periods can be detrimental. In the California
can ultimately result in catastrophic failure [50–52]. post-mortem studies, a hazard period of up to 10 days fol-
At the other end of the ‘exercise scale’, a few studies have lowing a 60+-day period of rest was identified as being most
demonstrated the deleterious effect of a lack of fast train- significant with respect to the risk of fracture [63]. As previ-
ing work on the risk of fracture during racing [53–55]. The ously intimated [64], the authors hypothesized that this may
ability of bone to adapt to its mechanical environment is be due to the fact that osteoclastic resorption had taken
well documented [56, 57], and in the racehorse this is prin- place, but osteoblastic remodelling was not yet complete.
cipally influenced by the training programme to which the The bones of horses returning to exercise before the
horse is exposed. Changes to the distal condyles of Mc/Mt3 remodelling process is complete are likely to be less able to
of horses in race training have been observed [58, 59], and withstand training load than before the period of rest. Based
Risk Factors, Predisposing Factors and Evidenc 61
on the differing rates of osteoclastic and osteoblastic activi- study conducted approximately 10 years later failed to
ties, the hazardous period of rest is hypothesized to be identify the same toe-grab-related associations [45]. The
between 30 and 90 days [65]. Humeral fractures were found authors suggest that this may have been due to the con-
to have significant acute callus formation, indicating stress founding effect of other exercise-related variables. It is also
fracture remodelling prior to catastrophic failure [63]. It is likely that publicity surrounding the initial work and the
plausible that it is only for fatigue/stress fractures that the subsequent banning of high toe grabs on front shoes is a
length of rest period is important. Greater data resources demonstration of intervention and messaging that has had
will enable the refinement of case definitions to allow the the desired effect. In other words, 10 years on, the effect of
investigation of risk factors for specific injuries. It is there- this particular risk factor has somewhat diminished.
fore likely that future studies will identify associations with The value of being able to include treatment records in
periods of rest for other fracture types that have a similar predictive models was demonstrated in a study examining
pathogenesis to humeral fracture. the hazard of musculoskeletal injury in the days and weeks
following local corticosteroid injection [62]. This compared
the incidence in untreated horses or in horses prior to
The Importance of Detailed Information About
treatment with local corticosteroid injection (1.22 per 100
Horses Under Investigation
horse months) with that post treatment. On average, the
Current epidemiological work aimed at minimizing fracture hazard increased by 4.8 times and only returned to a level
incidence is moving towards prevention by way of accu- that was indistinguishable from that seen in untreated
rately identifying horses at significant risk. In order for such horses or horses prior to treatment after 49 days. Work from
predictive models to be useful, it is important that the overall the USA was less precise in the estimates of risk, but never-
accuracy of prediction is high. At present, the predictive theless also showed that once a horse has been placed on a
ability of models (Section Predictability and Potential for ‘vets list’ the risk of fracture for that horse was 80% greater
Effective Screening) is too low for use in a regulatory frame- in all future starts, regardless of how long after being placed
work. One of the reasons for this is a lack of detailed infor- on the vet list those starts occurred [19]. In certain races in
mation regarding specific aspects of exposure to a wide South America, declared use of phenylbutazone is permit-
range of risk factors. A few studies have demonstrated the ted, and horses competing in these races were at approxi-
value of proactively acquiring, otherwise unavailable infor- mately 80% greater odds of musculoskeletal injury
mation. Characteristics of the hoof [66] and shoe [45, 67] compared with horses competing in races in which phe-
and details of veterinary history [19, 62, 68–70] have all been nylbutazone was not permitted [68, 69]. Similarly, in a case
shown to be associated with risk. series of almost 1500 horses receiving intrasynovial medi-
Multiple measurements of hooves from horses that were cation, those horses that had received more than three pre-
subject to euthanasia due to Mc3 condylar fracture or sus- vious ‘treatments’ were more than twice as likely to sustain
pensory apparatus failure were compared with hooves a fracture within 56 days, compared with those that had
from horses whose death was unrelated to the musculo- been medicated fewer than four times [70]. Finally, a ques-
skeletal system [66]. Increasing toe angle, increasing lat- tionnaire survey of attending veterinarians in California
eral ground surface width and increasing sole area demonstrated that horses that had been subject to euthana-
difference (difference between the lateral sole area and sia due to catastrophic musculoskeletal injury were more
medial sole area) were all associated with significantly likely to have been lame in the period three months prior to
lower risk of condylar fracture. Increasing sole area differ- the date of death [71]. The study also attempted to identify
ence was also associated with lower risk of suspensory associations with recent medication usage, but largely due
apparatus failure, while increasing toe–heel angle differ- to the high proportion of horses (both cases and controls)
ence was associated with an increased risk of suspensory on medication and the relatively low level of statistical
apparatus failure [66]. power, no such associations were identified.
Horse shoe characteristics, in particular the use of toe In order to better determine the true relationship between
grabs, were strongly associated with the risk of suspensory veterinary and medication history and the risk of fracture or
apparatus failure and Mc3 condylar fracture. Compared other injury, it is essential that racing jurisdictions make fur-
with horses shod without toe grabs, low toe grabs increased ther attempts to encourage the accurate recording of and
the odds of each outcome by 6.5 and 7 times, respectively, willingness to share medical records. Once issues surround-
while the use of regular toe grabs increased the odds by 16 ing confidentiality are addressed and this becomes normal
and 17 times, respectively [67]. The odds of suspensory practice, the inclusion of such data in future predictive mod-
apparatus failure, for horses with rim shoes, was about a els will undoubtedly improve our ability to better identify
third that of horses without [67]. Interestingly, a follow-up horses at increased risk of fracture.
redictability and Potential

P demonstrating a clear difference when the prevalence of the
for Effective Screening outcome of interest is so different. In the study population,
because the work was designed as a case–control study, the
The majority of work in the field of prediction and screening prevalence of lateral condylar fracture was 47%, thus pro-
for injury or fracture has focused on joint injury and potential ducing a positive predictive value of 84%. However, when
biomarkers in blood or urine [72–74]. The link between joint proposed as a screening tool for, at the extreme, all
injury and subsequent fracture is often referred to in these Thoroughbreds in training (for which the prevalence of lat-
publications, suggesting that the ultimate goal is to predict eral condylar fracture was estimated to be 0.5%), the posi-
and prevent catastrophic fracture (as well as less dramatic tive predictive value drops significantly to 3%. In other
lesions such as osteoarthritis). A recent review highlights words, only 3% of ‘test-positive’ horses would be truly posi-
that there is some way to go before blood or urine biomarkers tive and therefore at genuine risk of lateral condylar frac-
will be useful, and highlights the need to establish standard- ture [75]. Nevertheless, the authors do point out that routine
ized methods of sample collection, reproducible marker MRI assessment of the depth of dense subchondral/trabec-
measurement and well-documented biobanks [72]. ular bone within the palmar half of the lateral sagittal
Two papers looking at biomarkers for fracture or musculo- groove of distal Mc3 can be a useful ancillary test when
skeletal disease in two- and three-year-old Thoroughbreds investigating lameness in racehorses. In essence, the clini-
demonstrate both the difficulties and also their potential for cal examination in this situation is acting as the pre-
future use [73, 74]. The first failed to identify any significant screening test, selecting for MRI examination those horses
associations between ‘start of season’ bone biomarker levels that are more likely to be at risk of fracture.
and subsequent fracture [73]. This is perhaps unsurprising as Work with computed tomographic images [77, 78] and
fractures often occurred some months after blood samples microradiography [79] has shown some potential to predict
were taken. The second study addressed this deficiency by fractures of the lateral condyle of Mc3 [77] or proximal
acquiring monthly blood samples during training [74]. When sesamoid bones [78, 79]. Bone density at the distal articular
longitudinal samples were investigated, there were some sig- surface of Mc3 was significantly greater in fractured bones
nificant associations between changes in a range of biomark- and contralateral bones from the same horse, compared
ers and subsequent musculoskeletal disease (one of which with bones from horses that had sustained a non-limb-
was stress fracture). The authors quote a 73.8% ability to correlated death or euthanasia while racing. The heterogene-
rectly classify horses as injured or not. However, further calcu- ity of articular surface bone density was also greater in
lations from their data show negative and positive predictive fractured bones [77]. In proximal sesamoid bones, mor-
values for all injury types of 81 and 68%, respectively. In other phometric differences were detected between fractured
words, 68% of subsequently injured horses would be identi- and non-fractured bones such that the abaxial margin of
fied as at risk before the event. This may be seen as some the medial base of fractured bones was up to 3.5 mm more
degree of success, but as in the imaging studies referred to prominent than in non-fractured bones [78]. Both frac-
below, it is important to remember that positive predictive tured and non-fractured bones from horses that had sus-
value is strongly influenced by the prevalence of the outcome tained a proximal sesamoid bone fracture had more
under investigation. So, when trying to predict catastrophic compact trabecular bone than bones from horses that had
fractures, which are relatively rare, without a test specificity of died for other reasons [79].
very close to 100% the positive predictive value of a test will If identification of markers for pre-fracture change can
always drop off very quickly meaning that the number of false be detected, using either existing or future imaging modali-
positives generated by that test will be high [75]. ties, then reliable screening methods for fracture risk can
More recently, magnetic resonance imaging (MRI), com- be developed. A key advance will be our ability to correctly
puted tomography and microradiography have been identify and select horses for whom such ‘intensive’ screen-
assessed with regard to their ability to identify pre-fracture ing would be most useful. Identification of a reliable pre-
changes in Thoroughbreds. As with the blood biomarker imaging screening test that effectively rules out a large
study [74], some encouraging findings were identified in a proportion of horses from being at risk of fracture should
study of MRI and the risk of lateral condylar fracture in therefore be the priority. In other words, a simple, quick
Mc3 [75, 76]. In particular, the authors identified an opti- and cheap pre-screening test that has a very high sensitiv-
mal cut-off in the depth of dense subchondral and adjacent ity (resulting in very few false negatives and a high negative
trabecular bone in the palmar half of the lateral parasagittal predictive value) is required so that only those horses that
groove, detectable using MRI, that could best discriminate are at greatest risk are evaluated. This would effectively
between bones of horses that had and had not sustained a increase the prevalence of fracture in the population sub-
lateral condylar fracture. The authors went as far as calcu- jected to the secondary test with resultant improvement in
lating the positive and negative predictive values of this cut- its positive predictive value. A substantial reduction in
off in horses with fractures, and the wider population false positive results increases the reliability of a positive
Reference 63
result and thus enhances confidence in making recom- such as alterations to training regimens based on known
mendations for future training. Such screening pro- risk factors that, in turn, should reduce the likelihood of
grammes would permit the introduction of interventions, fracture in susceptible horses.
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67
Imaging Fractures
S.M. Puchalski1 and G.J. Minshall2
1
Puchalski Equine Inc., Petaluma, CA, USA
2
I ntroduction use the technique accurately and to its fullest capacity.

Understanding the information provided by individual
Fracture is defined by Dorland’s Medical Dictionary as ‘a modalities together with anamnesis and results of the
break or discontinuity in bone’. In almost all cases, diagnos- clinical examination are critical in order to choose, utilize
tic imaging, in its various forms, is necessary to identify, and accurately interpret the best diagnostic test(s) for each
classify and monitor fractures. The goals, independent of patient. Similarly, knowledge and understanding of the
modality, are to accurately depict, characterize and quantify expected biological behaviour of bone are necessary in
bone defects. Ideally, the imaging test would also identify all order to use diagnostic imaging to monitor fracture healing.
other injuries including associated soft tissue and vascular
damage. Accurate and comprehensive evaluation is impor-
Image Quality
tant to direct a rational course of action, predict clinical
dangers, avoid potential complications and to provide an Image quality is a broadly understood concept, and assur-
accurate prognosis. ance of diagnostic quality is critical to accurate use of med-
In its simplest form, the diagnosis of a fracture is binary so ical imaging. There are several measures of image quality
with perfect sensitivity and specificity of the diagnostic imag- that are common to all techniques. Understanding these
ing test, a fracture either is or is not present. The reality of and their interactions aids in the recognition of a high-
clinical medicine is that numerous and complicated factors quality image and variation from this.
are involved in the identification and interpretation of imag- Contrast is the greyscale value difference between adja-
ing or roentgen findings that lead to a true and fully character- cent regions on the image. On the final image, this is deter-
ized diagnosis. These include, but may not be limited to, mined by a number of factors including the inherent
factors associated with the biological system (pathophysiology subject contrast, detector contrast and displayed contrast.
of fracture genesis, patient health etc.), the utilized imaging Subject contrast is determined by the tissues and the type
modality (-ies) and the observer. Most diagnostic imaging of energy (radiation, sound wave and signal intensity)
tests are a representation of the anatomy with some modali- recorded. Detector contrast refers to the way that an input
ties providing a representation of the physiology. All tests signal is converted to an output or a recorded signal. In
require that the observer accurately identifies the pertinent most digital radiography (DR) systems, the characteristic
imaging signs and interprets them correctly. curve or relationship between the energy of the X-rays
The means by which discontinuity in bone is identified hitting the detector and the emitted or recorded image is
depends on the imaging modality used. Radiography, close to linear. A linear characteristic curve without
ultrasound, computed tomography (CT) and magnetic image processing would appear very ‘flat’ or washed out.
resonance imaging (MRI) are morphological or anatomical Almost all digital imaging systems therefore process the
studies, and nuclear scintigraphy is a functional study. All output so that contrast is increased and the displayed image
are commonly used in equine practice and employ different has a non-linear output. Displayed contrast simply refers to
physics to create images. While overlap of principles exists, the ability of the end user to manipulate the greyscale so
each has unique characteristics that must be understood to that the image can have more or less contrast as desired.

68 Imaging Fractures
To put this into context, in order to identify a fracture on radiation can shift the ratio towards useful information.
radiographs, subject contrast would be the variation in tis- In MRI, this is achieved by recording intensity multiple
sue density between the fracture gap and the fracture mar- times (number of excitations).
gins, the detector contrast would be determined by the Bit depth determines the number of possible shades of
settings of the radiographic system and its processing, and grey that can be applied to the imaging systems output.
the displayed contrast would be chosen by the observer at Most medical imaging devices range from 10 to 14 bit depth
the viewing station. Together these have a substantial influ- thus having the capability of recording 1024, 4096, or
ence on the ability to detect a fracture. 16 384 shades of grey. This is beyond the limits of most
Resolution (spatial resolution) is the ability of an imag- digital displays and human resolution. The conversion of
ing system to depict two objects as separate as these get the image from a 10 bit depth image (1024) shades of grey
smaller and closer together, i.e. how small an object can be to something more useable occurs by the application of a
seen on a given modality [1]. Higher spatial resolution is lookup table that determines the displayed greyscale values
the ability to see objects that are smaller and closer together. relative to the recorded greyscale value.
The historical method of measuring radiographic and CT Contrast-to-noise ratio (CNR) and signal-to-noise-ratio
spatial resolution was by using test phantoms that actually (SNR) are computations that describe the relationship
measured the ability to separate line pairs per millimetre. between the important image quality parameters and the
Many factors influence spatial resolution for all modalities. noise of the image. CNR computes the difference in signal
Most importantly, in digital imaging systems is the pixel between the object and background, divided by the
size. The size of the pixel is determined by the number of background noise. SNR computes the integrated signal of
pixels across the field of view. Thus, a larger field of view the object (pixel signal minus noise), on a per pixel basis,
with the same pixel matrix will result in lower resolution. independent of size and homogeneity, divided by the
Objects smaller than the pixel size cannot be resolved as background noise. The SNR is a useful metric that is closely
separate structures. Blurring in the image will also detract related to lesion conspicuity or the observer’s ability to
from spatial resolution, thus geometric magnification and detect the lesion. Even without a numerical (computed)
motion (patient or imaging apparatus) should be avoided. value for SNR, it becomes a visual cue to experienced
In cross-sectional imaging, in plane resolution is directly observers whereby image degradation due to a low SNR is
related to pixel size, but the z-axis (slice thickness) readily evident (Figure 5.1).
determines the voxel size. In cross-sectional modalities, the Accuracy and precision are necessary for reliable
z-axis is an important consideration in the identification of interpretation of images. These, in turn, depend not only
fractures. If a linear structure or plane such as a fracture is on image quality but also the ability and experience of the
oblique to the acquisition plane, the margins of the line/ observer to identify true positives and true negatives.
plane will be blurred by a factor related to the slice thickness
(z-axis/voxel size) and the angle of obliquity through the
Image Interpretation
image. Spatial resolution is particularly important in the
diagnosis of incomplete or non-displaced fractures. For Principles of radiographic interpretation can be applied to
many modalities, the disruption of mineral substance in all diagnostic imaging modalities, and the classic Roentgen
these cases will be at the limits of spatial resolution. findings of variations in size, shape, opacity, number,
Image noise is an important contributor to degradation margination and position can be modified as appropriate
of image quality or degradation of the utility of a given for each of the modalities, or in the case of MRI, for each of
image. Noise caused by various systematic or random the sequences. Accurate identification and description of
variables contributes extraneous optical density (echo- the imaging signs are critical to interpretation and should
genicity, signal intensity, etc.). Digital imaging systems not only include the bone or joint in question but also the
(as compared to film screen systems) have systematic surrounding soft tissues.
noise from the electronics and the structure of the detec-
tor. Anatomic structures that are not of interest to the
Negative Studies
viewer are also a form of noise, e.g. radiographs with
bowel superimposed over the lumbar vertebral bodies. Imaging findings will be determined not only by the time
Quantum noise is important in digital diagnostic imag- since injury but also on associated tissue status, e.g. where
ing. In most instances, images made with X-rays and on the spectrum of osseous remodelling the patient is.
gamma rays use the lowest number of rays (quanta) pos- Depending upon the modality being used and the patient’s
sible to obtain a diagnostic image. When the dose is lim- signalment and anamnesis, the response to a negative
ited, the ratio of useful to non-useful information (noise) study will vary. This may lead to repeat imaging at a later
shifts in favour of the latter. Thus, increasing the dose of time point or utilizing a different modality. The observer
Radiograph 69
(a) (b)
Figure 5.1 T1W 3D dorsal plane standing MRI images of a front foot. (a) With a slice thickness of 3 mm. (b) With a slice thickness of
0.7 mm. The narrower slice thickness produces a decrease in SNR with resultant image degradation.
must take an active role in the assessment of risk to the

patient that a negative study affords and the level of rigour
that should be applied for additional or different imaging.
R
adiography
General Principles
In practice, radiography is the most commonly used imag-
ing modality and remains a cost-effective screening test for
fracture identification. Radiographs principally provide
structural information and are considered to have high
specificity but carry the risk of false negative studies.
Currently available portable generators have the output to
produce excellent studies of the appendicular skeleton from
Figure 5.2 Medial to lateral radiograph of the cranial thorax
the carpus and tarsus distally and parts of the head in all
made with the limb closest to the detector extended craniad.
sizes of patient. Radiographs of the upper limb, and axial The position of the trachea provides a window of reduced
skeleton in larger patients, can succumb to image degrada- attenuation allowing improved visualization of the rib fracture.
tion through attenuation and scatter, and a higher output
gantry-mounted generator together with selective use of a The radiographic technique utilized should provide
grid improves image quality. This is particularly important excellent bone detail but allow for evaluation of adjacent
in cases in which the radiographic features are subtle and soft tissues. Digital radiography, which includes computed
susceptible to being obscured by low or limited energy radiography (CR) and direct digital radiography, also
transferred to the imaging plate. Utilizing air-filled ana- referred to as digital radiography, has superseded film/
tomic structures such as the trachea to reduce attenuation screen systems. While not without inducible artefacts,
can also be beneficial to highlight lesions in shoulder and these are much more forgiving of exposure errors than tra-
cranial thoracic locations (Figure 5.2) or the caudal lung ditional film/screen combinations. The fundamentals of
over the thoracic vertebral bodies. patient preparation, source–image distance, collimation,
positioning, appropriate beam angle and minimizing from the standard projections may be required to produce
motion are prerequisites irrespective of the system used. parallel alignment between the X-ray photon beam and the
When using digital formats, there are a plethora of post- fracture plane (Figure 5.3). When this occurs, the resultant
processing possibilities including alteration of window lack of attenuation by the fracture results in a relative
width and level, image sharpening, edge enhancement, increase in energy to the imaging plate and a radiolucent
noise reduction and smoothing filters which allow images line on the processed radiograph.
to be optimized [2]. It should be noted that new information The shape of the structure being imaged also requires
is not generated by image processing; it helps the consideration. For example, the distal aspect of the equine
information to be more readily perceived, thus increasing third metacarpal/metatarsal bone differs both between
the detection rate for abnormalities [2]. medial and lateral condyles and the dorsal and palmar/
plantar articular surfaces which have different shapes and
radii [3]. Optimal identification of lesions in the distal pal-
Technical Considerations
mar/plantar surface therefore requires a projection that is
Projections both tangential to the region of interest and has minimal
Following clinical localization, a standardized approach to superimposition of other osseous structures [3, 4]. This can
image acquisition is usually the most rewarding and strongly require several projections altering the degree of fetlock
recommended. For adequate assessment of common distal flexion and/or incident X-ray photon beam angle to high-
limb fractures, a minimum of four orthogonal projections in light different areas and effectively evaluate the condylar
addition to lesion-oriented oblique projections are recom- surfaces (Figure 5.4).
mended. This not only enables identification and mapping Select radiographic views of the contralateral limb are
of the fracture but also detection of additional factors that often helpful. Examples include cases when there may be
may affect case management. As a two-dimensional repre- bilateral lesions such as stress fracture predilection sites, in
sentation of a three-dimensional object, small adjustments exercise-related fractures, when radiographic evidence is
(a) (b)
Figure 5.3 Parasagittal fracture of a right forelimb proximal phalanx. (a) Dorsopalmar radiograph (lateral to the left). Two fine linear
radiolucencies (white arrows) can be appreciated in the proximal third of the bone corresponding to the fractures in dorsal and
palmar cortices. (b) Dorsal 10° lateral–palmaromedial oblique of the same limb. The dorsal and palmar fracture lines and X-ray
photon beam are aligned. A discrete continuous fracture line is now evident (white arrows) extending from the metacarpophalangeal
joint to the distal aspect of the medullary cavity. The nutrient foramen is identified by a yellow arrow.
Radiograph 71
(a) (b)
(c) (d)
Figure 5.4 Images of a right metacarpophalangeal joint. (a) Flexed dorsopalmar radiograph (lateral to left). (b) Altering limb position
(reduced flexion) and beam angle (dorsal 20°distal–palmaroproximal oblique) reveals a small radiolucent fissure in the palmar lateral
condyle. (c and d) Sagittal and dorsal plane reformatted CT images illustrating lesion location in the condyle.
weak and in skeletally immature patients to compare involves mathematical manipulation of the image. Unsharp
growth plates, apophyses, subchondral development, etc. masking is used to obtain pixel values that are closer
Fractures of the cerebral and visceral cranium are often together when faced with structures with large differences
difficult to assess, and in such cases the clinical assessment in density, such as orthopaedic devices and bone, so they
and secondary features, e.g. gas lucency in the subcutis and both can be viewed with one lookup table. The processing
soft tissue swelling, can assist in directing optimal obliq- causes edge enhancement that gives the radiograph high
uity for the incident X-ray photon beam. Opposing oblique contrast and edge definition. However, fine detail around
views allow for comparison between sides and are always metallic implants is lost, and noise increases creating a
recommended even when trauma is sided. stripe of reduced density parallel to the interface between
the two dissimilar densities [5, 6]. Failing to understand this
Artefacts and Other Misleading Features can lead to incorrect conclusions of osteolysis, implant loos-
Numerous artefacts can masquerade as fractures, and ening or infection.
knowledge of these can avoid erroneous diagnosis. Fascial planes are more radiolucent than muscle, and if
Mach lines describe enhanced edge perception: a dark superimposed on bones can create an artefact but it is usu-
edge appears darker and a light edge lighter than expected ally clear that this extends beyond the bone margins.
from optical density alone. They are thought to be caused Both poor and absence of packing of solar frog clefts and
by lateral inhibition of retinal receptors. sulci can be detrimental to interpretation. Radiolucent
The Uberschwinger artefact (overshoot or rebound effect) lines should be scrutinized carefully to determine if they
is an artefact of DR. The basis of digital image processing remain within the bone or extend beyond osseous margins.
If this is inconclusive, then radiographs can be repeated Principles of Interpretation

following repacking and/or without packing. Alternatively,
Depending upon time frame and aetiopathogenesis, fractures
differing degrees of obliquity of the incident X-ray photon
can produce differing appearances in compacta (cortical and
beam will either project the artefact away from the bone or
subchondral) and trabecular (spongiosa or cancellous) bone.
confirm that a radiolucent line remains with the bone.
Radiographic findings are also dependent on the individual
New bone production can create the appearance of a
bone and location. In acute fractures, the presence of a radio-
relative decreased opacity in the adjacent bone.
lucent line, cortical discontinuity or altered contour or
A range of normal anatomic features can be mistaken for
impacted or displaced bone fragments may be identified. In
fractures. The fibrocartilage between the distal lateral radius
contrast, in incomplete fractures there may be only a subtle
and lateral styloid process (phylogenetic ulna) which is radi-
cortical lucency followed by periosteal reaction and endosteal
olucent for an inconstant period is a common example.
callus formation. Fractures of trabecular bone may exhibit
Physes can also be variable in appearance, but usually they
only faint increased radiopacity (sclerosis) due to microcallus
are bilaterally symmetric. Nutrient foramina are tunnels in
formation [17]. A line of sclerosis perpendicular to the tra-
the cortices of long bones which house blood vessels cours-
beculae can also be representative of a fracture [18]. Fractures
ing to and from the medullary cavity [7, 8]. Position can be
that occur secondary to progressive bone failure may have
variable but size, uniformity of the adjacent bone and trajec-
evidence of plastic deformation, mild to extensive periosteal
tory help to distinguish from a fracture (Figure 5.3).
and/or capsular new bone formation or subchondral opacifi-
Prominent parallel-sided bone trabeculae can, on first
cation, demineralization or a combination thereof which
assessment, give the illusion of a fracture. Careful scrutiny
precede the development of a discrete fracture line.
and magnification of the image will demonstrate a slightly
meandering course and no interruption of the trabecular
lines.
Fracture Types
Distinguishing suture lines in the cerebral and visceral
cranium from fractures can be challenging. Good anatomic Monotonic Fractures
knowledge and reference to an anatomic specimen are Monotonic fractures generally present with gross cortical
important. The spheno-occipital suture can pose difficul- and trabecular disruption and can usually be regionalized
ties. It remains visible up to five years of age [9], can be up following clinical examination. If there is severe guarding
to three times wider ventrally than dorsally [10] and when by the patient, lesions involving the axial skeleton and ribs
a fracture is present there may be limited displacement may prove more difficult to isolate but, within minutes to
leading to a false negative. hours, following the development of muscular swelling or
a sympathetic cutaneous response the target area can usu-
ally be identified.
Limitations
The initial radiographic study should aim to establish the
The principal limitations of radiography are that it is a two- precise location and configuration of the fracture and
dimensional representation of a three-dimensional object indicate the possibility of accompanying injuries. This
and that there can be a delay between injury and identifica- information will direct appropriate management.
tion of structural change [11] (see Figures 5.12a and d
and 5.13b). In the absence of displacement or distraction, Stress Fractures
fracture identification requires approximately parallel It had been suggested that the term stress fracture be
alignment of the osseous discontinuity and incident X-ray restricted to cases of osseous structural failure detected
beam. If there is trabecular injury only, intact overlying radiographically by a fracture line and that the term stress
cortex may efface the fracture [12]. Recently formed, thin, reaction be used to describe the series of changes in bone
woven bone (periosteal callus) is insufficiently mineralized pathophysiology associated with repetitive loading [19]. As
for radiographic visualization [13] and can take two to identification of a discrete fracture line is temporally and
three weeks to become apparent [14, 15]. It has been modality dependent, an accurate description is fundamen-
reported that for acute lytic lesions 30–50% bone loss is tal to interpretation.
necessary for radiographic identification [15, 16]. In the Initial findings in cortical bone can include a subtle
digital era, more subtle changes can be identified, but, in radiolucent zone or faint intracortical radiolucent stria-
basic terms, if the sum of the osteoclastic and osteoblastic tions followed by periosteal and endosteal new bone and
processes is not sufficiently out of balance to change the in some cases the appearance of a delicate fracture
recognizable radiographic density, a lesion may remain line [20]. Further periosteal callus, endosteal thickening
radiographically silent. and increased opacity (sclerosis) and a frank fracture line
Radiograph 73
may be identifiable at a later time point [21–24]. The the database of injuries, and knowledge of common con-
reactive bone is generally confined to a small area and figurations aids radiographic evaluation (Chapter 29).
usually involves only one cortical surface. Ultimately, the
area of periosteal reaction thickens and the fracture line, Fissure Fractures
if seen previously, disappears [21]. Following trabecular Fissure fractures are unicortical or involve a single sub-
microfracture, osteoblasts lay down new bone along the chondral bone plate. Beam angle is critical to identification,
injured trabeculae. Depending upon the timeline, this and multiple slight variations in projection orientation
may produce subtle blurring of the trabeculae with faint should be made if a fracture is suspected but not identified
increased radiopacity and later thickened trabeculae pro- (Figure 5.4a and b).
ducing more evident sclerosis secondary to peri-
trabecular callus [20, 25]. Trabecular bone is reported to Avulsion Fractures
have a metabolic turnover eight times faster than cortical Avulsion fractures represent disruption of all or part of an
bone [26], leading to the possibility that subtle changes enthesis. They can happen at any location and may be mono-
may be identified in this location first. tonic or fatigue related. The radiographic findings are related
In man, the limitations of conventional radiographs for to the area of involvement and time frame of the injury.
detection of stress injuries are well documented [22,
27–29]. The multifaceted variables in the continuum of the Compression Fractures
stress response account for the variation in radiographic Acute, minimally displaced, compression fractures can be
appearance [30]. Given the microscopic remodelling that difficult to identify, and time for associated osseous
occurs in the early stages of a stress injury, the overall resorption and/or callus production may be necessary for
sensitivity of radiographs can be low and findings may be confident diagnosis.
reserved until the healing phase, 12–21 days [14, 20, 31–34]
and in some instances four to six weeks [35] after a stress
Accompanying Features
fracture, has occurred (see Figure 5.10a and c). Advances
in radiography since the digital era have made subtle Soft Tissue Swelling
changes easier to recognize, but sometimes fractures never The degree and nature of soft tissue swelling, whether intra-
become radiographically apparent [34, 36–39]. capsular, extra-capsular, focal or diffuse, with accompanying
If a fracture is identified, this provides a risk bracket for the effacement of facial planes or fat pads, can help focus on a
patient which assists with management strategies and whether region of interest. For example, radiographs of a transverse
the nature of the changes supports radiographic monitoring. If stress fracture of the distal third metacarpal bone may ini-
the radiographs are negative, depending upon the area, it may tially reveal no osseous disruption and show only a subtle
be advisable to repeat radiographic examination in 7–14 days adjacent soft tissue swelling. Over ensuing weeks, the radio-
and/or consider an alternative imaging modality. graphs can progress dramatically (Chapter 22). Following a
skull fracture, haemorrhage in the guttural pouches can
Articular Fractures obliterate the normal gas lucency which is replaced by soft
A fracture is considered articular if it communicates with a tissue opacity or produce a fluid line secondary to a gas–fluid
joint. From a radiographic perspective, this involves interface. Accompanying features of ventral deviation of the
discontinuity in subchondral bone and by implication dorsal pharyngeal wall and dorsoventral attenuation of the
overlying cartilage. A high index of suspicion for articular nasopharynx may also be visible.
involvement can be raised with the presence of synovial
distension. Articular involvement can have a major impact Presence of Gas Lucency
on case management and prognosis and, when suspected, Open fractures are most commonly secondary to impact
radiographs should be carefully scrutinized using lesion- injuries. The presence of an open wound can be seen radio-
oriented oblique projections. graphically as disruption of and/or defects in the normal soft
Slab fractures connect two, usually proximal and distal, tissue opacity with varying degrees of gas opacity inclusions.
articular surfaces of cuboidal bones. Third carpal and Gas opacity extending to the fracture on two orthogonal pro-
central and third tarsal bones are most commonly affected. jections suggests direct communication with the wound.
Dorsoproximal–dorsodistal (skyline) radiographs of the A gas cap in the most proximal extent of a synovial cavity
proximal and distal rows of the tarsal bones are not raises the suspicion of synovial penetration (see Figure 26.18).
possible, which can make identification and determination In the absence of a wound, gas in a joint can be explained by
of configuration difficult particularly with respect to the vacuum phenomena [40]. The authors have seen this occa-
central tarsal bone. CT has made a major contribution to sionally following third metacarpal bone condylar fractures
that have had concomitant joint capsule tearing identified The time frames will vary according to intrinsic factors, e.g.
during arthroscopy. Gas can also accumulate in the suba- degree of osseous compromise and patient age, and extrinsic
rachnoid and cervical epidural spaces following some basi- factors, e.g. external coaptation and loading.
lar skull fractures [41]. Frontal or sphenopalatine sinus A delayed union is a clinical rather than a radiographic
fractures or a fractured petrous temporal bone in combina- diagnosis since the radiographic features mirror those of
tion with a ruptured tympanic membrane can also lead to second intention healing. Appearance of callus in non-
free gas within the calvarium [10, 41]. union fractures provides the radiographic descriptors,
hypertrophic, oligotrophic or atrophic (Chapter 6).
Monitoring Fracture Healing
One of the most obvious but salient requirements of
follow-up radiographs is that the images must be compara-
U
ltrasonography
ble to those taken previously. Small changes in position can
General Principles
result in the X-ray photon beam not being parallel to the
fracture plane. Endosteal and periosteal new bone forma- The advantages of ultrasonography over other imaging
tion can also appear to be reducing or increasing. Both modalities include the practicality of being a patient side
errors lead to incorrect conclusions which in turn can com- tool, it does not involve ionizing radiation, the acquisition
promise case management. is real time and it can be used in a dynamic manner.
Healing and remodelling of fracture margins occur simul- Bone surfaces reflect approximately two-thirds of incident
taneously. Even with internal fixation and primary healing acoustic waves, and the other one-third is absorbed. Reflection
(Chapter 6), there is often initial resorption along the frac- is caused by the large difference in acoustic impedance
ture line. It is important to establish an expected time frame between bone and surrounding soft tissues. The surface of
for uncomplicated fracture healing for individual sites. For compact bone creates a smooth, hyperechoic, continuous
example, bone in and adjacent to the proximal subchondral contour with strong acoustic shadowing artefact. The latter
bone plate can take the longest to heal in parasagittal proxi- ordinarily produces a ‘clean’ shadow as absorption of the inci-
mal phalangeal fractures [42]. Awareness of common dent ultrasound beam at the bone surface is larger than the
accompanying features is also needed. For example, peri- beam width [45, 46]. Discontinuity in compact bone is neces-
osteal new bone formation on the dorsal proximal aspect of sary for positive fracture identification. However, in the acute
the proximal phalanx frequently extends further distad phase, secondary signs of bone trauma such as soft tissue
than radiographically identifiable fracture lines [43]. swelling, fluid accumulation around the cortex/periosteum
Surgical implants are examined carefully for evidence of and haematoma formation are also useful findings. In the
migration, bending, breakage or adjacent osseous lucency, subacute phase identification of periosteal callus and enthe-
which may suggest instability or infection (see Figure 14.5c). seous new bone can also be helpful.
Care must be taken to differentiate abnormality from Ultrasound is commonly used to identify suspected pelvic
Uberschwinger artefact. With healing, adjacent soft tissues (Chapter 33) and rib (Chapter 35) fractures and other loca-
should exhibit reduced swelling and more clearly defined tions not amenable to radiography. It is also utilized to assess
fascial planes. Persistent swelling whether generalized or concomitant injuries to soft tissues and/or synovial cavities.
focally over an implant generally warrants further scrutiny
(see Figure 14.5a).
In articular fractures, the cartilage space, articular mar-
gins, subchondral bone and entheses are evaluated for evi- Transducers
dence of reactive or degenerative changes. Resolution or The ultrasound transducer used is defined by the area to
persistence of intra-articular fat pad effacement in applica- be evaluated. For long bones and flat bones, a linear
ble joints provides a guide to joint distension. transducer (7.5–13.0 MHz) is optimal. The elongated flat
In the first week or two of second intention healing contact footprint and high frequency optimize the reso-
(Chapter 6), there is an initial loss of mineral density adjacent lution of superficial structures. Although the long axis
to the fracture resulting in reduced sharpness of the margins view is used, in some instances it can be technically eas-
and a possible increase in the fracture gap. It usually takes ier to dynamically survey in short axis then use oblique
10–12 days for endosteal and periosteal new bone formation and longitudinal views to build up information once the
to become evident. Within 30 days, the fracture line should be area has been localized. Rotating from long to short axis
less distinct and callus demonstrate increased radiopacity. By also helps to discriminate the bone cortex from other
three months, the callus should have remodelled with an echogenic structures. Long axis evaluation can also
appearance close to the bone’s original conformation [44]. assess angular and step displacement. Irrespectively, a
Ultrasonograph 75
second orthogonal plane is routinely used to complete incidence to bone surfaces can result in the false appearance of
fracture evaluation. Axial and most proximal appendicu- irregular surface margination. At entheses, the probe must be
lar structures can be assessed using alcohol/spirit con- perpendicular to the tendon or ligament otherwise a hypo-
tact. However, when assessing superficial, acute injuries, echoic area is created due to off incident scanning of an aniso-
the probe should be placed gently using ultrasound cou- tropic structure. Avulsion fragments, when present, will result
pling gel to minimize patient discomfort. Depending on in hard shadowing that precludes evaluation of structures deep
the degree of soft tissue swelling, a stand-off may be con- to (or behind) the fragment. Fractures which involve bone sur-
tributory, but this may be offset by patient sensitivity faces that normally hold tendons or ligaments in tension will
since the increased pressure used to produce reasonable result in relaxation of the tendon or ligament. Relaxation arte-
contact may not be tolerated. fact on ultrasound has a characteristic but unusual appearance
A convex low-frequency (2.0–6.0 MHz) transducer is and can provide indirect evidence for fracture. When there is an
employed for deeper structures or if a wider field of view is avulsion fracture there can be a lack of tension in part or all of a
required. There is a loss of axial resolution, but this does not ligament, and sequential assessment can help determine rela-
usually inhibit fracture identification. When surveying ribs, tive osseous and ligamentous contributions.
a convex probe can be used first. The wide field of view ena- Nutrient foramina and other vascular canals through the
bles more than one rib to be imaged which makes it easier to bone surface interrupt cortical acoustic shadows.
discern specific rib numbers. Once abnormalities are Knowledge of their location and expected ultrasonographic
located, a linear probe with improved resolution can then be appearance differentiates them from fractures. Awareness
employed to assess displacement and/or callus formation. of the normal appearances of physes at different ages,
Other transducers should be used as needed to evaluate amphiarthroses and ossification fronts in juvenile patients
specific structures. A micro-convex transducer (4.0–10.0 MHz) are also essential to avoid misinterpretation.
may be required for assessment of the deep digital flexor ten-
don in horses that have sustained an accessory carpal bone
Limitations
fracture [47] (Figure 5.5) while, a linear rectal transducer
(8.0–12.0 MHz) is used for transrectal evaluation of the The physics of ultrasound confine definitive fracture identifica-
pelvis, sacrum and caudal lumbar spine. tion to points of discontinuity in ultrasonographically accessi-
ble cortices. Secondary evidence of fracture or stress remodelling
Artefacts and Other Misleading Features such as periosteal proliferation or abnormal contours changes
Artefacts are numerous and can be induced by the operator or with the evolution of the underlying pathology: a single time
as a result of the patient’s anatomy or injury(ies). Scanning off point ultrasound study may thus be misleading. Examinations
(a) (b)
Figure 5.5 Ultrasonographic evaluation of an accessory carpal bone fracture. (a) Oblique transverse image with a linear transducer
demonstrates a displaced fragment (yellow arrow) contacting the lateral margin of the deep digital flexor tendon (DDFT). (b)
Transverse ultrasound of the same patient with the limb partially flexed and using a micro-convex transducer provides a clear
identification of the fracture impinging the DDFT. During dynamic assessment, the extent of the resulting laceration was possible.
Palmaromedial is to the top of both images.
at multiple time points may be needed to monitor changes (or distal sesamoidean ligament entheses which can also be
lack thereof) and ascribe significance. impacted by fragmentation associated with chronic
enthesopathy (Chapter 20).
Principles of Interpretation
Secondary Features
With careful probe placement and beam incidence, discon- In acute phase assessment, haemorrhage or haematoma
tinuities or buckling of the bone’s accessible surfaces are formation may be recognized as swirling echogenic fluid in
readily identified. This may present as a small discontinu- actively haemorrhaging sites or as loculated cavities with
ity in the normally continuous hyperechoic contour or thin dividing septa. In reparative phases, neovascularization
overt displacement and step formation (Figure 33.4) with can be identified with colour flow Doppler. Later
or without the presence of haemorrhage (adjacent hypo- hyperechoic periosteal new bone or callus formation can
echoic area) (Figure 33.5a). Variable hyperechoic deposits, present with a spectrum of hyperechoic intensity and
contiguous with the bone surface, consistent with peri- range, determined by the stage of healing, from irregular
osteal new bone or callus (woven bone) formation, may be and interrupted to smooth and continuous.
present in stress fractures. Assessment of adjacent soft tis- Displaced fractures of the accessory carpal bone have
sues for evidence of concurrent injury to an enthesis, mus- been demonstrated to cause impingement and laceration
cle, joint capsule or the articular cartilage should be of the adjacent deep digital flexor tendon [47] (Figure 5.5).
routine. Ultrasonographic evaluation of the carpal sheath and its
contents is necessary to direct appropriate case manage-
Entheses ment (Chapter 24).
Evaluation of entheses should include the bone surface as
well as the tendon or ligament at and adjacent to its attach-
ment. A straight, on incident image of the soft tissue struc-
ture in question as it attaches to the bone surface optimizes Serial ultrasound examinations can assess developing dis-
identification of disruption in the bone surface, particu- placement, osseous resorption and callus formation and
larly if the avulsion fragment is small or the avulsion frac- maturation. At entheses, serial ultrasound helps to distin-
ture is partial. guish between structural disruption and temporary distor-
The suspensory apparatus entheses are frequently tion following haemorrhage. Following removal of apical
affected by fractures that include a mixture of avulsion and or abaxial fracture fragments from proximal sesamoid
fatigue injuries. Unicortical proximal palmar metacarpal bones, the formation and stability of granulation tissue
(fatigue) fractures, or proximal third metacarpal or meta- between the fracture bed and amputated suspensory liga-
tarsal avulsion fractures, usually involve only part of the ment branch can be monitored and rehabilitation tailored
enthesis. Ultrasonographic features of the former include according to healing (Chapter 20). Both percutaneous and,
accumulation of hypoechoic tissue between the fracture in applicable cases, transrectal ultrasonographic monitor-
and the dorsal aspect of the suspensory ligament with or ing of pelvic fractures is routinely performed.
without subtle changes to the osseous reflection of the
third metacarpal bone. Avulsions of the suspensory liga-
ment origin are demonstrated well ultrasonographically.
N
uclear Scintigraphy
This can also assess the amount of enthesis affected, degree
of fragment displacement and quantify accompanying
General Principles
desmitis.
The suspensory ligament branches are also affected by Nuclear scintigraphy provides both physiological and met-
acute injuries including avulsion fractures or become com- abolic activity information [31, 48, 49], aids in the diagno-
promised by fractures of the proximal sesamoid bones. sis of occult and stress fractures which can precede
Ultrasound can assess the amount of enthesis involved, the identifiable structural bone changes and can be used to
degree of associated desmopathy and consequent athletic monitor healing [22, 34, 36, 37, 50–62]. In man, sensitivity
potential (Figure 5.6). Utilization of colour flow doppler is is better than radiography for detection of both traumatic
useful to assess potential vascular compromise prior to and stress fractures with few false positives or negatives [28,
considering arthrodesis in biaxial mid-body fractures of 51]. In contrast to radiographs that rely on a significant
the proximal sesamoid bones. decrease in mineral content of bone, nuclear scintigraphy
Similar principles apply to fractures and fragmentation is relatively independent of calcium homeostasis [63].
of the bases of the proximal sesamoid bones and associated Following a negative radiographic examination in human
Nuclear Scintigraph 77
(a) (b)
(c)
Figure 5.6 Abaxial fracture (arrows) of a left hind medial proximal sesamoid bone. (a) Dorsolateral–plantaromedial oblique
radiograph. (b) Longitudinal ultrasound image of the medial suspensory ligament branch (proximal to the left). An abaxial avulsion
fracture is evident with fragment displacement and resultant loss of tension in the associated ligament. The proximodistal length of
the injury and degree of compromise of the suspensory ligament branch can be assessed. (c) Transverse ultrasound image (dorsal to
left) enables the dorsoplantar location of the fracture to be assessed and thus directs the surgical approach/technique.
patients, and provided it is not contraindicated [17], stress isodium oxidronate (HDP) and methylene hydroxydi-
d
fracture diagnosis has now moved to MRI regardless of phosphonate (MHDP) have all been used in equine scintig-
location [64]. However, in the equine patient, nuclear scin- raphy for their selective localization in bones. MDP
tigraphy remains the ‘gold standard’ for identification of historically has been used most and will be referred to in
fractures that have not been localized by other techniques. this chapter. Technetium 99m-MDP (99mTc-MDP) is admin-
The objectives are to locate lesions, evaluate their extent istered intravenously, is rapidly distributed throughout the
and phase of evolution and determine the presence of mul- extracellular fluid and accumulates in the skeleton by sim-
tiple lesions rather than define cause [49, 63] (Figure 5.7). ulating the movement of one or more of the inorganic com-
The physical decay characteristics of technetium 99m ponents of bone, principally the hydroxyapatite crystal [53,
(99mTc) make this currently the radiopharmaceutical of 63, 68, 69]. Accumulation is thought to be by both chemical
choice for equine diagnostic imaging. For the purposes of adsorption onto the surface and incorporation into the
bone evaluation, it is linked to a tracer phosphorous com- crystalline structure of hydroxyapatite [70, 71] and is great-
plex whose biodistribution favours localization in the skel- est where the body is depositing calcium phosphate. Blood
eton [65]. In man, methylene diphosphonate (MDP) flow, bone metabolic activity, capillary permeability and
initially became the tracer of choice due to high skeletal local extracellular volume govern this exchange pro-
uptake and fast blood clearance [32, 63, 66, 67]. MDP, cess [63, 65, 68]. At normal and subnormal rates of blood
Figure 5.7 Forelimb scintigram of a two-year-old Thoroughbred racehorse with reported loss of action. Visible physes are active and
symmetrical. Note multiple abnormal areas of increased radiopharmaceutical uptake in the radial carpal bones, third carpal bones and
dorsodistal aspect of the third metacarpal bones. To enable complete assessment, the physes should be masked during post-
processing to eliminate the effects of count capture.
flow to healthy bone, uptake appears proportional to blood and is effectively complete within two hours of administra-
flow; at higher rates, uptake is determined by the available tion [65]. Most imaging is delayed until between two and
crystal area [72, 73]. A low pH is also reported to be a fac- three hours post injection, depending on patient size, to
tor [71]. Increased osteocyte activity in an area of bone allow 99mTc-MDP not localized in the bone to be excreted in
trauma/fracture exposes more of the mineral face of the urine. This reduces non-skeletal activity and improves osse-
hydroxyapatite crystals, leading to increased adsorption. At ous image quality. The timing of acquisition is therefore
a cellular level, locally increased deposition of 99mTc-MDP called the delayed or bone phase. However, 2–4% of the dose
correlates histologically with the presence of osteoid in is retained in the renal parenchyma that images the kid-
early stages of mineralization [32, 66, 67]. neys [63] and may obscure rib and thoracolumbar lesions.
Skeletal uptake of 99mTc-MDP starts immediately after Assessment is made with a gamma camera that utilizes the
administration, reaches approximately 50% by one hour [48] gamma photon sensitivity of sodium iodide crystals. The 99mTc
decay emissions from the patient cause the crystals to produce point after not less than 10–14 days (Figure 5.8) [91, 92].
scintillation light. This is detected by photomultiplier tubes, The financial and ionizing radiation implications would, in
transmitted to an electronic circuit and then displayed on a most circumstances, support an initial delay.
computer monitor [69]. It is planar (two-dimensional) imag-
ing. Normal skeletal uptake is symmetric [63], so active bone Patient Preparation
formation causes increased tracer deposition and increased Cold limb syndrome appears as areas of complete or patchy
radiopharmaceutical uptake (IRU). photopenia in the carpus/tarsus and distal limb which can
Osteogenic aberrations identified by 99mTc-MDP uptake efface areas of IRU. It can occur in any patient, but the
represent a non-specific response of osteoblasts to activation. incidence increases in cold weather and when the horse
Once an area of abnormal uptake is identified, alternative cannot be exercised. The majority of suspected fracture
imaging is necessary if structural information is required. patients will be unsafe to exercise in a manner that will
It has been demonstrated consistently that different pat- enhance distal limb perfusion. In order to try and minimize
terns and locations of 99mTc-MDP uptake can be predictive of the incidence of cold limb syndrome and to optimize
certain pathological findings. Both humeral and tibial stress perfusion, and thus radiopharmaceutical distribution,
reaction and stress fractures can be identified more readily on patients can be stable bandaged and rugged overnight and,
nuclear scintigraphy than radiography [15, 74, 75]. prior to injection of the radiopharmaceutical, placed in a
stable with radiating heat lamps and a deep shavings bed
Technical Considerations (for at least one hour) and administered acetylpromazine.
Maintaining the patient in a stable with heat lamps for the
Time of Evaluation period between injection and image acquisition has proved
Osteoblasts have been seen forming callus in experimental the most reliable method for minimizing/eliminating cold
fractures within hours of injury [76], and in man limb syndrome.
scintigraphic uptake has been observed at fracture sites
between 6 and 72 hours following the onset of pain [77–79].
Image Acquisition
A human study concluded that the minimum time for a
Acquisition of images has become increasingly uniform
bone scan to become abnormal following monotonic frac-
and refined and, in most facilities, follows a set protocol.
ture was influenced by age with younger patients having a
Images should overlap to ensure that the entirety of the
quicker detection time [77]. This likely reflects a confound-
requested areas is evaluated. The field of view of the
ing effect of metabolic bone disease in older patients and
gamma camera detector will have a bearing on the number
should have limited impact on the majority of equine
of images required to achieve this. In man, at least two
patients. It is likely that most stress fractures will be identi-
orthogonal views of stress fractures are obtained to evalu-
fiable scintigraphically when lameness is evident and this
ate the degree of cortical penetration [48].
has been documented in human and equine patients [27,
Although protocols have been documented [94, 95], each
28, 31, 36–39, 62, 79–90]. However, there are two scenarios
patient should have the study tailored and modified
that may contribute to false negatives. It is possible that
according to the appearance of the images as they are being
very early stress reactions characterized only by cortical
acquired. Real-time assessment is therefore optimal. In
tunnelling in the absence of new bone formation may
addition to standard acquisition protocols, the following
appear as unremarkable cold spots [91]. Secondly, in the
views can provide additional information;
equine patient when pelvic fractures are presented in
prodromal or per acute phases, a combination of location ●● Dorsal and oblique images of the spine help to differenti-
with muscle and distance attenuation can conceal IRU. ate IRU in laminar arches and spinous processes.
This can result in a negative scan with retrospective diag- ●● Lateral (costal fovea to costochondral junction) and
nosis following osseous displacement [92] or in the case of dorsal images of the ribs will confirm IRU within ribs
a stress reaction, progression to fracture when the horse rather than superimposed structures. Cranial images of
returns to training. To avoid false negatives, a delay is rec- the thoracic inlet (Figure 5.9c) and a modified lateral
ommended between the onset of lameness or trauma and image with the forelimb closest to the detector pulled
nuclear scintigraphy. Five to seven days have been pro- backwards [96] permit assessment of cranial rib fractures.
posed as a minimum [93]; however, a 10–14 day delay ●● Oblique images of the cranial [97] and caudal pelvis reduce
would make the possibility of obtaining a false negative superimposition together with soft tissue and distance
unlikely. Alternatively, if the initial evaluation is negative attenuation and can better image ilial wing, ilial shaft,
and a pelvic fracture is still suspected, an additional scinti- ischial and pelvic floor fractures. They also help differenti-
graphic examination could be performed at a second time ate proximal ilial wing, tuber sacrale and sacral fractures as
(a) (b)
Figure 5.8 Adult warmblood showjumper that went acutely lame in its left hindlimb while jumping. (a) Initial nuclear scintigraphy
study 48 hours post lameness. Note activity from excreted 99Tc-MDP in the urinary bladder superimposed over the cranial left ilial
shaft (dashed blue circle) and how the presence of both the urinary bladder and motion artefact degrades the dorsal pelvis image
quality. (b) Second study nine weeks post lameness. Diffuse area of marked IRU involving the caudal left ilial wing and cranial ilial
shaft (arrows) consistent with a fracture.
these areas are superimposed in dorsal images. It can also ●● A combination of dorsal and lateral views of the scapula
differentiate lesions when there is a question over possible can differentiate stress fractures of the scapula and verte-
superimposed urine pooling: if the IRU is within the skele- bral lesions [39].
ton it will maintain a constant relationship with the bone ●● Cranial views of the shoulder and proximal humerus aid
irrespective of gamma camera position (Figure 5.8). identification of deltoid tuberosity fractures.
●● In addition to the standard view of the tuber ischii (detec- ●● A cranial view of the elbow and distal humerus can high-
tor positioned at 45° to vertical with the tail lifted to one light subtle IRU in the distal medial humerus (stress
side to avoid overlay and effacement of the axial ischium fracture) or in the medial humeral subchondral bone
and symphysis), positioning the detector at 90° (again (compression fracture): on lateral projections alone both
with the tail lifted to the side) can give further information can be obscured by attenuation.
regarding fractures of the ischium and tuber ischium. ●● A flexed dorsal view of the carpus separates the carpal
●● Proximal tibial stress fractures can occasionally be pre- bones and helps in identification and localization of
sent caudomedially and have the potential to be over- lesions.
looked on the lateral view if IRU is mild. Additional ●● Flexed lateral views of the fetlocks can help separate the
caudal views of the stifle are recommended. metacarpal/metatarsal condyles from the proximal sesa-
●● Mid-diaphyseal tibial fractures can be missed if there is moid bones and change the orientation of the condyle
inadequate overlap between lateral hock and lateral sti- with the proximal phalanx.
fle views, especially if the detector field of view is small: ●● Flexed dorsal views of the fetlocks can differentiate par-
a lateral image of the entire tibia is useful. asagittal IRU from condylar IRU [98].
(a) (b)
(c)
Figure 5.9 Scintigrams of the proximal forelimb of a two-year-old Thoroughbred racehorse with acute onset right forelimb
lameness. (a) Lateral scintigram centred on the scapulae. Normal symmetrical metabolic activity in the proximal humeral physes is
evident, which produces count capture. An area of abnormal IRU is indicated (blue arrow). (b) Postprocessing masking of the physes
highlights the abnormal IRU more clearly. (c) Following identification of the abnormal IRU, contemporaneous additional cranial
projections were acquired. IRU in the proximal aspect of the first right rib is confirmed and highlighted (blue arrows).
●● Solar views of the foot can provide further information Descriptors

for distal phalangeal and navicular bone fractures. IRU is described by location, pattern (focal or diffuse),
shape and intensity expressed as mild (up to 10%), moder-
In skeletally immature individuals, there is normal
ate (10–50%) and marked (>50%) in comparison with the
intense localization of 99mTc-MDP in the physes. As this
opposite and matching anatomical site [75]. The shape,
produces count capture, it is important to mask these areas
intensity and pattern of uptake are determined by the size,
during post-processing to ensure that areas of abnormal
extent and activity of the local remodelling process as well
IRU are not obscured (Figure 5.9).
as its blood supply [54].
Image Quality
Multiple factors affect the quality of the generated image, Quantitative Assessment
including patient preparation, the time between injection Regions of interest (ROIs) can be defined and compared to
and acquisition, uptake of 99mTc-MDP (intrinsic and extrin- counts obtained at the same site in the contralateral limb or a
sic factors), count density, total counts, motion [94, 99], separate defined region in the same patient. The relative
inherent resolution and sensitivity of the gamma camera uptake ratio is calculated by dividing the mean counts per
and management of urinary tract excretory content. All pixel for the target ROI by the mean counts per pixel for a
aspects should be optimized, and it must also be recog- reference ROI on the same image to account for variability in
nized that poor operator technique can significantly affect absolute counts. Profile analysis can also be used if ROI anal-
study quality. ysis is equivocal. It has been reported that subtle differences
or abnormal radiopharmaceutical uptake may be more read- negative result whether or not the clinical features are
ily identified by using ROI analysis [100]. However, informa- related to an impending condylar fracture.
tion may be lost from the averaging effect, and subjective
assessment has been reported as superior for focal areas of
IRU [101].
Results of nuclear scintigraphic examinations have
Qualitative Assessment been documented in racing Thoroughbreds [75] and
Subjective methods of interpretation have been shown to Standardbreds [107], and horses used for showjumping,
correlate highly with semi-quantitative techniques [102]. eventing and hunting [108], reporting the distribution of
Subjective evaluation for fracture assessment is generally areas of IRU and their variability between disciplines.
made in greyscale. For thoracic spine assessment, the blue, Interpretation of the presence of a stress reaction relies on
green and red colour display has been reported to have knowledge of injury predilection sites. The spectrum of
greater sensitivity for detecting IRU than continuous grey- IRU in stress fractures can vary from a focally marked fusi-
scale [103]. As with all image interpretation, the experi- form area of cortical IRU to an area less intense or well
ence of the interpreter has a significant bearing. defined which can represent the pathophysiological con-
In contrast with human studies [19, 28], qualitative and tinuum between fracture and stress reaction. Asymptomatic
quantitative analyses of equine tibial stress fractures dem- foci can reflect prodromal change, active remodelling or
onstrated no correlation between grades of IRU, lameness healing. Alternative imaging may be needed to determine
or radiographic findings [104]. There was also no correla- the significance of findings.
tion between calculated ratios and lameness grade at pres-
entation or performance outcome [105]. Dorsal Cortex of the Third Metacarpal Bone
The stress continuum in the dorsal metacarpus and
metatarsus in racing and non-racing horses has been
Clinical Indications
studied [58, 109], and a grading scheme of one to four [109]
Nuclear scintigraphy remains the mainstay for stress frac- suggested. Scintigraphy exhibited excellent sensitivity, but
ture identification and risk assessment in horses such as the false positives with clinically normal limbs having
requirement for keeping a patient cross-tied and guiding IRU [109]. Interpretation is further complicated by cross
the length of rehabilitation programmes. It is indicated in over between dorsal metacarpal disease and cortical stress
the evaluation of severely lame horses that are devoid of fractures as one process maybe superimposed on the
confident diagnosis (Figure 5.10) and those with clinical other [110]. Nuclear scintigraphy has been utilized in
signs referable to the axial skeleton including the pelvis. In Thoroughbreds to differentiate between dorsal metacarpal
addition to determining location, fracture displacement can disease, defined as uniform diffuse IRU in the dorsal cortex
frequently also be identified, e.g. third trochanter, deltoid relative to the palmar cortex and metaphyses, and cortical
tuberosity, tuber ischium and tuber coxa fractures. stress fractures, defined as focal intense IRU in the dorsal
cortex [58]. In this location, the focal nature of the IRU has
been considered more significant than intensity [61].
Limitations
Activity in the distal condyles of the third metacarpal Enostosis-like Lesions
and metatarsal bones requires careful assessment to dis- These lesions are identified scintigraphically by IRU located
criminate a stress-related response from a potential frac- within the trabecular bone determined on two tangential
ture [98]. It has been suggested that scintigraphy of horses projections. Although reported to be found close to nutrient
that are lame or performing poorly is not an effective foramina [111], this is not consistent. No definitive aetiology
screening technique for prodromal condylar frac- has been established, but one proposal is that they are tra-
tures [106]. It would be more accurate to say that nuclear becular microfractures caused by cyclical stress [112, 113].
scintigraphy does not predict the likelihood of sustaining a The degree of IRU uptake can vary from mild to marked.
condylar fracture. It is known that bone fatigue associated
with condylar fractures may develop rapidly, arise in sound
horses and result in a fracture before an osteoblastic
response is initiated [98]. This is indeed the risk carried by Nuclear scintigraphy has been used in man to monitor
any horse in training undertaking fast work when prodro- healing in both monotonic and stress fractures [19, 28, 77,
mal features may not be apparent. However, in the pres- 114]. In the first (acute) phase, there is a diffuse area of IRU
ence of lameness a bone response is likely to have been due to increased blood flow around the fracture site. This is
initiated, and scintigraphy is unlikely to produce a false greater than the morphological fracture and persists for
(a) (b)
(c)
Figure 5.10 Four-year-old Thoroughbred racehorse with acute severe right hindlimb lameness. (a) Caudocranial radiograph of the right
tibia on the day of presentation. No abnormalities detected. (b) Lateral and caudal scintigrams of the right tibia. Linear IRU is present in
the distal tibial metaphysis and diaphysis compatible with a propagating tibial fracture. (c) Radiographs taken at two, four and eight
weeks post injury. Progressive osseous resorption permits identification of sharply marginated radiolucent fracture lines (black arrows).
Areas of increased radiopacity are consistent with formation of trabecular and cortical callus (white arrows), which gradually bridges the
fracture. Note also the distal lateral fracture line eight weeks post injury that is slow to become radiographically apparent.
two to four weeks after injury. The second (subacute) stage application in horses has recently evolved rapidly. Like
has the most intense well-defined IRU which corresponds radiography, it measures tissue attenuation of penetrating
more accurately with the anatomical fracture and lasts for photons; however, the X-ray source rotates around the
8–12 weeks (Figure 5.8b). Over the coming weeks and patient. Multidetector row CT affords excellent spatial res-
months as callus remodels during the third (reparative) olution and thin and overlapping slices, which approach
stage, there is a more localized area of IRU with greater isotropic, allow for multi-planar reformatted (MPR) images
separation between normal and abnormal tissues followed that can be reconstructed in any chosen plane. The MPR
by a gradual reduction in activity. The time of scintigraphic reconstruction and thin slices both optimize fracture iden-
normalization is greater than that identified clinically or tification. Articular surfaces can be assessed [117, 118],
radiographically due to ongoing bone remodelling. In man, and the superior bone detail produced by CT enhances
monotonic fractures can take up to 24 months [77] and identification and mapping of fissures, subchondral bone
stress fractures between four to six months [28]. In stress fractures, unicortical fractures and other articular frac-
fractures, severity was a major determinant of time to tures. Three-dimensional surface rendering details the
resolution, and patients who failed to rest and had continu- topographical aspects of the fracture configuration and
ing pain had persistent unresolved lesions [28]. with segmentation permits selective removal of overlying
It has been suggested that horses with evidence of stress tissues in order to visualize the complexity of a fracture.
fracture undergo scintigraphic review before they return to Cone beam CT (CB-CT) has recently been introduced to
work [106]. This is not routinely practised in the UK where equine use. It requires markedly different image recon-
financial constraints and well-accepted stress fracture struction, does not provide quantitative information about
management regimes have precluded longitudinal studies. tissue density and hosts a new complement of imaging
Horses in training that have undergone nuclear scintigraphy artefacts that can detract from diagnostic accuracy.
in subsequent seasons have demonstrated subtle uptake at
previous fracture sites. The degree and distribution of the
99m Technical Considerations
Tc-MDP uptake is usually mild, ill-defined and
compatible with bone remodelling. CT requires precise and relatively rapid movement of the
In a study of equine distal phalangeal fractures, activity patient relative to the photon source and detectors (gantry).
was reported to persist for >25 months. This was ascribed Moving gantry CT scanners allow the horse to be supported
to a fibrocartilaginous union, fracture instability, osteolysis by a surgery table, and the gantry itself is responsible for
and osteoid formation [115]. movement accuracy. Equipment for CT in the standing
A study of dorsal cortical fractures of the third metacarpal horse is now possible using both conventional and CB-CT
bone reported correlation between persistence of a scanners for the head, cervical spine and distal limbs.
radiographically evident fracture line with less intense CT provides quantitative imaging information with high
scintigraphic uptake and individuals who did not heal and spatial resolution. Each pixel is assigned a value described as
required surgical intervention [58]. The supposition made a CT or Hounsfield unit (HU). This is a measure of each pix-
was that the degree of 99mTc-MDP uptake was directly el’s density with respect to pure water which is arbitrarily
correlated with osteogenesis and rate of repair, thus designated a value of zero HU. Pixel size is determined by the
diminished uptake in the absence of radiographic resolu- field of view (set at the time of image acquisition or recon-
tion indicated either a delayed or non-union. struction) and the pixel matrix of the image; it is often sub-
Sequential evaluations in the days and weeks following millimetre size. HUs are based on X-ray attenuation in tissue.
surgery were reported in three horses (four year old, Gas is generally −1000 HU, fat is approximately −120 HU,
yearling and foal) that had sustained a variety of traumatic soft tissues 100–200 HU, cancellous bone 400–600 HU and
fractures to the third metacarpal or metatarsal bones. Two cortical bone in the range of 1500–2000 HU; dental enamel is
cases developed photopenic regions less than six days post- higher than cortical bone. Slice thickness can be varied in
operatively, one was described as extensive and at necropsy some machines to sub-millimetre size, resulting in high-
this correlated with osteomyelitis and sequestration [116]. resolution images even when reformatted. CB-CT is not
quantitative and does not produce a measurement of HU.
Image processing occurs through mathematical manipula-
tion of the density data and has a profound impact on the
C
omputed Tomography
appearance and clinical utility of an image. Unprocessed or
raw CT data are typically not used in diagnostic imaging and
General Principles
may not even be stored by the acquisition device or picture
CT is a high-resolution, X-ray based, quantitative, cross- archiving and communication system (PACS). Most CT scan-
sectional imaging technique. It has for some time been ners have several processing algorithms that allow the opera-
integral to fracture diagnosis and management in man, and tor to choose the degree and type of processing at the time of
Computed Tomograph 85
acquisition. The methods of processing evolve but in general through the gantry at the same time. Even if the operator
will include bone, sharp or edge-enhanced algorithms along reduces the field of view to include only one limb, the effect
with soft tissue or smoothing algorithms. Complete examina- of the pair will be visible in the images.
tion of an anatomic region should include both so that all Motion produces image blurring or mismapping of anat-
tissues can be evaluated. A sharpening algorithm will pro- omy. These can have negative impacts on the identification
duce very pleasing diagnostic images of bone and fractures of fragments if the blurring causes margins to become
but will enhance artefacts such as high-density edge gradient inconspicuous or in fracture evaluation when a hypoat-
artefacts causing streaking through regional soft tissues. tenuating area such as fracture gap can be mismapped to a
Image display is flexible. The end user is able to selectively different region.
manipulate the image to emphasize structures of different Photon starvation is seen in areas of high attenuation, par-
density. Window width refers to the range of HU over which ticularly associated with metal implants. Insufficient pho-
the greyscale is applied, and window level refers to the cen- tons reach the detector, and during reconstruction noise is
tre point of the window. In order to fully evaluate a region, greatly magnified in these areas creating streaks in the image.
both window level and width require manipulation.
CT produces excellent bone images due to the inherent
high subject contrast when using tissue density/X-ray attenu-
ation (400–2000 HU). It is particularly good for imaging frac- In anatomically accessible areas, CT has the potential to
tures due to the combination of high inherent contrast provide additional and useful information for the identifi-
between intact and disrupted bone and high spatial resolu- cation and characterization of all fractures, whether they
tion that permits identification of very small areas of disrup- are managed conservatively or with surgical intervention.
tion. In principle, soft tissues have less inherent contrast and The benefits must be weighed against the potential risks
are imaged less well. Modern scanners, capable of high tube associated with acquisition such as general anaesthesia and
output, produce very good soft tissue image quality, although moving the horse to or through the scanner.
when immediately adjacent to a high-density tissue, such as CT is considered the gold standard for fracture diagnosis
cortical bone, this can be more problematic. and evaluation of three-dimensional configuration. Complex,
comminuted, articular fractures, small, minimally displaced
Artefacts fractures of long bones or simple fractures in complicated
CT, like all imaging modalities, has its own complement of anatomic regions are best evaluated with cross-sectional CT
artefacts. These are defined as a discrepancy between the CT imaging with or without 3D or surface rendering. In humans
number or HU in the reconstructed image and the actual and horses, CT has been shown to be more sensitive than
attenuation coefficient of the object. Non-conventional use of radiographs for identifying fractures and recognizing
CT technologies, such as standing CT, results in an additional comminution [117–121].
gamut of artefacts that must be understood and evaluated for The three-dimensional nature of CT has proved integral to
what they are. presurgical planning and has been reported for the central
Partial volume averaging results in the incorrect assign- tarsal bone [122], distal phalanx [123, 124], navicular
ment of an HU value when the values of two structures are bone [124] and proximal phalanx [125]. This is also the case
averaged in one voxel. This is problematic in fracture iden- in the authors experience for third carpal bone fractures
tification if the fracture is non- or minimally displaced (Figure 5.11); further applications are documented through-
and/or running obliquely through the scan plane but can out the book. It has been repeatedly shown to give better spa-
be mitigated by reformatting the images into multiple dif- tial information and thus recognition of fracture configuration
ferent planes. and complexity and the structure of affected bones and frag-
High-density edge gradient or beam hardening occurs ments [126]. In addition, areas with complex anatomy or
when a very dense subject is present in the scan plane, shape, such as the distal phalanx, where dimensions vary
attenuating the low-energy portion of the polychromatic according to orientation, and cases with multifocal pathology
photon beam and resulting in a preponderance of higher are only adequately assessed by CT [123, 126, 127].
energy X-rays. This results in dark bands or streaks either Osseous trauma of the skull is better evaluated with CT
between two high-density structures (e.g. petrous temporal than plain radiographs with respect to identification [128],
bone) or around the margins of a high-density structure classification and surgical planning [129], although small
such as a metallic implant. Beam hardening can be difficult fractures maybe missed if inappropriate window parameters
to avoid in equine patients. Most CT scanners have beam are chosen [130] (Chapter 36). The basics of acquisition, i.e.
hardening reduction software that may or may not be thin slice thickness, and appropriate reading, i.e. bone algo-
available to the operator. Photon starvation is caused by rithms, are essential [131]. CT can also differentiate between
beam hardening between two dense objects. This is of structures that radiographically mimic fractures such as
particular importance in horses when two limbs are placed suture lines or overlapping sinuses.
(a)
(b)
Figure 5.11 Evaluation and surgical planning of two-third carpal bone fractures. (a) Dorsal 35° proximal–dorsodistal oblique
radiograph demonstrating a parasagittal plane fracture of the radial facet and corresponding dorsal plane reformatted CT image
revealing the fracture line to extend from the middle carpal joint to the distal subchondral bone plate. A lag screw was therefore
placed in a central position in the bone. (b) Flexed dorsal 35° proximal–dorsodistal oblique radiograph demonstrating a dorsal plane
fracture of the radial facet and corresponding sagittal plane reformatted CT image demonstrating the fracture to be located in the
proximal third of the bone. The surgical implant was therefore placed proximally in the bone at the mid-point of the fracture.
Small, portable CT machines can be used during surgi- provide a visual map of intra-osseous fluid accumulation
cal procedures. CT-assisted surgery of navicular bone as shown by fluid-sensitive MRI sequences.
and distal phalangeal fractures has increased surgical When imaged with X-ray technology, soft tissues have
accuracy and reduced surgery time. Barium paste as low intrinsic subject contrast thus generating images with
markers for orientation applied to the hoof wall [124], low contrast resolution. This is further exacerbated when
and surgical skin staples [122] have been used as surface soft tissues abut high-density bone surfaces, e.g. cartilage
locators. over subchondral bone or the deep digital flexor tendon
over the navicular bone. Modern and appropriate image
processing mitigates these effects and, in general, soft tis-
Limitations
sue imaging is fair to good in conventional scanners.
CT is an excellent determinant of bone morphology but Contrast media can also help by increasing subject contrast
does not provide information about biological activity. This and should be considered when excellent bone and soft tis-
can be inferred by interpretation of the complement of sue or cartilage imaging is required.
morphological changes but does not reflect the level of Availability of CT remains limited and most require gen-
activity as seen in nuclear medicine studies (scintigraphy eral anaesthesia. Standing CT offers shorter acquisition
or positron emission tomography [PET] scanning) or time than MRI; however, the reliance on changes in bone
Magnetic Resonance Imagin 87
density before a discrete fracture line can be identified e lectromagnetic RF energy pulse, synchronized to the pre-
means, that as a screening tool, there remains the possibil- cessional (Larmor) frequency for hydrogen, causes absorp-
ity of false negatives. tion of energy and displacement of the magnetic moment
from equilibrium. Following the RF pulse, a gradient is used
to produce a small, known variation in the magnetic field.
Subsequent emission of energy (relaxation), which restores
Image production relies on the same attenuation coeffi- equilibrium, is proportional to the number of excited
cients as radiography. Thus, a lack of attenuation due to the protons in the tissue volume. Protons may lose energy by
presence of a fracture is self-evident with a hypoattenuat- dissipation into the surrounding molecular environment (T1
ing or dark region on the processed image. Occult fractures recovery), transfer between protons (T2 decay) or due to
are defined by the presence of a sharp hypoattenuating line inhomogeneities of the magnetic field (T2* decay). Differing
within the trabecular bone pattern and a break in continu- proton density and relaxation methods between tissues cre-
ity of the cortex [132]. ates contrast. Multiple repetitions of the RF pulse enable the
signal in an entire volume of tissue to be recorded by a
receiver coil and, following a complex of mathematical
processes, slices of cross-sectional images are formed.
Magnetic Resonance Imaging Sagittal, transverse and dorsal planes are acquired as stand-
ard. However, MRI is multiplanar and images can be
General Principles
acquired in any slice plane without changing the position of
MRI is a cross-sectional, multiplanar modality that has tran- the region of interest. A number of textbooks delve into the
sitioned from expensive and logistically difficult to ubiqui- physics of MR image generation, and interested readers are
tous in equine practice. The multiplanar imaging capability, referred to these for further information. [1, 137, 138].
improved contrast resolution, capacity to assess both bone Contrast resolution in MRI is high compared to radiogra-
and soft tissue and ability to identify injury to trabeculae phy, ultrasonography and CT. Multiple factors contribute to
make it an excellent modality for detecting fractures that are the spatial resolution, including field and gradient strengths,
not depicted radiographically. This is also the case for radio- matrix size and slice thickness. The magnetic field strength
graphically negative studies in areas with complex anatomy is measured in Tesla (T). In general, greater field strengths
and substantial superimposition, e.g. the tarsus [133]. In create images with improved contrast and more signal. Both
man, it is the preferred modality for assessment of stress frac- high field (1.0–3.0 T) systems, which require general anaes-
tures [23] where it has been demonstrated to be the most sen- thesia, and low field (0.27 T) standing MRI (sMRI) systems
sitive and specific imaging test in the lower limb [134]. It is are available. Though sMRI units are purpose built, some
also the only modality that can identify bone marrow lesions institutions will use these scanners in horses under general
(BMLs) which enables occult bone injury to be identified, anaesthesia. The SNR increases in a nearly linear relation to
although this is not always definitive and false positives can magnetic field strength [139].
occur [135]. Trabecular bone trauma can be identified with The sequence generated is based on the pattern and tim-
MRI which can be difficult to appreciate radiographi- ing of acquisition parameters. The main sequences used are
cally [12]. Scintigraphy and MRI grades for stress fractures in spin echo (SE), fast spin echo (FSE) and gradient recalled
human patients are closely correlated [23], but MRI provides echo (GRE). Their values pertaining to the specific tissue
more diagnostic information including identification of frac- type is different, and each has a trade-off in terms of acquisi-
ture lines and periosteal oedema. MRI has also been instru- tion time, spatial resolution and SNR. SE and FSE have
mental in early recognition of subchondral fractures [136]. higher contrast resolution than GRE, but this has a higher
MRI is based chiefly on the presence and properties of resolution relative to acquisition time and provides a more
hydrogen atoms in tissue. Their large magnetic moment and robust scan for sMRI if patient motion becomes challenging.
abundance in the body, including in water and fat, makes Most manufacturers have proprietary sequences, particu-
this clinically useful. Following injury or disease, the amount larly high field scanners intended for human use, which are
of water can alter markedly which increases the sensitivity developed to optimize imaging of a specific tissue type.
of MRI to these processes. The rudimentary components are Users must understand for which tissue or tissues proprie-
the magnetic moments of hydrogen nuclei (protons), the tary sequences were developed, or understand with which
magnetic field strength of the magnet and the resultant net traditional sequence they are most closely aligned, e.g. fluid-
magnetic moment (net magnetization vector). Acquisition sensitive sequence with higher anatomic detail.
involves the focus area being placed in a magnet, which Fat suppression can be achieved using a short tau inver-
applies a strong magnetic field (B0), and a radiofrequency sion recovery (STIR) sequence or fat saturation. The latter
(RF) coil placed over the region of interest. An is not possible in sMRI units. Fat suppression is essential in
a fracture study; once the high signal from fat is eliminated agent’s interface resulting in signal loss or void and is most
from the image, any remaining hyperintensity pertaining prominent on gradient echo sequences as the gradient
to a possible fracture is clearly discernible. reversal is unable to compensate for the phase difference.
Image contrast is generated through tissue weighting. Implants also cause distortion of the magnetic field and
T1 weighting (T1W) has high signal and good anatomical can complicate interpretation.
detail, but due to the increased shades of grey the contrast is Within each voxel, the signals received are averaged cre-
reduced. T2 weighting (T2W) has lower signal than T1W or ating the potential for volume averaging artefacts. Increased
proton density weighting (PDW) but greater contrast resolu- slice thickness and the poorer resolution of sMRI exacer-
tion between normal and abnormal tissue. T2* weighting bate this process [140]. A common example occurs in the
(T2*W) is susceptible to magnetic field inhomogeneities and metacarpal/metatarsal condyles where the curvature and
ferrous materials, but since it is created using a GRE thin articular cartilage can be susceptible to volume aver-
sequence it is rapidly acquired with thinner slices. It is also aging artefacts.
fluid sensitive and creates phase cancellation artefact that is
helpful for ascertaining the presence of intra-osseous fluid
accumulation. PDW signal intensity and contrast are con-
nected to the mobile population of protons within the tissue. The decision to use MRI in the equine fracture patient is
They have good resolution and tissue contrast and can delin- multifactorial, but prior regionalization of the injury is a pre-
eate between articular cartilage and synovial fluid. requisite. Lesion location, patient comfort level and the type
Each sequence gives different information. The signal of system available are all determinants. In the absence of
intensity of tissue on a number of sequences needs to be definitive radiographic findings, the commonality of frac-
ascertained in order to characterize a lesion. In assessing ture location in horses in training (carpus, fetlock and pas-
human fractures, a T1W SE or PDW SE is utilized for the ana- tern) means that sMRI can provide a safe method to
tomic detail it affords and a fluid-sensitive sequence, such as determine the presence, suspicion or absence of features
a STIR or fat-suppressed T2W SE sequence, for emphasizing supportive of a fracture (Figure 5.12). MRI has also proved
contrast differences between normal and abnormal tissues. beneficial in sports horses for fractures when there are dis-
In sMRI of horses, a T1W 3D or GRE, depending upon the crete clinical findings, but radiographs have been nega-
area, and a fluid-sensitive sequence (ideally both STIR and tive [141] or following localization with diagnostic analgesia,
T2*W) are principally employed using the same rationale. again with negative radiographic and ultrasonographic find-
ings (Figure 5.13). In addition to assisting in diagnosis, MRI
also gives an insight into the health of subchondral
bone [142]. When considering the bone stress injury con-
Appreciation of artefacts is necessary in order to avoid tinuum, a BML depicting stress reaction at a predilection site
interpretation errors. Absence of patient motion is for an exercise-related fracture can represent prodromal
important. Many fracture evaluations will employ sMRI, damage [88, 143]. Following the bone’s normal pathogenetic
but it is necessary for horses to be sufficiently comfortable response, a discernible fracture line may, in time, become
to stand square without resting pain. Immobility is essential evident [144] and demonstrate a lesion that requires surgical
to avoid phase mismapping and loss of image quality. The intervention. MRI under general anaesthesia is not usually
team involved in patient handling, sedation and acquisi- indicated in suspected equine fractures.
tion have a substantial bearing on end image quality.
Phase cancellation or chemical shift artefact is the result
Limitations
of the differing precessional frequencies of protons in
water and fat, caused by hydrogen in water being arranged The principal limitations in equine fracture detection are
with oxygen and hydrogen in fat being arranged with lesion location, acquisition time, motion artefact and low
carbon. When they are in phase their signals add together, SNRs associated with STIR sequences in sMRI. The low
and when they are out of phase their signals cancel out. signal intensity of normal compact bone complicates the
This results in a dark line at the interface of fat and water detection of subtle non-displaced cortical fractures [145].
which is extremely useful in highlighting the presence of This is particularly important if secondary signs of fracture
intra-osseous fluid accumulation on T2*W GRE sequences. such as intra-osseous fluid accumulation are not identified.
Susceptibility artefact is produced by agents that disrupt In addition, the low signal intensity of compact bone,
the local magnetic field due to their ability to become tendon and ligament can make avulsed bone fragments
magnetized, e.g. ferromagnetic materials or blood difficult to identify [146]. In general, identification of any
degradation products. This results in dephasing at the small osseous or osteochondral fragment can be difficult if
Magnetic Resonance Imagin 89
(a) (b) (c)
(d) (e)
Figure 5.12 Four-year-old Thoroughbred racehorse with acute onset right forelimb lameness and pain on palpation of the
dorsoproximal aspect of the proximal phalanx. (a) Dorsopalmar radiograph on day one: no abnormalities evident. Same day T1W GRE
(b) and STIR FSE (c) dorsal plane sMRI depicting sagittal area of T1W hypointensity and intense STIR hyperintensity in the proximal
third of the bone (arrows) compatible with a short incomplete proximal phalangeal fracture. Dorsopalmar (d) and lateromedial (e)
radiographs taken six weeks post-operatively. A sharp radiolucent line can be seen in the subchondral bone of the proximal phalanx
(arrow), and periosteal new bone is evident dorsally (arrows).
the fragment is near to compact bone or intact collagen. s urrounding the hyperintense area provides further evi-
The requirement for multiple coil placement for the evalu- dence of significance.
ation of long fractures in sMRI has both time and sedation
implications [145].
Lack of pathological correlation in many areas of equine
MRI means that interpretation is frequently subjective. As with other modalities, the diagnosis of fracture requires
This is particularly relevant to the parasagittal grooves of evidence of osseous discontinuity. Osseous trauma on MRI
the metacarpal and metatarsal condyles. Fissures have is associated with other changes in tissue composition, most
been described which may represent normal variation in importantly, the presence of bone marrow signal alteration
condylar groove morphology or a genuine fissure fracture. (fluid) that can result from injury even in the absence of a
The presence of intra-osseous fluid accumulation visible fracture. Histological evidence suggests that less
(a) (b)
Figure 5.13 Six-year-old eventer with acute onset moderate right forelimb lameness with a positive response to local analgesia of
the medial and lateral palmar metacarpal nerves at a proximal metacarpal level. (a) T2*W GRE transverse plane sMRI image at the
level of the proximal metacarpus. A large triangular zone of high fluid signal is present in the palmar medial aspect of the third
metacarpal bone. The zone of high fluid is demarcated by phase cancellation artefact. (b) Radiograph taken six weeks post injury. A
linear radiolucent fracture line is evident in the palmar medial cortex of the third metacarpal bone. No abnormalities were detected
on radiographs taken two weeks post injury.
severe trauma can cause marrow oedema without obvious

injury to the cellular elements, while more severe trauma
causes microfracture and haemorrhage [12]. In man, T1W
SE and STIR sequences consistently demonstrate prominent
signal abnormalities at fracture sites including patients with
subtle radiographic signs [147]. The high sensitivity of MRI
for recent fractures is due to the fracture line being high-
lighted by intra-osseous fluid accumulation [148]. The pat-
tern of intra-osseous fluid accumulation has been described
as like a footprint left by the injury [149] (Figure 5.14).
An acute non-displaced trabecular fracture may present
as a discrete hypointense linear, solid or broken lesion in
T1W images [150] surrounded by intra-osseous fluid accu-
mulation, i.e. STIR hyperintensity [151]. Where a fracture
gap is present, there is a hyperintense line on T1W, T2*W
and STIR sequences in compact and/or trabecular bone
along with decreased T1W signal intensity and increased
T2*W and STIR signal intensity in the trabecular bone.
Occult fractures have been variably described, ranging from
diffuse trabecular intra-osseous fluid accumulation, intra-
osseous speckled or linear regions of low signal intensity on Figure 5.14 T2* GRE dorsal plane sMRI image of a
metatarsophalangeal joint. The phase cancellation artefact
T1W images to irregular areas of high signal intensity in delineating the fluid signal associated with a lateral condylar
corresponding areas on fluid-sensitive sequences [132]. fracture leaves a ‘footprint’.
Compression fractures of trabecular bone can present sim-
ply as a zone of intra-osseous fluid accumulation.
Reference 91
Pathological changes in the bone surrounding fractures as 99mTc-MDP nuclear scintigraphy studies where the radi-
can include sclerosis (detected as reduced signal intensity on onuclide is taken up by exposed mineral matrix in osseous
all sequences), BML (increased signal intensity on fat tissues. 18F-NaF is a small molecule with rapid distribution
supressed images) or bone resorption (most typically detected when administered intravenously. The half-life of 18F is
as increased signal intensity on all sequences). The fracture 109 minutes. These factors allow for scanning to occur rela-
plane itself can vary in appearance depending on the tively soon after intravenous injection (30–60 minutes) and
sequence, fracture configuration, width and location [145]. for the horse to clear to a safe level of radioactivity rela-
tively rapidly (five to six hours depending on regional radi-
ation safety regulations). Dosage is based on extrapolation
from humans; however, the group at the University of
Healing is monitored by assessment of fracture gap, mar- California, Davis, has found that the total dose can be
gins, degree of displacement, periosteal proliferation and reduced to ~15 mCi per horse without reducing image
degree of mineralization along with the changes in associ- quality (M. Spriet, personal communication). 18F positrons
ated bone marrow signal. The persistence of increased have a much higher energy (511 keV) than X-rays or gamma
bone marrow signal intensity is not a clear indicator of a rays used in radiography or technetium scintigraphy: its
lack of progression (healing) since it is known that STIR implications must be understood for radiation safety.
hyperintensity can persist despite resolution of lameness. Human PET scanners are often coupled with a CT scan-
Furthermore, mature fibrous tissue as seen in delayed or ner to allow fusion of the high anatomic detail of the latter
non-union fractures can have mixed T2 signal but is gener- with the functional images provided by the former. The
ally T1 hyperintense, making the degree of mineralization physical construct of the human scanners is typically a
difficult to assess. PET scanner in series with a CT scanner. This arrangement
Bone stress injuries in humans have been graded accord- would be a major limitation to equine use. This is circum-
ing to MRI features of the periosteal surface, bone marrow vented by a novel PET, purpose-built scanner developed in
and the presence of a fracture line. Depending on anatomi- concert with UC Davis that can accommodate a horse limb
cal location, these can be used to develop management and can be coupled with CT images acquired by a different
strategies and return to exercise [144]. machine. Originally, the equipment was used in horses
under general anaesthesia, but recently the group devel-
oped a PET scanner for standing, sedated horses, which is
P
ositron Emission Tomography in use at Santa Anita Racetrack. Software also allows for
semi-automated fusion of the PET images with either MRI
PET is a cross-sectional, nuclear medicine emission tech- or CT images acquired at a different time. This particular
nique that is often used in combination with other imaging scanner has an 8 cm detector length that can translate over
modalities such as CT or MRI. It is a recent addition to 14 cm, resulting in an acquisition time of 3–10 minutes
equine diagnostic imaging but has broader use in human depending on the area being scanned.
medicine. A radioactive, positron emitting material is Clinical indications for musculoskeletal PET scanning in
administered systemically in order to map physiologically the horse are similar to those for nuclear scintigraphy with
active anatomic regions in a tomographic fashion resulting the obvious caveat that the region of interest must physi-
in cross-sectional images. cally fit into the scanner. Thus, PET scanning can be used
The positron emitting radionuclide fluorine-18 (18F) is for the investigation of fractures and stress remodelling,
incorporated into a biologically active molecule, such as assessment of crack and other osseous defect significance
fluorodeoxyglucose, a glucose analogue that is associated and the investigation of subchondral injuries. There is also
with high cellular metabolic activity. This is the most com- interest in assessing its potential to identify prodromal
mon usage in human PET scanning. In horses, for pur- pathology that could predispose (race-)horses to cata-
poses of mapping skeletal activity, 18F‑sodium fluoride strophic fractures. To date, there are few publications docu-
(18F-NaF) can be used. This works on the same principles menting its use in horses [152–154].
R
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97
Bone Healing
C.E. Kawcak
Veterinary Teaching Hospital, Colorado State University, Fort Collings, CO, USA
Introduction and Principles damage. The fracture configuration is usually unpredictable.

Instability can be significant, often requiring invasive repair
Bone has a well-organized architecture of mineral, organic techniques to restore mechanical support. Fatigue (stress)
matrix and cells that has developed and adapted for fractures are consistent in location and configuration and
mechanical efficiency and dynamic response to change in result at the end of a cumulative pathologic process in which
loading. The aim of ‘scarless healing’ is to restore this coalescence of osteoclastic resorption of bone remodelling
organizational paradigm in order to optimize use: fortu- and/or microdamage produce a clinical fracture [1]. These
nately, bone has the capacity to fulfil this goal. Nonetheless, can be minor or catastrophic, depending on the amount of
optimizing fracture healing in the horse presents many energy accumulated at the time of bone failure, and result-
challenges, including the size and behavioural nature of ing fracture configurations can be consistent or variable
the animal, the location and configuration of the fracture, respectively. Incomplete fractures are usually stable since
the amount of soft tissue damage and the ultimate stability the fracture does not break out from a secondary site [1].
of the fracture and/or its repair. These features, in turn, However, they can become complete without immediate
affect the mechanical and physiological environments of coaptation and attention. Complete fracture can be dis-
the injury, which are the two factors with the greatest influ- placed or non-displaced; the latter being more stable [1].
ence on healing. This chapter discusses the interactions of Comminuted fractures are complex and can be composed of
physiological and mechanical factors in bone healing multiple pieces often with significant soft tissue and vascu-
together with the influence of stability on cellular function lar damage, compromising both mechanical and physiologi-
and pain and the influence of pain on cellular events. It cal factors that favour healing [1]. Fracture configuration
describes molecular, cellular, tissue- and organ-based greatly influences the mechanical and physiological envi-
factors significant to fracture healing in order to identify ronments, which is reflected by the variable prognosis given
those processes that can optimize repair and those that can for each type of configuration. The quality of fracture heal-
lead to derangements in healing. Finally, current evidence ing depends on a sensitive balance of physiological and
for the use of exogenous physical, pharmacological and mechanical factors that function in parallel through the
biological techniques is reviewed. healing phases to regenerate tissue. The mechanical envi-
Fracture healing is principally influenced by its nature, i.e. ronment can have a significant effect on physiologic response
location, configuration, etc., and by its stability. The classic and vice versa.
fracture types are characterized in Chapter 3. From a per- Primary or direct bone healing occurs in a stable envi-
spective of stability, the fracture classification has signifi- ronment in which the fracture ends are directly and com-
cance. Fractures occur either in normal bone that fails due to pletely opposed to promote early vascular bridging and
a catastrophic force (monotonic fractures) or in pathologic direct bone remodelling [2]. Classically, there is no inter-
bone that fails from sub-catastrophic forces (fatigue frac- mediate step and bone heals without a scar. The process
tures). Monotonic fractures are acute in nature and caused requires rigid stability, usually with internal fixation. In
by a force that overloads the material properties of the bone. this situation, the bone ends are not only put in close prox-
These fractures are often in multiple pieces (comminuted) imity (reduced), but are also frequently compressed to
and accompanied by significant soft tissue and vascular eliminate any fracture gap. Stability also provides pain

98 Bone Healing
relief that in turn creates a favourable environment for the Derangements in fracture healing may be produced by
horse’s other limbs. Although direct healing is typically all and any influencing factors. These are broadly classified
described for cortical bone, the same principles apply to as delayed, non- and mal-unions. Delayed union occurs
subchondral compacta with the goal of precise articular when the repair process is slower than normal. Non-union
reconstruction and normalization of joint homeostasis. occurs when the fracture fails to heal radiographically [6].
Primary bone healing is the ultimate goal for the surgeon. There are several types of non-union fracture characteris-
Primary or direct bone healing is further classified by frac- tics that reflect the individual processes that negatively
ture gap size and interfragmentary strain. Contact healing affect healing. Mal-union occurs when the fracture heals
occurs when the fracture gap is less than 0.01 mm and the with abnormal fragment orientation.
interfragmentary strain is less than 2% [3]. In this situation,
osteoclasts at the ends of the osteons closest to the fracture
ends establish cutting cones that cross the fracture, creat- Phases of Bone Healing
ing continuous cavities that residing osteoblasts fill with
osteoid. This simultaneously re-establishes bone union The classic stages of bone healing have been known for dec-
and an intact Haversian system without callus forma- ades and provided the guiding principles for fracture repair.
tion [4]. Gap healing is similar but lacks simultaneous However, it has become apparent that these are not finite and
establishment of healing and Haversian system reforma- that individual fractures are likely to exhibit variations in the
tion. Gap healing occurs in defects less than 1 mm in size. intensity and duration of each stage. For any type of tissue to
Lamellar bone is initially deposited perpendicular to the heal, there are several basic requirements. Progenitor cells
long axis of the bone by vascularized osteons over three to must migrate into the damaged area either from local or
eight weeks, creating matrix in which secondary remodel- systemic sources [7, 8]. Extracellular matrix needs to be
ling can occur [3]. produced by local clotting factors, clotting cascades and
Secondary or indirect healing occurs in an environment progenitor cell production [2]. Growth factors are necessary
in which there is micromotion (from instability) or a gap to induce differentiation of progenitor cells into the desired
between the bone ends [2]. It results when precise apposi- cell type that may be vascular, chondrocytic, osteoclastic or
tion and/or rigid fixation are not completely achieved. The osteoblastic [2]. Adequate blood supply is also necessary to
classic phases of fracture healing, including progression provide appropriate oxygen tension, nutrients and, specifi-
from haematoma to creation of soft callus, formation of cally for bone, minerals [2]. The coordination of these events
hard callus and ultimately bone remodelling, follow in impacts the quality of healing and resulting function.
sequential order as mechanical stability increases. Further In the haematoma/inflammatory phase (Figure 6.1a), a
in the chapter, secondary healing is used as a model to clotting cascade and inflammatory/immune factors are
explain the physiologic progression of bone healing. released to stimulate fibrin formation and cell signalling of
In reality, many fractures have a combination of primary progenitor cells [9]. In the soft callus phase (Figure 6.1b),
and secondary healing [2]. Although most fracture repairs chondrocyte proliferation and intramembranous woven
appear clinically stable, they are all likely to have some bone formation occur due, at least in part, to relative local
areas of imperfect apposition in which secondary healing hypoxia and/or continued motion [10]. Once vascularity to
occurs. In equine fracture repair, gap healing can occur the area is restored, ossification will follow, resulting
either throughout an entire fracture or within parts of the in hard callus formation by both intramembranous
repair as precise anatomic alignment and absolute mechan- bone production and endochondral ossification [11, 12]
ical stability are often impossible. This is an important (Figure 6.1c). As these phases progress, mineralization and
principle as micromotion can produce significant stress on, expansion of the callus produce more rigid stability and
and ultimately result in, failure of implants. pain is likely to be reduced. Bone remodelling (Figure 6.1d)
Appropriately stabilized fractures heal with primary, a follows the hard callus phase and completes healing [10].
combination of primary and secondary or secondary heal- The stages are interdependent and overlap throughout.
ing. However, over-stabilized (which almost never happens The classic staging of bone healing provides a guide and
in horses) and under-stabilized repairs (which is more working template for consideration of potentially beneficial
common in horses) can lead to derangements in heal- interventions. For the equine surgeon, establishing stability
ing [5]. Over-stabilized repairs, which can occur in man and comfort are key to success.
and small animals, remove mechanical strain that is Information, principally from other species, has demon-
needed to stimulate a healing cascade in the fracture envi- strated that the molecular, cellular and tissue-based mech-
ronment. Reduced strain leads to a poor physiologic anisms involved in fracture repair are not only complex,
response and tissue atrophy. but also well synchronized in order to optimize the tissue
(a)
Fracture Environment Mechanical Environment
Damaged periosteum and soft tissues High Interfragmentary Strain Pain

Hypoxia
Instability
Haematoma
Haematoma Fibrin matrix
Fibrin matrix
Strain
Hypoxia
High Strain
Osteomac release
Cellular Response
Cell Signalling
Embedded Osteomacs
Neurovascular and Osteomac
signals
PMN Remove Debris
Tissue Debridement
Monocyte and Macrophage Remove Debris
Vascularity
Cell Recruitment
Osteoprogenitor Cells
Osteoclasts Remove Debris
(b)
Central
Repair Strain
Slow increase Oxygen Tensions
Fibrin (type III collagen) Unrepaired
Fibrin Cartilage Bone

Fibrocartilage
(type III/II Collagen)
Strain
Peripheral
Rapid increase Oxygen Tensions
Mineralized Matrix
(type I Collagen)
Cellular Response
Cell Signalling
VEGF, PGE2
Osteoclasts Remove Debris
Central Vascularity/Oxygen Tension

Low Oxygen = Chondrocytes Fibrocartilage
Oxygen = Chondrocytes Cartilage BMP, TGFB
Peripheral
Relatively High Oxygen = Osteoblasts
Mineralized Matrix
Figure 6.1 The process of secondary bone healing is a coordinated cascade of biological and mechanical influences leading to
progression of bone union. (a) Haematoma/inflammatory phase. Source: Modified from Walters et al. [9]. (b) Soft callus phase.
Source: Based on Sathyendra and Darowish [10]. (c) Hard callus phase. Source: Based on Aro and Chao [11]; Kwong and Harris [12]. (d)
Remodelling phase. Source: Based on Sathyendra and Darowish [10].
100 Bone Healing
(c)
Central
Slow increase Oxygen Tensions Repair Strain
Chondro-osseous Tissue Unrepaired

(type II/X/I collagen)
Mineralized Matrix
(type I Collagen) Strain
Peripheral
Mineralized Matrix
Callus
Cellular Response
Central
Cell Signalling
Chondroclasts Remove cartila VEGF, PGE2
Osteoblasts Mineralized Matrix
Vascularity/Oxygen Tension
Peripheral
Osteoblasts Mineralized Matrix BMP, TGFB
Bone remodelling
(d)

Central
Slow increase Oxygen Tensions Repair Strain
Chondro-osseous Tissue Unrepaired

(type II/X/I collagen)
Mineralized Matrix
(type I Collagen) Strain
Peripheral
Mineralized Matrix
Callus
Cellular Response
Central
Cell Signalling
Chondroclasts Remove cartila VEGF, PGE2
Osteoblasts Mineralized Matrix
Vascularity/Oxygen Tension
Peripheral
Osteoblasts Mineralized Matrix BMP, TGFB
Bone remodelling
Figure 6.1 (Continued)

Cellular and Humeral Influences on Bone Healin 101
environment for bone healing. Equine surgeons have acrophages (osteomacs) and their influence on vascularity
m
become better at fracture repair (mostly through improved and both anabolic and catabolic processes in bone heal-
stabilization techniques), recognizing factors that influ- ing [15]. Cells become activated in the deranged environ-
ence healing and identifying problems early. Not all comment caused by tissue damage and subsequently signal
mon practices favour fracture healing. As new medications other cellular cascades to mobilize for healing.
become available, surgeons and researchers can better pre- Fractures result in immediate disruption of vascularity
dict their influence on fracture healing and can use this and, if complete, compromise stability. In cortical bone,
information to develop strategies to enhance primary the periosteum is also damaged resulting in further vascu-
repair and to manage complex or failed repairs. lar disruption. In trabecular bone, vascularity and marrow
In considering the physiological environment of fracture homeostasis in the area are compromised. Failure of sub-
healing, both the condition of the bone and the surround- chondral compacta can result in an articular fracture. All
ing soft tissues must be taken into account. In the majority stimulate immediate cellular and cell signalling responses
of animals, the most common cause of fracture is an acute resulting in pain and inflammation, which influence sub-
traumatic episode in which either external or internal forces sequent healing [15].
lead to bone failure. However, in the equine athlete, there is In the haematoma phase of healing, bleeding occurs at
strong evidence to show that many fractures occur within the site, stimulating the coagulation cascade and formation
pathologic bone [13, 14], and its influence on bone healing of fibrin (Figure 6.1a). This usually occurs within the first
must be taken into consideration. It is expected that healing 24 hours, and the fibrin becomes the initial matrix upon
of compromised bone is not the same as normal bone. The which inflammatory and progenitor cells will have an
influence of the individual problem (vitality, remodelling, effect. Within 24 hours, inflammatory cells invade the area,
demineralization, hypermineralization, osteopenia, etc.) first neutrophils and then monocytes and macrophages [15].
and treatment on prognosis requires consideration. At this point, the environment can be altered markedly by
case management and specifically by reduction, repair and
reconstruction techniques. If a degree of instability remains,
ellular and Humeral Influences
C vascular integrity and hence oxygen tension are reduced,
on Bone Healing creating an environment conducive to a chondrocytic cell
population [15]. If fibrocartilaginous matrix produced by
The goal of this section is to introduce the basic building chondrocytes improves the local strain environment, then
blocks for understanding the processes of bone healing. vascular ingrowth principally from peripheral tissues fol-
This includes an understanding of the importance of vas- lows [16] (Figure 6.1b). As the fracture gap fills with chon-
cularity, the role of inflammatory cells and the immune drocytes and fibrocartilage matrix, mechanical stability
complex within the healing environment, the role of pro- increases. Chondrocytes undergo hypertrophic differentia-
genitor cells that are released within or migrate to the area, tion that further increases stabilization, decreases strain
the importance of the extracellular matrix and biochemical and enhances neovascularization. The cartilage matrix is
factors that influence healing. remodelled, local bone morphogenic proteins (BMPs) are
Bone follows the same basic healing processes as other tis- stimulated and osteoblasts are recruited to form woven
sues. Immediately following the insult/bone failure, the bone [17]. During this cascade, stability progressively
immune system responds not only to remove damaged tissue increases, strains are reduced and the healing environment
but also to signal a number of cellular processes. The immune begins to enter the hard callus phase (Figure 6.1c). Woven
system is integrated with the osteoresponsive cascade as bone is initially produced at the periphery and ultimately
immune-based cells, namely macrophages and monocytes, replaces the entire cartilaginous callus. As osseous callus
not only stimulate vascular, osteoblastic and osteoclastic matures, further improvement in local strains allows sec-
responses, but can also form into osteoclastic cells [15]. ondary remodelling that ultimately leads to a functional
At a cellular level, the biological and mechanical environ- and usually more anatomically correct shape to the bone. In
ments are interconnected. The process in which the mechan- long bones, all phases are considered complete once the
ical environment influences cell processes and development medullary cavity is reformed (Figure 6.1d). In the presence
is termed developmental mechanics [5]. Relatively unstable of continued instability, there is usually persistently com-
environments induce cellular mechanisms that can delay or promised vascularity that allows formation of granulation
inhibit healing and vice versa. There is an emerging field of and fibrous tissue only and results in a non-union [18].
study around the inflammatory and immune regulation of Vascularity strongly influences healing capability. Initially,
the fracture environment, particularly the role of osteal the damaged environment becomes avascular and as
102 Bone Healing
c hondrocytes thrive within a hypoxic environment this leads increase vascularity and regulate mesenchymal stem cell
to their initial proliferation. As healing progresses, neovascu- migration and differentiation. Osteomacs also influence and
larization brings nutrients essential to cellular optimization regulate the remodelling cascade. In this manner, inflamma-
and minerals needed for hard callus formation. Oxygenation tory cells and the immune system have essential anabolic
is key for conversion of soft to hard callus. Thus, the mechan- effects on bone, and suppression of the inflammatory phase
ical environment and degree of soft tissue damage influence can negatively influence bone healing [24].
vascularity, neovascularity and hence stability. Progenitor cells can either be local in origin or can be
Immediately after fracture, inflammatory cells are released produced systemically and migrate to the area. Trabecular
into the environment. This is stimulated by multiple factors, bone has a vast marrow network with osteoprogenitor cells
including neurovascular components (especially if the peri- that can act locally. Cortical bone also contains progenitor
osteum is involved) and local immune cells and factors that cells that can be released and act locally. Osteoprogenitor
are embedded within the bone tissue. These cells can then cell migration and differentiation is regulated by the osteo-
stimulate a systemic response for migration of inflammatory macs. Osteoclasts are stimulated and released systemically,
cells to the site. The term ‘osteomacs’ has been introduced to while osteoblasts can be triggered and recruited locally or
describe the importance of the immune cells in regulating systemically (Figure 6.2).
bone healing [19]. Polymorphonuclear cells remove debris, The extracellular matrix is essential for cells to have an
macrophages and monocytes stimulate osteoclastic and pro- influence on tissue. Damaged and non-viable tissues must
genitor cells, and based on the integrity of the vascularity, be debrided by the inflammatory cells to optimize the envi-
chondrocytes and osteoblasts are activated. ronment for repair. At the same time, clotting factors in
Inflammation has a major impact on bone healing, and dys- cells induce fibrin formation that provides the initial frame-
regulation of the inflammatory cascade can lead to increased work on which cells and osteogenic factors can act. Matrix
resorption and decreased formation [15]. Studies in osteoim- components, both mineralized and non-mineralized,
munology have identified critical links between the immune within bone allow cellular and biochemical functions nec-
system and bone healing [20]. The fact that haematopoietic essary for fracture healing and also provide the foundation
stem cells and mesenchymal stem cells both reside within the for which various repair techniques can be used. The char-
bone marrow and share similar signalling factors is evidence acteristics of the extracellular matrix can positively or nega-
of their integrated and coordinated function. Haematopoietic tively influence cellular and biochemical factors within the
stem cells function along the monocytic–macrophagic– environment. First, fibrin is formed at the site followed by
osteoclastic line, while mesenchymal stem cells are necessary type III collagen, proteoglycans and glycoproteins. Type III
for osteoblast formation. Cross-talk between inflammatory collagen can induce capillary proliferation and osteopro-
and bone formation cells is necessary for healing, and the two genitor cell migration to the site. These influence mechani-
lines interact through cell signalling to optimize repair [21]. cal integrity and cell signalling [10]. Type II collagen matrix
As in other tissues, following an adverse event, macrophages is common with chondrogenic cell proliferation typical of
and monocytes regulate a sequence of events to mitigate the endochondral ossification; although type I collagen is pre-
insult and optimize the healing cascade. The cells remove sent in limited amounts during all phases of healing, it sig-
damaged tissue, stimulate neovascularity and trigger healing nificantly increases with bone formation.
by release of signalling factors. In the acute stages, inflammatory cytokines such as
Neutrophils are the first inflammatory cells to occupy a interleukins, tumour necrosis factor and prostaglandins
fracture site. They function to recruit monocytes and mac- are released from platelets and inflammatory cells, stimu-
rophages and to regulate the signalling factors that are neces- lating progenitor cells to migrate to the area of damage [15].
sary for the healing cascade to occur. Although neutrophils Local cells and the forming matrix then release stimulatory
are necessary for healing, with severe trauma, ongoing inflam- factors such as fibroblast growth factor (FGF), platelet
mation can slow healing [22]. Overproduction of cytokines derived growth factor, transforming growth factor beta,
continually damages tissue and impairs vascularity. However, BMPs and Wnt glycoproteins [15]. These have all been
if inflammation is suppressed, particularly along the mono- shown to have a stimulatory effect on bone healing, at both
cytic and macrophagic cell lines, then a decrease in healing cellular and macroscopic levels. Vascularity at the site is
signalling can occur [23]. Osteomacs are macrophages located also stimulated by release of vascular endothelial growth
within periosteum and endosteum that work in the local envi- factor (VEGF) and prostaglandin E2 (PGE2) [25].
ronment. Macrophages remove and remodel the fibrin matrix, In contrast, chronic inflammation (which is most com-
while osteoclasts, differentiated from monocytes, remove monly due to infection) results in persistence of inflamma-
bone fragments. In the presence of tissue damage, signalling tory cytokines, consequential degradation of healing tissues,
factors from osteomacs recruit other inflammatory cells, pain and continuation of an immature matrix that cannot
Mechanical Influences on Bone Healin 103
d1 HSC
ge
MSC ag MSC
dj
an
lig
Runx2 Runx2
F
tch
EG
ES
Osx No Osx
NT
6
,V
IL-
RA
β
F-
1,
1,
TG
IL-
P-
MC
-α,
,
10
OP
F
6,
IL-
TN
G
IL-
1,
Monocyte
IL-
OP -β
G GF
α,
F-
Osteoblast RA M-CSF ,T 1 Osteoblast
MP
TN
NK M-CSF IL-
RANKL
L B -γ,
T NF
IFN-γ
RANKL TNF-α IL-1, IL–6
Osteoclast Macrophage
Osteocyte Osteocyte
Figure 6.2 Relationship of inflammatory and osteogenic cells. Source: Florence Loi et al. [15]. Reproduced with permission of Elsevier.
stimulate an osteogenic response. At the cellular level, the intramembranous ossification, strains of less than 15% lead
controlled release of inflammatory mediators is over- to endochondral ossification and strains greater than 15%
whelmed, leading to dysregulation of the osteoimmunologic result in formation of fibrous tissue and hence lead to non-
response. Osteoblast proliferation is reduced, thus decreas- union. In contrast, excessive reduction in the local strain
ing the immunosuppressive balance they induce. In the environment due to over stabilization by a repair (which
presence of infection, bacterial factors such as endotoxic has never been documented in horses) can lead to reduced
lipopolysaccharide (LPS) produce soluble inflammatory fac- bone healing. Loss of low-level strain can lead to reduced
tors leading to osteolysis [26]. external callus formation, fracture end osteolysis and
adverse remodelling [32]. The vascular response to frac-
ture, since it is dependent on local strain, will cause differ-
Mechanical Influences on Bone Healing ences in healing type. With physiologically sound rigid
stability and compression of fracture ends, local vascularity
Unlike other tissues, the mechanical environment of bone is enhanced and bone formation can occur [18, 30, 31].
has a significant influence on the healing environment. However, in secondary bone healing, increased strain and
Roux initially coined the term ‘developmental mechanics’ a void between the fracture ends will lead to a relatively
in which he hypothesized that the cell type involved in hypoxic area in which only chondrocytes can thrive.
healing is based on the mechanical load [27]. Wolff Progenitor cells differentiate into chondrocytes, and as these
described skeletal tissue as organized to optimize strength fill the fracture gap (the soft callus phase of healing), strain
in response to loading [28]. Pauwels took this further to decreases due to a relative increase in stability and the envi-
show that progenitor cells differentiate in response to the ronment becomes conducive to the formation of hard callus.
nature of mechanical load [29]. This classic work explains As stability is a major factor in influencing healing, metic-
the influence of the mechanical environment on bone ulous attention must be paid to adequate reduction, debride-
adaptation and demonstrates that the stability of a fracture ment, and application of fixation principles for optimal
will dictate the type of cells and tissue matrix that will stabilization. With the advent of minimally invasive proce-
occupy the site and thus determine the quality of healing. dures, debridement through open reduction is often not nec-
The mechanical strain that occurs at the time of fracture essary. In minimally displaced fractures, the requirements
can lead to significant vascular changes. Increased strain for meticulous reduction to produce stability is overcome by
results in continued vascular damage, decreased oxygen enhanced rigidity of the locking plate system. As experience
tension and consequent stimulation of chondrocyte with minimally invasive techniques increases, the limits of
formation [18, 30, 31]. Local strains of less than 5% lead to reduction will be tested and further guidelines will evolve.
104 Bone Healing
Discussion of the mechanical environment raises the humans. Biological non-reactive, non-viable non-unions
question of appropriate time for implant removal. At the are defined by lack of activity on nuclear scintigraphic
later stages of bone healing, it is possible that implants can examination. This is typically caused by lack of vascularity
shield stresses that may be necessary to complete healing at the fracture site. Torsion wedge non-unions fail to heal
and restore full bone strength. This continues to be debated due to lack of fragment vitality. Comminuted fracture non-
in human and veterinary medicine as clinicians constantly unions are characterized by a devitalized intermediate
question when the mechanical strength of the bone (with- fragment; the fracture ends are vascular, but the interven-
out the implants) is optimal for removal without reinjuring ing fragment is avascular. Defect non-unions occur at sites
the fracture site [33]. This is difficult to determine objec- of bone loss or an intervening infected area. Non-unions
tively. In most equine repairs, either a staged removal when fibrous tissue alone develops within the defect are
occurs for example if two plates are used or the animal may described as atrophic [6]. In appropriate cases in humans,
be exercised with the implants in place in order to apply vascular grafts and stabilizing techniques can be used to
some stress to the bone before removal. The form of exer- overcome non-union healing. However, the need for imme-
cise can vary according to individual circumstances. A pro- diate weight-bearing and cost often restrict use of these
gressive transition in mechanical environment can follow techniques in horses.
implant removal to apply gradually increasing loads. Care In clinical practice, objective assessment of fracture heal-
must be taken from the clinical perspective to be assured ing is difficult. Clinicians generally rely on pain and planar
that the healing bone is not overloaded. However, at this imaging (radiographs) to dictate management. Pain is con-
time there are no objective means of determining bone stantly monitored. In cortical bone, the periosteum con-
strength or resilience, and judgement must be made on the tains many nerve endings, and in fractures these are
basis of clinical signs and results of imaging. activated creating painful stimuli. The associated inflam-
matory response also increases nociception, and there is
evidence that even with fracture repair, there is an ingrowth
Monitoring Bone Healing of nerve endings into the site [34]. Chronic pain frequently
reflects instability, and one of the primary goals of repair is
Most derangements in fracture healing require surgery or to produce a rapid decrease in pain in order to prevent con-
further surgery and a change in fixation technique. tralateral limb overload (Chapter 14). In most cases, this
Exogenous therapies may also be of benefit (Section can be achieved with rigid internal fixation, giving the cli-
Exogenous Factors That Influence Fracture Healing). The nician a good subjective baseline from which to monitor
point at which revision must be considered is difficult to progress. If repair is compromised there is usually instabil-
determine objectively, but persistent or progressive pain ity, and resultant pain is probably the most sensitive indica-
and/or instability are pivotal in decision-making. tor of bone healing and construct integrity. Additionally, in
Fractures with impaired healing are usually described as humans, although not well characterized in horses, persis-
delayed or non-unions. A delayed union requires increased tent pain leads to a central upregulation of pain sensitivity
time, but healing will occur without surgical (or further which can, in turn, lead to chronic dysfunction [35].
surgical) intervention [6]. In adult horses, normal cortical Diagnostic imaging is important in monitoring fracture
bone healing is thought to occur within four months, and healing in horses. Ultrasound has been used to monitor the
in foals within three months [16]. In contrast, a non-union soft tissue environment around implants in order to identify
cannot heal without surgical intervention [6]. Mechanical potentially infected sites at an early stage (Chapter 14) [36].
factors, principally lack of stability, are the most common Radiography is the most commonly used modality (Chapter 5).
causes of non-union; however, biological factors including Changes in bone density and architecture are monitored. It is
impaired vascularity (usually due to severe soft tissue dam- common, especially in conservatively treated fatigue frac-
age) and infection can play a role. Non-unions have been tures, for the fracture gap to appear wider after two to three
defined by their radiographic appearance and clinical weeks due to normal osteoclastic function [37] (Figure 6.3).
symptoms divided into biological reactive and biological Soft and hard calluses can be monitored and their activity
non-reactive, non-viable unions [6]. Biological reactive characterized over time. This allows correlation with clinical
non-unions are further classified according to radiographic progress and can help direct rehabilitation (Chapter 15). In
appearance: hypertrophic non-unions (elephant foot non- delayed unions, the radiographic fracture line is persistent
unions) have exuberant callus formation due to instability, and there is minimal callus; intramedullary opacification may
while oligotrophic non-unions lack callus. Horses with also be evident [16]. Non-unions lack osseous bridging or cal-
non-unions generally have less callus formation and are a lus, the bone ends or margins become diffusely opaque (scle-
milder form of hypertrophic non-union compared to rotic) and blunt, and the fracture line persists [6].
Healing of Stress Fracture 105
(a) (b) (c)
Figure 6.3 Conservatively managed long oblique fracture of the radius (yellow arrows). (a) Presentation. (b) Five weeks post fracture
demonstrating osteolysis and widening of the fracture gap and initial periosteal (white arrow heads) and endosteal (black arrow
heads) callus formation. (c) Eight weeks post fracture demonstrating continued periosteal and endosteal (trabecular) callus formation
resulting in medullary opacification and partial loss of demarcation of the fracture line.
Although it can present practical difficulties, nuclear Internal sensors on implants have been developed on an
scintigraphy has been advocated as the most sensitive indi- experimental basis and in the future may be of clinical
cator of vascular integrity at fracture sites [38]. In human benefit [39].
medicine, nuclear scintigraphy can also be used to identify
and characterize fracture-related infection. Gallium scans,
white blood cell scans and 18FDG-PET appear to be most Healing of Stress Fractures
sensitive and specific, particularly when combined with
computed tomography [36]. Fatigue or stress fractures are common in young equine ath-
Volumetric imaging techniques can also be used to moni- letes and can occur in compacta (cortical or subchondral) or
tor fracture healing. In most cases, this is accomplished trabecular bone. Pathogenetically, repetitive stress causes
through computed tomography that can be used to monitor microdamage accumulation in areas of rapidly remodelling/
the fractured gap and the surrounding tissues. This provides modelling bone where osteoclastic activity outpaces osteo-
more objective information than two-dimensional radio- blastic repair, leaving affected bone relatively osteoporotic
graphs and does not suffer from superimposition of normal and thus predisposed to further microdamage, or progres-
and abnormal tissues. Implants create difficulties in inter- sion to failure [37]. Cortical stress fractures occur commonly
pretation, but metal reduction algorithms aid interpreta- during training in young Thoroughbred racehorses. Initially,
tion/visualization and sequences are being improved [36]. they can result in reduced performance, but if unrecognized
106 Bone Healing
can progress to complete and sometimes catastrophic Healing of Displaced Fractures

fracture. If discovered early, most cortical stress fractures
heal completely. Even if a fracture plane cannot be imaged, Satisfactory secondary healing of displaced fractures in horses
this is likely to be a form of gap healing as callus production rarely occurs. The few exceptions are discussed in individual
is usually seen. Some that fail to heal in a timely fashion and location chapters. In the appendicular skeleton, persistent
are in amenable locations can benefit from internal fixation. pain, malunion and permanent limb dysfunction generally
Stress fractures in subchondral compacta and trabecular preclude this approach. Conservatively managed articular
bone are also common in young athletes, often leading fractures will almost always result in osteoarthritis and
either to articular fragmentation, articular fracture, sub- chronic pain which of itself reduces healing and increases the
chondral pain or osteoarthritis [14]. Continued repetitive likelihood of opposite limb overload (Chapter 14). Meticulous
stress in long bone epiphyses or cuboidal bones can cause reduction, congruent joint surfaces and adequate mechanical
accumulation of microdamage or an attempted reparative support are necessary to optimize healing and prognosis.
response of bone modelling. In the absence of an outer cor-
tex on which responsive bone can be deposited, thus increas-
ing diameter and strength, the bone can become intensely
dense (often termed sclerotic) leading to brittleness and ealing of Reduced and Repaired
H
failure/fracture or other osteoarticular damage [14]. In some Fractures
situations and locations, healing can occur with rest [40].
The goal for reduced and repaired fractures is to create
mechanical and physiological environments that promote
Healing of Incomplete Fractures primary bone healing. In most (equine) circumstances,
repair will result in a hybrid of primary and secondary heal-
When an incomplete fracture occurs, the visible gap at the ing. As a rule of thumb, the closer to the former that the
site makes primary healing unlikely. If the site is relatively surgeon can achieve, the better the prognosis and less com-
stable, then secondary healing can follow. Incomplete oste- plicated the post-operative care required. In primary bone
oarticular fractures can heal with rest, but the current con- healing, in which rigid internal support is provided, inflam-
sensus is that provision of interfragmentary compression, matory and haematoma cascades still occur to some degree
which should induce primary bone healing, produces a because there will be a delay between fracture and repair.
more predictable healing process, decreases the period of When open approaches are used for reduction and internal
required immobilization, reduces progressive articular car- fixation, fracture haematoma and any damaged bone will
tilage damage and shortens convalescence. be removed in order to optimize reduction and architectural
reconstruction. In these cases, the benefits of reduction and
absolute stability outweigh potential contributions from the
initial clot. It is possible that osteomac stimulation has
ealing of Complete Non-displaced
H already occurred, but surgical trauma and the inflamma-
Fractures tory response to it should also contribute to cell signalling.
Lag screws and/or plate fixation are used to maximize fric-
Complete, non-displaced fractures can also heal with con- tion between fracture ends or across fracture planes, thus
servative management. This involves secondary bone heal- reducing the intervening space and optimizing the environ-
ing, but the time to pain relief, radiographic healing and ment for primary healing. With reduction and stability, the
return to work are often unpredictable. Complete, non- sources of healing originate from the periosteum, the
displaced fractures are often best treated surgically to bet- endosteal tissues and the Haversian system [25]. This cas-
ter assure quality and timing of healing. Interfragmentary cade, in which some form of inflammation and haematoma
compression can result in reduced pain, enhanced stability formation occurs on a microscale, theoretically bypasses the
and direct bone healing, producing a more predictable out- instability and hypoxia that leads to soft and subsequently
come. Delayed surgical repair is sometimes undertaken if hard callus formation. It is likely that at a histologic level
an initial conservative approach proves unsuccessful. In these stages also occur as some local degree of hypoxia is
this situation, the presence of fibrous, fibrocartilaginous, likely to occur until vascularity is restored. However, this is
cartilaginous tissue or even woven bone in and/or around quite rapid as the surrounding soft tissues, periosteum,
the fracture gap usually makes complete compression endosteal tissues and Haversian system are sources of neo-
impossible. Some form of gap healing must occur, but vascularity. Acute restoration and maintenance of stability
increased stability provided by internal fixation stimulates by fracture repair improves the speed of neovascularization
and enhances the process. from these sites [18] and, as long stability is maintained,
Effects of External Fixation on Bone Healin 107
direct bone remodelling across the fracture will lead to a ffects of Internal Fixation on
E
relatively rapid healing process. Bone Healing
Gap healing is a form of primary healing that occurs when
fractures are not in perfectly uniform alignment and/or con- In the horse, internal fixation, whether through open reduc-
tact. This is likely to occur in many complete equine fractures, tion or minimally invasive techniques, is the most com-
regardless of how stable they are, because perfect architec- monly used method for repairing fractures. In simple,
tural reconstruction is often not possible. It is inevitable in usually articular fractures, one or more lag screws can be
complex and comminuted fractures and is probably also the used to re-appose the joint surface and provide compression
situation in all complete fractures at a histologic level. In this to promote primary fracture healing. In these cases, the
case, the gap may heal through more of a secondary healing severity of articular deficits and/or articular cartilage dam-
process even though the entire bone is stabilized. Alternatively, age usually dictates prognosis as the fractures are usually
there may be areas of healing in a single fracture which are stable. In equine athletes, this commonly occurs through
closer to primary repair and others in which secondary pathologic bone as seen in the carpus (Chapter 24) or in the
healing predominates. A (unheard of in equine patients metacarpo/metatarsophalangeal joints (Chapters 19–21)
but is recognized in small animals) theoretical concern with [14]. In these locations fractures usually heal, but the patho-
gap healing is that some fractures can be over-stabilized, and logic bone commonly influences the articular surface and
consequently non-union or atrophic union results. Mechanical consequently reduces the prognosis for an athlete.
loading and a degree of micromotion are necessary stimuli The stability and process of fracture healing following
for secondary bone healing. Deprivation of these in the plate fixation, whether by open reduction or minimally
presence of a fracture gap prevents both primary union and invasive approaches, is highly dependent upon anatomic
the cascade of secondary healing. location and the quality of reduction and stabilization at
Secondary bone healing follows use of external fixators or the site. Even with meticulous reconstruction of a long
internal fixation in which the architecture of the original bone bone fracture, perfect anatomic reduction usually does not
is not perfectly realigned and stabilized. In secondary healing, occur, and some areas undergo gap healing. It is generally
the inflammatory and haematoma phase is more prolonged accepted that the proportion of load that can be borne by
than in primary repairs due to relative instability and soft tis- bone has a direct bearing on outcome. The role of gap heal-
sue trauma. Locking plates, especially if placed in a minimally ing on cyclic fatigue of implants is unknown but is a poten-
invasive fashion, allow for stabilization with gap healing while tial factor in determining the risk of repair failure.
maintaining the clot and the inflammatory mediators for an Intra-osseous nails are used in anatomically appropriate
optimized local environment. Stability is the most important situations to convert highly unstable fractures to ones with
influence on the effectiveness and timing of the stages in sec- sufficient stability to permit secondary bone healing. Strict
ondary bone healing, although other factors such as contami- anatomic reduction does not occur. They maintain bone
nation and/or infection can impact negatively on the process. length, i.e. prevent diaphyseal overriding and reduce bend-
ing and torsional forces. Rush pins have similar goals, but
in horses rarely are able to be of benefit.
Healing of Repaired But
In limb fractures, wires are sometimes used to help main-
Non-reduced and/or Unstable Fractures tain reduction, especially in long oblique fracture repairs.
However, small screws and/or countersunk lag screws are
The size, physiology and behavioural characteristics of
often most appropriate. Wire can also be used to create a
horses are such that long bone fractures commonly fall into
tension band, usually as a supplement to other fixation
this category. Despite improvements in implant design and
techniques in order to optimize the biomechanics of repairs.
surgical techniques, many repairs are to some degree
In fractures of the mandible and maxilla, wires are used to
incompletely reduced (often due to missing or avascular
close fracture gaps and increase stability in order to improve
fragments) and/or slightly unstable. In these scenarios,
the environment for secondary bone healing (Chapter 36).
secondary healing, or at best some gap healing, is likely. It
is then a race between the stable fixation (the combination
of reduced/stable areas and the implants engaging them)
providing enough mechanical stability to brace the unsta- ffects of External Fixation on Bone
E
ble areas until they are supported by secondary healing. Healing
The balance between these two processes dictates outcome.
If there is evidence of gross instability, revisionary surgery In the horse, in which bed rest cannot be enforced and
or external support should be considered to restore some because of their large size, external fixation (Chapter 13) is
stability to the microenvironment of the fracture. only used when no internal fixation techniques are viable,
108 Bone Healing
such as with highly comminuted fractures or occasionally Non-steroidal Anti-inflammatory Drugs

with an open fracture. The typical ring external fixator Non-steroidal anti-inflammatory drugs (NSAIDs) are a
applied in other species is not commonly used in horses, and mainstay of reducing pain in horses. Their effect on bone
instead either a pin cast or customized external fixator is healing is controversial [44], and use in horses undergoing
employed [41]. The technique is dependent on secondary fracture repair is a source of debate [45]. In people and
bone healing, and providing sufficient stability for this pro- experimental animals, it has been well documented that
cess is critical to success. Pin breakage or bone failure in the the early inflammatory phase is key to bone healing
region of the pins are not uncommon sequelae and can lead (Section Cellular and Humeral Influences on Bone
to failure [42]. Pin loosening can also result in reduced stabil- Healing). In addition to experimental animal evidence,
ity at the fracture site, which impedes healing, and increases there is some suggestion in humans that fracture healing
pain. External fixation is inevitably a race between fracture can be delayed, and in most clinical situations, NSAIDs are
healing (decreasing pain) and pin and/or bone failure. avoided following fracture repair [46]. In one study, phe-
nylbutazone decreased mineral apposition rate in cortical
bone, but there was no difference in the percentage of min-
Intrinsic Factors That Affect Healing eralized tissue [45]. A recent study in dogs showed no sig-
nificant difference in tibial osteotomy healing with
The most common, and likely the greatest, source of nega- short-term administration of carprofen (two weeks); how-
tive effects that inflammation can have in equine fracture ever, there was significant delay in healing with long-term
healing is infection. Infection can result from contamination administration (eight weeks), leading to the conclusion
at the time of fracture or at the time of repair. The presence that NSAIDs should only be used in the perioperative
of foreign material (i.e. implants) commonly makes resolu- period [47]. The evidence is therefore inconclusive. The
tion impossible until these are removed. A number of proce- author is unaware of any clinical evidence to suggest that
dures exist to prevent and combat infection (Chapters 9, 11, NSAIDs used in the perioperative period have a negative
and 14). At a tissue level, the development of chronic inflam- impact on fracture repair in horses. The potential negative
mation can lead to compromised vascularity, impaired cell effects on bone healing must also be weighed against the
signalling, instability and persistent pain [26]. possible positive effects on healing, especially in the case of
In other species, host factors have been correlated with severe soft tissue trauma and ongoing inflammation [15],
the quality of fracture healing. In people, age, immune sta- and on the overall status of the patient. Phenylbutazone,
tus, metabolic status and social behaviours can all have flunixin meglumine and firocoxib can all be considered.
negative impacts [10]. Although there has been no correla-
tion between quality of fracture healing and systemic met- Bisphosphonates
abolic conditions in the horse, it appears plausible and Bisphosphonate therapy has come into the equine market
logical. In humans and other species, ageing has a negative in recent years, and its use in fracture management has
effect [43]. This may be mediated through the immune sys- been debated [48]. Bisphosphonates have a number of
tem and/or negative influences on angiogenesis, mesen- pharmacologic properties. Of principal interest in relation
chymal stem cell activity and reduced progenitor cell to fractures is their ability to suppress osteoclastic activ-
numbers and activity [43]. Clinical experience suggests ity [49]. However, they also exert anti-inflammatory and
that age also appears to be correlated with fracture healing analgesic effects [50–52]. There is evidence in experimen-
in horses. It is likely that both size and healing capacity tal animals that bisphosphonate administration may
explain why young animals have a better chance of suc- inhibit osseous adaption responses and result in mechani-
cessful repair than adults. cally weaker bones [53] and delay fracture healing [54–56].
This is logical when considering the role of osteoclasts in
bone healing. The potential impact on fracture healing also
xogenous Factors That Influence
E depends on the time of administration [57]. In the early
stages, bisphosphonates can inhibit the essential immune
Fracture Healing
cascade (macrophages and monocytes) while later, since
osteoclasts are essential in the remodelling phase, they can
Pharmacologic Influences
also have a negative effect. Studies in experimental animals
Various medications can have differing effects on cells, cell have shown no delay in the formation of a hard callus
signalling, osteoimmunologic pathways and tissues at dif- (which in fact grows larger in the face of bisphosphonate
ferent times and thus may have positive or negative effects therapy) but a significant delay in remodelling from woven
on fracture healing. to lamellar bone [58]. Despite the large callus size, these
Exogenous Factors That Influence Fracture Healin 109
fractures have been shown to be mechanically equivalent PRP has been suggested as a product that could be applied
but not superior to those found in untreated animals. It at fracture sites [63]. Analysis of data does not provide con-
also appears that the timing of bisphosphonate administra- vincing proof of efficacy, but various experimental and clini-
tion does not influence healing. In humans, the results cal studies suggest that it has promise, especially in light of
have been mixed and no clear conclusions can be made. the critical role of the clotting cascade in fracture healing.
There appears to be some positive response to bisphospho- PRP is defined as a blood derivative where the platelet con-
nate therapy in human osteoporotic patients suffering frac- centration is above baseline levels. It is meant to provide
tures, but this condition has not been recognized in horses. high concentrations of growth factors that are presumed to
The established impact on osteoclastic function and bone be anabolic to healing of any tissue. Several studies have
remodelling suggest use should be avoided, and a recent shown positive effects including evidence for antimicrobial
review has suggested caution in young racehorses and in activity of platelet lysate [64]. In a meta-analysis of PRP use,
the presence of active bone remodelling [52]. There is also 91% of studies showed positive effects; histologic assessment
anecdotal evidence in horses that bisphosphonate use in of positive outcome reduced this to 84%, and radiological
the face of fracture repair may have a detrimental effect and biomechanical analyses dropped the positive benefit to
(L. R. Bramlage, personal communication). 75 and 73%, respectively. Potential use of PRP in bone defects
therefore continues to be debated [63].
Antimicrobials Cellular product such as mesenchymal stem cells have been
Antimicrobials are essential in surgical repair, especially in advocated to enhance fracture healing. Mesenchymal stem
cases of open contaminated fractures. Many different drugs cells can be acquired from many tissues, but for fracture man-
can be used, each with well-documented systemic effects agement they are generally obtained from bone marrow. In
and potential toxicity; however, effects on bone healing in horses, bone-marrow-derived stem cells have been used in
horses are lacking. In vitro and in vivo experimental studies multiple tissues, but beneficial effects in fractures have not
have shown that systemic administration of antimicrobials been proven. In experimental studies in other species, positive
in general seems to have little or no direct effect on bone effects have been seen using bone marrow injections
cells. However, implantable delivery systems that release alone [65]. Bone marrow aspirate has been clinically evalu-
high concentrations over time have shown some detrimen- ated and found to have positive effects [66], and bone marrow
tal effects on bone [59]. This has also been shown on metal grafting has been shown to be successful for treating non-
implant coatings [60]. In a study of multiple antimicrobi- unions in human patients [67]. Autologous, culture-expanded
als, although detrimental effects on osteoblast number and mesenchymal stem cells have been reported in clinical studies
activity were seen, amikacin, tobramycin and vancomycin or case reports in people. Most of these have been combined
were the least cytotoxic [61]. Despite the potential negative with scaffolds to create a cell–scaffold composite which in
influences, the positive effects outweigh concerns. Ideally, itself has been challenging. Healing of large cortical bone
use should be targeted (Chapter 14) but, in reality, antimi- defects have been reported, but use in clinical cases has not yet
crobials are usually started before target organisms are been defined. Bone marrow aspirate, bone marrow aspirate
known, and clinicians must choose drugs based on their concentrate and culture-expanded mesenchymal stem cells
understanding of likely pathogens, severity of infection have been used for non-unions, osteotomies, distraction oste-
and potential consequences. ogenesis, spinal fusion and fractures; although the outcomes
appear positive, more work is needed [68].
In the horse, there is experimental evidence supporting use
Biological Techniques
of stem cells in bone healing. Stem cells loaded onto a trical-
Osteobiologics is an emerging field of study in all spe- cium phosphate (TCP) implant with BMP improved healing
cies [62]. Various blood products, cellular treatments and in a third metacarpal bone defect model [69]. Others have
growth factors are included in this group. Each have shown shown no improvement in healing with osteoprogenitor cells
some positive effect on bone healing when dissecting the in fibrin glue [70]. A review of the field has provided basic
reams of literature around their use. discussion around the theoretical use of stem cells to augment
The two main blood products used in horses that have fracture healing, but critical experimental and clinical work
potential for use in fracture management are interleukin-1 around the best cell type, application method and matrix car-
receptor antagonist protein (IRAP) and platelet-rich plasma rier is needed before recommendations can be made [71].
(PRP). IRAP is usually used as an intra-articular medication, Growth factors have been used in human, and in some
and for fractures involving the joint in which articular carti- cases of equine, fracture repair. BMP has been most highly
lage damage is present, there is a logic to use. The author is studied to date. BMP2 is known to stimulate progenitor
unaware of intralesional IRAP use in fractures. cells to differentiate into osteoblasts, and BMP7 is known
110 Bone Healing
to stimulate angiogenesis. There is good clinical informa- dictated by patient recumbency and surgeon preference.
tion in humans, although ectopic bone formation and high Autogenous cancellous bone graft contains mesenchymal
price are negative factors to its use [72]. In an experimental stem cells, matrix proteins and a large surface area which
equine model, no significant increase in healing from stimulates vascularity and host integration. The graft helps
BMP2/7 gene therapy application was seen [73]. FGF has form the haematoma, initial inflammation and granula-
also been shown to stimulate progenitor cell differentiation tion tissue bed. Neovascularization is stimulated, and oste-
and angiogenesis. VEGF is initially released from the hae- oid forms around some of the tissue. Autogenous
matoma and promotes development of endothelial cells vascularized cortical grafts provide vascular integrity so
and vascular invasion and may be secreted by chondrocytes that the grafted bone can remodel and heal. They are rarely,
within callus to stimulate angiogenesis and new bone for- if ever used in horses. Autogenous cortical bone grafts are
mation. Parathyroid hormone (PTH) has been shown to rarely used in horses and can only be incorporated through
produce increased bone mass, bone strength and reduced creeping substitution via osteoclastic function and long-
bone loss, especially in cases of osteoporosis. Although term osseous integration. Osteochondral grafts are com-
PTH can stimulate fracture healing, it does not appear to monly used in humans and occasionally in horses [77].
act as a differentiation factor and may not be effective if Allogenic grafts are acquired from a different animal of
the early stages of fracture healing are not optimized. the same species with the benefit that they can be acquired,
Exogenous PTH has been found to be safe in horses [74]. stored and used off the shelf. Allogenic bone grafts can be
PTH has also been implanted within a fibrin matrix into an in the form of cancellous chips, cortical bone segments
equine subchondral bone cyst with a positive effect [75]. (which are used in humans to provide mechanical stabil-
Overall, the use of exogenous growth factors appears logi- ity), osteochondral grafts or decalcified bone matrix.
cal, but a cost versus potential benefit debate is necessary However, allogenic grafting triggers an immune response,
before deciding on use. and the consequential increased inflammatory phase may
impede healing. They are rarely used in horses.
Decalcified bone matrix has been used for decades in the
Bone Grafts
human field but showed no positive effect on healing in an
Bone grafts can provide both mechanical support and experimental equine study [78]. Decalcified bone matrix is
enhanced osteoregeneration. Different graft types work in prepared by eliminating potential allogenic substances
differing ways. The three principal properties are osteocon- through a decalcification procedure that maintains the
duction, osteoinduction and osteogenesis. Osteoconduction non-calcified bone matrix including potential growth fac-
refers to the ability to support attachment of osteoprogeni- tors and allows for osteoconduction. Decalcified bone
tor cells and allow migration and growth within the three- matrix is rarely used in equine fracture repair but may have
dimensional architecture of the graft. Osteoinduction a place in fractures with large residual defects [76].
occurs when the graft itself can induce progenitor cells to
develop into bone forming cells. Osteogenesis is defined as
Synthetic Bone Substitutes
osteodifferentiation and new bone formation by donor
cells derived from the host or the graft [76]. Because of limited availability and morbidity associated
Autogenous bone grafts are most commonly used in all with cancellous bone grafts in humans, bone substitutes
species. In humans, it is second only to blood transfusions are commonly used [76].
as the most common tissue transfer, although there is a Calcium sulphate (plaster of Paris) has been used in horses
search for non-autogenous bone regenerative products principally because it can be implanted with antimicrobials.
because of the limited supply and morbidity caused by Like many bone substitutes, it is osteoconductive, biode-
acquisition. Horses tend to have a large supply of suitable gradable and can be combined with autogenous bone graft
autogenous bone, and morbidity at the retrieval site is usu- at a defect site. Calcium phosphate ceramic (CPC) has also
ally minimal. Autogenous bone is the gold standard by been used and can be modified to a calcium hydroxyapatite
which all other graft products are compared, and it is still implant that has some indication of stimulating bone heal-
the most effective for inducing bone healing. Autogenous ing. These have some potential but are rarely used in horses.
bone grafts provide all three methods of function (osteo- Exogenous hydroxyapatite has been used in humans. It is
conduction, osteoinduction and osteogenesis). They can be osteoconductive and stimulates osteointegration with
either cortical, cancellous or vascularized. Autogenous mechanical properties similar to cancellous bone. The
cancellous bone graft is most commonly used. In horses, it implant has good porous characteristics to enhance cell
is typically acquired from the tuber coxae and packed into migration and bone remodelling. TCP is more porous and
the fracture gaps at the time of surgery. Alternative sites degradable than hydroxyapatite which increase vascular
include the proximal tibia, humerus and sternebrae. Site is invasion. There are reports of TCP use for osteochondral
Conclusion 111
repair [79]. BCP is a combination of hydroxyapatite and TCP horses [94] and that the mechanism may be induction of
mixture, and CPC is an injectable form that has been used to bone microfracture [95]. However, there is no evidence that
enhance healing. Bioglass is a silicate-based implant that has ESWT can enhance fracture healing in horses.
been shown to enhance binding to host bone. Hydroxyapatite Vibration therapy has been introduced to the equine
coatings have been shown to enhance osteoprogenitor cells market. In humans and experimental animals, the ten-
and protein binding. Polymethylmethacrylate (PMMA) has dency is for bone healing to be improved in individuals
been used as a spacer in staged healing in humans. In with osteoporosis [96]. Although it has been suggested for
horses, it is the most commonly used delivery vehicle for equine rehabilitation purposes (Chapter 15) [97], its use to
antimicrobials [80]. stimulate bone healing is questionable.
Hyperbaric oxygen therapy has been advocated to stimu-
late bone healing, but systematic reviews of the therapy have
Exogenous Devices been inconclusive [98]. Considering the cost and need to
transport the animal, it is unlikely to be clinically viable.
Pulsed electromagnetic fields have been used with some suc-
cess for stimulating fracture healing, especially in cases of
delayed healing in people (Chapter 15). The technique has Conclusions
been used for over 40 years and functions by passing a cur-
rent through a conductor to generate a magnetic field [81]. Bone healing is a complex paradigm, and thorough under-
Although most studies have shown a positive effect used standing of the process is necessary in order to make sound
in vivo, ex vivo and clinical trials, some have shown none or clinical judgements when managing fracture cases. An
negative effects. The variability may be explained by the man- understanding of the healing process is also necessary as
ner of application (frequency, timing and dose), the stage of new techniques and medications become available. In
healing at which it is applied, tissue densities and application human medicine, the ‘diamond concept’ has been proposed
method [81]. Although there is no recent evidence to support as a means to follow fracture healing (Figure 6.4). This
its use in horses, some older studies reported a positive influ- addresses all the various factors that influence fracture heal-
ence on bone repair. Meta-analysis of the human literature ing, including the osteogenic cell population, osteoinductive
also suggests that it can be efficacious [82]. stimulants, osteoconductive matrix, mechanical stability,
Electric stimulation therapy has been studied for dec- vascularity and host factors. These guidelines should all be
ades; although experimental use has generally shown posi- considered when managing fractures in horses.
tive effects, its efficacy in clinical trials is mixed [83]. It is
theorized that bone formation is stimulated by electrical
fields generated within the bone .
Vascularity
Low-intensity pulsed ultrasonography (LIPUS) has also
been advocated for use in fracture repair (Chapter 15). The
ultrasound waves are assumed to cause material deforma-
tion of bone at the site of application and upregulate cel- OSTEOGENIC Host OSTEOCONDUCTIVE
lular and biochemical processes to stimulate bone CELLS SCAFFOLDS
formation [84, 85]. Meta-analysis of clinical studies shows

modest effects overall [86]. There is some evidence that
LIPUS is slightly better than electrical stimulation early in DIAMOND
fracture repair [87]. Although low-intensity ultrasound has CONCEPT
some evidence of efficacy in humans [88], limited use in
horses has shown no positive effects [89].
There is some evidence that extracorporeal shockwave
therapy (ESWT) can effectively be used to treat non-union MECHANICAL GROWTH
fractures in humans [90]. Meta-analysis of its use in humans ENVIRONMENT Host FACTORS
showed no differences in healing of acute fractures, but

there was a trend for increased comfort in treated
patients [88]. ESWT has been shown to decrease lameness in
Vascularity
equine osteoarthritis with a simultaneous increase in bone
biomarkers [91, 92]. It has also been shown to have analgesic Figure 6.4 The diamond concept for fracture repair demonstrating
properties in some studies, but not in others [93]. There are the key elements involved in the complex organization of bone
some indications that ESWT can promote osteogenesis in healing. Source: Based on Giannoudis et al. [23].
112 Bone Healing
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117
Triage and Emergency Care

I.M. Wright and J. Daglish
I ntroduction decision-making can follow. Use (maintenance) of a bridle

or fitting a chifney is highly recommended.
Equine fractures are an emotive subject. In acute phase Fractures should be a principal differential for all racing/
assessment of horses with suspected fractures, efficient tri- training-induced lameness. In the acute phase, this is irre-
age is important. Attending veterinarians have an obliga- spective of the degree of lameness or other orthopaedic
tion to be well informed and decisive. There are often compromise present. Horses with incomplete, and some
important welfare and financial considerations. Actions with complete, non-displaced fractures can present with
taken and advice given are also frequently subject to later relatively mild lameness initially, particularly at the end of
scrutiny. In ambulatory service including attendance at a race. Localizing clinical signs at first can be relatively
racecourses and other sporting events, veterinarians’ subtle but commonly will then progress. Although there
responsibilities can be summarized as: may be clinical suspicion at this time, accurate diagnosis
requires further investigation. This may involve subse-
i) To relieve pain and anxiety quent radiographic examination of a suspect area. Multiple
ii) To establish a diagnosis projections are necessary but, in the acute phase, a number
iii) To move the animal to appropriate facilities for care of common racing/training-related fractures can be radio-
and investigation graphically silent (Figure 7.1).
Horses have a commodity value, but many will also be of On the racecourse, screens of sufficient number and size to
considerable emotional and sentimental value to owners permit evaluation and initial case management out of the
and this will influence markedly decision-making pro- public gaze should be available. Screens should be high
cesses in the face of injury. enough to obscure spectators’ sight lines from grandstand
This chapter focuses on fractures of the appendicular views [1] (Figure 7.2). They should be positioned with this in
skeleton. Triage and emergency care of vertebral and skull mind, but sufficiently distant from the horse to permit all
fractures are discussed in Chapters 34 and 36, respectively. round access for strategic personnel and for ambulance posi-
tioning without adding to the horse’s anxiety. It has been rec-
ommended that at least one set of screens should be 14.5 m
R
acecourse Fractures long and 2.5 m high [2] and should be with the following
veterinarians on course with reinforcements, accompanied
Fractures that result from cumulative overload are most by adequate numbers of trained personnel, mobile and read-
common in horses moving at speed and are therefore seen ily available for rapid deployment to all racecourse locations.
principally in racehorses. Complete fractures that occur Effective management of racetrack fractures requires
during training and racing will readily displace, some careful planning and the establishment of protocols suita-
markedly, causing extensive soft tissue damage before the ble for dealing with all equine emergencies at all possible
horse stops or can be pulled up. The primary objective at sites on the course/racetrack. A team approach is critical.
this time is control; first of the horse and then of the unsta- Depending on the course, a number of teams, each led by
ble limb. Once these are achieved, logical clinical an experienced veterinarian, will be necessary. All team

118 Triage and Emergency Care
(a) (b)
Figure 7.1 Dorsopalmar radiographs (a) at presentation with marked forelimb lameness at the end of a race and (b) the same limb
nine days later revealing a comminuted fracture of the proximal phalanx.
Figure 7.2 Racecourse use of screens to shield a stricken horse.
members (drivers, ambulance personnel, horse handlers, non-public, communication between teams and with the
screen raisers, etc.) will require training and practice. Free racecourse officials is essential. Exchange of veterinary
movement and access to all parts of the racetrack accessi- information is sensitive and should be passed discreetly
ble to horses is paramount and should include a thorough and only to authorized individuals. Each team should be
knowledge of course exits and entrances. Designation of comprehensively equipped for its area of service and the
spectator-free emergency routes for horses, ambulances, inventory of drugs, splinting materials, etc., checked before
veterinary and medical attendants is desirable. Closed, i.e. racing commences. In addition to the above, equipment for
Clinical Assessmen 119
catching, restraining and turning horses is also necessary involves systematic evaluation of limb dysfunction, abnor-
on the course. This should include headcollars, halters, bri- mal limb position or posture, pain, local trauma, swelling
dle, lead ropes (3 m), long ropes (10 m) and a twitch. and crepitus. The most important initial decisions are to
Suitable equipment and drugs for euthanasia including establish whether a fracture is, or may be present, the bone
intravenous catheter sets are also necessary. or bones that may be involved, the classification of the sus-
Aesthetics and public awareness are important, but pected fracture (in as far as this can be determined from
horse welfare is paramount. Most injured horses can be clinical examination) and the presence or absence of addi-
humanely moved from the racetrack for more considered tional problems. At this time, the attending veterinarian
evaluation. In the majority of circumstances, recognition must keep an open mind with respect to differentials
and assessment of developing clinical signs raises signifi- including fractures and soft tissue injuries. The value of
cantly the confidence of diagnosis. It also permits dialogue assessing the whole horse cannot be overstated.
with connections before definitive opinions and manage- Visual assessment is important; the animal’s posture fre-
ment advice are given. Euthanasia of some horses with quently is revealing. Assessment of limbs should include
fractures on the racetrack will be necessary, but should be appraisal of angles and alignment, segment lengths and
reserved for animals in which there is confidence of the developing swellings and distensions (Figure 7.3) [1].
inhumanity of movement in the face of a hopeless progno- Careful palpation follows. This may be expeditious, but
sis for humane preservation of life. should be meticulous as localizing clinical signs in the
Regulatory aspects of racetrack fracture management vary peracute phase often can be subtle. The majority of
throughout the world and are beyond the scope of this book. intrinsic (athletic) fractures in the distal limb involve
Racetrack veterinarians must be aware of pertaining legisla- articular surfaces, thus rapidly developing distension of
tive authority in cases that justify destruction on humane associated joints from intrasynovial haemorrhage fre-
grounds. While discussion with owners or their authorized quently is the first palpable abnormality. Extra-articular
representatives (frequently the trainer) is recommended, haemorrhage, manifesting as pitting swelling, usually
there will be instances when this is not possible or practical follows adjacent to fracture sites often producing clinical
or when permission to subject a horse to euthanasia is with- features that are typical of individual fractures
held. Additionally, there may be insurance implications. (Figure 7.4). At this time, digital pressure over fracture
Following assessment and based on the information given sites frequently will be resented. If necessary, cautious
by the racecourse veterinarian, owners or the owners’ author- manipulation can follow in order to assess the range of
ized representative may decide to have a horse with a fracture motion and to detect crepitus and signs of pain. Soft tis-
subjected to euthanasia. This may be based on the prognosis sues are not easily and completely assessed at initial frac-
or reasonable expectations issued by the veterinarian, on eco- ture evaluation but can have major management and
nomic grounds, for philosophical reasons or based on their prognostic implications [5].
previous (often unrelated) experience of injured horses. Haemorrhage due to laceration of major vessels is
uncommon with fractures distal to the elbow or stifle joints
but can be significant proximal to these levels. This is seen
I nsurance particularly with fractures of the humerus, scapula, femur
and pelvic girdle [6] (Figure 7.5). In such cases, assessment
In acute assessment, veterinarians may be informed and/or and management of hypovolaemic shock is logical but, in
should enquire if a horse is insured under an All Risk the absence of techniques for acute stabilization, is gener-
Mortality (ARM) insurance policy. In Great Britain, Ireland ally futile. In distal limb fractures, vasospasm following
and much of the rest of the world, in order to satisfy the repeated stretching and/or direct trauma to vessels is of
criteria to justify a claim, insurers require compliance with greater concern due to the potential for peripheral vascular
guidelines for recommended euthanasia issued by the compromise [1, 7, 8] (Chapter 20).
British Equine Veterinary Association (BEVA) [3]. In the Evaluation and acute phase management of fractures of
USA, different guidelines have been issued by the American the axial skeleton is dominated by consideration of their
Association of Equine Practitioners (AAEP) [4]. neurological implications [1, 9, 10] (Chapters 34 and 36).
Displaced fractures of the skull can produce profuse haem-
orrhage. Horses with fractures involving the nares will fre-
Clinical Assessment quently have epistaxis, and when the ethmoturbinates are
traumatized this can be marked. Fractures involving the
Systematic evaluation of all injured horses is important, basal bones can produce haemorrhage into adjacent gut-
although approaches differ somewhat between potential tural pouches as a result of tearing of the rectus capitis
fractures of the axial and appendicular skeletons. The latter muscles.
(a) (b)
(c) (d)
Figure 7.3 (a and b) Soft tissue swelling and angular deviation associated with comminuted fracture of the proximal phalanx. (c and
d) Malalignment of the tarsus and metatarsus with adjacent swelling produced by fracture of the proximal second, third and fourth
metatarsal bones and subluxation of the tarsometatarsal joint.
Cervical fractures are frequently accompanied by focal horses will exhibit forelimb lameness, and some will paw
guarding pain, a fixed neck position, stiffness and/or ina- persistently [10]. Abnormal cervical angulation may be vis-
bility to move the neck and muscle spasm (Figure 7.6). ible or palpable by aligning transverse processes.
Focal sweating and or/swelling are inconsistent, but suspi- Posture is critical to assessment of all vertebral fractures
cious clinical signs. Ataxia is not always present. Some and luxations that involve or impinge on the spinal canal.
Clinical Assessmen 121
(a) (b) (c) (d)
Figure 7.4 Distension of the MCP joint and lateral haemorrhage associated with a complete fracture of the lateral condyle of the left
(a and b) and right (c and d) third metacarpal bones. The degree of haemorrhage is commonly proportional to the amount of
displacement.
(a) (b)
Figure 7.5 (a) Inguinal, thigh and crural swelling resulting from haemorrhage following pelvic fracture. (b) Abaxial deviation and
swelling associated with an acute right scapular fracture.
(a) Distal Phalanx

Lameness varies from relatively mild to non-weight-
bearing as determined by location, configuration and time
frame. Clinical signs (increased arterial pulse amplitude,
etc.) commonly raise the foot as a focus of suspicion.
Distension of the distal interphalangeal joint usually
accompanies articular fractures.
Navicular Bone
Lameness is usually acute in onset and severe in intensity.
Localizing signs commonly and rapidly are referable to the
foot. Palpable distension of the distal interphalangeal joint,
sometimes accompanied by ill-defined soft tissue swelling
in the angle between the palmar/plantar surface of the
middle phalanx and collateral cartilage, may be detected.
Transverse/horizontal fractures frequently displace, mark-
edly compromising palmar/plantar support to the distal
(b) interphalangeal joint and producing subluxation. With
fractures of the sloping margins (wings), localizing signs
may be sided and less severe.
Middle Phalanx
Geography and pertaining case load are major determi-
nants of both incidence and type of fracture encountered.
Twisting, turning sports such as Western Performance
events and polo are over-represented. They occur occasion-
ally as paddock accidents but are an uncommon racing
injury [11]. Affected animals are commonly non- or mini-
Figure 7.6 Cervical fracture. (a) Head and neck held in mally weight-bearing, and instability in the region of the
extension with ventral swelling due to haemorrhage. (b) proximal interphalangeal joint may be clinically apparent.
Corresponding lateral radiograph centred at the affected fourth Diffuse soft tissue swelling of the distal pastern is generally
cervical vertebra.
rapid in appearance.
In the acute phase neurologic evaluation can be challeng-

ing, but observing segmental degrees of voluntary effort Proximal Phalanx
can assist in localizing lesions [9]. Sagittal and parasagittal fractures of the proximal phalanx
are one of the two commonest training and racing long
bone fractures in Europe. They are most common in fore-
linical Features of Specific
C limbs. These fractures are also seen in non-racehorses but
Fractures are relatively uncommon.
Horses with complete and comminuted fractures usually
The comments below aim to supplement presenting signs are unable to continue to gallop. Jockeys riding horses that
described in individual chapters to which readers are suffer comminuted fractures are aware immediately of a
referred. They represent additional observations that per- severe injury. Some are audible as a loud crack and the
tain to acute phase assessment such as on the racecourse, horse will try to pull up. Horses are severely lame, i.e. non-
training track, at competitions and in other field condi- or minimally weight-bearing and sometimes will fall.
tions. Specific emphasis is placed on clinical features that Comminuted fractures of the hindlimb proximal phalan-
can guide management and support before definitive diag- ges are rare except in complex injuries centred on the meta-
nostic information is available. tarsophalangeal (MTP) joint when they occur together
Clinical Features of Specific Fracture 123
with displaced fractures of the lateral condyle of the third s ingle most common site [12]. They exhibit a wide varia-
metatarsal bone and proximal sesamoid bones. Distension tion in clinical compromise which is not necessarily pro-
of the metacarpo/metatarsophalangeal (MCP/MTP) joint portional to the severity of the injury. Some horses will be
by haemorrhage usually occurs rapidly. Unstable commi- unable to continue to gallop, some will complete the race
nuted fractures may exhibit visible shortening of the pas- or training gallop and exhibit lameness on pulling up;
tern, instability is frequently evident and they generally are others will be recognized only later during or after cooling
readily palpable. Circumferential pitting swelling due to off. Occasionally, they can occur bilaterally, although lame-
haemorrhage ensues. Fractures that extend into the proxi- ness and clinical signs may dominate, at least initially, in
mal interphalangeal joint will usually produce palpable one limb. Complete fractures disarm the lateral collateral
distension. ligament of the MCP/MTP joint leading to instability and
Non- or minimally displaced fractures can be equally potential creation of an open fracture or disruption of the
lame. Swelling, including distension of the MCP/MTP proximal scutum.
joint, is less dramatic. In the acute phase, horses usually Clinical evaluation is an important guide to fracture
exhibit pain on firm digital (thumb) pressure dorsoproxi- location and configuration. Most result in early distension
mally between the extensor branches of the suspensory of the MCP/MTP joint due to haemorrhage. In the acute
ligament (Figure 7.7). phase, incomplete fractures may exhibit little else. Pitting
The initial presentation of fractures of the palmar/plan- swelling (haemorrhage) in the distal lateral metacarpus/
tar processes is similar to that of parasagittal fractures. tarsus usually accompanies complete fractures of the lat-
However, pain is usually elicited directly over the affected eral condyle (Figure 7.4). Firm digital pressure at this site
process(es). Twisting the proximal phalanx on the third commonly is resented. Pain on digital pressure further
metacarpal/metatarsal bone may also be resented, but proximally in the metacarpal/metatarsal diaphysis warns
other proximal phalangeal fractures will react similarly. of the potential presence of a proximally propagating frac-
ture. These are most common, but not exclusively, medi-
ally. There may or may not be visible or palpable evidence
Distal Condyles of the Third Metacarpal
of associated soft tissue swelling (haemorrhage).
and Metatarsal Bones
Fractures of the metacarpal and metatarsal condyles are
Forelimb Proximal Sesamoid Bones
the most common training and racing long bone fractures
worldwide, and fractures of the lateral condyle are the Biaxial mid-body fractures of the proximal sesamoid bones
are predominantly racing and training injuries in
Thoroughbreds and almost exclusive to forelimbs. Their
incidence varies with geography and track surfaces [13–
15]. The injury disarms the suspensory apparatus. Horses
are unable to continue to gallop and abruptly falter.
Lameness is usually severe. In the peracute phase, most
horses will make toe-only foot–ground contact, but even
with minimal loading hyperextension of the MCP joint is
usually obvious. Swelling develops quickly. It is most
marked in the region of the MCP joint, but is not confined
to this and generally envelops the proximal sesamoid bones
and suspensory ligament branches. Palpable crepitus is
common. Prompt recognition or suspicion of biaxial frac-
tures that destabilize the suspensory apparatus is critical to
horses’ potential for survival. Immediate support of the
distal limb in a fixed flexed position is critical (Destabilizing
fractures of the proximal sesamoid bones; Chapter 20).
Other fracture configurations (Chapter 20) are seen in
racehorses and also in horses in other activities. The sever-
ity of lameness is usually proportional to the degree of
compromise of the suspensory apparatus. Fractures that
Figure 7.7 Digital pressure applied dorsoproximally frequently
elicits a painful response in horses with non-or minimally involve the articular surface usually result in haemorrhagic
displaced sagittal/parasagittal fractures of the proximal phalanx. distension of the associated joint. In the acute phase,
s ensitivity to digital pressure over the fracture site is a com- articular insult. Dorsal (frontal) plane slab fractures which
mon feature. Crepitus occasionally can be appreciated. most commonly affect the third carpal bone (Chapter 24)
can result in acute, severe lameness, although most horses
will load the limb. Haemorrhage into and thus distension
Transverse and Oblique Fractures of the Diaphysis
of the middle carpal joint are rapid in onset and, with dis-
of the Third Metacarpal and Metatarsal Bones
placed fractures marked. Acute distension (haemorrhage)
Complete transverse or oblique fractures of the metacarpal of middle and antebrachiocarpal joints should alert the cli-
diaphysis are inherently unstable and often displace imme- nician to the possibility of a slab fracture involving the
diately. Comminution is common, and due to the paucity proximal row of carpal bones, most usually the radial car-
of overlying soft tissue they frequently are, or become, pal bone.
open [16–19]. When these occur during racing, the distal Complete dorsal (frontal) plane fractures of the acces-
limb is uncontrollable and afflicted horses may fall; if pos- sory carpal bone frequently disrupt its axial fibrocartilagi-
sible, the horse should be restrained (physically and chemi- nous surface and thus result in haemorrhagic distension of
cally) in this position until subjected to euthanasia. the carpal sheath of the digital flexors. Displacement of
Standing horses are markedly anxious and sometimes principal fracture fragments and/or comminution com-
panic. Transverse and oblique fractures of the diaphysis of monly lacerate the adjacent deep digital flexor tendon [20]
the third metatarsal bone are uncommon in adults but gen- which generally increases the severity of presenting clini-
erally are traumatic. The majority are currently not amena- cal signs. When displacement is marked, then there is visi-
ble to repair. Immediate sedation and sometimes physical ble dorsopalmar foreshortening of the accessory carpal
restraint are necessary to effect control long enough for bone and axial rotational displacement of the palmar frag-
euthanasia to be organized. These fractures are more comment (Figure 7.8).
monly repairable in foals (Chapter 22).
Carpal Subluxation and Collapsing Carpal Fractures
Cuboidal Bones of the Carpus
Multiple displaced and/or collapsing cuboidal bone slab
The severity of lameness and degree of acute distension fractures can result in angular deviations of the carpus.
associated with cuboidal bone fragmentation are highly These usually are comminuted and frequently involve
variable but generally are proportional to the degree of bones in both proximal and distal rows with consequential
(a) (b)
Figure 7.8 Displaced dorsal plane fracture of the accessory carpal bone with distension of the carpal sheath (arrows) and
dorsopalmar foreshortening produced by axial rotation of the palmar fragment (dashed arrow).
collapse of the affected side. Radial with third and/or sec- (Chapter 26). In the acute phase, swelling is proportional
ond carpal bones are most common, resulting in varus to the degree of soft tissue damage caused by the initiating
deformity [21, 22]. It is not known whether such fractures trauma, fracture haemorrhage and laceration of adjacent
occur concomitantly or from sequential overload. muscles by fragments.
Lameness is marked and usually is sufficient to prevent the
horse from continuing to run. Angulation generally is visi-
Humerus
ble and accompanied by crepitus with an abnormal range
of mediolateral motion. Joint distension (haemorrhage) is In adults, diaphyseal fractures can occur as training or rac-
quickly evident together with peri-articular swelling over ing injuries and as paddock accidents. Horses with com-
the affected bones as joint integrity commonly is compro- plete fractures are invariably non-weight-bearing. They
mised. Dorsopalmar subluxation is uncommon but can usually displace and override to result in an uncontrolled
accompany multiple palmar cuboidal bone fractures. limb with shortened brachium. The close proximity of the
brachial artery and its major trunks means that marked
haemorrhage with rapidly developing swelling commonly
Radius
accompanies diaphyseal fractures (Figure 7.9). Control of
Chip fractures of the distal dorsal articular margin of the pain is difficult and rarely satisfactory. Crepitus may be pal-
radius generally present with modest lameness and disten- pable and/or audible. The elbow and carpus cannot be
sion of the antebrachiocarpal joint. Fragmentation, par- fixed, but in the peracute phase it is difficult to be confident
ticularly of the intermediate facet, can extend into the whether this is a result of disarming the tricep apparatus
attachment of the fibrous joint capsule. This commonly and/or due to laceration of the radial nerve by the displaced
will result in pitting swelling dorsolaterally between the fracture. In adults, since the majority of horses with com-
extensor carpi radialis and long digital extensor tendons plete displaced fractures currently cannot be saved, swift
and their sheaths. Fractures of the distal radial epiphysis humane destruction is indicated [18, 25].
and metaphysis are relatively uncommon, but the most fre- If the horse is recumbent with the injured limb upper-
quent configuration is parasagittal. The degree of lameness most, then a clinical diagnosis can usually be established
is usually substantially greater than with chip fractures, without the need to get the horse to its feet. If this limb is
and there is adjacent localizing swelling consistent with on the underside, then turning the horse may be necessary
developing haemorrhage. Fractures of the diaphysis and in order to establish the reason for recumbency. In most
proximal metaphysis are usually traumatic monotonic circumstances, this is readily achieved by attaching ropes
injuries. In complete fractures, both flexor and extensor to the underside fore and hind limbs, but if there is suspi-
muscles are deprived of an intact skeletal strut and become cion of fracture in either of these then use of both upper
abductors of the distal limb about the fracture site. and lower limbs is recommended. As the horse is initially
Catastrophic medial skin perforation commonly follows [7, raised, the loss of skeletal continuity in the underside limb
8, 23, 24]. In the acute phase, radiographic identification of may be immediately apparent. In field situations, ultra-
an incomplete fracture at this site warrants extreme cau- sonographic evaluation can provide supportive diagnostic
tion as some complete fractures only become recognized information.
when there is sufficient bone resorption. In foals and yearlings, paddock accidents are the com-
monest cause of humeral fractures. Diaphyseal fractures
present in a manner similar to adults, but in smaller indi-
Ulna
viduals the prognosis is less grave and, provided the radial
Fractures of the ulna are almost invariably traumatic and nerve is intact, reconstruction may be possible (Chapter 27).
are frequently accompanied by overlying wounds that Fractures of the lateral tuberosity of the humerus that
often ooze blood and, in some cases, sanguineous synovial extend distally to involve varying amounts of the cranial
fluid. Most are second degree open fractures but this does lateral diaphysis and deltoid tuberosity can result from falls
not usually compromise prognosis. Infrequently, some particularly in jump racing. Afflicted animals may, on ris-
markedly displaced fractures are first degree, and in adult ing, be non-or minimally weight-bearing. Crepitus may be
horses this diminishes markedly the prognosis. Complete evident over the lateral proximal humerus. The amount of
fractures of the olecranon tuberosity disarm the triceps haemorrhage is variable, but almost always less than that
apparatus, and the horse cannot fix the limb in extension. seen with diaphyseal fractures and it is restricted to the
This causes marked anxiety usually accompanied by fracture area. There is no brachial shortening, and within a
repeated lifting and placing activity. The further distal the few minutes the horse usually will tentatively load the limb
fracture location, the more likely it is to retain stability although protraction will be restricted. In contrast to
Figure 7.9 Non-weight-bearing lameness with rapidly developing swelling (haemorrhage) and shortened brachium associated with a
displaced fracture of the humeral diaphysis. Note the profuse sweating that commonly accompanies such catastrophic injuries.
complete diaphyseal fractures, these often are amenable to

repair with return of function [26]. Field ultrasonographic
evaluation can again aid recognition and therefore guide
appropriate management.
Scapula
Fractures of the scapula can result from stress overload in
flat racehorses or from falls in jump racing [25, 27]. The
latter most commonly involve the supraglenoid tubercle
which can also be fractured in horses of all types from falls
or other traumatic incidents. After a short initial period of
non-weight-bearing, horses with fractures of the supragle-
noid tubercle will load the limb; although as the origin of
biceps brachii is lost, the cranial phase to the stride (pro-
traction) is severely reduced.
Complete fractures of the neck and body of the scapula
commonly displace and override. Trauma to axial neuro-
vascular elements is common and haemorrhagic swelling
can rapidly develop. Afflicted horses are often non-or min- Figure 7.10 Shortened scapular length in the complete
imally weight-bearing and usually are markedly distressed displaced/overriding fracture in Figure 7.5b.
with minimal relief from analgesics. Viewed from the
front, swelling can appear to result in abaxial displacement s capular length (assessed as the distance from the proximal
of the scapula from the thoracic wall (Figure 7.5b). The margin of the scapula to the proximal margin of the lateral
scapulohumeral joint (usually judged by the lateral tuber- tuberosity of the humerus) is highly suggestive of a com-
osity of the humerus) may appear ventrally displaced; this plete, displaced fracture (Figure 7.10). Adequate imaging
is not of itself pathognomonic, but shortening of the of distressed animals in the peracute phase can be
challenging, but ultrasonography can provide a useful bridges the centrodistal joint, and interdigitation of the
guide. In the authors’ hands, complete, displaced fractures tibial malleoli and distal intermediate ridge with the talus
in adult horses carry a hopeless prognosis for humane pres- provides osseous support to the remaining joints. Collateral
ervation of life. Even short-term comfort while connec- and short intertarsal ligament disruption is inevitable and
tions are consulted can be difficult to achieve. Sedation and most are also accompanied by marginal fragmentation of
combination analgesia are employed, while decision- tarsal bones. Complete or partial reduction is often sponta-
making processes are expedited but in most circumstances neous when the limb loaded. Horses are generally comfort-
euthanasia is inevitable. able to stand in this position but may become distressed
when asked to move. Swelling is generally modest.
Tarsus
Tibia
A number of fractures may involve the tarsocrural joint.
Fractures of the lateral malleolus of the tibia are most Complete fractures of the tibial diaphysis can result from
common [28]. Lameness is generally modest at presenta- external trauma (monotonic) or as the catastrophic end
tion, but distension of the tarsocrural joint is consistent point of stress fractures [18]. They are usually highly unsta-
and rapid in onset. Large fragments may also produce ble, and laterally situated muscle masses produce distal
adjacent pitting soft tissue swelling, and in some cases limb abduction [8, 23, 24]. Such fractures thus have a pro-
there may be palpable crepitus. Sagittal fractures of the pensity to become open medially. Adults with unstable
talus when non-displaced may not produce marked dis- fractures usually require immediate sedation and restraint
tension of the tarsocrural joint and can be difficult to followed by expeditious euthanasia. Occasionally, non- or
localize clinically. Fractures of the trochlear ridges of the minimally displaced fractures are encountered, particu-
talus, most commonly laterally, usually result from blows, larly in small individuals that may be amenable to repair.
and there may be open communication of the tarsocrural Fractures involving distal or proximal metaphyseal growth
joint with associated wounds. With closed fractures dis- plates are relatively common in foals. These often displace
tension of the tarsocrural joint is marked and rapid in to produce visible angular (valgus) deformity (Chapters 30
onset, while acute open fractures will usually drain san- and 37).
guineous synovial fluid.
Frontal plane slab fractures of the third tarsal bone are
Stifle Joints
common training and racing injuries. Lameness is variable
in severity, and in some horses there are few localizing clin- The patella is the most common site of fracture involving
ical signs. There is usually no palpable joint distension, but the femoropatellar joint, but fractures of the trochlear
some horses will, in the acute phase, resent digital pressure ridges may also be encountered. The most frequent cause
dorsolaterally. Slab fractures of the central tarsal bone pre- of patellar fractures is impact, and collision with fixed
sent in different types of horses and do not appear to have jumping obstacles is most common. Fractures range in size
such consistent configurations. Distension of the tarsocru- and complexity (Chapter 31). Those involving the medial
ral joint is common, but not invariable and usually is not pole, which is the most common site, can be highly varia-
marked. ble from small marginal fragmentation to fractures close to
Complete fractures of the calcaneus are uncommon, but the midpoint of the patella. The degree of limb compro-
traumatic fragmentation, usually from kicks and fre- mise and lameness are generally proportional to the size of
quently accompanied by wounds, is common. These may the fracture. Full thickness fractures can preclude engage-
communicate with the calcaneal bursa and, in the acute ment of the medial patellar fibrocartilage over the troch-
phase, ooze of sanguineous synovial fluid is common. lear ridge of the femur and thus prevent stifle extension
Similarly, traumatic fragmentation of the proximal fourth and ‘locking of the patella’. Distension of the femoropatel-
metatarsal bone that most commonly results from kicks lar joint is usually marked, and there may be adjacent
may be accompanied, in the acute phase, by leakage of san- medial soft tissue swelling due to haemorrhage in muscle
guineous synovial fluid from adjacent wounds. masses and leakage of synovial fluid through the fracture
plane and disrupted joint capsule. Clinical signs associated
with smaller marginal fragments are usually less marked.
Tarsal Luxation and Subluxation
Fractures of the lateral trochlear ridge of the femur are
These are uncommon injuries. They generally occur most commonly caused by kicks, and when accompanied
through the tarsometatarsal or talocalcaneal–centroquar- by associated wounds these may ooze sanguineous syno-
tal (proximal intertarsal) joints; the fourth tarsal bone vial fluid. When open and draining, distension of the
f emoropatellar joint is usually less marked than with closed (Chapter 33). Other fractures of the pelvic girdle can result
fractures. Lameness in such cases can be relatively mild at from falls or impact injuries. The location and volume of
presentation. haemorrhage associated with displaced fractures are
Fractures of the medial tibial eminence are the most closely related to fracture site and type and can be of major
common fracture of the femorotibial joints. They usually prognostic significance (Figure 7.11). Identification is often
are articular and produce distension of the medial femo- the first step in triage and determines the risk category for
rotibial joint. This can be marked initially but usually rap- ongoing management and advice to connections.
idly improves. Most do not compromise significantly the The ilial wing is the commonest site of stress fracture in
adjacent insertion of the cranial cruciate ligament, and the Thoroughbred racehorses [31]. These may be unilateral or
joints therefore are stable. bilateral with varying degrees of limb dominance. Fractures
Most fractures of the tibial tuberosity are extra articular; can be complete or incomplete in dorsoventral and cranio-
occasionally, large fractures will extend sufficiently caudad caudal planes. Complete fractures exhibit varying degrees
to involve femorotibial (usually medial) joints. Some will of displacement determined principally by fracture loca-
be accompanied by wounds. The proximodistal extent of tion and configuration. Fractures that present with pera-
the fracture is the major determinant of patellar ligament cute lameness are normally complete and frequently
involvement (Chapter 30) which, in turn, is the principal displaced. Trauma to dorsally lying gluteal or caudally
influence on the degree of lameness and limb compromise positioned iliolumbar arteries will result in varying
at presentation. In the acute phase, before there is substan- amounts of haemorrhage into overlying muscle masses
tial soft tissue swelling, the fractures frequently are palpa- (Figure 7.12). This may be visible as a protuberance or
ble with associated crepitus. increased convexity at this site. Affected animals frequently
are in marked pain, but the amount of haemorrhage rarely
is life threatening. Usually, horses exhibit intense muscle
Femur
spasm and guarding of the affected hindquarter.
Fractures that present as acute injuries are most commonly Asymmetry of osseous landmarks is indicative of fracture
diaphyseal, complete and displaced. Limb shortening displacement; however, postural abnormalities, soft tissue
(greater trochanter to patella distance) due to overriding of swelling and pre-existing muscle atrophy can be mislead-
fragments and rotational instability are common. Marked ing. Additionally, the longevity of asymmetry always must
haemorrhage frequently follows as the femoral artery and/ be questioned. As determined by location, simple displaced
or major emergent vessels are lacerated by fracture frag- fractures of the ilial wing may result in displacement of the
ments. The animal’s thigh may be seen to enlarge visibly tuber sacrale or tuber coxa. When unilateral, the tuber
minute by minute. The prognosis is generally hopeless, and sacrale frequently is ventral to its intact counterpart. Firm
pain and anxiety are usually inadequately controlled.
Horses with evidence of haemorrhage should be moved as
little as possible and, as soon as a confident diagnosis is Gluteal
reached, the animal should be subjected to euthanasia to
avoid the potential for painful and distressing exsanguina-
tion. Fractures that are suspected but which do not exhibit
marked acute haemorrhage may be moved for further eval-
uation. Medial to lateral radiographs can be very helpful. In Internal
Iliolumbar
field conditions, ultrasonography can be of assistance. Iliac
Fractures of the greater trochanter occasionally are External
encountered but exhibit few reliable localizing signs in the Iliac
peracute phase. Swelling as a result of haemorrhage may
Iliacofemoral
follow. Horses will usually load the limb. Fractures of the
third trochanter do not usually present as peracute
injuries.
Pelvis Figure 7.11 Pelvic bones with sites of immediately adjacent

arteries. Displaced fractures are commonly accompanied by
Fractures of the pelvic girdle are common and potentially
large volume haemorrhage due to laceration of major arterial
life-threatening training and racing injuries. These are trunks. The site of haemorrhage can be used as a guide to
stress related and as such have predilection sites [29–31] fracture location.
downward pressure at this site is often resented [29]. cases, the affected hemipelvis often appears narrower than
Displacement of the tuber coxa, presumably as a result of its intact counterpart when the horse is viewed from
continued muscular traction, is accompanied by rotation behind. There may also be pain on palpation of the tuber
in a cranioventral direction towards or into the sublumbar coxa, and crepitus may be appreciated in the acute phase
fossa [31]. Narrowing of the space between the last rib and before significant haemorrhage has developed.
tuber coxa often is a useful guide (Figure 7.13). In such Fractures of the ilial shaft are immediately life threat-
ening. While the degree of pain/lameness exhibited is not
an accurate guide to the location or severity of the injury,
horses with unstable fractures of the ilial shaft usually are
extremely distressed. Pain in these animals often is not
controlled adequately by any analgesic. Displacement of
ipsilateral tuber sacrale and tuber coxa must be viewed
with extreme caution as it necessitates fracture of the ilial
shaft, wing shaft junction or a comminuted fracture of the
ilial wing. Displaced fractures of the ilial shaft, or at the
junction of the shaft and wing, commonly lacerate iliaco-
femoral arteries and may lacerate the parent internal iliac
artery or, less commonly, the external iliac artery
(Figure 7.11). This frequently is catastrophic, resulting in
distressing haemorrhagic shock and exsanguination.
Swelling may first be visible in the pubic or perineal areas
as haemorrhage dissects through fascial planes before the
whole hindquarter increases in size. Pain commonly is
only minimally or temporarily controlled. At this stage, in
the authors’ experience, survival is rare and euthanasia
on humane grounds is justified. Afflicted horses can
become uncontrollable, so intervention should not be
delayed unduly. Supportive or palliative care is futile. In
one series, 6 of 11 racetrack pelvic fractures died from
Figure 7.12 Swelling (arrows) produced by haemorrhage into exsanguination within one hour of injury [32]. Of equal
the gluteal muscles following fracture of the left ilial wing.
(a) (b)
Figure 7.13 (a) Displaced fracture of the right ilial wing resulting in a cranioventrally displaced tuber coxa with narrowing of the
costo-coxal space. (b) Unaffected left ilial wing with normal paralumbar fossa dimensions.
concern is the fact that fracture of the ilial wing and shaft
may not displace immediately, but can do so in a ‘creep-
ing’ manner over following days or weeks with equally
catastrophic scenarios.
Fractures of the pubis and ischium are less common.
They can be seen as training and racing injuries or follow-
ing a fall. Most are non-or minimally displaced, so vascular
trauma and clinical presentation are consequently less dra-
matic. Crepitus may be appreciated, particularly with frac-
tures involving the acetabulum. If not evident on external
palpation or manipulation, this may be detected on rectal
examination [33].
On the racetrack or training gallop, all animals with a
potential differential diagnosis of pelvic fracture must be
managed with caution. In the peracute phase, confident
differentiation of fracture location is frequently not possi-
Figure 7.14 Ultrasonographic evidence of haemorrhage (yellow
ble. Additionally, several of these are complex fractures, arrows) adjacent to an acute fracture of the ilial wing (curved
some of which may not displace until hours, days or even arrow).
weeks later [31]. Horses should be moved carefully on low-
loading trailers or boxes. Unloading should also be per-
formed cautiously with appropriate sedation and analgesia
to maintain control throughout. Animals should be super- Sedation
vised and tied to prevent lying down.
Ultrasonography can offer quick confident confirmation Sedation is usually necessary for acute phase control of
of a number of displaced fractures, particularly of the ilial horses with fractures in order to permit clinical assessment
wing. However, in the acute phase, non-displaced fractures and is frequently needed for application of emergency sup-
may not be evident, and confusing acoustic shadows can be port. The required speed of onset necessitates intravenous
created by intramuscular vessels [30]. Images of the ilial administration. Horses with competition-related fractures
shaft should be interpreted with caution, but any evidence are usually excited, and the duration of sedation is fre-
of osseous discontinuity is of concern. For emergency eval- quently foreshortened. The dose should be determined not
uation, it is not necessary to clip the horse; adequate con- only by the animal’s size, but also its demeanour at the
tact will be obtained from liberal application of alcohol [30]. time, the nature of the injury, the efficacy of limb immobi-
In the absence of osseous discontinuity, hypo-to anechoic lization and potential transport consideration. Alpha-2
zones in the muscle pattern consistent with haemorrhage adrenergic agonists are most suitable, and recommended
adjacent to the bone must also be viewed as suspicious [31] dose rates are given in Table 7.1.
(Figure 7.14). Sometimes independent movement of the Intravenous xylazine provides good short duration (up to
fracture can be seen on limb manipulation during real- 20–25 minutes) sedation, has analgesic properties with
time ultrasonography [30, 31]. In some cases of ilial wing minimal side effects and can safely be repeated [7, 23, 24,
fracture, callus indicative of prodromal pathology may be 38]. Other α-2 adrenoceptor agonists, such as detomidine
present before complete fracture and can be identified or romifidine, offer longer duration of action. These are
ultrasonographically [30]. frequently combined with opioid analgesics, principally
Fractures of the tuber coxa/ventral ilial wing can be butorphanol. It has been claimed that romifidine may
training/racing injuries and may also result from impact cause less ataxia than detomidine [23]; however, this has
trauma, commonly from collision with door frames, gate been shown to result from dose differences [39], and the
posts or similar. Fractures can be simple or comminuted lower volume of the latter is an added advantage. The doses
and frequently displace, almost invariably cranially and of detomidine (0.01–0.02 mg/kg body weight), which are
ventrally. There is usually a rapidly developing fracture effective when administered intravenously to calm resting
haematoma, but distortion of osseous land marks is gener- horses, are less effective when given immediately after
ally both visible and palpable. Occasionally, fractures maximal exercise, but doubling the dose (0.04 mg/kg) pro-
become open, usually by penetration of skin by sharp edges duces good sedation [40–42]. Syringes pre-filled with 8 mg
of the fractured parent bone rather than the displaced detomidine and 10 mg butorphanol have been recom-
fragments. mended for racecourse use [1].
Analgesi 131
Table 7.1 Appropriate sedatives for acute fracture g lucocorticoid administration is common with CNS inju-
management. ries, evidence of benefit is questionable [9].
Sedative Dose (mg/kg)
Xylazine 0.2–2.2
Analgesia
Detomidine 0.01–0.04
The overriding principle of analgesia in equine acute frac-
Romifidine 0.04–0.12 ture management is that no chemical agents provide the
Medetomidine 0.003–0.007 analgesia and diminish the anxiety that accompanies a
Source: Based on Hubbell et al. [34]; Cantwell and Robertson [35]; fracture (particularly an unstable fracture) as well as cor-
Swor and Watkins [36]; Driessen [37]. rectly applied physical support and immobilization.
Analgesic agents therefore are never an adequate substi-
All α-2 adrenergic agonists also have some analgesic tute for physical intervention.
activity: this may be of shorter duration than their sedative Pain is a complex sensory experience normally generated
effects [37, 43] but is reported to be longest with xylazine. by the activation of high-threshold receptors (nocicep-
They can cause long-lasting reduction in gastrointestinal tors) [50]. Maladaptive pain occurs from disease (defined
motility with repeated administration [37, 43–47]. This can as a disorder with a specific cause and recognizable signs)
be of concern when combined with other recognized pre- and, as far as fractures are concerned, it is expressed as
disposing factors to colic, such as reduced exercise, dietary abnormal sensory processing due to tissue damage (inflam-
change, stress, administration of phenylbutazone, etc., matory pain) and produces stress [51]. Direct measure-
which all are commonly part of clinical fracture management of a subjective experience is not possible; therefore,
ment. Prolonged decrease in head height has been reported pain is assessed from indirect evidence of behavioural and
in horses sedated with medetomidine (0.01 mg/kg body physiological indices. The latter were found to be invalid in
weight i.v.) [48], which should be considered in horses that evaluating orthopaedic pain in an experimental model, and
require immediate transport. It has been reported that behavioural parameters such as posture, pawing and head
xylazine and romifidine produce fewer cardiopulmonary movement were more reliable indicators [50]. It is impor-
changes than detomidine in foals [43]. tant to be cognizant that the intuitive response of horses to
Acepromazine tranquilization is effective in calming aversion is ‘flight’. Multimodal analgesia [50, 51] is logical
horses exhibiting signs of stress and reduces the amount of but impractical in most acute, field situations.
alpha-2 adrenergic agonist necessary to produce adequate Tissue damage and inflammation cause acute pain.
sedation. It has been suggested that phenothiazine tran- Activated nociceptors send electrical signals to the spinal
quilisers may cause sufficiently severe hypotension to cord and brain in multiple parallel neuroanatomic path-
result in fainting in animals with high circulating levels of ways [51]. This is mediated principally by large myelinated
catecholamines [7, 23]. Caution is necessary in hypovolae- A-δ and small unmyelinated c fibres [35]. Acute pain and
mic patients [49], but this is rare in anything other than inflammation also lead to up-regulation of nociceptive
pelvic fractures. Acepromazine maleate has good anti- pathways often within minutes of the inciting cause. For
anxiety activity and can be combined (at 0.02–0.03 mg/kg this reason, analgesics are most effective when adminis-
i.v.) with other sedative/analgesic combinations in order to tered as early as possible in the pain cycle [51, 52]. The time
produce more profound sedation (and therefore control) of of onset of pain, as distinct from the anxiety associated
markedly distressed horses. It will also prolong the activity with loss of limb support or control, is impossible to deter-
of other sedative/analgesic combinations. Due regard mine. That some horses continue to gallop after suffering a
should be paid to its suggested contraindication in entire fracture, showing signs of pain only, later may be akin to
males but, in emergency situations, when given at the the latent pain syndrome seen in high catecholamine
above dose to a horse with a retracted/non-protuberant charged human injuries [52].
penis, the potential benefits outweigh the risk of priapism. Nonsteroidal anti-inflammatory drugs (NSAIDs) have
Despite theoretical concerns of transient hypertension been the mainstay of equine pain management [43, 53].
that may exacerbate central nervous system haemorrhage They are anti-inflammatory by inhibiting cyclo‑oxygenase
and then result in respiratory depression, administration of enzymes thus decreasing release of prostaglandins and
α-2 adrenergic agonists in sedating/controlling horses with thromboxane, but they also have central activity [53].
head trauma is frequently necessary. If seizures are evi- NSAIDs also decrease platelet adhesion which may help in
dent, diazepam at 5 mg (foal) to 25–100 mg (horse) doses reducing intravascular thrombosis [8]. In most cases, once
can be used and repeated as necessary [9]. Although the horse has been restrained and the limb appropriately
immobilized, little analgesia over and above the use of Opioids carry an increased risk for development of ileus,
NSAIDs is necessary or advantageous. Phenylbutazone particularly with repeated administration [37, 62–64] and
(4 mg/kg bwt i.v.) is the NSAID of choice for musculoskel- with well-supported/stabilized fractures usually are unnec-
etal pain [37]. Flunixin meglumine (1 mg/kg bwt i.v.) and essary [24]. It has been suggested that butorphanol should
ketoprofen (2 mg/kg bwt i.v.) are alternatives. The former be avoided with forelimb fractures because it causes the
has been recommended [49], but in the authors’ experi- horse to lean forward and thus increases difficulty in stand-
ence phenylbutazone has demonstrated greater clinical ing [36]. In the authors’ hands and when used judiciously,
efficacy. It has been suggested that in hypovolaemic endur- its benefits have outweighed any disadvantages. Systemic
ance horses high doses of NSAIDs that may cause renal butorphanol appears to be safe in foals (including
compromise should be delayed until fluid therapy is neonates) [43].
instigated [54]. Transdermal fentanyl patches are a potential adjunct to
Opioids (e.g. morphine, methadone and fentanyl) and acute pain management [35, 65]. Uptake from transdermal
opioid agonist–antagonists (e.g. butorphanol) act via spe- patches is variable, and these may be most useful in foals.
cific receptors in the brain and spinal cord, but peripheral Evidence of efficacy for orthopaedic analgesia in adult
receptors also have been recognized [55, 56]. They also horses is currently lacking [43, 66]. Two or three 10 mg
inhibit c-fibre transmission and reduce inflammatory pain patches placed on a shaved area of skin are recommended
by inhibiting release of substance P [35]. They have well- for adults, and it has been suggested that this can confer
documented analgesic properties [57–59], but there are a 48–72 hours of continuous analgesia, commencing within
number of undesirable side effects that must be consid- one hour of application. This also can safely be repeated.
ered [56]. Most opioids cause a dose-dependent increase in Foals can be given 5–10 mg in a similar manner [66].
muscle tone and locomotor activity when given to horses Caudal epidural administration of analgesic agents has
that are not in pain; these usually are described as central theoretical advantages for some acute, hindlimb inju-
excitatory effects. When given to horses in acute pain, ries [37, 43], although to date it has received limited use in
excitatory effects of opioids given at clinically recom- field/ambulatory circumstances, principally because of the
mended doses are uncommon. Nonetheless, opioids most risks of ataxia and necessity to transport the majority of
frequently are given in combination with sedatives [7, 23, patients. However, it can be useful for acute pain control
35, 37]. Although the latter diminish the risk of undesira- with pelvic or other hindlimb fractures [23] once horses are
ble excitement, and opioids appear to enhance the sedative in a suitable environment. Preservative-free epidural mor-
potency of the α-2 adrenergic agonists, the evidence for phine (0.1 mg/kg bwt) and methadone (0.1 mg/kg bwt) are
synergistic analgesia is mixed [56]. The analgesic potency claimed not to cause excitement or ataxia [35]. The latter
of opioids is not readily and consistently quantifiable, and has a quicker onset of activity (15 minutes) and lasts three
no studies are available pertaining to the pain and anxiety to seven hours; the former has a duration of action of
that accompanies an acute fracture or that mimic, in any 6–24 hours, but onset takes between 45 and 60 minutes.
form, the environment in which opioid analgesia is neces- Both are given slowly in 20 ml of saline through an epi-
sary. Doses, therefore, are necessarily empiric, but recom- dural catheter. For further information on technique, the
mendations are detailed in Table 7.2. In acute fracture reader is directed to source [37]. Morphine (0.2 mg/kg)
situations, the authors recommend restriction of use to with xylaxine hydrochloride (0.17 mg/kg) or morphine
those horses that have, following (whenever possible) (0.2 mg/kg) plus detomidine hydrochloride (0.03 mg/kg)
appropriate support and immobilization, an inadequate are alternative recommendations [36].
response to phenylbutazone.
Radiography
Table 7.2 Recommended doses of opioid analgesics.
Radiographic examination remains the cornerstone of
Opioid Dose (mg/kg) Route Interval (h) fracture identification and determination of location(s),
type(s) and configuration (Chapter 5). In acute injuries it
Morphine 0.1–0.7 i.v. or i.m. q4–6 is critical to all decision-making processes, but timing is
Methadone 0.1–0.2 i.v. or i.m. q4–6 important. In the presence of an unstable fracture, this
Butorphanol 0.1–0.4 i.v. or i.m. q2–4 should be delayed until the limb has been temporarily
immobilized. This will aid markedly in controlling the
Source: Based on Mudge and Bramlage [23]; Driessen [37];
Kalpravidh et al. [38]; Bennett and Steffey [56]; Kalpravidh et al. [60]; horse and hence the quality of radiographic information
Love et al. [61]. and prevent or limit additional (principally soft tissue)
Principles of Temporary Immobilizatio 133
damage. Sufficient diagnostic information can almost Commonly recommended broad spectrum antimicrobial
always be made with splints or other temporary support combinations used for initial administration to fracture
in situ. patients include:
Digital radiography has made a major contribution to
i) Potassium benzyl penicillin (22 000 iu/kg i.v. q 8 h)
fracture management permitting rapid, accurate diagnosis
with gentamicin sulphate (6.6 mg/kg i.v. q 24 h).
and/or elimination of differentials, thus optimizing acute
ii) Sodium benzyl penicillin (30 000 iu/kg i.v. q 8 h) with
care, prognostication and formulation of management
gentamicin as above.
plans. It also permits remote consultation with surgeons
iii) Sodium ceftiofur (4 mg/kg i.v. q 8 h) or similar cephalo-
and/or radiologists, and when appropriate referral centres
sporin with gentamicin (as above).
can receive diagnostic information in advance of, and thus
be prepared for, the horse’s arrival.
Principles of Temporary Immobilization

Ultrasonography
Appropriate temporary immobilization can be an impor-
Ultrasonography is pivotal in the assessment of pelvic frac- tant determinant of case outcome and diminishes the pain
tures and is equally applicable for ambulatory use at other, and anxiety that accompany a fracture. If a fracture or a sus-
principally proximal limb, sites which are not readily eval- pected fracture can be localized, then appropriate support
uated radiographically in non-hospital locations. The deci- should be applied before the horse is moved. However, if a
sion to transport horses with suspected humeral, scapular fracture is suspected but the region is unknown, then indis-
or femoral fractures can then be rationalized in an objec- criminate support is contraindicated and it is preferable to
tive manner. Ultrasonography permits a degree of risk move the horse carefully for further evaluation rather than
assessment with suspected fractures of the pelvic girdle to apply inappropriate support. Additionally, non-
which, in turn, is an important step in counselling connec- contributory distal limb support should be avoided particu-
tions prior to decisions to move and/or cross tie horses. larly in the presence of proximal limb fractures as the
bandage/splint weight can act as a pendulum increasing the
horse’s pain, ambulatory compromise and can potentially
W
ounds contribute to fracture displacement. Incomplete fractures
may not benefit from temporary immobilization per se, but
Individual surgeons vary in their preferred wound protocol this still can be contributory in neutralizing potential dis-
prior to referral of fractures. The authors’ preference is for tracting forces and for applying counter pressure. The forces
minimal interference, i.e. removal of gross debris only, little to be neutralized are determined by the individual fracture
or no wound exploration, no clipping and no topical anti- site, its orientation and configuration and by the forces act-
septic or antimicrobial application. In the distal (free) limb, ing over this area [7, 8, 11]. Osseous discontinuity means
the wound can be covered with a non-adherent dressing that in many cases the fracture may become a focus of
and appropriate temporary support applied prior to hospital movement beyond the normal parasagittal range of motion
referral. In the proximal limb and on the head, a sterile of equine limbs. Additionally, the supporting suspensory
gauze pad can be oversewn to minimize further contamina- and reciprocal apparati, which rely on an intact osseous col-
tion and to protect the tissues in transit. Others have recom- umn, become dysfunctional. The forces created by their
mended that wounds should be lavaged with copious sterile constituent parts are changed, which challenges further the
polyonic fluid to remove gross debris and decrease bacterial demands of effective temporary immobilization [7, 8].
contamination. This may be followed by topical antiseptic Horses with appendicular fractures frequently exhibit
and/or antimicrobial medicaments to the wound site before ‘lifting and placing’ of the fractured limb accompanied by
placement of a sterile dressing [49]. Adequate tetanus variable attempts at limb loading. This activity is highly
prophylaxis should be assured in all cases, including admin- destructive to fracture margins, resulting in fragmentation
istration in animals with unknown or unreliable vaccina- and eburnation that can preclude or compromise the poten-
tion status [49]. In the presence of a wound, including tial for reconstruction. Additionally, it can traumatize
potential communication with oral or nasal cavities, gut- severely associated articular surfaces. Most horses cease or
tural pouches or sinuses, broad spectrum antimicrobial diminish markedly ‘lifting and placing’ movements once
administration is appropriate [1, 8]. Similarly, the presence effective temporary immobilization has been applied and a
of blood associated with a suspected head fracture is an degree of limb control has been restored. Loading may
indication for antimicrobial administration [9]. remain markedly reduced or absent but abolishing or
diminishing the repetitive movement contributes greatly to

preservation of osseous and osteochondral tissues together
with soft tissue and neurovascular elements. The impor-
tance of soft tissue preservation and vascular integrity to
successful fracture repair and healing has long been recog-
nized [7, 8, 67]. Skin is readily penetrated by the sharp ends
of fractured bone, and preservation of cover is critical. A
correctly applied splint also imparts counter pressure, thus
reducing the amount of blood and inflammatory exudate
imbibed by adjacent tissues. Control of the swelling itself
will contribute further to analgesia. Application of tempo-
rary immobilization should not be delayed, pending estab-
lishment of an accurate or confident diagnosis, and in most
circumstances should take precedent following initial clini-
cal examination.
The objectives of acute immobilization can be summa-
rized as: Figure 7.15 Distal forelimb Robert Jones bandage.
●● Neutralization of distracting forces
Restoration of limb and/or segmental control
Wall thickness therefore will vary to compensate for limb
●●
Relief of pain and anxiety

contours and, for full limb Robert Jones bandages, the nat-
●●
Application of counter pressure

ural taper of limb diameter from proximal to distal. It con-
●●
Protection of soft tissues

sists of multiple layers of cotton wool each held in place
●●
Theoretically, the limb should be stabilized by incorpo- and compressed by gauze. Each layer in turn is applied
rating articulations proximal and distal to the fracture. more tightly than the previous. To be effective, the bandage
Splinting should neutralize distracting forces on the frac- must be layered, each less than two centimetres thick.
ture, but as these vary with fracture configuration it is Thicker layers result in shifting and compaction of mate-
sometimes not possible to determine the most appropriate rial negating the principles of use, compromising its contri-
technique until radiographs are available. bution and potentially becoming detrimental [8].
Temporary immobilization of fractures or suspected Wide (150 mm) conforming gauze such as Kling™
fractures can be accomplished by application of bandages, (Johnson and Johnson, New Brunswick, NJ, USA), Knit
splints, casts or combinations thereof. The advantages and Firm™ (Millpledge Veterinary, Retford, Notts, UK) or
disadvantages of each must be assessed in the light of indi- Conform™ (Kendall Animal Health/Kendall, Dublin, OH,
vidual case compromise. Historically, temporary immobili- USA) is suitable to compress cotton wool layers. Cotton
zation has been based on regional considerations [7, 8, 68], wool rolls torn in half are more readily contoured to the
but in each region there is no single technique that is opti- limb. Strips of the same can be used to provide further filler
mal for all fractures. layers as required but particularly at the top and bottom of
the bandage and over the dorsal fetlock. Each circumferen-
tial passage of the cotton wool should overlap the previous
to avoid creasing; a flat palm can also be used to smooth
Techniques for Temporary Immobilization out developing creases within individual layers before
more are added. The initial layers of gauze are applied with
Robert Jones Bandages
finger pressure, while at the end there should be sufficient
Although bearing his name, the surgeon Robert Jones cotton wool bulk that the gauze can be pulled as tight as
never published the construction or use of ‘the pressure possible. The bandage is finished by application of self-
crepe bandage over copious wool dressing’ [69]. A Robert adhesive tape such as Tensoplast (BSN Medical Ltd,
Jones bandage relies on provision of a mass of conforming Healthcare House, Hull, England), Elastikon™ (Johnson
material sufficient to resist movement. It can be an effec- and Johnson, Skillman, NJ, USA), Elastient™ (Vet-1,
tive means of reducing range of motion but is poor in Hampshire, UK), Flexoplast™ (Robinson Animal
resisting bending [70]. To be effective, a Robert Jones band- Healthcare, Worksop, UK) or similar materials. Application
age should increase the diameter of the leg by a factor of of duct tape aids in fixation to the foot and offers a degree
three [8, 23] and create a parallel sided tube (Figure 7.15). of protection from soiling.
Techniques for Temporary Immobilizatio 135
Immobilization of the distal limb by application of a to provide counter pressure. In the authors’ experience, the
Robert Jones bandage from the bearing surface to proximal reduced bulk also provides a more stable base for the appli-
metacarpus or metatarsus requires 3 rolls of cotton wool, cation of externally applied rigid splints. It is also generally
10–12 rolls of conforming gauze and approximately 4 rolls better tolerated in hindlimbs.
of elasticated bandage. A full limb Robert Jones bandage,
extending to the level of the elbow joint (or, less commonly,
Splinted Robert Jones Bandages
the proximal tibia), requires 6–8 rolls of cotton wool, 18–20
rolls of gauze and 8–10 rolls of elasticated bandage. During A Robert Jones bandage can be reinforced by the external
application of the full limb bandage or a distal hindlimb application of splinting material to provide additional rigid-
bandage, it is useful to have an assistant maintain the limb ity. Adjustable aluminium splints have recently become
in extension (Figure 7.16a). available (Modular Extendable Splints, Newmarket Premixes
In common parlance, the term ‘modified Robert Jones Ltd, Newmarket House, Catley Cross, Halstead, Essex, UK).
bandage’ is generally used to describe a bandage of similar These are lightweight and adjustable to individual horse and
design but with less bulk (Figure 7.16). This is less effective regional needs. They are spring locked, secure, tolerated well
as a form of immobilization but can usefully be employed and have been used in fore and hindlimbs at all stages of
(a) (b) (c) (d) (e) (f)
(g) (h) (i) (j) (k)
Figure 7.16 Construction of a distal hindlimb modified Robert Jones bandage. (a) Positioning the limb in extension often requires
protraction. An assistant’s hand on the point of hock helps to maintain position. (b) Strips of cotton wool torn in half make good
fillers at sites of limb narrowing to produce an even overall bandage. (c) Leaving an extra half roll of cotton wool for incorporation
around the toe when the limb is lifted produces more even tension over the dorsal pastern and coronary band. (d) Initial layers of
gauze are applied with finger pressure. (e) A flat palm can be used to smooth out developing creases. (f) Subsequent layers can be
applied with greater tension to produce a uniform, firm outer layer. (g and h) Application of self-adhesive tape should be uniform and
applied without additional tension. An overlap of a half roll is ideal. (i) A prepared sole covering of three to four layers of duct tape is
readily applied and then secured with circumferential duct tape. (j and k) The finished modified Robert Jones bandage.
prevent twisting and/or rotation as they are circumferen-

tially secured. To be effective, splints must be rigidly (tightly)
applied either with inelastic tape (duct tape or similar) or
with elasticated tape pulled to its elastic limit. In the authors’
hands, the latter is preferable but can, if required, be rein-
forced by a further layer of duct tape (Figure 7.18).
The authors previously used wooden splints cut to appro-
priate lengths from strips of 20–25 mm × 45–50 mm cross-
section [68, 71]. These can be cut in readiness to
recommended lengths or tailored individually with a hack-
saw at the time of need. Plastic pipe of 120–150 mm diam-
eter cut into half or third diameter is an alternative [68, 71].
Piping should be of 10–15 mm thick material or alterna-
tively constructed of multiple layers of thinner material.
Poorly applied splints can be a marked encumbrance to
an injured animal and must be avoided. Splinted full limb
Robert Jones bandages can be reinforced further by appli-
cation of an outer layer of fibreglass casting material. This
should not be thick, two layers generally are adequate, to
avoid excessive weight and increasing encumbrance to the
horse.
Bandage Cast
The most complete immobilization and splinting offered
by a bandage is achieved by the bandage cast (Figure 7.19).
Fibreglass casting tape can be placed over almost all distal
(free) limb bandages to provide two-dimensional immobi-
lization. This hybrid technique requires less bulk than a
Robert Jones bandage (generally doubling the diameter of
the limb to produce a parallel sided tube) and less casting
material. In most circumstances, three layers of fibreglass
tape are adequate. There is also no requirement for an
intervening layer beneath the fibreglass; this is applied
Figure 7.17 Modular extendible splints.
directly over the modified Robert Jones bandage.
The bandage cast has many merits and has been underu-
emergency support, including transport and induction of tilized as a technique for temporary immobilization. They
general anaesthesia. The splints are made from hollow are readily applied, well tolerated and in hindlimbs are
38 × 18 mm aluminium stock (Figure 7.17). Two lengths are often the temporary immobilization technique of choice.
available: one which extends from 35 to 67 cm and the sec- When used for short periods (generally less than 48 hours),
ond from 55 to 87 cm. The splints also stack producing rigid complications are rare. The majority are applied with the
support of any length. Splints should be positioned strategi- limb in a weight-bearing position with fibreglass extending
cally to resist movement/distracting forces appropriate to to the bearing surface; 12.5 cm (5 in.) rolls are usually most
the fracture or suspected fracture. Greatest stability is suitable. Once initial curing has occurred, and if desirable,
achieved with lateral and medial splints by placing them in the sole of the foot can also be enclosed with a further roll
contact with the widest part of the hoof and then utilizing of fibreglass tape.
compressed cotton wool layers to fill the ‘dead space’
between the splint and leg. This will provide stability and
help to keep the splint perpendicular to the ground. Casts
Alignment of splints is critical to their function, and these Cast materials, construction and application are discussed
should be secured to the bandage during application either in Chapter 13. This section contains only comments
by an assistant or, preferably, by strips of inelastic tape to specific to acute phase management of fractures.
(a) (b) (c) (d)
Figure 7.18 Construction of a splinted Robert Jones bandage for the distal hindlimb. (a) Splints should be positioned medially and
laterally in contact with the widest point of the hoof from the bearing surface to the level of the third (medially) and fourth (laterally)
tarsal bones. The lateral splint is often longer in consequence. Sufficient cotton wool is added to fill the space between limb and
splints. Minimal bandage material is applied at the level of the hoof to maintain the hoof/splint interaction. (b) Splint alignment is
maintained by application of inelastic tape to prevent twisting or rotation while enclosing elasticated tape is applied. (c and d) The
completed splinted bandage.
In emergency situations, stockinette requires too much

limb manipulation to be readily applicable as a base layer.
A thin layer of conforming bandage such as cellulose fleece
(Soffban, BSN Medical Ltd [Smith and Nephew]) is pre-
ferred. Normal casting technique (Chapter 13) follows.
To enclose the foot, either the solar surface, heel bulbs
and distal half of the hoof wall can be enclosed first (which
is the preferred technique) or the cast can be completed as
far distal as the bearing surface before the limb is raised to
enclose the distal wall and sole. The latter technique gener-
ally results in less immobilization of the foot, but for tem-
porary techniques it is quite acceptable. Horses should
stand for 15 minutes to allow cast curing to near comple-
tion before being moved. Although not generally necessary
with casts used for temporary immobilization, application
of a layer of thermoplastic polymer (Vet-Lite; Runlite SA,
Avenue de la Cooperative 9, Micheroux, Belgium) to the
foot is abrasion resistant and helps reduce slipping.
Figure 7.19 Distal forelimb bandage cast.
If an appropriate limb/joint position can be obtained, Compression Boots

casts offer the best immobilization/stabilization and coun- The Newmarket Compression Boot (Newmarket Premixes
ter pressure of all techniques. Cast constructs frequently Ltd) provides rigid circumferential distal forelimb support
involve multiple materials as determined by site and pur- (Figure 7.20). It is suitable for fractures, suspected fractures
pose, but are invariably based on fibreglass tape impreg- and other injuries that require, or will benefit from,
nated with water-activated polyurethane resin. external support with the limb in a normal weight-bearing
Figure 7.20 Newmarket Compression Boot. Readily applied, radiolucent and rigid construct. The design enables the horse to load the
limb in a normal position.
position. This includes sagittal and parasagittal fractures of The palmar half is then closed and secured by sequential
the metacarpal condyles and proximal phalanx which are tightening of adjustable ski boot clips. When the boot edges
the commonest fractures in training and racing. It is the are opposed, immobilization is secure. Newmarket
authors’ temporary immobilization of choice for these Compression Boots are shaped to a fetlock angle of approx-
injuries. The boot is readily applied ‘trackside’ and can be imately 150° which is comfortable for loading and ambula-
maintained for radiography and transport. The boot is also tion. The boot is lined by ethylene polypropylene diene
used for hospital support and induction of general monomer (EPDM) closed cell foam, and the foot plate is
anaesthesia. covered by styrene butadiene rubber (SBR) that protects
The boot is a rigid construct of fibreglass reinforced with the shell and provides a cushioned grip to the bearing sur-
plastic with an abrasion-resistant polyester resin and gel coat. face. The dorsal plate of the boot extends to the level of the
Each boot is made from a single mould and divided medially metacarpal tuberosity transferring load to this level. The
and laterally. The dorsal portion is contiguous with a sole palmar plate is shorter to permit carpal flexion.
plate to which the palmar portion is hinged distally. Boots of Less substantial alternatives include the Hinged
two widths are produced, and additional removable rubber Compression Boot™ produced by Veterinary Inclusive
foot plates are provided to accommodate hooves of differing Prosthetics/Orthotics (Bushell, FL, USA) and the Almanza
sizes. The boots are radiolucent, robust and long lasting. Emergency Compression Boot (www.redboot.com.ar);
Application is easy. The boot is opened, and the non- both are secured by Velcro™ straps. Compression boots
weight-bearing leg is placed into the dorsal half of the boot. neither fit nor are tolerated well on hindlimbs.
Dorsal Splint A proprietary aluminium splint is adjusted or rigid

wooden splint is fashioned to extend from the metacarpal
The MCP/MTP and interphalangeal joints can be immobi-
tuberosity of the third metacarpal bone to the dorsal
lized in increasing degrees of flexion by use of dorsal, pro-
weight-bearing surface of the hoof when the third metacar-
prietary flexion and palmar/plantar splints (Figure 7.21).
pal bone and phalanges are in a neutral position, i.e. when
As with all other temporary immobilization procedures,
their dorsal surfaces are aligned (Figure 7.21a). Sufficient
selection of a technique should be based on the nature (or
bandaging is used only to cushion the splint against the
likely nature) of the injury and thus the distracting forces
metacarpal tuberosity and then to fill in any minor ‘dead
that are to be resisted.
(a) (b) (c)
Figure 7.21 (a) Dorsal, (b) proprietary flexion and (c) palmar/plantar board splints produce increasing degrees of supported distal
limb flexion.
space’. For fitting, the leg can be held in a flexed retracted phalanges in a neutral (180°) position. Dorsal splints are
position such that the distal limb lies flat on the splint. therefore inappropriate.
Alternatively, an assistant should hold the limb beneath
the caudal antebrachium (forearm) in a protracted posi-
Flexion Splints
tion. In this location, the distal limb will hang passively
with the third metacarpal bone and phalanges all at 180° The Newmarket Flexion Splint (Newmarket Premixes Ltd)
(Figure 7.21a). The splint then can be secured with tape or, and Leg Saver Splint™ (Kimzey Metal Products, Woodland,
for greater rigidity, with fibreglass casting material [7, 8, CA, USA; www.kimzeymetalproducts.com) produce good
24]. It is essential that the splint is rigidly fixed to the limb distal joint flexion. These are very easily applied and are
and that the whole foot is enclosed in the procedure. the temporary immobilization technique of choice for inju-
Failure to do so will result in a loss of stability, and the ries that require the distal forelimb to be fixed in flexion
splint then can become an encumbrance to the already (Figure 7.21b).
compromised horse. Both are made of aluminium with a secure foot plate and
With a secure splint, horses can walk with toe-only foot– conjoined foam lined angled dorsal splint that extends to
ground contact and this frequently is adequate to assist the the proximal metacarpus. Here a shallow, foam-covered
horse with balance during transport. A dorsal splint with- concave ‘T’ supports the proximal metacarpus at the level
out a cast offers no significant mediolateral stability, and of the metacarpal tuberosity. Three nylon and Velcro straps
with toe-only ground contact mediolateral movement is secure the splint to the leg, and a fourth strap fastens over
exacerbated. In order to ameliorate the latter, a substantial the heel bulbs to the palmar aspect of the foot plate. Both
wedge (usually of pre-cut wood) is placed beneath the splints offer two-foot plate sizes.
heels. The size and gradient of the wedge must be suffi- The flexion splint is the technique of choice for fractures
cient to fill the space between the dorsal splint, bearing sur- of the forelimb proximal sesamoid bones (Figure 7.22) and
face at the heels and ground. Enclosing the whole in a cast other injuries which compromise the suspensory appara-
improves mediolateral stability. tus. In biaxial mid-body fractures of the proximal sesamoid
In hindlimbs due to the reciprocal apparatus, it is impos- bones, prompt application is life-saving (Destabilizing frac-
sible to adequately align or immobilize the MTP and inter- tures of the proximal sesamoid bones; Chapter 20). A mod-
phalangeal joints with the third metatarsal bone and ification, the ‘Equine Salvage Splint’ (Ballarat Veterinary
(a) (b) (c) (d)
(e)
Figure 7.22 Use of a flexion splint to reduce and immobilize mid-body fractures of the proximal sesamoid bones. Schematics
illustrating distracting forces (a) and use of a splint (b). (c) Fitted splint. (d and e) Lateromedial radiographs of uniaxial (d) and biaxial
(e) fractures before and after fitting a flexion splint.
Recommended Emergency Suppor 141
Practice, Ballarat, Victoria, Australia), is claimed to offer Comminuted fractures can be unstable in multiple
greater foot stability by incorporating a heel block. In the planes. Cast immobilization is likely to be most effective.
authors’ experience, the splint is not sympathetically Fractures of the palmar/plantar processes are distracted
angled and consequently less well tolerated. by distal limb extension under load and counteracted by
flexion. In forelimbs, proprietary flexion splints work well.
In their absence, a dorsal splint can be used. A plantar
Palmar/Plantar Splint
splint is the only effective technique in hindlimbs and can
A palmar/plantar splint produces the greatest degree of also be used in forelimbs.
MCP/MTP and interphalangeal joint flexion (Figure 7.21).
The originally described board splint [72], provides excel-
Proximal Phalanx
lent emergency support for horses with traumatic disrup-
tion of the suspensory apparatus. However, this occurs The principal distracting forces for simple sagittal and par-
almost exclusively in forelimbs where commercial flexion asagittal fractures are thought to be lateromedial, and stabil-
splints are the most effective, readily applied, well tolerated ity is optimized by MCP/MTP joint extension and flat foot/
and preferred alternative. A plantar splint is the only effec- ground contact. Incomplete fractures may not require exter-
tive means of securing (uncommonly needed) distal limb nal support, but distal limb immobilization and counter-
flexion in hindlimbs as the reciprocal apparatus precludes pressure usually improve comfort. Additionally, it is often
use of dorsal techniques. When this is required for off track not possible in the acute phase to be confident that fractures
support, transport to hospital facilities or prior to surgery, are incomplete. The rigid circumferential support of the
two adjustable aluminium splints are the recommended compression boot is ideal for all forelimb parasagittal frac-
alternative. These are placed side by side against the solar tures. A Robert Jones bandage may be adequate for incom-
surface of the foot with the distal joints flexed until the sole plete fractures, but in the absence of a compression boot and
is vertical (perpendicular to the ground). The splints are in hindlimbs, temporary immobilization of complete frac-
then adjusted to extend to the plantar tarsus (Figure 7.21c). tures can be achieved with a bandage cast, cast or reinforc-
A conforming dressing is applied to the distal limb, and the ing a Robert Jones bandage with lateral and medial splints.
leg is secured to the splints or board with adhesive tape. Distracting forces on fractures of the palmar/plantar pro-
If the splint extends to a tarsal level, the relatively weak cesses are countered by MCP/MTP joint flexion using the
digital extensor muscles are readily disarmed and horses same techniques as their middle phalangeal counterparts
usually will ambulate well loading the dorsodistal hoof (Section “Middle Phalanx”). Uncommonly, these will
(toe). It is not suitable for long-term case extend sufficiently dorsad to disarm the collateral ligament
management [73]. and produce instability of the MCP/MTP joint which, in
turn, is most stable in extension. This changes the immobi-
lization priority. Flat foot/ground contact is most easily
Recommended Emergency Support achieved in forelimbs with a compression boot. Alternatives
and options for hindlimbs include a bandage cast, cast or
The authors recommendations are based on clinical obser- re-enforced Robert Jones bandage with lateral and medial
vations and current knowledge of distracting forces for splints extending from the bearing surface to the proximal
individual fractures. metacarpus/metatarsus.
Distal Phalanx and Navicular Bone Distal Condyles of the Third Metacarpal/Metatarsal
Bones
There is little to be gained over and above the support pro-
vided by the hoof capsule. Some animals are more comfort- Complete fractures are displaced by MCP/MTP joint flex-
able in distal limb casts, which is presumed to result from ion and reduced by extension (Figure 7.23). All immobili-
limiting distal interphalangeal joint movement. zation techniques should therefore include extension; any
that involve flexion are contraindicated. For non-displaced
fractures the goal is to prevent displacement, and for dis-
Middle Phalanx
placed fractures immobilization techniques should maxi-
Simple fractures benefit from mediolateral support and mize reduction and stabilize the MCP/MTP joint. The
counterpressure. A compression boot, distal limb Robert requirement for incomplete fractures is to reduce MCP/
Jones bandage, cast bandage or cast all suffice, but the foot MTP joint movement and apply counterpressure. It should
must be enclosed. also be recognized that in the per-acute phase it may not be
(a) (b)
Figure 7.23 (a and b) Post-mortem photographs of a horse with a complete fracture of the lateral condyle of the third metacarpal
bone. (a) With the MCP joint in extension the fracture is effectively reduced and (b) with the joint flexed the fracture displaces.
possible to confidently distinguish fracture types. Based on f ractures (Chapter 20) as integrity of the suspensory appa-
this, the application of a compression boot covers the ratus is disrupted. Immobilization with the MCP joint (the
options in forelimbs, although short unicortical fractures injury is almost always in forelimbs) in flexion reduces dis-
are unlikely to require or benefit from support. In placement. This is desirable with unilateral fractures, but
hindlimbs, the authors recommend a Robert Jones band- prompt application of suitable support is critical for sur-
age for incomplete, with medially and laterally splinted vival of horses with bilateral fractures. Proprietary flexion
Robert Jones bandages, or a bandage cast for complete frac- splints do this well (Figure 7.22). They are easy to fit, toler-
tures. In the absence of a compression boot, these tech- ated well and are the technique of choice in all situations.
niques are also appropriate for forelimbs. Uncontrolled hyperextension of the MCP/MTP joint
Propagating fractures which become complete and dis- results in thrombogenic stretching or laceration of the
placed (fail catastrophically) do so in the middle of the dia- palmar arteries and subsequent irreversible distal limb
physis even if the fracture extends further proximad. It is ischaemia. Disruption of the scutal fibrocartilage and com-
considered likely that this is precipitated by bending forces. munication between the MCP joint and digital flexor ten-
Ideally, temporary immobilization should therefore resist don sheath also expose the deep digital flexor tendon to
mid-diaphyseal bending. Full limb casts are poorly tolerated trauma by sharp fracture margins [74]. In the absence of a
and in most emergency situations impractical. Reliable results proprietary flexion splint, dorsal or palmar splints can be
have been achieved with reinforced Robert Jones bandages in used as substitutes.
which splints extend from the bearing surface to the level of
the third carpal or third (medially) and fourth (laterally) tarsal
Diaphyseal Fractures of the Third Metacarpal/
bones (Figure 7.18). Alternatively, a cast or bandage cast can
Metatarsal Bones
be applied to this level. These do not interfere with ambula-
tion and are tolerated well through to and including induction Third metacarpal and metatarsal bones are subject to
of general anaesthesia. Compression boots can be used in the marked bending forces, and complete fractures are inher-
forelimbs for track side support and transport. ently unstable even if not displaced. Casts provide the only
contributory support. These should be half limb enclosing
the foot (Chapter 13). In the forelimb, the cast extends to the
Proximal Sesamoid Bones
level of the third carpal bone. In the hindlimb, the dorsal
The principal distracting forces on almost all fractures are aspect of the cast should be taken to the level of the central
proximodistal and produced by extension of the MCP/MTP tarsal bone, but the plantar aspect can extend further proxi-
joint. This is of particular importance with mid-body mad to overlap the fourth tarsal bone and distal calcaneus.
Recommended Emergency Suppor 143
Fractures of the Carpus muscle masses with a modified Robert Jones bandage
distally which is of sufficient bulk only to fill the dead
Cuboidal fragmentation and simple slab fractures do not
space between the distal limb and the splint. An additional
compromise axial stability, and bulky bandages can
cranial splint placed at 90° to this provides increased rigid-
increase discomfort and act as an encumbrance. Light elas-
ity (Figure 7.25). Although appearing ungainly, these
tic bandages appear subjectively to improve comfort.
splints are well tolerated.
Fractures of the accessory carpal bone do not cause
instability, but unstable dorsal (frontal) plane fractures are
displaced by carpal flexion. This is most easily controlled Ulnar Fractures
with a dorsal splint extending from proximal antebrachium
to distal metacarpus (Figure 7.24a). Bandage bulk should Fractures that disarm the triceps apparatus compromise
be sufficient only to avoid point contact between the leg movement and cause substantial anxiety. However,
and splint. mechanical disability is countered by splinting the car-
Ideal support for the mediolateral instability produced pus in extension. This restores an element of control and
by collapsing slab fractures is provided by a sleeve cast enables the horse to use the limb as a prop during trans-
(Chapter 13). A splinted Robert Jones bandage with a lat- port. The authors’ preference is a single cranial splint
eral splint extending from elbow to ground and cranial extending from proximal antebrachium to distal meta-
splint from elbow to distal metacarpus (Figure 7.24b) or carpus applied over a relatively light bandage to mini-
incorporating a caudally placed elbow to ground splint of mize the pendulum effect while protecting the skin
half or one-third diameter piece of PVC piping are less (Figure 7.24a). Splinting animals with a functional tri-
effective alternatives. ceps apparatus, i.e. which can lock their elbow, is coun-
terproductive. Young foals generally do not tolerate
splints well and are usually best transported without
Fractures of the Radial Diaphysis attempts at support.
The principal goal in temporary immobilization is preven-
tion of distal limb abduction. This is achieved by fitting a
Fractures of the Humerus and Scapula
long lateral splint from the level of the proximal scapula to
the ground. The splint should contact the lateral proximal There are no techniques that support or limit instability.
(a) (b)
Figure 7.24 Adjustable aluminium splints applied over a modified Robert Jones bandage (a) to prevent carpal flexion and (b) to
support carpal instability: two stacked splints are used laterally.
the ground to the tarsocrural joint and is bent cranially to

follow the tibial diaphysis. At the stifle, it is bent caudally
to lie on the surface of biceps femoris to the level of the
coxofemoral joint. It is reported that the splint is most
effective if it is bent back on itself retracing its course to the
bearing surface.
Temporary immobilization of small horses can be
achieved with a broad laterally positioned board splint.
This should be approximately 10–15 cm wide and extend
from the ground to the level of the coxofemoral joint. The
board should lie on the lateral aspect of biceps femoris, and
sufficient bandaging is applied to the distal limb to produce
uniform contact. During application, the leg is held slightly
caudal to its intact counterpart extending the tarsal and sti-
fle joints. The board is then tightly secured with adhesive
tape to the whole of the free limb. Board width restricts
rotational movement [8].
The absence of viable reconstruction options for most
cases means that there are few occasions when these tech-
niques are put into practice. Foals and yearlings rarely tol-
erate splints, and fractures of the metaphyseal growth
plates uncommonly become open. These are therefore best
Figure 7.25 Splinting for radial fractures. Stacked lateral unsupported for transport.
aluminium splints extending from the ground to proximal Large fractures of the tibial tuberosity which disarm the
scapula prevent limb abduction. Further rigidity is provided by a patellar ligaments can compromise markedly a horse’s
cranial splint from proximal antebrachium to distal metacarpus. ability to fix the femoropatellar joint. This cannot be aided,
and most animals will make sufficient toe-only foot/
Fractures of the Tarsus ground contact to maintain balance for transport. There is
The majority of tarsal fractures do not create instability, no benefit to attempts at support in horses with smaller
and therefore external coaptation is rarely of benefit and fractures.
can be counterproductive. Some horses will react adversely
to immobilization of the tarsocrural joint by lifting and Fractures Involving the Stifle Joints, Femur and Pelvic
abducting the limb sufficiently high to lose balance and Girdle
fall. Fractures of the tibial malleoli which extend proxi-
mally beyond the origin of the collateral ligaments will There are no external applications that are contributory.
produce lateromedial instability of the tarsocrural joint.
This is most effectively combated with a short tarsal sleeve
cast (Chapter 13). Transport
The critical points in transporting horses with fractures are

Tibial Fractures
loading and unloading. With appropriate support, it is
Complete fractures of the diaphysis are invariably unsta- uncommon for fractures or associated lesions in the free
ble. In the absence of an intact osseous crus, the reciprocal limb to progress during movement. The decision to trans-
apparatus exacerbates displacement frequently with over- port a horse that is severely lame and in which a fracture is
riding fracture ends, and an uncontrollable distal limb suspected but cannot be identified or localized is difficult,
results. This usually is abducted, and fractures have a pre- and guidelines are impossible. However, the principle that
ponderance to become open medially. The reciprocal appa- neither appropriate treatment nor prognostication is pos-
ratus also complicates provision of external support, and sible without an accurate diagnosis is valid. The decision to
the normal flexion angles of the stifle and hock prevent the move horses with fractures or potential fractures of the pel-
use of cranial or caudal splints [7, 8, 23]. A lateral splinting vic girdle is always difficult. Horses with complete fractures
technique has been described [7, 8]. This involves a of the ilial shaft cannot be safely transported. However, in
lightweight metal bar that extends in a straight line from the acute phase, confident identification of such fractures
Transpor 145
frequently cannot be made. Complete fractures of the ilial artially suspend the horse but simply to allow the horse
p
wing, pubis and ischium are less likely to be life threaten- to sink into the harness if it wishes temporarily to relieve
ing. Compromised horses should be given supportive care limb load [24].
and moved with due caution to the best available expertise The transport of horses with axial fractures should be
for assessment and subsequent, frequently surgical, treat- considered and planned in light of the potential for a posi-
ment. For the appropriately splinted and supported horse, tive contribution to outcome. Low-load vehicles are ideal
the duration of transport (distance) is of little conse- with close partition spacing for support while leaving the
quence [7, 8, 11, 75, 76]. horses head and neck free, i.e. they should not be tied up.
Minimizing the distance that the horse walks to the vehi- Transportation of recumbent horses is generally associated
cle is important. Lorries or trailers therefore should be with neurological compromise. If necessary, they can be
manoeuvred as close as possible to the injured horse [11, transported on air mattresses in custom-built ambulance
24]. Ramp angle/incline should be as low as possible. Low trailers [24]. The reader is referred to other texts for discus-
load ambulance trailers and small low chassis horseboxes sion and description [9, 24, 77].
are good for onward transit to hospital. If normal transport Whenever possible, having due regard to vehicle legisla-
only is available, steep ramps can be obviated by loading tion, injured horses should be attended by experienced
ramps. Most injured horses, however fractious they may horsemen during transport. This can provide comfort and
previously have been, will load readily into even unfamiliar reassurance while minimizing the horse’s anxiety. A hay
vehicles. Manual assistance may be necessary, and use of a net can provide an excellent distraction. Soaking hay
quoit can be helpful. Some horses will respond well to a reduces the risk of choke, and use of a double net reduces
lunge line fixed to each side of the trailer entrance and the bulk obtainable while occupying the horse for a longer
crossed behind the horse providing a channel into the period.
trailer. Waving, flapping, shouting, etc., all should be Unloading is as critical as loading. Minimizing ramp
avoided and, in as far as circumstances will permit, an incline, adequate control in a bridle or chifney, firm but
atmosphere of quiet calm should prevail. Within the trailer, sympathetic handling and, if necessary, sedation are all
the entrance to the stall should be made as wide as possible important. Unloading should be slow with the horse given,
to encourage the horse to enter. Once loaded, supporting if necessary, assistance with the injured limb. This gener-
walls and bars can then be repositioned. The front ramp ally is not necessary for appropriately supported distal limb
and/or door should be opened for similar reasons. In the fractures. Horses with proximal forelimb fractures com-
absence of good daylight, internal lighting should be monly will be reluctant to protract the injured limb. They
switched on [11, 24]. can be aided by either lifting the leg and placing it forward
Close rigid partitioning is important, permitting the by hand or by passing a loop of rope, lunge line or similar
horse to lean on the horsebox side and/or partitions for around the pastern area and assisting limb protraction
support, both side to side and front to back [8, 11, 23]. with controlled and appropriately timed traction
Within this, the head and neck should be allowed as much (Figure 7.26). Minimizing the distance that the horse has to
freedom as possible in order that these can be used by the walk after unloading has obvious advantages.
horse for counterbalance. In purpose-built ambulances, Some horses require additional consideration. Whenever
the horse stall is centrally situated in the vehicle which possible unweaned foals should be moved with the mare.
ensures the smoothest ride. As acceleration is usually more Acepromazine is a very good and effective tranquiliser in
controlled than deceleration, it has been recommended foals and can be combined with appropriate analgesic
that horses with fractures of the forelimbs should be trans- medication. Foals generally do not tolerate limb splints
ported facing rearwards and vice versa [7, 8, 23, 76]. This is well and often cope better with casts. Foals with fractures
logical, but often not permitted by horsebox design; horses of the proximal limb are frequently best maintained and
also travel best when in a familiar environment and transported recumbent (with splinting if necessary). They
orientation [11]. can be carried on blankets or rugs, and sedation can be
Some authors favour the use of a supporting harness topped up as required en route. Weaned foals and other
and believe that horses arrive in hospital in better condi- unhandled young stock are often best transported with a
tion [24]. If tolerated, they can permit horses intermit- quiet companion that can reduce stress and movement.
tently to rest and shift position. Most consist of broad body Broodmares with foals at foot should be transported with
bands that can be slung ventral to the thorax and abdo- the foal even if subsequent separation is anticipated.
men. However, one should be cautious with their use as Stallions generally do not need any particular considera-
some animals will find them an irritation and resent the tion, although frequently will travel best with a known stal-
additional confinement. They should never be used to lion man.
The GG Ambulance™ (www.ggengineering.com.au)

also lowers to ground level and has a walk on and walk off
design with integrated winch, drag mat and screens. At the
time of writing, there appears to be no commercial equine
ambulance production in the USA, but a number of manu-
facturers (e.g. Turnbow Trailers Inc., Oilton, OK, USA;
www.turnbowtrailers.com) offer bespoke services.
A motorized horse ambulance is available in Europe
(Equisave Motorised Horse Ambulance) (Figure 7.27d).
Trailers provide excellent racetrack and off-road use, but in
the UK it is illegal for personnel to travel on public roads
within a towed trailer. The motorized horse ambulance has
access to the lorry cab with seating for up to six attendants
in the rear. It has a low chassis and is fitted with air suspen-
sion which gives a smooth ride and allows the rear of the
vehicle to be lowered for loading and unloading. Access is
via a long, wide, low ramp, and the horse travels in a cen-
trally padded stall with adjustable partitions on both sides.
Front and rear doors on the horse compartment provide
all-round access for personnel. Once the casualty is loaded,
the air suspension is raised to the travel position. The horse
stall is fitted on a turntable so that the horse does not turn
for unloading. It is swivelled through 180° to unload from
the rear of the vehicle (a side flap on the vehicle being
Figure 7.26 A rope or slip passed around the pastern can be
used to help the horse protract an injured limb.
raised to permit the horse’s head to protrude during this
procedure) or, if preferred, the horse can be rotated 90° and
unloaded via a side ramp. The rotating horse stall also per-
Ambulances mits horses to travel facing rearwards if this is considered
desirable. The air suspension is lowered again to unload
A number of requirements for ambulance trailers have
the horse. A hand winch canvas sling is mounted on and
been recorded in the literature [11, 24, 32, 78]. The largest
accessed through the partition. A drag mat and portable
European manufacturer of equine ambulances (Equisave
electric winch are provided at the front for recovery of
Horse Ambulances, Bury Road, Stradishall, Newmarket,
recumbent casualties.
Suffolk, England) has two models that are in widespread
use on racecourses. These feature a swing away towing sys-
tem that permits rear load and front unload. In the first Nursing and Supportive Care
design, once the towing system is moved, the trailer lowers
hydraulically to ground level (Figure 7.27a). In the second Physiologic and metabolic exhaustion may accompany
model, long, wide (including front flap extensions) ramps fractures in extreme competition circumstances such as
are provided to minimize slope (Figure 7.27b and c). The endurance events, and provision of large volumes of intra-
horse travels centrally. Partitions are moved to the side of venous polyionic fluids via an aseptically place jugular
the trailer to encourage and facilitate loading and then are catheter may be necessary [54, 79].
moved in close proximity to the horse in order to provide Horses frequently finish races in a dehydrated state and,
support. The partitions and therefore the horse stall can be when the voluminous sweating and rapid respiration that
angled if required. Adjustable bars, front and rear, provide commonly accompany racetrack fractures are superim-
further restraint and support. Each partition has an access posed on this, circulatory compromise can result. In most
panel through which a supporting sling can be passed, and circumstances, oral rehydration is adequate and requires
there is a moveable front mounted electric winch and drag little more than attending personnel to regularly offer
mat. Each trailer is equipped with screens that can attach water; this often is forgotten as people’s attention is focused
to the trailer and thus be erected and operated by one per- on fracture management, organization of transport, etc.
son. A CCTV camera can be mounted in the front of the Clinical experience indicates that the horse’s anxiety
trailer, so the horse can be monitored from the towing with most free (distal) limb fractures results more from
vehicle. their inability to control the limb than from pain per se.
Nursing and Supportive Car 147
(a) (b)
(c) (d)
Figure 7.27 Equine ambulances with central ride partitions. (a) Swing away tow unit (white arrows) allows the trailer to be lowered
to ground level and side extensions unfold to widen the front unload ramp. (b) Long wide ramps minimize the gradient in modified
conventional trailer designs. Screens (black arrows) are carried for racecourse deployment. (c) Partitions move to provide widened
access. (d) Low chassis motorized ambulance with air suspension and space for attendants to travel with the horse.
Once appropriately splinted, and the flailing limb con- (Figure 7.28) or overhead wires and, at least for the first few
trolled, the horse’s anxiety diminishes with consequential days, should be maintained under close supervision. In
reduction in respiratory and perspiratory fluid losses. addition to clinical monitoring, supportive care and nursing
The necessary limitation of movement of horses with will be necessary in order to minimize the risks of pleuro-
racing/training fractures delays cardiovascular and meta- pneumonia, overload laminitis, etc. Horses should stand on
bolic recovery [40]. Horses with fractures therefore may deep conforming bedding. Water and some forage should be
benefit from techniques to compensate for the absence of present at head height. In addition, feed should be offered at
an active cool down period. This does not need to be sophis- ground level, while the horse is held, at a minimum of four-
ticated. Cooling is effectively achieved with repeated, dif- hour intervals. This allows the horse to stretch down pro-
fuse application and removal of cold (4–10 °C) water, and moting mucociliary drainage of the respiratory tract [6].
this reduces stress [80–82]. Fractures in foals can inhibit mobility sufficiently to reduce
All horses with suspected fractures of the pelvic girdle nursing; physical support to do so, fluid and, in some cases,
should be prevented from lying down by use of cross-ties intravenous nutritional support may therefore be indicated.
Figure 7.28 Cross-tying a horse with a pelvic fracture. A corner location, preferably by a window, helps horses settle and reduces risk
of being startled. The horse is secured by double padded headcollars with independent ties each side. Tie chains are attached to
headcollars by double bale string as fail-safes.
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153
Surgical Equipment, Implants and Techniques for Fracture Repair

J.A. Auer
University of Zurich, Zurich, Switzerland
P
rinciples Stable Internal Fixation
Again, in the early years this was an absolute must as rigid-
Undoubtedly, the single greatest influence in establishing ity of fracture fixation enables direct bone healing and
the principles and practice of fracture repair has been the avoids callus formation (Chapter 6) [3]. Later implementa-
Arbeitsgemeinschaft für Osteosynthesefragen (AO) tion of minimally invasive fracture fixation in human and
Foundation. It was founded in 1958 by four Swiss surgeons small-animal trauma surgery led to a rethinking of the
and quickly developed into a worldwide organization [1]. need for absolute rigidity (see later). Avoiding open reduc-
In 1984, the AO Foundation was established, to which all tion and internal fixation (ORIF) allows the haematoma
the rights for royalty income were bestowed. The company surrounding fracture ends with all its growth factors and
providing implants and instruments for the AO Foundation, polyplurent cells to be maintained, leading to potentially
Synthes Inc., was sold to Johnson & Johnson in 2012. It improved and accelerated bone healing. However, frac-
continues to manufacture and provide instruments and tures with an articular component require both accurate
implants to the AO Courses and to sell them to healthcare reduction and stable internal fixation to avoid compro-
providers in the human and veterinary field under the mised joint function and development of degenerative
name DePuy Synthes and DePuy Synthes Vet, respectively. joint disease. Additionally, to permit immediate weight-
The veterinary specialty within the AO Foundation, bearing, complete long bone fractures in horses usually
AOVET, was founded in 1969, and in 2008 it was accepted require re-establishment of an axial column, which in most
as a fully funded speciality next to AOTRAUMA, AOSPINE cases requires rigid internal fixation.
and AOCMF (cranio–maxillo–facial) [2]. Like its parent
foundation, AOVET has established itself as the world
leader in the treatment of fractures in animals. The four Preservation of Blood Supply
fundamental AO principles of fracture fixatio"n [1] are
Preservation of blood supply is of paramount importance
detailed in Sections “Anatomic fracture reduction”, to
in all species; this principle has stood the test of time.
“Early, active mobilization.”
Anatomic Fracture Reduction Early, Active Mobilization

While being an absolute dogma in the early years of the AO As it is not possible to keep an animal in a recumbent posi-
Foundation, this principle has been somewhat modified tion for a prolonged period, fracture fixation must with-
latterly, as further research has increased understanding of stand the stresses placed upon it during recovery from
bone healing (see Chapter 6). However, in the majority of anaesthesia and in post-operative healing. External support
equine fractures, accurate reduction remains important, can protect constructs during this vulnerable period, but
and in articular fractures it is critical to return to athletic prolonged immobilization has a negative impact on fracture
function. healing and homeostasis of other tissues (Chapter 13). The

154 Surgical Equipment, Implants and Techniques for Fracture Repair
benefits of physiotherapeutic programmes and gradually induction of anaesthesia and aseptic preparation of the
increasing controlled exercise have benefited recuperation surgical site, an aseptic surgery suite, a safe recovery room,
of human fractures and are increasingly appreciated in dedicated anaesthesia personnel and a number of box
equine surgical practice (Chapter 15). stalls to maintain the animals in a clean, safe environment
during the post-operative period. Additionally, a wide
variety of surgical equipment is essential. General surgical
Pre-operative Planning and Approach to Bone
instruments are needed for open approaches to bones and
Careful diagnostic imaging is mandatory before consider- arthroscopic equipment for minimally invasive repair of
ing surgery. This should include multiple radiographic articular fractures. The author has recently provided a
views at a variety of angles. In selected cases, additional detailed description of the former [6], and the latter have
information may be obtained from ultrasonography, scin- been described in a specialist arthroscopy text [7]. The
tigraphy, computed tomography (CT), and magnetic reso- instruments used vary widely between surgical locations,
nance imaging (MRI) (Chapter 5). All can aid in selection, but the principle of preparing sets for all possible scenarios
location and direction of implants. Soft tissues must also be is valid. It is important to use high-quality instruments for
considered from the perspectives of surgical approach/ any type of surgery. They may be somewhat more expen-
access to the fracture(s) and potential interference by sive, but do not undergo oxidation (rust) and stay sharper
implants. In fractures involving joints, reconstruction of for a significantly longer time. The author has had excel-
articular surfaces is the principal determining factor to lent experiences with instruments manufactured by
approach and application of implants. There are fractures Sontec Instruments Inc., Centennial, Co.
in which surgery should not be attempted, for example a The purpose of this chapter is to describe instruments
multifragment fracture of the radius with substantial and implants presently employed in equine fracture repair
defects in the caudal cortex. In this situation, inherent and to discuss how they are used. Thorough knowledge of
instability results in continuous cycling of implants and the basic principles of internal fixation, application of the
eventually leads to failure. It is prudent to conduct a instruments available and the different implants is a pre-
detailed discussion with the owners before surgery includ- requisite for success. It is suggested that anyone interested
ing anticipated outcome, potential complications and the in treating fractures should attend an AOVET continuing
costs of the particular fracture repair. A comprehensive education course on internal fixation. Additionally,
pre-operative plan including a checklist of potential implants available from different companies should be
implants and instruments needed is an absolute prerequi- studied in depth.
site for success (Chapter 9). Most instruments and implants are manufactured from
The approach to the bone should be carried out rapidly high-quality 316L stainless steel, although implants manu-
and carefully, respecting Halsted’s principles of good surgi- factured from titanium and titanium alloys have recently
cal technique. Special attention should be paid to the blood become popular in human surgery. The chrome–nickel–
supply, avoiding severance of major vessels. The perios- molybdenum-alloyed austenitic stainless steel used for
teum should be maintained with the underlying bone most instruments and implants, including those produced
whenever possible. If necessary, periosteum is stripped off by DePuy Synthes Inc., complies with international ISO
the bone only immediately under selected implants, such standards and relevant national DIN and ASTM stand-
as dynamic compression plates (DCPs). More recently, ards [8]. The material properties of the various metals and
developed implants, such as the locking compression plate alloys employed in equine fracture repair have recently
(LCP), are usually applied over the periosteum. Excessive been reviewed [9]. In this chapter, most of the comments
dissection should be avoided because it facilitates accumu- pertain to the instruments and implants developed by the
lation of blood and serum. Planning the approach relative AO group and manufactured by DePuy Synthes Vet, West
to the selected implants is important. For example, the Chester, PA.
approach to the dorsal metacarpus is made through longi- For the DePuy Synthes products, stainless steel is pro-
tudinal splitting of the common digital extensor tendon, duced according to stringent specifications, requiring that
which facilitates secure closure of soft tissues and skin over the composition, mechanical properties and cleanliness of
the implants [4, 5]. the microstructure meet stricter standards than those spec-
ified by official guidelines [8]. The high purity of the steel
improves corrosion resistance; this is achieved by ensuring
Instruments and Implants
that the carbon and sulphur contents are maintained
A prerequisite for effective and successful fracture repair within low limits and by employing a special re-melting
in horses is a well-equipped hospital with rooms for process. The raw material is tested prior to being shipped to
Equipment for Internal Fixatio 155
the instrument and implant manufacturing plant, where it

is tested again. The two tests are compared and if disparate
results are detected, the material is returned. Identical
measures are applied to pure titanium and the various tita-
nium alloys. Presently, a number of titanium alloys are
being tested to further improve the currently available tita-
nium implants, which are now used almost exclusively in
human trauma surgery [8].
The austenitic instruments and implants manufactured
by DePuy Synthes and used by the AO group form a func-
tional system. The instruments are used in a logical
sequence, each fulfilling a specific task during the prepara-
tion of bones to accept implants. The instruments are inter-
dependent and cannot be readily substituted with other
manufacturer’s instruments; this risks possible failure of
the repair.
Instruments are manufactured from various corrosion-
resistant steels, the type determined by the function of the
instruments. All implants are manufactured from the same
Figure 8.1 The Trauma Recon large battery-powered drill
steel type [8]. However, the hardness or ductility may vary. works very well in equine fracture fixation. Source: Courtesy
Very hard steel is used for K-wires and Steinmann pins, a DePuy Synthes Vet, West Chester, PA, USA.
moderately hard steel for plates and screws, and soft steel
for cerclage wires and reconstruction plates.
power/air tubes near the surgery field can improve asepsis.
Standard electric power drills used for wood and metal-
working are not recommended.
Equipment for Internal Fixation
Depuy Synthes Instruments Large Fragment Set

The instruments and implants originally developed by AO The large fragment set contains all instruments for the
and later transferred to DePuy Synthes, Zuchwil, insertion of 4.5 and 5.5 mm cortex screws, 6.5 mm cancel-
Switzerland, via Synthes Inc., Paoli, PA, are assembled in lous screws and 4.0 and 5.0 mm locking head screws (LHS)
sets according to the size of implant [4]. Additional sets (Figure 8.2). There are three separate screw racks, one for
include the various instruments needed to reduce a frac- 5.5 mm cortex screws (Figure 8.3), one for 4.5 mm cortex
ture, to apply a plate or to remove stripped or broken and 6.5 mm cancellous screws, and one for 4.0 and 5.0 mm
screws. For fracture repair in horses, mostly large and LHS. An additional individually assembled plate set con-
selected small instruments and implants are used; mini- tains selected DCPs, LCPs (Figure 8.4) and equine LCPs.
implants are rarely employed and are not discussed here. The various instruments needed for screw insertion and
plate application are presented below. There is also a
3.5 mm set for screws and plates.
Power Drill
The use of a power drill is strongly encouraged for fracture
Drill Bits
repair in horses. Until recently, the most widely used power
drills were air driven. These can be sterilized easily and Two sizes of double fluted drill bits are used for each size of
allow quick and effective implant insertion. Treatment of screw when these are inserted in lag fashion. The larger
long bone fractures is also expedited by power equipment, 3.5, 4.5 and 5.5 mm bits are used to prepare the respective
which becomes important in major fracture repair in glide hole; the smaller 2.5, 3.2 and 4.0 mm bits, which rep-
adults [4]. For power tapping, oscillation between the for- resent the core diameter of the respective screws, prepare
ward and reverse drives, to facilitate cleaning of the bone the thread hole. The size of each bit is marked on the quick
swath material into the flutes of the tap, can be accom- coupling device; 4.3 and 3.2 mm drill bits with a centimetre
plished rapidly. Recently, increasing numbers of battery- scale are included in the set for the 5.0 and 4.0 mm LHS,
powered electric drills are employed (Figure 8.1). Lack of respectively.
Figure 8.3 DePuy Synthes large fragment set. The 5.5 mm

screw rack contains 10 screws of each of the most frequently
used screws between 30 and 70 mm, as well as some smaller
screws. Additionally, there is one compartment (on the right side
in figure) where no sizes are marked that is intended to be filled
by screws that the customer wants to select personally; a set of
labels specifically for this purpose is supplied. Source: Courtesy
DePuy Synthes Vet, West Chester, PA.
Universal Drill Guide

The universal drill guide is used for plate application and
contains on one side a 3.5, 4.5 or 5.5 mm sleeve and on the
other side a spring-loaded 2.5, 3.2 or 4.0 mm sleeve. By
applying pressure to the spring-loaded part, the hole is
drilled in a central, neutral position (Figure 8.5a); when no
Figure 8.2 The DePuy Synthes large fragment set contains all pressure is applied and the drill guide is positioned eccen-
the drill bits, taps, guides, screwdrivers (hexagonal and star trically, at the far end of the plate hole, the hole is drilled in
drive), T-handle, countersink, depth gauge, push–pull device, load position across the underlying bone (Figure 8.5b).
tension device, socket wrench and torque limiting device that
Because the smaller drill guides are spring-loaded, they
are needed to insert screws directly into bone as well as
through DCPs, LCPs and LC-DCPs. The instruments are arranged cannot be used for preparing the respective thread holes.
in three trays that fit on top of each other into the holding box. Therefore, these drill guides are only used during plate
Pictographs facilitate correct introduction of each instrument. application, where position screws are applied. The tip of
Source: Courtesy DePuy Synthes Vet, West Chester, PA.
the spring-loaded side is attached to the instrument by
means of counterclockwise threads. Because the power
drill rotates the drill bit in counterclockwise threads, the
tip tends to be loosened during its use and from time to
Double Drill Guide
time needs to be retightened.
Both ends of the double-drill guide are used when insert-
ing screws in lag technique. Only the narrower end is used
Special Drill Guides for Plate Application
in preparing holes for position screws. It helps to guide,
prevents bending of the bit and protects surrounding soft Sets include special 3.2 mm double-ended drill guides for
tissues. One end of the instrument contains the 3.5, 4.5 or 4.5 mm position screws applied through plates including a
5.5 mm guide, and the other end the 2.5, 3.2 or 4.0 mm 3.2 mm diameter guide for 4.5 mm screws, and a 4.0 mm
guide, respectively. The 2.5 mm drill guide fits into the diameter guide for use when 5.5 mm screws are inserted into
3.5 mm glide hole, the 3.2 mm drill guide into the 4.5 mm 4.5 mm DCPs. The guide barrel of each instrument marked
glide hole and the 4.0 mm drill guide into the 5.5 mm glide with a green ring allows drilling of a central (neutral) hole
hole, which ensures concentric drilling of the thread hole through the oval plate hole, and the barrel marked with a
relative to the glide hole. The appropriately sized drill yellow ring facilitates preparing a 1 mm offset hole to pro-
guides are also used as tap guides. vide axial compression as screws are tightened in the plate.
Figure 8.4 DePuy Synthes large fragment

set: LCPs, locking instruments and LHS.
Plates are arranged in three trays that fit
into the plate set (left). The screw set is only
partially filled. The instruments needed for
implantation of LCPs are arranged in front of
the screw set and a selection of broad and
narrow 5.0 mm LCPs and soft aluminium
templates are in front of the plate set.
Source: Courtesy DePuy Synthes Vet, West
Chester, PA.
(a) (b)
Figure 8.5 The universal drill guide: (a) in the ‘neutral’ position (spring compressed) in the centre of LCP combi hole and (b) in ‘load’
position (spring not compressed) on the far side of the combi hole. Source: Courtesy DePuy Synthes Vet, West Chester, PA.
Drill Guides for Locking Head Screws LHS has to be inserted through deep tissue such as through
a stab incision across muscle masses. It is imperative that
Two drill guides for the 4.0 mm and four drill guides for the
the drill guides are connected perpendicular to the top sur-
5.0 mm LHS are included in the instrument set. These have
face of the plate. If the screw is inserted at an oblique angle
a double helix thread (half a turn separated) at the tip so
to the plate, it loses the major part of its holding power
that they can be threaded vertically into LCP holes
within the threaded plate hole.
(Figure 8.6). Care has to be taken to insert them into the
plate perpendicularly in all planes. If the guide is initially
turned backwards half a turn, a little ‘click’ is heard when
Countersink
it connects with the threads, and at this point the drill
guide can be directed forwards and appropriately threaded The countersink is used to prepare a conical groove in the
into the plate hole. It is also prudent to double-check the superficial bone cortex to accept the screw head. One coun-
orientation of the guide relative to the plate before drilling tersink fits the 8 mm diameter heads of 4.5 and 5.5 mm cor-
is initiated. The guides also contain threads at the proximal tex and 6.5 mm cancellous screws. Its 4.5 mm diameter tip
end, which allows attachment of an additional same-sized fits into the glide hole. A similar countersink is produced for
drill guide. This double-length drill guide can be used if a the 6 mm head of 3.5 screws. The countersink depression
Tap
The tap precisely cuts appropriate threads for screws in the
thread hole bone. When lag technique is used, threads are
not cut in the over drilled glide hole, which has the same
diameter as the tap. The tap is inserted through the respec-
tive drill guide/tap sleeve to protect the soft tissues from its
sharp cutting edges. The tap has three flutes along the cut-
ting portion, to accept bone debris formed during the cut-
ting action. In hard equine bone, the tap is advanced three
half turns followed by a half turn in the reverse direction,
to facilitate transport of swath particles into the flutes.
The cancellous tap creates threads wider than the core
size of the cancellous screw, which are cut along the entire
hole length. It contains a scale in 5 mm increments on the
shaft, which can be compared with the measured hole
length to monitor tapping depth.
Figure 8.6 A 5.0 mm drill guide threaded into a combi hole of a
5.0/4.5 mm LCP. The drill bit has to be perpendicular to the plate in
all directions to permit solid engagement of the screw head threads
Screwdrivers
in the plate. Source: Courtesy DePuy Synthes Vet, West Chester, PA.
The 4.5 and 5.5 mm cortex and 6.5 mm cancellous screws
reduces the load at the screw head–shaft junction. A solitary contain either a hexagonal or star-lock hole in the head to
contact point that develops when a screw is inserted accept the corresponding screwdriver that fits all three.
obliquely or across a slanted surface, or a contact ring if the Firm seating of the screwdriver tip in the screw ensures
screw is inserted perpendicular to the bone surface, are tight implant placement without the risk of screw head
transformed into a broad contact area. The depression also damage and metal debris being shed into surrounding tis-
reduces screw head protrusion on the bone surface, which is sues. LHS also contain either a hexagonal or a star-lock
especially desirable with the 4.5 and 5.5 mm screws. hole. The star-lock screwdriver sits firmly in the hole and
It should be noted that countersinking cannot be per- obviates the need of a screw holding device to collect the
formed when a position screw is inserted outside of a plate screw from the rack. With the star-lock drive, force applica-
because the nozzle does not fit into the 3.2 mm thread hole. tion occurs at a much more favourable angle, which effec-
If this is required, the thread hole has to be enlarged with tively prevents stripping of the connection. Hexagonal and
the 4.5 mm drill bit for about 8 mm. star drive screwdrivers with quick coupling device ends for
power drill attachment are valuable additions, especially for
plate fixations, in which many screws have to be inserted.
Depth Gauge The 3.5 mm screws are also available either with hexago-
The depth gauge allows exact determination of the length of nal or star-lock holes and appropriate screwdrivers. The
the prepared hole and therefore dictates the screw length. 3.5 mm hexagonal holes are especially prone to be stripped
This device measures the screw length including the screw during implant removal if the screwdriver is not properly
head and contains a conically shaped nose, which fits into inserted into the hole.
the countersink depression in bone or the plate holes of
DCPs and LCPs. For transosseous screws, the countersink
Torque-Limiting Devices
depression is made prior to determining the screw size
needed. The long thin probe of the depth gauge is inserted Because LHS primarily tighten into the threaded section of
across the entire hole, and the opposite bone surface is the combi holes within LCPs and not into the bone (as is
engaged by a small hook on its end. A direct measurement of the case with the regular screws) torque-limiting/load
hole length is provided on the barrel of the instrument. reduction devices were designed (Figure 8.7). Their use is
especially important when titanium implants are used
(standard in human surgery) to prevent cold welding
T-Handle
between screw and plate. In equine surgery, stainless-steel
The T-handle has a quick coupling device into which taps implants are usually used, and cold welding is not a major
are inserted for manual tapping of thread holes. problem. Nevertheless, the use of either the torque-limiting
(c)
(b) (a)
Figure 8.8 The tension device is hooked in the last plate hole
(a) and is attached to the bone with a short screw (b). Twisting of
the hexagonal screw head (c) closes the arms of the tension
device and pulls the plate towards the anchoring screw (a) thus
applying axial compression to the fracture.
Figure 8.7 The 4 N m load reduction device attached to a star

drive screwdriver during LHS insertion. The plate is attached to
the bone with the push–pull device. Source: Courtesy DePuy
Synthes Vet, West Chester, PA.
attachment for the compact air drive or the Colibri air drive
is encouraged as this allows full insertion of LHS. A torque- Figure 8.9 Detail image of the push–pull device. Source:
limiting hand screwdriver is available, but because LHS Courtesy DePuy Synthes Vet, West Chester, PA.
threads are thinner and have a lower pitch, insertion takes
many more turns: it is therefore easier and quicker using humans with 2 mm separation from the underlying bone;
power equipment. however, in equine surgery plate-bone contact is usually
desirable. The drill bit connected to the tip of the push–pull
device is positioned into the desired plate hole and pow-
Tension Device
ered into the bone at a slight angle. The collet is then
The tension device (Figure 8.8) is used to reduce and com- twisted downwards until it makes contact with the plate
press distracted long bone fractures when the fracture gap (Figure 8.7), and by continuing with turning, the plate is
is too wide to be closed by use of the offset screw technique. pressed onto the bone surface.
Plate screws are inserted in the bone remote to the tension
device which is then connected to the bone at the end of a
Plate Bending Press
plate by a short screw. A hook engages the plate, and as the
tensioning screw in the instrument is turned, it pulls the Contouring plates is an important part of long bone frac-
plate (and thus attached bone) in the direction of the device ture repair. It is important to contour DCPs to the exact
thus applying axial compression to a fracture plane or anatomic shape of the bone with a slight (1 mm), acute
across a joint. Once achieved, one or two screws are overbend at the fracture site to ensure axial compression
inserted through the plate on the near side of the fracture around the entire circumference of the bone. With LCPs,
before the tension device is removed and screws are precise contouring is less important as plate/bone contact
inserted through the remaining plate holes. is not integral to function or construct stability.
The bending press allows controlled contouring. Standard
plates are easily contoured, whereas the 5.5 mm special
Push–Pull Device
equine plates require considerable force. To properly bend
This instrument (Figure 8.9) is used to hold LCPs on to the plate, one hand is placed on the footplate of the press
bone but can also be employed to press the plate onto the and the other on the long handle. Adjusting the anvil
bone surface. LCPs were initially designed to be applied in until the handle is almost horizontal allows bending to be
performed in a controlled manner (Figure 8.10a). The con- Bone Clamps

tour of the piston and that of the underlying anvil are
Bone clamps or bone-holding forceps come in a variety of
designed to correspond (Figure 8.10b). To prevent surface
shapes and sizes, and are used for fracture reduction (see
damage, the plate has to be placed at slightly different loca-
figures in [6]). The Verbrugge bone-holding forceps is
tions on the anvil of the bending press for concave and con-
curved to the side with one arm longer than the other, con-
vex bends. Placing the plate next to the central part of the
tains a speed lock or a ratchet, and is available with modifi-
press at the back of the anvil allows convex bends
cations such as a reverse jaw. The Kern bone-holding clamp
(Figure 8.10c), whereas placing the plate at the tip of the
is suitable for equine long bone fracture reduction and has
anvil creates concave bends (Figure 8.10d). Trying to bend a
symmetric, straight, strong jaws and a ratchet at the end to
plate with the handle pointing upwards requires excessive
maintain the bone-holding force. The Stefan bone-holding
force and leads to uncontrolled overbending (Figure 8.10e).
forceps has rounded and sturdy jaws and contains a speed
lock.
The pointed reduction forceps (clamp) has two pointed
thin jaws and comes with either a ratchet or a speed lock.
The most recent version is slightly stronger and contains
an automated ratchet mechanism between the handles
(Figure 8.11). When the manual force stops, the clamp
maintains the compression. This is released by flipping a
(b′)
(a′) small lever.
Additional Instruments
(c′)
The basic set includes a 2 mm drill bit and its pointed drill
(a) (b) guide, which can be used as a marker for potential screw
sites. It is inserted a few millimetres into the bone at the
proposed location; its direction and location are then veri-
fied with radiography or fluoroscopy.
Screw Types, Sizes and Techniques

(c)
Synthes Inc. and its partners have developed several types
of screws. The same screws can have a number of applica-
tions and fulfil different functions, determined by require-
ments at individual fracture locations.
(d)
The various sizes, types and shapes of screws generally
employed in equine surgery together with pertinent data,
such as glide hole, thread hole and tap diameters, are
(e)
Figure 8.10 Correct use of the bending press. (a) Plate

contouring should be performed with the lever close to the
horizontal position. (b) The anvil for the plate (a′) and the piston
(b′) have complementary contours, allowing bending without
damaging the plate. The resting plate can be moved up and
down (arrow) with the turning nut (c′) at the bottom of the
bending press. (c) For a convex bend, the plate is positioned
towards the centre of the press matching the contours of the
resting plate and anvil. (d) For a concave bend, the plate is
positioned towards the front of the bending press, again
matching plate and anvil contours. (e) It is not possible to
produce a controlled gentle bend with the lever in this position;
an acute excessive bend will result. The turning nut should be
used to lower the anvil until the lever is in a horizontal position. Figure 8.11 The new pointed reduction forceps with built-in
Source: From Auer [4]. ratchet device and pressure release trigger (a).
Screw Types, Sizes and Technique 161
summarized in Table 8.1. Screws are classified as large, inserted after tapping showed no significant differences in
small and mini-screws and are generally identified by insertion torque or pullout force [12]. The only manufac-
their outside thread diameter. Large screws include the turing differences between the DePuy Synthes 4.5 mm
4.5 and 5.5 mm cortex screws, the 4.5, 7.0 and 7.3 mm can- self-tapping and standard 4.5 mm cortex screws are a
nulated screws, the 6.5 mm cancellous screw and the 5.0 slightly tapered core diameter at the tip and three adjacent
and 4.0 mm LHS. Small screws encompass the 4.0 mm short, large volume, cutting flutes, over a length of approx-
cancellous, the 3.5 mm cortex and the 3.5 mm LHS. imately 3 mm. Studies in human cadaveric femora showed
Screws of smaller diameters, commonly used in small that insertion of self-tapping screws raised the surface
animals and humans, are not described here. For infor- temperature to approximately 40 °C. Taps raised the tem-
mation on these and other implants, the reader is referred perature to approximately 30 °C, and screws inserted into
to the AO Manuals and DePuy Synthes Vet catalogues. a tapped hole to 33 °C. If a non-self-tapping screw was
inserted in an untapped hole, the temperature reached
approximately 50 °C. The heat generated by the self-
Cortex Screws
tapping screw or by a tap, in relation to the speed of inser-
Cortex screws (Table 8.1) are fully threaded with a relation, is not significant [12].
tively short thread height of 0.5 mm in 3.5 mm screws, An experimental study evaluating self-tapping screws,
0.7 mm in 4.5 mm screws and 0.75 mm in 5.5 mm screws. manufactured by different companies, in hard adult equine
They are the most widely used, and 4.5 mm cortex screws bone, revealed significant differences between one product
are the single most commonly used screw in equine frac- and the others [13]. However, with power tapping, screws
ture management. The 5.5 mm cortex screw was developed were easily introduced without any complications: this is
specifically for compact equine bone and has been shown therefore appropriate in clinical situations.
in adult bone to have greater strength than the 4.5 mm cor-
tex screw [10]. In foal bone, it is comparable to 6.5 mm can- Screws Inserted in Lag Technique
cellous screw [11]. These mechanical advantages can be This is the most frequent application for cortex screws in
clinically useful, and the implants are commonly used in horses [4]. The near (cis) cortex is overdrilled using the
critical locations where potential increased strain and large drill guide with a bit that has the same size as the
movement may occur. The 5.5 mm screws can also be outside thread diameter of the screw to be inserted
inserted when the threads in a 4.5 mm hole have been (Figure 8.12a). During subsequent screw insertion, the
stripped and fail to engage the screw. threads do not engage the bone surrounding the hole, but
The 3.5 mm cortex screws are used in lag technique to glide through, giving rise to the name glide hole, for this
provide compression of small fragments such as slab frac- portion. The smaller portion (insert) of the double-drill
tures of cuboidal bones in the carpus or tarsus. Their small guide is inserted into the glide hole to facilitate concentric
heads can also be countersunk to become flush with a bone drilling of the thread hole, which has the same diameter as
surface which allows them to be used in reducing long the core diameter of the screw. This hole is drilled across
bone fractures prior to plate fixation. Occasionally, smaller the trans (far) cortex (Figure 8.12b). In most cases, a coun-
diameter (usually 2.7 mm) cortex screws are used for small tersink depression is created to optimize seating and maxi-
fragment repair. Screws with narrower diameters are avail- mize the contact area between screw head and bone
able but are rarely used in horses. Cortex screws may be (Figure 8.12c). This results in decreased force per square
applied as lag screws, position screws or plate screws – the unit of contact area. The countersink is rotated in a 360°
latter two using the same insertion technique. motion; this should be done carefully, particularly if the
cortex is thin as excessive countersinking may result in the
Self-tapping Cortex Screws screw head pulling right through the cortex. Residual
Self-tapping describes screws that can be inserted into a swathe produced by the countersink is flushed away with
pre-drilled thread hole directly, without first cutting saline before the depth gauge is used to determine the
threads. There are two categories: thread cutting and length of screw needed (Figure 8.12d). It contains a small
thread forming. Thread cutting screws are usually used in hook at the distal end, to engage the outer surface of the
hard cortical compacta. They cause much less damage to trans-cortex. Pulling gently to tighten the shaft of the depth
bone microstructure and require less insertion torque and gauge allows determination of the exact length of the
axial force than thread-forming (squeezing) screws [12]. entire screw (including the head). The measured length is
The DePuy Synthes self-tapping screws for diaphyseal generally used, but 2 mm are subtracted if closure of a frac-
application are thread cutting. An experimental study ture gap is anticipated. Using the tap sleeve (large drill
comparing self-tapping and standard 4.5 mm cortex screws guide), the tap is placed through glide hole and threads cut
Table 8.1 Design details of screws commonly used in equine surgery including drill and tap requirements.
3.5 mm 4.5 mm 5.0 mm 55 mm 73 mm

Screw name Cortex Cortex 3.5 Locking 4.0 Locking Locking Cortex 63 mm Cancellous Cannulated 2.4 mm UniLOCK 3.0 mm UniLOCK
Screw O/ 3.5 4.5 3.5 4 5 5.5 6.5 7.3 2.4 3

Glide hole O/ 3.5 4.5 None None None 5.5 4.5 7.3
Thread hole O/ 2.5 3.2 2.8 3.2 4.3 4 3.2 5 1.8 2.4
Tap O/ 3.5 4.5 None None None 5.5 6.5 7.3 Optional
Screw shape
Cannulation guide — — — — — — — 300 mm long — —
pin /2.8 mm
Type thread Cortical Cortical Cortical Cortical Cortical Cortical Cancellous Cancellous Cortical Cortical
narrow narrow narrow
pitch 1.25 1.75 0.8 1 1 2 1.75 2.75
Screw head O/ 6 8 5 6.6 6.6 8 8 8.2 4 4
Special head design — — Conical Conical Conical — — — Flat/ + Screwdriver Flat/ + Screwdriver
threaded threaded threaded
Thread length Fully Fully Fully Fully Fully Fully 16 mm/32 mm/fully 16 mm/32 mm Fully threaded Fully threaded
threaded threaded threaded threaded threaded threaded threaded
Shaft O/ — — — — — — 4.5 4.8 — —
core O/ 2.4 3.1 2.9 3.4 4.4 3.9 3 4.5 1.7 2.4
Self-tapping Yes Yes Yes Yes Yes Yes No Yes Yes Yes
Self-drilling No No Available Available Available No No Yes No No
Source: From Auer [4].
c08.indd 162 12/17/2021 12:25:46 AM

(a) (b)
(c) (d)
(e) (f)
Figure 8.12 Lag technique demonstrated on a third metacarpal bone lateral condylar fracture. The distal screw is already inserted.
(a) The glide hole is drilled with the large drill bit in the double-drill guide; (b) the insert portion of the double-drill guide is inserted
into the glide hole and a concentric thread hole cut with the small drill bit; (c) the countersink creates a depression in the cis-cortex;
(d) the depth gauge fits in the countersink groove and determines the length of the screw needed; (e) the tap housed in the drill guide
passes through the glide hold and cuts threads in the narrower thread hole including the trans-cortex; (f) a screw of predetermined
length is inserted with the hexagonal tipped screwdriver and tightened.
in the thread hole (Figure 8.12e). The hole is then flushed, screw head, especially with 3.5 and the 4.5 mm screws. The
and the screw of predetermined length is inserted and 5.5 mm screw is very difficult to break.
tightened (Figure 8.12f). Solid force should be used, but The lag technique is identical for all sizes of screw; only
overtightening should be avoided as this may break off the the sizes of the drill bits and instruments vary. When many
screws are needed, power equipment is recommended for thread lengths or as fully threaded screws. The geometry
tapping and insertion. This can be performed with both air maximizes holding power in soft cancellous bone.
and the newer battery-powered drills, but should be prac- Historically cancellous screws have also been used when
tised extensively prior to surgical use. cortex screws failed to adequately engage bone. However,
during healing, the threads cut in the bone for their inser-
Position Screws tion will fill with bone, and if removal is subsequently
The position screw technique is used if a fragment has to required this is met with increased resistance and can lead
be maintained at a certain distance, for example when to screw head breakage or fragmentation of bone.
compression (lag technique) would pull the fragment into Partially threaded cancellous screws are designed to act
the medullary cavity or if a small fragment is to be kept in as lag screws. Generally, only one size hole, the thread
place and subsequently protected by a neutralization plate. hole, is drilled across the entire bone. Threads are then
With the position screw technique, only a thread hole is cut along the total length of the hole with the cancellous
drilled. The entire hole is tapped and, because the threads tap, and the lag screw is inserted. The threads in the cis-
engage both cis and trans cortices, there is no interfrag- cortex are not engaged because the screw threads are only
mentary compression when the screw is tightened. No located on the far side of the fracture plane and in the
countersinking can be performed, except with 3.5 mm trans-cortex, thus producing interfragmentary compres-
screws, because the nozzle of the 4.5 mm countersink is too sion (Figure 8.14a). However, if threads are partially (or
wide to fit into the thread hole. An alternative involves completely with fully threaded screws) located in both
placing a washer under the screw head to distribute the the cis- and trans-cortices, no compression is achieved
forces applied to the bone. (Figure 8.14b). Partially threaded 4.5, 7.0 and 7.3 mm can-
nulated screws and partially threaded 6.5 mm cancellous
Plate Screws screws can be directly used as lag screws. To achieve com-
In most instances, insertion of screws into non-locking pression, all other screws have to be applied in lag
plates uses the same technique as a position screw, i.e. a technique.
thread hole is drilled across the entire bone. Since the plate It should be noted that since 5.5 mm cortex screws
hole is larger than the thread diameter, the threads do not became available, cancellous screws are rarely needed in
engage the plate, and by tightening the screw the plate is equine fracture repair.
pressed solidly onto the bone (Figure 8.13). It should be
noted that this does not apply to LHS in LCPs (see Sections
“Locking Head Screws” and “Human Femoral Locking (a)
Compression Plates”).
Cancellous Screws
Cancellous screws (Table 8.1) have a different pitch (angle
of the threads relative to the long axis of the bone) and
greater thread height (1.45 mm) than cortex screws. They
are available as partially threaded, with either 16 or 32 mm
(b)
Figure 8.14 Cancellous lag screw technique. (a) A cancellous

screw of correct thread length inserted into the tapped thread
Figure 8.13 A plate screw inserted through a DCP. Because the hole. All the threads are located past the fracture plane,
outside screw diameter is smaller than the hole in the plate, this allowing this to be compressed; (b) a threaded portion that is
is not engaged. Screw tightening therefore presses the plate too long, resulting in the threads on the cis-side of the fracture
solidly onto the bone. plane, prevents compression.
Cannulated Screws tively a ‘threaded bolt’ that provides significantly greater

breaking resistance than cortex screws [15]. The LHS tips
Cannulated screws (Table 8.1) have similar geometry to
are either equipped with a self-tapping device (Figure 8.15)
cancellous screws but contain a central canal to allow
or, as occasionally used in human surgery, a self-drilling–
insertion over a guide pin. The 7.3 mm cannulated screw
self-tapping device. The latter is only used as a unicortical
has reverse-cutting threads to facilitate removal after bone
screw because protrusion of the sharp self-cutting part
healing has occurred. A special set has been assembled
would damage surrounding soft tissues.
containing various sizes of cannulated screws and the
Drill guides for LHS are threaded into the plate as it is
instruments needed for insertion; however, they are rarely
critical to position the guide perpendicular to the plate to
used in equine fracture repair.
ensure correct seating of the screw head in the plate.
The fracture is reduced, and the location for screw inser-
Oblique insertion of a LHS results in minimal holding
tion selected. A guide wire may be placed adjacent to the
power and potential fixation failure. The 5.0 mm LHS are
site, and its position and angle evaluated by fluoroscopy or
most frequently used in equine fracture management:
radiographs. A 2.5 mm hole is drilled parallel to the guide
4.0 mm LHS can be used in the same plate but are weaker.
wire and advanced to the desired depth. A guide pin is
3.5 mm LHS are available for use in corresponding sized
inserted, and the direct measuring device is placed over it.
plates.
A screw approximately 5 mm shorter than the measured
It is important to note that these screws lock in the plate
length is selected. Care is taken to also select the correct
hole and not in the underlying bone like cortex and cancel-
thread length, to ensure compression during tightening.
lous screws. A LHS can therefore feel tightly inserted even
The cannulated drill bit is placed over the guide pin and
if there is no bone underneath the plate hole. Because the
the hole prepared to the desired depth, which is verified
threads of screw head and the threads in the plate are sol-
using an image intensifier or radiographs. The thread hole
idly intertwined, they form a unit that prevents micro-
is tapped over the guide pin using the cannulated tap, and
movement between the screw head and the plate (which
the selected screw is then inserted with the cannulated
happens in DCPs). All LHS applied to a plate therefore feel
hexagonal tipped screwdriver.
solid, but this does not mean that the screw is securely
Cannulated screws are not ideal for equine use because
inserted into the bone underneath the plate.
they break much more easily than solid cortex and cancel-
lous screws. While implantation across supraglenoid
tubercle fractures was facilitated compared to cortex or Headless Screws
cancellous screws, several screws broke in the days follow-
Headless screws were initially introduced into the human
ing surgery (D. Richardson, personal communication,
market to avoid protrusion of the screw head beyond the
2019).
bone, particularly in and near joint surfaces. The Herbert
screw1 is a self-contained compression screw. This is
Locking Head Screws threaded over its entire length including the head which is
wider than the rest of the screw and can be completely bur-
LHS are only applied through LCPs. The screw head has a
ied in the bone. The Acutrak screw2 is a cannulated tapered,
conical double thread (Figure 8.15) that is captured in the
variable pitch, self-compressing screw made of titanium. It
threaded part of the combi hole in LCPs through more
is 45 mm long, has a diameter of 6.5 mm at its base and
than 200°, which, according to finite-element analysis, is
tapers to a diameter of 5.0 mm at its apex. The tapered
sufficient to provide angular as well as axial stability [14].
shape obviates the need for a glide hole. A study comparing
LHS have a greater core diameter and a reduced thread
this with 4.5 mm cortex screws inserted in lag fashion
height and pitch than cortex screws. The result is effec-
reported similar biomechanical shear properties, but the
Acutrak screw provided only 70% of the compression
achieved with the cortex screw [16]. Pushout strength was
reported to be higher with the Acutrak screw [17].
Screw Removal
Intact Screws
Cortex screws, LHS and fully threaded cancellous screws
Figure 8.15 A 5.0 mm locking head screw with the threads are readily removed because they are fully threaded.
around the screw head and self-tapping tip. However, after a fracture has healed, a partially threaded
screw may be impossible to remove from hard equine bone. counterclockwise motion an extraction force is applied to
During healing, the pre-cut threads in the cis-cortex fill the screw, allowing it to be removed (Figure 11.9). Screw-
with solid bone, surrounding the shaft. Removal requires retrieval devices are available for all sizes of screws.
the threads to cut their own way backwards through this
bone. Most threads are not designed for this and it can Broken Screws
result in breakage of the screw, usually at the head–shaft A special set has been developed for the retrieval of screws
junction. The surgeon therefore has to give careful consid- with stripped heads, and broken screws, drills bits or taps
eration before using cancellous screws in hard equine bone (Figure 8.17). The extraction kit contains hollow reaming
where later implant removal might be necessary. cutters and extraction bolts for all screw sizes (1.5, 2.0, 2.7,
Cannulated screws are manufactured with a self-cutting 3.5, 4.0, 4.5, 5.5, 6.5 and 7.0 mm screws).
device in the proximal most threads to facilitate removal. If part of the broken screw can be grasped with a special
However, no experimental evaluation has been performed pair of pliers, it is retracted manually by routine backing
in the horse, and it is questionable whether these devices out with counterclockwise action. If the screw has sheared
will be sufficient in hard equine bone. off flush with the cortical surface, a gouge can be used to
expose adequate portions of the broken shaft to allow the
Stripped Hexagonal Screw Head pliers to grasp the shaft and back out the broken end
Occasionally, the hexagonal socket in the screw head is (Figure 8.18a and b). When the broken shaft is deeply
stripped during screw removal. This occurs when the embedded in the bone, a hollow reamer (akin to a core
screwdriver is improperly seated, often because the hole is saw) with centring pin (Figure 8.19) is used to remove the
partially filled with tissue preventing complete insertion. bone cortex circumferentially around the screw or tap
Subsequent application of extraction force (counterclock-
wise motion on the screwdriver) may strip the walls of the
socket in the screw head. This problem is most commonly (a)
(b)
(c)
encountered with the hexagonal (not the star drive) tipped (d)
(e)
head of 3.5 mm cortex screws. A special screw-retrieval (f)
instrument, the so-called conical extraction screw, has

been designed for such situations (Figure 8.16). Its shaft
has a conical, threaded tip that is inserted into the stripped
socket of the screw head. The threads of the tip have a
reversed orientation compared with the screw threads so
that when the cone is tightened in the screw head with a
Figure 8.17 The broken screw removal set. The major

components are arranged in two rows with smaller parts in the
front row and include (a) power screwdriver inserts; (b) conical
extraction screws, for stripped screw heads; (c) extraction bolts,
for broken screw, drill or tap shafts and (d) hollow reamer tubes
for attachment to the centring pin (e) and shaft (f) to expose a
portion of the broken screw to allow the extraction bolt to
extract a broken screw. A T−handle with quick coupling which is
Figure 8.16 Removal device for stripped 3.5 mm screw heads. used for all attachments. Additional instruments not shown
An intact hexagonal hole in the screw head is shown. This is include extraction pliers for gripping round shaft broken
smaller than the conical tip of the device. However, once the screws, and a gouge to expose the stump of shallow seated
hole in the screw head is stripped, the tip (whose threads are broken screws. Source: Courtesy DePuy Synthes Vet,
oriented in the direction opposite to those in the screw) will fit. West Chester, PA, USA.
Plate 167
(a) (b) P
lates
The performance of steel implants is influenced by the way

the steel is processed [9]. Extruded, unworked steel-like
orthopaedic wire has a macrocrystalline structure, which
makes it very malleable. As the material is cold worked
(pressed and rolled at room temperature), the crystalline
structure becomes denser, defects are removed and the
yield stress and fatigue resistance increase. As ductility also
decreases, worked steel becomes more difficult to bend.
(c) (d) For plates and screws, a medium cold worked level is ideal,
whereas pins and K-wires are preferably made from highly
worked steel [9].
Various plates are employed in the treatment of equine
fractures. However, distinction has to be made between
type and function because a particular plate of the same
type may be applied to fulfil various functions. Until
recently, the DCP was considered the standard plate across
the world, but with the introduction of locking implants
this has changed. The LCP has now become the plate of
choice in many situations, although DCPs remain in com-
mon usage.
The standard plates for equine fracture repair are the
Figure 8.18 Shallow broken screws can be exposed with the 3.5 mm broad, 4.5 mm narrow and 4.5 mm broad DCPs and
gouge (a) and removed with pliers (b); the assembled hollow
LCPs. A number of special plates, including human femo-
reamer exposes deep seated broken screws (c) for extraction
bolt entry and removal by anticlockwise rotation (d). ral and distal femoral plates (DFPs), T-plates, UniLOCK
plates, variable-angle LCPs (VA-LCPs), limited contact
(a) DCPs (LC-DCPs), the dynamic hip and condylar screw sys-
tems, one-third tubular plates and leg lengthening plates,
also have applications in equine fracture repair. Pertinent
data are summarized in Table 8.2.
(b)
Dynamic Compression Plates
The DCP is considered the basic plate in equine fracture
treatment. There are two plate widths of the 4.5 mm plate:
(c) narrow with holes arranged in a straight line and broad
with holes offset to the left and right of the midline. The
3.5 mm broad plate, developed mainly for small animals, is
Figure 8.19 Broken screw extraction bolt. Assembly of the manufactured from the same plate stock as the 4.5 mm nar-
hollow reamer with (a) centring pin, followed by (b) reamer row DCP. However, because of the stiffness and configura-
barrel, allowing (c) cutting of bone over the broken screw shaft
by rotation of the assembled unit. tion of the plate, it is stronger than the narrow 4.5 mm DCP
and therefore may have applications in foals [4]. The holes
fragment until it can be secured by the inside surface of an in a DCP are designed to achieve dynamic axial compres-
extraction bolt that contains threads in the opposite direc- sion with tightening of the screws. The holes are machined
tion to the screw threads (Figure 8.18c and d and according to the sliding spherical principle with an incline
Figure 11.8). The kit also contains a plier-type forceps with or slope pointing downwards towards the central portion
curved jaws for gripping broken screw shafts, a dental pick of the plate. When a screw is inserted in the load position
for cleaning out bone from around a broken screw shaft (offset 1 mm from the centre of the drill guide), the screw
after hollow reaming, a hollow gouge to expose shallow head contacts the plate at the top of the incline. When
screws and a useful etched metal instruction set to guide tightened, the screw head moves down the slope until it
the surgeon. comes to rest at the bottom of the incline, just about in the
Table 8.2 Geometric details of standard and special plates used in horses.
Old one New one

third third
DCP 3.5 DCP 4.5 4.5 LCP LCP 3.5 Equine tubular tubular Distal
Name broad DCP 4.5 narrow broad DCS plate T-plate LCP 3.5 broad LCP 4.5 narrow LCP 4.5 broad LCP 5.5 broad plate plate femur plate
Plate type Standard Standard Special Special Special Special Special Special Special Special Special Special
Plate
cross-section
Width (mm) 12 12 16 16 13.5 11 13.5 13.5 17.5 17.5 9 9 16 (shaft)
Thickness 3.6 3.8 4.8 5.4 4.2 3.3 4.2 4.2 5.2 6 1 1 5.5 (shaft)
(mm)
Length (mm) 86 (7 39 (2 holes) to 103 (6 114 (6 91 (4 27 (2 94 (7 66 (3 holes) to 107 (6 holes) 180 (10 25 (2 33 (3 156 (5
holes) to 390 (24 holes) holes) to holes) to holes) to holes) to holes) to 287 (16 holes) to 323 (18 holes) to 324 holes) to holes) to holes) to
194 (16 423 (26 370 (22 199 (10 287 (22 289 (22 holes) (18 holes) 145 (12 141 (12 179 (13
holes) holes) holes) holes) holes) holes) holes) holes) holes)
Horizontal bar — — — — 3 holes — — — — — — — 7 holes
(‘head’
section)
Plate angle Straight Straight Straight 95° Straight Straight Straight Straight Straight straight Straight Straight Curved
Angled portion — — — barrel — — — — — — — — —
25 mm long
Screw size 3.5, 4.0 CS 4.5, 5.5/6.5 CS 4.5, 5.5/6.5 4.5, 5.5/6.5 4.5, 5.5 3.5, 4.0 CS 3.5, 4.0 CS 4.5, 5.5/6.5 CS 4.5, 5.5/6.5 4.5, 5.5/6.5 3.5 CS 2.7, 3.55 4.5,
(mm) CS CS 5.0 LHS 3.5 LHS 3.5 LHS 5.0 LHS CS CS CS 5.0 LHS
4.0/5.0 LHS 4.0/5.0 LHS 3.5 LHS
Hole Straight Straight Staggered Staggered Straight Straight Straight Straight Staggered Staggered Straight Straight Straight
arrangement
Hole spacing 12 16 16 16 18 13 13 18 18 18 12 12 20
Hole design DCP DCP DCP 2 Round Combi Combi Combi Combi hole Combi hole Combi hole Oval w/ Round w/ Combi
rest DCP hole hole hole collar collar LHS Hole
Plate Yes Yes Yes No No Yes Yes Yes Yes Yes Yes Yes No
mid-section
Hole-spacing 16 25 25 — — LO–LO LO–LO LO–LO 13 LO–LO 13 LO–LO 13 16 16 —
in plate 9.4 9.4 DCU–DCU 20 DCU– DCU–
mid-section DCU– DCU– DCU 20 DCU 20
DCU 15 DCU 15
DCP: dynamic compression plate; DCS: dynamic condylar screw; DCU: dynamic compression unit; LCP: locking compression plate; LHS: locking head screws; LO: locking.
Source: From Auer [4].
c08.indd 168 12/17/2021 12:25:59 AM

Plate 169
centre of the oval screw hole. Thus, when the screw ‘moves’
towards the fracture line, the bone in which it is inserted
follows, resulting in axial compression of the fracture. The
centre of the plate should be located over the fracture site, Figure 8.20 A 10-hole veterinary LCP. The plate has a rounded
and offset drilling can be carried out on either side of the end containing a stacked combi hole through which either a
LHS or a cortex screw can be inserted. The other end has a
fracture. Two screws on either side of the fracture can be tapered pointed tip to facilitate minimal invasive plate insertion.
compressed using the plate holes alone, thus providing a The threaded parts of the combi holes are oriented towards the
maximum of 4 mm compression. Prior to tightening the centre, and the DCU parts of the combi holes are positioned
second screw, the first screw on the same side of the frac- towards each end of the plate. The stacked combi hole contains
a LHS with star drive pattern; a cortex screw with a hexagonal
ture plane has to be loosened to achieve the additional socket is inserted into the DCU portion of the adjacent combi
1 mm compression. Following tightening, the loosened hole. Source: Courtesy DePuy Synthes Vet, West Chester, PA.
screw is tightened again. Closure and compression of frac-
ture gaps >4 mm requires use of the tension device.
Locking Compression Plates

The 4.5 and 3.5 mm LCPs are manufactured from the same
plate stock and have similarly arranged holes as corre-
sponding narrow and broad DCPs [14, 18, 19]. The plates
are equipped with combination (‘combi’) holes, which con-
sist of a threaded part for LHS and a dynamic compression
unit (DCU) for cortex screws: the threaded part on the side
towards the centre of the plate and the DCU portion
towards the ends of the plate (Figure 8.20). One end of the
plate is tapered and pointed for minimally invasive plate
insertion; the other end has a rounded, slightly tapered
shape that contains a stacked combi hole through which
either a LHS or a cortex screw can be inserted (Figures 8.20
and 8.21). LHS must be inserted perpendicular to the plate;
limited angling is possible with cortex screws. A special
5.5 mm LCP was developed exclusively for use in horses
and is manufactured out of dynamic condylar screw (DCS)
(see Section “Dynamic Condylar Screw And Dynamic Hip
Screw Implant Systems”) plate stock. It has a width of
17.5 mm, a thickness of 6 mm and the holes are staggered.
An experimental study using an artificial bone compos-
ite compared the DCP, LC-DCP, LCP and the clamp-rod
internal fixator (CRIF) in torsion and bending (the LC-
DCP has now been abandoned and the CRIF is not used in
horses because of its bulky size and inferior holding prop-
erties). The LCP was significantly stiffer than the other Figure 8.21 Polyurethane specimen of an equine radius with
an oblique mid-shaft fracture repaired with a cranially applied
implants which was attributed mainly to the locking head human 16-hole LCP and a laterally applied human 16-hole
technology preventing movement of the screw heads femoral LCP. Note that the slight bend along the lateral plate
within the plate holes [20]. allows it to be applied along the entire bone.
plate length [4]. Long plates reduce the pull-out forces act-
Principles of Plate Fixation
ing on individual screws as a result of an increased work-
In small animals and humans, guidelines for plate span ing leverage. Shorter plates can be used but ideally are
width, i.e. length of plate in relation to overall fracture staggered to ensure that both plates together cover the
length, have been adopted. This quotient should be >2–3 in entire length of the bone. In human and small-animal sur-
multifragment fractures and >8–10 in simple fractures [21]. gery, shorter plates are usually used, but a minimum of
In horses, plates usually span the entire bone to maximize three bicortical screws (six cortices) should be engaged on
either side of the fracture [22]. At least four screws are pre- between the plate and the bone [26]. Luting is done after all
ferred for long bone fractures in horses, but because plates screws in the plate have been inserted. In double plaiting
usually span the entire bone and all plate holes are filled techniques, the screws of one plate are loosened, the plate is
with screws, this minimum is usually fulfilled. lifted off the bone, and PMMA in a doughy consistency is
When possible, screws should be inserted perpendicular placed between the bone and plate. All the screws are then
to the surface of the bone. If a second plate is used, it immediately retightened using power equipment. Penetration
should be placed, whenever possible, at a right angle to the of bone cement into the fracture line must be avoided
first and positioned such that the screw holes are located because it prevents bony union. Excess soft cement is
between the screws of the other plate to reduce the likeli- removed, and the procedure is repeated with the second
hood of inadvertent contact between the screws of the two plate. To ensure effective local tissue concentrations of
plates [5, 23, 24]. Every hole in a plate should be filled with antimicrobials, selected drugs may be incorporated into the
a screw [5]. If a hole traverses a fracture line, lag technique PMMA. The hardening process of the PMMA is exother-
should be applied by overdrilling the cis-cortex, to place a mic, requiring cooling of the bone and metal with sterile
screw that engages the opposite cortex at least 5 mm distant saline solution. The soft cement also enters the oval hole of
to the fracture. Where no support can be achieved in a cor- the DCP and provides additional support to the screw head,
tex, polymethyl methacrylate (PMMA) bone cement may making the fixation extremely rigid. Plate luting increased
be placed into the gap or the medullary cavity and the stress protection on intact equine cadaver MCIII or
screw implanted: after the cement hardens, the screw will MTIII [27]. A subsequent study in which only the plate
be solidly fixed. However, this technique is only applied holes were filled with PMMA demonstrated a similar
when additional screw holding power is urgently needed increase in stress protection [28], suggesting that the main
because PMMA within the medullary cavity or in a bone effect of plate luting is additional stability to the screw
defect prevents bone healing at that site. heads by filling the plate hole around them rather than
Insertion of 4.5 mm cortex screws through DCPs allows enhancing plate–bone contact. Plate luting is not used in
25° longitudinal and 7° lateral angulation, while 4.5/5.0 mm humans and small animals because of the danger of pro-
LCPs allow 40° of longitudinal and 7° of lateral angula- ducing bone avascularity under the plate, resulting in path-
tion [4, 25]. Insertion of a 5.5 mm cortex screw through the ologic fracture following implant removal [29]. While these
same hole allows approximately 25° of longitudinal and 5° complications have not been encountered in horses, the
of side-to-side angulation in these plates. introduction of LCPs has largely made the technique
Plates have to be contoured to fit the surface of the bone. redundant.
For large plates, the bending press is preferred overbending
irons. If the plate is perfectly contoured to the bone surface,
Plate Functions and Applications
only the near cortex will be under compression; the far cor-
tex will be distracted. Plates are therefore slightly over bent, Neutralization Plates
to leave an approximately 1mm gap between the plate and A neutralization plate is applied after fracture reconstruc-
the bone at the fracture site, which places the far cortex tion and compression with strategically placed cortex
under compression as well. screws inserted in lag fashion. They are used when fracture
In oblique fractures, ideally, the most distal end of the configurations are judged unable to withstand significant
proximal fragment should be wedged between the plate loading forces, for example during recovery from anaesthe-
and the opposing distal fragment. Plate location is there- sia. They aim to neutralize the potential diverging shear,
fore not only determined by application to the tension side bending and rotational torque forces by effectively bridging
of a bone but also by fracture configuration [3]. Surgical the entire long bone. It is important to plan the whole con-
approaches should avoid severely bruised skin or discrete struct ahead of time to prevent interference of screws that
defects. Whenever possible, plates should not be positioned may be applied in various planes across the bone with the
at sites where the bone is immediately underneath the eventual plate screws. To enhance the strength of the fixa-
skin: although application is easier, the risk of surgical site tion, usually two plates are applied over the entire length of
infection is substantially higher. the bone.
Stability of fixation with DCPs is derived from friction
between the plate and the bone, which in turn is propor- Compression Plate
tional to the amount of contact. This is achieved primarily A compression plate is used in long bone fractures when
by accurately bending and contouring plates but can be interfragmentary compression is required. The fracture is
enhanced by plate luting, which aims to produce 100% reduced, possibly with screws inserted in lag technique or
plate–bone contact, through interfacing bone cement by simply aligning fragments and securing them with
Plate 171
pointed reduction forceps. Axial compression is achieved the screw initially inserted on that half of the bone has to
either with the dynamic compression design of the plate be slightly loosened to allow motion of the plate relative
hole(s) or with the tension device. Most plates used in long to the bone as the additional compression is applied. The
bone fractures in horses are applied as compression plates. remaining screws are then inserted in neutral positions
throughout the plate.
Buttress Plates The screws in a DCP may be applied either in neutral,
If a cortical defect persists after fracture reduction, it cre- load or buttress positions. To create a hole in load position,
ates a region of mechanical weakness; a buttress plate the arrow on the yellow drill guide points towards the frac-
bridges such a defect to prevent collapse. Compression ture line. This results in 1 mm of compression. If the arrow
cannot be applied because this would promote collapse, points away from the fracture line, the screw is placed in
result in an altered bone axis and likely alter alignment of buttress position and does not provide fracture compres-
associated joints. Screws through the bridging plate are sion. The green drill guide creates a centrally located (neu-
therefore either placed in neutral or in buttress positions. tral) hole. In double plating, only two screws are placed in
In the latter, the screw head is eccentrically located in the load positions in the second plate.
end of the plate hole close to the fracture, thus resisting
compression. This prevents collapse of the bone and main-
Application of a Locking Compression Plate
tains its axis while healing occurs. The cortical defect
should be filled with a cancellous bone graft or a bone sub- The LCP was developed to include the axial loading capa-
stitute. To maximize stability, screws placed through the bilities of the DCP, the decreased plate–bone contact of the
plate in the region of the defect should engage the opposite LC-DCP and the rigidity and stiffness of the Less Invasive
cortex. All the other principles of fixation remain. Stabilization System (LISS), where LHS were first used [15,
16]. The goals were met by designing a dual purpose
(combi) hole into which either standard or LHS can be
Application of a Dynamic Compression Plate
inserted, i.e. it is not necessary to use only the latter. LHS
The technique is illustrated in Figure 8.22 using a LCP are substantially more expensive, but by substituting cortex
(which is presently the plate of choice) with the same screws through some holes, costs can be significantly
technique. After a fracture is reduced, and in some cases decreased without jeopardizing the stability and stiffness
repaired by means of 3.5 or 4.5 mm cortex screws in lag of the construct. Without use of the push–pull device or
fashion, the plate is contoured and then attached to the cortex screws, which will press the plate onto the surface of
bone with screws. The first screw hole is drilled towards the bone, there will be a gap of 2 mm between the LCP and
the end of the plate in neutral position with either the the bone after its application. At the onset of LCP applica-
universal drill guide without pressing it down or the tion, it must therefore be decided whether the plate need to
green DCP drill guide. The screw is inserted but not com- be in close contact with the bone. In almost all equine situ-
pletely tightened. This allows displacement of the plate to ations, it is desirable to have bone–plate contact to increase
a loaded position. The same effect can be achieved by ini- friction and thus stability. However, bending LCPs more
tially drilling the hole using the load (yellow) DCP guide than 5° at a locking hole results in significant weakening of
and maintaining the plate in the same position. To create LHS [30]. It is therefore preferable to bend LCPs between
compression, a hole for the second screw is drilled on the two combi holes, tending somewhat towards the axial com-
other side of the fracture, again towards the end of the pression part of the hole.
plate, using the load drill guide. Care is taken to ensure The plate is positioned with the plate holder and the
correct plate position and alignment along its entire push–pull device inserted through the DCU portion of the
length prior to drilling the second hole. Especially, when combi hole (Figure 8.23a). By turning the piston in the
long plates are used, inserting the first screws towards clockwise direction, the plate can be pressed onto the bone
each end of the plate ensures that the entire plate is posi- surface. If desired, a second such device can also be applied
tioned along the bone surface. If the initial screws are through the stacked combi hole at the other end of the
placed near the centre of the plate, only a minor abaxial plate. Next, all the strategic cortex screws are inserted near
placement of the plate may result in its ends being located the ends of the plate with an additional one near the mid-
off the bone. The hole is prepared, tapped and the screw dle and tightened to ensure a solid bone–plate contact. The
inserted. Interfragmentary compression is achieved through push–pull device and the plate holder are removed, and if
alternately tightening the two screws. One additional a second plate is being applied this is positioned and
screw may be applied in load position on either side of the secured in a similar manner (Figure 8.23b). The locations
fracture line. If an additional screw is placed under load, where LHS will be implanted are selected to avoid contact
(a) (b) (c)
Fracture Stabilized
reduction fracture
forceps
3.5 mm cortex
screws placed
in lag position
2.5 mm drill bit
(d) (e) (f)
(g) (h)
Figure 8.22 Repair of a simple oblique fracture of the third metacarpal bone with two 3.5 mm cortex screws applied in lag technique
combined with a broad LCP as a compression plate using only cortex screws. (a) Large pointed reduction forceps maintain alignment
during implantation of the two 3.5 mm cortex screws. (b) When the screws have been inserted, the reduction forceps are removed. (c) A
10-hole broad LCP is applied to the dorsolateral aspect of the bone. The plate was overbent at the fracture site, allowing introduction
of an aluminium template between the bone and the plate. (d) A thread hole is drilled across the bone through the second most distal
plate hole using the universal drill guide in neutral position (drill sleeve not pressed down). (e) A cortex screw of predetermined
length is inserted but not completely tightened, followed by preparation of a hole in load position (drill sleeve pressed down) at the
opposite end of the plate. (f) The second screw is inserted and both are alternately tightened, placing the fracture under axial
compression. One additional screw is inserted in each major fragment in neutral position and tightened. (g) A cortex screw is
implanted in lag fashion across the fracture plane. (h) The remaining screw holes are prepared through the universal drill guide in
neutral position. All screws are inserted and tightened again.
Plate 173
with interfragmentary screws. The drill sleeves are then because the distance between two adjacent DCP holes and
inserted, the holes drilled and the screws implanted the combi holes is different. Once locking screws are
(Figure 8.23c–e). Pre-planned screw/plate positions are inserted, the plate is solidly fixed in position.
critical with LCPs because the LHS must be inserted per- The LHS drill guide is carefully twisted into the threaded
pendicular to the plate. Surgeons should also be cognisant part of the combi hole (see Section “Drill Guides For
that screw positions differ if a LHS or a cortex screw is used Locking Head Screws”), and when solidly seated, its posi-
through a combi hole. This situation is exacerbated if a tion relative to the plate is re-evaluated to ensure perpen-
DCS plate with mainly DCP holes and a LCP are combined dicular orientation. All the LCP drill guides provided in the
(a) (b) (c)
(d) (e) (f)
Figure 8.23 Application of two LCPs to an oblique mid-shaft third metacarpal fracture. (a) The fracture is reduced and stabilized by
the two 3.5 mm cortex screws applied in lag fashion. A 10-hole broad LCP is applied to the bone with the plate holder and temporarily
fixed in place with the push–pull device. By turning the piston clockwise (arrow), the plate is pressed onto the bone surface. (b) To
facilitate good plate–bone contact along the entire plate, cortex screws are implanted and tightened using the plate screw technique
at both ends and in the centre near the fracture. A lateral 11-hole narrow LCP is applied to the bone using the same technique. Note
that the plate can be applied farther distad on the lateral aspect of the bone than on the dorsal aspect. (c) The holes where LHS are
to be inserted are selected, and the drill guide is twisted into the threaded portion of the combi hole. Because the plate is solidly
fixed to the bone, all four drill guides provided in the set are applied and the holes drilled. (d) LHS are inserted and tightened. The
four drill sleeves for the LHS are then placed into selected holes in the lateral plate, making sure that screws can be placed
perpendicularly without interfering with previously inserted implants. (e and f) All the remaining plate holes are filled with cortex
screws inserted using the plate screw technique, but where indicated lag technique is applied to increase interfragmentary
compression.
set can be fixed to the plates, and all the holes drilled to
speed up the procedure (Figure 8.23c). The drill guides are
removed, and using the depth gauge screw sizes are deter-
mined. The 4 N torque-limiting device is attached to the
power drill followed by the insertion of the power attach-
ment of the star drive. By pressing the screwdriver into the
star drive indentation of the LCP screw in the rack, the
screw is selected and advanced into the predrilled hole
using power-tapping technique. The torque-limiting device
idles when the 4 N insertion force is reached. Although use
of the torque-limiting device is encouraged, equine bone is
hard and, particularly with long screws, the 4 N threshold
may be reached before complete engagement of the screw
head threads in the plate. It is therefore prudent and good
technique to undertake final tightening with the hand
screwdriver. Once all required LHS are implanted, any
empty plate holes can be filled with cortex screws through
the DCU portion of the combi hole using angles necessary
to avoid contact with screws in the other plate.
The LCP is now the preferred plate for equine fracture
fixation despite its higher costs, which mainly results from
the screws [31]. However, its versatility is such that if
finances are constrained it can still be employed using only
cortex screws. A recent study comparing 4.5 mm LCPs with
4.5 mm LC-DCPs confirmed the superior strength and stiff- Figure 8.24 A six-hole equine T-plate with a stacked combi
ness of the LCP [32]. A 5.5 mm LCP, designed for equine hole at the distal end and three stacked combi holes in the
fracture repair, has been developed to replace the 5.5 mm horizontal bar.
the LC-DCP.
Screws of up to 50 mm can be inserted in the horizontal bar
without risking impingement of the screw tips. The plate is
Human Femoral Locking Compression Plates
available either with 4, 6, 8 or 10 holes in the vertical bar.
The equine radius has a slight craniocaudal curvature. It is These plates are suited to areas, which are mainly under
therefore not possible to apply a straight plate to its lateral tension, without bending, when there is insufficient space
aspect and span the length of the entire bone, either the for application of a regular straight plate. A (7 + 3)-hole
middle holes are behind the bone or the proximal holes are human T-shaped narrow 4.5/5.0 mm LCP, the precursor of
in front of the bone. The human femoral LCP has a slight the new veterinary T-LCP, was successfully applied to a tar-
bend that matches the equine radius perfectly so that the sometatarsal subluxation [33]. The three stacked combi
ideal combination for a radial diaphyseal fracture is a holes in the horizontal bar of the human plate are directed
5.5/5.0 mm equine LCP applied cranially and a human distally at slightly converging directions compared with the
femoral LCP applied laterally (Figure 8.21) [4]. The veterinary plate, where they are directed at a 95° angle.
implants are available in stainless steel in all sizes. Veterinary T-LCPs have been used, with encouraging
Guidelines for application are as described for the LCP results, for arthrodeses of the tarsometatarsal and distal
(Section “Application of a Locking Compression Plate”). intertarsal joints, partial carpal arthrodeses and step oste-
otomies in MTIII (F. Rossignol, Personal communication,
2017).
Veterinary T-LCP
A new 4.5 mm LCP T-plate (T-LCP) has been developed by
Human Distal Femoral Locking Compression
DePuy Synthes in conjunction with the Large Animal
Plates
Veterinary Expert Group of AOVET. This is thicker than
the original T-plate developed by the AO Foundation and The DFP represents another human implant that has
accepts either cortex or LHS (Figure 8.24) [4]. Three slightly recently been applied in equine fractures. It is a forged, pre-
converging plate holes are arranged in the horizontal bar. shaped, very strong LCP that contains seven stacked combi
Plate 175
Figure 8.26 An eight-hole UniLOCK plate that was cut to size,

with 2.4 mm (top left) and 3.0 mm (top right) UniLOCK screws.
broad 4.5/5.0 mm or a 5.5/5.0 mm LCP is recommended for

greater stability.
Compact 2.4 UniLOCK System

As the name suggests, the UniLOCK system is a member
of the locking plate group. It consists of a flat plate and
screw head surface, which is well suited for reconstruction
of craniomaxillofacial fractures [4]. Either 2.4 mm cortex
or 3.0 or 2.4 mm LHS can be inserted in all holes
(Figure 8.26). The plates are provided in three lengths: the
160 mm (20 holes) straight plate is well suited for equine
Figure 8.25 Front view of a right-sided human distal femoral craniomaxillofacial surgery (Chapter 36). The plates are
LCP. Three small holes allow the insertion of 2.5-mm K-wires to
temporarily attach the plate to the bone, and three indentations readily cut to the required length. The slots on both edges
around the stacked combi hole in the centre of the plate head and the thinner connection between the plate holes per-
allow connection to an application jig. mit access for the specifically designed plate cutter. Prior
to bending the plate, so-called bending screws are inserted
and tightened into the plate holes where the bending
holes in the head of the plate (Figure 8.25) [4]. The shaft is occurs. The remaining application follows the technique
available in several lengths. There are three indentations described for the LCP (see Section “Application of a
arranged around the centre, stacked combi hole in the plate Locking Compression Plate”).
head that allow fixation of an application jig. Additionally,
it is possible to attach it temporarily to the bone through
Variable-angle Locking Compression Plates
2.5 mm K-wires, for which three holes are prepared. One of
these holes also contains an indentation [4]. Two specific Because of the disadvantages posed by the need for LHS to
plate designs are available, conforming to right and left be inserted perpendicular to the long axis of the plate,
femurs. Because the plates contain a slight bend, the correct attempts were made to develop a locking mechanism that
plate shape has to be selected for the fracture at hand. The allows various angles of screw insertion. Accordingly, the
shape is suited to a number of different equine locations VA-LCP was created. Screws can be angled anywhere
and can be used instead of a DCS plate when a relatively within a 30° cone around the central axis of the plate hole.
small fragment must be fixed to the main portion of a long The plate hole has a cloverleaf shape containing four
bone, such as fracture of the supraglenoid tubercle of the threaded ridges, where the specially constructed screw
scapula. Application follows the technique described for head can interlock with the plate. The head of the variable-
the LCP with the difference that several diverging LHS can angle locking screw is rounded to facilitate various angles
be inserted in the clover-shaped head of the plate. The abil- within the locking hole. A special double-drill guide allows
ity to insert multiple LHS at predetermined, diverging drilling of the variable-angle screw holes on one side and
angles into the smaller fragment represents a major advan- fixed-angle drilling on the other. The nozzle of the drill
tage and results in superior strength of the repair [4]. If guide inserts coaxially into the central hole. In contrast to
used in long bones, combination with either a standard standard drill guides that support the drill bit along its
entire length, the funnel shape of the angled guide allows and an 8 mm shaft diameter. The shaft is flattened on
the drill bit to glide along the guide wall at a 30° angle in two opposing sides to prevent rotation when introduced
any selected direction. The design was first implemented in into the barrel of the plate, which contains complemen-
the 2.4 mm variable-angle LCP distal radius system for tary cross-sectional geometry. The lag screw is inserted
humans, which is anatomically contoured to the volar at a predetermined angle of 95° for the DCS plate
aspect of the distal radius. If it proves advantageous in (Figure 8.28) and 135° (standard) for the DHS plate.
human surgery, it will hopefully be applied to other locking Application of these systems is much easier than the
plates [4]. ABP. The hole for the screw shaft and plate barrel and
countersinking for the barrel–plate junction are pre-
pared with a triple reamer, and after tapping the threads
Limited Contact Dynamic Compression Plates
for the DCS the plate is applied (Figure 8.29).
In humans and small animals, DCPs have resulted in avas- Aside from the 5.5 mm LCP, the DHS and DCS plates are
cularity underneath the plate, which occasionally culmi- the strongest plates in the DePuy Synthes system. They are
nated in pathologic fracture following implant removal. To versatile, rapidly implanted and can be useful in treating
counteract this, the LC-DCP contains undercuts in the sur- long bone fractures in adult horses [4, 37]. The DCS system
face adjacent to the bone thus reducing the contact area has been useful in metaphyseal fractures of MCIII or
between the bone and the plate, and studies in sheep have MTIII, proximal and distal radius, and femur. The DHS has
shown that these reduce vascular disturbance under the been applied in selected femoral fractures [38]. When com-
plate [34]. No such detrimental changes have been reported bined with 5.5 mm screws and occasionally plate luting,
in horses. The plates have some mechanical advantages [35, these plates produce extremely strong fixations. However,
36] but have been taken off the market. with the introduction of the LCPs their importance in
equine long bone fracture management has reduced. Some
DHS (but not the DCS) plates are available in LCP design.
Dynamic Condylar Screw and Dynamic Hip
The DCS is particularly useful in metaphyseal fractures,
Screw Implant Systems
where only a few screws can be secured in the smaller frag-
The DCS and dynamic hip screw (DHS) implant sys- ment. The most important step in the application of both
tems are further refinements of the angled blade plate systems is the correct placement of the 2.5 mm guide pin
(ABP). A special instrument set is needed for applica- (Figure 8.30a) [37]. Drill guides for the different angles
tion (Figure 8.27). The plates consist of a long lag screw ensure exact placement, which is verified with an image
with a 12.5 mm thread width, a 25 mm thread length intensifier or intraoperative radiographs. Once this is con-
firmed, subsequent steps are carried out swiftly because all
instruments contain a central canal to accept the guide pin.
The triple reamer is placed over the guide pin, to allow
drilling of the shaft hole for the large lag screw, drilling of
Figure 8.27 The instrument and implant set for the DHS
implant system. Top: implant set; bottom left: instrument set;
bottom right: screw set. Figure 8.28 Two DCS plates of different lengths.
Intramedullary Implant 177
(a) implantation, the DCS and plate are joined with the con-
necting screw, uniting the two components into one
(Figure 8.30f). Tightening of the connecting screw creates
interfragmentary compression, provided the DCS threads
have passed beyond the fracture line. Remaining screw
holes in the DCS plates are filled by 4.5 or 5.5 mm screws
either under load or in neutral positions. The two holes
adjacent to the DCS can only be placed in neutral
positions [37].
(b)
One-third Tubular Plates
These thin plates have limited application in horses. The
3.5 mm third tubular plate is most frequently used for fixa-
tion of proximal fractures of the second or fourth metacar-
pal/metatarsal bones [4], where they are ideal because they
are thin and, together with the 3.5 mm screws, provide
adequate fixation. A new one-third tubular plate (3.5 mm)
with round holes and a collar that accepts 3.5 mm LHS is a
valued addition for fractures, such as nondisplaced olecra-
non fractures in young foals (Figure 8.31) and MCIV and
MTII/MTIV fractures in adult horses. Application follows
the technique described for LCPs (Section “Application of
a Locking Compression Plate”).
Leg Lengthening Plates

Lengthening plates are manufactured from the same plate
stock as the broad 4.5 mm DCP. However, the plate holes are
round and the mid-portion of the plate is devoid of screw
holes [4]. If compression is required, it has to be applied with
Figure 8.29 DCS application to a distal radius specimen. the help of the tension device. This implant is available with
(a) The triple reamer is inserted; (b) the plate is applied. 8 or 10 holes, i.e. four or five holes each side, respectively.
The central portion without holes can measure from 30 to
the 12.5 mm hole for the plate barrel and to bevel the cone- 60 mm in the 8-hole plate and 50 to 120 mm in the 10-hole
shaped plate–barrel interface (Figure 8.30b). The threads plate each in 10 mm increments. They may be applied in
for the DCS are prepared using the corresponding tap pancarpal arthrodesis and other special indications [4].
(Figure 8.30c). The pre-selected and pre-bent plate is slid
along the screw insertion shaft, and a screw of appropriate
length is connected to the shaft by aligning slots in the Intramedullary Implants
screw end and corresponding lips in the shaft, followed by
tightly screwing the shaft tip into the DCS end (Figure 8.30d). Intramedullary (IM) implants have been used infrequently
Once the sleeve is attached over the screw, the screw is in large animals. There are few positive reports of diaphy-
inserted to lie about 5 mm below the bone surface. When seal fracture repair, but success has been reported in phy-
the shaft of the screw and the barrel are aligned, the barrel seal fractures including the femur, humerus, proximal tibia
slides easily over the shaft and the plate position can be and olecranon [38–44].
adjusted before impacting it onto the bone (Figure 8.30e).
The barrel has the same inside configuration as the screw
Steinmann Pins
shaft cross section (8 mm and flattened at two opposite
sides). This prevents screw rotation within the barrel after Steinmann pins are infrequently used in treating equine
the plate is attached to the bone, making loosening impos- fractures, principally because of their limitation in provid-
sible. The DCS plate has a barrel length of 25 mm. After ing stability. Insertion of multiple parallel pins across capital
(a) (b) (c)
(a′)
(d′) (c′)
(c′) (c′)
(b′) (b′)
(b′) (a′)
(a′)
(d) (e) (f)
(e′)
(c′)
(b′)
(d′)
(c′)
(b′) (a′)
(a′)
Figure 8.30 Application of a DCS plate to the distal radius. (a) In this example, the fracture is reduced, temporarily fixed with two
3.5 mm cortical screws placed in lag fashion across the fracture plane and a 14-hole broad LC-DCP is applied in compression to the
tension side of the bone. Using the 2.5 mm drill bit through the DCS angled guide (a′) before distal radial cortex is penetrated, prior to
insertion of the threaded 2.5 mm DCS/DHS guide wire (b′) through the predrilled hole and with the help of the DCS angled guide. The
DCS/DHS measuring device (c′) is placed over the guide wire; once the desired depth is reached, the penetration depth of the guide
wire determined (see inset: 70 mm). (b) The DCS triple reamer is assembled and set for the desired drilling depth (see inset: 65 mm),
which is 5 mm less than the penetration depth of the guide wire and ensures the latter’s firm seating in the bone during the entire
procedure. The triple reamer is placed over the guide wire (a′), and the shaft hole for the screw (b′), the barrel hole for the plate (c′)
and the bevelled contour for the barrel–plate junction (d′) are prepared. (c) The DCS/DHS centring sleeve (c′) is mounted over the
DCS/DHS tap (b′) which is then placed over the guide wire (a′) and slid into the barrel hole of the same diameter, which facilitates
seating of the centring sleeve in the barrel hole. The shaft hole is tapped to the desired depth (see inset: to a depth of 65 mm). (d) The
DCS/DHS coupling screw is inserted into the wrench (d′) and the DCS plate (e′) of the desired length (12-hole plate) slid over the
wrench, prior to connecting the 60 mm DCS/DHS screw (b′) to the coupling screw. After mounting the centring sleeve (c′) over the
wrench, the entire assembly is placed over the guide wire (a′) and the screw inserted into the bone to the desired depth of 65 mm (see
inset: setting on the wrench: 5 mm). (e) After tightening the DCS/DHS screw and adjusting the horizontal bar of the wrench (c′)
parallel to the long axis of DCS plate (b′), the plate is seated over the DCS/DHS screw with the help of the DCS/DHS impactor (a′) and
a mallet (not shown). Orientation of the instruments and implants is important because the DCS/DHS screw (left inset) and the plate
barrel (right inset) contain identical parallel contours, which have to be aligned to allow sliding of the barrel over the screw shaft.
(f) The DCS/DHS compression screw is inserted through the barrel and tightened into the DCS/DHS screw. Insertion of the remaining
screws and final tightening of all screws complete the procedure.
Intramedullary Implant 179
better than a single IM pin. In fractures with adequate

obliquity, the addition of a cerclage device will improve sta-
bility, but cerclage wiring in large animals is frequently
inadequate to provide stability.
SPF has been used successfully in the management of
short oblique and transverse fractures of the mid-humeral
diaphysis and femoral fractures in foals [4, 41]. As many
¼ in. (6.3 mm) Steinmann pins as possible are inserted;
usually four or five pins can be placed in a foal humerus or
femur. The space between the ¼ in. pins is then filled with
pins of smaller (such as 5/32 in./0.4 mm) diameter to maxi-
mize contact between the pins and the diaphyseal cortex.
IM pins are placed in normograde fashion. Some expo-
sure of the fracture is necessary to allow re-alignment and
temporary stabilization of the fragments with a bone clamp
or similar device. Adequate exposure of the proximal aspect
of the bone is also needed to allow pin placement. Driving
Figure 8.31 A nondisplaced ulna fracture in a young foal multiple IM pins, the length of the diaphysis can be difficult
repaired with an eight-hole third tubular plate. even with power equipment. Ideally, the medullary canal is
first reamed (Section “Interlocking Intramedullary Nails”)
femoral physeal fractures has produced some success [38, which simplifies placement and increases contact between
41]. Steinmann pins have also been used in combination pins and bone. After reaming via the fracture, fragments are
with tension band wires in the treatment of olecranon frac- aligned and stabilized with a bone clamp before commenc-
tures in very young foals [42–44] (Chapter 37) and in fixa- ing pin placement.
tion of proximal Salter–Harris type II fractures of the tibia SPF shares all of the complications associated with other
in which multiple pins were inserted transphyseally from forms of ORIF but, in addition, because of inherent insta-
the medial, cranial and lateral sides [40]. They are used in bility, implant migration is a major concern. With use of
external fixation device repair of mandibular fractures the limb, motion at the fracture site often initiates pin
(Chapter 36), and large diameter pins have also been used migration, which tends to be retrograde, particularly if
in transfixation casts (Chapter 13). there is axial collapse at the fracture site. As pins migrate,
stability is compromised, allowing more motion at the frac-
Stacked Pin Fixation ture site and perpetuating the cycle. Eventual success or
Stacked pin fixation (SPF) involves the introduction of mul- failure is a race between the increasing ability of the heal-
tiple pins parallel to each other to fill the entire medullary ing fracture to sustain the forces of weight-bearing and the
space throughout the narrowest portion of the diaphysis decreasing ability of the fixation to provide stability.
(the isthmus) of a long bone. This maximizes frictional Migrating pins can also penetrate the skin allowing envi-
forces between the implants and cortical bone. Studies per- ronmental contaminants to follow pin tracts, gaining
formed on transverse fractures in dog femurs showed that access to the medullary cavity and osteomyelitis may result.
SPF provided up to three times more rotational stability Instability, when complicated by infection, seriously com-
than a single IM pin [45, 46]. Axial and rotational stability promises the healing capacity of the affected bone, time to
are highly dependent on the location and configuration of union is prolonged and in some cases an infected non-
the fracture; although SPF increases resistance to torsional union results.
forces, significant rotational instability remains. Transverse
and short oblique fractures in the mid-diaphysis are best
Rush Pins
suited to SPF. Fractures in this location provide maximal
contact between the implants and endosteal cortex of the Rush pins have a slight even curve along their length with
bony cylinder on either side of the fracture. When the med- a one-sided bevelled tip on the concave side. The opposite
ullary canal is filled by the implants, translation, telescop- end is bent back to produce a notch. The pins are intro-
ing and overriding of the fracture fragments is prevented. duced obliquely into the distal fragment and advanced
Although rotational stability relies heavily on fracture inter- towards the opposite cortex. The tip slides off the opposite
digitation, friction between the medullary cortical bone and cortex and is redirected towards the cis-cortex. The pin
stacked IM pins will resist rotational forces significantly length has to allow the tips to engage in the cis-cortex both
proximal and distal to the fracture to provide three- or of fluoroscopy and sophisticated targeting devices to inter-
four-point contact. Usually, two pins are introduced, one lock the distal fragment.
from each side of the bone. With correct insertion, there is Interlocking the intramedullary device to the major
good rotational stability with a minimum of implants and proximal and distal bone cylinders provides a static form of
surgical trauma. Correct use is an ‘art’ [47] and was popu- fracture fixation, which resists compressive and rotational
lar before bone plates were developed. It is now rarely forces and provides bending stability. Fixation positioned
practised and is not applicable to multifragment or open near the centre of the bone, close to the neutral axis of the
fractures. diaphysis, imparts a significant mechanical advantage over
plate fixation, particularly when the bony cylinder cannot
be reconstructed. In vitro tests using a multifragment sub-
Interlocking Intramedullary Nails
trochanteric femoral fracture model showed that in com-
Intramedullary nails may have a place in equine long bone bined bending and compression, IIN supported the highest
fracture repair, but the ideal implant has not yet been loads to failure [60]. IIN constructs rely less on the recon-
developed [4]. Initial use of hollow intramedullary nails structed fracture to bear the forces of weight-bearing. This
manufactured for human application had limited suc- reduces the necessity for accurate anatomic reduction and
cess [48]. Use of a solid titanium interlocking nail was rigid fixation of all fracture fragments, which are recom-
reported in treating comminuted fractures of the third met- mended for most forms of plate fixation [60].
acarpal bone and for arthrodesis of the metacarpophalan- IIN systems for large-animal fracture fixation are not
geal joint [49, 50]. However, introduction of the nail widely available. Implants used in human orthopaedics are
through the third carpal bone is undesirable and more bio- for the most part slotted, tubular designs, which compro-
mechanically logical plating techniques are now available. mise the strength of the fixation. Evaluation of an IIN
A system of intramedullary interlocking nails (IINs) has designed for use in the human tibia found that the yield
been developed at Texas A&M University for equine humeral torque for constructs was less than that associated with
(Figures 27.17 and 27.18) and femoral (Figures 32.9 and strains measured in vivo in the tibia of the horse at the
32.10) fractures [51, 52]. In experimental studies, compari- walk [57]. The slotted design of human nails reduces stiff-
sons of INNs and plating techniques have produced mixed ness and results in a drop in the torsional moment of iner-
results [53–57]. tia to approximately 1/50th of a non-slotted nail of equal
Transfixation of the major proximal and distal bone frag- dimension and wall thickness [61]. The slot also has to be
ments to an intramedullary rod was first described by oriented towards the tension surface of the bone to achieve
Küntscher, which he termed the ‘detensor nail’ [58]. maximal bending stiffness. If oriented in another direction,
Modifications by Klemm and Schellmann were later incor- bending forces are likely to cause buckling of the nail.
porated, and the device was renamed the intramedullary The equine IIN for use in the humerus and femur of
interlocking nail (IIN) [59]. In human orthopaedics, IIN foals [51, 52] is manufactured from one-half inch diameter,
fixation is recommended for a variety of complex fractures implant grade, 316L stainless-steel rod. Holes for interlock-
of the femur and is also used in tibial fractures [59]. In ing accept 5.5 mm cortex screws and are positioned
most human fractures, it is accomplished using closed throughout the length of the nail to allow use of multiple
techniques, which provide excellent stability at the fracture transcortical bone screws to engage the major fracture frag-
site, with minimal operative trauma to the overlying soft ments. Screw holes are targeted with a jig, which accepts
tissues, and provides a biological and mechanical environ- drill guides and other instrumentation for hole prepara-
ment that supports fracture healing and allows early mobi- tion. The rigid nature of the nail allows use of an attached
lization of the limb. Many of the complications associated targeting device for locating screw holes.
with open reduction and plate fixation are avoided. Techniques for fracture fixation using the IIN system are
Intramedullary nailing in people usually utilizes a similar to SPF. Initially, the fracture is exposed and
slightly flexible nail passed normograde down the pre- debrided. The medullary canal proximal and distal to the
reamed medulla, although IINs have recently been intro- fracture is reamed. In most instances, the distal bone cyl-
duced which eliminate the need for prior reaming. Once in inder is reamed retrograde, commencing from the fracture
the medulla, interlocking is accomplished in the proximal and advancing distally. Rigid medullary reamers of
fragment using a targeting jig attached to the nail, which increasing size are used to reach a final diameter of 13 mm.
positions the cortical drill hole to coincide with a prefabri- The proximal bone cylinder is usually reamed in normo-
cated hole in the nail through which an appropriately sized grade fashion, beginning from the proximal end of the
screw is placed. The slightly flexible nail, while allowing it bone and progressing to the fracture site. The fracture is
to fit the contour of the medullary cavity, requires the use then reduced and temporarily stabilized using a bone
Reduction Device 181
clamp. An appropriate length nail is chosen and, with the fractures of the proximal sesamoid bones and/or rupture of
targeting jig attached, passed into the reamed medullary the suspensory apparatus ([66], Chapter 20).
canal. Screw holes are drilled and interlocked. If possible,
at least three, 5.5 mm cortex screws are interlocked on
Cables
both sides of the fracture. This is described as an IIN-3/3
construct, delineating the number of interlocking screws Originally, cables were manufactured from multiple, braided
proximal and distal to the fracture. The distance between 316L stainless-steel wires. Cable has much higher static and
the two screws nearest the fracture should be as short as fatigue loading resistance compared to monofilament wire.
possible. Fractures with significant obliquity are afforded The static strength of the Synthes 1.0 mm steel cable is 1200 N
additional stability by placing one or two interlocking and that of 1.7 mm diameter cable 2770 N compared to cer-
screws across the fracture in lag fashion. If this is not fea- clage wire at 250 N. Cable also has only about 10% of load-
sible, then some form of cerclage fixation is advised. induced elongation compared to monofilament wire [67].
Washers are recommended to prevent the conical head of Tightening of cable constructs is performed with a special
the interlocking screws penetrating the cortical bone. tensioning device and is maintained by application of a crimp
Fractures located near the epiphysis are less readily sta- clamp. It is recommended that tension should not exceed
bilized using IIN fixation, and the epiphyseal segment is at 50 kg as this may cause the cable to cut through soft or osteo-
an increased risk of secondary fracture through the inter- paenic bone (which is not a problem in horses). Although to
locking screw holes. In these instances, some form of sup- date cables have been used infrequently in equine fracture
plemental fixation is desirable: a LCP applied to the cranial repair, their favourable mechanical properties suggest that
cortex at approximately 90° to the interlocking screws is they may be well suited to further applications.
the preferred technique. Bicortical screws are positioned Ultra-high-molecular-weight polyethylene (UHMWPE)
through the plate when possible, but in the diaphysis, the 16-gauge cable has been tested in an in vitro model for the
presence of the IIN necessitates that some screws are repair of proximal sesamoid bone fractures and compared
monocortical. Because of the close proximity of the IIN with 16-gauge monofilament stainless-steel cerclage wire
and plate, these will need to be 4.5 mm screws, as the short- (SSCW) [68]. The ultimate tensile strength of UHMWPE
est available 5.5 mm screw is too long. cable constructs was 34% greater than that of SSCW con-
structs. Fatigue strength was 2–20 times greater for UHMWPE
than for SSCW constructs. Separation of fragments was also
153% less for cable constructs compared with those repaired
Wire and Cable
by wire using a transfixed cerclage technique. These cables
may also be beneficial as a palmar figure-of-eight tension
Orthopaedic (Cerclage) Wire
band in metacarpophalangeal arthrodesis following suspen-
Orthopaedic, marketed as cerclage, wires are manufac- sory apparatus breakdown (Chapter 20).
tured from extruded, unworked steel whose macrocrystal-
line structure makes it very malleable [9]. Wire used in
horses is usually of heavy gauge (generally 0.8–1.5 mm) R
eduction Devices
material. Various tensioning pliers and devices are availa-
ble to apply, tighten and twist wires. Tightening the wire The simplest reduction device is the Hohmann retractor,
ends is a critical part of the application technique. It is which has multiple variations. After tenting fragment ends
important to evenly twist both ends around each other. For out of the fracture bed and re-aligning them, a Hohmann
that purpose, the wire ends are held in the pair of pliers, retractor can be introduced into the fracture to maintain
pulled up and subsequently while releasing the tension the reduction as the bone is pushed back into the wound in a
ends are twisted. One wire twisted around the other risks controlled manner.
the straight wire backing out of the twists of the other. Traction can be applied to limbs by a variety of devices includ-
Wires are relatively frequently employed in human and ing overhead hoists, pulley systems and foetal distractors (calf
small-animal fracture repair [62, 63] but are less commonly pullers). Their goal is to gradually fatigue contracted muscles to
used in horses. Cerclage wire has been successfully used in permit reduction of overriding fragments.
for the treatment of proximal sesamoid fractures ([64];
Chapter 20) and to create a tension band in ulnar fractures
Fragment Distractor
in foals ([65], Chapters 26 and 37). Wire is also used to pro-
vide palmar tension support to metacarpophalangeal The fragment distractor consists of an L-shaped bar that is
arthrodesis following breakdown injuries caused by bilateral threaded along its long arm (Figure 8.32). The short arm of
threaded ring is located on either side of the bar. Different

sizes of drill bits and bolts complete the fragment
distractor.
A
iming Devices
The C-clamp was the first aiming device available for

equine fracture treatment. This was taken from the human
set and employed for many years, particularly in repair of
distal phalanx fractures. However, it was easy to dislodge
and was eventually abandoned.
Another aiming device was developed for the manage-
Figure 8.32 The large fragment distractor set consists of, from
top to bottom, the assembled distractor with the two guide
ment of transverse proximal sesamoid fractures. There
sleeves for Schanz screws that are temporarily implanted into were two clamps, one for medial and the other for lateral
the fragments to be distracted, a socket wrench, two different proximal sesamoid bones. The anatomic situation and
diameter Schanz screws, a double trocar assembly for blunt apical tip meant that these were difficult to use reli-
transcutaneous insertion of the Schanz screws and a pin wrench
to move the spindle carriage in the desired direction along the
ably and they were taken out of production.
threaded arm.
Equine Aiming Device
the bar contains a drill guide whose direction can be
adjusted as needed, and once the direction is selected it can The current equine aiming device is a modular system of
be fixed solidly. Along the long arm of the bar, a short different arms that can be adapted to individual anatomi-
adjustable arm contains a second adjustable drill guide, cal needs (Figure 8.33a). It consists of a bar with a centi-
which can be moved freely into the selected position. A metre gauge along which the proximal part of the aiming
(a) (b)
Figure 8.33 The equine aiming device. (a) The modular system has different distal arms that can be exchanged as required by
individual anatomic situations. Appropriately sized drill guides are introduced into the upper arm. (b) Device fitted to repair a distal
phalangeal fracture.
Reference 183
device containing the drill guide can be adjusted and needed and can be fastened to remain in place throughout
fixed. The distal, pointed part can be exchanged according the procedure (Figure 8.33b). A similar aiming device is
to the anatomic location; there are four different configu- also manufactured by IMEX Veterinary Inc., Longview,
rations from which the surgeon can choose. Different TX.
insert drill guides are available according to the size of the An aiming device is essential for repair of most distal
screw needed. Because the two parts of the aiming device phalanx (Chapter 16) and all distal sesamoid (Chapter 17)
are adjusted relative to each other in a parallel mode, the fractures in conjunction with intraoperative fluoroscopy
aiming device is readily applied to the exact location or CT.
Notes
1 Zimmer Orthopedics, Warsaw, IN. 2 Acutrack Equine Screw, Acumed® Veterinary, Hillsboro, OR.
R
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187
Pre-operative Planning and Preparation

C. Lischer1, K. Mählmann1, and C.E. Kawcak2
1
Freie Universität, Berlin, Germany
2
Veterinary Teaching Hospital, Colorado State University, Fort Collings, CO, USA
Increasing knowledge about fracture repair, bone healing I ntroduction

and biomechanics in conjunction with technical improve-
ments have made surgical treatment of fractures an estab- The first step is comprehensive evaluation of the patient
lished service in many specialized equine hospitals. The and the fracture. This determines potential methods for
outcome depends on many different factors some of which fixation and appropriate pre-operative treatment. Multiple
are case specific such as body weight, fracture site and people are involved, and the pre-operative plan covers a
complexity and the integrity of soft tissues. They cannot be number of important complex tasks. Surgeons must be
changed but need to be addressed to optimize outcome. realistic and honest about their qualification, ability and
Other factors such as surgery time, quality of repair and experience in attempting individual fracture fixations. The
post-operative management can be positively influenced availability of trained personnel, instruments, and imaging
by clinical understanding, surgical skills and pre-operative modalities are also important prerequisites to successful
planning. Potential complications and their sequalae are surgery. If the planned fracture repair is beyond the team’s
anticipated and prevented. It is generally accepted that the experience, expertise or equipment, then referral should be
complication rate is much lower in simple fractures that recommended. Pre-surgical planning involves communi-
can be repaired with lag screws [1–3] compared to complex cation with the anaesthetist to discuss pre-operative medi-
fractures [4–8]. cation, the type of anaesthesia, the approximate duration
Pre-operative planning is the first and essential part of of the surgery and recovery requirements. Potential com-
fracture treatment. Meticulous planning optimizes treat- plications during the procedure need to be anticipated, and
ment and can prevent complications during the surgical strategies for alternatives to the original plan considered.
procedure and problems in the post-operative period. It The success of checklists in aviation lead to their adapta-
involves not only a plan for fracture fixation itself, but also tion for surgical procedures by the World Health
preparation of facilities, instruments, implants and imag- Organisation (WHO) in 2008 with the intention of reduc-
ing requirements and communication with involved ing the number of deaths, estimated at about half a million
personnel. per year, caused by avoidable surgical error [9–12].
The necessary time and details of the plan can be Introduction of surgery checklists and standardized proto-
adjusted according to the complexity of the surgery and the cols in human medicine significantly reduced morbidity
familiarity and experience of the surgical team with the and mortality. After implementation of the WHO surgical
proposed procedures. The following summary is based on a checklist, the death rate in eight hospitals all over the world
combination of scientific data and personal experience and declined from 1.5 to 0.8% [13]. Similar success was also rec-
may serve as a guide to establish a structured plan for ognized in a recent study in small animal hospitals, in
osteosynthesis. which the frequency and severity of peri-operative [14] and

188 Pre-operative Planning and Preparation
post-operative [14, 15] complications were reduced signifi- ●● Preparation of the patient
cantly after introduction of a checklist adapted from the ●● Planning of medication, anaesthesia, analgesia and
WHO standard. A written list, followed up with verbal recovery
communication, is recommended. ●● Strategies for complications
The overall pre-operative plan for fracture fixation
To the inexperienced, meticulous pre-operative planning
should include the following points:
appears time consuming and cumbersome; however, the
●● Detailed plan of the surgical procedure advantages substantially outweigh effort. Surgery and
●● Availability and preparation of instruments and implants anaesthetic times are reduced, the quality of repair is
●● Availability of appropriately trained and experienced improved, mistakes are avoided and success rates increase.
personnel The authors’ recommended checklist plan for equine oste-
●● Availability and preparation of imaging modalities osynthesis is provided in Table 9.1.
●● Preparation of the operation room (OR)
Table 9.1 Pre-operative surgical checklist for equine osteosynthesis.
Patient: Procedure: Date:
Item Check
1 Relevant radiographs ●● Available
Detailed surgical plan ●● Made, communicated and available in theatre
2 Implants ●● Available
●● Screws ●● Size
●● Wires/cables ●● Number
●● Sterile
●● Functional
●● Reserves
Instruments ●● Available
●● Orthopaedic instruments ●● Sterile
●● Retractors ●● Functional
●● Bone reduction forceps ●● Set complete
●● Plate bender ●● Reserves
Consumables ●● Available
●● PMMA ●● Sterile
●● Local antimicrobials
●● Fluids
●● Drapes
●● Sutures
●● Bandage/cast
●● Medications
●● Others (list)
3 Personnel ●● Trained personnel available (surgical assistance,

intra-operative imaging and anaesthesia)
●● Surgical plan is known and communicated
●● Everybody is known by name and role
4 Intra-operative imaging required ●● Available
●● Radiography ●● Functional
●● Fluoroscopy ●● Anatomical localization determined
●● Computer tomography ●● Markers available
●● Arthroscopy ●● Radiation protection for all people in the OR
●● Endoscopy ●● Instructed staff
●● Measures to maintain a sterile field
(Continued)
Introductio 189
Table 9.1 (Continued)
Patient: Procedure: Date:
5 Preparation of the OR ●● Floor, surfaces and lights clean

Instrument tables, imaging modalities ●● Clean
and anaesthetic machine ●● Positions determined (floor plan)
Surgery table ●● Clean
●● Functional
●● Padding and support available
●● Position/fixation of the horse on the table
defined
Traction equipment ●● Availability and location, fixation to the horse,
fixation of the horse on the table and fixation
of the table to the floor (breaks or additional
measures)
6 Preparation of the Patient ●● Identity confirmed
●● Site of surgery confirmed
●● Positioning of the horse on the table
(surgical approach)
●● Procedure confirmed
●● Pre-operative check
●● Movement from stall to induction organized
●● Horse groomed
●● Tail braided
●● Hooves cleaned +/− trimmed
●● If hoof is involved: hoof is rasped
●● Laminitis prevention
●● Area to clip and prepare is defined
●● Clipping outside the OR performed
7 Antimicrobials ●● Confirmed with anaesthetist
●● Pre-operative antimicrobials administered
<60 minutes before surgery
●● Redosing during surgery prepared
●● Additional local administration prepared
Anaesthesia ●● Pre-operative check reviewed
●● Drugs prepared
●● Machine checked and functional
Analgesia ●● Local anaesthetic techniques prepared
●● Special medications prepared
8 Recovery ●● Method determined
●● Recovery box clean, dry and prepared
9 Strategies for complications
Equipment ●● Spare items or strategies available
Inability to reduce the fracture ●● Instruments +/− additional persons available
Technical errors ●● Instrumentation available
Anaesthetic crisis ●● Drugs prepared
Complications during recovery ●● Drugs and equipment available
Peri-operative planning can be broken down into a three- position (Figure 9.2). Radiographs of the contralateral intact
time point checklist [15]: sign in (before induction of bone can also serve as a template for the reconstructed bone.
anaesthesia), time out (before surgery starts), and sign out This technique enables the surgeon to choose the appropriate
(at the end of the procedure and before recovery). implants and determine optimal positions and lengths of the
screws [16–18]. Use of this traditional method of pre-operative
planning has been reduced with digital radiography and,
Detailed Plan of the Surgical Procedure when available, has been replaced by CT. In comminuted frac-
tures, multiplanar reconstruction (MPR) or 3D modelling is
Assessment and Understanding of the helpful to understand fracture configuration (Figure 9.3).
Fracture Configuration and Plan for Fixation Digital planning tools have been developed for some proce-
dures in human surgery. Using picture archiving communi-
Sufficient radiographs should be taken to fully assess the frac-
cation system (PACS) files, software recognizes the outlines
ture, to define the surgical approach and to determine the fixa-
of the fragments and rearranges them into anatomic align-
tion technique. Complex fractures may require computed
ment. The localization and size of implants is calculated, and
tomography (CT) to completely understand the configuration.
these can be applied virtually to the reduced fracture [18, 19].
At this stage, appropriate and necessary measurements
They are most commonly used to plan hip surgery, but tools
are obtained from the images. For this purpose, a radio-
to plan other kinds of fracture fixation are also available
paque marker of known size is placed on the skin or the
(Materialise, OrthoView, Stryker, Peekmed and TraumaCad).
bandage at the level of the fracture. On analog radiographs,
CT has further improved the accuracy of pre-operative plan-
a magnification factor is calculated. On digital radiographs,
ning for total hip replacement [20–23] and complicated frac-
measurements can be made directly with the measurement
tures of the tibial plateau and acetabulum [24, 25].
tool of the DICOM viewer after calibration (Figure 9.1).
Once the surgical plan is made and agreed, surgeons and
In displaced fractures, the outlines of fragments can be
all other personnel should ensure that they are familiar
drawn on tracing paper and aligned in the normal anatomical
with it. The plan and all relevant radiographs and other
images must be available in the OR (Figure 9.4). The check-
lists and floorplans should also be saved for further occa-
sions, when similar fractures are treated. This improves
safety and efficiency and permits ongoing improvements
and refinement of techniques and procedures.
Access to the Surgical Site

The exact landmarks and location of the skin incision(s) are
defined. In an acute fracture, the landmarks can potentially
be obscured by soft-tissue swelling. In open fractures the
standard approach might be not ideal, and a modification or
different approach should be considered. Musculature or
tendons to be dissected, separated or retained, and vital
structures that need to be preserved are reviewed. If bleed-
ing is expected, appropriate methods for haemostasis are
planned. For open fractures, the treatment of the wound
before definitive fracture fixation is organized and strategies
for local antimicrobial treatment are considered.
Positioning the Horse and Limbs

The fracture pattern and surgical approach to the bone deter-
mine the position of the horse on the operating table. Support
and padding for the affected limb are planned, and the poten-
tial requirement for traction is considered. Other legs are
positioned so that they do not interfere with osteosynthesis
Figure 9.1 Pre-operative plan for lag screw fixation of a simple
and intra-operative imaging, while minimizing the risk of
sagittal fracture of the proximal phalanx including glide holes
and full length of drill holes at predetermined sites of screw compression or stretching nerves and muscles. If a bone graft
placement. Note the marker to calculate the magnification factor. is anticipated, a harvest site should be determined.
Detailed Plan of the Surgical Procedur 191
(a) (b)
Figure 9.2 Planned repair of an oblique, displaced, distal diaphyseal fracture of the tibia in a pony (a) caudocranial and lateromedial
radiographs (b) reconstruction of the fracture using tracing paper. It is important to calculate the magnification factor before
determining implants size.
(a) (b)
(d) (e)
(c)
Figure 9.3 CT evaluation of a complex fracture of the middle phalanx. Volume rendering of the bone (a, b) and multiplanar reconstruction
(c–e) are used to plan sites, trajectories and sizes of implants. It is also useful to recognize the level of the coronary band (e).
Position: Right lateral recumbency
Approach:
• Skin incision form the proximal point of the olecranon
• Incision of the subcutaneous fascia
• Identify and protect ulnar nerve
• Blunt dissection between ulnaris lateralis and ulnar head of the deep
digital flexor muscle
• Sharp dissection of the ulnar head of the DDFM and the flexor carpi
ulnaris muscle proximal/caudolateral
• Sharp division of the insertion of the triceps muscle
Reduction and Fixation:

• Removal of the fragment of the anconear process aided by flexion of the
elbow joint
• Reduction of the fracture using reduction forceps
• Control radiograph
• Contour 11 hole narrow LCP plate by aid of the aluminium template
• First screw: (hole #4) cortical screw in compression model/load
fracture–not fully tightened
• Second screw: (hole #6) cortical screw in compression model/load
position distal to the fracture
• Tightening of both screws
• Third screw hole #1, cortical screw in compression mode; crossing the
apohysis
• Insertion of locking head screws in the remaining combiholes
• Closure of the fascia (0 Vicryl), subcutis (2-0 Monocryl) and the skin (0-
Prolene), application of a stent bandage
Recovery with head and tail rope
Post-op: 5 days amoxicillin 15 mg/kg TID, gentamicin 6.6 mg/kg SID,

phenylbutazone initially 4.4 mg/kg BID (reduce gradually), omeprazole 4 mg/kg
SID
• Box rest eight weeks
Figure 9.4 Pre-operative plan for repair of an olecranon fracture.
Anticipated Methods for Reduction important if two or more locking compression plates (LCPs)
and locking head screws (LHS) are used. Plates need to be
Fracture reduction can be open or closed, and different
arranged at a 90° angle to each other and in a staggered man-
manipulations can be used to restore length and three-
ner to prevent interference of the screws. The sequence of
dimensional alignment of the bone. If traction is used in
insertion is crucial if LHS and cortical screws are used in
lateral recumbency, the horse needs to be fixed on the
combination: the cortical screws, which pull the plate close
table. Ropes need to be attached to the limb and a fixed
to the bone, need to be inserted first [8, 26]. If cortical screws
metal eyelet in the wall. Traction equipment divides the
are used in a load position, the sequence of insertion and
surgery room, potentially interfering with intra-operative
tightening also need to be anticipated.
imaging, equipment and access for personnel (Figure 9.5).
If the horse is in dorsal recumbency, the limb is placed
Imaging
directly underneath a hoist used for traction in order that
force is applied in a straight line with the leg. Bone reduc- The requirement for intra-operative imaging is determined by
tion forceps and retractors should be available. the configuration of the fracture and joint involvement, and
can include digital radiography or fluoroscopy, arthroscopy,
ultrasound or CT. A floor plan for the localization of equip-
Fixation
ment in the theatre is useful to minimize interference with
The correct size and types of implants and an exact plan for traffic and sterility and to optimize projections. Staples or nee-
the positioning and sequence of insertion are made pre- dles can be used as radiopaque markers to identify landmarks
operatively. This includes strategical screws for temporary and to determine implant positions and trajectories.
fixation and implants for definitive fixation. All are planned Arthroscopy is the imaging modality of choice to achieve
according to the guidelines and biomechanical principles reduction at articular surfaces, and portal positions need to be
explained in Chapter 8. The position of the horse is especially planned with respect to fracture access. The critical timepoints
Instruments, Implants and Disposable Item 193
Figure 9.5 With horses in lateral recumbency, traction equipment divides the surgery room but should not interfere with intra-
operative imaging, approach to instrument tables and access for technicians and assistants without compromising sterility.
at which radiographs (or other imaging techniques) are lengths of operated and contralateral limbs, this should be
required should be documented in the surgery plan. compensated by applying a support shoe or similar to the
contralateral limb (Chapter 13).
Wound Closure
Laminitis Prophylaxis
Methods of wound closure and required materials are
determined pre-operatively after consideration of case- If prolonged pain and/or limb dysfunction is anticipated or
specific details such as anticipated tension, movement or possible, then a plan to prevent supporting limb laminitis is
presence of dead space. made at the pre-operative stage. This is detailed in
Chapter 14.
Bandaging and External Coaptation
Recovery from Anaesthesia
In some cases, a bandage to cover the wound is sufficient,
but in others rigid external support may be required for the The recovery needs to be planned with respect to the injury,
recovery phase or for a longer period after surgery. The available facilities and personnel and the temperament of
materials needed are prepared in advance. The horse’s the horse (see Chapter 10).
temperament and possible reaction to external coaptation
should be considered. If a full limb cast is planned for
recovery, then a full limb splint or cast bandage can be Instruments, Implants and Disposable Items
applied before surgery both to assess the horse’s response
and to allow it to become accustomed to the immobiliza- A list of required implants and instruments should be pro-
tion. If the external coaptation technique causes unequal vided to the operating room personnel (ORP) as early as
possible. The ORP, in turn, need to have good control of operative debate and to make anaesthesia time as short as
prepacked sterile packs such as screws and plates to possible, a pre-operative team briefing is helpful to discuss
ensure that omissions are not discovered at surgery. any open questions. This should include discussion of the
Hospitals also need good relationships with suppliers anticipated pain level and preventative strategies with the
making overnight shipping for emergency cases possible anaesthetists so that responsibility for administration is
at any time. agreed.
Implants:
Availability of appropriate sizes of all potentially needed
I maging Modalities
●●
screws, plates, etc. should be checked.

●● Spare implants should be available.
Planned imaging modalities should be checked for availa-
●● All implants should be sterile.
bility and functionality. The appropriate protective clothing
●● Consider if plates can be pre-bent.
must be provided, and it is important to check that there is
Instruments: a suitable person to operate the relevant equipment.
●● All instruments that are or may be needed for the sur-
gery should be checked for availability, functionality and Radiography
sterility.
A digital radiography system with capability for fast
If sterility either by date or package integrity is question-
●●
●●
image review should be available for reasons of sterility
able, instruments must be re-sterilized.
and effectivity.
●● Replacements should be available for instruments such
Ensure that wireless digital radiograph detectors have
as drill bits that can be worn down or break during the
●●
fully charged batteries and extra batteries are

surgery.
available.
●● Additional instruments that may be required, e.g. a tour-
Appropriate machine positions for different projections
niquet, electrocautery, soft-tissue retractors, suction
●●
during surgery can be marked on the floor.

pump, etc. should be made ready.
Sterile waterproof covers for the cassette or detector
The anaesthetic machine is checked and functional.
●●
●●
should be available.
Disposable items: ●● A plate holder can be prepared if applicable.
An inventory of requirements should be compiled and ●● Position/size markers (staples, needles) should be made
checked. This includes analgesic drugs, irrigation fluids, ready.
antimicrobials, catheters for intravenous regional limb pro- ●● Trained staff (only) should operate the X-ray machine.
fusion (IVRLP), antimicrobial beads, bone substitutes, ●● Appropriate protection (lead aprons) and dosimeters
sutures, drapes, drains and materials for planned band- must be worn by surgeons and other personnel in the OR.
ages/external stabilization.
Fluoroscopy
P
ersonnel Fluoroscopy has similar requirements to radiography for
functionality, sterility, protection of the personnel, etc.
The manpower needed varies according to the nature of Special drapes for the C-arm should be available.
the repair and complexity of the surgery, and before com- Positioning the C-arm in relation to the table and struc-
mencing it is important to ensure that enough trained staff tures to be imaged is of particular importance. Maintenance
are available for all aspects of the operation. It is also most of sterility of the surgical field [27] and range of motion of
important that any new members of the team are fully the C-arm need to be considered.
instructed and introduced before surgery. The ORP need to
know in which order instruments, implants and consuma-
Computed Tomography
ble items are needed and they have to be familiar with their
names. The ORP should be aware of fixed time intervals for Indications for CT include comminuted fractures or loca-
changing gloves or redosing antimicrobials that can then tions in which accurate screw positioning is difficult and
be prepared in advance. The plan for the surgical procedure important. Positioning and draping must be planned to
and the anticipated time needed are communicated to the produce optimal images and maintain a sterile field.
ORP so that the surgery itself can be performed in a quiet Radiographic markers are placed on the limb for orienta-
and concentrated environment. In order to reduce intra- tion [28, 29].
Preparation of the Operating Roo 195
Arthroscopy ost-operative myopathy or neuropathy. The horse and

p
limbs are positioned so that the surgical site is accessible
If arthroscopy is planned, instrumentation and consuma-
for surgeons and imaging modalities.
ble items including gas or fluid supplies are checked and
●● Traction equipment
prepared. The position of the arthroscopy tower is deter-
–– Anchor points to fix the equipment are checked, and
mined to make sure that it does not interfere with other
the surgery table is positioned in an appropriate place
equipment or imaging modalities and to ensure that the
and limb in correct orientation to apply tension. The
surgeon has the most appropriate view of the screen.
table is then locked in the required position to with-
stand forces during traction.
Endoscopy –– Anchor points in the wall to fix the equipment should be
Endoscopy of the upper airways may be needed in horses strong enough to withstand traction with a pulley which
with skull fractures. If used in a sterile field or operated by sometimes can be needed to apply adequate tension.
the surgical team, the endoscope should be prepared –– Once the position of the limb and the traction equipment
accordingly. Positioning in the OR is given the same con- is fixed, hobbles or wire attached to the hoof are applied.
sideration as other imaging modalities. –– When the horse is positioned in dorsal recumbency
and a hoist is used for vertical traction, the risk for
contamination of the surgical field needs to be mini-
Preparation of the Operating Room mized by careful draping and by ensuring that the
machinery is dust free.
●● The OR (floor, surfaces and lights) should be checked for
cleanness.
Floor Plan
●● The table should be clean and checked for functionality
including, when appropriate, battery status. The positions of the surgery table, instrument tables and
●● Necessary equipment for padding and to provide support all other equipment needed for surgery such as imaging
for the limbs is available. modalities, suction pump, electrocautery, traction devices,
●● The exact position of the horse on the table is defined. anaesthetic machines, etc. are arranged to minimize inter-
Padding and positioning are optimized to avoid ference and optimize workflow and sterility (Figure 9.6).
Figure 9.6 For complex procedures, e.g. when using axial traction, arthroscopy and fluoroscopy, a floor plan is useful to optimize
familiarity and to identify the position of the surgical team and the access for technicians.
With unfamiliar or non-routine procedures, it can be help- drapes can be used to secure the drape to the patient or to
ful to sketch out the plan or to use a digital room planning provide draping of a larger area without obscuring land-
tool. To facilitate positioning of the different elements, marks. However, there are conflicting results regarding
anticipated positions can be marked on the floor with tape. their potential benefits. Although some studies revealed
reduced bacterial counts after hip surgery in man [31],
systemic review in human surgery revealed an increased
risk for surgical side infection (SSI) rates [32]. Others
Preparation of the Patient
studies have shown no benefit in various types of proce-
dures such as ovariohysterectomy or stifle surgery in
All general principles of surgical patient preparation apply,
dogs [33] and hernia repair in humans [34].
but the following are of special importance in fracture
Sterile drapes should cover the entire horse. This is not
repair:
●●
only important to prevent contamination by hair or dirt

●● The identity of the horse is confirmed. but also allows instruments such as air lines to be
●● The site of the surgery and the procedure are reviewed positioned.
●● A pre-anaesthetic examination of the horse is performed ●● In long procedures, a urinary catheter connected to a uri-
(Chapter 10). nary bag (an empty perfusion bag) is prepared
●● The horse is groomed; if possible, the hooves are cleaned
and the tail is braided or wrapped.
●● Support, appropriate to the fracture, is applied to move P
eri-operative Antimicrobials
the horse from the stables or diagnostic area to the induc-
tion box. The use of prophylactic antimicrobial administration has
●● The shoes are removed if this can readily be done. been debated for years in all types of surgical procedures,
●● In elective procedures, hooves are trimmed in anticipa- especially when implants are used. It is safe to say that it is
tion of convalescence. generally accepted for many equine orthopaedic proce-
●● In selected cases, laminitis prophylaxis is applied to the dures, including repair of simple, closed fractures [35].
contralateral foot. Administration in closed fracture repair in people has been
●● If the hoof is involved in surgery, it should be prepared debated [36–38] with the general consensus that use is
by removing loose horn and a thin superficial layer of the warranted especially with soft-tissue damage [39]. Of
horn capsule (the periople). All extraneous organic mat- greater debate is the use of single, prophylactic dosing vs
ter must be removed. After a pre-disinfection step includ- multiple dosing. In general, it has been shown that no sig-
ing scrubbing the hoof twice with povidone iodine soap nificant difference exists between the two, making single
for two minutes, rinsing with sterile saline and drying dosing more economic and less apt to cause systemic side
with a sterile towel, the hoof is prepared aseptically for effects [39]. In general, systemic prophylactic antimicro-
four minutes by iodine tincture or povidone iodine. bial use in repair of closed fractures is generally favoured.
Soaking for 12 hours with these preparations should be This should be weighed against regional delivery methods,
avoided as skin can be damaged. Bacterial recolonization which appear to have reduced the incidence of post-
was noted after povidone iodine soaking [30]. operative infection in equine orthopaedic surgery [40].
●● Clipping and preparation of the skin should be per- However, there is conflicting information on its true effi-
formed over a wide area centred on the anticipated inci- cacy that requires further investigation [41]. General guide-
sion. In the region of the radius, ulna or other proximal lines that have been proposed to determine if prophylactic
regions, the limb should be lifted slightly to access axial antimicrobials should be used include those procedures
areas. Clipping of limbs should be circumferential. with a >5% incidence of infection without use and those
●● Draping should be performed in two layers to ensure a with potentially devastating consequences [42], which
sterile field. It is important to fix drapes sufficiently to many consider infection of implants to carry.
avoid slipping due to manipulation during fracture Administration is determined by the health status of the
reduction. The position and integrity of the drapes patient, the classification of the fracture, the invasiveness
should also be checked regularly. and anticipated length of the surgery and the regional bac-
●● Draping of the surgical site should not interfere with terial flora. Choice is dependent on a number of factors,
instruments and imaging modalities and therefore should including bacterial isolates and their susceptibility patterns
be kept slim. It is also important to not obscure land- particular to a specific hospital, their changes over time,
marks and visual orientation of the limb. Towel clamps the potential to cause systemic side effects and surgeon
should not interfere with areas to be imaged. Adhesive preference. A paradigm of continual reassessment should
Strategies for Complication 197
be used to ensure awareness of emerging susceptibility determined by individual fracture characteristics. Intra- and
concerns. In general, the most common gram-negative post-operative administration of antimicrobials are discussed

isolates are Enterobacter species with streptococcus and in Chapter 14.
staphylococcus species the most common gram-positive
isolates [41, 43, 44]. However, one study recognized entero-
coccus as the most common gram-positive isolate [41]. P
ain Management
Broad-spectrum activity based on thoughtful evaluation of
local isolates and susceptibility patterns is ideal. Bactericidal Pain is a critical factor in managing equine fractures. True
drugs such as penicillins and cephalosporins are typically reduction of pain, as opposed to reducing the perception of
used to combat gram-positive bacteria, and aminoglyco- pain (as commonly used in human medicine), is essential.
sides are most commonly used to combat gram-negative Reducing pain will improve weight-bearing, overall well-
bacteria. Metronidazole is indicated if anaerobic organisms being and ability to heal. Physical means of reducing pain
are a concern. include fracture stabilization and pressure bandaging. A
Intravenous administration is generally preferred and bandage alone can frequently reduce stimulation of mech-
should be given within an appropriate time frame (usually anoreceptors and reduce painful swelling. In addition to
<60 minutes) before incision to ensure adequate concentra- reducing pain, stabilization also reduces the anxiety pro-
tion as the surgery site. Redosing is indicated if the procedure duced by a dysfunctional limb.
goes beyond 1–2 times the half-life of the individual drug(s) In some cases, assisted support such as a sling can be
or (rarely) if there is excessive blood loss [35, 45]. Although beneficial, but the temperament of the horse and the expe-
many surgeons use prophylactic antimicrobials well beyond rience of the treatment team must be considered before
24 hours, their efficacy is challenged [45] and the trend is for this is planned. Bedding characteristics should also be con-
surgeons to reduce post-operative dosing. It makes sense that sidered, especially if a horse is willing to lay down.
as the use of minimally invasive procedures increases the Sometimes deep bedding can be beneficial, but it can also
desire for prolonged antimicrobials will be reduced, although inhibit the horse’s ability to move a cast or splinted limb
this should be weighed against the amount of soft tissue and around the stall. Thick bedding in the corners can certainly
potential vascular compromise at the site. help, and in some cases a prop (such as a straw bale) can be
Antimicrobials can be delivered through various modali- used within the stall on which the horse can learn to lean
ties in order to prevent and treat surgical site infection. in order to relieve weight-bearing and consequent pain.
Systemic administration remains central, but drug toxicity Pharmacological aids are usually necessary. Non-steroidal
must be considered and monitored. Regional limb perfu- anti-inflammatory drugs are central but should be used
sion is now considered a standard part of treatment and judiciously. Sedatives and opioids are often used peri-
prevention of surgical site infection in fracture repair [46]. operatively, and in a highly controlled setting, constant rate
The venous route is usually selected over interosseous infusion of lidocaine and ketamine can be employed [49].
routes, although opinions vary [47]. In some circum- Fentanyl patches have also shown some efficacy [50]; two
stances, intra-articular administration can also be benefi- 10 mg patches can be applied over the saphenous or cephalic
cial. Implantable devices that can elute antimicrobials over veins. In some hindlimb fractures, epidural morphine and/
a set period of time can also be employed [47]. These are or alpha-2 agonist drugs can be beneficial. In complex artic-
usually reserved for contaminated wounds or those that ular fractures, intra-articular morphine can be used.
have pre-existing surgical site infection [48]: they are rarely Regional analgesia is sometimes employed but must be con-
used on a prophylactic basis (Chapter 14). sidered carefully to minimize the risk that increased weight-
A degree of hypoxia at and adjacent to the fracture is bearing might compromise fracture repair. Intra-operative
inevitable and may limit vascular delivery of antimicrobi- nerve blocks can reduce the dose of anaesthetic drugs nec-
als to the site. Selection of drugs and routes of administra- essary during the procedure (Chapter 10).
tion are therefore critical in the pre-operative,
intra-operative and post-operative periods.
In open contaminated fractures, systemic administration Strategies for Complications
should begin as soon as possible after diagnosis: an intrave-
nous catheter is inserted, and broad-spectrum antimicrobials Pre-operative preparations and checklists minimize com-
are given. Immediate pre-operative administration should be plications but it remains important to prepare strategies for
timed in order to best guarantee adequate tissue concentra- all eventualities. This can make the difference between
tions at the time of surgery. With re-administration in lengthy complications being recoverable and those resulting in
procedures. The length of post-operative administration is failure.
Equipment Recovery
●● Are spare items available if an instrument breaks?
●● Is there an alternative if the C-arm or the X-ray machine ●● The chosen method of recovery must be planned in light
does not work? of the fracture type and repair, presence or absence of
external coaptation, facilities and personnel available
and the horse’s age, size and temperament (see
Failure to Effect Reduction
Chapter 10).
●● Are there additional instruments or strategies if the ●● The recovery box needs to be clean, dry and prepared for
planned method fails? the intended recovery method.
●● Is another experienced and able person available?
Technical Errors During Implant Insertion Open Fractures

●● If a screw thread strips is a larger diameter or alternative
Open fractures require particular consideration and
screw type available?
planning. A fracture is considered to be open when dis-
●● What can be done if a screw is in a wrong place?
ruption of the skin and the underlying soft tissues
●● Is equipment available if a broken screw or a screw with
results in communication between the fracture and the
a damaged head needs to be removed during the repair?
outside environment. Open fractures are often caused
●● Are alternative methods and equipment available if a
by high energy trauma such as kick injuries or falls.
fragment splits, for example cables or wires?
Restoration of soft-tissue viability and integrity is criti-
cal to outcome.
Anaesthetic Crisis Open fractures are the most common reason for surgical
●● Are drugs and equipment available for anaesthetic site infections (SSI) [6, 7, 51]. Trauma results in reduced
emergencies? tissue oxygenation and devitalization. Contamination with
●● If the horse moves, can the surgical site and equipment foreign material and microorganisms and the presence of
be protected? devitalized tissue represent major risk factors for subse-
quent infection. Various bacteria can be isolated from ini-
Complication During Recovery tial injuries, but microorganisms found in cultures taken
from infected wounds are often different [52–55].
●● Additional sedatives should be pre-drawn for immediate Open fractures are most commonly classified according
administration. to the system developed by Gustilo and Anderson [56] and
●● A cast saw should be available if the horse struggles to subsequently modified with respect to mechanism of
stand up with a cast in place. injury, soft-tissue damage, fracture pattern and contamina-
●● If there is a failure of fixation, can the horse be re- tion (Table 9.2 and Figure 9.7) [57, 58]. Definitive classifi-
anaesthetized while further plans are discussed? cation follows surgical exploration and debridement, and
in human surgery the categories correlate well with the
risk of infection and other complications. Subjectively,
Sign Out infection rates in horses appear to be higher, but there is
little published information.
Has the correct procedure been performed and if more
Prevention of infection involves the application of basic
●●
than one procedure was required have all planned sur-

surgical and fracture management principles [59], which
geries been performed?
in horses involves the following:
●● Are all implants of correct length and position and/or do
any need to be replaced? ●● Emergency management including administration of
–– Completion of counting: intravenous antimicrobials and assurance of tetanus
–– Instruments prophylaxis.
–– Swabs ●● Assessment of the wound and fracture.
–– Needles ●● Primary wound intervention: first scrub, surgical prepa-
●● If samples are taken, check specimen labelling. ration, draping, debridement, lavage and wound
●● Are there any issues concerning surgical instruments or closure.
anaesthetic/monitoring equipment? ●● Secondary fracture intervention: second scrub, surgical
●● Does the animal have any special risk during recovery, preparation, draping, fracture stabilization and healthy
and how should it be handled? soft-tissue closure.
Open Fracture 199
Table 9.2 Classification of open fractures and reported risk of infection in humans.
Type Definition Infection rate
I Wound <1 cm, clean, simple fracture pattern 0–2%

II Wound >1 cm, soft-tissue damage not extensive, no flaps 2–5%
or avulsions, simple fracture pattern
III Including: IIIA Extensive soft-tissue damage but adequate coverage of 5–10%
●● Extensive soft-tissue damage the bone
●● Multifragentary fracture, segmental IIIB Extensive soft-tissue damage with periosteal stripping 10–50%
fracture or bone loss and bone exposure, major wound contamination
●● Crush injuries or vascular injuries IIIC Open fracture with arterial injury requiring repair 25–50%
requiring repair
●● Severe contamination including
farmyard injuries
Source: Adapted from Gustilo and Anderson [56].
Emergency Management Antimicrobial prophylaxis covering the gram-positive

spectrum is recommended in type I and II fractures with
Appropriate first aid includes stabilization of the patient
additional gram-negative targeted medication for type III
and initial assessment. The skin wound and additional
fractures [62]. Evidence of the optimal duration of antimi-
soft-tissue injury, vascularization, extent of contamination
crobial therapy in open fractures in man is inconclusive.
and the fracture pattern are evaluated. Although some of
Guidelines include 24 hours in type I, 24 or 48 hours in type
these examinations can be performed on an emergency
II and 48–72 hours in type III fractures [63, 64].
basis, some details can only be evaluated at the time of sur-
In horses, recommendations for the duration of antimicro-
gical exploration.
bial therapy usually range from 10 days to several weeks,
Broad-spectrum antimicrobial therapy is initiated. The
depending on the presence or absence of clinical signs of
usual regimen of choice in horses is a combination of
infection. Documented post-operative infections after fracture
30 000 IU/kg of crystalline penicillin and 6.6 mg/kg of gen-
repair in horses were most often caused by Enterobacteriaceae,
tamicin sulphate, both intravenously. Evidence from
followed by Streptococcus spp., Staphylococcus spp. and
human medicine indicates that antimicrobial therapy
Pseudomonas spp. [6, 44, 65]. Broad-spectrum antimicrobial
should start as soon as possible after trauma [60, 61]. The
treatment such as the combination of a β-lactam antimicro-
state of tetanus vaccination should be checked and in cases
bial and an aminoglycoside, covering the gram-positive and
of doubt antiserum administered.
gram-negative spectrum, is thus logical. Bacteria should be
The wound is covered with a sterile gel to prevent further
considered non-susceptible if an infection develops despite
contamination. The hair surrounding the wound is
antimicrobial therapy. In these cases, selection of alternative
removed, the skin cleaned and macroscopic contaminants
antimicrobials should be based on culture and sensitivity of
of the wound are removed. A sterile dressing is applied,
isolated organisms.
and if possible the limb is immobilized to prevent further
Local antimicrobial therapy provides a high concentra-
soft-tissue damage.
tion at the surgical site while avoiding systemic side effects
Horses with open fractures should undergo surgery as
(Chapter 14). Use has been reported to reduce the overall
soon as possible. However, particularly at night, stability of
infection rate in open human fractures [66, 67]. In horses,
the patient and the availability of personnel (anaesthetists,
regional limb perfusion at the time of the surgery maxi-
ORP, radiography assistant and assistant surgeons) may
mizes concentration at the surgical site [46]. Administration
necessitate postponing surgery until next day.
technique is determined by fracture location and surgeon
preference.
Use of Antimicrobials
In human medicine, intravenous antimicrobial therapy is Debridement and Lavage
recommended to start within three hours of injury [60]. In Debridement and lavage are of paramount importance.
man, the value of cultures before and after debridement of Debridement should not be delayed as higher infection and
open fractures has been questioned as only a minority of complication rates have been reported if this was under-
SSI are caused by bacteria found at these times and wounds taken after 24–72 hours [68, 69]. However, the diligence of
with negative cultures can develop infection [52–54]. debridement appears to be more important [70–80].
(a)
(b) (c)
Figure 9.7 Open fractures. (a) Type I : a small wound of <1 cm can be identified at the medial aspect of the tibia. The radiograph
demonstrates a simple, displaced, diaphyseal, spiral fracture. (b) Type II: a wound slightly larger than 1 cm is visible at the lateral
aspect of the distal metacarpus. (c) Type III B : a large severely contaminated wound at the lateral aspect of the proximal phalanx
exposes a comminuted fracture.
Skin should be prepared with soap and disinfectant, The wound is then lavaged to further decrease bacterial
avoiding direct contact of the latter with the wound before load. Debate remains concerning optimal irrigation solu-
the area is draped. Exploration and debridement of the tion, volume, and delivery pressure. Available additives
wound is performed from superficial to deep and from the can be divided into three categories: antiseptics (povi-
periphery to the centre. In some cases, the initial wound has done‑iodine, chlorhexidine, polyhexanide, octenidine and
to be extended for adequate exploration and debridement. NaOCl/HOCl), antimicrobials (amikacin, bacitracin, poly-
The approach for the fracture fixation should be considered. myxin B and neomycin) and soaps that work by removing
All contaminants and devitalized tissue including small microbes, instead of killing them. These solutions have
loose bone fragments have to be removed starting at the been compared in a number of animal and in vitro studies,
skin and progressively advancing to the level of the bone. but controversies remain [81]. A cross-sectional survey of
Finally, the fracture ends are exposed, cleaned and debrided. lavage techniques used by 984 surgeons revealed that 70.5%
Reference 201
used sterile saline alone while 16.8% added bacitracin; low is possible to oppose without tension, (iv) there is no
pressures were used by 71%. Of note was a high willingness farmyard or gutter contamination, (v) the surgeon is
(94.2%) to change practice if a large randomized controlled satisfied with the debridement and (vi) there is no vas-
trial provided positive evidence for one solution or pres- cular insufficiency [99].
sure [82]. In a further multicentre study of 2447 patients If possible, open fracture wounds that have been ade-
with open fractures, there was no difference in the re- quately debrided should be closed at the end of the surgery.
operation rate for different irrigation pressures. However, Immediate closure reduces the risk of nosocomial infec-
the re-operation rate was higher if irrigation was performed tion and additional tissue damage due to exposure of soft
with 0.45% sterile castile soap solution (14.8%) compared tissues [58, 68, 100–102]. Primary closure in human open
with sterile saline (11.6%) [83]. tibia fractures resulted in decreased rates of infection, re-
No statistically significant difference was found in the operations and time to bony union [103, 104].
infection rate of open fractures after lavage with isotonic In horses, active drains with a closed suction system may
saline, distilled water and boiled water [84], and in a be indicated in open fractures proximal to the carpus and
clinical trial of 109 open fractures in distal limbs, wound the tarsus to minimize the risk for haematoma and seroma
healing times were not significantly shorter for wounds formation.
and open fractures irrigated with distilled water com-
pared to isotonic saline [85]. In a clinical study of 40
Fracture Stabilization
open tibia fractures, use of a commercial hydro-jet device
reduced the number of wound debridements until wound After completing the primary wound care, the limb is posi-
closure [86]. tioned for fracture repair and the skin is aseptically pre-
Increasing volumes of lavage solution remove more con- pared as for a new procedure. Similarly, the surgical team
taminants, but as might be expected there is a plateau repeats hand antisepsis and applies new gowns and gloves.
effect [87]. Three litres have been recommended for grade 1, The instruments for osteosynthesis can then be opened.
six litres for grade 2 and nine litres for grade 3 open fractures Whenever possible, the skin incision to approach the
in man but this is not supported by scientific evidence [88]. fracture avoids the traumatic skin wound. Stabilization of
The delivery of lavage fluid can also be modified by pressure open fractures protects soft tissues and reduces dead space,
and continuity. Higher pressures have been more effective in which in turn reduces the risk of infection and offers the
removal of contaminants [89, 90]. Low-pressure irrigation of best environment for fracture healing [105–107].
5–15 pounds/square inch (psi) was effective in the removal In horses, external fixation techniques have been sug-
of bacteria from contaminated tissues in experimental stud- gested for open fractures distal to carpus and tarsus, in
ies, while higher pressures were associated with potential order that fracture stabilization can be achieved without
soft tissue and bone injury [91–96] and can transfer bacteria the presence of implants at the fracture site. In addition to
into deeper tissue layers [97]. Pulsed lavage showed no addi- preventing bacterial colonization of implants, external fix-
tional benefit in clinical and experimental investigations ation can also help to reduce soft-tissue manipulation and
compared to continuous lavage [98]. vascular disruption at the fracture site.
Soft Tissue Closure Prognosis

When the wound is clean the skin is apposed or packed Open fractures remain a challenge and have a significant
with sterile gel or antimicrobial gel if closure is not negative impact on outcome. Treatment can be successful,
possible. In man, primary closure of open fracture but required meticulous care and adherence to the princi-
wounds is recommended if (i) debridement is per- ples detailed above.
formed within 12 hours, (ii) there is no skin loss, (iii) it
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207
10
Anaesthesia and Analgesia

E. Vettorato and F. Corletto
Abbreviations POMN post-operative myopathy/neuropathy

RR respiratory rate
ABG arterial blood gas SaO2 arterial oxygen saturation
ABP arterial blood pressure SpO2 pulsatile arterial oxygen saturation
ACP acepromazine TSH thyroid-stimulating hormone
ACTH adrenocorticotropic hormone V/Q ventilation/perfusion
ADH anti-diuretic hormone
ASA American Society of Anesthesiologists
CI confidence intervals P
re-operative Evaluation
Co coccygeal and Consideration
COX cyclooxygenase
CPAP continuous positive airway pressure The overall peri-anaesthetic mortality of healthy horses is
CPR cardiopulmonary resuscitation about 1% [1]. This is a hundred to a thousand times higher
CRI constant rate infusion than in humans (0.01–0.001%) [2, 3], 20-fold greater than
CRT capillary refill time dogs (0.05%) and 10-fold greater than cats (0.1%) [4].
FGF fresh gas flow Reported figures vary according to the definition of mortal-
FiO2 inspired oxygen fraction ity, the number of post-operative days considered, the type
GA general anaesthesia of study and whether or not general anaesthesia (GA) was
HR heart rate considered to be directly related to the outcome [5, 6].
IAAs inhalational anaesthetic agents Fracture fixation has been associated with greater mor-
IPPV intermittent positive pressure ventilation tality across a number of studies [1, 6, 7, 8]. This associa-
IV intravenous tion might be partially explained by the longer GA and
MRL maximal residual limits surgical time required to repair a fracture [6, 7, 9]. Short
NSAIDs non-steroidal anti-inflammatory drugs procedural time significantly reduces the risk of complica-
OR odds ratio tions and mortality probably because the anaesthetic agent
P(A-a) alveolar–arterial oxygen gradient is less likely to accumulate and thus is eliminated more
PaCO2 arterial carbon dioxide partial pressure rapidly, decreasing the risk of ataxia and potential injury
PaO2 arterial oxygen partial pressure during recovery [10]. High levels of circulating catechola-
PC post-operative colic mines and activation of the stress response are seen, par-
PD pharmacodynamic ticularly in horses with fractures which are admitted from
PE'CO2 expired carbon dioxide pressure the racetrack. Higher concentrations of inhalational anaes-
PEEP positive end-expiratory pressure thetic agents (IAAs) may be necessary to maintain GA and
PIP peak inspiratory pressure this, in turn, promotes accumulation. High levels of cat-
PIVA partial intravenous anaesthesia echolamines also impair the sedative effect of alpha-2 ago-
PK pharmacokinetic nists. This can result in a shorter but more ataxic recovery,
PNBs peripheral nerve blocks further increasing morbidity and mortality. Depending on

208 Anaesthesia and Analgesia
the horse’s level of stress and clinical condition (e.g. dehy- treating surgical pain with morphine because of the
dration), the severity, instability and risk of further dis- potential risk of developing PC is questionable.
placement of the fracture, the clinician should assess on a Thorough clinical examination, preferably in a quiet
case-by-case basis if surgery should be performed immedi- environment and after a brief period of acclimatization,
ately or delayed for 24–36 hours. It is also documented that should be performed before GA in order to evaluate the
emergency surgeries and surgeries performed out of nor- function of the main body systems: cardiovascular, res-
mal working hours or at weekends have been associated piratory and gastrointestinal. Character, attitude of the
with higher risk of post-operative death [1]. If adequate horse and pain intensity should also be assessed in order
support of a fractured limb can be provided and surgery to plan sedation (type, dosage and route of administra-
can be postponed, then the clinical condition of the horse tion) and to predict the horse’s behaviour during recov-
can be stabilized by administering analgesia and fluids. ery from GA. The horse should also be weighed to allow
This period of time also facilitates the horse’s acclimation more precise anaesthetic drug calculations, but the ani-
to the new environment, decreasing the level of stress and mal’s physical condition should also be considered.
catecholamines, and allows more time for surgical plan- Alpha-2 agonists should be administered according to
ning and preparation. However, it should be recognized body surface area; large heavy (e.g. draft) horses require
that, in some situations, the most effective means of reduc- relatively lower doses per kg of body weight than lean
ing horses’ stress is acute surgical intervention. Experience Thoroughbreds. The length of the surgery should be esti-
and judgement are critical. mated to decide the most appropriate anaesthetic tech-
Post-operative colic (PC) increases mortality and mor- nique. For example, the authors prefer to infuse an
bidity rates, hospitalization time and costs incurred by alpha-2 agonist during fracture repair longer than
the owner [11]. In a retrospective study performed at a 60–90 minutes in order to decrease the amount of IAAs
University Teaching Hospital in UK, the prevalence of necessary to maintain GA. This also provides a back-
PC in horses that underwent orthopaedic surgery was ground sedation once the horse is placed in the recovery
2.8% (14 surgeries out of 496), with the majority of cases box, improving recovery quality [19].
showing colic signs within 72 hours from the sur- Cardiovascular examination should include rhythm,
gery [12]. Of these, only one horse required explorative quality and rate of the pulse (e.g. facial artery) and car-
laparotomy; the remaining cases resolved with medical diac auscultation. Mucous membrane colour and capil-
treatment. In multivariable analysis, the administration lary refill time (CRT) should be assessed to evaluate
of morphine compared to no opioid or butorphanol was peripheral perfusion. Elasticity of the skin and the pres-
associated with an increased risk of PC (odds ratio [OR] ence of sweat or previous sweating are guides to hydra-
4.1%, 95% confidence intervals [CI] 1.4–12.2); out-hours tion status. In hot weather, or in horses with fractures
surgeries were also associated with an increased risk of that occurred during training or racing, it is not unusual
PC (OR 3%, CI 1–8.8). Considering the low number of for significant dehydration (>7%) to be present and to
horses that develop colic signs, the association found contribute to an elevated heart rate (HR). In such situa-
between morphine administration and PC should be tions, water should be offered or intravenous (IV) fluid
interpreted with caution. There are additional risk fac- therapy with a balanced solution (e.g. Ringer Lactate)
tors. Thoroughbreds have higher incidence of PC than started alongside pain relief which will also reduce ongo-
non-Thoroughbred horses (OR 1.55%, CI 1.04–2.3), and ing respiratory and sweat loss (Chapter 7). Rectal temper-
the administration of some antimicrobials (e.g. sodium ature should also be checked. Respiratory rate (RR) and
benzylpenicillin) increases the risk further [13]. pattern of breathing should be assessed and thoracic aus-
Transportation, hospitalization, surgery and GA are all cultation performed, preferably when the horse is calm.
stressors that may further increase the risk of PC. Pain Based on the horse’s history and presentation, thoracic
can increase stress and may be an additional contribut- radiographs should be considered in cases with abnormal
ing factor. Morphine was not found to be associated with breathing or lung sounds. Auscultation of gastrointesti-
an increased risk of PC in horses undergoing magnetic nal borborygmi should also be performed. Pre-operative
resonance imaging and non-abdominal surgery [14] and, laboratory tests should be performed if there are clinical
in a clinical setting, peri-operative morphine (0.1 mg/kg concerns: a dehydrated horse will have high haematocrit
IV) did not increase the risk of PC [15]. Peri-operative (normal reference rage 32–52%) and total protein (normal
morphine has also been reported to reduce the need for reference range 60–85 g/l). Electrolytes, particularly
supplementation of IAA [16] and to improve the quality potassium and calcium, should be evaluated in exhausted
of recovery [17, 18], which can be crucial following frac- animals such as endurance horses and if necessary cor-
ture surgery. The authors therefore consider that not rected with appropriate supplementation.
Pre-operative Analgesi 209
Following clinical evaluation, it is possible to assign the 3) Release of anti-diuretic hormone (ADH or vasopressin)
horse to a specific category as defined by the American from the posterior pituitary gland and the activation of
Society of Anesthesiologists (ASA): the renin–angiotensin system within the kidney.
4) Release of ß-endorphin and endogenous opioid
1) Normal healthy patient
peptides.
2) Mild systemic disease with no functional limitation
5) Release of thyroid-stimulating hormone (TSH) and thy-
3) Severe systemic disease with definite functional
roid hormone.
limitation
6) Decreased production of insulin from the pancreas.
4) Severe systemic disease that is a constant threat of life
5) Moribund patient unlikely to survive 24 hours with or
The physiological aim of stress response is to preserve or
without surgery
restore homeostasis, allowing the animal to survive until
‘E’ is used to identify an emergency procedure. the injury has healed. However, prolonged activation has
This classification summarizes the physical status of the an overall negative impact on homeostasis. Activation of
horse, rather than identifying the risks related to GA and the sympathetic nervous system and release of catechola-
the surgical procedure which are affected by other varia- mines result in tachycardia, vasoconstriction and hyper-
bles. While the fracture of a metacarpal bone is unlikely to tension and increased myocardial oxygen consumption.
have systemic repercussions in a dog or a cat, it can be Further, the sympathetic nervous system decreases gastric
argued that any locomotor conditions in horses are likely to emptying time, reduces gut motility and promotes post-
have a significant effect on its physical condition and may operative ileus and colic in horses [22]. Immunodepression
even represent a threat to life. This peculiar aspect of increases the risk of infection and delays healing processes.
equine pre-anaesthetic assessment should not be under If not treated, acute pain, initially masked by endorphins,
estimated. can exacerbate this process and results in hyperalgesia,
A jugular cannula should be placed at presentation fol- allodynia and chronic pain promoting weight loss, muscle
lowing local anaesthetic infiltration of the skin. The can- wastage and ileus. Provision of analgesia is therefore not
nula allows safe injection of potentially extravascular only of ethical but also of medical benefit. If pain cannot be
irritant medications (e.g. phenylbutazone), sedatives and controlled effectively, the animal should be euthanized on
other analgesic drugs, administration of fluids and, if nec- humane grounds.
essary, collection of blood. The cannula should be placed The arguments commonly used to justify lack of analge-
with aseptic technique and secured to the skin with sutures. sia in horses are (i) that pain promotes immobility, reduc-
Pre-operative briefing and planning between surgical and ing the risk of further damage by the use of the injured
anaesthesia teams, organization and pre-anaesthetic check- part; (ii) knowledge about the pharmacology and potential
ing of equipment and anaesthetic monitors are fundamental side effects of analgesic drugs is incomplete; (iii) analgesic
to safety and efficiency (Chapter 9). These decrease anaes- drugs are expensive and not economically viable; (iv) pain
thetic time, risk of errors and improve outcome [20, 21] and recognition is challenging as horses do not show readily
should be performed routinely in every equine hospital. A identifiable signs of pain.
checklist example can be downloaded from the AVA website Analgesic drugs decrease and modulate sensitivity to
(www.ava.eu.com/anaesthetic-records-saftey-checklists). pain; they do not prevent an animal from feeling pain. Local
anaesthetics are the only class of drugs that can completely
inhibit the perception of pain by interrupting transmission
to the dorsal horn of the spinal cord. Thus, in a conscious
Pre-operative Analgesia horse with a fracture, administration of local anaesthetic in
close proximity to a nerve that will result in completely
Trauma, including fractures and their repair, transporta-
blocking nociceptive and sensory inputs from the injured
tion, pharmacologic restraint, GA and recumbency, trigger
area might increase the risk of further damage. All other
a series of neurohumoral and metabolic coping mecha-
analgesics, such as opioids and non-steroidal anti-
nisms identified as a ‘stress response’ which includes the
inflammatory drugs (NSAIDs), do not block pain but modu-
following:
late it. The animal feels more comfortable, but pain
1) Release of catecholamines and activation of the sympa- sensation is maintained during movement, or if an external
thetic nervous system. stimulus is applied to the injured area. The argument that
2) Activation of the pituitary–adrenal system and the analgesics are expensive and therefore should not be used is
release of adrenocorticotropic hormone (ACTH) and unfounded; most commonly used analgesic drugs (e.g. phe-
cortisol. nylbutazone and morphine) are relatively inexpensive.
Several NSAIDs (phenylbutazone, flunixin meglumine, not very lipid soluble and therefore uptake from the epi-
ketoprofen, carprofen, meloxicam, etc.) are licenced for dural space is slow, resulting in prolonged onset (1–5 hours)
the treatment of acute pain and inflammation in horses, and duration of analgesic effect (16–22 hours) compared to
but no study has yet showed superiority of a specific parenteral administration [34]. This could be an advantage,
NSAID despite pharmacological differences in their inhib- decreasing the need for repeated administrations and
itory activity on cyclooxygenases (COX1:COX2 ratio). A potentially reducing the risk of side effects [35]. In horses
review of NSAID actions has been published [23]. All can undergoing bilateral stifle arthroscopy, epidural morphine
potentially trigger side effects (e.g. gastrointestinal ulcera- (0.2 mg/kg) and detomidine (0.03 mg/kg) produced pain
tion, diarrhoea, renal failure, hypoproteinaemia and anae- relief for 20–22 hours [36]. Epidural administration of
mia), especially if overdosed, used in young foals or in 0.2 mg/kg of morphine to pain-free horses caused a
hypovolaemic animals. For this reason, choice of NSAIDs decrease in faecal production for eight hours, but did not
is mainly guided by familiarity, availability and cost. produce clinical signs of ileus or colic, or abolish gastroin-
Whichever is utilized, because of potential inter-individual testinal sounds [37]. In horses undergoing laparoscopic
variability, efficacy should be monitored, and the drug cryptorchidectomy under GA, epidural morphine (0.1 mg/
changed if it is not effective. NSAIDs are the cornerstone kg) produced analgesia and did not affect gastrointestinal
of analgesia in horses with fractures. However, if they are motility [38]. Several drug combinations have been admin-
insufficient to control pain, other drugs (e.g. opioids) istered epidurally, but it is difficult to translate findings to a
should be considered. clinical setting, and there is a paucity of applied stud-
Opioids are often not administered in horses for the fear ies [39]. Epidural administration of a local anaesthetic car-
of side effects: excitation, increased locomotor activity, ries a risk of ataxia or recumbency and is not advisable,
ileus and colic. Horses have a specific receptor profile and especially in the presence of a pelvic limb fracture. Epidural
density that make them more prone to side effects, but cor- administration of an alpha-2 agonist has the potential to be
rect dosing limits clinical relevance. If the dose is inappro- synergistic with opioids, prolonging effect, but may also
priate, or if opioids are used in pain-free horses, the risk of cause sedation and ataxia.
behavioural side effects is greater. Use of morphine in Recognition of acute, severe pain such as that produced
horses has been associated with excitation and increased by a complete, unstable fracture of a long bone is often
locomotor activity. However, there is a marked individual straightforward (Chapter 7). Mild or moderate pain associ-
variation in response; the median dose used in pain-free ated with less severe fractures can be more difficult to
horses was 0.91 mg/kg IV [24]. In pain-free horses, lower detect. Evaluation of facial expression, posture, human
doses of morphine (0.05–0.5 mg/kg IV or IM) temporarily interaction and attitude towards feeding have been used to
reduced intestinal motility and frequency of defecation help recognize if a horse is painful [40–42]. If in doubt, an
and increased water and hay consumption, and stomach analgesic should be administered and the animal’s behav-
size, without showing behavioural changes or colic iour and clinical signs reassessed. A review of pain assess-
signs [25–27]. In a clinical setting, administration of ment in horses has been published [43].
morphine (0.1–0.2 mg/kg) did not cause excitatory effects Horses with fractures should be kept quiet, and sedation
and improved quality of recovery from GA [15–18]. should be used if analgesic administration alone is not suf-
Buprenorphine has been associated with compulsive walk- ficient (Chapter 7). This should be administered to effect in
ing in horses. Butorphanol is more useful in control of vis- order to keep the horse calm, but avoiding ataxia and inco-
ceral rather than somatic pain as caused by fractures; it also ordination. Acepromazine may be sufficient to decrease
still affects gastrointestinal motility [28, 29]. Although use response to environmental stimulation and causes mini-
in horses is increasing, the analgesic potency and the clini- mal ataxia, but without any analgesic effect. Alpha-2 ago-
cal efficacy of opioids are still not completely defined. nists are more reliable sedatives and confer a degree of
Epidural administration of opioids at the level of the first analgesia at spinal and supraspinal levels, but should be
two coccygeal vertebrae (Co1–Co2) is an alternative to sys- used judiciously as they may cause marked ataxia. Xylazine
temic administration in horses with pelvic limb frac- can cause more ataxia and muscle relaxation than romifi-
tures [30, 31]. Segmental analgesia extending from the dine and detomidine and has a shorter acting effect.
coccyx to the thoracic dermatomes has been reported fol- Addition of an opioid enhances the sedative and analgesic
lowing Co1–Co2 epidural morphine administration [32]. effects of alpha-2 agonists. Sedation is also useful to per-
Nonetheless, it is advisable to introduce an epidural cathe- form radiographic investigation, apply limb support
ter and advance it to the thoracolumbar level to increase (Chapter 7), perform standing surgery (Chapter 12) or as
the effectiveness of analgesia for the thoracic limb, or if pre-anaesthetic medication before surgery. Dosages of
multiple administrations are necessary [33]. Morphine is drugs used for sedation are reported in Table 10.1. Early
Induction of Anaesthesi 211
application of appropriate limb support (Chapter 7) from poor perfusion and hypoxia. Vasodilation produced
reduces the risk of displacement. by ACP might also improve muscle blood flow and there-
fore reduce the risk of post-anaesthetic myopathy. The
addition of ACP to romifidine–butorphanol combination
Induction of Anaesthesia also limited the drop in PaO2 and V/Q mismatch [46] and
may therefore improve oxygen delivery to tissues. A combi-
In the presence of a fractured limb, induction of GA can be nation of ACP and alpha-2 agonist with or without an opi-
critical. It is always advisable to adequately sedate the oid is commonly used (Table 10.1). In healthy adult horses,
horse prior to induction and to minimize noise until the the authors prefer to administer ACP (0.02 mg/kg IV)
horse is anaesthetized. However, excessive sedation should 30 minutes before induction of anaesthesia. The mild seda-
be avoided as it causes ataxia that may compromise the tion produced by ACP also facilitates entrance of the horse
ability to control quality of induction. An enquiry into peri- into the induction box and correct positioning for induc-
operative fatalities in horses indicated that pre-medication tion. Once the animal is correctly positioned, an alpha-2
with ACP alone reduced the risk of death compared to agonist (e.g. romifidine 0.07–0.08 mg/kg IV) is adminis-
other sedative combinations [1]. There are a number of tered to induce deeper sedation.
possible explanations. Acepromazine has a long acting The induction technique used depends on facilities,
effect; it might help to decrease requirement of IAAs dur- availability and experience of personnel, together with the
ing surgery [44] and may still be exerting a sedative effect location and stability/instability of the fracture. In the
in the recovery period. Acepromazine reduces the sensitiv- authors’ opinions, assisted induction techniques such as
ity of the myocardium to catecholamines and therefore the pushing the horse against the induction box wall
likelihood of lethal ventricular dysrhythmias, especially if (Figure 10.1) or using a swinging gate are preferred over
halothane is used as an IAA [45]. It may work during peri- free techniques in order to control transition to recum-
ods of bradycardia, when the refractory period ends long bency, thus minimizing the risk of fracture displacement.
before the next heartbeat, leaving the ventricles vulnerable If possible, one person should take charge of the fractured
to ectopic beats that could progress to more severe dys- Limb. The horse should be positioned next to the induction
rhythmias [1]. However, serious ventricular dysrhythmias box wall and, as far as possible, with a fracture should have
are not common in horses, particularly as isoflurane and a square stance. The fractured limb is positioned on the
sevoflurane have substantially eliminated the use of halo- side of the personnel (i.e. away from the box wall). As the
thane as IAAs. It is possible that ACP reduces myocardial horse starts to become weaker after administration of the
work by reducing afterload and protects the myocardium induction agents, a nurse or an assistant should support
Table 10.1 Dose ranges of sedative and opioid drugs commonly used in horses.
Drugs Dose Comments
Acepromazine 0.02–0.05 mg/kg IV–IM Administer at least 20–30 minutes before induction of
0.075–0.22 mg/kg orally anaesthesia. Use with caution in hypovolemic or
dehydrated animals.
Xylazine 0.5–1 mg/kg IV Dose-dependent sedation. Consider lower doses if given
1–2 mg/kg IM after acepromazine or in conjunction with an opioid.
Detomidine 0.01–0.02 mg/kg IV Dose-dependent sedation. Consider lower doses if given
0.02–0.04 mg/kg IM after acepromazine or in conjunction with an opioid.
0.04 mg/kg sublingually
Romifidine 0.05–0.1 mg/kg IV Dose-dependent sedation. Consider lower doses if given
0.1–0.2 mg/kg IM after acepromazine or in conjunction with an opioid.
Butorphanol 0.01–0.1 mg/kg IV–IM Usually in combination with an alpha-2 agonist.
Buprenorphine 0.005–0.01 mg/kg IV–IM Give an alpha-2 agonist five minutes before. Increase
locomotor activity when the effect of alpha-2 agonist
disappears.
Morphine 0.1–0.3 mg/kg IV–IM Usually in combination with an alpha-2 agonist.
Methadone 0.1–0.3 mg/kg IV–IM Usually in combination with an alpha-2 agonist.
Figure 10.1 Horse positioned against the

recovery box wall for induction of general
anaesthesia.
the head and slightly lift it, while the remaining personnel Table 10.2 Dose ranges of induction agents and muscle
gently push backwards and against the wall, so its rump relaxants commonly used to induce general anaesthesia in horses.
touches the back wall. The horse can then gradually sink
into the corner, supported by walls on two sides and per- Drugs Dose Comments
sonnel on the third side.
Ketamine 2–3 mg/ Horse needs to be sedated first with
Several combinations of injectable drugs have been used kg IV an alpha-2 agonist. Diazepam,
to induce GA in horses; however, ketamine or thiopental, midazolam or guaifenesin should
with benzodiazepine (e.g. diazepam or midazolam) or be used to provide further muscle
guaifenesin, are most commonly used (Table 10.2). The relaxation.
authors preference is IV ketamine (2.5–3 mg/kg) combined Thiopental 4–12 mg/ After sedation with an alpha-2
kg IV agonist, 2–3 g of thiopental is
with diazepam (0.05–0.06 mg/kg).
sufficient if used together with
Once GA has been induced and the trachea intubated, guaifenesin. Higher dosages are
the horse can be lifted using a hoist and transferred to the necessary if used without guaifenesin.
operating table. The horse can be lifted by hobbles on the Diazepam 0.03– Used as muscle relaxant together
non-fractured limbs and a rope used to support the frac- 0.06 mg/ with ketamine.
tured one (Figure 10.2). The operating table should be kg IV
well padded to avoid points of compression. In lateral N.B.: Not to be used alone.
recumbency, the dependent thoracic limb should be Midazolam 0.05– Used as muscle relaxant together
extended cranially and upper thoracic and/or pelvic 0.1 mg/kg with ketamine.
IV
limbs supported to decrease compression of the lower
limbs and reduce the risk of post-operative myopathy/ N.B.: Not to be used alone.
neuropathy (POMN) (Figure 10.3). In dorsal recum- Guaifenesin 50 mg/kg Used as muscle relaxant with
to effect ketamine or thiopental in sedated
bency, the horse should be kept as straight as possible
IV horse.
using inflatable pillows or similar at the level of both
shoulders. Additional small mattresses can be used to N.B.: Not to be used alone.
decrease compression of the quadriceps muscles
(Figure 10.4a). The croup of the horse should not over-
hang the table as this can result in sciatic impairment and reduce surgical time. Side effects seen in humans
and/or damage to the cauda equine (Figure 10.4b). include neuropraxia together with skin and muscle dam-
Prolonged periods of hindlimb extension and locking of age. Pain with increased HR, systemic vascular resistance,
the stifle joints should be avoided. central venous and arterial blood pressure (ABP) and acti-
An Esmarch bandage and tourniquet are commonly vation of coagulation have been also documented in
applied to distal limb fractures to improve visualization humans [47]. Application of a pneumatic tourniquet at
Maintenance of Anaesthesia and Intra-operative Analgesi 213
to the relative paucity of muscle in the distal limbs.

Nonetheless, the duration of application should be mini-
mized to decrease the risk of complications and tourniquet-
induced pain. In humans, the maximum advised time for
tourniquets is 1–3 hours [50]. A maximum time for tourni-
quet application in horses has not been determined.
Nonetheless, it is advisable to monitor ABP once the tour-
niquet has been released.
aintenance of Anaesthesia
M
and Intra-operative Analgesia
IAAs are most commonly used to maintain GA in horses.

Despite numerous studies comparing them [51–57], none
is clearly superior. Horses anaesthetized with isoflurane
might require more inotropic support (e.g. dobutamine)
compared to sevoflurane [55]. Recovery time is shorter
after isoflurane anaesthesia, but quality might be worse
than halothane [54], and for this reason post-operative
Figure 10.2 Horse with a condylar fracture of the left third
metacarpal bone hoisted onto the operating table: a rope is sedation with an alpha-2 agonist is recommended [58]. No
used to support the splinted fractured limb. differences in recovery times and quality were found com-
paring isoflurane and sevoflurane in horses undergoing
600 mmHg for 120 minutes caused localized acidaemia and magnetic resonance imaging [56].
increased serum potassium concentration in horses [48]. A All IAAs cause dose-dependent respiratory depression
significant drop in ABP was recorded in horses after release and hypoventilation, and for this reason mechanical venti-
of a tourniquet [49], possibly secondary to reperfusion lation should be available. They also cause hypotension
release of catabolites produced during the ischaemic and decreases in stroke volume and cardiac output. ABP
period. Clinically apparent problems associated with tour- should therefore be closely monitored, and if necessary
niquet use in horses appear uncommon. This may be due positive inotropes or vasopressors used to maintain
(a) (b)
Figure 10.3 Horses positioned in lateral recumbency: (a) the dependent thoracic limb has been extended cranially and (b) the
non-dependent pelvic limb is supported.
(a) (b)
Figure 10.4 Horse positioned in dorsal recumbency. (a) A small mattress has been placed between the table and the horse to
decrease point compression of the quadriceps muscle. (b) The croup of the horse should not overhang the table as this may result in
damage to the cauda equine or sciatic impairment.
peripheral perfusion [59, 60]. In order to provide analgesia of drugs that can be used for PIVA have been pub-
and thus to decrease the requirement for, and potential side lished [19, 65, 66].
effects caused by IAAs, a sedative (e.g. alpha-2 agonist) Ventilation/perfusion (V/Q) mismatch is a well-
and/or analgesic (e.g. opioids, local anaesthetic or keta- recognized complication of equine anaesthesia. Hypercapnia
mine) can be infused intra-operatively to provide partial and relative or absolute hypoxaemia are common, espe-
intravenous anaesthesia (PIVA). The superiority of PIVA cially in horses anaesthetized in dorsal recumbency.
compared to standard inhalation anaesthetic techniques Intermittent positive pressure ventilation (IPPV) can be
has not been absolutely proved [61, 62], and it is not clear advantageous, allowing regular delivery and uptake of oxy-
which combination of injectable drugs is best. The phar- gen and IAAs. If started immediately after induction of
macokinetic and pharmacodynamic (PK–PD) interactions GA, it achieves higher arterial oxygen partial pressure
between drugs are difficult to predict, particularly in an (PaO2) and lower alveolar–arterial oxygen gradient (P(A-a)),
anaesthetized horse in which hypotension and decreased therefore less pulmonary shunt compared to spontaneous
liver perfusion could affect drug disposition [63]. In frac- ventilation or IPPV started later in anaesthesia [67, 68].
ture repairs requiring anaesthetic times longer than The concomitant use of IPPV and positive end-expiratory
60–90 minutes, the authors’ preference is to administer an pressure (PEEP) at 10 cmH2O is preferred to IPPV alone in
infusion of alpha-2 agonist (e.g. romifidine). If romifidine healthy horses, especially for prolonged GA [69]. If atelec-
is used as pre-anaesthetic medication, a constant rate infu- tasis has already developed, PEEP and IPPV cannot resolve
sion (CRI) can be immediately started after the horse has it. In such situation, alveoli should be recruited maintain-
been positioned on the operating table (0.04 mg/kg/hour) ing, for example, a peak of inspiratory pressure (PIP) at
and continued until the end of the surgery. In a clinical 60–80–60 cmH2O for 10–12 seconds each, and PEEP should
study in horses undergoing arthroscopy, romifidine CRI be applied afterward [69, 70] or, alternatively, PEEP could
failed to reduce the isoflurane requirement to maintain GA be increased in a stepwise manner (i.e. 5 cmH2O every
but recovery quality was better with more horses standing 10 minutes up to 30 cmH2O) and then decreased in a simi-
without ataxia at the first attempt [62]. Despite alpha-2 lar way [71]. Continuous positive airway pressure (CPAP)
agonists causing vasoconstriction and decreasing cardiac could be used instead of IPPV to decrease development of
output, romifidine CRI did not affect the cardiac index [62] pulmonary shunt [72, 73], but this is not technically as easy
or increase plasma lactate concentration [64] in anaesthe- as IPPV with PEEP. IPPV and PEEP could contribute to
tized horses. Xylazine, detomidine, medetomidine and worsening arterial hypotension by reducing venous return
dexmedetomidine have also been used successfully as part and decreasing sympathetic stimulation caused by
of PIVA. Medetomidine and dexmedetomidine are not increased arterial carbon dioxide pressure (PaCO2). This
licenced for use in horses, while xylazine and detomidine might be more obvious in hypovolemic or endotoxic
could increase ataxia in recovery. Comprehensive reviews a nimals. In a study of healthy horses anaesthetized with
Peripheral Nerve Block 215
i soflurane and medetomidine CRI, cardiovascular perfor- c ompromise the ability of the horse to stand in a coordi-
mance during IPPV targeting a PaCO2 between 50 and nated manner and lead to injury. A list of PNBs that could
60 mmHg was similar to spontaneously ventilating horses, be used for appendicular fracture repair is provided in
with similar PaCO2 [74]. A comparison of haemodynamic Table 10.3. Comprehensive guides to performing specific
performance during eucapnia and mild, moderate and PNBs have been published [82, 83]. PNBs suitable for use
severe hypercapnia (PaCO2 40, 60, 80 and 110 mmHg, in management of individual fractures of the ribs and head
respectively) concluded that hypercapnia presents a bipha- are provided in Chapters 35 and 36, respectively.
sic effect on cardiac output, with only moderate and severe The choice of the local anaesthetic depends on availabil-
hypercapnia improving it [75]. In light of the acid–base ity, desired onset and offset of effect, and licencing.
modifications induced by hypercapnia and their possible Mepivacaine and lidocaine are most commonly used for
effects on the horse, the argument for spontaneous ventila- diagnostic PNBs in horses, with mepivacaine apparently
tion during equine anaesthesia is not strong. Nevertheless, presenting lower neurotoxicity in human cells [84]. Their
if not used with judgement, IPPV and PEEP could result in pharmacological profile is similar and their effects last for
alveolar overdistension and cause lung inflammation with- about two hours. A solution of lidocaine or procaine mixed
out improving gas exchange [76]. The different ventilatory with adrenaline is licenced in UK for PNBs in horses. The
strategies that can be used in anaesthetized horses have addition of adrenaline decreases systemic absorption pro-
been recently reviewed [77]. longing effect [85]. Bupivacaine is not licenced for horses
High-inspired oxygen fraction (FiO2 > 90%) has been in Europe but is on the ‘essential or positive list’ (EC No.
associated with rapid onset of atelectasis and pulmonary 1950/2006) for the medical treatment of Equidae, in
shunt [46, 78]. Therefore, it is advisable to mix oxygen with
medical air and administer lower FiO2 (e.g. 50–60%) and
monitor the pulsatile arterial oxygen saturation (SpO2) and Table 10.3 Peripheral nerve blocks used to produce analgesia
of the distal limb.
the PaO2. If SpO2 and PaO2 are low, the FiO2 can be
increased to maintain oxygen delivery. However, the clini-
Nerve block Anatomical part anaesthetized
cal consequences (with respect to mortality and morbidity)
of using high FiO2 in healthy horses are not fully Lateral and Blocking just proximal to the collateral
understood. medial palmar cartilage produces anaesthesia of the entire
Aerosol administration of salbutamol, a β2 receptor ago- digital (heel sole, navicular bone and bursa, soft tissues
block) of the heel, entire distal intraphalangeal
nist, through the endotracheal tube has been reported to
joint (coffin joint), distal aspect of deep
successfully increase PaO2 in hypoxaemic horses. It has digital flexor tendon and distal sesamoidal
been suggested that this is mediated by bronchodilation of ligament. The pastern joint may be partially
perfused lung regions [79], but the exact mechanism is still desensitized.
unclear. Systemic absorption and an extra-bronchial effect Lateral and Blocking at the level of the proximal
cannot be excluded as sweating, and a positive chrono- medial abaxial sesamoid bones produces anaesthesia below
sesamoid the fetlock joint.
tropic effect have been reported [80, 81]. Salbutamol could
Low palmar Blocking medial and lateral palmar nerves
therefore be considered as temporary therapy for increas-
four point adjacent to the deep digital flexor tendon
ing PaO2, but alveolar recruitment procedures should still with medial and lateral palmar metacarpal
be performed in case of atelectasis. nerves at the level of the distal end of the
second and fourth metacarpal bones
produces anaesthesia of the fetlock and
structures distal to it.
Peripheral Nerve Blocks
High palmar Blocking medial and lateral palmar nerves
four point adjacent to the deep digital flexor tendon
Peripheral nerve blocks (PNBs) are commonly used to (suitable for slightly below the carpometacarpal joint
allow standing fracture repair (Chapter 12); however, they standing with medial and lateral palmar metacarpal
can also be part of a balanced technique in anaesthetized fracture nerves axial to the second and fourth
repair) metacarpal bones produces anaesthesia of
horses. PNBs allow the amount of IAA necessary to main-
the thoracic limb distal to the block.
tain GA to be reduced and provide analgesia during the
High plantar Blocking medial and lateral plantar nerves
recovery. Although this could be of advantage in terms of six point with the medial and lateral plantar
recovery quality, a risk/ benefit assessment needs to be (suitable for metatarsal nerves and dorsal metatarsal
performed on a case-by-case basis. While desensitization of standing nerve just distal to the tarsometatarsal
the most distal part of the limb is unlikely to have a signifi- fracture joint provides anaesthesia of the distal
repair) pelvic limb.
cant negative impact on recovery, higher PNBs may
accordance with the directive 2001/82/EC of the European considered a warning of impending movement. If the head
Parliament. Despite the absence of information on maxi- and neck of the horse are not accessible, then anal tone and
mal residual limits (MRL), bupivacaine can be used in reflex can be evaluated, bearing in mind that this is not a
horses that may enter the food chain provided a withdrawal very reliable method of assessing depth of GA.
period of at least six months is observed. The advantage of Pulse quality, CRT and colour of mucous membranes
bupivacaine is the longer (up to six to eight hours) duration provide clinical information on stroke volume/cardiac out-
of effect [86, 87]. Although in other species it has been sug- put, ABP, tissue perfusion and blood oxygenation.
gested that if used in low concentration bupivacaine can Respiratory rate and pattern should also be monitored
cause selective sensory blockade [88], there is no literature throughout GA. Breathing becomes prominently diaphrag-
investigating or supporting this finding in horses. matic when GA is deeper, while changes in rate and pat-
Ropivacaine 0.75% which is structurally related to mepiv- tern should be interpreted in the light of other clinical
acaine and bupivacaine produces similar effect to bupiv- signs of depth of anaesthesia. It is not uncommon for
acaine [86] but, as it is not included in the positive list, in anaesthetized horses breathing spontaneously to have a
EU countries it can only be used in horses certified not to low RR, with a large tidal volume. If ventilation is con-
enter the food chain. trolled, spontaneous breathing attempts suggest light
anaesthesia, or inadequate ventilation and/or oxygenation.
If the expired carbon dioxide pressure (PE'CO2) is normal
onitoring and Cardiovascular
M or low, anaesthesia depth is adequate and the horse is fight-
Support ing the ventilator. Arterial blood gas (ABG) should be ana-
lyzed to rule out significant V/Q mismatch affecting gas
Anaesthetic monitoring and good record keeping are of exchange, and therefore making the capnograph reading
fundamental importance from the medico-legal point of inaccurate (see below).
view and to identify trends within an individual procedure. Clinical monitoring should be systematic and done at
Clinical and physiological monitoring are used to docu- regular intervals regardless of the use of instrumental
ment normality, to identify abnormalities and then to monitoring. While brief GA in otherwise healthy horses
assess the effect of treatment(s). A typical example in can be managed with clinical monitoring alone, for longer
equine anaesthesia is monitoring ABP to detect hypoten- procedures such as fracture repairs instrumental monitor-
sion and then treat it. There is no evidence-based consen- ing is recommended. Instrumental monitoring is more
sus on minimum standards for equine monitoring, objective than clinical monitoring and allows documenta-
although guidelines promoted by scientific associations tion of trends, even when they are slowly developing.
exist [89]. Electrocardiography using a three lead configuration is
Clinical monitoring including position of the eye, palpe- commonly used. Frequent abnormalities are I and II degree
bral reflex, muscle relaxation, presence of nystagmus and atrioventricular (AV) blocks that are generally indicative of
lacrimation remains the cornerstone of assessing depth of high vagal tone, related to fitness and/or drug administra-
GA in horses. While certain signs such as the presence of tion (alpha-2 agonists). Atrial fibrillation can also be found
nystagmus are generally related to inadequate anaesthesia in athletic horses. This is generally primary and therefore
and are highly correlated to incipient movement, it should of little relevance for GA provided the ventricular rate is
be recognized that some horses may move without present- acceptable. While a rapid increase in HR may indicate
ing nystagmus or have nystagmus throughout an otherwise response to surgical stimulation due to inadequate anaes-
uneventful anaesthetic period. Lacrimation is generally a thesia or analgesia, an anaphylactoid reaction should be
sign of superficial GA. During GA the eye should be central considered if the event occurs during or immediately after
or cranially rotated, with sluggish to no palpebral reflex, drug administration. Hypovolaemia is relatively uncom-
and nystagmus should be absent. Rotation of the eye occur- mon in horses subject to fracture repair, but it should be
ring during GA should not be confused with nystagmus. recognized that horses anaesthetized immediately after
Muscle tone is generally assessed at the level of the neck, exercise, following long journeys or after prolonged, inad-
palpating the sternocephalic and brachiocephalic muscles equate analgesia, may have some degree of dehydration.
when the horse is in dorsal recumbency, and the brachioce- Pulse oximetry is useful provided it is accurate and works
phalic and cervical portions of the serratus muscle when reliably. Unfortunately, this is not always the case.
the horse is lateral recumbency. Jaw tone can also be Performance of different brands and different probes is
assessed. This can be very useful in foals, but is not easy in highly variable, depending on hardware, software, type
adults with well-developed masticatory muscles. Muscle and location of the probe and, not least, conditions affect-
tension associated with a brisk palpebral reflex should be ing tissue perfusion [89–93].
Monitoring and Cardiovascular Suppor 217
It must also be appreciated that, due to the technology likely to develop V/Q mismatch, it is necessary to question
used, pulse oximetry is extremely unlikely to overestimate whether systematic ABG analysis in horses at low risk of
SpO2, and more commonly underestimates it. The practical developing V/Q problems is justified on risk/benefit/cost
implication is that the technique is more sensitive than analysis. It is the opinion of the authors that in mechani-
specific: while a normal reading documents adequate cally ventilated healthy athletic horses repeated ABG anal-
SpO2, a low reading may be caused by artefacts (low tissue ysis is necessary only if clinically indicated, such as to
perfusion caused by hypotension, vasoconstriction or check PaO2 and SaO2 in the absence of pulse oximetry
excessive probe pressure). Pulse oximetry should therefore readings, if SpO2 is low in order to exclude hypoxaemia or
be used to document adequate SpO2, rather than to identify to check PaCO2 to assess ventilation and rule out alveolar
with specificity an abnormal gas exchange. In the specific dead space in the presence of unexpected low PE'CO2.
setting of a fracture repair in an athletic horse, the likeli- ABP monitoring, on the other hand, should be instituted
hood of a low reading being genuine is small, due to the in all but the shortest procedures, i.e. it is indicated for all
level of fitness of the animal and the likely absence of horses undergoing fracture repair. Despite reports of suc-
comorbidities. On the other hand, if the horse anaesthe- cessful use of non-invasive ABP measurement in
tized is not an athlete, is large (e.g. a draft horse), has a anaesthetized horses [96], the ease of arterial cannulation
history of respiratory disease, is a foal, or based on clinical makes invasive monitoring practical in all procedures per-
assessment it is possible that the reading may be genuine, formed in a hospital setting. The transverse facial, facial and
then it should be further investigated by ABG analysis. metatarsal arteries are most easily accessed, generally using
When discussing the role of pulse oximetry in relation to a 20G cannula. Although focal destructive lesions of the
blood oxygenation, the peculiar shape of the haemoglobin proximal sesamoid bones following metatarsal artery can-
dissociation curve must be considered when using a high nulation in three horses have been reported [97], this com-
FiO2: even in the presence of moderate V/Q mismatching, plication appears very rare, considering the number of
saturation could still be close to 100%. Correlation coeffi- horses in which the procedure is performed, and if an asep-
cients of 0.85–0.97 have been reported, with errors result- tic technique is used it should not be considered a deterrent.
ing from inability to read or underestimation of SpO2 [94, Hypotension is probably the most common complication
95]. Performance of a pulse oximeter may be worse in com- encountered in equine anaesthesia and has been linked to
promised horses and in horses breathing spontane- reduced intestinal perfusion [98] and post-operative myo-
ously [91]. It is therefore important, when choosing a pulse pathy [99]. Myopathy is thought to result from inadequate
oximeter, to first test its performance. Using an unreliable perfusion of the muscles during GA, caused by incorrect
monitor is costly and may trigger unnecessary investiga- positioning on the surgical table, hypotension or a
tion and treatment. combination of these. Reperfusion at recovery may further
Capnography is the only means (excluding ABG analy- damage the muscle. Long duration of GA and mean
sis) of monitoring adequacy of ventilation. However, its ABP <70 mmHg have been linked to post-anaesthetic myo-
performance in horses is not as accurate as in small ani- pathy in halothane anaesthetized horses [100]. Muscle per-
mals, mostly due to the greater frequency of V/Q mis- fusion depends on the difference between compartmental
matching, and in particular alveolar dead space pressure (opposing blood flow) and mean ABP (driving
(PaCO2 – PE'CO2 > 5 mmHg) ventilation. In horses at blood flow). Since compartmental pressure in dependent
greater risk of V/Q mismatching or in the presence of a low equine limbs is approximately 30–60 mmHg and in the
PE'CO2 in the absence of hyperventilation, the reading uppermost limb is 4–16 mmHg, it has been suggested that a
should be confirmed by ABG analysis. Accuracy of capnog- mean ABP of at least 70 mmHg is maintained during halo-
raphy in estimating PaCO2 is greater in healthy horses and thane anaesthesia [101]. Current evidence suggests that the
during IPPV [91]. When ventilation is constant (the venti- effect of IAAs on muscle blood flow in horses is directly
lator settings have not been changed, or an increase in dead related to the degree of cardiovascular depression caused,
space ventilation has not occurred), the PE'CO2 is mostly and thus to mean ABP. It appears that muscle blood flow is
affected by lung perfusion, therefore a change in PE'CO2 is better preserved with isoflurane than halothane [53, 102].
suggestive of a change of cardiac output in the same Despite the mechanistic explanation of post-anaesthetic
direction. myopathy, which considers dependent limbs more at risk
The propensity of horses to develop V/Q mismatch is the and mean ABP a crucial factor, there are occasional reports
rationale for systematic ABG determination. However, in of myopathy developing only in non-dependent limbs, sug-
view of the above considerations of performance of pulse gesting that other phenomena may be involved [103]. Based
oximeters and capnographs in this species, and the poten- on this evidence, it may be advisable to use positive ino-
tial to predict, with some accuracy, which horses are more tropes and/or vasopressors to maintain a mean ABP greater
than at least 60 mmHg in isoflurane anaesthetized horses. towel and ‘plugging’ the ear canals with swabs can help to
The effect of dobutamine infusion on cardiac output, mus- reduce stimulation); (iii) the urinary bladder should be
cular blood flow and intestinal perfusion in both halothane catheterized especially after prolonged GA, infusion of a
and isoflurane anaesthetized horses has been investigated. large quantity of IV fluid or repeated administration of
Infusion of dobutamine is effective in reversing depressant alpha-2 agonists (e.g. CRI as part of PIVA); (iv) provision of
cardiovascular effects of IAAs, thus improving perfu- adequate analgesia as pain can lead to a rapid violent
sion [102, 104–109]. The best results are achieved by admin- recovery; (v) administration of post-operative sedation par-
istering a bolus of fluid alongside dobutamine infusion [109]. ticularly following use of IAA.
Interestingly, it appears that administration of dobutamine There was no significant difference in time to first attempt
improves muscle blood flow even at doses that are not caus- to stand and recovery quality using detomidine (2 μg/kg IV),
ing an evident increase in ABP [102]. Other vasopressors, romifidine (8 μg/kg IV) or xylazine (0.1 mg/kg IV) in horses
such as dopamine, phenylephrine and ephedrine, are also not undergoing surgery anaesthetized with isoflurane for
effective in increasing ABP, but may have a less predictable two hours. However, recoveries were significantly worse
effect on muscle and intestinal blood flow while potentially without any sedation [58]. In a clinical study, romifidine at
having significant side effects [102, 108]. 20 μg/kg IV improved recovery quality compared to lower
Monitoring IAA concentration is a helpful early warning doses of the same drug (10 μg/kg IV) or xylazine (0.1–0.2 mg/
of changes in anaesthetic depth, and if used alongside clin- kg IV) in horses anaesthetized with isoflurane for longer than
ical monitoring may reduce the risk of movement during one hour [113]. In nervous horses or after prolonged GA, the
anaesthesia. Management of fresh gas flow (FGF) can also authors prefer to administer an alpha-2 agonist (e.g. romifi-
be titrated with greater accuracy, reducing anaesthetic dine 0.02–0.03 mg/kg IV) together with acepromazine (0.01–
wastage and pollution. If not promptly identified, excessive 0.02 mg/kg IV) to prolong sedation, allowing the animal time
or too early reduction of FGF will cause a rapid decrease of to exhale as much IAA as possible. In the presence of severe
end-tidal anaesthetic concentration, which may result in pain, the administration of morphine (0.1–0.3 mg/kg IV) pro-
an inadequate anaesthetic plane. Clinical monitoring will ducing analgesia and potentiating the sedative effect of
allow late identification of such a situation compared to alpha-2 agonists and acepromazine can be beneficial.
end-tidal anaesthetic monitoring. On the other hand, Although it has been suggested that longer recovery
unnecessary use of FGF will result in wastage of IAA, with times are linked to better recovery quality [9], it seems that
increased cost and pollution. Limitations of IAA monitor- when desflurane is used, the administration of sedation in
ing, which must be considered during clinical use, are that recovery does not improve its quality despite prolonging
accuracy of the reading is greater in IPPV compared to recovery time [114]. Interestingly, a difference in recovery
spontaneous ventilation and is lower when anaesthetic quality and time between isoflurane and sevoflurane was
concentration changes rapidly (i.e. immediately after not found in horses that received romifidine prior to GA
induction of GA). Additionally, some older monitors are and underwent magnetic resonance imaging without being
methane sensitive which, in equine anaesthesia, can result sedated in recovery [56]. In another study, sevoflurane pro-
in unpredictable errors [110, 111]. duced a quicker and better recovery than isoflurane in
horses that were pre-medicated with xylazine and sedated
with the same at the end of GA [51].
Recovery from Anaesthesia Based on current knowledge, it is more likely that the cru-
cial factor is not the duration of recovery per se, but keeping
Recovery from GA is critical in horses. In a general survey, the horse down long enough for the anaesthetic effect on
fractures during recovery accounted for 25.6% of the total coordination and muscle strength to be minimized. The PK
deaths in horses that underwent non-colic surgery [1]. profile of desflurane may make sedation unnecessary
More recently, in a population of 1416 horses that under- because of the extremely rapid washout period. It is postu-
went colic or other emergency surgery, 1.1% died or were lated that the anaesthetic concentration at which horses are
euthanized in the recovery box and of these 71.4% were conscious enough to attempt to stand is still sufficient to
due to fracture or dislocation [112]. It is recognized that cause ataxia and incoordination [9]. On this basis, it is neces-
horses that undergo fracture repair, arthrodesis or osteot- sary to prevent the horse trying to stand at this stage. A point
omy are more at risk of injury during recovery [1, 8, 10]. to consider if further GA is necessary, e.g. for cast changes,
Continuous monitoring and attention to simple details implant removal, etc., is that recovery quality improves in
can make a major difference: (i) the surface of the recovery the event of repeated anaesthetic episodes [115].
box should be dry to prevent slipping; (ii) environmental Attempting to physically restrain a horse in lateral
stimulation should be minimal (covering the eyes with a recumbency sitting behind the horse’s head with one knee
Recovery from Anaesthesi 219
recovery can be performed. The one-man head and tail

rope technique requires two metal rings bolted through the
wall positioned at about 220 cm above the horse’s head,
locking carabiners, mountaineering ropes (10–11 mm of
diameter) and a self-braking belay descender device for
emergency quick release (e.g. Petzl Grigri). A strong recov-
ery headcollar without metal rings is fitted to the horse’s
head. One rope is connected to the headcollar and one to
the tail (Figure 10.6a). As the horse attempts to stand, the
operator pulls the rope attached to the tail using the self-
braking descender to help it raise the pelvic limbs while
using rope attached to the headcollar to balance the ani-
mal. Once the horse has stood, both head and tail ropes are
used to stabilize the animal [116]. The two-man technique
involves similarly placed rigs with divergent head and tail
Figure 10.5 Horse physically restrained in early recovery from rope traction (Figure 10.6b).
general anaesthesia.
As with other assisted recovery techniques, a calm and
cooperative horse is essential and personnel should be
trained and experienced [116]. In a recent retrospective
on the neck (Figure 10.5), while administering sedation, study of 5852 horses, undergoing different surgeries, recov-
can delay the first attempt to stand and contribute to suc- ered with a one-man head and tail rope technique, 12
cessful recovery. For small ponies and foals, it is possible to horses (0.2%) died or were euthanized: 4 had cardio-
fully assist recovery by hand support of the tail and the pulmonary arrest, 3 developed myopathy, 2 fractured dur-
head with a headcollar. This technique is not risk free for ing recovery, 1 had a joint luxation, 1 had severe metabolic
personnel and therefore should be only used by experi- acidosis and in 1 malignant hyperthermia was presumed.
enced handlers and limited to calm, good-tempered horses. Eighteen horses (0.3%) suffered minor non-fatal complica-
Use of head and tail rope assistance has recently become tions, five of which were related to equipment failure: loose
popular [116] and, compared to free recovery, it has been halter, broken tail hair, tail rope slipped off and facial
reported to require fewer attempts to stand, reduce the paralysis [119].
incidence of recovery-induced minor injuries and both
accelerate and improve the quality of recovery in horses
Deflating Air Pillow
undergoing elective surgeries. Nevertheless, the same
number of fatalities was found [117]. The evidence of supe- A 5 cm thick high-density foam mat and a rapid inflation–
riority of an assisted technique versus free recovery in deflation air pillow/mattress made of vinyl is used to cover
horses is not strong [118] and, in common with all systems, the floor of the recovery box. When fully inflated, the cush-
it can create problems of its own. Some horses (in the ion is 46 cm thick and completely fills the floor of the
authors’ experience particularly Thoroughbreds and young recovery box (Figure 10.7a). Elastic ropes attached to each
animals) do not tolerate such restraint and will become agi- corner of the vinyl cover top are connected to the corners
tated and may twist while held with the ropes. In one of the recovery stall, keeping the top surface under tension
report, 38.1% of the mortality related to GA occurred when the pillow is later deflated. The rationale is to keep
because of fractures during head- and tail-rope-assisted the horse recumbent until it appears ready to stand.
recovery [10]. A number of recovery techniques have been Following surgery, the horse is placed in the centre of the
reported (Sections Head and Tail Rope Techniques to Tilt recovery box on the deflated air mattress; shoes, which
Table), but whichever system is used personnel involved could damage the pillow, must be removed. The pillow is
should have adequate training to decrease the risks for rapidly inflated with air using a fan outside the recovery
people and horses. box (Figure 10.7b). The soft pillow prevents the horse from
rolling into sternal recumbency. Once the horse is consid-
ered ready to roll into sternal, the fan is switched off and
Head and Tail Rope Techniques
two 92 cm zippers along the sides of the air mattress are
Depending on the size of the recovery room, an indoor opened to produce rapid deflation (Figure 10.7c). As soon
(handler standing in the recovery room) or outdoor as the pillow is flat, the horse can roll into sternal
(handler standing outside the recovery room) assisted recumbency and attempt to stand at will (Figure 10.7d).
(a) Figure 10.6 Head and tail rope

recovery systems technique that
can be performed by (a) a single
person operating both ropes and (b)
ropes operated by two different
people. Source: Courtesy of Prof. RE
Clutton, Royal (Dick) School of
Veterinary Studies, The University of
Edinburgh, UK.
(b)
The system can be used to recover any horse, does not is raised when the horse attempts to move from lateral to
require special training and is safe for personnel. The sternal recumbency. Head and tail ropes help to stabilize
cost of the air mattress and fan should be considered. In the patient during this process. Personnel should be
a prospective study comparing recovery from GA in trained in fitting the sling, and a calm and cooperative
horses undergoing different surgical procedures, there horse is essential for successful recovery. More informa-
was no difference in the overall recovery quality scores tion about large animal vertical lift can be found on www.
between deflating air pillow and spontaneous tech- largeanimallift.com.
niques. However, horses recovered on the deflating air
pillow spent more time in lateral before attempting to
Sling Recovery
attain sternal recumbency and stand. Once the pillow
was deflated, horses were also able to stand after fewer Sling systems may be useful to decrease loading of a frac-
attempts [120]. tured limb or to protect an external skeletal fixation device
during the recovery process. The sling must be fitted and
attached to an overhead hoist while the horse is
Large Animal Vertical Lift
a naesthetized (Figure 10.8). When the horse attempts to
The large animal vertical lift is a lightweight aluminium stand, the sling is lifted to raise all four legs from the
spread bar with two robust body slings that are attached to ground; the animal is then lowered again. If the horse is
an overhead hoist in the recovery box. It is said to assist awake enough, it will be able to support its weight and
heavy horses or horses with neuropathies and/or myopa- stand as soon as its hooves touch the floor. Three main sys-
thies that are unable to stand spontaneously. The maxi- tems are available: the Shell System, Liftex 3 and Anderson
mum weight that can be lifted is about 1000 kg. The hoist 4. Regardless of the sling used, this method is applicable
(a) (b)
(c) (d)
Figure 10.7 Deflating air pillow recovery system: (a) centrally positioned horse with a secured endotracheal tube and inserted
oxygen line; (b) fan for pillow inflation positioned outside the recovery box with a floor level portal; (c) zippers for deflation on the
side of the mattress; (d) horse standing on the deflated mattress. Source: Courtesy of Dr DS Hodgson, College of Veterinary Medicine,
Kansas State University, Manhattan, USA.
only to calm and cooperative horses and personnel must be retrospective study of 104 horses [121], the system was
trained and experienced in using the device. well tolerated in 72%, associated with minor complica-
The Shell System sling consists of two glass-fibre-enhanced tions in 22% and had to be aborted in 6% of cases, in
plastic shells connected to each other by a short girth. which despite sedation with xylazine, patients did not
The shells support most of the animal’s weight in front, tolerate the sling. It can be used in horses weighting
while transverse girths passing in front and behind the between 280 and 685 kg.
thighs support the caudal body. The edges of the shells The Liftex sling can be used during induction of anaes-
and the transverse girths are hooked on four hoists. A thesia and/or to transport horses with major musculoskel-
headcollar is placed on the horse, and a rope connects etal trauma from the induction box to the surgery table or
this to the ceiling of the recovery box while a tail rope is from the table to a recovery pool. It works as a vertical lift,
attached to a fifth hoist. The Shell System is fitted while but the rear piece of the sling prevents the animal from
the horse is anaesthetized and placed in dorsal recum- backing out of the support. It is made of a breathable nylon
bency. It can then be allowed to lie in lateral recumbency. fabric that can be adjusted to fit horses of different sizes.
As soon as the horse is judged conscious, it is allowed to Although the fulcrum of suspension from the lifting rings
roll into sternal with the head supported. It is then lifted can be adjusted to promote sternal over abdominal sup-
up by all five hoists into a standing position. In a port, it may still limit chest excursion.
The Hydro-Pool is a rectangular water pool (3.7 m long,

1.2 m wide and 2.6 m deep) with a hydraulic, stainless-steel
grate floor that can be raised and lowered. Grate-covered
drains that span along either side of the pool allow rapid
water drainage as the mobile floor is raised. The pool water
is heated close to body temperature (32–37 °C). After sur-
gery, the anaesthetized horse is placed in a sling and
hoisted into the pool. An air-filled buoyance device is
placed in front of the neck, allowing the horse to rest its
head without risk of drowning and water aspiration. Two
ropes are attached to a headcollar to support the head and
provide restraint during recovery. The sling remains in
place, while the entire body is submerged in the water pool
but does not support weight (Figure 10.9a). While in the
pool the animal has to be carefully monitored for signs of
Figure 10.8 Horse with a cast on the right thoracic limb respiratory distress and cardiovascular dysfunction, a
following spiral condylar fracture repair recovered from GA in a
sling. Source: Courtesy of Prof. R. Bettschart-Wolfensberger,
demand valve may be helpful to support ventilation.
Vetsuisse Faculty, University of Zürich, Zürich, Switzerland. Sedation should be administered to keep the animal calm.
Once the horse is considered conscious, the floor of the
The Anderson 4 sling is a specially designed system pool is initially raised until it touches the horse’s hoofs,
attached to a metal frame that can be affixed to either an allowing the patient to bear some weight. If the patient
overhead hoist or a hydraulic apparatus with a power sup- demonstrates sufficient weight-bearing capability and
ply. Unlike most slings that support the horse by its chest independently supports its head, the pool floor is raised
and abdomen, the Anderson 4 sling claims to support the further until the water level reaches mid-thorax. At this
animal through its skeletal system, distributing weight point, the air-filled flotation device is removed and the
evenly without affecting muscles, nerves or respiratory floor lifted to ground level (Figure 10.9b). The sling can
function. In addition, the hydraulically controlled overhead then be detached, and the horse walked from the recovery
frame provides the option for fine adjustment of weight dis- pool. In a retrospective study of 50 horses including 48 that
tribution between fore and hind, as well as left and right followed fracture repair, 44 had an excellent recovery, 3
limbs, based on the specific needs of an individual patient. good and 1 bad. The horse that had a bad recovery became
Finally, the design and additional padding makes this sys- excited probably because the pool was not deep enough.
tem significantly more comfortable, allowing horses to stay Post-operative complications included suture infections
in the sling for extended periods of time post-surgery. In a (6), bone infections (8), combination of suture and bone
retrospective study of 32 assisted recoveries, 5 were consid- infections (1), joint infections (1) and re-fracture (1). Eight
ered excellent, 5 very good and 20 good. No direct injury or (18%) horses died or had to be euthanized because of post-
complications were reported, but the sample size is small. operative complications; these included bone infections,
Two recoveries were poor, one horse repeatedly bucked in radius fracture during recovery and broken implants [126].
the sling and the second horse was intolerant of the support A second study reported 60 recoveries including 20 frac-
and needed to be re-anaesthetized [122]. tures. Ten (17%) horses developed pulmonary oedema of
which one died. Two horses had incisional infections and
one horse developed infected arthritis [124].
Pool Recovery System
The Pool-Raft system consists of a round recovery pool
Pool systems appear logical for recovery of horses with (6.7 m diameter and 3.4 m deep) surrounded by a cantile-
long bone fractures and/or extensive soft tissue trauma. vered deck. The pool is filled with water heated to a con-
However, they are not free of complications. Increased stant temperature of 36 °C. After surgery, the horse is sling
wound infection rates and pulmonary oedema have been lifted into the raft, and then both raft and horse lowered
documented. Cyanoacrylate glue spray and water- into the pool. The animal floats in the raft while recovering
repellent bandage or cast material may reduce wound from GA. Sling and raft are suspended on independent
contamination [123–125]. As with all assisted techniques hoists. The raft is secured to rings on the pool deck, while
it is not suitable for all horses, and temperament is the horse’s head is secured using cross-tied head ropes and
important when considering its use. The two pool recov- it rests on an air cushion attached to the raft (Figure 10.10).
ery methods currently in use are Hydro-Pool and Pool- Oxygen supplementation and mechanical ventilation are
Raft systems. provided with a demand valve if necessary. Sedation is
(a) (b)
Figure 10.9 The Hydro-Pool system. (a) Horse immersed with head supported and restrained with a nasal oxygen line in situ. The horse
is in a sling with a tail rope to reduce movement. (b) The same horse following recovery standing on the grate floor. The sling remains
attached but is not loaded. Courtesy of Prof. R. Bettschart-Wolfensberger, Vetsuisse Faculty, University of Zürich, Zürich, Switzerland.
Figure 10.10 Horse with a shoulder fracture

recovering in the Pool-Raft system. Source:
Courtesy of Dr DW Richardson, New Bolton Center,
School of Veterinary Medicine, University of
Pennsylvania, Philadelphia, USA.
necessary to keep the animal calm, especially immediately and labour intensive, but in the right hands can contribute
before removal from the pool. Once fully awake, the patient to fracture management.
is lifted out of the raft to the adjacent recovery stall
(Figure 10.11). The raft appears to have fewer complica-
Tilt Table
tions than the Hydro-Pool. In a retrospective study of 471
recoveries including 287 long bone fractures, 34 (7%) The use of a tilt table has been reported for recovering
horses had complications within the pool and 62 (13%) had horses after orthopaedic surgeries [127]. When in vertical
complications after being moved to the recovery stall. position, the tilt table is part of a standing stock: it has
Deaths resulting from failure of internal fixation, pulmo- Dutch doors located on both ends and a squeeze gate,
nary dysfunction or a combination of these were reported opposite to the table, that can be opened in either direction,
in 10 (2%) of horses [125]. The system is highly specialized which makes recovery in both right and left lateral
Figure 10.11 Horse transported in a sling from a Pool-Raft system to the recovery box. Source: Courtesy of Prof. R. Bettschart-
Wolfensberger, Vetsuisse Faculty, University of Zürich, Zürich, Switzerland.
r ecumbency possible. The gate must be kept fully open broke casts and one had a minor displacement of the lat-
while tilting the table to avoid the horse hitting the steel eral tubercle of the humerus. One horse re-fractured the
gate frame [127]. The table is 3.05 m long, 2.74 m wide and repaired limb after hitting the steel frame of the squeeze
2.13 m high. It has a lifting capacity of 1250 kg and has a gate that was not fully opened and was euthanatized. Six
padded surface, a hydraulic tilt and is bolted to the floor of horses refused to bear weight, and after several attempts
a special recovery room. they were re-anaesthetized and transferred to a conven-
Once on the table, the horse is secured in lateral recum- tional recovery room. Three of these were euthanized
bency with several anchoring points to prevent excessive because of recovery-related complications [127].
movement and to ensure horse and personnel safety: (i) a
tightly fitted halter is secured to the table with shanks to
Other Potential Complications
three rings located at the bridge of the nose, side and poll
of the halter; (ii) the tail is secured to the table by means of Post-operative myopathy and/or neuropathy (POMN)
a rope; (iii) two heavy girths, each with a width of 20 cm (Figure 10.12) can impede recovery, with consequences rang-
and a length of 135 cm (one chest band just behind the ing from worsening quality to complete inability to stand [99,
elbow and one abdominal band just in front of the tuber 103, 128]. POMN may also increase incoordination and
coxae), are used to secure the horse’s body to the table. ataxia, and could cause the horse to fall after standing risking
Limbs are protected with wraps and independently secured injury. Management consists of analgesia, fluid administra-
to the table by use of leather straps around the pastern. tion to reduce the risk of renal injury resulting from myoglo-
Sedation should be administered as necessary to keep binuria and assistance to stand. Use of a sling may be
the animal calm. Once the horse is considered conscious, necessary in severe cases. To minimize risk of POMN, it is
the straps are removed from the limbs and the table is advisable to (i) maintain adequate ABP and muscle perfusion
slowly tilted into a vertical position, ensuring head and and optimize oxygenation; (ii) correctly position the horse on
tail support. As the horse slowly regains a standing posi- the operating theatre table using pads to minimize points of
tion, head and tail ropes are used to stabilize the animal. compression; (iii) reduce anaesthetic and surgical times.
When the horse is standing, the squeeze gate can be Post-operative paraplegia without deep pain and loss of
closed for restraint until it can be safely walked to its box. anal tone is indicative of myelomalacia. This is most fre-
A report documented over 54 tilt table recoveries after quently reported in draft horses and is a distinct entity
orthopaedic surgeries in 36 horses: 39 recoveries (72%) did from POMN [129].
not have complications. Four cases incurred skin abra- The risk of developing hypoxaemia during recovery
sions, lacerations, pressure sores or myositis. Three horses from GA should be considered. The switch from a high
(a) (b)
Figure 10.12 Horses recovered from GA showing neuropraxia of the left thoracic limb (a) and bilateral pelvic limbs (b).
FiO2 during GA to a low FiO2 at this time may worsen the secured (Figure 10.13). However, such interventions are
effect of pulmonary venous admixture on arterial oxygen- not risk free and pre-emptive placement of a nasotracheal
ation and produce hypoxaemia. Hypoxaemia triggers sym- tube or leaving the endotracheal tube for recovery may
pathetic nervous system activation; the horse may trigger further respiratory complications [5, 131], there-
therefore attempt to stand sooner, worsening the quality fore the decision on use should be taken on an individual
of recovery. To minimize development or progression of risk versus benefit basis.
hypoxaemia, it is advisable to (i) place the horse in the In the CEPEF, cardiac arrest accounted for one-third
same lateral recumbency used during surgery even if the of the fatalities and was most frequent in the first
operated limb is dependent; (ii) if surgery was performed 30 minutes of anaesthesia [1]; cardiac arrest during
in dorsal recumbency place the horse in left lateral, when recovery from GA is uncommon but is still a potential
possible, as the right lung has a greater ventilation capac- complication. A recent report described successful car-
ity; (iii) if there is apnoea use a demand valve to ventilate diopulmonary resuscitation (CPR) in a horse that suf-
the lungs and administer oxygen; (iv) ensure that the fered of cardiac arrest as soon as it was positioned in
horse is breathing spontaneously and able to ventilate lateral recumbency within the recovery box possibly
through the nose before tracheal extubation. The adminis- associated with a Belzold–Jarish reflex [132].
tration of an oxygen flow ≥15 l/minute through the nos- Resuscitation consisted of external cardiac massage
trils may help to increase FiO2, bearing in mind that the (three men jumped with the knees on the horse’s chest
peak inspiratory flow is 120 l/minute in a 500 kg horse, and with a frequency of 40–60 compressions/minute),
therefore the overall impact on arterial oxygenation may adrenaline (0.01 mg/kg IV) and oxygen administration
not be significant, unless a very high flow is used [130]. using a demand valve (six to eight breaths/minute).
Ensuring adequate nasal airflow, using vasoconstrictors Generally, cardiac arrest carries a poor outcome in
and a nasal tube can have a significant effect on PaO2 in horses mainly because of the difficulties performing
the event of nasal congestion. Alternatively, the horse can effective CPR. However, early detection and trained
be recovered with the tracheal tube left in place and staff are key to potential success.
Use of IAAs for induction of GA has been linked to a

greater risk of mortality in foals compared to a balanced
anaesthetic technique [1]. IAAs should therefore be used
for maintenance only. Large animal anaesthetic machines
might not be suitable for anaesthetizing foals weighing less
than 120 kg. Small animal equipment including a circle
breathing system, 3–6 l rebreathing bag, ventilator and
endotracheal tubes with internal diameters 9–16 mm
should be available.
The foal should be kept with the mare until induction to
minimize distress. The mare should be sedated prior to
restraining the foal: a combination of IV acepromazine
(0.01–0.02 mg/kg) and romifidine (0.03–0.05 mg/kg), with
or without butorphanol (0.01–0.02 mg/kg) can be adminis-
tered to calm the mare and reduce stress resulting from
separation from the foal. The duration of action of this
Figure 10.13 Horse with severe nasal oedema and upper combination is usually sufficiently long to calm the mare
airway obstruction recovering from GA with the endotracheal for most surgeries.
tube left in place. Jugular cannulation is mandatory during anaesthesia:
strict asepsis should be adhered to. Sedation and immobil-
Anaesthesia of Foals ity in very young foals (<7 days) can be achieved adminis-
tering a benzodiazepine (e.g. diazepam or midazolam
The peri-anaesthetic mortality rate of foals is greater than 0.05–0.2 mg/kg) and an opioid (e.g. butorphanol 0.02–
adult horses, with the greatest risk in animals younger 0.1 mg/kg or morphine 0.1–0.2 mg/kg) IV. However,
than six months [1]. Immaturity, inadequate equipment repeated benzodiazepine administration can lead to accu-
and the emergency nature of the procedures usually per- mulation in foals younger than 2–3 weeks [135]. In older
formed have all been mentioned as possible explanations. foals, low doses of an alpha-2 agonist (e.g. xylazine 0.3–
While foals younger than two to three weeks should be 0.5 mg/kg or romifidine 0.03–0.05 mg/kg) can be combined
considered neonates, foals between three and eight weeks with an opioid and administered as pre-anaesthetic medi-
of age should be considered paediatric. The physiological cation. In the unlikely event, that it is not possible to gain
immaturity of both neonatal and paediatric foals influ- IV access due to the temperament of the foal, sedation can
ences the PK–PD of anaesthetic drugs, and therefore their be achieved with butorphanol and detomidine adminis-
effects need to be closely monitored. Foals older than three tered intramuscularly. Detomidine could also be adminis-
months are physiologically more similar to young horses; tered sublingually as a gel. Foals >3–4 months can be
however, anaesthesia can be still challenging because they treated like young horses. Acepromazine can therefore be
can be lively and difficult to handle. considered as a pre-anaesthetic medication, but should be
A thorough physical examination, including cardiac aus- used cautiously as it can participate in worsening hypoten-
cultation, should be performed on every foal prior to GA. sion especially when an IAA is administered to maintain
The presence of a machinery murmur could be related to anaesthesia.
persistent ductus arteriosus in very young foals. Neonatal An accurate body weight should be determined for cor-
foals have a high resting HR (up to 120–130 beats/minute) rect drug dosage calculations. Anaesthesia can be induced
and high RR (30–40 breaths/minute) compared with with diazepam (if not given in sedation) and ketamine
adults [133, 134]. Heart rate is the main factor governing (2–3 mg/kg) or propofol (2–3 mg/kg to effect) administered
cardiac output and therefore ABP. For this reason, HR IV. Propofol is not licenced in horses, but from 2013 it has
should be preserved and drugs causing bradycardia (e.g. been added to the EC No. 1950/2006. Endotracheal intuba-
alpha-2 agonists) used cautiously in neonates. Different tion of very young foals is not as easily accomplished as it
ranges of ABP have been reported in conscious neonatal is in adult horses due to their size and the risk of iatrogenic
foals: MAP may be as low as 50 mmHg in one-day-old pony trauma. However, careful use of silicone tubes, bougies and
foals, rising to 60–70 mmHg between the 2nd and 3rd gentle repositioning of the head generally are sufficient.
weeks of age [133]; MAP in Thoroughbred foals ranges The tube should not be forced into the trachea. The trachea
between 70 and 90 mmHg during the first 10 days of life, of even the youngest foals is of sufficient diameter to allow
increasing to 105 mmHg after the first month [134]. endoscopy-assisted intubation: the endoscope is placed in
Anaesthesia of Foal 227
cardiovascular effects, in young foals it may contribute to

increasing the cardiorespiratory depressant effects of
anaesthetic agents. Respiratory rate should be appropriate
to the age of the foal, so it is not unusual to use ventilator
rates around or in excess of 20 breaths/minute. Compliance
of the chest and lungs can be significantly less than adult
horses, thus relatively high PIP may be needed to expand
the chest.
Due to the relatively high HR of young foals, the perfor-
mance of non-invasive ABP monitors is acceptable. Thus, in
many cases arterial cannulation can be avoided, particularly
in short procedures in which the risk of haemodynamic
instability is relatively small [134, 137]. The cuff may be
placed in the metacarpus or metatarsus or on the tail. The
cuff should be at the level of the heart, and if this is not the
case, a correction must be applied to the measurement; grav-
ity will increase or decrease blood pressure reading by
7.5 mmHg for each 10 cm that the cuff is respectively lower
or higher than the heart. The cuff width should be approxi-
mately 40% of the circumference of the limb or tail. There
are no specific studies suggesting a threshold for treating
hypotension in anaesthetized foals. However, considering
their smaller body mass (and therefore the limited risk of
Figure 10.14 Supraglottic airway device for foals. developing myopathy) and the range of MAP reported in
non-anaesthetized foal [133, 134], a MAP greater than
50 mmHg should be adequate. Dobutamine can be used to
the tube, then advanced into the trachea and finally the treat hypotension [138], and if necessary bradycardia can be
tube is slid over the endoscope in the trachea. Supraglottic treated with glycopyrrolate (0.005 mg/kg).
airway devices (more commonly known as ‘laryngeal Due to their small size, fluid therapy should be cautious.
masks’) are currently being developed for foals and may It is possible to administer relatively large amount of flu-
circumvent this problem (Figure 10.14). Insertion is blind, ids rapidly in foals, which may lead to overload. While not
rapid and does not require passage of a tube into the tra- significant in adult horses, hypoglycaemia and hypother-
chea, yet provides a seal adequate to allow IPPV. mia are potential complications of foal anaesthesia.
Anaesthesia can be maintained with isoflurane or sevo- Prevention of suckling prior to GA is not necessary in foals
flurane. Regardless of the agent used, it is important to <3 months of age. Older foals are empirically prevented
appreciate the differences between young foals and foals from eating solid food for four hours prior to GA, but the
older than three to four months, which can be treated simi- beneficial effects of this are uncertain. Blood glucose
lar to adults. Alternatively, a total intravenous technique should be monitored and if necessary supplemented using
(e.g. propofol CRI) can be used [136]. Due to their rela- 2.5–5% glucose solutions. Increased body surface area to
tively small body and muscle mass, smaller functional weight ratio and immature hepatic function are predispos-
residual capacity, higher metabolism and increased blood ing factors for hypothermia. An active heat device, such as
brain barrier, anaesthetic depth can change very rapidly, the Bair Hugger™ System, should be used to prevent intra-
making foals particularly at risk of both under- and over- operative hypothermia and restore normothermia during
dosing of anaesthetic agents. Assiduous clinical monitor- the recovering phase. The immunization status of foals
ing of anaesthetic depth is therefore critical. should be checked and, if necessary, tetanus anti-toxin
Respiratory depression induced by IAAs is more evident administered.
in foals than adult horses, therefore controlled or assisted Acute pain caused by a fracture and its repair can be
ventilation is often required. Controlling ventilation is also effectively controlled with a systemic NSAID and/or opioid
effective in ensuring consistent IAA delivery and anaes- in most foals, but loco-regional techniques (e.g. epidural
thetic depth, as well as avoiding severe hypercapnia and and PNBs) can also be considered. Information regarding
resulting respiratory acidosis. While in adult horses a mod- PK–PD of analgesic drugs in foals is limited. Opioids can be
erate degree of respiratory acidosis may have beneficial administered to foals at the same doses used for adult
horses. Foals might become more sedated but do not show omeprazole are commonly administered to foals in order to
increased locomotor activity. NSAIDs are commonly used reduce the risk of gastro-intestinal ulceration.
in foals, and PK data are available for most drugs [139– Recovery of foals form GA is generally more rapid than
144]. Foals might have a reduced ability to eliminate adult horses, and sedation is needed only when the foal
NSAIDs compared to adult horses [139, 140], and accumu- size is such that manual assisted recovery may be hazard-
lation can lead to side effects such as gastro-intestinal ous for the operators. For smaller foals, recovery can be
ulceration, nephrotoxicity and platelet dysfunction. managed by two operators. The foal should be reunited
NSAIDs should therefore be administered judiciously in with the mare as soon as it is able to stand with minimal
young, hypovolaemic or critically ill foals. Ranitidine or ataxia.
R
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11
Intra-operative Complications
There are numerous causes for failure of a repaired frac- man include inadequate reduction (30%), incorrect implant
ture or arthrodesis, but they can loosely be categorized as positioning (30%), use of the wrong implant (18%), wrong
complications due to construct failure (acute overload or length of implant (11%) and incorrect use of an implant
fatigue) or to infection. Both are strongly related to errors (8%) [12]. Additional reported technical errors include
that occur during surgery. Fortunately, not all problems hardware joint penetration and malalignment [13–22].
lead to complications; however, the greater the difficulty of Some mistakes can be recognized and corrected during
repair, the greater the demand for an error free fixation. surgery, while others might not be recognized or corrected
Many technical errors are avoidable and require both and lead to complications. High-quality radiographs at
knowledge and strict application of the principles of asep- critical time points are important to detect inadequate
tic surgery, operating room (OR) hygiene and AO/ASIF reduction, incorrect implants or inappropriate implant
technique to prevent them. location. Intra-operative radiographs must be taken in ade-
Poor case selection increases the risk of failure. Fracture- quate planes including the direction of intended implant
related concerns include its configuration and location and placement, perpendicular to the fracture line and in the
the condition of the soft tissue envelope. A specific risk of orientation of the fracture line. It may also be necessary to
intra-operative complications is underestimation of the perform additional views to exclude other issues including
complexity of the fracture configuration: acute fractures impingement of joints or soft tissues.
can appear less complicated or less propagated. Failure to Education for fracture fixation is most effectively pro-
accurately diagnose additional fracture lines may be due to vided by formal course attendance from basic to specialist
insufficient pre-operative imaging such as not taking all levels [23, 24]. Retrospective in-house evaluation of frac-
relevant radiographic views or lack of three-dimensional ture repairs including peer review and open discussion has
modalities (computed tomography [CT] and magnetic res- also been shown to reduce the incidence of technical
onance imaging [MRI]). Some fracture lines may only be errors [13].
radiologically apparent later when osteoclastic activity has
started [1].
F
racture Reduction
T
echnical Errors Anatomic reduction is a cornerstone of fracture repair, and
in articular fractures perfect alignment of the joint surface
Common surgical errors in human hospitals are reported to is paramount. Any step, incongruity, or gap can lead to per-
arise from inadequate surgeon specialization [2–4], sur- manent irritation of the joint and subsequent osteoarthri-
geons in training [5], low hospital caseloads [6, 7], person- tis. Reduction at the articular surface is, wherever possible,
nel fatigue [8], time of day [9] and problems in best observed arthroscopically.
communication [10, 11]. Individual surgeons’ experience is In general, when considering plate fixation, it is impor-
recognized as an important factor in reducing the frequency tant to achieve cortical contact throughout the circum-
of errors [12]. Specific errors in long bone fracture repair in ference of the bone by reconstruction of the fracture

236 Intra-operative Complications
fragments. Inadequate fracture reduction can put exces- Fracture reduction can be time consuming, and testing
sive loads on implants, and as a consequence the repair on many fronts: accuracy, experience and patience, are
may fail in single (usually recovery) or cyclic (post- essential.
operative movement) loading. If fragments are not per- Technical problems that can preclude reduction include
fectly reduced, cyclic loading can also lead to micromotion the following cases:
and fatigue failure of implants. Interfragmentary strain
●● Comminution or other debris in the fracture gap. The
may also lead to impaired fracture healing [25, 26]. Bone-
first step is thus evacuation and debridement of the frac-
to-bone contact is particularly important on the com-
ture plane (Figure 11.2).
pression side, e.g. palmar/plantar third metacarpal/
●● If a lag fashion screw inserted into a blind-ending hole
metatarsal bones and caudal radius and tibia. Even if the
exceeds the length of the drilled hole, compression can-
fracture appears aligned care must be taken to ensure
not be achieved; either a shorter screw has to be inserted
that there is definitive cortical abutment of the compres-
or the hole needs to be drilled further.
sion cortex. There are several methods for reduction of
●● If the threads in the bone strip such that the screw does
fractures, and instruments used should be suitable for
not gain purchase, this has to be replaced by a larger
the location and must not damage the bone (Figure 11.1).
screw. Appropriately sized glide and thread holes for the
larger screw must then be prepared.
(a) ●● A thread hole that is not fully threaded results in inade-
quate compression. The screw has to be removed and
additional threads cut.
●● In lag screw technique, if the glide hole is not drilled
across the fracture plane, an inserted screw is positional
and keeps the fracture gap at a constant size. The glide
hole has to be drilled until it reaches or crosses the frac-
ture plane.
●● Inappropriately positioned screws can fail to create ade-
quate compression. Screws that are not perpendicular to
the fracture plane can create shear forces. Insufficient
compression can also result if the screw is too far from
the origin of the fracture line.
●● Multiple screw reinsertions reduce the security of fixa-
tion; the difference is most significant between the first
and second insertions [27].
(b)
Splitting Bone Fragments
Bone fragments can split or shatter while applying instru-

ments for manipulation and reduction or while drilling,
tapping or tightening screws. Adequate instruments must
be used for bone handling: drill bits and taps should be
sharp and clean to prevent shear forces and heat produc-
tion. Inadequate countersinking causes stress risers at the
screw head (Figure 11.3a) while excessive use, particularly
with a thin cortex, can result in the screw head being pulled
through bone (Figure 11.3b). This can be a particular prob-
lem with 5.5 mm screws in which the contact surface is
Figure 11.1 (a) Intra-operative photograph of a displaced relatively small because of the low head/shaft diameter
humerus fracture. Reduction was achieved only after applying
ratio [28]. In all situations, implants should be of appropri-
large reduction forceps to the proximal fragment. (b) A defect
was found later where the tips of the forceps had been located ate size and force applied should not exceed the strength of
(white arrow). the bone.
Implant Locatio 237
(a) (b) (c) (d)
Figure 11.2 (a) Lateromedial radiograph and (b)–(d) multiplanar reconstruction of a severely comminuted fracture of the proximal
phalanx. On the multiplanar CT images, a piece of cortical bone is visible in the fracture gap preventing reduction.
(a) (b)
Figure 11.3 (a) Intra-operative lateromedial radiograph after fixation of a frontal plane fracture of the proximal phalanx. Blue
arrows indicate screws with inadequate bone contact which can lead to stress at the screw-head–bone interface. (b) Intra-operative
dorsopalmar radiograph of a moderately comminuted fracture of the proximal phalanx. The most distal screw head has been pulled
through the cortex due to excessive countersinking.
I mplant Location stability can be compromised. Implants and their positions

should be planned in advance, and plates should be
Inadvertent Screw Contact arranged in a staggered manner. If screw/screw contact
occurs the threads of the screw inserted second can be
In complex repairs that involve multiple screws, interfrag- damaged sufficiently to preclude purchase in the bone.
mentary screws inserted before application of plates or
application of more than one plate can lead to inadvertent
contact of screws or instruments (drill bit/tap) and screws Screws in Joints
(Figure 11.4a). This must also be considered if locking Articular penetration is usually be recognized intra-
compression plates (LCPs) with angle-stable screws are operatively by decreased movement of the joint, by arthros-
used (Figure 11.4b). Screws can be damaged, and fracture copy or radiography (Figure 11.5). Pre-operative planning
(a) (b)
Figure 11.4 (a) Intra-operative radiographs during fixation of a moderately comminuted fracture of the proximal phalanx. The drill
bit has damaged the second and third most distal screws; metal debris is deposited within the screw holes. (b) Post-operative
radiographs after subtotal carpal arthrodesis. The two proximal locking head screws in the dorsal and medial plates are in contact.
Use of angle stable screws and the restricted space for insertion are risk factors.
including estimation of screw lengths and angulation, dili-

gent choice of drill trajectories, and multi-planar intra-
operative radiographic imaging are important preventative
measures. Misplaced screws need to be removed and redi-
rected or replaced with a shorter screw. If bone debris
enters the joint, this should be flushed clear.
Screws in the Fracture Plane

A screw inadvertently placed into the fracture plane can
force this apart and/or prevent placement or compression
by other screws (Figure 11.6).
Screw-induced Malalignment
Screw tightening can generate shear along an oblique frac-
ture plane with resultant fragment movement and mal-
reduction. Shear forces may also occur if a thread hole is
not concentrically aligned with the glide hole; malalign-
ment or screw bending can result.
Growth Plates
Special consideration should be given to implants that

might impinge, cross or bridge growth plates. These can
not only directly influence growth as deliberately done
Figure 11.5 Post-operative craniocaudal radiograph after with transphyseal retardation techniques, but also result in
fixation of a tibia fracture. The shaft of the most distal cortical
screw impinges on the medial trochlear of the talus and had to remote articular incongruency as seen in radio-ulnar fixa-
be removed in a second surgery. tion in juveniles (Chapters 25 and 26).
Locking Implant 239
Figure 11.7 Post-operative radiograph after fixation of a type

IV ulnar fracture. The most distal screw is too long and has bent
as a result of contact with the cranial cortex of the radius: the
screw could not be tightened because the thread hole was
damaged. The second screw is also too long and has contacted
the subchondral bone so that the screw has bent and its head
has not engaged the plate.
need to be inserted exactly perpendicular to the LCP to

successfully lock in the threaded part of the combi hole. If
the screw is tilted more than five degrees, fixation strength
and angular stability are significantly decreased, and
Figure 11.6 Post-operative dorsopalmar radiograph after
screw loosening may occur [30]. This can be a problem if
double plate fixation of a metacarpal fracture. A screw in the the plate is applied close to a joint or more than one plate
dorsal plate (arrow) has been inserted into the fracture line. is used. Strategical cortical screws or monocortical LHS
can be inserted to prevent interference. Eccentric place-
ment of the plate on the bone should be avoided as it can
S
crew Length result in screws penetrating the cortex tangentially [31].
The cortex can be substantially weakened representing a
In addition to penetrating joints, screws that are too long stress riser. This complication can be avoided by using
can also interfere with soft tissues for example during prox- cortical screws within the combi hole at critical sites
imal/phalangeal fracture repair or proximal interphalan- because they allow a transverse screw angulation of 14°.
geal joint arthrodesis on the palmar/plantar aspect of the If cortical screws are used in combination with LHS, the
pastern. cortical screws should be inserted first as they press the
Screws that are too long for blind ending holes cannot be plate to the bone. If the LHS are placed first, subsequent
inserted completely and can lead to inadequate fracture insertion of a cortical screw results in compression of the
reduction. Contact with the trans-cortex of a bone can also plate to the bone and stress on the LHS plate interface [17,
result in screw bending (Figure 11.7). Such screws might 29, 32]. It is also important that soft tissue does not
not adequately fix the plate onto the bone, and a stress riser become trapped between the screw head and combi hole
in the trans-cortex can be created. as this can prevent fully tightening and threading of the
In fixation of mandibular fractures, screws should not screw into the plate [32]. If a self-tapping screw is inserted
interfere with dental roots. In most cases, this can be in monocortical fashion, the tip must not contact the
avoided by accurate placement of the plate and insertion of trans-cortex before it locks in the screw hole as this would
short, monocortical locking screws (Chapter 36). destroy the bone threads of the cis-cortex. The situation
can be corrected by drilling the far cortex and inserting
the LHS in a bicortical fashion.
L
ocking Implants The threading or drilling portions of self-tapping and
self-drilling screws should protrude from bone in order to
There are some special considerations regarding use of ensure full engagement of the threads. However, long pro-
locking head screws (LHS) inherent to their design and truding lengths may traumatize adjacent vascular or neu-
their purpose to lock into LCPs [29] (Chapter 8). LHS ronal structures.
Screw Breakage and Damage The hexagonal or star-drive indentation of the screw
head can be damaged during insertion if high torques are
Screws can break at the head/shaft interface during inser- applied. It occurs especially if a worn-out screwdriver is
tion. Screws in which the head is broken off can be removed used: this should therefore be checked regularly. Such
after freeing the screw shaft from surrounding bone with a screws can be removed using pliers or with an appropri-
gouge or a hollow reamer either with pliers or the extrac- ately sized conical extraction screw (Chapter 8)
tion bolt (Figure 11.8) (Chapter 8). (Figure 11.9). It has been suggested that a LHS with a
stripped star-drive recess could be removed with a hexago-
nal screw driver [33].
I nstrument Breakage
With correct usage, breakage of drill bits or taps

(Figure 11.10) is uncommon. A retrospective study of 7775
human surgeries documented 14 instrument breakages, of
which 11 were drill bits [34]. Drill bits may break if bent,
inserted at an angle, by contact with other implants, or if
the tip contacts the far cortex at an angle and then bends;
excessive heat production also predisposes to break-
age [35]. Use of old drill bits may increase the risk of break-
age by increased heat production in dull instruments or
weak spots after use [34, 36]. Drill bits are less corrosion
resistant as they are made from uncoated hardened steel. If
there is no contact with an implant, broken drill bits left in
situ are mostly well tolerated. In one study, 7 of 11 broken
Figure 11.8 The extraction bolt is a conical, hollow instrument drill bits were left in bone and none of the patients reported
to remove screws with the head broken off. The threads on the
negative effects [34]. If removal causes no additional
inside engage the threads of the screw, and the screw can be
removed with anticlockwise rotation. trauma, broken drill bits close to a joint should be
(a) (b)
Figure 11.9 Implant removal when the hexagonal socket of the screw head has been stripped. (a) Conical extraction screw is
inserted anticlockwise in the indentation. Further rotation extracts the screw. (b) Extraction screws are available in different sizes.
Asepsis and Prevention of Surgical Site Infectio 241
Inability to Tighten or Stripping of Screws
Surgical tightening of a screw reaches torque close to

thread stripping [40]. If a cortical screw is tightened until
the complete loading force is reached, there is no reserve
left to withstand additional functional load. In human sur-
gery, tightening to about two-thirds of the maximal torque
is recommended. Overtightening leads to failure of threads
at the screw–bone interface [41]. Stripped screws cannot
generate compression and have markedly reduced pullout
resistance [42–44]. Among human surgeons, there was a
good correlation between subjective judgement of holding
power of a screw and pullout strength [45]. In another
study, 90.8% surgeons did not recognize stripping of a
screw in synthetic cancellous bone. Individual surgeons
appeared to have dispositions to strip screws independent
of their experience [46]. The right torque to achieve opti-
mal purchase without stripping the screw is important for
fixation stability [47]. To date, there is no data available for
screws in equine bone.
In some situations, for example if a screw is not the ideal
length, a cortical screw may be removed and replaced by
another. This can lead to thread damage and as a conse-
quence to decreased pullout strength. The holding strength
is most significantly reduced between the first and second
insertions [27]. By the third reinsertion, screws lose about
one-third to one-half of their initial maximal insertion
torque before stripping [48]. Screw replacement should
therefore be minimized by good pre-operative planning
Figure 11.10 Post-operative caudocranial radiograph after
fixation of a tibia fracture. The tip of a broken drill bit (arrow) and accurate length determination.
remains in the distal and lateral aspect of the bone. This may
have been caused by bending of the drill bit when inserted at an
angle to the far cortex. It did not prevent insertion of important sepsis and Prevention of Surgical Site
A
screws or cause post-operative problems. Infection
The causes for surgical site infection (SSI) in repair of
removed [35]. This can be during the first surgery or subse- closed fractures are multifactorial. The low infection rate in
quently if implant removal is planned [37]. man and relatively low case numbers in horses also make it
If implants and drill bits are in contact, corrosion difficult to assess the contributions of preventive factors.
occurs [35] but is generally well tolerated. Galvanic corro- Evaluation of the effects of single measures is challenging
sion that results from electrochemical potential difference because usually several preventive measures are used in
and leads to corrosion of the less noble material was combination. Sterile preparation of the surgical field, team
thought to be a problem if implants of different alloys were and instruments and the prevention of contamination of
combined. However, in vitro studies showed more corro- the surgery site are important factors for every surgical pro-
sion with combinations of steel with steel than of steel with cedure. It is not the intention to give an overview in this
titanium [38]; while corrosion was altered by the surround- chapter but to highlight some points particularly relevant
ing medium, it was not changed by the combination of to osteosynthesis.
materials [39].
Broken drill bits and taps can preclude subsequent use of
Preparation of the Surgical Field and Draping
the hole/area. Additionally, contact between drills or taps
with implants can produce dulling of the instrument and/ Surgical field preparation should be wide, and in the free
or damage the implant. limb this should be circumferential. Clipping is performed
outside the OR, and all hairs vacuumed from the surgery its most common cause [54]. Once the fracture is exposed
field (see Chapter 9). Standard methods for clipping and and reduced and a plate is contoured, it is prudent to check
aseptic preparation should be established in all hospitals gloves for perforation or to routinely change gloves before
and monitored regularly. proceeding with repair.
A study evaluating the dispersal of airborne particles in To prevent contamination, implants should remain cov-
an OR recognized increases during unfolding of surgical ered before use. In a study comparing covered and uncovered
gowns, removing gloves, putting the arms through the implants, significantly more positive bacterial cultures were
sleeves of the gown and unfolding surgical drapes [49]. obtained from the latter [55]. In an experimental setting, a
Particles do not necessarily contain bacteria but might similar effect was obtained by covering the entire instrument
function as vectors. Therefore, drapes should be applied table [56]. During surgery, instruments should be kept clean.
carefully and with minimal creation of dust. Drill bits and taps need to be cleaned frequently from bone
The entire horse should be covered with drapes to reduce debris as accumulation leads to excessive heat production.
particle contamination of the air. Draping should be per- During surgery, they can be stored in a vessel containing ster-
formed with impermeable, disposable, non-woven drapes ile saline and antimicrobials or antiseptics.
in two layers to ensure a sterile field. Hooves of fractured
limbs are covered with two sterile gloves and fixed with a
Intra-operative Wound Irrigation
sterile cohesive bandage. Drapes need to be secured care-
fully by towel clamps as there is a high risk of slipping dur- Prophylactic intra-operative wound irrigation (IOWI) is
ing limb manipulation. Adhesive drapes can be used for used commonly to reduce SSI [57, 58]. Potential benefits
attachment to the patient or to drape a large area without include constant tissue hydration together with dilution
obscuring landmarks. However, there are conflicting and removal of bacteria and debris. Methods of application
reports regarding risks and benefits (Chapter 9). Draping and solutions used vary between studies [59], and recom-
should not obscure landmarks and preserve visible orienta- mendations have often been contradictory: The National
tion of the limb. Adhesive drapes, sterile gloves and sterile Institute for Health and Care Excellence (NICE) do not rec-
cohesive bandages can be used in order to optimize visibil- ommend routine IOWI [60], whereas the Society for
ity. If limbs are manipulated during surgery, then the posi- Healthcare Epidemiology of America (SHEA) and the
tion of the drapes should be checked thereafter. Infectious Diseases Society of America (IDSA) are in favour
of antiseptic incision lavage [61].
A recent metanalysis to evaluate IOWI as a prophylactic
Prevention of Airborne Contamination
measure was done with the intention of developing guide-
In man, contaminants derived from the patient’s skin lines for the WHO [59]. Analysis of 21 studies revealed that
account for only about 2% of recovered microorganisms. The irrigation with saline only was not effective in preventing
majority come from external sources including the surgical SSI [62]. Saline applied with a syringe and some pressure
team, instruments and air [50, 51]. Thirty percent of air- compared to no irrigation or pulsed pressure irrigation
borne particles settle directly on the surgical wound and 70% compared to saline irrigation only reduced the risk for
on the surgeon or instruments [52]. Airborne particles SSI [63–65]. The addition of povidone iodine (PVP-I)
include skin squames, dust and droplets. Depending on (0.35–10%) to the irrigation fluid was beneficial in clean
their size, particles either sediment (>100 μm) or are sus- and clean-contaminated wounds in gynaecological,
pended in the air for a longer time (<5 μm); particles in- abdominal, spine and bone surgery [66–72] with an OR of
between may settle and migrate to other sites [53]. In human 0.31 (CI 0.13–0.73; p = 0.007). The application of topical
surgery, it is recommended that airborne particles <5 μm antimicrobials or irrigation with antimicrobials had no
should not exceed 3500/m3 (ISO 5). Several methods of fil- positive effect compared to saline or no irrigation in non-
tration, laminar airflow, positive pressure and air exchange orthopaedic surgeries [73–76] (OR 1.16; 95% CI 0.64–2.12;
can be used to decrease airborne contamination. Such tech- p = 0.63). There were no adverse effects reported [66, 68,
nology may not be available in equine ORs, but simple meas- 70, 71], and in spinal surgery no differences in fusion time
ures such as keeping doors closed and the number of people or bone quality have been reported for irrigation with
and traffic to a minimum will have positive effects. 0.35% PVP-I [70, 71] or 0.35% PVP-I followed by sterile
saline [70]. The evidence for irrigation with PVP-I had a
low quality, and the evidence for pressure irrigation was
Handling of Implants and Instruments
moderate to very low; it was therefore concluded that there
Implants should be handled as little as possible to prevent was a need for high-quality randomized controlled trials to
inadvertent contamination and glove perforation as provide more evidence. Studies using PVP-I were
implants and instruments used in orthopaedic surgery are over-represented, and newer wound antiseptics had not
Communicatio 243
been included. Many reviewed studies were not recent, and and glove perforation [85], particularly in the absence of
general methods of antisepsis and SSI prevention had sub- pre-operative antimicrobials [86, 87]. Risk of glove perfora-
sequently improved [59]. Based on the review, the WHO tion in human, small animal and equine surgeries increased
‘suggest considering’ prophylactic IOWI with diluted PVP-I with longer procedures (>60 minutes) [54, 88, 89], in ortho-
after a decision-making process. The use of antimicrobial paedic operations [54, 90], if power tools, plates, screws,
additives to irrigating fluids was not recommended [77]. external fixators or wire were used [54], and in invasive
In total joint arthroplasties PVP-I was used to irrigate surgeries [88]. The primary surgeon [54, 88] and the non-
the surgical field before wound closure; the risk for SSI was dominant hand [89] posed particular risks.
reduced without reported adverse effects [78]. There are no Studies have reported that only 25–34% of perforated
clinical studies focusing on IOWI as a prophylactic meas- gloves were recognized by surgeons in [54, 88], which
ure in osteosynthesis. could be improved by wearing coloured undergloves [91].
If perforation is noted, gloves should be changed immedi-
ately. Measures to prevent possible consequences of unrec-
Operating Room
ognized glove perforation include regular changes (every
Increases in the number of people present and amount of 60 minutes) [88, 89] and wearing double gloves [92].
talking can increase the number of airborne microorgan-
isms. Furthermore, people entering the OR can distract
personnel [79]. Higher numbers of door openings result C
ommunication
when items are needed because of insufficient pre-
operative planning and when people do not have specific Pre-, intra- and post-operative communication are all
assigned roles in the procedure [80]. OR traffic and turno- important as failures at any time can lead to delays, a tense
ver of personnel were found to be risk factors in joint pros- atmosphere in the OR and adverse consequences in patient
thesis [81] and neurosurgical procedures [82]. Traffic in care [10, 11, 93]. Failures were identified in approximately
the OR should therefore be reduced in high-risk proce- 30% of team exchanges [11]. Common problems include
dures like osteosynthesis. status asymmetry, decreased familiarity of surgeons with
Contamination of the surgery site may occur from over- the patient, diverted attention, responsibility ambiguity,
head lights or light handles [83]: handling should therefore incomplete or inaccurate information, unresolved pre-
be minimized. Lights should be cleaned and meticulously surgical issues and exclusion of key individuals [10, 11, 93].
disinfected before surgery and should not be placed directly In man, ‘five comprehensive institutional habit changes’
over the sterile field [53]. have been proposed to minimize problems [93] which
might be also helpful in veterinary medicine.
Intra-operative Imaging 1) Establish clarity about who is responsible and make it

easy to reach the responsible person.
Intra-operative radiography or fluoroscopy are frequently
2) Assign specific patient care tasks and responsibilities to
used in osteosynthesis and can be sources of contamina-
providers in a clear and unambiguous manner.
tion. Sterile draping of cassettes and/or C-arm are there-
3) Designate one patient care team as the primary team for
fore mandatory. Contamination may arise from the X-ray
each patient.
generator, which is normally not draped, but sometimes
4) Routinize and formalize the sign-out procedure among
needs to be placed above the area to be radiographed. A
incoming and outgoing surgical team members to facili-
critical point during fluoroscopic imaging is the acquisition
tate effective exchange of information and patient care
of horizontal views that necessitate rotation of the lower
responsibilities.
part of the C-arm out of the unsterile area (below the level
5) All patients expected to come under or be released from
of the table) to the sterile zone. Special draping of the
the care of a patient care team should be included in
C-arm has been recommended in human surgery [84].
patient care handoffs.
Diagnostic imaging should be performed as often as neces-
sary to optimize fracture fixation. However, both for steril- Critical appraisal of surgery is important in all hospitals.
ity and radiation safety, use should be judicious. After each procedure, the surgery team should quickly
come together and list the most important facts that can be
improved next time. This should include all aspects, e.g.
Glove Perforation
floorplan, technical details to improve reduction of the
Perforation of surgical gloves breaks the aseptic barrier fracture, selection of implants, etc. The information should
between surgeons’ skin and surgical wounds. Several stud- be recorded in writing, logged for quick future reference
ies in human medicine reported correlation between SSI and included in future pre-operative planning.
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249
12
Standing Fracture Repair

R.J. Payne and T.P. Barnett
Rossdales Equine Hospital, Newmarket, UK
Development and Philosophy tions of sedative drugs, notably α-2 agonist and opioid
combinations (Chapter 10).
Surgical techniques for the repair of fractures of the equine The equine distal limb lends itself to standing fracture
distal limb including the proximal phalanx (P1), third met- repair due to its minimal soft tissue covering and the ability
acarpal bone (Mc3) and third metatarsal bone (Mt3) have to reliably and effectively achieve regional anaesthesia. The
become well established during the past 30 years. In clini- first published reports described internal fixation of distal
cal practice, such fractures are most commonly encoun- Mc3/Mt3 condylar fractures [4, 5]. It was suggested that
tered in racehorses. Traditionally, fracture repair is carried elimination of the GA recovery risk and the need for only
out under general anaesthesia (GA), the risks of which one surgical intervention made the technique safer and
have been documented [1] and remain significant. Despite more cost effective, when compared to the combinations of
all reasonable precautions, there is still a risk of fractures plates, lag screws and external coaptation traditionally used
propagating to catastrophic configurations, both during for repair under GA [4]. A further paper provided an addi-
induction and recovery. Risk appears to be greatest for tional description of standing fixation for non-displaced P1
medial condylar fractures of Mt3, which have a tendency to and Mc3/Mt3 fractures [2]. These two locations are particu-
propagate proximally in an unpredictable, but often spiral larly common in young racing Thoroughbreds, with Mc3/
or ‘Y’-shape fashion [2]. One report estimated a 42% risk of Mt3 condylar fractures making up 14.5% and sagittal frac-
catastrophic failure of such fractures during the post- tures of P1 accounting for 10.4% of fractures [6]. Knowing
operative period, following lag screw fixation [3]. the indications for standing fracture repair and understand-
Recently, there have been significant improvements in ing the techniques involved will therefore be of particular
the quality and availability of advanced imaging tech- use to surgeons working with such athletes.
niques, most notably the introduction of computed tomog- Early studies, although involving low case numbers,
raphy (CT) to equine hospitals. The three-dimensional demonstrated comparable success rates to established fixa-
imaging offered by CT has improved fracture diagnosis and tion techniques carried out under GA: 10/13 (77%) horses
allowed surgical planning and fixation to be carried out returning to training with 8 successfully racing [4]; 20/34
with increased accuracy. More advanced fixation tech- (59%) horses returning to racing at a median of 7.43 months
niques have also been developed, such as the use of locking following repair, with 60% being placed in at least one
compression plates for the repair of spiral Mt3 fractures in race [2]; 4/4 horses returning to racing by seven months
an attempt to improve overall outcome. However, such sur- post-operatively [5].
gical procedures are more time consuming and expensive. However, as all the studies illustrate, standing fracture
Additionally, if the horse is intended for athletic use, a sec- repair has its own difficulties. It is posturally demanding for
ond GA most likely will be required to remove the plate. the surgeon. The possibility that a patient moves or kicks
Within the whole field of equine surgery, many proce- during the procedure can be minimized by careful selection
dures that previously would have been carried out under of horses with a suitable temperament, but cannot be elimi-
GA are now routinely undertaken in the standing, sedated nated. The consequences of movement range from a minor
patient, using local anaesthesia. This has been facilitated break in aseptic technique, through to surgical failure, dam-
by the development of efficacious and reliable combina- age to equipment and injury to personnel. In one report, a

250 Standing Fracture Repair
horse that moved during drilling resulted in breakage of the are suitable for standing repair. Fractures of the condyles
drill bit that subsequently could not be retrieved [4]. Patient that have a spiral or unpredictable configuration as they
compliance through optimal sedation and desensitization propagate proximally are more challenging. Several differ-
to pain is vital and careful case selection is essential so that ent fixation techniques have been suggested [8, 9], but
horses of an unsuitable temperament are identified before standing repair combined with a post-operative bandage
standing surgery is attempted. The option for conversion to cast may be a viable option and is worth considering in
GA surgery must always be available. restricted economic circumstances.
The two main contraindications for standing fracture
repair are unsuitable patient temperament and unsuitable
Indications and Contra-indications fracture type. Fractures that are displaced are not suitable
for standing repair due to inability to manipulate or reduce
Fractures suitable for standing repair should be non- fragments in the weight-bearing patient. Fractures with
displaced. In the authors’ hospital, these most commonly incongruities at the joint surface should be repaired follow-
involve P1 and distal Mc3/Mt3 (Figure 12.1). Both short ing reduction under arthroscopic control. Standing repair
and long, incomplete P1 fractures are suitable for standing of Mc3/Mt3 fractures is also contraindicated when there are
repair. In the UK, such fractures are mainly seen in the concomitant PI or proximal sesamoid bone fractures [4].
young flat-racing Thoroughbreds, but from time to time
they are also encountered in horses of other breeds and
uses. It is important to appreciate that although these frac- Case Selection
tures often have predictable configurations, radiographs
obtained immediately after the fracture may underestimate As in all cases, thorough radiographic assessment of the
their true extent, which may only become apparent on entire fractured bone should be carried out when surgical
post-operative or subsequent radiographs. Complete sagit- repair is to be considered. This should include sufficient
tal fractures of P1, which enter the proximal interphalan- radiographs to assess joints at the proximal and distal lim-
geal joint, should be scrutinized carefully for incongruities its of the fracture. Fracture lines are then scrutinized care-
of the joint surface, and if available and affordable CT fully for evidence of a spiral configuration, comminution,
should be performed. unusual propagation or remote fracture lines. Once the
Short fissure fractures of the condyles of Mc3/Mt3 are fracture has been identified as suitable for standing repair,
most common in Thoroughbred racehorses in training. the temperament of the patient, personal preference of the
Diagnosis is made by detailed radiographic examination or, surgeon, the economic circumstances and the owner’s
on occasion, by magnetic resonance imaging (MRI) that wishes are all used to guide the decision-making process.
may also identify prodromal fracture changes [7]. These Although the objective of standing fracture surgery is not
(a) (b) (c) (d)
Figure 12.1 Four examples of fracture types that are amenable to standing repair: (a) short unicortical medial condylar fissure
fracture (arrow); (b) short incomplete sagittal fracture of P1; (c) non-displaced lateral condylar fracture; (d) medial spiral parasagittal
fracture of Mc3.
Pre-operative Preparation, Sedation and Local Anaesthesi 251
to save money, avoidance of GA brings with it a cost saving use of open-sided stocks [4]. The individual layout and facil-
that will appeal to some owners. ities of different hospitals will influence the choices.
If there is any uncertainty about fracture configuration, A standard AO/ASIF fracture repair kit should be avail-
three-dimensional imaging is advisable in order to provide a able with a suitable range of implants: usually 4.5 and
thorough assessment and to assist with surgical planning and 5.5 mm cortical bone screws. The use of a cordless battery
implant placement. Some clinicians have advocated the use powered drill offers a significant advantage over an air-
of single sequence standing MRI to evaluate the extent of driven drill. If an air drill is used, an extra surgical assistant
fracture lines. Unfortunately, prolonged sequence acquisi- should be dedicated to the drill and hose to ensure that the
tion times mean that it is not always possible, especially in hose does not contact the floor or trolley outside of the ster-
horses that are unable to fully weight bear. Pre-operative CT ile field. An appropriate, preferably wireless, digital radiog-
is a valuable imaging modality for complex or uncertain frac- raphy system is essential for set-up and monitoring of the
ture types. At the current time (2020), most CT systems procedure. Surgical equipment should be placed on a
require a GA, so it is logical for fracture repair to be carried wheeled trolley so that, if the need arises, it can be moved
out at the same time. However, technology is changing fast. away swiftly (Figure 12.2).
The emergence of CT systems for standing assessment of the
distal limb may well allow fractures to be assessed in the con-
scious patient, before deciding on the optimal repair method. re-operative Preparation, Sedation
P
and Local Anaesthesia
Facilities and Equipment Meticulous preparation is essential to optimize efficiency

and minimize procedure time. Preparation of the surgical
Successful standing surgery requires a clean, quiet, undis- room, the patient, personnel and equipment are key con-
turbed environment. The authors’ preference is to use an siderations. Standard pre-operative assessment of the
anaesthetic induction or recovery box. The floor is non-slip, patient, including clinical examination and routine haema-
and the soft surface may dampen the effects of vibration dur- tology, should not be overlooked in order to ensure there
ing drilling [5]. An additional advantage is the close proxim- are no concurrent health issues or pre-operative concerns.
ity to the operating theatre, which allows easy conversion to The informed consent of the owner or agent must be
GA in the event of the procedure not being tolerated or com- obtained after a balanced discussion about treatment
pleted with the horse standing. Some surgeons advocate the options, techniques and risks.
Figure 12.2 Set-up for standing

repair of a proximal phalangeal
fracture. Trolleys with digital
radiography system and instruments,
scrubbed assistant, kneeling surgeon
and horse positioned with covered
distal limbs.
An indwelling intravenous catheter is placed in the jugu- tive non-slip pad (such as kennel liner) to prevent moisture
lar vein ipsilateral to the fractured limb, and the horse is from scrub solutions wetting the floor. Routine primary
groomed to remove dirt and loose hair. Pre-operative clip- aseptic skin preparation is carried out before local anaesthe-
ping is most efficiently carried out at the time of initial sia. The exact local anaesthetic technique is dependent upon
radiographic examination, usually soon after admission, the fracture configuration and the surgical plan but usually
when splinting materials are removed. The entire circum- involves a conventional four-point (forelimb) or six-point
ference of the distal limb is clipped from the level of coro- (hind leg) (Chapter 10). The perineural block is then usually
nary band to the distal aspect of the radius or tibia. Splinting converted into a ‘ring block’, by circumferential infiltration
devices or bandaging materials are then reapplied to facili- of additional local anaesthetic. One percent mepivacaine is
tate safe movement to the surgery room. the local anaesthetic of choice, and a total volume of 20 mL
The patient is pre-medicated with acepromazine approx- is typically be used in order to complete the perineural and
imately 30–45 minutes prior to the anticipated start of the the ring block. Ideally, the surgeon should personally per-
surgical procedure. Once moved to the designated surgical form the blocks to be confident of efficacy and to avoid third
area, the patient is positioned adjacent to the wall, with the party blame if there is reaction from the patient. The use of a
fractured limb outermost. Sufficient working space around winged infusion (‘butterfly’ catheter) may be helpful if
the horse will be required for instrumentation, equipment access to the medial aspect of the limb is awkward or the
and personnel. Adequate restraint and perfect positioning patient is difficult. Skin sensation is always tested after
of the patient are absolute necessities for successful stand- blocking and before final aseptic preparation.
ing repair, and the value of a competent, trusted horse han- The foot should be placed so that the distal limb is straight
dler, who is experienced in this procedure, cannot be in a sagittal plane with Mc3/Mt3 perpendicular to the floor.
overemphasized. This person is crucial in ensuring the The limb should not be abducted or adducted. Under aseptic
safety of the team around the horse. conditions, the surgeon carries out precise palpation of the
Once appropriately positioned, the horse should be distal limb to allow the placement of sterile skin staples
sedated. The authors’ preference is α2-agonists in combina- medially and laterally at the level of the fetlock joint space
tion with an opioid, usually detomidine hydrochloride and and on the lateral surface of the leg at approximately 2 cm
butorphanol. The aim is to achieve a stable plane of seda- intervals for the entire fracture length. Correct positioning of
tion, without ataxia. Profound sedation, which could result the skin staples is confirmed by dorsopalmar/plantar and
in stumbling or falling, and light sedation allowing lateromedial radiographs (Figure 12.3). The staples act as
increased awareness and movement are both potentially markers of local anatomy and guides for screw placement.
hazardous. The choice of constant rate infusion (CRI) or With marker staples in the correct position, a final prepara-
intermittent ‘top-up’ bolus technique is dependent on the tion and aseptic scrub is undertaken. A sterile cohesive
clinic and surgeon’s own preference. CRI allows a fairly bandage is applied to the contralateral limb from the coronet
constant plane of sedation to be achieved for prolonged to the middle of the radius or tibia. The limb to be operated
periods whilst intravenous ‘top-ups’ minimize the com- is bandaged in a similar fashion from the proximal extent of
plexity of the set-up, if the procedure is being performed in the surgical field to the same level. A tourniquet is not
an open room with an unconfined patient. required [2] and is discouraged as it acts as a source of dis-
The α2-agonists used for sedation are diuretics, which comfort to the horse, which may stimulate limb movement.
increase urine production and bladder filling. This stimu- Before the start of surgery, the surgeon should stand
lus can make the horse agitated and uncomfortable, back and carefully review the limb, in order to appreciate
increasing the risk of movement as they attempt to posture any valgus or varus conformation. It is particularly impor-
and urinate. Pre-emptive placement of a urinary catheter tant to appreciate that hind legs naturally ‘turn out’ from
allows the bladder to be drained prior to surgery and mini- the hock. Screws will most commonly need to be placed
mizes the risk of contamination of the operative field by perpendicular to the fracture plane, which is often not at
urine voided during the procedure. Pre-operative systemic 90° to the horse. The surgeon should fix a mental picture of
analgesia should be administered, and a rational peri- the horse’s position and conformation into his/her mind
operative antimicrobial regime adopted (Chapter 9). before commencing surgery as this perspective is easily lost
Once the horse has settled in a stable position, the sup- once kneeling beside the leg.
porting splint, cast or bandage is removed. From this point, An assistant surgeon or scrub nurse is essential during the
until the fracture has been repaired, there is a theoretical operative procedure to pass equipment to the surgeon. If an
risk of the unsupported fracture becoming displaced, air-driven drill is used, a third assistant should be employed
although the authors have not encountered this problem. to control the hose. A cordless (battery operated) drill offers
The foot of the limb to be operated on is placed on an absorp- a marked advantage and is a worthwhile investment.
Operative Techniqu 253
(a) (b) (c)
Figure 12.3 Placement of marker staples: (a) careful palpation of landmarks; (b) placing staple markers over distal Mc3;
(c) radiograph to confirm accurate staple placement.
Operative Technique
Individual surgeon preference will determine the exact

method of draping, and different techniques have been
described. The authors prefer minimal draping of the limb.
The distal pastern and foot are covered by an impervious
drape that is secured to itself with a towel clamp on the
medial aspect of the pastern. This drape extends across the
floor surface immediately around the leg to maintain a
sterile field (Figure 12.4). More extensive draping methods
have been described [4] where a laparotomy drape, secured
around the abdomen, covers the trunk and the contralat-
eral limb. Other variations include complete draping of the
operated limb, with a window cut-out to access the surgical
field, and sterile self-adhesive drapes [5]. The use of sterile
gloves to cover the foot is also worth considering. Careful
attention is required during draping to ensure there is no
break in aseptic technique.
The repair technique for standing surgery is identical to
that described for repair under GA. A lateral approach to
the leg is preferred for all fracture configurations. Although
medial access is possible, with the contralateral limb posi-
tioned caudal or cranial to the affected leg [4], it increases
difficulty and decreases safety. A medial approach may be
considered for propagating fractures of the medial condyle
of Mc3/Mt3. However, such fractures have successfully
been repaired from a lateral approach both under GA [8, 9]
and standing [2] (Figure 12.5).
Although the pre-placed staple markers are the primary
guide for screw placement, careful palpation and review of Figure 12.4 Limbs positioned and prepared for surgery.
(a) (b) Figure 12.5 (a) Skin staples placed in preparation for
lateral to medial repair of a long medial parasagittal
fracture of the medial condyle of Mc3. (b) Dorsopalmar
radiograph of the limb after placement of 4 × 4.5 mm
cortical screws with lateral to medial trajectories.
surface of the bone. The glide hole is prepared through

the cis-cortex using a 4.5 mm drill bit in an appropriate
sleeve (Figure 12.7a). The glide hole should be measured
to confirm that it has crossed the fracture line, and if
there is any doubt an intraoperative radiograph, with the
drill bit in place (disengaged from the drill), should be
performed. A 3.2 mm insert sleeve is then placed into the
glide hole, and a 3.2 mm bit used to drill the thread hole.
For standard fractures of P1 (short and long incomplete),
the thread holes should always exit the trans-cortex in
order to ensure adequate cortical bone is engaged by the
implants. When the drill bit exits the trans-cortex, it can
be palpated which provides confirmation of satisfactory
and safe screw hole placement. For fractures of distal
Figure 12.6 Accurate screw placement for repair of a short Mc3/Mt3, the thread hole does not have to exit the trans-
lateral condylar fissure fracture. cortex in the distal condylar region, where bone density
and screw holding power are greater.
The cis-cortex is carefully countersunk, and the length of
the local anatomy and conformation throughout the surgi- the screw is determined using a depth gauge. If self-tapping
cal procedure are essential. Advice on orientation from an screws are not used, then the thread hole is tapped in a
experienced, standing, surgical assistant to ensure that the routine fashion (Figure 12.7b). The screw is positioned and
drill bit does not deviate from the ideal dorsopalmar/plan- tightened fully with the horse weight-bearing (Figure 12.7c).
tar or proximodistal plane is also invaluable. Intraoperative Some surgeons [5] advocate raising the distal limb and
radiographs may be required to confirm accurate and unloading it in order to fully tighten the screw, but the
appropriate drill tract or implant placement (Figure 12.6). authors do not consider this necessary. It adds time and
When the radiographic screen or plate enters the surgical complexity to the surgery, may provoke movement of the
field, it should be covered in a sterile drape or bag to main- horse, adds to the risk of a break in aseptic technique and
tain asepsis. may inadvertently result in poorer subsequent limb posi-
At each screw position, an 8 mm skin incision is made tioning. Further screws can be inserted in a similar fashion
with a number 10 scalpel blade and then deepened to the as determined by the fracture configuration and surgical
Post-operative Car 255
(a) (b) (c)
Figure 12.7 Illustration of the surgical procedure: (a) drilling a 4.5 mm glide hole; (b) tapping threads; (c) inserting a 4.5 mm cortical
screw.
verrunning is usually due to poor planning or unfore-

o
seen technical difficulties. A stripped screw is most com-
monly encountered in the proximal half of P1 (usually
the second screw distal to the fetlock joint). The surgical
team should be prepared for this event. Recent CT studies
of P1 fractures have shown a variable dorsal–palmar/
plantar location of the fracture line [10]. In such cases,
the insertion of two adjacent screws placed proximally in
P1 may be advocated.
Post-operative Care
Post-operative Bandaging and Immobilization

Although bandage requirements will vary according to the
case and individual surgeon preference, common princi-
ples apply. Bandage type and size must be adequate to pro-
tect, support and immobilize the fractured bone in the
immediate post-operative period. It should be applied for
sufficient time to be confident that the integrity of the
Figure 12.8 Short incomplete P1 fracture repair.
repaired bone is no longer at risk. There are of course dis-
advantages to bandaging: the production of bandage sores
plan (Figures 12.5 and 12.8). At the conclusion of surgery, and prevention of early, controlled mobilization. In each
stab incisions are closed with skin staples or sutures and case, a balanced consideration of the pros and cons is
are covered with a non-adhesive sterile dressing before needed. Bandage support for the contralateral limb should
application of an appropriate bandage. also be considered in the first two weeks post-operatively,
The most commonly encountered intraoperative prob- especially if the horse is sore on the operated limb.
lems are patient movement and stripped screws. Patient Fractures that are considered to be of a predictable con-
movement is commonly caused by the horse attempting figuration and unlikely to be at risk of post-operative
to posture to urinate and is usually a consequence of pro- propagation (for example short non-displaced P1 and
longed operative and/or preparation times. Most standing lateral condyle of Mc3) should be maintained in a light
repairs should have a surgery time of 20–30 minutes; supportive cotton-wool-based bandage for a minimum of
two weeks. After two weeks, the skin sutures or staples are drugs that have an effect on gastrointestinal motility
removed and a further two weeks of light bandaging (for together predispose the patient to impaction colic. For this
example a ‘stable wrap’) is advised. reason, pre-emptive administration of fluids and electro-
Fractures that are considered to be of low to moderate risk lytes via stomach tube is recommended immediately after
of propagation (such as sagittal oblique P1 fractures) should surgery and as required thereafter. A laxative diet should
be immobilized in a Robert Jones bandage for at least two be fed, and the daily faecal output monitored.
weeks or until follow-up radiographs demonstrate no frac- If there is significant, unexpected or prolonged lameness
ture progression. Bandage support may be reduced at this following fracture repair, a plausible explanation must be
stage. Fractures that are of an uncertain configuration or at determined without delay. The contralateral foot should be
high potential risk of propagation (for example medial spiral monitored carefully for signs of supporting limb ‘overload’
parasagittal fractures of Mc3/Mt3) should be immobilized in laminitis, and pre-emptive measures carried out at an early
a Robert Jones bandage, or a bandage cast, for a minimum of stage (Chapter 14). High standards of intravenous catheter
four weeks. Further management is determined by radio- care are also important to avoid the frustrations of jugular
graphic and clinical progress. After four weeks, the risk of vein thrombosis and/or infected thrombophlebitis.
unexpected catastrophic failure is minimal.
When a repaired fracture is at known or perceived
increased risk of propagation, tying the horse up on a ‘run- Rest, Review and Return to Training
ning rail’ for four weeks post-operatively may be considered.
The aim of this is to discourage the horse from lying down The precise rest period required will depend on the indi-
and standing up, during which process uncontrolled loading vidual case. The repair phase of primary bone healing is
including bending and torsional forces can lead to cata- usually achieved within 12 weeks of fracture fixation, and
strophic fracture failure, most commonly in the hindlimb. the principle of early mobilization and incremental load-
This type of management does not suit the temperament of ing in an effort to optimize healing and encourage adaptive
every horse. Constant head elevation also limits drainage of remodelling is well established. The challenge in the
bronchial secretions, which can predispose to the develop- equine patient is to make this a controlled process. In most
ment of pneumonia. In order to minimize the risk of pneu- cases, the authors recommend four to six weeks of post-
monia, the tied-up horse should be ‘let down’ to eat under operative box rest followed by radiographic examination.
direct supervision, i.e. while being held, multiple times daily. Assuming satisfactory evidence of fracture healing and
The temperature of tied-up horses should be monitored at clinical soundness at walk, increased mobilization and
least twice daily, and if any elevation occurs, blood samples loading should then be encouraged by the introduction of
(haematology and inflammatory markers) should be taken incremental hand walking or horse walker exercise for a
and an ultrasound scan of the chest performed to look for further six weeks. By 12 weeks post-operatively, return to
signs of pneumonia. ridden walking or turnout in a playpen/nursery paddock is
usually appropriate. A gradually increasing training regime
may be implemented from this stage.
Medical Management
The rest period may be shorter in a simple case. For
Post-operative pain relief is routinely provided by non- example, a period of four week post-operative box rest
steroidal anti-inflammatory medication: phenylbutazone before return to walking exercise may be sufficient for a
remaining the drug of choice. This should be administered simple Mc3/Mt3 condylar fissure fracture. Conversely, a
judiciously for five to seven days, on an individual case basis, Mt3 spiral fracture may require at least eight weeks of box
to ensure adequate clinical comfort. Opioid analgesia, typi- rest following repair. Walking exercise may follow subject
cally morphine, can be added to pain management if deemed to satisfactory clinical and radiographic progress.
necessary. Broad spectrum antimicrobials are administered In a series of horses that had undergone standing frac-
pre-operatively and continued for 24 hours post-operatively. ture repair, the mean time for return to racing was just
under seven and a half months [2]. Although one cannot
draw exact comparisons, the outcome for horses that have
General Nursing Care
undergone standing fracture repair appeared equivalent to
High standards of post-operative monitoring, husbandry those in which surgery has been carried out under GA. In
and nursing care are essential to minimize complications. this study, approximately 72% of horses that had surgical
Transport, hospitalization, box rest and surgical interven- repair of a P1 or Mc3 lateral condylar fracture returned to
tion all represent changes to the normal routine of a fit ath- racing [2]. Despite being influenced by numerous varia-
lete. In particular, the abrupt reduction in exercise, changes bles, this information is likely to be helpful to owners,
in feeding and management and administration of sedative agents and trainers when faced with decision-making.
Reference 257
Summary sents a viable option that avoids the inherent risks and
expense of GA. As acceptance of the procedure grows,
Standing fracture repair in horses has been validated as an increasing novel applications are likely to develop as docu-
acceptable technique. It is not suitable for all surgeons, all mented in a case report detailing the successful standing
horses and all fractures but in carefully selected cases repre- repair of a fracture of the greater tubercle of the humerus [11].
References
1 Johnston, G.M., Eastment, J.K., Wood, J., and Taylor, P.M. 7 Ramzan, P.H.L., Palmer, L., and Powell, S.E. (2015).
(2002). The confidential enquiry into perioperative equine Unicortical condylar fracture of the thoroughbred fetlock:
fatalities (CEPEF): mortality results of phases 1 and 2. Vet. 45 cases (2006-2013). Equine Vet. J. 47: 680–683.
Anaesth. Analg. 29: 159–170. 8 Smith, L.C.R., Greet, T.R.C., and Bathe, A.P. (2009). A
2 Payne, R.J. and Compston, P.C. (2012). Short-and long- lateral approach for screw repair in lag fashion of spiral
term results following standing fracture repair in 34 horses. third metacarpal and metatarsal medial condylar
Equine Vet. J. 44: 721–725. fractures in horses. Vet. Surg. 38: 681–688.
3 Richardson, D.W. (1984). Medial condylar fractures of the third 9 Wright, I.M. and Smith, M.R.W. (2009). A lateral
metatarsal bone in horses. J. Am. Vet. Med. Assoc. 185: 761–765. approach to the repair of propagating fractures of the
4 Russell, T.M. and Maclean, A.A. (2006). Standing surgical medial condyle of the third metacarpal and metatarsal
repair of propagating metacarpal and metatarsal condylar bone in 18 racehorses. Vet. Surg. 38: 689–695.
fractures in racehorses. Equine Vet. J. 38: 423–427. 10 Brünisholz, H.P., Hagen, R., Fürst, A.E., and Kuemmerle,
5 Perez-Olmos, J.F., Schofield, W.L., Mcgovern, F. et al. J.M. (2015). Radiographic and computed tomographic
(2010). Standing surgical treatment of spiral longitudinal configuration of incomplete proximal fractures of the
metacarpal and metatarsal condylar fractures in 4 horses. proximal phalanx in horses not used for racing. Vet. Surg.
Equine Vet. Edu. 18: 309–313. 44: 809–815.
6 Ramzan, P.H.L. and Palmer, L. (2011). Musculoskeletal 11 Madron, M., Caston, S., and Kersh, K. (2012). Placement
injuries in thoroughbred racehorses: a study of three large of bone screws in a standing horse for treatment of a
training yards in Newmarket, UK (2005-2007). Vet. J. 187: fracture of the greater tubercle of the humerus. Equine
325–329. Vet. Edu. 25: 381–385.
259
13
External Coaptation
I.M. Wright
I ntroduction followed by eight weeks of progressively increasing exer-

cise documented loss of trabecular bone and a generalized
The goal of external coaptation is provision of a temporary loss of mineral including bone mineral density and bone
exoskeleton [1]. External immobilization of fractures can mineral content. Bone mass and bone mineral content did
be effected with splints, casts, transfixation casts or exter- not return to normal values after eight weeks of exercise
nal fixation devices. Splints are generally used for tempo- although this appeared to increase remodelling activ-
rary rather than definitive immobilization of equine ity [2]. In a further experimental study, casts enclosing the
fractures: these are therefore discussed in Chapter 7. foot and extending to the proximal metacarpus were
applied for eight (changed at four) weeks to eight skele-
tally mature horses. All exhibited reduced bone density in
C
asts the metacarpal condyles and proximal sesamoid bones.
Seven had changes in deep digital flexor tendons and three
Casts are employed to provide rigid external immobiliza- fragmented proximal sesamoid bones. Twelve weeks of
tion of limb segments either as temporary stabilization for remobilization following cast removal failed to reverse the
transport, the primary treatment modality or as an adjunct changed completely [5]. In a clinical report, two horses
to internal fixation. This may be to protect the repair dur- suffered bilateral fractures of hindlimb proximal sesamoid
ing recovery from general anaesthesia or, by immobilizing bones following cast immobilization for 32 and 39 days;
the limb for a period, to decrease cyclic loading of the both were noted to have marked osteopenia [6]. In the
enclosed construct. Casts are also used in some cases to author’s experience, these are extremely unusual events.
protect soft tissues. Minor changes in proteoglycan content and synthesis and
While intuitively immobilization appears to be an in cartilage cellularity were found in metacarpophalan-
entirely positive contribution to fracture healing, in prac- geal joints after 30 days of immobilization in distal limb
tice there are negative components that can have impor- casts. These were considered likely to be of little clinical
tant implications for fracture repair. Limited movement at consequence [7]. However, protracted immobilization
fracture sites can have a positive influence on fracture can, unsurprisingly in light of its poor regenerative capac-
healing (Chapter 6). Removing load also results in disuse ity, result in permanent cartilage damage and can be a sig-
atrophy, generally seen as osteopenia in bones [2], while nificant limitation to recovery from injury. The published
both laxity from loss of tendinoligamentar support and effects of immobilization on joints have been reviewed [8].
reduced ranges of joint motion are also encountered. All The authors recognized that, in some circumstances, the
are usually reversible when movement is restored. collective compromise, colloquially referred to as ‘fracture
Osteopenia has been reported after six [3] and eight [4] disease’, resulted in permanently dysfunctional joints. The
weeks of experimental cast immobilization. Recovery of subject is complex, range of effects broad (Figure 13.1) and
bone mass was enhanced by post-immobilization exer- implications wide reaching. In equine clinical practice,
cise [4]. An experimental study in which distal forelimbs there are age and location differences in concerns, but the
were immobilized in half-limb casts for seven weeks overriding principle is that each case has an imprecise

c13.indd 259 12/17/2021 12:31:15 AM

260 External Coaptation
Cartilage atrophy,
Regional osteoporosis
including reduced
Synovial adhesions
thickness and loss of
glycosaminoglycans and
water
Increased production of Cartilage necrosis at

reducible collagen contact points
cross-links
Effects of
Immobilization on
a joint
Weakened ligament
Increased collagen insertions with reduced
turnover and reduced energy absorbing capacity
mass
Disorganization of cellular Increased ligament

and fibrillar ligament compliance
alignment
Figure 13.1 Effects of immobilization on joints summarized. Source: Based on Akeson et al. [8].
tipping point at which the negative effects of immobiliza- impose marked biomechanical changes on the radius and
tion outweigh benefits. The attending clinician’s role is to tibia respectively changing their compression and tension
keep this debate under constant review. surfaces [12].
Although some of the disadvantages of rigid immobiliza-
tion may be overcome by semi-rigid coaptation techniques,
Materials and Construction
these and appropriate materials are not sufficiently rigid to
reduce motion or counteract forces at fracture sites [9]. Virtually, all casts employed in equine fracture manage-
They have not therefore been widely adopted in equine ment are based on fibreglass casting tape. There is univer-
surgical practice. sal agreement that this is superior to plaster of Paris in all
The long-standing guidance for application of casts in respects except conformability [13, 14]. This is generally
fracture management is that, in order to provide effective ameliorated by combining fibreglass with additional
immobilization, these should include at least one joint materials to provide safe and effective immobilization
proximal and distal to the fracture site. However, this is not (Figure 13.2). In the presence of a surgical wound or (less
dogmatical: the anatomy and associated mechanics of the commonly) an open fracture, the wound is covered with a
equine distal limb allow some latitude. Casts immobilizing dry sterile dressing. The skin is then generally covered with
fractures involving the metacarpophalangeal/metatar- a light dressing material. Traditionally, stockinet has been
sophalangeal joints generally extend only to a proximal employed (e.g. Cast stockinet, 3M, St Paul, MN, USA;
metacarpal/metatarsal level. Delta-Dry stockinet, BSN Medical, Hamburg, Germany). A
The biomechanical consequences of casts must also be thin layer of conforming cellulose fleece bandage (e.g.
considered. An experimental study using cadaver limbs Soffban, BSN Medical Ltd, Hull, England) or similar syn-
demonstrated that loading characteristics at the level of the thetic material is equally suitable. Stockinet is usually
metacarpophalangeal joint were changed by application of employed as a double layer each 4–8 cm longer than the
a half-limb cast [10], and application of a full limb cast intended length of the cast. Limb size determines the
shifted the side of most tension in third metacarpal diameter chosen. It should fit sufficiently snuggly to avoid
bones [11]. Full limb casts in both fore and hindlimb wrinkles. In preparation for application, one-half of the
c13.indd 260 12/17/2021 12:31:21 AM

Cast 261
Figure 13.2 Materials required for application of a standard distal limb cast: non-adhesive dressings to cover surgical incisions,
adhesive cast felt strip for the proximal margin and two orthopaedic felt doughnuts for the heel bulbs; two conforming bandage rolls
(cellulose fleece), six 10 cm rolls of plaster of Paris, two 7.5 cm and three 12.5 cm rolls of fibreglass casting tape, one roll of conforming
knit material to apply soaked to the cast during curing, and one 10 cm roll coarsely weaved polyester casting tape for application to
the sole and distal perimeter.
stockinet is rolled outwards and one inwards. The former is West Midlands, England). This may also be used, if
rolled onto the leg first from foot to the top of the cast area. required, at the bottom of sleeve (tube) casts. It can also be
The junction is then twisted over the foot and the inwards cut into pieces and stuck over limb prominences to amelio-
roll is applied. The top of the stockinet should then be rate pressure distribution. Cutting central holes in the cast
secured to the limb. foam pieces (doughnut like) (Figures 13.2 and 13.3)
Skin and soft tissues at the top of casts are usually improves this function. In the forelimb, heel bulbs, acces-
provided with additional protection from impingement of sory carpal bone and styloid processes of the radius and in
the rigid outer fibreglass. A 3–5 cm strip of adhesive ortho- the hindlimb, heel bulbs, calcaneus and the tibial malleoli
paedic foam or felt is applied circumferentially. A number all generally benefit. Cast foam/felt is available in various
of suitable materials are commercially available (e.g. thicknesses, and these are chosen in accordance with the
Orthopaedic Felt, Hartmann USA Inc., Rockhill, SC, USA; site and size of the horse. Hydrocolloid dressing materials
Hapla Swanfoam, Cuxson Gerrard & Co. Ltd, Oldbury, have been promoted for similar protection of pressure
c13.indd 261 12/17/2021 12:31:24 AM

(a) (b) (c)
(d) (e) (f)
(g) (h) (i)
Figure 13.3 Application of a distal forelimb cast. (a) Cast foam squares cut as doughnuts placed over each heel bulb and covered by
a thin layer of conforming dressing material. (b) A strip of cast foam has been applied to the proximal metacarpus. A cupped limb
support is placed at the level of the distal antebrachium (arrow), and the limb is maintained in extension by an assistant pushing the
carpus into the cup and using this as a point of leverage to pull the toe cranially and proximally. The assistant remains constantly
positioned throughout cast placement, expediently removing and replacing the hand at the toe as material is added. (c) Fully soaked
plaster of Paris bandage is applied leaving a thin strip of proximal cast foam exposed. (d) Two rolls of 7.5 cm fibreglass tape are
applied with finger tension over the wet plaster of Paris, allowing interdigitation of the materials. (e) Three 12.5 cm rolls of fibreglass
include the hoof capsule. (f) Tepid water is used to keep the fibreglass wet during application maximizing polyurethane activity.
(g) Continued application of tepid water, and circumferentially rubbing of the cast with flat palm contact optimizes lamination of the
fibreglass layers. This continues while bubbling polyurethane curing is visible. (h) A soaked conforming bandage wrapped around
the cast encourages continued curing and lamination, while polyester casting tape is applied around the sole. (i) The completed cast.
points and/or subsequent sores, but in the author’s hands of plaster of Paris is suitable for most situations. Alternatives
have been less resilient. include Delta-Dry™ cast padding (BSN Medical), Procell
The next layer should be a conforming material that is Cast Liner™ (W.L. Gore and Associates, Flagstaff, AZ,
less rigid than the outer fibreglass shell. It should also bond USA) or 3M Custom Support Foam™ (3M Healthcare).
with this to avoid independent movement. Plaster of Paris These use resin-impregnated polyurethane foam pad-
(calcined gypsum) serves this purpose well [1, 15–17]. ding [18] : this is said to remain dry and allows evaporation
Milled powder is incorporated into a cotton bandage. When that helps to keep the enclosed skin dry. Expanded polyte-
water is added, this forms a thick white paste that quickly trafluoroethylene (Aqua Cast Liner, Judd Medical Ltd,
sets in a mild exothermic reaction as the calcium sulphate Bromsgrove, Worcestershire, UK) is also marketed with
become less soluble (Figure 13.3). Plaster of Paris interdigi- similar claims.
tates well with fibreglass producing a secure bond. It is also Fibreglass casting tape (Vetcast™ 3M or Delta-cast™
very absorbent, and water can wick through it. This drying BSN), which has a high strength to weight ratio, is univer-
effect reduces moisture accumulation beneath the fibre- sally employed as the outer rigid layer of the cast and is
glass and is sufficient to preclude bacterial and fungal pro- available from a number of manufacturers. Varying widths
liferation in enclosed hooves that generally emerge dry are produced, and most equine casts are constructed from
even after several weeks of enclosure. A 5–8 mm thick layer 7.5 cm (3 in.) and 12.5 cm (5 in.) (Figures 13.2 and 13.3) and
c13.indd 262 12/17/2021 12:31:29 AM

Cast 263
occasionally 10 cm (4 in.) rolls. Fibreglass tape is impreg- packages. It is important that this seal is maintained until
nated with water-activated polyurethane resin which glues the moment that an individual roll is to be used. Pressure
the layers together to create a strong laminate that, in turn, will also commence resin activation and therefore rolls of
produces an unyielding and immobilizing shell. cast material should not be stacked too high or have mate-
Fibreglass is rigid, durable and sets rapidly with almost rials placed on top of them. If on opening the pouch this is
full strength within 20–30 minutes [19], which is ideal for discovered (generally by the fibreglass tape turning brown
equine use. The open weave of fibreglass casting tape or being firm to touch), then the roll should be discarded.
makes casts water permeable [13] but water resistant [19]. Activating water temperature is critical, and most manu-
A number of studies have demonstrated the superiority facturers recommend tepid (21–25 °C) water into which
of its material strength [14, 19–22]. The strength of the the required roll of material is immersed. Fibreglass cast-
fibreglass cast is dependent on the two-dimensional tening tape is highly hydrophilic and is not taken from its
sile and compressive strength of the set/cured casting wrapping until immediately before immersion in water. It
tape, the strength of the resin and the quality of the lami- is immersed for approximately 10 seconds without squeez-
nation produced by the interaction between the resin and ing and is applied wet. Curing is temperature dependent,
fibreglass tape [23]. In practical terms, the latter is critical. and excessively warm water produces setting before ade-
The strength in bending is also determined by cast thick- quate lamination can occur thus producing a weak cast. If
ness and diameter, i.e. thicker and wider casts offer greater plaster of Paris is used, the fibreglass is applied immedi-
resistance to bending [23]. Strength in bending increases ately while this is wet which aids bonding between the
with the width of casting tape [24]. Reinforcement of materials. The fibreglass tape is unrolled and applied with
cylindrical casts with longitudinal splints of material on finger pressure only. Each turn overlaps its predecessor by
tension and compression sides can provide additional 50% progressively moving up and down the leg and avoid-
bending strength [24], but in clinical practice this is gener- ing folds and wrinkles in the material. In most circum-
ally not contributary. Strips of laminated constructs stances, the cast should be of equal thickness throughout.
demonstrated superior working and specific strengths, Proximally, the fibreglass should expose circumferentially
resistance to abrasion and good radiolucency [14]. Early in a rim of cast felt and, if used, plaster of Paris. Bubbling of
the development of fibreglass casting materials, several the wet fibreglass tape indicates activation of the
studies evaluated and documented specific properties of polyurethane, and the cast should be kept wet until this
individual propriety products [13, 14, 23]. Since this time, ceases which indicates the end of the curing period.
product properties have been refined and are more uni- Circumferential rubbing of the cast encourages polyure-
form. Cylinders of six different fibreglass casting materials thane bonding between the layers (Figure 13.3g). This
were evaluated in bending [23]. Tensile strength, fatigue should be done with flat palms only to minimize depres-
strength, exothermicity, permeability and radiolucency of sions in the cast that can act as points of impingement.
eight synthetic materials in laminated constructs were The curing cast can also be kept wet, while the foot is
also evaluated [13]. All casts became rigid enough to reinforced by application of a soaked gauze bandage
be weight-bearing within 30 minutes of application. (Figure 13.3h).
Individual products had advantages and disadvantages,
and all performed adequately for clinical use although
Application
Hexalite™ (now marketed as Vet-lite™) was noted to have
poor radiolucency. Studies evaluating the significance of When casts are applied under general anaesthesia, the
exothermicity during polymerization demonstrated that limb should be supported and maintained in the desired
five layers of fibreglass casting tape did not generate position throughout construction. This most commonly is
enough heat to become uncomfortable [13] and that six in an extended, i.e. normal weight-bearing, position.
layers did not produce temperatures that might cause Lateral recumbency with the affected limb uppermost is
burns [25]. Additionally, tepid water is usually applied to preferred, and therefore when fractures are repaired in dor-
curing casts to aid lamination and this has a cooling effect sal recumbency, it is usually advised to move the horse into
(Figure 13.3f and g). Six layers of fibreglass casting tape the recovery box before the cast is applied. For all casts,
are adequate for most purposes. There are no significant maintenance of sagittal/axial limb alignment is important,
differences between currently available products, and i.e. there should be no adduction, abduction or rotation of
choice is largely personal. any segments.
Application is simple, but accurately following guide- For distal forelimb casts, i.e. which terminate in the prox-
lines is critical. Wearing latex gloves is essential. The mate- imal metacarpus, the limb should be perpendicular to the
rial is marketed in rolls that are sealed in waterproof body, i.e. as if the horse was standing square and placed on
c13.indd 263 12/17/2021 12:31:29 AM

a limb support positioned just proximal to the carpus. An

assistant pressing the limb into the support allows this to
be used as a fulcrum for extension of the metacarpophalan-
geal and interphalangeal joints. The assistant’s other hand
holds the toe and pulls this forward until the sole is perpen-
dicular to the long axis of the extended limb (Figure 13.3b).
When the cast material is passed around the toe, the assis-
tant momentarily releases and then replaces their grip.
Adherence to a planned routine reduces the number of
movements required. If necessary, further leverage can be
created by drilling a hole medially and laterally through
the distal hoof wall in the approximate location of the most
palmar nail positions in a shod foot. A length of orthopae-
dic wire is passed through this and the ends twisted to cre-
ate a loose vertical mattress suture. A farriers rasp or
similar instrument is then passed between the wire and Figure 13.5 Full limb forelimb cast applied to the level of the
sole. An assistant then effects extension by pushing the proximal antebrachium. All enclosed joints are maintained in
rasp handle proximally to create a lever against the dorsal extension and normal limb alignment to minimize impingement
lesions.
sole and hoof wall. The rasp remains in position until the
cast is constructed. It is then slid out. The wire and defect
in the dorsodistal cast are then covered in a final layer of joints are fixed in extension as above. However, an assis-
cast material. In the author’s hospital, this technique is tant has to manually maintain carpal extension with the
rarely required. flat of the hand placed on the dorsal carpus. As the cast
Distal forelimb casts in a 400–500 kg horse usually material passes repeatedly over the carpus, the assistant
require 6 × 10 cm rolls of plaster of Paris followed by removes and immediately replaces this hand taking care
2 × 7.5 cm and 3 × 12.5 m rolls of fibreglass casting tape. The not to produce focal depressions that can result in
narrower rolls of tape more readily mould to the limb con- impingement lesions beneath. Application of full fore-
tours and are applied first. The majority of distal forelimb limb casts is easier in dorsal recumbency. The limb is
casts should permit the horse to stand square and, as far as placed directly beneath an overhead hoist, the foot is
possible with respect to the enclosed injury, load both limbs secured to this by a wire loop through the hoof wall and
equally (Figure 13.4). the hoist is raised to produce an extended limb. When the
When applied in lateral recumbency, it is not usually pos- cast has been completed, the limb is released and the wire
sible to use a proximal limb support or fulcrum for casts that is cut and retrieved before one further roll of cast material
extend to the proximal antebrachium (full forelimb casts) is applied to enclose the sole. The author uses
(Figure 13.5). Metacarpophalangeal and interphalangeal 10–12 × 10 cm rolls of plaster of Paris, followed by 5 rolls
of 7.5 cm and 8–10 rolls of 12.5 cm fibreglass tape for full
forelimb casts in adult horses.
Horses with full forelimb casts can have great difficulty
in rising. Ponies appear more adept, and foals can be lifted
to their feet. Manual assistance for horses is recommended
but carries a degree of personal risk. It should not be
attempted without enough (not less than four) trained and
experienced people. The cast forelimb has to be placed and
maintained in front of the horse’s body when it moves to
sternal recumbency in order that it can use it to help lever
itself up. Tail lift is of assistance and reduces the risk of the
horse pitching forward and falling. If the cast leg is allowed
to get beneath the horse’s body, it will be unable to stand. If
the cast leg become adducted or abducted, the risk of cast-
induced fracture in the proximal limb is high. Recovery in
Figure 13.4 Appropriate application of a distal limb cast a pool is an excellent option but available only in a few cen-
should allow the horse to stand square. tres worldwide. A sling recovery system is potentially
c13.indd 264 12/17/2021 12:31:33 AM

Cast 265
contributory, but rope-assisted recovery does not appear to level of the proximal tarsus. An assistance grasps the gas-
be advantageous (Chapter 10). trocnemius insertion and pushes this with the calcaneus
Sleeve casts immobilizing the carpus can be applied in distally which produces tarsal, and thus distal limb, exten-
lateral or dorsal recumbency. If the preceding surgical sion. The toe can then be grasped to extend the distal inter-
interference permits, the latter is preferred. The limb phalangeal joint as in the forelimb. The process is aided by
should be positioned perpendicular to the body and pulled a second assistant pushing the femoropatellar joint into
into extension by a slip or hobble placed around the pas- extension and locking this with hand pressure directing
tern and fixed to a limb support or overhead hoist. To facili- the patella caudally on the femur. Alternatively, a single
tate use of the latter, the cast can often be most conveniently assistant grasping the toe with one hand and pushing cau-
applied en route to the recovery box. Sleeve casts extend dally on the patella with the other is sufficient to invoke the
from the proximal antebrachium to distal metacarpus, ter- reciprocal apparatus (Figure 13.7). Following the comple-
minating at the level of the metaphysis of the third meta- tion of the cast and moving to the recovery box, the limb
carpal bone. If the casts extend further distad, it will should be flexed several times to ensure that the patella is
impinge on the extended metacarpophalangeal joint when unlocked and the horse is able to flex the stifle and hock
the limb is loaded. If immobilization for recovery from during recovery. Inability to flex the proximal joints is a
anaesthesia is not critical then, to avoid the risks associated major encumbrance to a horse’s ability to stand after gen-
with long casts at this time, a dressing can be applied for eral anaesthesia and in some cases can prevent this.
recovery and a sleeve cast fitted after the horse has stood Dorsally casts terminate at the level of the metatarsal
(Figure 13.6). Sleeve casts suitable for adult horses can be tuberosity but can, if desirable, extend slightly further
constructed from 7–8 × 10 cm rolls of plaster of Paris fol- proximad on the plantar aspect. Distal hindlimb casts usu-
lowed by 3–4 × 7.5 cm and 5–6 × 12.5 cm rolls of fibreglass ally utilize similar quantities of materials to their forelimb
casting tape. counterparts. When correctly fitted, the horse should be
Hindlimb casts that enclose the foot and extend to the able to stand square (Figure 13.4) and walk over the limb
proximal metatarsus (distal hindlimb cast) are also most normally (Figure 13.8).
readily applied with the horse in lateral recumbency and
the limb uppermost. Use of a limb support to provide a ful-
crum is not possible, but the reciprocal apparatus can be
utilized. The limb should be placed in a limb support at the
Figure 13.7 Application of a distal hindlimb cast. (a) A limb

support is placed at the level of the proximal tarsus (arrow), and
the limb is maintained in extension by an assistant pushing the
Figure 13.6 A forelimb sleeve cast, applied standing, from the patella caudally and pulling the toe cranially and proximally.
proximal antebrachium to the level of the distal metaphysis of (b) The completed cast fixing metatarsophalangeal and
the third metacarpal bone. interphalangeal joints in extension.
c13.indd 265 12/17/2021 12:31:36 AM

It is generally recommended, and makes intuitive sense,

that sleeve casts extend the full length of enclosed long
bones, i.e. that they finish over the epiphysis or metaphy-
sis. This minimizes stress concentration at a point over the
diaphysis which may be sufficient to result in fracture [26,
28]. In light of the general intolerance and extreme diffi-
culty frequently encountered in horses attempting to stand
after fitting full hindlimb casts, the author has used, with
success, a short tarsal sleeve cast. This has been employed
to protect tarsal instability and repaired fractures of the
tibial malleoli and tarsus. The cast extends from the junc-
tion of the middle and distal thirds of the tibia to the proxi-
mal metatarsus (Figure 13.9). It provides mediolateral
support to protect the fractures particularly during recov-
ery from anaesthesia. However, it allows a small amount of
Figure 13.8 When correctly fitted, a horse should be able to sagittal movement so that the horse is able to flex its stifle
walk over the cast limb normally. and distal joint sufficiently to be able to stand more easily
than with a full limb cast. To date, no catastrophic injuries
Hindlimb casts that extend to the proximal crus (full have ensued although two horses have ruptured peroneus
hindlimb cast) are fortunately rarely of advantage or indi- tertius: one in recovery from anaesthesia and one subse-
cated. The limb is maintained in an extended position by cau- quently. Both recovered uneventfully. Short tarsal sleeve
dally directed hand pressure on the patella to ‘lock’ the stifle casts suitable for adult horses can be constructed from
with dorsal extension of the toe. In adults, recovery from gen- 6 × 10 cm rolls of plaster of Paris covered by 2 × 7.5 and
eral anaesthesia is hazardous with risks directly proportional 3 × 12.5 cm rolls of fibreglass casting tape.
to the animal’s size. Foals can be lifted to a standing position. The relatively smooth surface produced by water-
Animals up to 400 kg body weight benefit from tail lift assis- activated polyurethane-impregnated fibreglass tape is slip-
tance. During the process, the cast limb has to be in a pro- pery and susceptible to abrasion. Casts including the foot
tracted position, i.e. beneath the horse’s body. Adduction or are therefore supplemented by an additional solar cover-
abduction can result in catastrophic fracture of the tibia. ing. The author’s preference is a coarsely weaved polyester
Manual lifting of the hindlimbs has less impact in horses over casting tape impregnated with heat-activated polyurethane
400 kg but can still be of assistance. Rope systems (Chapter 10) (Vet-Lite; Runlite SA, Avendue de la Cooperative 9,
provide steadying resistance, but the sling recovery system is Micheroux, Belgium). This can be heated in a hot air oven
substantially better. Recovery pools (Chapter 10) are ideal but but is more conveniently activated by immersion in boiling
not widely available. Rupture of peroneus tertius is a recog- water. It cures/hardens rapidly so application and mould-
nized complication of full hindlimb casts [26, 27]. ing to provide a flat solar surface for the cast must be
Figure 13.9 Short tarsal sleeve

casts. A supplementary distal limb
bandage may be added to reduce
dependent soft tissue swelling.
c13.indd 266 12/17/2021 12:31:42 AM

Cast 267
e xpedient (Figure 13.3). The material also bonds well to the Casts that enclose the foot inevitably produce a degree of
underlying fibreglass cast creating a secure union. When limb lengthening. This causes horses to offload the cast limb
hot, the material is readily moulded (albeit for a brief period and therefore contributes to problems of contralateral limb
only) and, if desirable, can be fashioned to produce a wedge overload particularly when casts are maintained for a period
or heel raise. Alternatives include polymethylmethacrylate of more than a few days. A number of techniques can be
acrylic (e.g. Technovit, Jorgensen Laboratories, Loveland, employed to reduce this. In adult horses that are shod, the shoe
CO, USA) that is good at preventing abrasion but counter- can be maintained on the contralateral foot (Figure 13.10a)
productive in preventing slipping. It is also brittle and does which should then be covered to minimize risk of trauma in
not bond well to fibreglass. Elastoplast™ or similar mate- recovery from anaesthesia. In unshod horses, a shoe can be
rial covered by duct tape is simple to apply and can be used fitted to the contralateral limb. Ideally, this is done in the recov-
when casts are in situ for a short period. Stables with non- ery box while the horse is anesthetized to avoid loading the cast
abrasive floors (e.g. rubber) are preferred for preserving limb. This time also provides an opportunity to apply solar sup-
cast longevity. Shavings are ideal bedding; straw tends to port to the foot contralateral to the fracture. Use and choice of
become caught up by casts. materials/techniques vary between surgeons. Application of
When casts enclosing the foot are fitted electively, prior heart bar shoes, frog pads of varying sorts and silicone-based
foot trimming with removal of exfoliating solar and frog packing have all been reported. Commercial boots with soft
horn is ideal. In horses with fractures, this process usually solar padding can be employed (e.g. Soft-Ride boots; Soft-Ride
has to be expedited but should be carried out as far as cir- Inc., OH, USA; Nanric Ultimate, Nanric, Lawrenceburg,
cumstances allow. The foot excluding the coronary band Kentucky, USA) (Figure 13.10b). Contralateral limb frog and/
can also be painted with iodine solution, but if plaster of or solar support is advocated by some surgeons. Commercial
Paris is employed this is not contributory. frog supports include Lily Pad (Therapeutic Equine Products,
(a) (c)
Figure 13.10 Options to limit
limb disparity: (a) shoe left in situ;
(b) Soft-Ride boot; (c, d) wooden
block cut to size and attached with
superglue.
(b) (d)
c13.indd 267 12/17/2021 12:31:48 AM

Indianapolis, IN, USA) and solar supports include Newmarket than a few metres but is an important part of ongoing
Sole Support (Newmarket Premixes, Newmarket House, assessment. There are few fractures enclosed in a cast in
Catley Cross, Halstead, Essex, UK) and Advanced Cushion which this is contraindicated. Surface temperature of casts
Support (Nanric). If necessary or desirable, plywood board cut can be monitored thermographically [30], but circumferen-
to the shape and size of the foot can be glued to the solar sur- tial palm contact is generally adequate. Surface temperature
face of the foot, shoe or boot to provide further elevation commonly is raised over large subcutaneous blood vessels,
(Figure 13.10c and d) [29]. particularly over the proximal sesamoid bones. Appreciation
of this is an important but sometimes confounding issue as
this is also a common site for cast impingement and exco-
Monitoring and Maintenance
riation or pressure necrosis of underlying skin.
Horses vary in the first sign of cast-related complications. The contralateral limb should also be evaluated with par-
This may be lameness or an increase in lameness, increased ticular emphasis on digital arterial pulse amplitudes and
surface temperature or irritation manifesting as rubbing, coronary band morphology as warnings of overload lami-
chewing or nuzzling the cast. Later developing signs include nitis (Chapter 14). Raising or attempting to raise the con-
swelling above the cast and presence of exudate above distal tralateral limb is a good determinant of horses’ comfort in
casts, above or below sleeve casts or through the cast sur- the cast leg. Resistance should always raise concern and
face. The latter is frequently preceded by visible discoloura- merit investigation. Nonsteroidal anti-inflammatory drugs
tion. All horses in casts should have their temperatures that, for good reasons, are commonly administered to
monitored and recorded, but this is not a sensitive sign of horses with fractures may also delay recognition of clinical
cast-related complications. Throughout, attending clini- deterioration irrespective of cause. Laminitis was identi-
cians should be aware and constantly remind themselves fied in the contralateral/supporting limb of 14 out of 113
that the casts can and do cause problems of themselves but (12%) horses immobilized in 88 half limb, 11 full limb and
in addition prevent or retard recognition of complications 14 transfixation casts. Higher body weight and greater
associated with the original fracture and/or associated sur- duration of casting positively correlated with risk [31].
gery site. These include the classical inflammatory signs of In distal limb casts, sores caused by impingement or
heat, pain, swelling and exudation that in an exposed limb pressure are most common dorsoproximally on the third
would alert clinicians immediately. Regular observation is metacarpal or third metatarsal bones, over the palmar/
critical. Much can be learned from horses’ behaviour when plantar aspect of the proximal sesamoid bones and at the
undisturbed, noting limb loading, posture, spontaneous heel bulbs. In full and sleeve forelimb casts, the most com-
movement and demeanour. Horses should also be walked mon sites are the styloid processes of the radius and acces-
out of their stable each day. This does not have to be more sory carpal bone (Figure 13.11). The tibial malleoli are the
(a) (b) (c)
Figure 13.11 Cast sores: (a) dorsal proximal metacarpus; (b) palmar aspect of the proximal sesamoid bones; (c) medial styloid
process of the radius.
c13.indd 268 12/17/2021 12:31:57 AM

Cast 269
most frequent sites in full and sleeve hindlimb casts. Some with protracted application. This requires continuous reas-
surgeons fit distal forelimb casts in neutral rather than sessment of risks versus benefits of maintaining cast sup-
extended positions to reduce impingement on dorsoproxi- port. If horses with full forelimb casts do lie down, they can
mal third metacarpal bone. This is not consistently suc- experience difficulties in rising. In some instances, if the
cessful and increases limb lengthening. cast limb becomes dependent, the horse may be unable to
A retrospective study reported cast-related complications rise and will require rolling and assistance. Vigilant round
in four university teaching hospitals [32]. This included the clock observation is therefore necessary. Securing
345 fibreglass casts that all were lined with resin- horses in cross-ties or on an overhead wire may reduce
impregnated foam. Casts were applied to 136 forelimbs risks of lying down. Long-term use of a sling can obviate
(121 half and 15 full limbs) and 209 hindlimbs (157 half the risk but produces care and nursing concerns of its own.
and 52 full limbs). Legs were cast in neutral (92), flexed Mechanical cast failure is generally the result of intrinsic
(28) and extended (202) positions; limb position was not forces and usually occurs in bending which, in clinical
recorded in 23 horses. Initial casts were maintained for application, results in collapse on the compression side and
periods between 0 and 75 (median 15) days. Cast-related tearing on the tension side in a manner similar to that
complications were recorded in 179 (52%) cases. Clinical determined in vitro [23, 24]. Casts that crack should be
signs associated with complications in descending order of removed or replaced as repair is rarely successful. The solar
frequency were increased lameness, visible sores, discharge surface should be inspected at least once daily for signs of
or staining of the cast (strike through), soft tissue swelling abrasion thinning. Prospectively reinforcing this site is
proximal to the cast, increased surface temperature, frac- commonly necessary in horses that are cast for periods of
ture, pyrexia and cast intolerance. The single most com- weeks. Thermoplastic polyester tape can be topped up
mon complication was skin erosion (cast sore) which was readily, but prior removal of organic matter promotes
recorded in 165 (48%) horses. Overall, these were most bonding.
common on the palmar/plantar fetlock. In full hindlimb Soft tissue laxity in limbs frequently follows protracted
casts the commonest site was proximally on the tibia, and cast application. This is most commonly seen with the digi-
in half-limb casts the most common site was at the proxi- tal flexor tendons and suspensory apparatus, and foals
mal margin of the cast on the metacarpus/metatarsus. appear particularly susceptible (Figure 13.12) [33]. In foals
Heel bulbs were the next most common site. Cast breakage to avoid complications associated with growth, it is gener-
was seen in 17 (5%) cases with the highest incidence in full ally recommended that a single cast is not left in situ for
hindlimb casts. Limbs cast in flexion had significantly greater than two weeks. Coxofemoral luxation was reported
greater risks of developing complications than other posi- in two young (11 and 19 days old) foals fitted with proximal
tions [32]. In the author’s opinion, this is suitable for emer- (one full limb and one sleeve cast to proximal tibia)
gency short-term use only. hindlimb casts [34]. Such casts are uncommonly employed
Most horses with full limb casts do not lie down. Fatigue and genuine risk factors are difficult to assess, but this
of the contralateral limb is therefore a concern particularly should be considered if use is contemplated.
(a) (b) (c)
Figure 13.12 Cast-induced laxity in foals: (a) distal hindlimb cast applied for the treatment of a Salter–Harris type I fracture of the
third metatarsal bone; (b) marked extension laxity following 19 days of immobilization; (c) eighteen days later, after selective hoof
trimming and increasing levels of restricted exercise.
c13.indd 269 12/17/2021 12:32:01 AM

Removal Table 13.1 Equipment for cast removal.
Most casts are removed with the horse standing and Shoe removal kit
sedated, and many can also be replaced in this manner. Black marker pen
Casts may be removed under general anaesthesia if addi- Oscillating cast saw
tional interference is anticipated and/or cast replacement Engel’s plaster saw (or similar)
requires or is facilitated by this. Historically, obstetrical Cast spreaders
(Gigli) wire was incorporated medially and laterally into Scalpel blade
casts for manual removal, but oscillating cast saws are now Latex gloves
virtually universal (Figure 13.13a). The blades of cast cut- Appropriate sedation
ters have a finite life and should be removed when effi-
ciency reduces. Blades can be full circle or segmental. Most
are fitted with a hexagonal bolt that permits blade rotation widest point of the hoof. The person removing the cast
and therefore equal use. Circular blades are most com- should then put on latex gloves. The electrical oscillating
monly employed for horses and available in a variety of saw is switched on away from the horse to check its reac-
diameters. Blades can be stainless steel, titanium nitride, tion and if the level of sedation is appropriate. The handle
iron nitride and hard chrome or diamond coated. The of the cast saw (while turned on) should then be placed on
equipment needed is detailed in Table 13.1. the cast to assess the animal’s response to the vibration
If shod, the shoe is removed from the contralateral limb. (Figure 13.13b). If there is little or no response, then
At this point, the horse is usually sedated; a combination of removal can begin. The cast is first cut at the most proximal
acepromazine and alpha-2 agonist is preferred. While seda- aspect on the lateral side. The blade is applied perpendicu-
tion takes effect, a black marker pen is used to draw a line lar to the cast along the black line, and the operator should
down the centre of the cast on the lateral and medial sides maintain contact between the hand closest to the saw blade
(Figure 13.13b). In casts that enclose the foot, it should be and the cast at all time to prevent the blade slipping if the
ensured that the line finishes in the centre of the cast at the horse suddenly moves (Figure 13.13c). Using the blade to
(a) (b) (c) (d) (e)
(f) (g) (h) (i) (j)
Figure 13.13 Cast removal: (a) oscillating cast saw; (b) marker pen delineates the centre of the cast medially and laterally: the
handle of the saw is laid on the cast; (c) the saw is applied to the proximal lateral cast first; (d) the first cut gauges cast thickness; a
change in reverberation will be apparent as the saw cuts through the fibreglass and engages the plaster of Paris; (e) the cast is cut to
the level of the bearing surface to facilitate separation; (f) cutting the cast medially is most safely performed with the contralateral
limb slightly protracted and the saw and cable introduced caudal to this; (g) following lateral and medial division of the fibreglass
cast spreaders are introduced to separate the halves creating a hinge under the sole; (h) the plaster of Paris is cut along the division;
(i) manual pressure can then be used to open the cast: the plaster of Paris remains bonded to the fibreglass; (j) the limb is lifted out of
the cast.
c13.indd 270 12/17/2021 12:32:06 AM

Transfixation Cast 271
create a small groove along the black line is helpful. The

blade is then firmly applied to the proximal aspect until the
full thickness of the fibreglass is penetrated which is
marked by a sudden decrease in resistance (Figure 13.3d).
The blade is then moved distally and rolled on and off the
leading edge, minimizing removal and reapplication, to
produce a series of cuts all the way down the lateral aspect
of the cast. If Vet-Lite™ is used over the foot, it is necessary
to cut at a greater depth while taking care not to cut the
hoof capsule. Cutting should continue to the bearing sur-
face (Figure 13.13e) before the process is repeated on the
medial side (Figure 13.13f). Once the fibreglass has been
divided proximal to distal on both sides, cast spreaders are
introduced to separate the dorsal and palmar/plantar
halves of the casts (Figure 13.13g). At this point, the plaster
saw or a number 21 blade can be used to cut through the
intact plaster of Paris layer (Figure 13.13h). When this has
been divided, the cast can be separated by applying manual
pressure to the dorsal and palmar/plantar portions of the
cast (Figure 13.13i). Resistance indicates that the cast may
not be completely divided on both sides. Once the cast is
completely separated, except for a solar hinge, the leg can
be gently lifted out (Figure 13.13j) and supported back to a
weightbearing position. Cast foam and other dressing
Figure 13.14 Transfixation cast using three positive-profile
materials can then be removed. threaded pins in the third metacarpal bone to relieve axial
Lameness or an increase in lameness should be expected loading of a fractured proximal phalanx. Source: Courtesy of
immediately following cast removal [5]. When cast replace- Dr C. Lischer.
ment is necessary and cast sores are present, the use of cast
foam with a hole cut at the sore site can be helpful in mini- immobilization of fractures [40, 42]. The casts include the
mizing further impingement. Bandaging is almost always foot and, in some circumstances, may be reinforced by a
necessary after cast removal even if not contributory to metal ‘U’ bar through which the pins also pass. The bar
fracture management as it will control the ‘rebound’ swell- passes under the foot and extends proximally on the medial
ing that occurs until circulatory pressures return to and lateral sides of the cast. Such reinforced casts are fre-
normal. quently referred to as walking casts. The principle relies on
pin stability both within the transfixed bone(s) and enclos-
ing cast. Stability is determined by the strength of the con-
Transfixation Casts struct (pins and casts) and integrity of the bone–pin
interface [35]. Pins should be located as far distal in the
External skeletal fixation is indicated for the treatment of limb/cast as practical to maximize safety and efficiency
fractures of the distal limb that are not amenable to repair (Figure 13.14). Centrally threaded positive-profile pins are
by internal fixation. Fractures that are open, or where there currently recommended [35]. The most commonly used
is extensive soft tissue compromise, or in fractures that are implants have a core diameter of 6.3 mm and a central
so comminuted that stable reconstruction is impossible, threaded section that is 8 mm in diameter (IMEX™
are particular indications [35, 36]. Such techniques can Veterinary Inc., McKesson Drive, Longview, TX, USA).
also be used to augment internal fixation when repaired Holes are created with a 6.2 mm drill bit and tapped prior
constructs remain unstable or the risk of losing stability is to insertion. The pins are trocar tipped which aids place-
high [37]. ment (Figure 13.15).
Transfixation casts use pins placed through a cast and Kirk (1952) [43] is credited with first documenting trans-
enclosed bone(s) proximal to a fracture to relieve axial load fixation of the metacarpus, and Kendrick (1952) [44] with
from a fractured bone or bones by transferring this to the transfixation of the radius and tibia. Medzikaukas (1959)
enveloping cast: a principle that has been verified experi- reported creation of the first walking cast. The two con-
mentally [38–41]. They also, to varying degrees, provide cepts were combined by Reichel (1956) and Wikelidis
c13.indd 271 12/17/2021 12:32:06 AM

and resultant pin loosening often was the principal deter-

minant of the longevity of the cast. In the original publica-
tion, the average period of immobilization in the walking
cast was eight weeks. Casts in foals were changed at two
week intervals and others only when necessary. Thirty-two
horses (57%) survived and were able to be used for breeding
and/or light riding purposes [45].
Equipment and Construction

The bone–pin interface is the weakest point of all external
fixation techniques (in all species), and resultant prema-
ture loosening of transfixation pins is the commonest com-
plication [47]. Additionally, if attachment of transfixation
pins to the cast is suboptimal, rigidity will be compromised
and there will be increased stress at the bone–pin interface.
Experiments using fibreglass cylinders indicated that the
pin–cast interface experiences greatest strains [48]. Stress
at the bone–pin interface is a function of pin deflection
which, in turn, is proportional to the cube of the distance
between this and the external support [48]. Transfixation
casts therefore have a marked inherent advantage over
other forms of external fixation as this distance is mini-
Figure 13.15 IMEX large animal transfixation equipment: drill mized. Stress at the bone–pin interface results from both
bit, tap and centrally threaded positive-profile pins. the applied load and the bending moment of the pin which,
in turn, is determined by the pin diameter, the elastic mod-
(1960) and further refined by Nėmeth and Nuwmans ulus of the pin and the span from pin to cast. Bending
(1972) [45]. Grossman and Nickels (1979) [46] described results in uneven stress distribution with peak stresses on
transfixation cast repair of two foals with closed transverse the outer cortex. A cadaver study on radii demonstrated
fractures of metatarsals 2, 3 and 4. In both cases, 2 × 1/16 in. that the addition of tapered sleeves to extra osseous por-
Steinmann pins were inserted in transverse planes proxi- tions of 7.94 mm diameter transfixation pins strengthened
mal and distal to the fractures. Full limb plaster casts with the cast construct. This functions to increase effective pin
aluminium walking bars were applied to the limbs. diameter and reduces stress at the bone–pin interface [49].
Somewhat surprisingly, the principles of the technique They have been employed with apparent benefit in exter-
were not widely adopted for some time. nal fixation devices but have not been adopted into clinical
Further interest followed publication of the results of 56 use with transfixation casts.
fractures in 1991 [45]. These consisted of 35 horses and 21 Clinical observations supported the conclusion that the
ponies with fractures of the radius (13), metacarpus (11), bone–pin interface was a weak point in transfixation sys-
tibia (4), metatarsus (18) and proximal phalanx (10) and tems, and failure of external fixation devices was thought
included 10 open fractures. In 52 cases the walking cast to occur through torsional forces. Pins placed in multiple
was the sole means of treatment, while in 4 animals this planes produce more stable fixation. In one study, 30° sepa-
augmented internal fixation. Steinmann pins were used for ration of pins was associated with a 97% increase in tor-
transfixation. These had diameters of 4–8 mm determined sional strength [50]. Two-quarter inch Steinmann pins
by the size of the animal and anatomic location. Walking inserted parallel to each other were compared to similar
bars were made of steel, and holes were drilled on medial pins that diverged 30° from the frontal plane in cadaver
and lateral sides at the chosen sites of the transfixing pins. third metacarpal bones. This demonstrated the superiority
The holes in the bar were made slightly (3 mm) larger in of the latter in resisting torsional forces [42], and for a
diameter than the pin. After an initial layer of plaster of period the technique was adopted into clinical practice.
Paris enclosing the leg, the protruding pins were bonded to Transfixation casts utilizing quarter-inch Steinman pins
the steel frame and covered with methylmethacrylate. A were demonstrated to provide greater axial stability of
second layer of plaster of Paris was then applied around the oblique frontal plane osteotomies of cadaver proximal pha-
walking bars. Osteolysis adjacent to the pins was common, langes than simple casts applied to a proximal metacarpal
c13.indd 272 12/17/2021 12:32:07 AM

level [51]. There were no significant differences between Reduced heat generation and mechanical bone damage
transfixation casts with parallel pins, 30° divergent pins, or have been demonstrated in cadaver third metacarpal bones
with an incorporated ‘U’ bar. All limbs were enclosed in with non-self-drilling, non-self-tapping 6.3 mm positive-
similar fibreglass casts and at similar metacarpophalangeal profile transfixation pins compared to similarly sized self-
joint angles. This work also demonstrated that fibreglass drilling, self-tapping pins. Additionally, the former had a
casting material obviated the need for metal ‘U’ bars and more consistent thread pattern and greater pullout strength
the practical difficulties associated with their application. reflecting superior stability [55]. To minimize heat genera-
Subsequent clinical studies also found no difference in the tion and osseous damage in dense equine bone, holes
incidence of pin/bone failure between co-planar and diver- should be drilled with power equipment and at low speeds
gent pin placement [35]. Transfixation casts are now (less than 300 rpm) and should be pre-tapped [52, 54, 56].
applied in clinical settings without a ‘U’ bar and with co- Drilling sequentially larger holes decreases the maximum
planar pins. temperature and duration of increased temperature in
Threaded pins have greater pull out strength, allow less the bone [47, 57]. Following a cadaver study, a purpose
lateromedial migration and exhibit decreased pin loosen- designed step drill that varies from 4.5 mm diameter adja-
ing compared to smooth pins [35, 52, 53]. Additionally, cent to the tip to 6.2 mm in its proximal shaft was consid-
positive-profile pins, i.e. with an outer thread diameter ered a viable alternative [58].
greater than the shaft diameter, have a reduced stress riser Even with positive-profile pins, pin breakage can still be
effect at the junction of threaded and non-threaded por- a problem. The acute nature of the threaded to non-
tions of the pin [47, 54]. Osseous resorption at the bone– threaded junction acts as a stress concentrator [36]. A pin
pin interface results from thermal and microstructural with an increased shaft diameter and a tapered thread-run-
damage during pin placement followed by cyclic loading out (TRO) has therefore been introduced (Duraface pin,
and, in some cases, infection [53]. Resultant osteonecrosis IMEX). The shaft is 6.3 mm in diameter at the tip and this
can lead to sequestration of a ring of bone around trans- increases to 8 mm over the threaded section. The pins are
fixation pins [47, 54] and pin failure (Figure 13.16). Bone inserted after producing a 6.2 mm diameter drill hole
resorption leads to pin instability and this, in turn, causes which is followed by use of a tapered reamer before threads
pain usually manifesting as increased lameness [47, 53]. are created with a tapered tap. Pins are marketed with 65
(a) (b) (c) (d)
Figure 13.16 Dorsopalmar radiographs of a transfixation cast using 8 mm positive-profile threaded pins to manage a partially
reconstructed comminuted fracture of a forelimb proximal phalanx: (a) twenty-two days after application demonstrating osteolysis
at the bone/pin interfaces and failure of the proximal pin; (b) three weeks after placement of a second transfixation cast with
proximally located diverging pins; (c) seven weeks after second transfixation cast application at the time of removal; (d) fifteen
weeks after cast removal.
c13.indd 273 12/17/2021 12:32:10 AM

(a) Pin location is important for several reasons. Authors

appear agreed that pin placement as far distal in the cast as
(b) possible reduces risks of catastrophic fracture [35, 37, 41,
(c)
45, 47, 64]. Experimental cadaver third metacarpal bones
demonstrated that axial load born through proximal pins
(d) in transfixation casts exceeded distal pins [41]. The diame-
ter of metaphysis and epiphysis also exceeds that of the
(e) diaphysis, and therefore the impact of the cortical defects
created on reducing bone strength is diminished. It has
Figure 13.17 Instruments for insertion of IMEX Duraface®
also been suggested that a greater proportion of cancellous
large animal transfixation pins: (a) 6.2 mm drill bit; (b) tapered bone at these sites improves pin tolerance as this is tougher,
reamer; (c) tapered tap; (d) tapered pin with 65 mm thread less brittle and fails at a higher strain [37, 54]. In contrast,
length; (e) tapered pin with 85 mm thread length. observations on a recent finite-element model of the third
Source: Courtesy of Dr J. A. Auer.
metacarpal bone found that under axial load bone–pin
interface stresses were lower with pins placed in the dia-
and 85 mm thread lengths (Figure 13.17). However, despite physis than in the metaphysis. The most recent study found
their theoretical advantages, in one ex vivo study these that bone–pin interface stresses were reduced by increas-
failed in cyclic loading at clinically relevant load levels and ing pin diameter and number but minimally affected by
cycle numbers [59]. orientation or spacing. Stainless-steel pins also had lower
Pin size is an important consideration. Stiffness of trans- bone interface stresses than those made of titanium
fixation pins is proportional to the fourth power of their alloy [65].
diameter [47, 48, 51]. Larger pins also have more surface An in vitro study demonstrated that the strength of fibre-
area in contact with bone and thus less stress at the bone– glass casting tape and its attachment to transcortical pins
pin interface [47]. However, cortical defects created by pin were the principal limiting factors in resisting axial
insertion which are greater than 10% of the bone’s diame- load [48]. Problems at the bone–pin interface were the
ter act as stress concentrators, and at sizes greater than 20% principal limiting factors associated with straight smooth
there is a linear reduction in structural stiffness of the bone bone pins such as Steinmann pins. These included bone
in torsional loading [60]. Similarly, tests in four-point bend- necrosis and sequestration, infection of pin tracts, pin loos-
ing revealed a direct relationship between the size of a ening and bone failure/fracture [66]. The principal stresses
diaphyseal cortical defect and decrease in breaking at the bone–pin interface were considered to be bending
strength [61]. Use of pins of smaller diameter decreases the moments concentrated at the outer margins of the bone
size of associated cortical defects and therefore the risk cortex [67, 68]. In an effort to increase bone stiffness and
of bone failure [48, 61]. A study reported the influence therefore reduce stress at the bone–pin interface, a tapered-
of bicortical 7.94 and 9.53 mm lateromedial drill holes sleeve pin was developed for use with external fixation
through cadaver third metacarpal diaphyses in resisting devices [66].
torsion. Mechanical failure occurred as the hole diameter Following insertion pins are cut with bolt cutters 3–5 cm
increased as a percentage of the bone’s dorsopalmar diam- from the leg each side. This portion is incorporated into the
eter. Defects ranged from 22 to 38% of diameter and resulted cast construct. Any protruding after cast application can be
in failure strength reductions of 13 to 22% and reduced capped with fibreglass (the author’s preference) or methyl-
mean failure energy of 22 and 49% with 7.94 and 9.53 mm methacrylate. Transfixation casts inevitably result in limb
holes, respectively [62]. A single 9.5 mm transcortical hole lengthening. Compensatory raising of the contralateral leg
in equine cadaver radii reduced torsional strength com- makes a substantial contribution to horse’s posture, com-
pared with one, three or six similar holes of 6.35 mm diam- fort in ambulation and reduces risks associated with over-
eter. These represented means of 26 and 17% of the bone load of the same (Figure 13.18).
diameter, respectively. There was no significant reduction Close observation of transfixation casts is critical. Subtle
in bone strength when up to 3 × 6.35 mm holes were cre- decreases in loading can signal pin loosening. As radio-
ated. The authors therefore recommended use of three graphic evidence of osteolysis adjacent to pins precedes
transfixation pins in equine radii to maximize stiffness other signs of pin loosening, this may be used to monitor
while preserving bone strength [63]. A clinically estimated progress (Figure 13.16). It is recommended that loose pins
balance is therefore necessary determined, in part, by the are removed and replaced by a larger pin in the same hole
animal’s size and weight, the size of the transfixed bone or by another pin in an additional hole. Alternatively, the
and pin location within the bone. remaining pins are left in situ for continued support
c13.indd 274 12/17/2021 12:32:12 AM

(a) (b) (c) (d)
Figure 13.18 Management of a comminuted proximal phalangeal fracture using a transfixation cast: (a) the cast is applied with
the patient in dorsal recumbency under general anaesthesia, utilizing an overhead hoist to restore limb length and alignment;
(b) dorsopalmar radiograph 24 days following co-planar distal metacarpal point placement and cast application; (c, d) a wooden
block has been fitted to the contralateral foot to enable the horse to stand square and share load between the limbs.
ithout replacement of the loosened pin [35]. Whenever

w 30 animals and parallel in 5 animals. Transfixation casts
possible, transfixation casts are maintained until the distal were maintained for a median of 45 days (range 4–150) in
fracture(s) are able to withstand load. Unfortunately, confi- adults and 30 days (range 14–76) in foals. The median
dent assessment of this is impossible and, in practice, pin number of casts used was 2 (range 1–7). In 29 horses, the
loosening or intolerance of the cast and other features transfixation cast was replaced by a plain cast after pin
often determine longevity of use. After removal, risk of removal. Pin loosening occurred during the transfixation
failure through transfixed bone or through distal osteo- period in 13 (35%) casts and were loose at cast removal in
penic bone remains until both are restored to mechanical 12 (32%). In adults, smooth pins loosened at a median of
strength. 30 days (range 24–62) and threaded pins at 41 days (range
17–84). First pin loosening in foals occurred at a median of
27.5 days (range 14–44). All were preceded by radiological
Results
evidence of adjacent osteolysis. Fracture through pin holes
Experiences with 37 distal limb fractures in 27 horses and occurred in five adults; all were diaphyseal and occurred at
8 foals treated with transfixation casts in three university the most proximal pin site. Other complications included
teaching hospitals between 1994 and 2004 have been four pin hole sequestra, three broken and two bent pins.
reviewed [35]. These included a range of third metacarpal/ Twenty-seven (77%) horses survived to hospital discharge;
metatarsal (15), proximal phalangeal (12) and middle 25 of these had radiographic evidence of osteopenia distal
phalangeal (8) fractures of which 9 were open and 31 com- to the transfixing pins. Recorded reasons for euthanasia
minuted. All animals received antimicrobial medication included fractures through pin holes (3), laminitis (2), coli-
for a median of 13 days in closed and 34 days in open frac- tis (2), ischemic necrosis of the distal limb (1) and biaxial
tures. Fourteen horses had additional internal fixation pro- proximal sesamoid bone fracture secondary to disuse
cedures and the remainder were treated by transfixation osteopenia (1). Twelve individuals (seven adults and five
casts alone. IMEX centrally threaded positive-profile pins foals) were reported to have performed their intended
were used in 26 horses; 6.3 mm diameter pins were activities following repair. The number of individual vari-
employed in 17 animals weighing between 136 and 660 kg, ants were too small to assess confident associations with
and 4.8 mm pins were employed in 9 animals weighing outcome, but power insertion of implants appeared to
between 45 and 159 kg. The remaining horses (all from the reduce pin complications while utilizing more than two
larger weight group) were treated with smooth 6.3 mm pins was negatively associated with survival. The authors
diameter transfixation pins. Pins were divergent in concluded that centrally threaded positive-profile pins and
c13.indd 275 12/17/2021 12:32:17 AM

fibreglass material eliminated the need for a walking bar. In the third series, a modified technique was used in the
The pin–bone interface was consistently the principal site treatment of comminuted phalangeal fractures [37]. The
of technical compromise with diaphyseal locations (proxi- principal cast modifications were placement of pins in the
mal pins) most susceptible. Using two pins and localizing epicondylar fossa of the third metacarpal/metatarsal epi-
these as distal as practical was therefore recommended. In physis and 3–4 cm proximal to this in the metaphysis
order to balance the benefits of load relief provided by (Figure 13.18b). Pins were placed centrally and co-planar
transfixation casts against the negative influences of disuse in a frontal plane. Distal placement of pins was considered
osteopenia, the authors recommended that if fractures to reduce torsional forces and thus to permit co-planar
were grossly stable after six to eight weeks of transfixation placement. Plaster of Paris and fibreglass combination
casts these were followed by plain casts for a further three casts were used, and the authors described a technique for
to four weeks. Fracture healing was considered, at these figure of eight application of cast material around the pins.
time frames, to be in the fibrocallus phase (Chapter 6) This creates a strong and secure pin/cast bond. The cast
and thus may demonstrate little radiographic evidence of was also reinforced by incorporating commercially availa-
healing. ble fibreglass splints (Dynacast Prelude®; BSN Medical).
There are three reports of management of comminuted 6.3 mm positive-profile centrally threaded pins were
phalangeal fractures with transfixation casts [37, 64, 69]. employed. Horses were positioned in dorsal recumbency,
The first included six cases that were part of a series of 61 and a wire was placed between the hoof wall or between
horses; four (67%) healed, permitting animals to be used for this and a shoe. Fractures were reduced by traction
breeding [69]. The second documented 20 cases including generated by an overhead hoist attached to the wire
12 hindlimb and 8 forelimbs with 14 middle and 6 proximal (Figure 13.18a). The authors reported results of 11 horses.
phalangeal fractures. Eighteen fractures were closed and Eight fractures involved the proximal phalanx and three
two open. Nine horses were treated with transfixation casts the middle phalanx; nine were in forelimbs and two were
alone and 11 were combined with varying forms of internal in hindlimbs. Partial reconstruction of major fragments
fixation. 6.3 mm diameter centrally threaded positive- was performed in three horses, complete reconstruction in
profile pins were used in 15 horses, and smooth 6.3 mm three and no reconstruction in two fractures of the proxi-
diameter Steinmann pins in 5 horses. Nineteen horses had mal phalanx. Two middle phalangeal fractures had concur-
two pins inserted and one horse had three. Pins were placed rent arthrodesis of the proximal interphalangeal joint and
in a co-planar arrangement in 11 horses and diverged at an one had internal fixation. One proximal phalangeal frac-
angle of 30° from the frontal plane in 5 horses. Varying met- ture was open. Casts were maintained for between six and
acarpal/metatarsal locations were employed. Transfixation eight weeks with no pin loosening. These were then
casts were maintained for between 1 and 131 days (mean replaced by standard half-limb casts for a further three to
52; median 49). All were replaced by half-limb casts for four weeks. Nine horses (82%) survived and were capable
between 1 and 84 days (mean 25). Horses in which trans- of breeding or leisure activities.
fixation casts were maintained for over 40 days had a greater Transfixation casts have also been documented as part of
survival rate than those which were supported for a shorter a technique to arthrodese the distal interphalangeal
period. Hindlimb injuries had a better survival rate than joint [70] and in the management of unstable distal tarsal/
forelimbs. Fourteen (70%) horses survived to discharge. proximal metatarsal fractures [71]. There is also a report of
Fractures associated with the transfixation pins were the transfixation cast treatment of a comminuted, open,
commonest reason for euthanasia; these were all associated infected Salter–Harris type II fracture of a third metacarpal
with pins placed in the diaphysis. Lysis adjacent to trans- bone in a two-week-old foal [72].
fixation pins was identified in 12 horses (60%), 7 of which
(58%) yielded positive bacterial cultures. All transfixed
limbs developed osteopenia; one suffered subsequent biax- External Skeletal Fixation Devices
ial proximal sesamoid bone fractures, while the remainder
were not clinically limiting. No horses developed contralat- In 1952, Kirk [43] described two external skeletal fixation
eral overload laminitis. Follow up of more than one year devices (ESFDs) for equine distal limb fractures. The first
was available for 10 of 14 horses discharged from the hospi- was an adaptation of a Kirschner-Ehmer apparatus and the
tal. Eight were walking sound and exhibited slight lameness second, his own design, was remarkably similar to devices
at trot; two horses were lame at walk. The authors con- redeveloped and reported over 30 years later [73–76].
cluded that transfixation casts should be maintained for ESFDs utilize transcortical pins in a similar manner to
over 40 and less than 80 days to optimize support without transfixation casts, but these are connected and their load
producing case-limiting osteopenia [64]. transferred to externally positioned bars. In horses, ESFDs
c13.indd 276 12/17/2021 12:32:17 AM

External Skeletal Fixation Device 277
have been principally used to relieve load from complex However, morbidity was high [69, 75]; in one study, 5 out
distal limb fractures [36, 68, 74, 75] rather than engaging of 12 horses (42%) suffered metacarpal fractures through
fractures in a manner of true external fixation tech- pin holes and were euthanized [69]. Subsequent modifica-
niques [77–79]. As with transfixation casts, the bone–pin tions were made in pin and fixator design including use of
interface is the weakest component of the construct and tapered-sleeve transcortical pins that essentially extend the
the most common site of failure [53]. Similar clinical and support of the side bar frame to the bone, i.e. reducing the
radiological signs of compromise are also exhibited. The span to zero and reducing markedly its stress riser
principles of ESFDs in horses are sound but application is effect [66, 69, 85]. These were shown experimentally to
complex, and the skills and experience necessary have provide improved pin stiffness and more even distribution
been limited to only a few groups. The first designs also of stress at the bone–pin interface [66]. Substantially,
experienced, in common with many developing tech- reduced complications followed [69, 76].
niques, significant morbidity. ESFDs have therefore not As with transfixation casts, pin stress is related to abso-
widely been adopted into clinical practice [36]. lute vertical (weight-bearing) load, pin material and diam-
ESFDs are classified according to supporting frame and eter and the distance from the transfixed bone to the
transfixation pins. The longitudinal support is classified as supporting side bar. Pin deflection is proportional to the
unilateral, bilateral, triangular and quadrilateral [67]. cube of the bone-side bar distance, while stiffness is a func-
Segmental circular external fixation is frequently referred tion of the fourth power of its diameter [47, 76, 86]. Larger
to as an Ilizarov system after its Russian inventor (Gavriil diameter pins also have more surface area in contact with
Ilizarov) who pioneered studies on distraction osteogene- bone and thus less stress at the bone–pin interface [47], and
sis [79]. Non-circular devices are classified as type I (unilat- bone strain has been shown to decrease as pin size
eral fixation) that can be uniplanar (type 1a) or biplanar increases [82]. However, in common with transfixation
(type 1b), type II (uniplanar bilateral fixation) and type III casts, the biomechanical implications with respect to pin/
(bilateral biplanar fixation). Pins that penetrate one cortex hole diameter have to be taken into consideration. The same
of the bone are referred to as half pin and two cortices as problems and concerns regarding thermal and vascular
full pin [53]. Finite-element models have been employed to injury to bone during pin insertion and a sequela of oste-
evaluate variations in and between techniques on fracture onecrosis and ring sequestration experienced with transfix-
and bone–pin stresses [50, 67]. In addition to advantages in ation casts are also encountered with ESFD use [47].
application and load relief, ESFDs also offer ongoing access
to wounds in open fractures [78]. Application
In human and small animal surgery, three-dimensional The ESFD documented in the literature is no longer com-
pin configurations optimize resistance to torsional, shear mercially available. It utilized two 7.94 mm diameter trans-
and axial forces and protect bone from fracture propaga- cortical pins enclosed in tapered sleeves (TSP). These are
tion through pin holes [47, 50, 80, 81]. Such designs have, pressed against the bone surface to reduce the bending
because of difficulty in design, received scant attention in moment and stress at the bone–pin interface by nuts and
horses, although in experiments involving axial loading of locking washers through a welded collar steel tube. The
the metacarpus, as with transfixation cast techniques, no tubes, in turn, are welded to an aluminium foot plate onto
advantages were identified [51, 82, 83]. When used in true which the hoof is glued with acrylic adhesive [66, 76, 85].
external fixation techniques, i.e. when engaging fractures, Fitting requires general anaesthesia. The TSP ESFD is
angular separation of pins also provides greater stability designed for use in non-reconstructible distal limb frac-
while restraining movement in any direction [84]. ESFDs tures when the third metacarpal/metatarsal bone is intact.
suitable for use in mandibular fractures are described and It can also be used to relieve load on repaired or partially
discussed in Chapter 36. repaired fractures that remain unstable and/or require
additional protection from axial load.
Following routine skin preparation, bicortical 7.94 mm
Distal Limb ESFD
holes are drilled in the third metacarpal bone. A dual drill
The original Pennsylvania device [73] used three unpro- guide which is supplied with the ESFD ensures correct
tected 9.6 mm diameter centrally threaded stainless-steel spacing and central placement in the proximal and mid-
pins located in the third metacarpal bone proximal to frac- diaphysis. Pins are inserted using a cap to protect the
ture sites. These were connected by two side bars to a threads, and the sleeves are then placed over the pins and
rocker, wedged ground support base plate that was fitted to secured. The pin-sleeve portals are covered with sterile
the hoof like a shoe. This provided a major conceptual step dressings before the side tubes are assembled with ring
forward in management of collapsing distal limb fractures. connectors over the sleeves. The base is slid into the distal
c13.indd 277 12/17/2021 12:32:17 AM

ends of the tubes and fastened to the foot plate. Reinforcing proximal and distal to the fracture. The two central screws
rods are added to the tubes, and junctions are sealed with converged towards the fracture at 20° angles, while the
tape. The limb is then placed in traction to reduce fractures two remote pins were perpendicular to the third metacar-
(as far as possible) before the tubes are filled with polyure- pal bone. Pins were embedded in 19 mm diameter plastic
thane resin. The setting of this is exothermic, and cooling is pipes filled with methylmethacrylate medially and later-
recommended to limit pin heating. When the process is ally. At 42 days post-surgery, three pins were loose and the
complete, a dry dressing can be applied and the horse ESFD was removed [78].
recovered from general anaesthesia. A commercial four-ring circular ESFD with two multi-
Skin adjacent to the pins is cleansed daily, and pins are planar pins at each level appeared inadequate to stabilize
kept tight by adjusting the fastener nuts as necessary [85]. transverse mid-diaphyseal osteotomies with a 5 mm frac-
Additional post-operative monitoring and care are similar ture gap in adult third metacarpal bones [87]. However, a
to horses fitted with transfixation casts. Although it has similar system was successfully employed in treating a dis-
been claimed that pin loosening is a less frequent compli- placed comminuted mid-diaphyseal fracture of the third
cation with TSP ESFDs, serial radiographic monitoring is metacarpal bone in a four-week-old foal. This included
recommended [47]. Most ESFDs are maintained for graduated post-fixation distraction to restore limb length.
8–10 weeks as a balance between fracture stability and dis- Once this had been achieved, the ESFD was reinforced by
tal limb osteoporosis [76]. additional cross-bars between the rings [79].
Removal is done standing. The foot is cut from its plate, A displaced mid-diaphyseal tibial fracture was success-
and the lateral side bar is divided with a hack saw or small fully treated with a unilateral–uniplanar (type I) ESFD in a
motorized saw just below the distal sleeve. The nuts are 32-day-old foal. The same authors reported a similar tech-
removed from the threaded pins in the tapered sleeves, and nique applied to a comminuted femoral fracture in an adult
a supplied pin extractor is applied to each pin in turn. horse which failed due to technical error [88]
When these have been removed, the remaining ESFD can Mid-diaphyseal osteotomies in foals were repaired
be lifted away from the leg. They are usually replaced with using a type II ESF technique. 3 × 6.35 mm trocar tipped
a plain cast. The risk of failure of transfixed bone through Steinmann pins were placed with mediolateral trajectories
pin sites persists until cortical defects at least partially heal proximal and distal to the osteotomies and were secured by
and/or there is adjacent compensatory remodelling. Kirschner clamps to a 12.7 mm diameter stainless-steel rod
on each side of the bone. Stability was obtained and main-
Results tained in four of six foals. Treatment of five similar osteoto-
In a series of 13 horses with severely comminuted fractures mies using a type III, i.e. three-dimensional tent technique,
of proximal phalanges treated with two designs of ESFD, was unsuccessful [77].
including 5 using the tapered sleeves, 8 out of 13 (62%) In an experimental study, distal metaphyseal osteoto-
healed with residual lameness [69]. Using the system mies in cadaver radii were fitted with transfixation casts
described above, five of seven (71%) horses with commi- and two forms of ESFDs. In the former, two pins engaged
nuted fractures (six proximal phalanx and one middle pha- the mid-diaphyseal cortex of the radius, i.e. relieving load
lanx) survived including four horses in which fractures from the distal limb. Two pins in the ESFDs engaged the
were open. The non-survivors had both fracture site infec- third metacarpal bone and radius proximal to the osteot-
tions and contralateral limb laminitis [85]. omy (the distal radial fragments were not engaged). In one
The original ESFD design was also used in conjunction form of ESFD side bars were solid, and in the other the bars
with a cancellous bone graft to effect metacarpophalangeal were modular. Smooth (embedded portion) 7.94 mm diam-
arthrodesis in eight experimental horses and in one clinical eter transcortical pins were used throughout. Limbs were
case. This was successful in four out of eight animals tested to failure in axial static or cyclic loading. The modu-
(50%) [74]. lar ESFD was unsatisfactory. Solid side bar ESFDs were
The ESFD concept was innovative for its time but is con- stiffer and stronger than transfixation casts and were con-
sidered unlikely to re-appear. sidered to have potential for clinical development [89].
In a proof-of-concept study on bone substitutes, a hybrid
ESFD/transfixation cast and pin-sleeve cast was compared
Other External Fixation Devices
to a traditional transfixation cast. Under axial load, the pin-
A case report documented successful management of sleeve cast had reduced implant strain but comparable
open transverse fractures of the second, third and fourth axial displacement with the transfixation cast [90].
metacarpal bones in a five-day-old foal treated with a type Although the authors considered the system to have poten-
II, i.e. bicortical ESFD. Two smooth 4 mm pins were placed tial, no further work has yet been published.
c13.indd 278 12/17/2021 12:32:17 AM

Reference 279
R
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283
14
Post-operative Complications
Osteosynthesis in horses is challenging. Post-operative bio- i nstability, pain, increased risk of infection and are strongly
mechanical challenges mainly arise from the nature of the related to an unsuccessful outcome and euthanasia [4, 7].
patient including its temperament as a flight animal, its Catastrophic failure of the construct occurs if load exceeds
body weight, the physical forces acting on the repair and yield stress and deformation shifts from elastic to plastic;
difficulties of reducing the loading or immobilizing the this can affect implants and/or bone. Implant-related fail-
affected leg while minimizing overload of the contralateral ure results in bending or pullout of screws and/or deforma-
limb. Risk of infection is related to the use of metallic tion of plates. Bone-related failures are typically through
implants, soft tissue damage associated with the fracture stress risers or incomplete fissures that were not recog-
and/or its repair and the potential for both intra-and post- nized pre-or intra-operatively.
operative contamination. Hence, the most important com- Usually, the first challenge for the construct is recov-
plications after fracture fixation in horses are implant ery from general anaesthesia when the bone is exposed
loosening or breakage and incisional or implant-associated to the highest strains [8]. Measures to reduce these and
infection. Complications can be fatal or result in prolonged to support a calm and controlled recovery help (see
convalescence with the inherent risk of contralateral limb Chapter 10); in some cases, constructs can be protected
overload [1–4]. by external coaptation (see Chapter 13). Catastrophic
It is important to be aware of possible complications, to failures may also occur days or weeks after surgery often
anticipate and prevent them before, during and after sur- when horses get up from recumbency. Keeping horses in
gery and if they occur to recognize and manage them. In a rescue sling for six to eight weeks post-operatively can
most cases, complications are the result of an accumula- reduce the risk.
tion of unfavourable factors. For example, inaccurate pre- Fatigue failure of implants results from cyclic loads
operative planning or lack of surgical skills may lead to which are below yield stress (Figure 14.1). Implant break-
longer surgery times. Longer surgery times result in poor age depends on the number of cycles and the peak cyclic
anaesthetic recoveries and higher infection rate [3, 5, 6]. stress [9]. Some materials, including steel, have an endur-
Chapters 9 and 11 discuss the potential for pre-operative ance limit which means that stress below this does not
planning and good surgical practice to minimize risks. This cause failure in an indefinite number of loading cycles [10].
chapter addresses recognition and management of post- Ideally, the stability of fracture fixation should therefore
operative complications. prevent loading of implants beyond their endurance limit
and/or the time of bone healing does not exceed their
fatigue life.
C
onstruct Instability
Screw Loosening
Failure of the repaired fracture (construct) can be bone
related, i.e. re-fracture or secondary fracture that is usually The most common cause of screw loosening is bone infec-
the result of acute overload, or implant related which is tion. In horses with radial fractures, the risk of screw loos-
most commonly due to cyclic fatigue. Both result in ening was 17 times higher in the presence of surgical site

284 Post-operative Complications
Figure 14.2 Partial implant failure. Lateromedial radiograph

two weeks after fixation of a type IV ulnar fracture. Screw
bending (closed arrows) and loosening (open arrow) suggest
instability.
with hydroxyapatite lead to higher toleration of both

cyclic and single loading [13].
Figure 14.1 Implant failure due to cyclic loading. Lateromedial
radiograph of a metacarpal fracture four months after double
plate fixation. Abundant palmar callus formation has prevented I nfection
complete collapse.
SSI is a relatively frequent complication after fracture
repair in horses and is associated with delayed healing
infection (SSI). However, body weight may also be impor- and decreased prognosis. Of horses with SSI after long
tant as implant loosening was more frequent in adult bone fracture repair, only 59% [3] and 45.5% [14] were dis-
horses. It was also associated with decreased survival as charged from the hospital compared with 92 and 85.8%
seven/eight horses were euthanized as a result of construct without. SSI is classified by localization as superficial
failure [5]. Screw loosening or breakage can occur at any incisional, deep incisional and organ/space/implant
time until fracture healing is complete. In four horses with infection [15]. It is important to take superficial and deep
cannon bone fractures, instability because of screw loosen- incisional infections seriously as they can progress to
ing and breakage occurred on days 15, 35, 40, and 44 infection of the implants. This results in implant loosen-
post-operatively [7]. ing, pain, supporting limb laminitis (SLL), decreased
Screws can also loosen due to cyclic loading or because prognosis, increased costs and can be life threatening.
of technical errors during insertion. Micromotion Early recognition is an important prerequisite to preven-
between the threads of the screw and the bone can tion of devasting consequences. Implant-associated
induce loosening [11]. Screw compression decreases over infections are classified by the time of manifestation as
a period of months, during which time fracture healing early (<two weeks), delayed (two to ten weeks) or late
needs to occur [12]. If micromotion produces a strain (>ten weeks). Early infections are generally caused by
exceeding the limit of the bone, screws can become loose. microbial contamination during the trauma, surgery or in
Screw loosening in a plate increases stress on other the early post-operative period [16]. Later infections can
screws and potentially compromises the construct be caused by endogenous distant sources [17, 18].
(Figure 14.2). Peak overload can also loosen screws by SSI was reported in 27.6% [3] and 14.2% [14] of long bone
sudden stripping of the threads. The bone–screw inter- fractures, 44% of radial fractures [5] and 16–22% of ulnar
face is extremely important in internal fixation of frac- fractures [1]. Various fractures, treated with locking com-
tures in horses, and for this reason use of self-tapping pression plate (LCPs), developed an incisional infection in 32
screws is generally not recommended. Some surgeons and 22% and implant infection in 19 and 11% of cases [1, 4].
will even tap locking screws in hard cortical bone of Double plate fixation of proximal interphalangeal joint insta-
adult horses. In an experimental study, coating screws bility resulted in SSI in 2/30 (6.6%) horses [19]. Pre-operative
Infectio 285
planning to reduce surgery time, meticulous aseptic tech- Implant Associated Biofilm
nique and an appropriate peri-operative antimicrobial regime
Implant-associated infections can be hard to diagnose, per-
are all important in prevention (see Chapters 9 and 11).
sist despite antimicrobial therapy and are prone to recur-
rence. Although, the common concept is one of bacteria
Risk Factors growing naturally in suspension, most, if not all species of
bacteria thrive in a genetically programmed, alternative
The most important risk factors appear to be open frac-
lifestyle known as biofilm (extracellular glycocalyx) [21].
tures, long surgery time and open surgical techniques.
This was first defined as ‘A structured community of bacte-
Open fractures were 4.23 times more likely to develop an
rial cells enclosed in a self-produced polymeric matrix
SSI and were 4.5 time less likely to be discharged from hos-
adherent to an inert or living surface’ [22].
pital compared to closed fractures [3]. This was not con-
Implants including plates, nails, screws, wires, cables
firmed in a recent report from the same institution, but
and sutures are risk factors for development of SSI [23].
only a low number of horses with open fractures were
After implantation, these are covered by host proteins of
included [14]. Open radius fractures were 21 times more
which some, like fibronectin and laminin, promote adher-
likely to develop an SSI and 3.8 times more likely to not
ence of bacteria [24]. Bacteria use these together with their
survive to discharge [5]. Horses with closed fractures of the
own extracellular polymeric substances (EPS) to build up
metacarpus/tarsus had a 100% survival rate compared to
the biofilm matrix. Implants therefore provide two impor-
47% in horses with open fractures. The survival rate of
tant things to the bacteria: stable anchorage and access to
horses with open fractures was better in foals (6/7; 85.7%)
materials. The resultant biofilm consists of an organized
than in adult horses (1/8; 12.5%) [7]. Soft tissue injuries
assembly of bacteria producing an extracellular matrix.
resulting in reduced blood supply, oedema and devitalized
The matrix facilitates signalling between the bacteria,
tissue may predispose to infection.
the micro-organisms are protected from the hosts immune
Longer surgeries, particularly procedures 180 min-
system and many antimicrobials do not penetrate the bio-
utes [3] or >168 minutes [5], increased the risk of SSI.
film effectively [22, 25–27]. Accumulation of waste prod-
Closed reduction and internal fixation (CRIF) reduces
ucts and consumption of substrates within the biofilm
exposure and manipulation of soft tissues and bone.
cause bacteria to enter a slow growing state which makes
Fracture repair with lag screws through stab incisions car-
them even more resistant to antimicrobials [28]. In many
ries a very low risk for SSI [3, 20]. In one report, horses in
cases, removal of implants is required to resolve the situa-
which CRIF was used for plate fixation were 2.5 times less
tion [3]. In the future development of implants coatings
likely to develop SSI and 5.9 times more likely to be dis-
that are resistant to biofilm formation may become attrac-
charged from hospital compared to open reduction and
tive options to reduce SSI [29–33].
internal fixation (ORIF) [3], although this was not corrobo-
rated by a subsequent study of a small number of cases
treated with CRIF at the same hospital. Prevention
In general, the risk for SSI is dependent on the location
and complexity of the fracture and the amount of soft tissue Best practice pre-and intra-operative reduction of risk fac-
trauma, but in horses there is limited information on spe- tors are reviewed in Chapters 9 and 11. Appropriate post-
cific risk factors. In one report, different infection rates were operative care of the surgical wound is also important. The
found for different fracture sites [3]. Relatively low risks surgical incision is covered with a sterile dressing until
were reported for fractures of the proximal phalanx (OR: skin healing is completed. Bandage changes are only per-
0.39) and Mc3 (OR: 1). The fractures with the highest infec- formed, if necessary, with strict adherence to sterile tech-
tion rates were those of the radius (OR: 10.88; 21.7), femur nique and in clean areas. If drains have been placed, they
(OR: 14.5; 31) and fetlock arthrodesis when associated with are removed as soon as possible. Skin sutures are removed
traumatic disruption of the suspensory apparatus (OR: using sterile technique 10–14 days after surgery, and one
48.33; 31). In a more recent report, fetlock arthrodesis (OR more bandage is applied afterwards.
4.27) and ulnar fractures (OR 4.88) were more likely to
develop SSI [14]. Repaired distal phalanx fractures also had
Diagnosis
a relatively high risk of infection (46%, 6/13 cases) [3].
Females were reported to have a higher risk for SSI com- There is no blood test or imaging procedure which will
pared to colts and stallions but not geldings. One possible always identify an infected fracture. However, the presence
explanation is that more complicated fractures are of a draining sinus from the fracture site or the laboratory
attempted as only breeding soundness is required [3]. culture of micro-organisms from multiple, sterile deep
samples are pathognomonic. Close observation, monitor-

ing vital parameters, weight-bearing, local signs of inflam-
mation and haematological markers such as acute phase
proteins (fibrinogen, serum amyloid A [SAA]) all help to
identify trends and changes. However, a combination of
laboratory, histopathology, microbiology and imaging is
usually necessary to prove the presence of infection.
Recognition of an SSI can be challenging as signs such as
decreased appetite or lethargy can be subtle and develop
insidiously. These must be taken seriously as early recogni-
tion and prompt, aggressive treatment are essential for suc-
cessful management.
The United States Centre for Disease Control and
Prevention (CDC) recognizes three levels of SSI based on
the depth of the involved tissue. Superficial incision affects
only skin and subcutaneous tissue and is characterized by
localized signs such as heat, redness, pain or pus at the
incision site. Deep incision involves facial and muscle lay-
ers. It is characterized by abscess formation, presence of
pus and fever. The third level involves deep organ spaces
such as bones or joints [15]. A group of international Figure 14.3 Clinical signs of surgical side infection three
experts defined criteria: confirmatory of implant-related weeks after arthrodesis of the proximal interphalangeal joint:
infection as ‘fistula, sinus or wound breakdown; purulent diffuse swelling, skin reddening, partial wound dehiscence and
sero-purulent discharge.
drainage from the wound or presence of pus during sur-
gery; phenotypically indistinguishable pathogens identi-
fied by culture from at least two separate deep tissue/ Low-grade persistent or undulating pyrexia may signal
implant specimens; presence of micro-organisms in deep infection, particularly in horses receiving anti-
tissue taken during an operative intervention, as confirmed inflammatory drugs. Temperature should be measured at
by histopathological examination’ [34]. least three times daily to detect peaks, recorded and com-
pared over time.
Clinical Evaluation Wounds need to be examined thoroughly at bandage
Slightly decreased weight-bearing on the operated limb changes. Swelling, discharge, dehiscence, and reddening
may be interpreted as pain from the primary injury, but of the adjacent skin (if not pigmented) are all signs of
reduced limb loading can be the most important early sign infection (Figure 14.3). On palpation with sterile gloves,
of infection. The degree of weight-bearing must be com- the wound should not be excessively warm, oedematous,
pared over time and set in relation to the expected degree fluctuating or painful.
of post-operative pain and changes in analgesic medica-
tion. It should be monitored at least twice daily by observa- Cytological Analysis and Microbiological Culture
tion of the patient in the stall, walking short distances and Discharge from the surgery site or percutaneously asepti-
lifting up the contralateral limb. After successful osteosyn- cally aspirated fluid is collected in an ethylenediaminetet-
thesis, a horse should be comfortable and able to bear full raacetic acid (EDTA) tube and in bacterial culture medium.
weight. A horse with even a subtle change in weight- A modified transudate (protein > 25 g/L; WBC < 5 g/L)
bearing should be evaluated for signs of infection. Horses and/or exudate (protein > 25 g/L; WBC > 5 g/L), a high per-
with casts should be monitored similarly and the cast centage of neutrophils (>90%) and/or bacteria on a stained
checked for heat, moisture, integrity, pressure at the proxi- smear indicate infection. Tissue samples from the infected
mal rim and odour (Chapter 13). Ideally, all evaluations are site can also be evaluated histopathologically. Infection is
performed by the same person every day to establish com- considered proven if there are more than five neutrophilic
parability and to detect slight changes. granulocytes in one field of view at a magnification of
Pyrexia can be an important sign of SSI but is not neces- 400 [35].
sarily present in early stages. However, if the inner body Bacteria cultured from the outside of wounds are not
temperature rises above 38.6 °C (101.5 °F), and cannot be necessarily representative of those causing implant infec-
explained by other causes, SSI should be suspected. tion. Swabs from deeper layers are more conclusive, but
Infectio 287
culture of fluids aspirated after sterile preparation or tissue

samples increase sensitivity and specificity [36].
Samples need to be handled carefully and placed immedi-
ately in suitable vessels and media. Aerobic and anaerobic
culture and antimicrobial sensitivity testing are required. In
man, the culture of synovial fluid in blood culture vials is
more successful (90–92%) than swab cultures (68–76%) [37],
and blood culture medium enrichment optimized the rate
of isolation in horses [38]. Any removed implants should be
placed in medium or a sterile container and submitted for
culture. Sonication can be used to break up biofilm from
removed implants which enhances culture of bacteria
which would be otherwise protected [39, 40].
In one study, 40% of samples cultured from infected long
bone fracture repairs were polymicrobial, 32% contained
gram-positive bacteria, predominantly coagulase negative
Staphylococci, and 28% contained gram-negative bacteria,
predominantly Enterobacter cloacae [3]. However, these
data were received from one institution only which can also
change over time [14]. In man, a 9% rate of negative cultures
from infected fracture fixations has been reported [41]. Figure 14.4 Ultrasonographic image of the ulnar region two
Polymerase chain reaction (PCR) is relatively simple and weeks after fracture fixation. The plate is visible as a
hyperechoic line (white arrow) with a hypoechoic tract
can detect nucleic acid fragments by sequence amplifica- extending from the implant to the skin (arrowheads). Fluid was
tion providing same-day diagnosis [42]. Specific PCRs are aspirated from the tract under sterile conditions and submitted
limited to those organisms for which targeted primers are for cytologic and microbiologic examination.
included. Broad-range PCR allows the identification of
bacteria previously not thought to cause infection but lacks Diagnostic Imaging
sensitivity, making interpretation difficult. Ultrasound
Ultrasound of surgical sites is performed aseptically to pre-
Laboratory Parameters vent contamination. Sonography can determine size, extent
Peripheral blood tests depend on the host’s response to and location of fluid accumulation which can be subcuta-
infecting pathogens. Leukocytosis may be present in SSI neous, in deeper layers or associated with the implant
but is rarely reliable [43, 44]. Evaluation of acute phase (Figure 14.4). Hyperechoic particles may be present within
proteins such as SAA and fibrinogen may be more helpful. the fluid. Ultrasound can also guide aspiration of suspi-
Serum fibrinogen is a slow reacting acute phase protein cious fluid for laboratory analysis [51–53].
that increases 24 hours after onset of inflammation and
peaks after four to six days [43, 45]. However, increase is Radiography
not high (10-fold) and there is a wide reference range Conventional X-rays are often the first imaging modality
(2–4 g/L), depending on the laboratory and measurement employed and can be helpful in excluding other reasons for
method [44, 46]. It is a useful parameter in monitoring case discomfort, such as instability due to implant failure or
progression, but changes can be subtle [44, 47] and fibrino- additional fracture lines. Initial radiographs also serve as a
gen concentration below the reference value does not rule baseline for comparison with serial radiographs and make
out SSI [44]. recognition of subtle changes possible.
SAA is a reliable marker for distinguishing infected and Plain radiographs are often insensitive in the early stages
non-infected inflammatory conditions in the horse [43, of bone infection as at least 30–50% of bone mineral needs
44]. Concentrations in blood increases rapidly within six to to be lost before becoming apparent [54]. Initial subtle
eight hours from 0.5 to 20 mg/L to >100-fold and up to findings include focal or inhomogeneous soft tissue swell-
>1000-fold [48]. SAA peaks at 36–48 hours and decreases ing (Figure 14.5a), gas accumulation (Figure 14.5b) or oste-
to normal values within one or two weeks. It is therefore a olysis. Widening of the fracture gap and development of
useful marker to monitor response to therapy [49]. A sig- periosteal new bone which is not associated with fracture
nificant decrease in serial measurements reflects a positive healing also suggest an infective process [55]. Radiolucent
response to treatment [50]. areas around implants are indicative (Figure 14.5c) but this
(a) (b) (c)
Figure 14.5 Radiographic features of SSI and/or implant infection. (a) Inhomogeneous swelling of soft tissues adjacent to a proximal
interphalangeal joint arthrodesis three weeks post-operatively. (b) Soft tissue swelling and gas accumulations adjacent to implants
10 days after fixation of a type IV ulnar fracture. (c) A well-defined radiolucent area adjacent to the distal end of the plate and most
distal screw suggests implant infection. Radiopaque antimicrobial PMMA beads are visible caudal to the implant.
can be seen in aseptic loosening, and confident diagnosis Gallium 67 is used for detection of inflammation and infec-
may require corroboration with clinical features, labora- tion in man [55].
tory values, etc. Radiographic findings in chronic osteomy-
elitis can include a radiolucent abscess or periosteal new
Treatment
bone surrounding a sequestrum.
Therapy depends on the depth of infection, stability of the
Computed Tomography repair, stage of healing, time after fixation, tissues involved
Detection of implant-associated infection with computed and implant type. Basic principles involve effective drain-
tomography (CT) requires reduction of artefacts due to age, debulking bacteria and devitalized tissue and maxi-
metallic implants. This can be achieved with high voltage mizing the concentration of appropriate antimicrobials at
and ampere settings, narrow collimation and thin slices [56] the surgical site. If implants are infected, removal may be
together with optimizing positioning of the hardware and necessary to resolve infection. However, achieving or
algorithm parameters for reconstruction [57]. CT in horses maintaining stability at the fracture site is critical. If the
usually requires general anaesthesia, which is an additional fracture is not stable, implants have to be replaced or
disadvantage. another technique used.
Magnetic Resonance Imaging Drainage and Debridement

Implants used in equine fracture repair are made of stain- It is widely accepted that fractures can heal in the presence
less steel, which is non-magnetic. Although there are of infection provided they are stable, have good soft tissue
pulse sequences to minimize artefacts around implants coverage and effective bacterial suppression. Drainage acts
such as multi-acquisition variable resonance image com- by reducing bacterial load and potential nutrient media,
bination (MAVRIC) [58], magnetic resonance imaging reducing the volume of non-circulatory areas (dead space)
(MRI) is generally unsuitable for diagnosis of metallic in which bacteria can multiply while, at least partially,
implant-associated infection. shielded from antimicrobial drugs, and changes the local
tissue environment.
Scintigraphy Drainage at the surgery site can be facilitated by enlarge-
Nuclear scintigraphy using 99mTc coupled with methylene ment of an already present opening or creating one at the
diphosphonate (MDP) or hydroxymethylene diphosphonate most distal aspect of the wound. Fluid-filled cavities are
(HDP) identifies exposed hydroxyapatite and therefore detected by ultrasound, and drainage is established under
detects areas of increased osteoblastic activity (Chapter 5). sterile conditions. As far as possible, infected or dead tissue
The causes for the osteoblastic activity can be various, and including wound margins, sinus tracts and non-viable bone
decreased radiopharmaceutical uptake may be seen in should be removed. In severe human cases with extensive
infected osteitis [59]. White blood cells (WBCs) labelled with tissue necrosis, debridement is performed every two to three
99mTc hexamethylpropylene amine oxime (HMPAO) have days until only healthy tissues are present [62].
been used to detects orthopaedic infection in horses [60]. The During debridement, at least three to five tissue samples
cells can be alternatively labelled with 111In-oxinate [61]. from different anatomical sites should be collected for
Infectio 289
microbiologic culture. Preoperative administration of anti- employed. However, this is a major task, which will lower
microbial agents should be avoided as bacterial culture the prognosis and increase risks and costs. Therefore, as
results from infected implants can be affected [63]. During long as the implant provides stability, it should be retained,
the procedure, it is important to prevent contact between while infection is managed by drainage, debridement and
non-infected tissues and contaminated instruments. antimicrobial therapy. As time progresses, staged removal
Alternatives to classical methods of debridement include of implants may be possible.
use of a thin saline jet to remove bacteria and debris [64,
65] and to remove biofilm from metallic implants [66]. Antimicrobial Treatment
Biological debridement using sterile larvae of Lucilia seri- Central to effective treatment of implant-associated SSI is
cata was successful in a case of implant infection with intelligent use of antimicrobials that have to be effective
methicillin-resistant Staphylococcus aureus (MRSA) after against the targeted micro-organism(s) and reach appro-
fixation of a cannon bone fracture in a foal [67]. Maggots priate concentrations at the site even in poorly vascularized
secrete antibacterial factors against MRSA [68] and inhibit infected bone. Regional limb perfusion and/or the place-
biofilm formation on different materials [69]. ment of antimicrobial-impregnated materials achieve high
Wound lavage should be performed with solutions antimicrobial concentrations at the site with low adverse
which are not harmful to tissues. There is no clear evi- systemic effects. Chapter 9 provides information about the
dence for the use of antiseptics or different delivery sys- systemic use of antimicrobials. The goal of this chapter is
tems. For periprosthetic joint infection in people, some to give an overview of the different drugs and available
authors recommend the use of antiseptic fluids such as delivery systems for use in SSI.
octenidine and polyhexanide [70]. Compared to other The most reliable and rational method of choosing an
antiseptic irrigation fluids, these had the most favourable antimicrobial drug is following culture of appropriate sam-
biocompatibility index [71]. Povidone iodine has been ples and subsequent susceptibility testing. Frequent anti-
used to treat periprosthetic infection [72]. Large volumes microbial therapy has to be started in advance of results.
(six to nine litres) of sterile saline or dilute povidone‑iodine This is based on consideration of likely and frequently
in sterile saline was recommended for treatment of acute occurring micro-organisms and their susceptibility pat-
periprosthetic joint infection with debridement, antimi- terns with particular reference to recent cases. Bactericidal
crobials and implant retention [73]. Others have recom- are preferred over bacteriostatic agents. Water solubility
mended ‘large amounts of normal saline’ lavage for and hydrophilic properties are important for facilitation of
treatment of infection after fracture osteosynthesis [74]. antimicrobial release. Drugs should not be cytotoxic to
in vitro pulsed lavage is effective in removal of biofilm [75] eucaryotic cells or interfere with fracture healing. Systemic
but carries the risk of tissue injury or dispersal of bacteria side effects should also be considered.
into deeper tissue layers [76]. Local conditions such as biofilm, abscessation, decreased
Drains carry the inherent risk of ascending infection and blood supply, fibrosis, pH, exudate and devitalized tissue
irritation and if possible should be avoided. Negative pres- can influence the penetration and efficacy of antimicrobi-
sure therapy is an alternative. als. A route of administration should be chosen which will
reach the highest concentration at the site of infection with
Implant Removal or Replacement the least adverse effects. Local administration has several
Most SSIs only resolve when implants are removed because advantages compared to systemic treatment including
this is the most effective way to eliminate the adhered bio- higher concentration at the site, reduced side effects and
film. However, this should only be considered if there is decreased costs [77, 78]. In implant infection, the mini-
clinical and radiographic evidence of stability. In double- mum inhibitory concentration (MIC) may be underesti-
plated long bone fractures, staged implant removal is mated by biofilm protection of bacteria. The most
recommended. frequently used local antimicrobials are gentamicin, ami-
The decision to keep an infected implant is difficult. kacin, tobramycin, imipenem and vancomycin.
Retained infected implants will be coated in biofilm, which
potentially allows persistence of organisms. If removal of Intravenous Regional Limb Perfusion
an infected implant produces instability, alternative fixa- Intravenous regional limb perfusion (IVRLP) is an easy to
tion will be required, as the combination of instability and perform and reliable method to reach high antimicrobial
infection carries a poor prognosis. After implant removal concentrations in an infected area. A concentration of 10–12
and thorough debridement of the area, the fracture has to times the MIC is generally considered optimal. It involves
be re-stabilized with new implants or an alternative fixa- injection into a superficial vein previously separated from
tion device, such as a transfixation cast or external fixator the systemic circulation by application of a tourniquet. The
of concentration-dependent antimicrobial drugs is

dependent on the concentration (Cmax) delivered and
the ratio of Cmax to MIC. However, varying degrees of
post-administration effects are present thereafter.
As IVRLP is performed intermittently, concentration-
dependent antimicrobials are most suitable. The amino-
glycoside amikacin has a broad spectrum against
gram-positive and gram-negative isolates and is often
used before definitive microbiological results are avail-
able [85, 86].
A combination of amikacin and penicillin showed
elimination rates of 13.6 hours for amikacin and 2.8
hours for penicillin in metacarpophalangeal synovial
fluid. Frequent perfusions of penicillin therefore appear
necessary to maintain therapeutic concentrations [87].
Vancomycin at a dosage of 300 mg in 60 mL had no side
effects, and concentrations exceeded the MIC for
20 hours [88].
Fluoroquinolones should be used with caution and only
if no alternatives are available. Enrofloxacin has a toxic
effect on endothelium resulting in vasculitis [89], while
Figure 14.6 A wide Esmarch tourniquet is placed proximal to marbofloxacin led to increased thickness of subcutaneous
the carpus for IVRLP in the cephalic vein. The vein is punctured tissue [90] and has resulted in severe skin necrosis.
by a small butterfly needle (arrow), and the antimicrobial diluted
in sterile saline is slowly injected. Time-dependent antimicrobials require concentra-
tions to be constantly above the MIC for adequate anti-
microbial activity [91]. This makes them less useful
tourniquet is applied proximal to the infected area and in
although there are a few exceptions. Ceftiofur has a high
some situations also distal to it to reduce the volume of the
affinity to proteins and active metabolites that make it
perfused region (Figure 14.6). The perfusate is injected
suitable [92]; it is also possible that tissues may serve as
through a small gauge (20–26G) butterfly or over the needle
a depot for the drug. In horses, 2 g of ceftiofur adminis-
catheter [79]. An alternative providing the possibility of
tered in 60 mL saline into the lateral palmar digital vein
multiple injections is the placement of an indwelling cathe-
remained above the MIC in plasma for 12 hours and in
ter, but the incidence of phlebitis is substantially greater [80]
subcutaneous tissues for 24 hours, but in bone the con-
than with single use butterfly catheters [81].
centrations were only above MIC immediately after
The combination of concentration gradient and raised
tourniquet removal [93]. In synovial fluid, the concen-
hydrostatic pressure leads to high levels of antimicrobial in
tration remained above the MIC for more than
the perfused deep tissues including interstitium, synovial
24 hours [94]. Imipenem, a broad spectrum ß-lactam
fluid and bone although not apparently in superficial
antimicrobial that is effective against many resistant
wounds [82].
bacteria, was used at a dose of 500 mg in the cephalic or
The procedure can be performed under general anaes-
saphenous veins without negative effects and produced
thesia or in the standing sedated horse. In the latter, peri-
efficacious concentrations in the fetlock joint [95].
neural anaesthesia is more effective in decreasing
2) Dosage
discomfort than sedation alone or i.v. regional anaesthe-
Optimal doses vary according to individual circum-
sia [83]. However, addition of 500 mg mepivacaine to the
stances, and for all drugs several dosages have been
perfusate also decreased the nociceptive threshold without
used. One gram of amikacin in a low volume perfused
affecting antimicrobial activity [84].
in the cephalic vein produced concentrations over 10
Efficiency of IVRLP is dependent on several factors includ-
times the MIC in the radiocarpal joint if proximal and
ing the dosage, volume and characteristics of the antimicro-
distal tourniquets were used [96]. One gram of amika-
bial drug the tourniquet and time of administration.
cin in 50 mL perfusate injected into the palmar/plan-
1) Antimicrobial drug tar digital vein with a tourniquet at metacarpal/tarsal
The antimicrobial needs to be water soluble, of physio- level and 2 g in 100 mL perfusate injected in the
logic pH and osmolarity and non-irritating. The efficacy cephalic/saphenous vein with a tourniquet proximal
Infectio 291
to the carpus/tarsus both reached effective levels in reached after 15 minutes and did not increase there-
the fetlock joint [97]. Higher dosages may be used for after, which suggests that this is the ideal time for
isolates with higher MICs [98], although these may maintenance of the tourniquet [110]. Maximal con-
damage the endothelium [99]. The maximum dose for centration was higher and reached earlier in joints
local administration should not exceed the recom- with synovitis [111].
mended systemic dosage: empirically most drugs are Concentrations of antimicrobial drugs appear to
given at one-third of this [100]. decline to levels below MIC after 24 hours [98], although
3) Volume post-antibiotic effects have to be considered. In an
As the distribution of the antimicrobial is also depend- in vitro study, in horses, amikacin had a mean post-
ent on the hydrostatic pressure gradient, the volumes antibiotic effect of 3.43 hours for staphylococcal isolates
used for IVRLP may be important. In the distal limb, which increased with higher doses [112]. The generally
perfusion is commonly performed with a volume of recommended intervals to perform IVRLP are
60 mL [101] but lower volumes (20 mL) have been used 24–48 hours.
successfully [102].
Studies of carpal perfusion with 60 mL [103] and digi- After injection of the perfusate, pressure is placed over
tal perfusion with 40 mL of contrast medium [102] dem- the injection site and a bandage is placed after removal of
onstrated a distribution of the perfusate within the soft the tourniquet to minimize swelling. In one study, vein-
tissues, synovial membranes and bones. Proximal and related complications were reported in 19/155 (12%)
distal tourniquets can be employed to isolate areas that cases [81]. Application of topical diclofenac ointment
will increase the amount of drug delivery or allow low decreases signs of inflammation [113].
volumes of administration. With isolation of the carpus
by two tourniquets, a dosage of 1 g of amikacin in only Intra-osseus Perfusion
6 mL of perfusate reached values over 10 times the MIC Intra-osseous perfusion is an alternative for regional
in the radiocarpal joint [96]. perfusion if catheterization of a peripheral vein is not
For perfusion proximal to the carpus or tarsus 60 mL possible [103, 114, 115]. It can be performed in the
is a frequently used volume [103–105], but results of standing horse [116]. A hole is drilled into the chosen
studies investigating the influence of perfusate volume bone, and either a custom-made cannulated screw or a
on the antimicrobial concentration within synovial commercially available intra-osseous perfusion needle is
fluid are contradictory [106, 107]. inserted. Alternatively, the male end of a luer lock exten-
In foals, the volume should be adjusted to the size of the sion can be introduced into a 4 mm hole in the bone. A
limb; volumes of 10–35 mL have been recommended [99]. tourniquet is placed proximal to the injection site, and
4) Tourniquet the perfusate is injected.
The intravenous pressure that can be reached without Intra-osseous perfusion of the metacarpus with 0.1 mL/kg
leakage to the systemic circulation is influenced by the saline and 2.2 mg gentamicin per kg resulted in concentrations
tourniquet. It is dependent on the width of the tourni- exceeding the MIC of many pathogens in synovial structures
quet, the pressure with which it is applied, the volume and bones distal to the tourniquet, but concentrations in the
of the perfusate, the speed of injection, the anatomic latter were lower [116]. IVRLP produced a higher concentra-
site and individual characteristics of the patient. tion of amikacin in the DIP joint than intra-osseous infusion,
A pneumatic tourniquet applied to the antebrachium but both techniques achieved concentrations substantially
resulted in the highest concentration of amikacin in the exceeding the MIC [114]. Similarly, tarsal level infusion in the
metacarpophalangeal joint. A wide rubber tourniquet saphenous vein induced higher concentrations of amikacin
was less effective, although concentrations were above than infusion in the distal tibia [115]. Complications were
MIC: with a narrow tourniquet, concentrations were reported in 9/27 (33%) of horses receiving intra-osseous perfu-
insufficient [108]. In contrast with metacarpal venous sion including discharge around the screw, difficult injection,
occlusion in standing horses, an Esmarch tourniquet screw loosening and screw breakage [81].
was most effective [109]. Gauze rolls can be placed over
the veins to provide focal pressure in uneven regions or Antimicrobial-impregnated Implants and Local Delivery Systems
where veins are shielded by osseous protuberances. Local antimicrobial delivery systems permit high concen-
5) Administration time and intervals trations to be maintained over a long period in a defined
The maximum concentration of amikacin in the dis- area without the side effects and high costs of systemic
tal interphalangeal (DIP) joint after perfusion of 3 g use [117–119]. Two components require consideration: the
in 60 mL and use of a pneumatic tourniquet was antimicrobial and the delivery system.
The antimicrobial needs to be compatible with the deliv- used [128–131]. Rough and porous beads with a high sur-
ery system and produce concentrations in the infected tis- face to volume ratio release antimicrobial at a fast
sue that exceed the MIC for causative bacteria. The ideal rate [132]. After the initial peak, antimicrobials are
drug is non-irritant and stable both at body temperature released at a lower rate and concentrations above the MIC
and during creation of the implant. This is important when are maintained for approximately 30 days [133, 134]: mix-
polymethylmethacrylate (PMMA) is used as carrier, as ing of antimicrobials can affect kinetics [135].
polymerization is exothermic. The mechanical stability of PMMA is influenced by
The chosen delivery system should release antimicrobial the amount of antimicrobial added [136, 137]. Increasing
in a predictable concentration and time, ideally that which amounts of antimicrobial decreases stability [138].
is needed to resolve the infection without inducing adverse Mechanical strength is not generally critical, but a ratio
local effects. The ideal vehicle is prepared sterile or can be of >1:5 antimicrobial to PMMA powder can negatively
sterilized and is stable during storage. Non-biodegradable influence polymerization [128]. Levels between 5 and
implants may need to be removed after the infection has 20% of weight have been recommended [139–141]. A
resolved; biodegradable substances can be left in situ. common mixture in equine surgery is 20 g of PMMA
Antimicrobials contained within the matrix of the implant with 5 g of amikacin. Liquid formulations can also influ-
are released via diffusion along a concentration gradi- ence mechanical properties but improve elution [142].
ent [120]. This follows characteristic kinetics with different For liquid antimicrobials, the volume of the liquid MMA
materials and drugs, but generally a large amount is monomer should be reduced by half the volume of the
released initially and this tapers with time. In reservoir antimicrobial [141].
implants, the antimicrobial is enclosed by a permeable pol- Aminoglycosides, e.g. gentamicin, tobramycin and
ymer and is released more continuously. Materials include: amikacin [129, 130, 143–147], cephalosporins, e.g.
cefalexin and cefazolin [130, 144, 148, 149], imipe-
i) Polymethylmethacrylate nem [150], metronidazole [151] and vancomy-
Strings of antimicrobial-impregnated PMMA beads are cin [127, 136] can be used with PMMA. There are also
the most commonly used non-biodegradable implant. It commercial products in which antimicrobials are
is suitable to deliver high concentrations and elute them pre-mixed in relatively low concentrations. A sterile
for a long time. PMMA is biocompatible, has known bead chain of gentamicin-impregnated PMMA is
antimicrobial elution rates, is readily available and is available in two sizes each globe containing 7.5 and
easy to handle: disadvantages are its exothermic polym- 2.8 mg gentamicin sulphate, respectively (Septopal®
erization process and non-biodegradability [120]. Use chain and minichain).
in open type III fractures in man reduced infection rates If the antimicrobial is custom mixed with the PMMA,
from 42.9 to 8.7% [121]. the polymer and liquid monomer are pre-mixed and the
PMMA is prepared by mixing an MMA–styrene co- antibiotic added in small amounts to create a homoge-
polymer powder with a liquid MMA monomer. nous mixture [152]. This is carried out by hand in a
Incorporated antimicrobials need to be stable at tem- bowl without a vacuum as bubbles in the mixture
peratures reached during preparation. The heat pro- increase antimicrobial elution [153].
duced during hardening of the cement may damage Beads can be made using a sterile bead mould system
bone, but one study suggests that the temperatures pro- (Excelen bead mould system) [154] or formed manually
duced in a mixing bowl (110.2 °C) are not reached at the (Figure 14.7). A non-absorbable suture can be incorpo-
bone interface (49.1 °C) and no bone necrosis was rated to facilitate removal. PMMA beads are visible as
detected histologically which suggests that the body radiopaque structures on radiographs (Figure 14.5c).
conducts the heat rapidly [122]. Although it is reported that they can be left in place if
The PMMA can be prepared during the surgery from there are no associated complications [140], it has been
sterile substrates. Pre-prepared meropenem-impregnated suggested that biofilm may develop on the surface [155,
beads can safely be sterilized by ethylene oxide but not by 156] and that local tissue reactions can occur [157, 158].
steam [123], and antimicrobial activity of amikacin, They are therefore usually removed after infection has
enrofloxacin and ceftiofur in PMMA and plaster of Paris resolved. If beads are placed during fracture fixation,
was not influenced by gamma radiation [124]. they can be removed along with the implants.
Most of the antimicrobial is eluted rapidly in the first Antimicrobial-loaded beads have been used in cases
24 hours [125]. Elution depends on the size of pores in the of SSI, osteomyelitis and infected joints [159–161].
cement [126], bead size and surface area [127], fluid turn- However, use in joints is not recommended as beads can
over around the implants and the amount of antimicrobial cause synovitis, cartilage erosion and lameness [162].
Infectio 293
(a) (b) (c)
(d) (e) (f)
(g) (h) (i)
Figure 14.7 Construction of antimicrobial-impregnated PMMA beads. (a) The PMMA powder is poured into a sterile plastic cup.
(b) The liquid monomer is added (the volume is reduced by half the volume of liquid antimicrobial) and mixed thoroughly with the
powder. (c) The antimicrobial is added and components mixed. (d) Non-absorbable sutures are placed in the bead mould. The bead
mould used here is made of heat stable silicone material designed for baking. (e) The mixture is filled in a sterile bead mould with
preplaced sutures. (f) Care is taken to fill the holes entirely and remove excess material. (g) After the material has hardened, the beads
on the chain are removed from the mould. (h) Beads of different sizes on a non-resorbable suture material ready to be placed within
the wound. (i) Beads placed alongside the implant.
ii) Plaster of Paris iii) Calcium phosphate cement

Plaster of Paris (calcium sulphate hemihydrate) is a bioab- Calcium phosphate is an osteoconductive substrate [171]
sorbable, biocompatible and cheap substrate for local anti- that can be reinforced by polylactide-coglycolide chopped
microbial delivery [163–167]. It is also reported to have fibres to reduce compressive strength, brittleness and
osteoinductive and osteoconductive properties [163]. improve bending strength [172]. Resorption of the cal-
Elution after implantation is rapid and occurs mostly cium phosphate cement (CPC) alone takes approxi-
in the first 24–48 hours [168]. Thereafter, concentra- mately six months [173], but it is thought to be less for
tions decrease below MIC [164]. Amikacin elution the fibre-containing product [174].
occurs rapidly (<24 hours), whereas vancomycin elu- Gentamicin formulations of CPC show different
tion is slower. Bacterial growth was inhibited by vanco- in vitro release profiles depending on the product and
mycin for 56 days if used alone or for 5 days if used with the form (cement or granules) with burst release of gen-
amikacin [169]. Beads should be made in advance as tamicin for granules and a more sustained release (up to
the process is time consuming. Beads are prepared as 17 days) for cements [175]. Implant-associated infec-
described in the literature [164] and gas or gamma steri- tions in man have been successfully treated with
lized [124]. Storing for up to five months and steriliza- vancomycin-impregnated CPC (1 mg vancomycin/20 mg
tion did not affect elution [164, 165, 168, 170]. CPC and 1 mg vancomycin/12 mg CPC). Commercial
Commercial products are also available. products for preparation of beads are available.
iv) Hydroxyapatite cement 14.5 days) after the initial injury [190]. It has been suggested
Hydroxyapatite is almost inert, considered non- that it is caused by cumulative microdamage to the dermal
biodegradable [176] and is suitable for antimicrobial laminae resulting from regional, incomplete and intermit-
integration [177, 178]. in vitro release of gentamicin, tent occlusion of vessels. Another, less accepted theory pro-
amikacin and ceftiofur was greatest in the first 24 hours poses that pain from the initial injury and pain from laminitis
but persisted for over 30 days [133]. Gentamicin and are competing, and if the pain from the initial injury
amikacin were released in bactericidal concentrations decreases, laminitic signs become evident [188, 189, 191].
throughout, but ceftiofur did not provide long-term It is said to have an incidence of 2.3–16.1% in horses at
bactericidal concentrations. in vivo gentamicin sul- risk [4, 191–193]. Mortality is high [194]; in one study, only
phate concentration was maximal within the first 27.3% survived [195].
week. At 12 weeks, 70% had been released but levels
were still five times the MIC for Staphylococci [178]. In
Risk Factors
an experimental study of MRSA osteomyelitis in rab-
bits, debridement and treatment with vancomycin- Reported risk factors include duration [194] and severity of
impregnated hydroxyapatite cement (HAC) resulted in lameness [188], duration of casting and use of transfixa-
81.8% clearance of infection [179]. In a rabbit, osteo- tion or full limb casts [192]. Age, breed, gender, limb afflic-
myelitis model treatment with gentamicin (5 mg in 4 × tion, presenting condition, systemic status at admission or
3 × 3 mm cubes) was successful even in the presence of ability to bear weight on the affected limb do not appear
implants [180]. influential [192, 194]. One study reported a small correla-
v) Collagen sponges tion with body weight [192], while another found no
As a natural polymer, collagen is biocompatible, biode- influence [194].
gradable and has a low antigenicity [181, 182]. Sponges Even though there was no significant difference between
impregnated with gentamicin (200 mg in 10 × 10 × the number of non-weight-bearing and partially weight-
0.5 cm) are commercially available (Collatamp G). Their bearing horses that developed laminitis [192], it is sug-
principal use has been intra-articular. gested that horses that can bear weight and walk on the
vi) Cross-linked dextran gel (R-gel polymer) primary injured limb, thus temporarily releasing weight
R-gel polymer is a commercial product consisting of a from the contralateral limb, are less likely to develop SLL as
dihydrazide cross-linking reagent and a solution of oxi- movement is a prerequisite for laminar circulation [191].
dized dextran which polymerize after mixing. The gel is Individual pain tolerance, foot conformation and hoof
injectable and forms a flexible, non-abrasive matrix horn quality have been suggested as influential [191].
which persists for four to five weeks before being SLL is very uncommon in animals <2 years old [194,
degraded by hydrolysis. R-gel contains 50 mg clindamy- 195]. This has been ascribed to lower body weight,
cin HCl and 100 mg amikacin sulphate. Elution charac- increased activity, flexibility and greater tendency to lie
teristics were analyzed in vitro and suggest a combined down [196]. One report mentions it as a complication in
antimicrobial level above MIC for nine days [183]. In horses younger than one year after intramedullary inter-
horses, amikacin, vancomycin and amikacin/ locking nailing of humeral fractures [197].
clindamycin-impregnated cross-linked dextran gel main-
tained tissue concentrations above MIC for 8–10 days. No
Pathophysiology
adverse reactions were observed [184].
vii) Other biodegradable materials Exact mechanisms for development of SLL are not com-
Antimicrobial-implanted polylactic acid (PLA), polyg- pletely understood. Persistent mechanical overload appears
lycolic acid (PGA) and polylactide-coglycolide (PLGA) important [189]. During normal weight-bearing and move-
have also been tested and used successfully in the ment, dermal laminae are exposed to only one-tenth of the
treatment of infections [185–187]. pressure necessary to cause failure of the suspensory appa-
ratus of the distal phalanx (SADP) [198].
Constant weight-bearing results in reduced perfusion of
Supporting Limb Laminitis the dermal lamellae [199] of the SADP, which suspends the
distal phalanx in the hoof capsule [200, 201]. Computer-
SLL is a serious, potentially life-limiting complication. generated models show an occlusion of vessels at various
Unlike other forms of laminitis, the condition is restricted to sites depending on the load [189]. Lamellar perfusion also
the contralateral foot and is not caused by systemic dis- depends on limb load cycling frequency. Increased fre-
ease [188, 189]. SLL develops at unpredictable time points. quency induced by walking improves perfusion while
One study reported time frames of 4–100 days (median reduced frequency, but not increased weight-bearing, is
Supporting Limb Laminiti 295
associated with reduced lamellar perfusion [202]. In

healthy stabled horses, normal weight shifting occurs one
to five times per minute [203]. The reduced perfusion of
the dermal laminae may result in hypoxic injury and oxida-
tive stress [188, 204]. Lamellar ischaemia and energy fail-
ure starts about 48–72 hours after onset of excessive
weight-bearing [205]. The basal epidermal cells of the
lamellae have a high demand for glucose and oxygen [206,
207]: glucose is used for the synthesis and maintenance of
the hemidesmosomes of the basal membrane [198].
There may also be a degree of systemic drive. Pain and
stress increase systemic cortisol levels. Cortisol antago-
nizes insulin, leads to insulin resistance, hyperinsulinemia
and hyperglycaemia. Hyperinsulinemia can induce lamini-
tis in ponies [208], and hospitalization can cause decreased
insulin sensitivity [209]. Uptake of glucose into the cells is
decreased with insulin resistance [208], and in vitro depri-
vation leads to separation of basal epidermal cells and the
basement membrane [210].
Figure 14.8 Supporting limb laminitis: moisture and

Clinical Signs depression of the dorsal coronary band are reliable clinical signs
for sinking of the distal phalanx within the hoof capsule.
Constant clinical monitoring of horses at risk is of utmost
importance, and baselines should be established for all
parameters. Pulse amplitudes in the digital arteries and
Prevention and Treatment
changes in hoof temperature (usually elevated but can
decrease in the prodromal stage) [211] are monitored regu- Management of SLL should commence as soon as it is sus-
larly and preferably by the same person. Subtle changes in pected and ideally before structural damage is apparent. In
lameness are important. Differences can be shifting weight horses at risk, preventive measures are an important part
between injured and contralateral limbs, loading the heels, of management. Prevention and treatment are multimodal,
sudden improvement of the primary lameness or increased and most of the principles are common to both.
recumbency. Both limbs should be lifted daily to assess tol- The goals for prevention are to decrease strain on the SADP
erance of static loading. and to maintain perfusion of digital laminae. The most
In cases of SLL, sinking of the phalanx within the hoof important contribution is effective treatment of the primary
capsule is more frequent than in other types of lamini- fracture to achieve early weight-bearing and therefore load
tis [212]. In a series of 16 horses with SLL, only 1 had primary reduction on the contralateral limb. Additional strategies
rotation of the distal phalanx [194]. As clinical examination include pain management, podiatry, optimizing the environ-
appears to be more reliable than radiology in detecting sink- ment and reducing effective body weight [205].
ing [194, 212, 213] (Figure 14.8), the coronary band must be
checked regularly for signs of depression and moisture. Pain Management
Pain management begins pre-operatively. Pre- and intra-
operative analgesia reduce the wind-up phenomenon, and the
Radiography
amount of analgesic drugs needed post-operatively (Chapters
Radiography is important in diagnosis and monitoring. 9 and 10). Production of inflammatory mediators at the base-
Even though in acute stages, there may be no radiologic ment membrane and secondary epidermal laminae [220] leads
signs, baseline radiographs help recognize differences over to damage by tension and shear forces [221]. Vasoactive prod-
time. It is important to always use the same projection and ucts of the arachidonic acid pathway produce oedema, and
markers [214] to evaluate all forms of distal phalanx dis- separation of the dermo-epidermal junction follows.
placement: dorsal rotation, symmetric distal displacement Neuropeptides released by sensory nerve fibres induce inflam-
and unilateral distal displacement. Symmetrical distal dis- mation (vasodilation, extravasation and leukocyte migra-
placement (sinking) and dorsal rotation are evaluated on tion) [222, 223], and signalling from peripheral nerves leads to
the lateromedial and unilateral distal displacement (lateral spinal release of cytokines, prostanoids, tachykinins and excit-
rotation) on dorsopalmar projections (Figure 14.9). atory amino acids provoking central hyperalgesia [224].
Compartmental injury develops as a result of inflamma- be tailored individually to be effective and to limit negative
tory oedema, myelin sheaths disintegrate and the exposed consequences of both SLL and the medication [227].
nerve fibres become more mechanosensitive [225]. Sinking Control of orthopaedic and neuropathic pain may require
and rotation stretch nerve fibres resulting in both sponta- combinations of different classes of drugs [228].
neous impulses and sustained levels of excitability [224]. Non-steroidal anti-inflammatory drugs (NSAIDs) which
Severe tissue and somatosensory neuron injury lead to reduce inflammation by inhibiting the arachidonic path-
complex neuropathic pain. Neuromorphological changes way form the basis of treatment. Locally, pain is reduced by
and changes in gene expression and neuropathic modifica- decreasing the activation threshold of peripheral nocicep-
tions occur at local and central levels [226]. The calcium tors. At a central level, NSAIDs reduce COX 1 and 2
channel subunit alpha 2 delta, the target for gabapentin, is dependent production of prostaglandins which act as noci-
increased in dorsal root ganglia [225]. This complex inflam- ceptive neuromodulators [229, 230]. As both COX 1 and 2
matory and neuropathic combination requires a multi- appear to be involved in laminitic pain, non-selective
modal therapeutic approach. Pain management needs to NSAIDs can be used. Opioids in combination with alpha 2
(a)
Figure 14.9 Radiographic assessment of a horse with laminitis based on images [214] taken six weeks apart.
(a) Standardized lateromedial radiographs including a marker on the dorsal hoof wall indicating the coronary band are necessary to reliably
monitor the position of the distal phalanx within the hoof capsule. Note that the outline of the dorsal sole is marked by barium contrast.
Founder distance: The founder distance is the vertical distance between the most proximal aspect of the dorsal hoof wall, marked
with a radiopaque indicator, and the proximal margin of the extensor process. It is measured between two horizontal lines placed
through these landmarks (A). It should be evaluated on sequential radiographs to monitor sinking and is an important prognostic
factor [215]. A concave contour of the coronary band is another indicator of sinking [215].
Dorsal hoof wall width: The dorsal hoof width is the shortest distance of the distal phalanx and the outer hoof wall. It is measured at
distal and proximal sites (B and B′) and should be similar along the entire hoof wall. On subsequent radiographs, it can be compared
to baseline measurements [216]. A radio dense marker of known size is necessary to take magnification into account. Absolute width
is dependent on breed and size [216, 217].
Palmar cortical length of the distal phalanx: The dorsal thickness of the hoof wall (B or B′) can be set in relation to the palmar cortical
length of the distal phalanx (C, dot-dashed line). The relative values take into account individual and breed related variations: dorsal
hoof width >29% of the palmar cortical length of the distal phalanx is suggestive of SLL [194].
Sole thickness: The sole thickness (D) is important to evaluate progression and prognosis [194]. The distance from the apex of the
distal phalanx to the sole is between 11.1 ± 1.6 mm [218] in Thoroughbreds and 13 mm in warmbloods [219]. A radiodense marker of
known size is necessary to correct for magnification.
Rotation angle: Rotation of the distal phalanx in the hoof capsule occurs because of failure of the SADP and pull of the DDFT. The
rotation angle (a) is measured between the dorsal surface of the hoof wall and the dorsal surface of the distal phalanx. The two lines
should be (almost) parallel. The angle can be underestimated after the dorsal hoof wall has been trimmed.
Palmar angle: The palmar angle (b) measures divergence between the distal phalanx and sole. This increases when the distal phalanx
rotates within the hoof capsule.
Parallel distal displacement (sinking) of the distal phalanx within the hoof capsule is measured by increased founder distance (A) and
decreased sole thickness (D).
Supporting Limb Laminiti 297
(b)

(b) Dorsopalmar images of the same case. The outline of the sole at the tip of the hoof is with marked barium contrast.
Mediolateral asymmetry of the distal phalanx in the hoof capsule is assessed by (yellow) lines through the articular surface or solar
foraminae and the weight-bearing surface. Medial rotation is identified by progressive medial convergence of the lines.
Asymmetry can also be assessed from the width of the lateral and medial hoof wall (1) which should be approximately the same
when measured at equal heights. Increased medial width indicates unilateral distal displacement (medial rotation).
A diverging DIP joint space (2) can also indicate lateromedial asymmetry of the distal phalanx within the hoof capsule. On radiograph
2, the medial joint space appears wider on the side of the distal displacement.
Proximodistal asymmetry of the distal phalanx in the hoof capsule can be detected by measuring distances from medial and lateral
points on the distal phalanx to the weight-bearing surface of the hoof wall (white arrows).
Distance between coronary band and distal phalanx can be measured after placing a marker or contrast on the coronary band. This
was not performed on these radiographs. Asymmetry signals mediolateral rotation. Symmetric increasing distance indicates sinking. A
radiolucent line at the coronary band (white arrow heads in radiograph 2) also indicates sinking.
agonists can supplement NSAIDs and can also be used for A recommended regime for multimodal pain therapy is
epidural analgesia or constant rate infusion (CRI). lidocaine (3 mg/kg) and ketamine (0.6 mg/kg) in 1 L of
Systemically administered lidocaine was shown to have saline, with morphine (0.025 mg/kg), detomidine
antinociceptive effects in experimental studies, although (0.004 mg/kg) and acepromazine (0.002 mg/kg) in another
the mechanism of action is currently unknown [231]. It litre of saline administered at a CRI of 70 mL/h [240].
suppresses the development of peripheral hyperalgesia and The calcium channel alpha 2 delta blocker gabapentin is
central sensitization [232, 233]. Lidocaine is administered commonly used to specifically address the neuropathic
as a loading dose of 1.3–1.5 mg/kg i.v. over 15 minutes fol- component of pain in horses with laminitis [241, 242].
lowed by a CRI of 0.05–0.1 mg/kg/min. However, bioavailability in horses is quite low (16%) and at
The N-methyl-d-aspartate (NMDA) receptor is activated a dose of 20 mg/kg plasma concentrations decrease rapidly
by a persistent peripheral sensory nerve stimulation, and (two to three hours) below effective levels [243, 244].
with ongoing nociceptive input to the spinal cord is an
important factor in central sensitization [234] and appears
to be important in laminitic pain [235]. Ketamine is an Podiatry
NMDA receptor antagonist and administered in low doses, The central principles of podiatric measures are to reduce
binds to activated postsynaptic receptors in the spinal load on the SADP by transferring some weight-bearing to
cord [236, 237]. This is preferably carried out by CRI parts of the sole and frog and to decrease the moment arm
because it is distributed rapidly from the CNS and has a at the DIP joint [245, 246]. There are several ways to achieve
short plasma half-life [238]. Doses between 0.4 and 1.5 mg/kg these goals and most can be performed therapeutically and
proved save in conscious horses [238, 239]. prophylactically.
Trimming wedge cuff shoes that provide axial support with a 10° heel
Trimming is important to reduce forces on at risk or injured elevation and these have been reported to reduce the inci-
laminae. Loose horn and any excessive toe length are dence of laminitis in at risk horses [191]. In a finite-element
removed [188]. A long toe moves the centre of pressure of model, different hoof angles were shown to affect load on
the foot dorsally, increases the extensor moment arm on the the dorsal laminae and it was suggested that elevations
DIP joint and therefore stresses the dorsal laminae during should not exceed 10° [251]. Shoes are secured with an
breakover [247]. Lever arms, and therefore strains on the adhesive bandage or bonding material. Reusable shoes can
SADP, can be reduced by shortening the length of the toe be secured to the hoof with Velcro.
and elevation of the heel which locates pressure closer to the Commercial shoes are available with gel soles of differ-
centre of rotation of the DIP joint. When possible, shoes are ent densities and wedge angles, providing frog support and
removed: conventional shoes direct weight to the hoof wall reducing pressure at the tip of the toe by a softer cushion
which is likely to increase strain on the SADP. If a shoe (for example Soft-Ride boots). A wooden shoe (Steward
needs to be applied, it should be modified to reduce strain on clog) provides a solid base and roller motion. It is secured
the laminae [248]: a steel bar shoe with unsupported toe can with wood screws to the hoof after impression material has
reduce the strain in the dorsal hoof wall by 23% [249]. been applied to the sole and frog. The shoe can be modified
by scraping out parts of the sole to unload problem areas.
Load Re-distribution Adjustments can also be made to height and to facilitate
Load on the SADP can be reduced by including the frog and breakover. It is also claimed that, as wood is shock absorb-
palmar/plantar parts of the sole in weight-bearing (axial ing, it helps reduce pain [252].
support). This can be achieved with malleable material Hoof casts have been reported to decrease strain on the dor-
matching the consistency of the frog, for example silicone sal hoof wall by 59%. However, compression of the quarter
and elastomer (Figure 14.10). This is applied to the sole from walls is increased by 30%. They are therefore not suitable for
the tip of the frog to the bars. SADP loading is reduced fur- sinkers as in these horses the entire circumference of the SADP
ther by a slightly convex surface to the material. A heel ele- is affected [249]. If a cast is applied to the fractured limb, the
vation can be moulded if desired. An economic alternative is contralateral foot should be elevated to the same level to
the use of polystyrene foam insulation pads applied to the encourage symmetric weight-bearing [188, 253] (Chapter 13).
foot with tape. The weight is more equally distributed, and
the centre of pressure is positioned more palmarly [250]. Reducing Effective Body Weight
Wedged shoes aim to reduce tension on the DDFT and Body weight was identified as a risk factor for SLL in one
facilitate breakover and can be applied together with mal- study. Effective body weight is most consistently reduced
leable elastomer material to support the sole and the frog. by use of a sling. Horse compliance is a prerequisite, and
Venographic filling of the dorsal laminae was enhanced by close clinical monitoring is essential [246]. The commer-
cial ‘Swinglifter’ is mounted in a framework and effects
weight reduction of between 50 and 200 kg. The horse is
able to ambulate in the box and, by overcoming the thresh-
old of the adjusted weight reduction, can lie down (home-
page https://www.pmhuftechnik.saarland) (Figure 14.11).
Changes in Bedding
On hard surfaces, weight-bearing load is transferred primar-
ily to the hoof wall and causes strain on the SADP. In soft
bedding, the hooves sink in and load is shifted from the hoof
wall to frog and sole. Even if an orthopaedic shoe or other
form of axial support has been applied, soft, comfortable
bedding is still important to encourage the horse to lie down.
Medication
Historically, numerous drugs have been used to address
potential pathomechanisms of acute laminitis, but there is
insufficient evidence to support use. Improved lamellar
blood flows has been claimed for acepromazine at 0.02–
Figure 14.10 A silicone frog and sole support shifts load from 0.04 mg/kg i.m. every four to six hours [254]. Prevention of
hoof wall to sole. platelet aggregation/thrombosis has been suggested for
Reference 299
L
imb Deformities
Foals are less likely to develop SLL than adult horses.

However, in the immature skeleton, increased weight-
bearing in limbs contralateral to fractures can cause
angular limb deformity (ALD) which in most reported
cases is varus [259–261]. As predicted by the Hueter–
Volkmann law of physeal growth, increased pressure or
microtrauma suppresses growth and may lead to
ALD [188]. There are no specific preventative measures
apart from optimizing treatment of the fracture and ade-
quate pain management of which the former is the pri-
mary determinant. If ALD develops and there is still
growth potential at the physis, this can be addressed by
conventional treatment methods.
Flexural limb deformities can occur in fractured limbs
after a prolonged period of reduced loading, especially in
foals. A flexural limb deformity of the carpus developed in
3 out of 54 cases with radial fractures [5]. Effective fracture
management is the key to prevention.
P
ost-operative Colic
Post-operative colic has been reported after fracture fixation

under general anaesthesia [1, 4] and after standing
repair [262]. Orthopaedic surgery appears to be a risk for both
large intestinal [263] and caecal impaction [264]. Post-
Figure 14.11 The Swing lifter reduces effective body weight operative pain and hospitalization have been cited as causa-
during standing. The horse is able to lie down by overcoming tive [263, 265, 266]. Colonic motility is decreased by stable
the threshold.
confinement [267, 268] and transport predisposes to impac-
tion [268]. General changes in management and routine are
acetylsalicylic acid (20 mg/kg orally every other day) and also risk factors [269]. The effect of preanesthetic fastening is
heparin (40–80 IU/kg every 8–12 hours i.v. or subcutane- still unclear [263, 270]. Drugs such as morphine decrease GI
ously). Vitamin E (10–20 IU/kg orally every 24 hours) has motility, but involvement in post-operative colic is inconclu-
been proposed to reduce oxidative stress. sive [263, 265, 266, 271]. Thoroughbreds appear to be at
increased risk, and association with peri-operative adminis-
Cryotherapy
tration of sodium benzyl penicillin has been reported [272].
Cryotherapy limits lesion severity in oligofructose-induced
Post-operative monitoring of gastrointestinal function and
laminitis [255–257] and decreases incidence in horses with
preventive or early therapeutic measures may reduce prob-
colitis [258], but its effect in prevention or treatment of SLL
lems in horses at risk [263].
is unknown.
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311
15
Convalescence and Rehabilitation

M.R. King1, S.A. Johnson1, and J. Daglish2
1
College of Veterinary Medicine and Biomedical Sciences, Colorado State University, Fort Collins, CO, USA
2
I ntroduction overstress the site or cause excessive inter-fragmentary

movement which may impair the healing process. As the
Rehabilitation following orthopaedic injuries plays a critical remodelling phase begins, progressively increasing loads
role in restoring the equine athlete to function. Rehabilitation can be applied to injured tissues. The aims in this phase are
protocols are tailored specific to individual patient’s global to restore deficiencies in power, strength, agility and mus-
functional assessment, taking into account sports-specific cle endurance.
demands, goals for return to performance and the overall The healing process is a continuum, and phases overlap
prognosis [1]. Physiotherapy following fractures is standard with no definitive beginning or end points (Chapter 6).
in human medicine and is considered essential to maximiz- The most effective rehabilitation programmes utilize regu-
ing functionality. The rehabilitation specialist must have a lar, longitudinal patient assessments followed by adapta-
solid working knowledge of the stages of tissue healing in tion of protocols in line with both injury-specific and
order to develop protocols that provide appropriate loading whole-body considerations. This chapter reviews physical
and avoid placing excessive stress on naïve tissue. Following modalities and therapeutic exercises commonly employed
fracture repair, rehabilitation protocols are designed to mod- in fracture rehabilitation. Universal recommendations
ulate pain, enhance bone healing, improve proprioception, regarding indications, timing and frequency are lacking,
increase flexibility and to restore muscle strength, range of but as research defines specific parameters, advancements
joint motion, and neuromotor control. can be expected.
The process of indirect bone healing can be divided into
three overlapping phases: inflammatory, reparative and
remodelling (Chapter 6). During the inflammatory phase,
R
ehabilitation Goals
the primary rehabilitation goals are to modulate pain, min-
General Considerations
imize soft tissue inflammation and oedema, reduce muscle
spasms and address ranges of joint motion both proximal It is imperative that rehabilitation specialists understand
and distal to the immobilized region. To encourage deposi- the characteristics of individual fractures, the type of repair
tion of initial repair tissue, loading of the injured bone and and/or healing and the potential complications that may
surrounding soft tissues should be minimized during this occur in order to customize protocols for each patient.
period [2]. Stimulation of angiogenesis during the repara- Rehabilitation should begin in the immediate postopera-
tive phase has been shown to increase formation of granu- tive period, even if the horse is non-ambulatory and
lation tissue across the fracture site [3]. In addition, restricted to a cast. Active and passive assisted movements
appropriate controlled cyclic loading will increase callus can begin within two to three days of fracture stabilization
formation and improve mechanical bone strength [4]. and continue until function is restored. Table 15.1 provides
Protocols developed during the reparative phase should be general rehabilitation guidelines applicable to each phase
designed to stimulate tissue repair along the lines of of healing. Specific details of therapeutic methods are pro-
applied tensile force, but caution must be applied to not vided within the text.

Table 15.1 General rehabilitation guidelines.
Rehabilitation target
Rehabilitation Proprioception, balance

phase Pain modulation Oedema and swelling Range of joint motion and limb loading Muscular strength
Inflammatory Cryotherapy Cryotherapy

(Day 1–7) TENS Therapeutic Ultrasound
Laser therapy Laser therapy
PROM PROM
PEMF PEMF
Reparative Cryotherapy Cryotherapy Thermotherapy Varying surfaces Varying surfaces
(Day 7–30) TENS Therapeutic Ultrasound Therapeutic ultrasound Cavaletti poles Backing exercise
Laser therapy Laser therapy Varying Surfaces Resistive therabands Cavaletti poles
PROM PROM Cavaletti Poles Underwater treadmill Resistive therabands
PEMF PEMF PROM Proprioceptive balance pads Underwater treadmill
Underwater treadmill Weight-shifting exercises Weight-shifting exercises
Remodelling Thermotherapy Thermotherapy Thermotherapy Varying surfaces NMES
(Day > 30) Therapeutic Ultrasound Therapeutic Ultrasound Therapeutic ultrasound Cavaletti poles Varying surfaces
TENS TENS Varying surfaces Resistive therabands Cavaletti poles
Laser therapy Laser therapy Cavaletti Poles Proprioceptive balance pads Resistive therabands
PROM PROM PROM Underwater treadmill Underwater treadmill
PEMF PEMF Underwater treadmill Tactile stimulators Tactile stimulators
Tactile stimulators Backing exercise Backing exercise
Weight-shifting exercises Weight-shifting exercises
TENS: transcutaneous electrical nerve stimulation; PROM: passive range of motion; PEMF: pulsed electromagnetic field therapy; NMES: neuromuscar electrical stimulation.
c15.indd 312 12/17/2021 12:33:58 AM

Pain Modulatio 313
Inflammatory Phase introduced with due regard to the rate of individual frac-
ture healing, particularly when the reparative phase is
During this phase (days one to seven following injury or
protracted or retarded.
repair), the principal goals are management of pain, inflam-
mation, oedema and range of joint motion. Preserving joint
function is paramount throughout rehabilitation. Analgesia, Musculoskeletal Comorbidities
cryotherapy, passive range of motion exercises (PROM) and
Osteoporosis and disuse muscle atrophy commonly follow
global functional impairments such as epaxial muscle
immobilization. Muscle atrophy has been documented to
hypertension can simultaneously be addressed; however,
occur within 72 hours of immobilization, quickly leading to
these may be restricted by fracture immobilization. Under
loss of function and impaired mobility [5]. Slow-twitch oxi-
the guidance of the surgeon, early limb loading and weight-
dative type 1 fibres (postural control muscles) and muscles
bearing should be encouraged.
that cross only one joint are most susceptible [5, 6].
Restoration of muscle mass, strength and control often takes
Reparative Phase two to four times the duration of the immobilization, lead-
ing to prolonged convalescence even following adequate
In this phase (days 7–30), the focus is on stimulating frac-
fracture healing [6]. Practitioners are therefore encouraged
ture healing, re-establishing ranges of joint motion,
to maintain as much muscular strength and neuromotor
improving proprioception, initiating muscle strengthening
control as possible throughout the rehabilitation period.
techniques, and when possible encouraging limb loading
Muscular pain associated with compensatory changes in
and controlled exercise. Contractures of joint capsules and
posture may also be present. Rehabilitation techniques
muscles responsible for limb movement commonly follow
should address regions of axial and appendicular muscle
periods of immobilization. Techniques to address these
pain, spasm and hypertonicity using a combination of physi-
should be initiated as soon as possible after removal of
otherapeutic modalities and exercises appropriate to the
external coaptation to avoid chronic pain, loss of range of
stage of fracture healing. Table 15.2 documents techniques
motion and poor limb use. Weight-bearing exercises should
available to improve muscle function and reduce compensa-
be used with caution, especially early in the repair process
tory muscle pain.
to minimize risk of fixation failure.
Remodelling Phase P
ain Modulation
Techniques in this phase (days >30) target osseous
Cryotherapy
remodelling and a progression of proprioceptive engage-
ment, limb use, range of motion, muscular strength and Thermal therapy consisting of cryotherapy, heat therapy or
cardiovascular fitness. Exercises are increased in a combination thereof (contrast therapy) remains a corner-
intensity, duration, and frequency according to the sta- stone of many physical therapy programmes. Cryotherapy
bility of repair, stage of healing and ongoing assessment generally is indicated in acute injuries to reduce pain,
of patient response. Progressive exercise should be swelling, and inflammation, while heat therapy is utilized
Table 15.2 Techniques to improve muscle function and reduce compensatory muscle pain.
Muscular comorbidities
Thermotherapy Therapeutic ultrasound Laser therapy Myofascial release Core-specific exercises
Topical heat Continuous wave 6–10 J/cm2 Rapid release Perform one set of five
application for form 1 MHz Three treatments per therapy, manual repetitions once daily for up to
Consider at all 15–20 minutes 1.5–2.0 W/cm2 week up to a total of myofascial five days per week.
stages of 2-3x daily 10 minutes per 12–18 treatments release or Gently stretch muscles to the
fracture session Target epaxial muscle kinesiotape comfortable end of their range
healing based hypertonicity and trunk application of motion for a minimum of
2–7 times per week
on functional stiffness Use as needed 30 seconds immediately
Target focal regions of following heating modalities
assessment Hair coat should be
muscle spasm, pain or
contracture clipped to increase Relax for 60 seconds between
penetration stretches
314 Convalescence and Rehabilitation
in more chronic conditions to encourage soft tissue exten- 20–30 minutes every two to three hours during the first
sibility, decrease muscle spasms and increase local blood 48 hours after an acute injury [19]. Cryotherapy may be
flow [7]. Methods of application have been widely devel- indicated for up to 10–14 days post injury and can be con-
oped for use in the equine distal limb, but the axial skeleton tinued after cast removal and/or after physiotherapy to
remains challenging due to limitations in depth of penetra- reduce pain and inflammation associated with exercise.
tion and difficulty in securing equipment. The therapeutic General rehabilitation considerations are:
effects of cold applications are generated by reducing tissue
●● Inflammatory Phase: Apply for 15–20 minutes, two to
temperatures to 10–15 °C [8]. Tissue cooling produces
three times per day with appropriate surgery site protec-
vasoconstriction and decreased soft-tissue perfusion,
tion or as above for proximal limb and axial skeleton
which can reduce oedema and swelling at sites of injury.
fractures.
Cold therapy also mitigates tissue metabolism and apopto-
●● Reparative Phase: Apply for 15–20 minutes, two to
sis, inhibits the effect of inflammatory mediators and
three times per day. Following suture and/or cast
abates local enzymatic activity [9]. The application of cold
removal, ice-water immersion, cold salt water spa or
also modulates pain by decreasing nerve conduction veloc-
CCT can be used in the distal limb. Applications in proxi-
ities in local sensory neurons and by activating descending
mal limb and axial skeleton fractures are the same as
inhibitory pathways [10]. Cold therapies can penetrate up
above.
to 1–4 cm in depth, dependent on local circulation and adi-
●● Remodelling Phase: Cryotherapy is not applicable.
pose tissue thickness [11]. Human studies have docu-
mented the analgesic benefits of cryotherapy with a
15–20 minute application providing pain relief for
Heat Therapy
1–2 hours [12, 13]. In horses, ice-water immersion for
30 minutes reduced superficial and subcutaneous tissues in High energy trauma associated with fractures often results
the distal limb to within the optimal therapeutic range in extensive soft tissue damage. Limited weight-bearing on
compared to cold pack application [14]. Application of a an injured limb also places added stresses and altered mus-
compression boot with continuous circulating coolant cle recruitment on the remaining limbs and axial skeleton.
applied to the distal forelimb of horses for one hour reduced Functional impairments within corresponding muscles
the superficial digital flexor tendon (SDFT) core tempera- may result in regions of spasm, hypertonicity, muscle over-
ture to 10 °C [8]. Similarly, a dry sleeve perfused cuff with use and contractures. Applying heat to impaired muscles
continuous circulating coolant that included the hoof and during immobilization and rehabilitation phases may aid
distal limb was as effective as ice-water immersion in fracture healing by decreasing pain, improving vascular
reducing hoof wall surface temperatures to <10 °C over an supply and stimulating the production of muscle derived
eight hour period [15, 16]. osteoprogenitor cells [20]. Topical application of heat
In both humans and dogs, circulating cryotherapy and increases local circulation and tissue extensibility. It also
intermittent compression reduce pain, swelling and lame- induces muscle relaxation and therefore reduces muscle
ness, and increase the range of joint motion following spasm and associated pain [21, 22]. Increased local blood
orthopaedic surgery [17, 18]. Tissue cooling efficacy with flow mobilizes tissue metabolites and increases tissue oxy-
dry-interface circulating cryotherapy units (cold compres- genation and the metabolic rate of cells and enzyme sys-
sion therapy [CCT]) has been demonstrated to be equiva- tems. Clinically, the most profound physiologic effects of
lent to ice-water immersion, providing a clinically safe and heat occur when tissue temperatures are raised to
effective means of cryotherapy [16]. Where necessary, inci- 40–45 °C [21, 22]. Tissue temperatures above 45 °C can
sions can be covered with an Ioban drape1 and the dry- result in pain and tissue damage. During rehabilitation,
interface pneumatic sleeve applied to the limb. The heat decreases tissue viscosity and increases tissue elastic-
dry-interface pneumatic sleeve may also be applicable for ity, thus facilitating stretching exercises. Low-load, pro-
horses with soft tissue swelling and oedema above distal longed stretching of tissues heated between 40 and 45 °C
limb casts. Fractures within the proximal limb, axial skele- results in increased extensibility of tendons, joint capsules,
ton and regions inaccessible due to external coaptation and muscles [21, 23].
may benefit from the application of ice packs or cold packs, Heat is best applied after acute inflammation has sub-
use of circulating cryotherapy units without concurrent sided. Mechanisms of action are linked to the depth of pen-
compression, ice frozen in paper cups, ice massage or icing etration and the method used for heating. Superficial
blankets. heating sources usually penetrate the skin and subcutane-
Optimal duration and frequency of cold therapy have yet ous tissue to a depth of 1–2 cm. In horses, these include
to be defined, but a general recommendation is for topical hot packs or compresses and circulating warm
Physiotherapeutic Modalitie 315
water heating wraps. Deep thermal modalities (e.g. thera- may need to be clipped, depending on length, but should
peutic ultrasound) can rapidly increase tissue tempera- be cleaned from dirt and debris, wet down and ample cou-
tures by >4 °C at 3–5 cm depths. For deeper tissues, such as pling gel applied. For pain modulation following fractures,
muscle, 15–30 minutes is required to elevate tissue temper- the authors prefer to place electrodes over the appropriate
ature to the therapeutic range. When using heat sources spinal cord segments utilizing the chronic pain settings
warmer than 45 °C (e.g. a chemical hot pack), the source (low frequency/long pulse duration). The stimulus is toler-
must be wrapped in several layers of moist towels before ated well, with no observed undesirable responses or
application. Heat from these sources is usually applied for increases in activity level.
20–30 minutes. Although clinical effectiveness for superfi- General rehabilitation considerations are:
cial heating has yet to be demonstrated, it is often used
●● Inflammatory, Reparative and Remodelling Phases:
prior to exercise in both training and rehabilitation settings
Apply for 30 minutes twice daily using the low-frequency,
as mounted heating lamps or a solarium.
long pulse duration protocol. Electrodes should be placed
General rehabilitation considerations are:
over the spinal cord segments pertinent to fracture location.
●● Inflammatory Phase: Heat therapy is not applicable.
●● Reparative and Remodelling Phases: Superficial heat
applied for 20 minutes prior to PROM exercises. Wetting P
hysiotherapeutic Modalities
prior to application improves conduction.
Neuromuscular Electrical Stimulation
Neuromuscular electrical stimulation (NMES) uses a low-
Transcutaneous Electrical Nerve Stimulation
level electrical current that through stimulation of alpha
Transcutaneous electrical nerve stimulation (TENS) is motor neurons produces muscle contraction (Figure 15.1).
used primarily for pain modulation and involves electrical NMES has been successfully used by human physiothera-
current applied via surface electrodes to stimulate periph- pists to increase muscle strength, maintain muscle mass
eral nerves [24]. Pain relief is thought to be from stimula- during prolonged periods of immobilization and control
tion of inhibitory interneurons at the spinal cord level or oedema after injury. It assists neuromuscular function by
release of endogenous endorphins within the central nerv- enhancing the force capacity or ability of the muscle to
ous system [24]. ‘Conventional mode’ TENS that is fre- contract. It is unclear if the role of electrical stimulation in
quently used for more acute pain has a high-frequency improving muscle function is actually related to increasing
(>100 Hz) and low pulse duration (50 μs), and is thought to
modulate pain through the gate control theory (modula-
tion of sensory input from the skin before it evokes pain
perception and response) [24]. Pain modulation with con-
ventional TENS mode will be relatively short in duration
once the electrodes have been removed. The ‘acupuncture
like mode’ TENS setting, used for chronic pain, has a lower
frequency (<20 Hz) and longer pulse duration (200 μs) and
relieves pain through the release of endogenous opi-
oids [24]. The duration of pain modulation following
removal of the electrodes using the ‘acupuncture like
mode’ may persist for one to two hours. In humans, there is
moderate evidence to support TENS use in managing
pain [5]. There is no evidence of its effectiveness in horses,
but there may be some overlap in the mechanisms of
action, clinical indications and effects reported for
electroacupuncture [25].
TENS units are typically applied for 30 minutes, two to
three times daily. Electrodes can be placed on or around
the painful region (or associated derma-, myo-, or sclero-
tomes), over the spinal cord segments that innervate the
painful region or over trigger points. The further apart the Figure 15.1 Bipolar NMES electrodes placed over the middle
electrodes are placed, the deeper the penetration. Hair coat gluteal muscles.
muscle strength, improving voluntary contractions, restor-

ing motor control or due to proprioceptive activation
within injured or atrophied myofascial tissues [25]. The
combination of electrical stimulation and exercise has
been reported to be effective in alleviating pain and improv-
ing voluntary activation in human osteoarthritis patients,
but it did not enhance muscle strength or functional per-
formance [26]. NMES can also help to reduce oedema and
swelling as the direct current causes charged plasma pro-
tein ions within the interstitial spaces to move in the direc-
tion of the oppositely charged electrode, facilitating
movement into lymphatic channels.
NMES has additional therapeutic effects beyond regional
muscle physiotherapy. The electrical induction of muscle
contractions improves fracture healing by decreasing the
loss of bone mass and increasing blood flow to the fracture
site. In non-equine animal models of fracture healing,
NMES increased the rate of callus development with ear-
lier superior biomechanical properties compared to con-
trols [27]. Enhanced fracture healing will decrease the
development of comorbidities that are often associated Figure 15.2 PEMF boot application to the metacarpus.
with long rehabilitation periods. However, standardized PEMF coils are contained within the boot.
protocols are lacking. There are no validated treatment pro-
grammes due to large methodological variations in applied with 77.4% of the PEMF treated fractures healing com-
frequency, duration, disease stage, severity and patient pared to 48.1% in a sham group at four months [33]. PEMF
selection. Future studies are needed to address the dose– has been shown to increase bone volume fraction, trabecu-
response of NMES on fracture healing. lar thickness, trabecular number and suppress trabecular
General rehabilitation considerations are: separation in a rat model of induced knee osteoarthritis. In
the same study, PEMF was shown to promote WNT gene
●● Inflammatory Phase: NMES not applicable.
expression in subchondral bone. Activation of WNT pro-
●● Reparative and Remodelling Phases: NMES applied
motes osteoblast and osteocyte activity while indirectly
for 20–30 minutes, three times per week. Electrodes are
suppressing bone resorption and osteoclast differentia-
placed directly over the targeted muscle. Protocol
tion [34]. In non-equine species, targeted PEMF devices
recommended:
have also been shown to reduce pain and inflammation,
–– Frequency: 25–50 Hz
mainly through stimulation of the nitric oxide pathway,
–– Pulse Duration: 150–200 microseconds
which results in vasodilation and enhanced circulation.
–– Ramp Up/Down: 6 seconds
Recently, a targeted PEMF device (Assisi Loop2) demon-
–– Contraction: Relaxation Ratio – 1 :3 to 1:5 seconds
strated improved functional outcomes and reduced need
for systemic pain medication in dogs recovering from
hemi-laminectomy [35]. Devices that produce PEMFs vary
Pulsed Electromagnetic Field Therapy
by a number of important features, which include fre-
Pulsed electromagnetic field (PEMF) therapy uses an elec- quency, waveform, strength and types of stimulators.
trically generated magnetic field that is placed around an Particular attention should be paid to the parameters uti-
injured region or adjacent to a body segment of interest lized in studies that suggested efficacy as positive outcomes
(Figure 15.2). The induced magnetic field produces sec- are specific to the PEMF signal configuration [29].
ondary electrical currents within tissues that stimulate cel- In horses, initial reports of PEMF use were for treating
lular repair [29]. Of particular interest for fracture healing chronic non-union fractures and stimulating bone healing.
are reports of PEMF stimulating bone healing via enhanced An experimental model demonstrated that a PEMF setting
osteogenesis [29, 30]. PEMF has been shown to accelerate of 75 Hz delivered continuously for 30 days resulted in sig-
fracture healing in normal rats and in rats with induced nificant increases in mineral apposition rate and osteoblas-
osteoporosis [31, 32]. PEMF significantly improved success tic activity in defects in the diaphysis of the third metacarpal
rates in people with delayed union long-bone fractures bone [29]. However, an earlier study using the same PEMF
Physiotherapeutic Modalitie 317
parameters reported some positive and some negative

effects in third metacarpal metaphyses [30]. A similar
model incorporating cancellous bone grafts demonstrated
increased calcification rates when using PEMF settings of
1.5 Hz for 3 hours/day for up to 240 days post grafting [36].
Although improved healing rates of chronic non-union
fractures in people have been reported, the efficacy and
quantification of PEMF on fracture healing vary widely.
More research is necessary to understand its influence on
bone metabolism and to determine appropriate settings,
timing and duration of therapy.
●● Inflammatory, Reparative and Remodelling Phases:
A targeted PEMF device (e.g. Assisi Loop2) applied over
the region of interest for 15 minutes, twice per day.
Caution should be employed for other PEMF devices
when applied over metal implants: manufacturers guide-
lines must be scrutinized prior to use.
Whole Body Vibration Therapy

Whole-body vibration therapy (WBV) involves the applica-
tion of low-frequency, low-amplitude mechanical stimula-
tion and mechanotransduction in bone to stimulate
osteogenesis [37]. WBV has demonstrated promising
effects on callus formation, mineralization and bone
remodelling in non-equine species [38]. Additional, con-
tributory influences on bone healing may be generated Figure 15.3 A horse standing on a vertical displacing whole-
during muscle contractions from the tonic vibration reflex body vibration platform.
stimulated by WBV [39]. The vibration stimulus increases
alternating horizontal and vertical WBV frequencies of
vascular endothelial growth factor (VEGF) expression and
15–21 Hz [44]. Prolonged (60 days of twice daily, 30 min-
capillary density within the muscles surrounding injured
ute) WBV increased cross-sectional area and symmetry of
bone [40]. The response of the musculoskeletal tissues to
the multifidus muscle [45]. Only one study has been con-
vibration stimuli is determined by the frequency, direction
ducted in the horse evaluating effects of WBV on bone.
(vertical versus oscillatory), magnitude (displacement and
Twelve horses were confined to stalls for 60 days with half
acceleration), and duration of therapy.
the group exercised daily on a mechanical walker and the
Studies conducted in rodent and ovine models of fracture
other half receiving vertical WBV therapy at 50 Hz for
repair have utilized a wide range of vibration protocols, includ-
45 minutes, 5 days a week. Both groups had the same bone
ing alterations in frequency, magnitude and duration. Both
mineral content suggesting that WBV should be considered
closed and open fracture repair models in rodents demon-
for horses restricted to stall rest [46]. To date, there are no
strated that vertical vibration at a frequency of 45 Hz impaired
reports on vibration frequency, duration or magnitude
healing while vibration frequencies of 35 and 50 Hz enhanced
comparisons in the horse, and further work is necessary to
healing [41–43]. More specifically, 35 and 50 Hz vertical vibra-
determine potential contributions to fracture healing.
tion protocols accelerated osseous bridging, improved callus
formation and increased cortical density measured using com-
puted tomography and microradiography [38]. In contrast, ●● Inflammatory Phase: Not applicable.
horizontal oscillatory vibration therapy, regardless of fre- ●● Reparative and Remodelling Phases: Recommended
quency, demonstrated no positive or negative effects in rodent protocols for fracture healing in horses have not been
fracture healing models [38]. established, but vertical vibration at a frequency of 35 or
WBV has been applied to horses with anecdotal claims of 50 Hz for 30–45 minutes, 5 days per week, may be contribu-
effectiveness (Figure 15.3). No untoward clinical or haema- tory. Care should be taken to ensure patient tolerance as
tologic effects were recorded in horses undergoing the effect of vibration on surgical implants is unknown.
Therapeutic Ultrasound General rehabilitation considerations are:

Therapeutic ultrasound (TU) is a non-invasive form of ●● Inflammatory Phase: Apply for 10 minutes, from daily
mechanical energy that transmits high-frequency acoustic to two or three times per week, to regions of swelling prox-
pressure waves into tissues in order to influence healing. imal to casts or associated with proximal limb or axial
Therapeutic ultrasound machines can produce pulsed or skeleton fractures. Do not apply over surgical incisions,
continuous emissions to penetrate soft tissues up to a 5 cm cast material and or implants. Protocol recommended:
depth. Pulsed ultrasound waves have non-thermal effects, –– Frequency: 3.3 MHz
which include increased cellular function, enhanced pro- –– Duty Cycle: Pulsed 10–20%
liferation of fibroblasts and increased vascularity [47]. –– Intensity: 1.0 W/cm2
Continuous TU waves have deep thermal effects, which ●● Reparative Phase
include increased blood flow, enzyme activity, collagen –– Treatment of oedema and swelling – as for inflamma-
synthesis and extensibility, and decreased pain [48]. Tissues tory phase
with high protein or collagen content or tissue interphases –– Treatment of joint contracture, muscle spasm and
(e.g. periosteum or entheses) readily absorb sound waves, pain – as for remodelling phase
which results in energy transfer to the surrounding tissues ●● Remodelling Phase: Apply for 10 minutes, from daily
and a localized increase in metabolism [17]. In general, to two to three times per week. Conduct PROM exercises
continuous TU is indicated when deep heating would be immediately following treatment. Haircoat should be
beneficial to reduce pain, increase muscle relaxation and clipped to optimize capacity for deep tissue heating.
improve soft tissue extensibility; pulsed TU is used when Protocol recommended:
tissue heating is contraindicated. –– Frequency: 1.0–3.3 MHz
TU has been used with mixed success to stimulate bone –– Duty Cycle: Continuous
growth and fracture healing in animal models and human –– Intensity: 1.0–1.5 W/cm2
clinical trials. In humans, low-intensity pulsed TU has
been approved by the FDA to treat both acute and non-
Laser Therapy
union fractures [49]. An optimal intensity of 30 mW/cm2 at
1.5 MHz for 20 minutes has been established in both human Laser therapy is thought to have biomodulatory influ-
and non-human models. Success rates for the treatment of ences on cellular aerobic respiration and thus has poten-
human delayed union and non-union fractures ranged tial beneficial effects following injury [54] (Figure 15.4).
from 67 to 90%. Non-union fractures monitored by radio- The light energy is absorbed at a subcellular level that
graphs, densitometry and biochemical measures, in deep leads to an increase in ATP production, stabilizing the
locations (femur and humerus), had lower success rates cell membrane and increasing DNA activity and synthe-
than superficial bones [50]. Rodent models of fracture sis of RNA and proteins [54, 55] Although not all mecha-
healing have demonstrated enhanced osteogenesis and nisms are clearly understood, laser therapy is used as a
angiogenesis following TU treatment compared to con- non-invasive procedure to stimulate cell regeneration,
trols [51]. Rodent models using low-intensity pulsed ultra- increase angiogenesis, decrease inflammation and mod-
sound reported upregulated osteoblastic activity and ulate pain [56]. As with other physical modalities, the
enhanced fracture healing [49]. Conversely, a canine model exact light wavelength, dosage and treatment frequency
of fracture healing utilizing distal radial defects treated appropriate for treatment of musculoskeletal diseases
with low-intensity pulsed ultrasound (1.5 MHz, and are largely unknown. Effects in tissues depend on the
30 mW/cm2, five days per week for three month duration) wavelength (600–1000 nm), power that is used and the
found no significant difference from controls [52]. absorption potential of the tissue itself. Additional vari-
A substantial amount of in vitro research has demon- ables include light source deliverance as continuous or
strated promising results of TU on the mechanical stimula- pulsed, power of the light source (in mWatts or Watts),
tion of osteoblasts. Low-intensity pulsed TU enhances beam irradiance, duration of treatment per site, tissue or
osteoblast function, increases expression of osteocyte spe- site treated and the calculated delivered dosage (Joules/
cific proteins, and increases collagen production [53]. The treatment site).
in vivo and in vitro evidence for TU to augment fracture Laser therapy has been shown to reduce production of
healing and osteocyte stimulation is compelling; however, inflammatory cytokines PGE2 and TNFα in both human
equine studies are necessary to determine in vivo utility. in vitro and clinical studies [56]. Multiple studies have
Caution is necessary when applying TU over metal demonstrated that laser therapy applied to cell cultures
implants to avoid excessive heat accumulation. increases cell proliferation, migration and collagen
Physiotherapeutic Exercis 319
scores were observed compared to sham-treated dogs [63].

However, a wavelength of 635 nm, a power output of 5 mW
and an energy density of 1.5 J/cm2 in dogs recovering from
TPLO surgery had no beneficial effects on pain modula-
tion, bone healing or pelvic limb function compared to
sham-treated animals [64]. Laser therapy using different
energy intensities also had limited influence on bone heal-
ing in rodent fracture models [65, 66]. It therefore appears
that while cells in culture demonstrate promising results
for bone healing in response to laser therapy, positive
in vivo results have yet to be demonstrated and further
investigation into the effects of photobiomodulation on
fracture healing is warranted.
●● Inflammatory and Reparative Phases: Apply daily or
every other day for five to seven treatments at 1–6 J/cm2;
duration directed by treatment area. Non-contact laser
therapy to be used over surgical incisions prior to suture
or staple removal. Use caution when applying over
implants and do not laser over cast material.
●● Remodelling Phase: Apply two to three times per week
at 6–10 J/cm2; duration directed by treatment area. Use
caution when applying over implants.
P
hysiotherapeutic Exercise
Rehabilitation following fractures involves not only osse-

ous healing but also management of compromised soft tis-
Figure 15.4 Therapeutic laser applied over a gluteal muscle
trigger point. sues and articulations. As equine rehabilitation is in its
infancy, there is a reluctance to add physiotherapeutic
deposition [57, 58]. Rat aspirated bone-marrow-derived exercises to protocols, often fearing fracture or implant fail-
mesenchymal stem cells exposed to laser therapy at 5.0 J/ ure or compromise. A careful biologic balance exists
cm2 exhibited significantly enhanced production of growth between protecting the repair and encouraging safe limb
factors VEGF and NGF [59]. Human cell culture studies use. Loss of muscle mass has been documented to occur
have identified that energy doses applied between 0.5 and within 72 hours of immobilization [5], and in man, exer-
5.0 J/cm2 have a stimulatory effect on cellular responses, cises are often initiated within a few days of surgery to pre-
while higher doses (16 J/cm2) have an inhibitory effect [60]. vent fibrosis and to encourage muscle strengthening and
Human-cultured osteoblasts exposed to laser irradiation at neuromotor control.
10.34 J/cm2 with a 1064 nm wavelength exhibited enhanced
osteoblast migration [61], while equine bone-marrow- Proprioceptive Facilitation Techniques
derived mesenchymal stem cells exposed to 1064 nm wave-
length irradiation at 9.77 J/cm2 and a mean output power Human athletes that incorporated proprioceptive balance
of 13.0 W had upregulation of IL-10 and VEGF exercises into rehabilitation programmes were significantly
expression [62]. less likely to re-injure during a 12-month period following
Dogs treated with a wavelength of 800–900 nm, a power injury, compared to those with similar injuries that did not
output of 6 W and an energy density of 4 J/cm2 prior to tib- emphasize core strength (7% re-injury rate in the balance
ial plateau levelling osteotomy (TPLO) demonstrated training group versus 29% re-injury rate in the control
improved ground reaction forces at eight weeks post- group) [67]. Strengthening, improving proprioception and
surgery, although no differences in osteotomy healing balance control are central to human physical therapy
programmes, and while standardized investigations have

yet to focus on equine applications, there are several mecha-
nisms through which neuromotor control can be recruited.
Physical therapy aids such as ground poles, tactile stimula-
tors and incorporation of surface changes offer clinicians
passive means of engaging neuromotor control during
rehabilitation. Ground poles when arranged at various dis-
tances, heights and configurations can encourage increases
in the range of joint motion, stride length, controlled eccen-
tric loading and lateral thoracolumbar excursion. Hill work
combined with backing exercises can also be used to
improve muscular strength and challenge proprioceptive
acuity. Proprioceptive balance pads can be used to stimulate
isometric contractions and engage postural control muscu-
lature (Figure 15.5). Following a three-month rehabilitation
programme, horses that incorporated standing daily on bal-
ance foam pads demonstrated a significant strong correla-
tion between m. multifidus hypertrophy and improvements
in postural stability [68]. It is suggested that this enhances
proprioception and neuromotor control, thus protecting
both axial and appendicular skeletons.
There has been recent interest in the use of propriocep-
tive aids in equine rehabilitation including tactile stimula- Figure 15.6 A proprioceptive resistive band fitted around the
hindquarters.
tors and a system of elastic bands [69, 70]. Resistance band
training is successfully used in human physical therapy
studies investigating long-term use and potential mecha-
programmes to improve core strength and stability, specifi-
nistic pathways will help define its role in rehabilitation.
cally related to the lower back and pelvic regions [71–73].
Proprioceptive devices applied to the distal limb have
Commonly referred to as a Theraband,3 the two-piece elas-
been used to increase range of joint motion, re-establish
tic band system is thought to stimulate core abdominal
neuromuscular firing patterns and improve the strength of
muscles with the abdominal band and engage hindlimb
targeted muscles [70, 74, 75]. Tactile stimulators fitted to
musculature with the hindquarter band (Figure 15.6). It
hindlimb pasterns produced higher hoof flight arcs, with
was reported to reduce mediolateral and rotational move-
increased flexion of the fetlock, hock and stifle joints [70,
ment throughout the thoracolumbar region [69]. Further
74] (Figure 15.7). Additional application of ankle weights
increased hip flexion and work performed by the hip, stifle
and tarsal musculature [70]. However, there is often habit-
uation, whereby the greatest effects are observed initially,
followed by a rapid decrease in altered limb kinematics [74,
75]. Nonetheless, use of these techniques supports the
principle of using enhanced afferent input to indirectly
produce and modulate a targeted efferent response for the
purpose of re-establishing motor control and improving
range of joint motion.
●● Inflammatory Phase: Not applicable.
●● Reparative Phase
–– Controlled Exercise Over Varying Surfaces: Initiate
hand walking or horse walker exercise based on sur-
geon recommendations. Utilize variations in surface
consistency to provide subtle changes in ROM. Initial
Figure 15.5 A horse standing square on proprioceptive walking should be performed on a firm surface and
balance pads. introduce less dense surfaces gradually.
–– Tactile Stimulators: Five minutes, two to three times

daily. Apply lightweight tactile devices (e.g. overreach
boot or a lightweight chain attached to the Velcro strip
(Figure 15.7)) to the targeted limb. Walk on a non-slip
surface.
Aquatic Therapy
Aquatic modalities are often used in the treatment of
orthopaedic injuries. Aquatic therapies, including under-
water treadmills and swimming, have been reported in
humans to improve muscle strength and timing, increase
cardiovascular endurance, decrease limb oedema, improve
range of motion, decrease pain and reduce mechanical
stresses applied to limbs. Humans with lower extremity
injuries demonstrated a significant increase in limb-
loading parameters, improved range of joint motion and
reduction in the severity of balance deficits following
aquatic exercise [76–79]. In postmenopausal women, walk-
ing in water improves bone mineral density, muscle
strength, range of joint motion, neuromotor control, bal-
ance and proprioception [80]. Similar benefits may be
Figure 15.7 A tactile stimulator and pastern weight applied to extrapolated to horses recovering from fractures.
a horse’s forelimb to assist in increasing range of joint motion of In people, walking in water at an increased depth (level of
the carpus, elbow and shoulder and to stimulate concentric
activation of muscles responsible for forelimb flexion. xiphoid process) can be utilized in the early stages following
fracture repair (once incisions have healed) to improve mobi-
–– Cavaletti Poles: Incorporate ground poles gradually into lization and neuromotor control and to correct gait [81].
walking exercise. Increase the number of poles, num- Anti-gravity treadmills have also been used post-operatively
ber of passes over sequential poles or the height of poles in human patients [82]. This allows the patient to begin light
as the horse advances. Make singular adjustments in running while controlling velocity and body weight percent-
protocol each week to build up intensity of exercise. age independently. By changing one variable at a time, either
–– Proprioceptive Balance Pads: One to three minutes, weight distribution or speed, the therapist can safely advance
twice daily and progressing to five minutes twice daily. the patient to full weight-bearing and running [82].
Begin with firm pads and progress to less firm mate- Controlled mechanical loading during exercise is critical
rial. Initially place the targeted paired limbs on pads for promoting osteogenesis (Chapter 6), and deprivation of
and progress to all four limbs on pads. load (e.g. 100% buoyancy) negatively impacts bone metabo-
●● Remodelling Phase lism and likely delays fracture healing [83]. Underwater
–– Controlled Exercise Over Varying Surfaces: Increase treadmill exercise may provide a mechanism to decrease
duration and reduce firmness of walking surface. A axial loading on the limb. In comparison with land exer-
land treadmill can be employed to gradually increase cise, walking in water at increased depths attenuates distal
walking speed pending previous acclimation. limb forces to reduce distribution of load across the frac-
–– Resistive Theraband Exercise: To be worn for five min- ture site. In horses, water at the level of the tuber coxae
utes twice per day, gradually progressing to the full produces 75% reduction in body weight, whereas water at
duration of walking exercise. Apply hindquarter and/ elbow height reduces weight-bearing load by 10–15% [84]
or abdominal therabands firmly to produce a constant (Figure 15.8). Additionally, increased water depth pro-
proprioceptive input. motes improvement in ranges of joint motion and increases
–– Cavaletti Poles: Use alternate successive pole heights muscle recruitment. Increases in muscle contractions
or configurations to provide a variable proprioceptive alone can therefore provide an osteogenic stimulus and
input. increased bone mineral density [85]. The buoyancy effects
–– Proprioceptive Balance Pads: Introduce weight-shifting of aquatic therapy can produce both kinetic and kinematic
exercises and later core strengthening exercises in con- effects that are applicable to management of fractures in
junction with balance pad training. horses.
increase muscle strength [91] and to restore functional

movement patterns [90]. Specifically, conditions that result
in periarticular fibrosis or contracture, reduced mobility,
increased synovial fluid or adaptive shortening of soft tis-
sues, such as those observed following immobilization of
the distal limb [92], may respond positively to a programme
of stretching exercises [93, 94]. Evidence to support the use
of injury specific exercises following immobilization in
horses is lacking. Studies have been reported in other spe-
cies supporting the use of stretching following periods of
immobilization [95–97]. There are also clinical reports of
benefit following fracture repair and other orthopaedic
injuries in man. [98, 99]. Improvements in range of motion,
proprioception, supporting muscle development, tendon
healing and extensibility and pain reduction have been
demonstrated following targeted rehabilitative exercises,
including PROM in equine, canine, murine and human
studies unrelated to fracture healing [68, 88, 89, 100–104].
Figure 15.8 Use of an in ground underwater treadmill. Stretching exercises to lengthen shortened muscles and
to strengthen weak muscles are typically included after
three weeks. Low-velocity passive joint ROM exercises aim
●● Inflammatory Phase: Underwater treadmill not to relieve pain and restore pain-free movement. These
applicable. require application of an external force (including gravity)
●● Reparative Phase: Initiate following radiographic evi- with minimal resistance to motion. A gradual resistance is
dence of stability and healing with surgeon approval. met towards the end of the available ROM of the joint, lim-
Recommended protocol: ited by pain, soft tissue swelling, periarticular tissue fibro-
–– Water Depth: At the level of the point of the shoulder sis or osseous incongruency. Less commonly hypermobility
or higher to provide >50% reduction in axial loading. of a joint may be observed secondary to ligament laxity or
Stand horse on treadmill and bring water to desired stabilizing muscular atrophy [104] and should be accounted
depth before initiating walking. for when prescribing injury specific exercises. Active ROM
–– An initial speed of 0.7–1.2 m/s is suitable for most occurs as a result of voluntary movement produced by
adult horses. muscular contraction without external force applied [5].
–– Duration: 5 minutes per session, increasing by 5 min- Weight-shifting exercises are used to encourage early
utes total per week based on individual horse progres- limb use, induce isometric contraction of stabilizing mus-
sion, up to a maximum of 20–30 minutes. culature, small amplitude changes in joint motion and to
–– Frequency: Three to four times per week. encourage eccentric loading which, in turn, stimulate sup-
●● Remodelling Phase: Recommended protocol: porting muscle development [105]. Low-magnitude forces
–– Water Depth: At the level of the point of the shoulder placed on ligaments and tendons over time, as with PROM
or higher to provide >50% reduction in axial loading. or weight-shifting exercises, produce tissue elongation
Decrease water depth in line with improvements in which may be required in cases with joint contracture or
radiographic healing. adhesion formation [98]. Advancement of these exercises
–– Speed: Can be increased gradually once full duration can be achieved by altering the relative position of the
achieved but not beyond a brisk (medium) walk. loaded limb, lifting the contralateral limb and by combin-
–– Duration: 20–30 minutes per session. ing the exercise with proprioceptive balance pads to
–– Frequency: Up to five times per week. increase the magnitude of the effects.
–– Incline: If available a small gradient can be added. Baseline assessment of the patient will establish which
components of joint function are compromised. Injury-
specific exercises can then be adjusted to compensate for
Targeted Physical Therapy
restrictions secondary to pain, swelling, oedema, contrac-
Injury-specific Exercises ture or fibrosis and articular compromise. Modalities
Physiotherapy exercises have been reported to modulate described elsewhere in the chapter may be used in con-
pain [24, 86], improve proprioception [87, 88], soft tissue junction with exercises to enhance response. Heating tis-
extensibility and range of joint movement [89, 90], to sue prior to stretching reduced the force necessary and
increased the duration of elongation [106, 107]. This is per- with back pain demonstrated measurable asymmetry in the
tinent in the early stages of healing, where forces associ- m. multifidus cross-sectional area (CSA) at the level of osse-
ated with imposed exercise should not exceed the strength ous pathology [109]. In a follow-up study, regular perfor-
of healing tissues. If an increase in lameness is observed, mance of dynamic mobilization exercises was shown to
then the programme should be discontinued, clinical pro- increase m. multifidus CSA from T10 to L5 [99]. Eight clini-
gress assessed and techniques reviewed before restarting cally sound horses performed five repetitions of mobiliza-
gentle exercises. tion exercises five days per week, over a three-month period.
General rehabilitation considerations are: The exercises, which consisted of three cervical flexion
positions, one cervical extension position and three lateral
●● Inflammatory Phase
bending positions to left and right sides, resulted in
–– PROM Exercises: Two to three times per day (under sur-
increased CSA of the thoracolumbar multifidi muscles [99].
geon guidance) with cautious comfortable PROM in the
The results suggest that dynamic mobilization is a promis-
sagittal plane. In cast limbs, conduct PROM of available
ing rehabilitative technique for horses in which this muscle
joints, ensuring support of the cast region during the
has atrophied due to fracture-related pain, atrophy or disuse
exercise. In proximal limb and axial fractures, extreme
due to confinement. The exercises above may be contraindi-
caution is necessary as PROM may create instability.
cated in axial skeleton fractures or in fractures of the fore-
Consider contralateral limb weight-bearing as a comor-
limb during the inflammatory and reparative phases and
bidity when performing.
should be introduced in accord with functional assessment
●● Reparative Phase
and clinical progress. While blanket recommendations
–– PROM Exercises: 30–50 gentle sagittal plane PROM
regarding prescription of these exercises are not advised,
cycles two to three times per day. Target joint(s) of
core-specific exercises offer means through which various
interest and those proximal and distal to the affected
regions of the axial skeleton may be targeted progressively
area. Always move within the comfortable ROM.
during rehabilitation (Figures 15.9 and 15.10).
Increase the amplitude of stretch as directed by patient
tolerance and ability.
–– Weight-shifting Exercises: One set of five repetitions, ●● Inflammatory Phase: Perform one set of five repeti-
held for 5–10 seconds, performed two to three times tions of each core exercise once daily five days per
per day. There should be a 60 second relaxation period week. Core exercises may not be appropriate for axial
between repetitions. Wither pulls target forelimb skeleton and proximal limb fractures. Core exercises
weight shifting and lateral tail pulls target hindlimb can be performed carefully during cast immobilization
weight shifting.
●● Remodelling Phase
–– PROM Exercises: Two to three times per day, perform
50 low-velocity PROM cycles in the primary planes of
motion of the joint(s) as for reparative phase. It may
also be beneficial to use superficial heating prior to
exercise.
–– Weight-shifting Exercises: One set of five repetitions,
held for 10–20 seconds, performed two to three times
per day as above. Progression includes altering the
position of the limb so that load is increased at target
sites (e.g. protract or retract the limb), lifting the con-
tralateral limb to increase degree of loading or com-
bining weight-shifting exercises with proprioceptive
balance pad training.
Core-specific Exercises
Several core strengthening exercises and their role in acti-
vating deep epaxial musculature to improve postural motor
control and alter thoracolumbar kinematics have been
investigated in horses [99]. In response to pain, segmental
Figure 15.9 Baited ventral cervical flexion to the level of carpi,
neural inhibition may result in paraspinal muscle inactiva- resulting in engagement of cervical spine postural muscles, core
tion and atrophy and segmental instability [108]. Horses abdominal musculature and the thoracolumbar spinal region.
Goniometry
Goniometry is an objective method of determining range
of joint motion. It provides an evaluation of the influence
of pain and/or mechanical restriction and is often used to
assess articular responses to physical therapy [110].
Repeatability and reliability have been documented in
human, canine, and feline patients [110–112]. Equine
studies have also demonstrated that if used by the same
investigator goniometry is a promising tool in document-
ing passive flexion of the fetlock, carpus, and hock [113].
Following articular fractures, goniometric measurements
can provide an assessment of the severity of joint compro-
mise and monitor responses to therapy.
Pressure Algometry
Mechanical nociceptive threshold (MNT) assessment has
been investigated in human clinical studies [114].
Figure 15.10 Baited lateral cervical bending to the level of the Normal reference values [115, 116] and use in assessing
hock, resulting in engagement of the cervical and thoracolumbar axial and appendicular musculoskeletal pain in the horse
spine and abdominal musculature. have also been published [116, 117]. Pressure algometry
provides a repeatable, objective quantification of pain
and allows changes in stimulus intensity to be com-
on a non-slip surface with small amplitude movements pared [114]. Human studies demonstrated that MNTs are
to avoid limb overload. not only decreased over the injured region, but that lower
●● Reparative Phase: Perform one set of five repetitions of thresholds are often found over sites remote to the pri-
each core exercise once daily, five days per week. mary source of pain [114]. Similarly, experimentally
Following cast removal, and with surgeon input, exer- induced OA in the equine carpus resulted in lower MNT
cises may gradually progress to increase the ROM values both in the region of the carpus and at sites distal
achieved with due caution to minimize fracture site and proximal to this [117]. MNT testing can be used to
overload. quantify pain associated with the primary injury, to iden-
●● Remodelling Phase: Perform one set of five repetitions tify and localize referred musculoskeletal pain, and may
of each core exercise once daily, five days per week. assess nociceptive changes related to rehabilitative
Further gradual advancement can be made, including therapies.
combining exercises with proprioceptive balance pad
training if sufficient clinical progress allows.
S
ummary
O
utcome Measures In man, it has been demonstrated that when advances in
orthopaedic surgery and rehabilitation are combined
During the rehabilitation process, it is important to obtain patients experience accelerated recoveries and return to
reliable outcome measures in order to objectively monitor functional activities compared to traditional post-operative
treatment. Serial use allows the therapist to determine pro- management practices [118]. Equine surgeons face similar
gress, or lack thereof, and thus to make appropriately timed expectations from their clientele and are now recognizing
adjustments to each patient’s programme. Useful parame- the benefits of incorporating rehabilitation protocols into
ters include passive range of joint motion, mechanical fracture management. Increased understanding of comor-
nociceptive thresholds and limb circumference to assess bidities associated with fractures has also demonstrated
muscle mass and reductions in limb swelling including the potential benefits of effective, safe multimodal recov-
joint effusion. ery protocols.
Reference 325
Notes
1 3 M United Kingdom Plc., 3M Centre, Cain Road, 3 Equicore Concepts, LLC, 503 Mall Court #305, Lansing,
Bracknell RG12 8HT, United Kingdom. MI 48912, United States of America.
2 Assisi Animal Health, 230 Park Avenue, New York, NY
10169, United States of America.
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331
16
Fractures of the Distal Phalanx

D.W. Richardson
School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA, USA
A
natomy F
racture Types
The distal phalanx (P3/coffin bone/pedal bone/third pha- Although there is a continuum of fracture configurations
lanx) is the major skeletal structure within the equine hoof. It involving the distal phalanx, previous literature has evolved
bears enormous loads during locomotion and is also vulner- to a generally accepted classification scheme (Figure 16.1).
able to injury by kicking a fixed object or stepping on irregu- Type 1 fractures involve only the extra-articular portion
lar hard surfaces. It articulates proximally with the middle of a palmar/plantar process (Figure 16.1a).
phalanx and palmarly/plantarly with the navicular (distal Type 2 fractures go through the articular surface in an
sesamoid) bone. Its two major tendon attachments are criti- oblique plane through one palmar/plantar process.
cal to normal gait function. The common/long digital exten- Although current literature suggests that Type 2 fractures
sor tendon inserts in a broad manner dorsally and proximally are simple, more recent CT imaging has demonstrated that
to the extensor process, and the deep digital flexor tendon wedge-shaped comminuted fragments along the proximal
inserts in a fan-like manner to the central solar surface of the dorsal margin are very common, particularly in racehorses
bone. The bone has a central body with medial and lateral (Figure 16.2). CT has also shown that as work-related inju-
palmar/plantar extensions termed wings or processes. The ries in racehorses these fractures have a more consistent
distal phalanx has a less dense appearance than the cortex of obliquity than non-racehorses, particularly those caused
a long bone and does not have a medullary cavity. However, by kicking a fixed object (Figure 16.1b).
despite its more ‘trabecular’ appearance, the distal phalanx is Type 3 fractures are usually described as sagittal, but par-
a strong bone into which screws can be firmly tightened; it is asagittal fractures including the body should be considered
certainly not accurately described as ‘soft cancellous bone’ [1, 2]. to be in this classification because both principles and spe-
Its blood supply is from the palmar/plantar digital vessels cifics of treatment are similar (Figure 16.1c).
that branch to form connecting arcs within the bone. There is Type 4 classification includes a spectrum of fractures
a prominent somewhat centrally positioned vascular channel (Figure 16.1d), but their commonality is separation of part
termed the semilunar canal. Although various authors have or whole of the extensor process.
emphasized the common sense admonition to avoid this Type 5 fractures include a range of complex dorsal, trans-
structure, there are no reports of complications associated verse and comminuted fractures (Figure 16.1e).
with drill bits or screws impinging on it. Type 6 fractures involve the distal (solar) margin only
The inability to directly view the bone’s topography com- (Figure 16.1f).
bined with its complexly curved three-dimensional shape Type 7 are a non-articular fracture of a palmar/plantar
makes internal fixation challenging. The use of pre- process which are specific to young foals. Unlike Type 1,
operative and intra-operative computed tomography (CT) the primary fracture plane is not vertical and they tend to
markedly enhances both accuracy of diagnosis and result in the separation of a fragment along the distal
treatment [3–6]. (solar) margin of the bone (Figure 16.1g).

332 Fractures of the Distal Phalanx
(a) (b)
(c) (d)
(e) (f)
(g)
Figure 16.1 Examples of the seven described types of distal phalangeal fractures. (a) Type 1 non-articular fracture of the palmar/
plantar process (‘wing’). (b) Type 2 articular fracture of the palmar/plantar process (‘wing’). (c) Type 3 mid-sagittal fracture. (d) Type 4
fracture of the extensor process. (e) Type 5 complex/comminuted fracture. (f) Type 6 distal marginal fractures. (g) Type 7 juvenile
non-articular fracture of a palmar/plantar process.
Clinical Features and Presentatio 333
Figure 16.2 Transverse plane CT images of four Type 2 fractures demonstrating wedge-shaped comminution at the proximal dorsal
margin. It does not appear that its presence markedly affects outcome.
It is important to note that CT imaging has demonstrated racehorses (or any horse incurring the fracture at speed)
that the above classification, based on two-dimensional has an approximately 45° oblique plane and enters the
radiographs, is excessively simplistic. Many distal phalan- most abaxial quarter of the articular surface. In contrast,
geal fractures are more complex and have comminution Warmblood and kick-related fractures more often are in a
that may not be recognized on plain radiographs. nearly dorsal plane and enter the joint in a more axial
location (Figure 16.3).
Type 6 fractures (solar margin fragmentation) can be
Incidence and Causation traumatic but are commonly also associated with chronic
laminitis [10].
Distal phalangeal fractures occur in horses of all ages, Type 7 fractures are common and in one survey were
including young foals. Although it is not always possible identified in 19% of foals’ forelimbs [11]. Associations with
to be certain about the inciting cause, Type 2 fractures of foot imbalance have been reported [12] together with
the lateral palmar process in the left front and slightly anecdotal suggestions of association with firm paddock/
less commonly, medial wing of right front are the most ground conditions and fitting lateral extensions to foals
common fracture in racing Standardbreds, presumably with metacarpophalangeal varus.
because they are training/racing anticlockwise on hard
surfaces [7, 8]. All types of fractures are more common in
the forelimb [9, 10]. Hindlimb fractures are often caused Clinical Features and Presentation
by the horse kicking a fixed object or wall. Exercise on
irregular, rocky or frozen ground may also be in the In acute fractures, associated lameness is usually severe
history. and accompanied by sufficient clinical features to allow
The specific configuration of Type 2 fractures appears to localization to the foot from physical signs (increased
be related to aetiology. The stereotypical fracture in arterial pulse amplitude, sensitivity to percussion and/or
(a) (b) (c)
(d) (e) (f)
Figure 16.3 Type 2 fractures associated with exercise in racehorses have a fairly consistent slight dorsal abaxial to palmar/plantar
axial configuration (a–c), whereas those associated with direct trauma such as kicking a fixed object are more likely to have a more
transverse (dorsal or frontal plane) orientation (d–f). CT permits placement of a screw in an optimal position as close as possible to
perpendicular to the fracture plane.
compression). Sometimes this requires or is supported by Imaging and Diagnosis

diagnostic analgesia (palmar/plantar digital nerve block);
uniaxial blocks can also help to localize the problem within The majority of distal phalangeal fractures are identified by
the foot. Response to hoof testers is not consistent, digital radiography. Most can be recognized in either
particularly in an adult horse with a large, hardened hoof. dorsoproximal–palmar/plantarodistal oblique (D65Pr-Pa/
Articular fractures, especially Types 3 and 4, usually have PlDiO) or lateromedial projections. However, a complete set
distension of the distal interphalangeal joint. of images of the foot should include dorsal 45° proximal 45°
Frequently horses do not present acutely. It is quite lateral/medial-palmar/plantarodistal medial/lateral oblique
common (and understandable) to assume a horse with (DV oblique) projections as well as dorsopalmar/plantar (DP),
intense foot pain is most likely to have an abscess. palmar/plantaroproximal-palmar/plantarodistal oblique and
Therefore, many horses are soaked and poulticed for days horizontal oblique projections. If the clinician has a high
(even weeks) before radiographs discover the fracture. index of suspicion, multiple variations of the DV oblique
Non-traumatic Type 6 fractures can have less dramatic projections maybe necessary to identify hairline fractures of
presentations. Marginal fragmentation associated with the palmar/plantar processes or juveniles with palmar/
chronic laminitis is often identified as part of its investigation. plantar process (Type 7) fragmentation. Minimally displaced
Type 7 fractures can be asymptomatic in some foals and or distracted fractures may not be evident unless the X-ray
associated with lameness in others. beam is precisely parallel with the fracture plane. Some acute
Treatment Options and Recommendation 335
fractures also do not become radiographically evident until

there is sufficient mineral resorption in the fracture plane to
permit identification of discontinuity (Chapter 5).
Scintigraphy [8, 13–15] is a sensitive diagnostic tool in
identifying distal phalangeal fractures. Horses with acute
fractures can be expected to have focally increased
radioisotope uptake that is readily recognizable but, as
with nearly all planar imaging, it is important to obtain
multiple views. A medial wing fracture in a forelimb can be
comparatively subtle because of its distance from the
camera on standard lateral and dorsal views. Solar views
should be routine in any horse with a suspicion of a
problem within the hoof.
Three-dimensional imaging optimally defines fracture
configuration. Magnetic resonance imaging (MRI) and CT
are both valuable. CT is unequivocally the optimal
modality [3, 16], but as there are currently more MRI units
than CT machines that do not require general anaesthesia
it is less frequently used diagnostically.
Figure 16.4 Type 1 fracture associated with extensive

Acute Fracture Management mineralization of the lateral collateral cartilage.
Although there is some doubt that hoof ‘immobilization’

and exhibit little or no capacity for healing. Some will
with rim shoes, bar shoes, heavy quarter clips or fibreglass
become asymptomatic with time, but others will require
casting is advantageous in terms of long-term healing [9],
uniaxial neurectomy to return to working soundness.
clinical experience suggests that horses with distal
Additionally, and although not anatomically true Type 1
phalangeal fractures of all types are more comfortable with
fractures, extensively mineralized collateral cartilages
a shoe, especially one that affords additional rigidity. As
(‘sidebone’) can also fracture. However, it is important to
with all acute fractures, it is advisable to administer
recognize that separate centres of mineralization within
analgesics/anti-inflammatory medications until acute,
collateral cartilages are common and do not represent
severe lameness improves.
fractures. It is essential to localize the lameness with
local anaesthesia and useful to confirm focal intense radi-
opharmaceutical uptake with nuclear scintigraphy
reatment Options
T (Figure 16.5). Options for treatment included shockwave
and Recommendations therapy or unilateral palmar (these are usually in fore-
limbs) digital neurectomy.
Type 1 fractures have a good prognosis for return to Type 2 fractures have traditionally been managed with rest
soundness with conservative (non-surgical) treatment. and shoeing. However, as articular fractures, internal fixation
Although the traditional recommendation has been to is now considered the treatment of choice with the proviso
manage such injuries for several months with shoeing, that this can produce safe effective reduction and stability of
there is some evidence that attempts at immobilization are the fracture. Although a few surgeons have attempted internal
neither needed nor beneficial [9]. It also appears that fixation without CT guidance, this is considered imperative
osseous union is not necessary for a good clinical for consistent safe surgery [3–6]. In the author’s opinion, it is
outcome [9]. In horses that fail to become completely impossible to accurately and consistently place a lag screw in
sound or in horses that must return quickly to athletic the palmar/plantar process without 3D imaging.
work, an ipsilateral palmar/plantar digital neurectomy can Type 3 fractures generally do not have good outcomes
be efficacious provided there is acknowledgement of the when treated conservatively, and lag screw fixation is much
risks associated with the surgery per se. simpler than in Type 2 fractures. Although CT guidance is
Occasionally, Type 1 fractures will present in animals optimal, more readily available intra-operative imaging
with substantial collateral cartilage mineralization modalities (fluoroscopy or digital radiography) are often
(Figure 16.4). These are usually in large matures horses adequate to allow accurate screw placement [17, 18].
Figure 16.5 Fracture of a mineralized collateral cartilage visible in slightly oblique LM and DP radiographs with demonstrable
scintigraphic activity.
Although it has been suggested that horses <3 years old are distal phalanx within the hoof capsule appears to be
managed with external support and that surgery is considered enough to allow very young animals to heal well. In one
for horses 3 years old, evidence is lacking. The author large retrospective study, there was no significant difference
questions whether this is justifiable and recommends that in the outcome of ‘young’ versus ‘old’ horses, when three
surgical repair is considered for all suitable fractures except years of age was used as the classification division [9].
in foals. Nonetheless, it is reasonable to assume that the younger
Type 4 fractures [19–23] include three sub-types: the patient, the more likely it is that it will heal without
surgical intervention or therapeutic shoeing.
●● Small fragments that are readily removed
arthroscopically [24].
●● Acute, oblique or transverse fractures typically seen in Type 1 (Non-articular Wing) Fractures
younger horses which may be amenable to repair.
There is no universally accepted technique for managing
●● Chronic large horizontal fractures that appear to be over-
non-articular fractures, and there is some evidence that
represented in Friesian horses [19] which, even if large,
immobilization techniques (foot casts, rigid shoes with clips/
appear best removed [19, 21].
rims and bars) do not improve prognosis [9]. The most
Type 5 fractures include an array of configurations and common and practical therapeutic shoeing has been steel bar
until recently most have been managed with therapeutic shoes with heavy clips [10]. Fully cuffed glue-on shoes with
shoeing [25–28]. However, the development and availability complete foot plates also appear to afford good stability. Full
of CT guidance has, in a number of cases, now made rim shoes can be useful but are technically quite demanding
internal fixation an appropriate option. to fabricate and apply [32]. Fibreglass foot casts are easy to
Type 6 and 7 fractures are generally managed without apply but often loosen and require careful maintenance.
intervention [11–13, 29, 30]. Ipsilateral palmar digital neurectomy has been used
extensively for practical management, but there are no reli-
able published reports involving a series of such cases.
Specific Management Techniques
Type 2 (Articular Wing) Fractures
The following techniques are primarily directed at distal
phalangeal fractures in mature horses. In foals, even major These have been managed by therapeutic shoeing with
fractures (Types 2, 3 and 5) have an excellent prospect of some success [9, 33–35], but results in athletic horses,
healing with no treatment at all [30, 31]. The stability of the especially racehorses, have been inconsistent [34].
Specific Management Technique 337
Non-surgical treatment also has resulted in a high rate of

re-fracture in horses that are not raced in bar shoes [34].
Surgical treatment has been reported, but evaluation of
previously published cases and knowledge derived from
CT-guided repair of Type 2 fractures make it clear that non-
CT-guided lag screw fixation is very unlikely to be accurate.
More data is required, but the author’s current view is that
CT-guided fixation should be considered standard for
surgical repair.
CT-Guided Lag Screw Fixation

CT and surgery are performed in lateral recumbency with
the fractured palmar/plantar process (smaller fragment)
down. The leg is supported at a metacarpal/metatarsal
level with the distal limb free. The palmar/plantar digital
nerves are blocked with bupivacaine. There is no convinc-
ing evidence that overnight preparation of the hoof wall is
beneficial [36], but there is both logic and evidence [37]
that removal of the outer surface of the hoof allows more
complete disinfection. After meticulous physical cleaning
and scrubbing of the entire hoof, grinding off the superfi-
cial layer of horn with a power grinder (36 grit aluminium
oxide) is considered an essential first step. The hoof is then
prepared routinely using a chlorhexidine scrub, rinsed
with a 70% isopropyl alcohol and the surfaces wiped dry
with sterile sponges.
Radiodense markers (small dabs of barium paste or Figure 16.6 Marking the prepared hoof wall with radiodense
adhesive nipple artefact markers. It is essential to mark both the
adhesive nipple markers) are placed on the dorsal and heel entrance site through the dorsal hoof wall and the projected
hoof wall approximating the anticipated drill path, and a ‘exit’/target location near the heel.
CT evaluation is performed (Figure 16.6). The CT scan is
then manipulated using standard multiplanar reconstruc- this is positioned carefully, there is a very low probability of
tion (MPR) software. The MPR images accurately deter- an erroneous drill path. Either fluoroscopic or digital
mine marker locations relating to the entry and target imaging is performed to establish a projection parallel to
points on the hoof capsule. Markers are repositioned, and the fracture plane. This will allow the surgeon to check the
CT is repeated until the markers are perfectly three dimen- correct length of the glide hole.
sionally aligned with the intended drill trajectory A 6 mm drill bit is used through the aiming device to
(Figure 16.7). A shallow (1–2 mm) depression is then made make a hole in the hoof wall. Fluids are not be used at this
with a small (2–3 mm) drill bit exactly under the markers time as the hoof wall material coming from the drill bit
(Figure 16.8). The CT images also determine confidently flutes is more easily removed when dry. The aiming device
the depths of the hoof wall, glide hole and full thickness of is removed temporarily, and an 8.7 mm (11/32 in.) drill bit
the bone along the chosen trajectory (Figure 16.9). This held in a Jacobs Chuck is used to enlarge the hole. This is
also provides a reasonable estimate of screw(s) length(s). carried out cautiously by hand to avoid penetration of the
Using the technique described, it is not possible to use a distal phalanx. The aiming device is then replaced securely
standard depth gauge because the barrel will not reach the into the hoof wall hole and the far (heel) hoof depression
surface of the bone. (Figure 16.10).
At this stage, final aseptic surface preparation is com- Using the aiming device sleeve, a 4.5 mm hole is next
pleted before application of a film-forming solution of drilled through to the fracture plane. The drill bit can be
chlorhexidine gluconate and isopropyl alcohol (ChloraPrep, pre-marked with the required depth determined from the
Becton Dickinson, Franklin Lakes, NJ). Sterile draping of CT images, but this should be checked with radiographs or
the surgical site includes a transparent adhesive drape so fluoroscopy (Figure 16.11). In the majority of cases, the
that the shallow depressions are easily identified. surgeon can feel the glide hole bit entering the fracture
The aiming device (Figure 16.10) is positioned using the plane. Once assured, the aiming device is removed. The
dorsal hoof wall mark and the ‘exit’ mark near the heel. If 3.2 mm centring insert is inserted, and the thread hole is
(a) drilled carefully just through the far fragment to avoid

unnecessary injury to the hoof lamellae and definitely to
avoid penetration of the far hoof wall. Once the drill is
positioned in the sleeve, its shaft can be marked at the
required depth but this is best assured with radiographic
imaging (Figure 16.12a).
If using a non-self-tapping screw, the thread hole is
tapped routinely. The tapping procedure should also be
imaged to ensure that the entire length of the thread hole
39 mm 30 mm
(b)
Figure 16.7 Use of multiplanar reconstruction tools to

determine that markers exactly identify the correct trajectory for
the screw. Markers need to be moved and the hoof re-scanned Figure 16.9 Unlike plain radiography, CT provides accurate
until they are precisely positioned. It is important to look in both measurement of the intended screw path.
transverse (a) and oblique/sagittal (b) slices.
(b)
(a)
(c)
Figure 16.8 Once the markers are accurately positioned, a shallow (1–2 mm) depression (a) is made in the hoof wall in dorsal (b) and
palmar/plantar (c) locations. It should be large enough to be easily identified after aseptic preparation of the hoof and application of
an adhesive drape.
has been prepared, i.e. the tap should be seen to extend to

the end of the 3.2 mm hole (Figure 16.12b).
A 2 mm pin is placed in the hole to accurately guide a
cannulated 8 mm countersink tool (Femoral stepped
router no. 7207177, Smith & Nephew, Inc., Memphis,
TN). The standard countersink will not fit through the
hoof wall hole. Countersinking in this location aims to
fully recess the screw head, i.e. make it level with or just
below the surface of the bone (Figure 16.13). This has the
major advantage of allowing bone to grow over the screw
head, which permits restoration of lamellar continuity
and reduces the risk of implant infection if the horse
develops a subsequent hoof wall infection. Needless to
say, it also makes it quite difficult to remove the screw at
Figure 16.10 An aiming device is fitted with the pointed tip in any future time.
the palmar/plantar depression and the drill sleeve at the
dorsally marked location. In the photograph, the aiming device A screw of selected length is inserted and fully tightened.
drill sleeve with a 4.5 mm insert has been located into the hoof Because of the countersinking, tightening should be done
wall hole. repeatedly as there may be some collapse/compression of
(a) (b)
(c)
Figure 16.11 (a and b) Fluoroscopic image intensification used to ensure that the glide hole is made exactly to the fracture plane.
(c) It is possible but not necessary to use intra-operative CT to be certain of drill trajectory and glide hole length.
(a) (b)
(c)
Figure 16.12 Fluoroscopy used (a) to ensure that the (3.2 mm) thread hole is made to just penetrate the far fragment and (b) to
determine that the tap has cut threads through the entire fragment. (c) CT demonstrates appropriate glide and thread holes.
the bone under the screw head. The distal phalangeal bone covered by a rectangular (~4 × 8 cm) patch of biaxial
is dense, and a 4.5 mm screw can be firmly tightened. It can polyester fibre sleeve (A&P Technology, Inc. Cincinnati,
be difficult to be sure of the correct screw length because OH) applied with the adhesive hoof acrylic. If this is dyed, it
the countersinking is difficult to measure and often a screw can be more easily differentiated at future shoeing cycles.
shorter than previously calculated may be necessary. It is Finally, a fully cuffed glue-on shoe (Sigafoos Series I,
important that the screw does not exit the far side of the Soundhorse Technologies, Unionville, PA) is fitted with
bone (palmar/plantar process). This can result in impression material (Equinox 65, Smooth-On, Macungie,
recalcitrant infection if the horse develops a hoof abscess PA) and a removable 1/8 in. thickness aluminium hospital
near the exposed screw tip. In larger and/or more displaced plate (Figure 16.15).
fractures, two 4.5 mm screws afford better rotational The author usually performs regional limb perfusion
stability and appear to be advantageous. Intra-operative CT with amikacin while the shoe is being applied and then
confirms accurate screw placement and assesses fracture repeats this once daily for two more days. Systemic
reduction (Figure 16.14). antimicrobials (intravenous penicillin and gentamicin) are
A pneumatic tourniquet is inflated maximally to keep the given at the beginning of surgery and continued for
hoof defect as dry as possible and this is packed with sterile 24 hours.
collagen sponge (Ultrafoam, Davol Inc. Warwick, RI)
containing a small volume (0.5–1 mL) of amikacin. The Post-operative Care and Convalescence
collagen should fill just to the bottom of the hoof wall defect Following internal fixation, horses are generally limited to
so that the next layer of acrylic does not protrude into the stall rest with hand walking exercise only for three months.
soft tissue space. The remaining defect is filled with freshly Shoes are changed, and follow-up radiographs are taken at
prepared commercial adhesive hoof acrylic, e.g. 403/19 approximately six week intervals (Figure 16.16). The
adhesive (Lord Chemical, Philadelphia, PA). This is then hospital plate is usually removed at the second shoe
(a) extremity of the fracture such that good reduction of the

juxta-articular bone is not matched distally. Infection is
the principal surgical complication [3]. Screws remain
in situ unless positively associated with persistent
clinical compromise.
Type 3 (Mid-sagittal) Fractures

Unlike fractures involving the extremities, simple sagittal
fractures can be repaired reasonably accurately with less
sophisticated imaging. The ‘target’ for the screw is still
small but can be located with fluoroscopy or digital
radiography. Most authors agree that internal fixation with
(b) lag screw(s) is the optimal technique although some details
are still debated.
Screw Size
The majority of reported fixations have involved 4.5 mm
cortical screws placed in lag fashion. There are no reports
describing failure due to screw breakage or failure of the
fixation due to screw loosening, fracture displacement, etc.
Nonetheless, some authors have postulated that 5.5 mm
screws should be used because they, not unpredictably,
provide greater bending strength. In a cadaver study, larger
screws resulted in greater visible fracture reduction but the
study did not control the torque used to tighten the two
different sized screws [38]. A potential disadvantage of the
5.5 mm screw is that there is less difference between glide
hole and screw head diameters because both 4.5 and
5.5 mm screw heads are the same (8 mm). The consequence
is that the surface area of the screw head providing
Figure 16.13 An 8 mm cannulated countersinking tool placed compression as the screw is tightened is much smaller and
over a 2 mm smooth pin is used to recess the screw head in the can collapse resulting in the screw head ‘sinking’ into the
dorsal surface of the bone. glide hole and losing compression. This may also be
exacerbated by the aggressive countersinking performed at
change. Care is taken to preserve the innermost polyester/ this site to minimize impingement of the screw head on
acrylic patch covering the hoof defect until the site grows the lamellae.
down to the ground surface where it can be trimmed as
needed. Owners are advised to avoid horses immersing Screw Position
the operated foot in water until the access hole has fully Nearly all published cases have a single transverse lag
grown out. screw placed in a ‘central’ position midway between the
If radiographic healing is good four to six months after dorsal and palmar margins and just proximal to the semilu-
surgery, racehorses are often put back into gradually nar vascular canal. In an ex vivo model, it has been shown
increasing work on soft, level surfaces (sand tracks for that a more palmar position will allow a longer thread hole
Standardbreds). Sport horses can be put back to light and therefore a slightly stronger fixation [39]. The disad-
work under tack on good surfaces. Complete radiographic vantages of the more palmar position are a slightly greater
healing can take much longer than four to six months, chance of entering the semilunar canal and because of its
so expectations for a time frame to return to full work eccentric location possibly less symmetrical compression
should be flexible. Fracture healing nearly always occurs of the articular surface. There is no evidence in clinical
last at the distal margin. The author suspects that there cases that minor differences in screw position or damage to
is some degree of plastic deformation near the distal the vascular channel influence outcome.
(a) (b)
(c) (d)
Figure 16.14 CT images obtained before (a and c) and on completion (b and d) of repair of a Type 2 fracture using a double screw
technique. It is common for fracture compression to be more complete directly under the tightened screw(s).
Screw Number Lag Screw Fixation Technique

Almost all published repairs have utilized a single screw. The CT-guided technique for Type 2 fractures described
There should be greater stability and compression with above is readily adapted for simple sagittal fractures, but if
two screws [3], but the equally obvious disadvantages are unavailable the use of fluoroscopy or plain radiography is
to have more metal in the hoof capsule and thus greater fairly straightforward. The principal advantage of CT is
risk of infection and the technical challenges of accurately that it allows accurate measurements particularly of screw
placing two screws. The latter is mitigated with more length.
extensive intra-operative 3D imaging. The shape of the The estimated sites of drill entry and contralateral target
distal phalanx also suggests that lag screw fixation of point are determined from pre-operative, principally
mid-sagittal fractures may be less stable than Type 2 lateromedial, radiographs and marked on the hoof capsule
fractures because the latter have a longer thread length. with small shallow drill indentations. If available, these
The risk:value ratio of a second screw has not yet been can also be determined and appropriate bone depths
established in enough clinical cases to make measured using standing CT [4]. The hoof wall is prepared
recommendations. as described for Type 2 fractures. An aiming device is still
(a) (b) (c)
(d) (e) (f)
Figure 16.15 End of surgery foot care. (a) A pneumatic tourniquet minimizes bleeding at the circular hoof defect. (b) Insertion of
antimicrobial impregnated collagen sponge into the hoof wall hole filling the space between the screw head and the inside of the
hoof wall. (c) The hoof wall defect is filled with freshly prepared adhesive acrylic. (d) After the acrylic dries, it is ground down in
preparation for a permanent polyester fabric patch. (e) The patch is applied with adhesive hoof acrylic and wrapped in plastic to cure
while a regional limb perfusion is started. (f) A standard fully cuffed glue-on shoe with a sole plate is applied over the patch for
additional stability/protection.
highly desirable. Two sterile stainless-steel washers centred possible to slightly manipulate the reduction using the
on the indentations are attached to medial and lateral sides insert sleeve as a handle and then apply large pointed
of the foot with sterile adhesive strips, and radiographs reduction forceps.
taken until the washers are radiographically concentric If CT is not available, it can be difficult to select the
with their centres in the correct position for the screw correct screw length. On that note, surgeons should
(Figure 16.17). The aiming device is applied using the remember that marketed screw lengths include the head.
washer positions as entry and ‘exit’ sites. If an aiming Because the length of the thread hole is limited, the longest
device is not available, an 8 mm hole is drilled through the possible screw is desirable for maximum strength, but
hoof wall at the centre of the near washer and it is removed. without CT it can be difficult to determine if the tip of the
Thereafter, direct visual and radiographic guidance is used screw is protruding into the lamellae. The standard depth
to drill towards the centre of the washer on the far side of gauge will not work directly, and an estimate is made by
the hoof. measuring the depth of the drilled hole and subtracting
Standard lag screw technique follows. Imaging is the wall thickness. After the screw is tightened, numerous
necessary to check that the glide hole is exactly to the oblique projections can be taken to help determine if the
fracture plane. Every thread in the far fragment is important screw is protruding but it can be difficult to be certain
because the bone dimensions are small and the length of without CT. Fracture compression and reduction can be
the thread hole is short. verified arthroscopically.
After the glide hole is made and the insert sleeve is Managing the hoof defect(s), shoeing, regional
positioned, the dorsal aspect of the distal interphalangeal perfusion with antimicrobials, post-operative care, conva-
joint can be evaluated arthroscopically. Although most lescence and complications are as described for Type 2
Type 3 fractures are not markedly misaligned, it is fractures.
(a) (b)
(c) (d)
Figure 16.16 DV oblique and horizontal oblique radiographs are taken at six to eight week intervals when shoes are changed. As
demonstrated in this double screw repair ‘filling’ of the fracture plane usually occurs more slowly distally.
(a) (b)
(c) (d)
(e)
Figure 16.17 Repair of a Type 3 fracture using intra-operative fluoroscopy and radiography (a–c). Fluoroscopic images with steel
washers applied to the lateral and medial hoof walls (a, b) that are adjusted until the washers are in the correct location for the screw
and perfectly aligned (c). Careful measurements throughout surgery are essential because it is not possible to be confident of screw
length from radiographs (d, e).
Type 4 (Extensor Process) Fractures Conventional dorsolateral and dorsomedial arthroscope

and instrument portals are made, and an arthroscopic
All fractures of the extensor process are classified as Type 4
scalpel used to dissect the visible extensor tendon from the
(Figure 16.18). Small chip fractures are generally
fragment. Once dissection is as complete as it can be, a
straightforward cases for arthroscopic removal. Techniques
6–8 mm osteotome is arthroscopically directed at and
have been described in a specialist text to which readers are
seated on the fractured extensor process and a mallet used
referred [24].
to split the fragment in two or three pieces. These are then
The majority of large Type 4 fractures are chronic and
further dissected with a combination of sharp instruments
removal is recommended. The only suitable candidates for
and a motorized arthroscopic resector until each is defined
internal fixation are acute injuries. Most acutely diagnosed
well enough to grasp and remove through the normal
extensor process fractures are seen in younger animals, so
instrument portal.
internal fixation with one or two lag screws provides a good
prospect of healing with a reasonably normal looking foot
Repair
(Figures 16.19 and 16.20).
Internal fixation should probably be considered only in
acute injuries. The mechanical load on the screw(s) is not
Fragment Removal overwhelming, so smaller screws can be used and the head
Both arthrotomy and arthroscopy have been successfully of the 3.5 mm screw can effectively be countersunk into the
used for removal of large fragments, but more recent extensor process minimalizing protuberance. The smaller
results and the author’s experience suggest that the screw is also less likely to split the fragment. The positioning
advantages with arthroscopic removal are substantial. This of the drill is easy to monitor with intra-operative
is a difficult area to effectively close the joint capsule and radiography/fluoroscopy (Figure 16.19b). In large
skin, and motion can lead to wound dehiscence. Proximity fragments, two 3.5 mm screws increase rotational stability
to the ground also increases the potential for post-operative (Figure 16.20). The incision for the drill and screw insertion
contamination of the surgical site. With an arthroscopic necessarily involves the coronary band, so meticulous
approach, the principal challenge is that the fragment closure and post-operative bandaging and cleanliness are
cannot be removed intact through a standard-sized portal. critical.
(a) (b) (c)
(d) (e) (f)
Figure 16.18 Variations of Type 4 fractures. Small fragments (a–c) are readily removed by standard arthroscopic techniques. Large
chronic fragments (d) should be removed, but more acute large fragments (e, f) may be candidates for internal fixation.
(a) (b)
(c) (d)
Figure 16.19 Repair of an acute minimally displaced fracture of the extensor process with a single 3.5 mm screw.
(a) (b)
Figure 16.20 Repair of a large acute displaced fracture of the extensor process using two 3.5 mm screws.
Type 5 (Complex and Transverse) Fractures Type 6 (Solar Margin) Fractures

Nearly all cases in the literature and the majority treated by Most solar margin fractures are treated with rest or
the author have been managed non-surgically, i.e. with diminished exercise intensity and protective shoeing.
stabilizing shoes. It appears that the prognosis depends, as Fragments can either heal or be resorbed. With the latter, a
expected, on factors such as age, displacement and, perhaps radiographically identifiable defect in the bone contour fre-
most important, whether or not laminitis is a complication. quently remains evident. Most horses can return to work as
Many Type 5 fractures are not articular, so distal soon as they become clinically sound. Some fragments,
interphalangeal osteoarthritis is less often a reason for particularly dorsally, can displace dorsoproximally pre-
failure. venting normal proximal to distal tubular horn growth/
With current three-dimensional imaging, accurately migration.
directed lag screw fixation is possible by adapting the When associated with penetrating wounds, some
techniques described for Type 2 fractures [3], but as yet too traumatic fragments can sequestrate. Small fragments can
few have been done to know if outcomes are superior. autolyse or be ejected through draining tracts. Larger
sequestra require surgical removal to resolve persistent dis- cases in the peer-reviewed literature. Two papers reported a
charge, allow healing of the hoof capsule defect and resolve ‘guarded’ prognoses with non-surgical treatment in
lameness. Standardbred racehorses [34, 40]. Re-fracture or dehiscence
of an incompletely healed fracture and consequent osteoar-
thritis were problems in athletic horses. Better results were
Type 7 Fractures
reported in a different population with close to 70% appar-
Lame foals are usually restricted to small area turnout, ently returning to useful soundness [9]. Unpublished results
preferably on a soft/yielding surface until sound of CT-guided screw fixation of 51 Type 2 fractures recorded
(Chapter 37). Whenever possible, absolute restriction (box >85% returning to athletic soundness [41].
rest) should be avoided to minimize its negative impact on Type 3 fractures have fewer cases reported, but the con-
the animal’s osteochondral development. sensus is that internal fixation with screws affords a good
prognosis [9, 17]. A reasonable estimate is that at least 75%
of horses with correct internal fixation will return to ath-
Results letic soundness.
Type 4 fractures vary in size and chronicity, so it is not sur-
As a general statement and irrespective of type, the prog- prising that results of treatment are also variable [9, 19–21,
nosis for P3 fractures is better in hindlimbs than forelimbs 23]. Small fragments have an excellent prognosis, but the very
and fractures in very young animals will heal more readily large fragments commonly seen in Friesian horses appear to
than older horses. In common with most orthopaedic con- have a 60–80% chance to return to soundness. Internal fixa-
ditions, the literature can be difficult to interpret because tion is only indicated in acute injuries, and inadequate num-
of variations in definitions of a successful outcome which bers have been documented to determine prognosis.
is further exacerbated by horses having very different uses, Type 5 fractures are sufficiently uncommon that mean-
e.g. racing versus trail riding or ranch horse versus dres- ingful outcome data is not available. Individual case
sage horse, etc. reports, anecdotal reports and the author’s experience sug-
Type 1 fractures are consistently reported to have a good gest that non-articular fractures that are carefully shod and
prognosis with most references claiming successful out- given adequate rest have at least a 50–60% chance of return
comes to be at least 90%. It is difficult to be certain about to work.
the convalescent time required, but reports with larger Type 6 fractures are also are not well represented in the
numbers indicate that most are able to go back to work in literature, but the information available indicates a favour-
four to five months. able prognosis with shoeing and rest.
The prognosis for Type 2 fractures appears to be variable, Type 7 fractures are generally considered trivial in terms of
and there are still only small numbers of internal fixation their consequences for long-term athleticism [11, 12, 42, 43].
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351
17
Fractures of the Navicular Bone

M.R.W. Smith
A
natomy Trabeculae of the central spongiosa are oriented predomi-
nantly dorsal to palmar/plantar with marrow occupying
The navicular or distal sesamoid bone is small and shuttle the interstices. There is no distinct medullary cavity. The
shaped, with a transverse long axis, located between the blood supply to the navicular bone arises from branches of
deep digital flexor tendon and the palmar/plantar aspect of the palmar/plantar digital arteries, entering the bone prox-
the middle phalanx. The bone is central within the hoof imally, distally, medially and laterally [3].
capsule, just distal to the coronary band with the cartilages
of the foot abaxial to its medial and lateral margins. The
proximal surface is wider, grooved centrally, and becomes
Fracture Incidence and Aetiology
narrower and rounded medially and laterally. The dorsal
and distal surfaces form part of the distal interphalangeal
Parasagittal Fractures
joint and articulate with the middle and distal phalanges.
respectively. The distal border has numerous synovial The most common configuration is a complete, minimally
invaginations into the bone from the distal interphalangeal displaced parasagittal fracture. They are an infrequent
joint [1] and a prominent palmar/plantar ridge. The dorsal injury and usually unilateral. Bilateral fractures have been
articular surface has a central eminence and is flanked by reported [4] but may represent partitioned navicular bones
concave areas medially and laterally [2]. The plantar or (“Bipartite and Tripartite Bones” section). Forelimbs are
flexor surface is covered in fibrocartilage and resides within more commonly affected than hindlimbs [4–6]. Fractures
the navicular bursa, with the deep digital flexor tendon usually occur lateral or medial to midline and can be verti-
running over it. It has a prominent sagittal ridge that cor- cal or oblique, with a more proximal abaxial to distal axial
responds with a similar groove in the dorsal surface of the orientation (Figure 17.1). They have been reported to occur
tendon. The medial and lateral borders of the bone slope more commonly laterally and to be away from the centre of
towards a narrower distal border. The bone is suspended the bone because this region is thicker [5]. Comminuted
proximally by the collateral sesamoidean (suspensory) liga- fractures are less common [4].
ments, which originate medially and laterally from the dis- Fractures are a result of single event (monotonic) trauma,
tal end of the proximal phalanx. Distally, the bone is which may occur during exercise, following a slip or fall, or
anchored to the flexor surface of the distal phalanx by the by kicking out and hitting a wall [5, 6]. The mechanism of
inelastic distal sesamoidean impar ligament. Throughout fracture remains undefined and open to speculation. One
the range of motion of the distal interphalangeal joint, the author suggested fractures may occur as a result of incoor-
navicular bone moves with the distal phalanx, across the dinate movement of structures relative to each other,
articular surface of the middle phalanx. Medially and later- involving simultaneous torsion and extension of the distal
ally chondrosesamoidean ligaments connect to the carti- interphalangeal joint [7]. Another hypothesized that sud-
lages of the foot. In common with other sesamoid bones, den force applied to the bone in a palmar/plantar direction
there is no periosteal covering. The bone has an outer shell (e.g. by the middle phalanx pushing back into the distal
of dense compact bone, comprising relatively thick pal- interphalangeal joint), opposed by traction on the abaxial
mar/plantar and thinner dorsal subchondral plates. extremities of the bone through the collateral sesamoidean

352 Fractures of the Navicular Bone
appears most common in hindlimbs (I. M. Wright, per-

sonal communication).
Frontal Plane Fractures

Fracture in a frontal plane has been reported, but is rare
and information regarding clinical features and aetiology is
lacking [9].
Fractures of the Sloping Border

Fractures of the sloping border (wings) are uncommon
Figure 17.1 Dorsal 55° proximal-palmarodistal oblique injuries. The first report detailed fragmentation in associa-
radiograph of a complete, minimally displaced oblique fracture
of the navicular bone. Arrows delineate the fracture line. tion with rupture of the distal sesamoidean impar ligament
resultant from trauma [10]. Fractures may occur as impact
injuries (e.g. following kicking a wall) and may be associ-
ligaments, results in fracture [5]. Fracture secondary to ated with concurrent fracture or fragmentation of the distal
navicular bone degeneration and demineralization has phalanx (I. M. Wright, personal communication)
been cited [8], but evidence for this is limited. (Figure 17.3).
Transverse Fractures Distal Border Fragments

Rarely, fractures in the transverse plane are seen. These are Fragmentation of the distal and sloping borders of the
usually markedly unstable with proximodistal displace- navicular bone are seen with low frequency in horses free
ment although occasionally, presumably as a result of from lameness, but there is a higher frequency in horses
some restraining ligament integrity, there is less displace- with foot lameness and those diagnosed with navicular dis-
ment (Figure 17.2). A similar mechanism of fracture has ease. Reported incidence varies between studies, but has
been proposed to that described for parasagittal fractures, been reported to be 3.6–5.6% in horses free from lameness,
but with restraint by the distal sesamoidean impar liga- 13.6% in horses with foot lameness, and 29–45% in horses
ment resulting in transverse fracture. This fracture config- with navicular disease [11–15]. Fragments occur at the
uration has also been seen to occur during exercise and prominent palmar ridge of the bone [14] and involve or are
(a) (b)
Figure 17.2 Lateral radiographs of transverse plane fractures of hindlimb navicular bones. (a) Marked displacement of the proximal
fragment due to loss of distal sesamoidean impar ligament attachment. (b) Minimal displacement.
Parasagittal Fracture 353
(a) (b)
Figure 17.3 (a) Dorsal 55° proximal-palmarodistal oblique radiograph of a fragmented lateral wing of the navicular bone. Note
concurrent fragmentation of the plantar articular margin of the distal phalanx (arrows). (b) Corresponding arthroscopic image of the
lateral aspect of the navicular bone (N) viewed from the distal interphalangeal joint. P2: lateral condyle of the middle phalanx;
SL: disrupted suspensory ligament of the navicular bone adjacent to the fracture.
immediately adjacent to the distal sesamoidean impar liga- suggested congenital partitioning of the bone as most
ment. They may represent avulsion fractures, dystrophic likely with additional reasons given including minimal
mineralization, separate centres of ossification, synovial periarticular remodelling of the distal interphalangeal
osteomas, or fracture of an enthesophyte [15–17]. joint, and histopathologic features suggested to be incon-
Fragments vary in size and are usually ellipsoidal in shape, sistent with fracture. Histopathologic examination of two
with a corresponding defect in the opposing surface of the partitioned navicular bones identified a continuous
navicular bone. They may be located medially or laterally smooth lining of cartilage deviating into the bone at the
and are frequently bilateral [13–16, 18]. partition site [20]. However, there were fibrocartilage
within the partition site, cystic changes within the adja-
cent bone and adhesions between the partition site and
Bipartite and Tripartite Bones
deep digital flexor tendon which are consistent with frac-
Partitioned navicular bone(s) is an uncommon condition, ture and fibrous union.
which can result in bipartite or tripartite bones. The condi-
tion may be bilateral [19, 20], and the author has seen one
case with quadrilateral affliction. Bipartite (Figure 17.4a)
or tripartite (Figure 17.4b–f) navicular bones are difficult
Parasagittal Fractures
to differentiate from fractures, and their aetiology remains
Presentation and Diagnosis
a point of debate. Radiologically, bi-and tripartite navicu-
lar bones may demonstrate lucent zones either side of the Horses typically present severely lame in the acute phase
partition, rounding of the proximal margins of the frag- but improve with rest. Clinical features include increased
ments, and a wider lucent line between the pieces than digital pulse amplitudes, distension of the distal inter-
seen with acute fractures [20–22]. However, these radio- phalangeal joint and in some cases subtle swelling between
logic features would be characteristic of a chronic fracture. the heels. Pain may be elicited with firm digital pressure
The absence of a history of acute, severe lameness is often over the distal aspect of the deep digital flexor tendon and
cited as a differentiator [19, 20], although long-term his- by rotation and flexion of the distal interphalangeal joint.
tory may not always be available, and this would not rule In the acute phase hoof tester, application across the heels
out an undiagnosed juvenile fracture. Similarly, bilateral or frog may be resented.
affliction is considered supportive of partitioned navicular Perineural analgesia of the palmar/plantar digital nerves
bones, but juvenile fractures of the proximal sesamoid usually substantially improves lameness. Diagnosis is con-
bones are also frequently bilaterally or even quadrilateral firmed radiographically. Fractures are most readily appar-
and can present in the absence of previously noted lame- ent on dorsal 55° proximal-palmarodistal oblique
ness (Chapters 20 and 37). A recent review of three cases projections. Further information on fracture configuration
(a) (b)
(c) (d)
(f)
(e)
Figure 17.4 (a–f) Radiographs of all four feet of a horse with quadrilateral partitioned navicular bones. Note the typical rounded
appearance of the proximal margins of the fragments either side of the partition, radiolucent zones within the bone adjacent to the
partition and wide line representing the partition site.
(a) (b)
Figure 17.5 Further radiographs of the complete, minimally displaced oblique fracture depicted in Figure 17.1. (a) Palmar 45°
proximal-palmarodistal oblique projection. (b) Standing dorsopalmar projection. Arrows delineate the fracture line.
(e.g. displacement and comminution) may be obtained cases, there may be radiolucent zones with surrounding
from skyline (palmar 45° proximal-palmarodistal oblique) areas of increased opacity either side of the fracture gap,
and standing dosopalmar projections (Figure 17.5). consistent with fibrous union [6]. In such cases, lameness
Widening of the fracture gap occurs with resorption dur- is less marked, and radiographs of the contralateral foot
ing the initial weeks following injury. In long-standing should be obtained, to differentiate from partitioned
(a) (b)
Figure 17.6 Transverse CT images of the horse depicted in Figure 17.3 which kicked out at a wall resulting in fragmentation of the
lateral wing of the navicular bone (a) and the plantar aspect of the articular margin of the distal phalanx (arrows) (b).
navicular bones. Evidence of reactive or degenerative tendon. The bone is also bathed on either side in synovial
changes in the distal interphalangeal joint may be fluid, which may inhibit fracture healing. The sole blood
observed in horses with long-standing fractures. supply to the central portion of the bone is from the distal
Three-dimensional (3D) imaging such as computed artery [3]. There is a lack of progenitor cells, absence of a
tomography (CT) and magnetic resonance imaging may periosteum and poorly formed endosteum that may also
provide additional information regarding the fracture and contribute to poor fracture healing [6].
other associated injuries. Fractures that occur following In limited numbers of cases, improved results were
kicking out at a wall may also have concurrent fragmenta- obtained through elevation of the heels during convales-
tion of the distal phalanx, which can be difficult to identify cence. In one report, three cases were manged successfully
and characterize radiographically (Figure 17.6). Concurrent by heel elevation in combination with bar shoes, a leather
injury to the deep digital flexor tendon may occur with pad and packing [23]. Horses were confined to stable rest
acute fractures, and in long-standing cases there may be for two months, followed by a gradual increase in exercise.
adhesions between the fracture and tendon [23], which can More modest results from treatment with rest and heel
be identified with both modalities. elevation with a bar shoe were reported in a later series.
Two of four horses were able to resume work after
12 months [6]. A variation of this technique was reported
Conservative Management
in a further four successfully managed cases, which even-
Healing with conservative management is restricted to tually returned to work. Four 3° heel wedges were initially
fibrous (mal)union, and it is generally accepted that this is applied to elevate the heels to 12°, with the aim of prevent-
associated with a poor return to athletic function [4, 6, 23, ing weight-bearing contact between the navicular bone
24]. Occasional modest success with rest alone has been and the middle phalanx, and to reduce tension in the deep
reported, with two of five Standardbred horses in one digital flexor tendon. The shoe was reset every four weeks
report returning to racing, albeit at a lower level of perfor- with one wedge removed each time. Horses were initially
mance [6]. Various contributory factors have been sug- confined to a stable for 60 days and then began a similar
gested [6]. Instability and constant motion at the fracture period of hand walking exercise [25].
site are expected through normal loading forces. The navic-
ular bone is loaded dorsally by contact with the middle
Surgical Repair
phalanx, with restraining forces from attachments to the
collateral sesamoidean and distal sesamoidean impar liga- There are a number of unique difficulties associated with
ments. Additional and varying forces both in stance and repair of fractures within the hoof capsule, necessitating
movement arise from contact with the deep digital flexor complete reliance on intra-operative imaging and specially
developed guides. The navicular bone is completely encapsu- screw length selection. Intra-operative 3D imaging allows
lated within the hoof, there are no external reference points greater control of drilling distance and direction than 2D
and the bone cannot be exposed surgically. The cross-section imaging. Personnel radiation exposure can be reduced, and
of the navicular bone at its smallest point is typically slightly post-operative imaging allows far superior evaluation of
less than 10 × 15 mm in a Thoroughbred horse. However, the implant positioning and fracture reduction. To date, 3D
curvature of the bone leaves a small target window of approx- imaging techniques used include computer-assisted sur-
imately 4 × 12 mm for placement of a 3.5 mm screw, without gery (CAS), peripheral quantitative computed tomography
penetration of the dense compact bone beneath either the (pQCT) and CT [28, 30, 32].
flexor or articular surfaces. The depth of the navicular bone CAS was evaluated in cadaver limbs and compared to
within the hoof magnifies any errors in the positioning of screw insertion using a custom drill guide [30] as described
surface markers, at the level of the bone. The foot is a heavily in the initial description of repair [7]. Accuracy of screw
contaminated site and portals created in the hoof cannot be position was improved with CAS, although the technique
closed, necessitating meticulous pre-operative preparation has not been evaluated in clinical cases.
and post-operative care of the foot. There is very limited CT-guided surgery uses surface markers on the hoof wall
potential to manipulate displaced fracture fragments. Despite to determine the location and trajectory of drilling. Use of
these difficulties, internal fixation using lag fashion repair a pQCT scanner in cadaver limbs and in a clinical case has
still offers the best prospect of a return to athletic sound- been documented [31, 32]. Clinical use of a portable eight-
ness [5, 26–29]. slice CT scanner (CereTom TM, Neurologica) (Figure 17.7)
At around the same time, techniques for surgical repair was subsequently reported [28] and is the current tech-
of sagittal fractures of the navicular bone were developed nique of choice.
independently, using specially developed drill guides and a Single 3.5 mm cortex screws have most commonly been
C-arm fluoroscopy unit [7, 26]. Results of five cases were used, but use of a 4.5 mm screw has been reported [9]. A
reported in 1985 [26] followed in 2001, by 40 cases repaired 3.5 mm cortex screw is generally considered most appropri-
using a similar approach by a different author [5]. A cus- ate due to the small target window for repair. However,
tom drill guide was built around a solid base plate to which screw failure has been reported following repair with a
the ground surface of the foot was clamped. C-arm fluoros- 3.5 mm screw [9], and this complication may be avoided by
copy was considered insufficient to guide repair, and radi- use of a 4.5 mm screw. Comparison between stabilization
ography was used instead. A further series of 12 fractures, using a 3.5 mm and a 4.5 mm cortex screw in an equine dis-
repaired using a modification of the initial technique, was tal sesamoid bone fracture model identified a 28% increased
reported in 2008 [29]. All involved placement of a 3.5 mm mean stiffness with the larger screw [33]. However, place-
AO/ASIF cortex screw across the fracture, avoiding pene- ment of 3.5 and 4.5 mm cortex screws in cadaver limbs,
tration of the flexor or articular surfaces of the bone. guided by pQCT, resulted in satisfactory screw placement
There are limitations related to use of two-dimensional in 7/8 navicular bones using 3.5 mm screws, but only 5/8
(2D) imaging for guiding repair. Perfect lateral radio- using 4.5 mm screws. Unsatisfactory screw placement was
graphic projections are needed but are difficult to obtain
repeatedly. This can be time consuming, necessitating
multiple exposures (with associated radiation risk),
reflected in the duration of surgery reported previously,
typically 1.5–2 hours [5]. Due to the complex three-
dimensional structure of the navicular bone, it is impos-
sible to determine with complete confidence whether the
screw head has adequately engaged the navicular bone, is
accurately positioned and is of appropriate length.
Accurate measurements relating to the depth of the
navicular bone within the hoof and length of the frag-
ments cannot be obtained and reduction cannot be accu-
rately assessed with 2D imaging.
More recently, intra-operative 3D imaging has been used
to aid repair [28, 30–32]. Pre-operative planning is vastly
superior to radiography, enabling accurate pre-operative
measurements (e.g. depth of the bone within the hoof cap- Figure 17.7 A portable eight-slice CT scanner (CereTom TM,
sule, distance to the fracture and width of the bone) and Neurologica) provides practical 3D imaging for guiding repair.
defined as either deformation or penetration of either the chlorhexidine scrub, and once clean, this is rinsed off with
articular or flexor surface of the bone with the screw [31]. industrial methylated spirit. A final prep is then completed
In a further study using CAS to guide 3.5 and 4.5 mm screw by painting the hoof with 10% iodine.
placement across the navicular bone, all screws were able
to be placed without penetration of the articular or flexor Computed Tomographic Imaging
surface of the bone, but the larger head of 4.5 mm screws The previously reported lightweight (438 kg) 32 cm bore CT
resulted in the modification of either the articular rim or scanner [28] is used routinely in the author’s hospital. The
the rim of the flexor surface of the bone in 8/10 limbs [34]. unit is mounted on wheels for portability and lowers onto
Fracture of the cis fragment has also been reported clini- caterpillar tracks enabling horizontal movement over the
cally when undertaking repair with a 4.5 mm cortex target for scanning. Images can be obtained from 1.25 to
screw [9]. 10 mm slice thickness. Imaging software is installed on a
patient side PC terminal, permitting 2D, 3D and multiplanar
Pre-operative Planning (MPR) reconstruction. Images are transferred wirelessly
To reduce time spent under general anaesthesia, pre- from the CT unit to the PC. In the author’s hospital, CT
operative radiography can be employed to guide approxi- scans are acquired with 1.25 mm slice thickness at 120 kV
mate placement of hoof wall markers medially and and 4.0 mA.
laterally, along the proposed screw trajectory. Needles of
different sizes placed into either side of the hoof wall, are a Surgical Technique
convenient way to achieve this (Figure 17.8). Once cor- Following induction of general anaesthesia, the horse is
rectly positioned, a 2 mm drill bit is used to create shallow positioned on the surgical table in lateral recumbency.
marks in the hoof wall. The affected limb should be positioned with the smaller
fracture fragment uppermost, to enable maximal screw-
Surgical Preparation thread engagement in lag fashion repair. The limb is sup-
Prior to surgery, the foot should be trimmed, the sole and ported in a cup at the proximal metacarpus/metatarsus,
frog pared to remove loose and exfoliating horn and the leaving the foot free, for CT scanning and aiming device
periople removed with a rasp. Painting of the hoof wall and application. An Esmarch bandage and tourniquet mini-
solar surface of the foot with 10% iodine 24 hours before mizes haemorrhage during surgery, and if utilized should
surgery is commonly employed, although no greater reduc- be applied prior to the initial CT scan. In previous reports
tion in bacterial load is observed compared to immediate of the technique for surgical repair, the distal interphalan-
pre-operative surgical preparation of the foot [35]. If this geal joint was fixed extension in attempt to stabilize the
step is taken, the coronary band should be protected with navicular bone between the deep digital flexor tendon
petroleum jelly prior to application of iodine. Following and middle phalanx [5, 28]; no problems have been
preparation of the foot, a dressing is placed to prevent soil- observed by the author in cases repaired without under-
ing of the hoof. taking this.
Various techniques for surgical site preparation have Needles of different sizes (e.g. 16G and 19G) are placed
been described. In the author’s hospital, the foot and skin into the marked sites on the medial and lateral aspects of the
up to the fetlock are aseptically prepped, initially with a hoof wall, and CT examination is performed (Figure 17.9).
Three-dimensional MPR reconstruction of images into
transverse, sagittal and dorsal planes permits assessment of
the hoof wall markers as a guide for drill trajectory. Images
are reconstructed along the exact planes of the hoof wall
markers. These are then moved as necessary, and CT is
repeated until the markers correspond exactly with the
intended implant trajectory (Figure 17.10). An alternative
technique involves application of multiple spots of barium
sulphate paste, in a grid fashion, over projected drill entry
and target sites, and selecting the appropriate markers using
3D and MPR reconstructed images [28]. Once the location
for drill entry and target (projected exit) points have been
identified, shallow 3.2 mm drill holes are created into the
Figure 17.8 Lateral radiograph with marker needles placed
medially and laterally in the hoof wall at the projected drill hoof wall medially and laterally at the determined sites. This
entry and target locations. allows recognition of the sites after final aseptic preparation
lar bone, (ii) the fracture and (iii) the far side of the navicular
bone. The length of the fracture fragment and the total length
of the navicular bone should also be measured (Figure 17.11).
Following final aseptic preparation, the horse and CT
scanner are moved through to theatre. The foot is wrapped
with a sterilized adhesive bandage (VetWrap™), and an
extremity drape is applied over the foot and secured at the
level of the fetlock. Windows are created in the foot band-
age to expose the 3.2 mm holes marking the entry drill site
and target (projected exit) point (Figure 17.12). For intra-
operative CT examination, the foot and distal limb are cov-
ered with a sterile plastic bag (Figure 17.13).
Direction of drilling is controlled using an aiming device
(Universal Aiming Device, IMEX) (Figure 17.14). The
device has both 3.5 and 4.5 mm interchangeable drill guides
(Chapter 8). The initial drill hole through the hoof wall and
to the surface of the navicular bone is best made with a
Figure 17.9 Marker needs are placed in the pre-determined 4.5 mm drill bit. Previous recommendations have described
locations in the hoof wall, and CT is performed to assess using a 3.5 mm drill bit, but in the author’s experience the
projected drill entry and target locations. smaller drill bit is susceptible to bending, which can result
in inaccuracies in drill trajectory. The 4.5 mm guide is fitted
of the hoof (and differentiation from the 2 mm marks cre- into the aiming device, which is then fastened tightly to the
ated prior to anaesthesia). hoof wall at the marks depicting the site of drill entry and
MPR images along the proposed drilling trajectory are used exit. A 4.5 mm drill bit is used to drill through the hoof wall
to take planning measurements for surgery. Distances to be and cartilage of the foot. Depth is periodically checked
determined include hoof wall to (i) the surface of the navicu- using a depth gauge against pre-operative CT measurements
(a) (b)
(c)
Figure 17.10 3D multiplanar reconstructed CT images used to assess the location of projected drill entry and target locations
in (a) transverse, (b) dorsal and (c) sagittal planes.
Figure 17.11 3D multiplanar reconstructed CT image at the

site and in the plane of proposed screw placement. Once
satisfactory locations of hoof wall markers have been Figure 17.13 Asepsis is maintained during intra-operative CT
determined, measurements are taken along this axis to guide by placing the foot and distal limb in a sterile, impervious bag.
the procedure.
Figure 17.14 Universal aiming device (IMEX) with a 3.5 mm

drill guide in place.
Figure 17.12 Aiming device attached to the hoof wall through

windows in the sterile foot wrap.
(the depth of the aiming device needs to be taken into

account). Throughout drilling, it is useful to mark the drill
bits with a sterile pen at the approximate distance to be
drilled. Once the surface of the navicular bone is reached,
a radiograph is obtained to confirm drill depth and trajec-
tory. The 3.5 mm drill guide insert is now placed into the
4.5 mm guide in the aiming device, and drilling continued
to the fracture. Once the appropriate depth is reached, a
dorsopalmar radiograph is obtained with the depth gauge
Figure 17.15 Intra-operative radiograph with depth gauge
in place to confirm that the fracture has been reached passed through the aiming device to check that the glide hole
(Figure 17.15). The aiming device is then removed and a has crossed the fracture.
2.5 mm drill sleeve insert is passed through the hoof wall Post-operative Care
and into the glide hole in the navicular bone. The thread Various techniques for dressing the surgical site and provi-
hole is drilled to the pre-determined depth to emerge at the sion of support have been described [5, 26, 29]. In the author’s
far side of the navicular bone. The entry hole in the hoof hospital, at the end of surgery, the hole in the hoof wall is
wall is then enlarged to 8 mm, taking care to ensure that packed with a thin strip of absorbent non-adherent dressing
the drill is in the same plane as projected screw placement. material (Melonin™) soaked in metronidazole. The foot and
A countersink is used to cut through the cartilage of the lower limb are then immobilized in a distal limb cast to the
foot (if necessary) and countersink the surface of the navic- level of the proximal metacarpus/metatarsus (Chapter 13).
ular bone. Following lavage, the thread hole is tapped and Horses are allowed to recover unassisted from general anaes-
a 3.5 mm AO/ASIF cortex screw of pre-determined length thesia. The duration of casting is not critical, but while the
(from CT measurements) is inserted and tightened. A final horse is comfortable, the cast can be maintained and acts as
CT scan is now obtained to assess screw position and frac- an impervious sterile dressing. After cast removal, the hoof
ture reduction (Figure 17.16). wall defect is patched with fibreglass and acrylic (leaving the
surgical packing in place) and a plain shoe is fitted.
(a) (b)
(c)
Figure 17.16 3D multiplanar reconstructed CT images obtained during surgery to assess screw length and position in (a) transverse,
(b) dorsal and (c) sagittal planes.
An alternative regimen has been reported [28]. At the end in the single case with radiographic follow-up from the ini-
of surgery, the defect in the hoof wall is cleansed and lightly tial report [26] but was achieved in only 1/6 [5] and 5/8 [29]
packed with amikacin impregnated collagen foam over the subsequent cases with radiographic follow-up.
screw head to the level of the sensitive lamellae. The hoof Of the first five cases reported, two returned to general
wall defect is then filled with amikacin-impregnated poly- riding activities and two trotters returned to training [26].
methylmethacrylate (PMMA) and allowed to cure. When The largest series, with follow-up information for 40
the PMMA is hard, the edges are sealed with multiple appli- repaired cases, reported 26 sound and in work at the time
cations of cyanoacrylate adhesive and a woven carbon fibre of follow-up. These included all six flat racehorses and two
patch applied. A glue-on shoe with a 1/8″ aluminium sole out of three jump racehorses. Four cases were euthanized
plate is applied, and impression material is injected into the for reasons directly related to surgery and anaesthesia
space between the sole and plate. In the report, the shoe was (infection, myositis, ruptured diaphragm and ruptured
drilled and tapped to accept adjustable wedges. Intravenous cruciate ligament). Four of eight cases reported most
regional limb perfusion with amikacin was performed dur- recently using radiographic guidance for repair became
ing the application of the hoof wall patch and shoe. sound and returned to work, with the remaining four cases
Peri-operative antimicrobials are appropriate. Non- considered pasture sound [29]. All three sports horses that
steroidal anti-inflammatory drugs are given post-operatively underwent CT-guided repair became sound and returned
as determined by levels of comfort. to work [28].
Following surgery, the author advises one month of box
rest, followed by a further eight weeks of box rest with a Complications
graduated programme of walking exercise. Thereafter, if Screw emergence through either the flexor or articular sur-
horses are sound, trotting exercise is introduced, and after face of the bone is a serious complication and reflects the
a further six to eight weeks horses are gradually returned to level of technical difficulty of repair. Accuracy of screw place-
work. Radiographic monitoring during rehabilitation is ment is markedly enhanced by 3D imaging. Nonetheless, the
recommended (Figure 17.17). margins of error are extremely small, and the procedure
should only be contemplated by surgeons with a high degree
Outcome of technical ability and experience in fracture repair.
Generally, favourable outcomes have been reported follow- Inadequate fracture reduction will likely lead to poor
ing surgical repair. Collectively, 37/56 reported cases outcomes. Endoscopic evaluation of the distal interphalan-
returned to work [5, 26, 28, 29]. Osseous union was reported geal joint and navicular bursa provides limited visual
(a) (b)
(c)
Figure 17.17 (a–c) 42 day post-operative radiographs demonstrating an appropriately positioned 3.5 mm screw and early fracture healing.
assessment of the fracture, and attempts to manipulate tralateral to the fragmented side of the bone. Using an ipsi-
fragments for reduction have been unsuccessful to date. lateral instrument portal, the fracture fragments are
Infection has been rarely reported, although the surgical dissected from attachments to the collateral sesamoidean
site (hoof) and inability to close tissues over the screw and chondrosesamoidean ligaments prior to removal.
demand particular pre-operative preparation and post- There are no reported cases in the literature, but of two
operative care. Thoroughbred racehorses that also had concurrent frag-
Small ponies have been cited as problematic. It has been mentation of the plantar articular margin of the distal pha-
suggested that the small size of the navicular bone relative lanx, one returned successfully to racing (I. M. Wright,
to a 3.5 mm screw increases the risk of screw emergence personal communication).
through articular or flexor surfaces and results in greater
disruption of intra-osseous blood supply [5, 26].
Palmar/Plantar Digital Neurectomy
Fragment Removal Persistent lameness following fracture may be managed by

neurectomy of the palmar/plantar digital nerves. Criteria
Fragmentation of the sloping border of the navicular bone for case selection should include a positive response to
is most appropriately treated by arthroscopic removal via local anaesthesia at this level. Neurectomy can be an effec-
the distal interphalangeal joint. Surgery is performed with tive means to improve lameness, and even allow return to
the horse positioned in dorsal recumbency and with the work, but is not without risk of complications. Subluxation
distal limb semi-flexed. An Esmarch bandage and tourni- of the distal interphalangeal joint has been reported fol-
quet minimizes intra-articular haemorrhage during sur- lowing neurectomy, presumably as a result of rupture of
gery. A routine arthroscopic approach is made to the distal the deep digital flexor tendon. Persistent or recurrent
interphalangeal joint, with the arthroscope positioned con- lameness has also been observed [4, 6].
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365
18
Fractures of the Middle Phalanx

Veterinary Medicine and Biomedical Sciences, Texas A&M University, College Station, TX, USA
A
natomy the PIJ insert on the abaxial proximal margin of the middle
phalanx and scutum. The digital flexor tendon sheath is
The middle phalanx is a short, compact bone that develops closely associated with the pa/pl surface of the middle pha-
from three centres of ossification. The distal epiphysis is lanx, and the dorsal margin of the sheath is confluent with
fused with the diaphysis at birth. The proximal epiphysis the soft tissues that attached on the pa/pl eminences and
remains separate until 8–12 months of age [1, 2]. The proxi- scutum of the middle phalanx.
mal articular surface is concave with a slight axial ridge Forces acting on the middle phalanx during weight-
articulating with the distal condyles of the proximal pha- bearing and ambulation are thought to be complex, involv-
lanx to form the proximal interphalangeal joint (PIJ). The ing compression, torsion and tension. Tensile forces
proximal palmar/plantar margin is characterized by prom- predominate on the pa/pl aspect of the bone as a result of
inent eminences. The palmar/plantar (pa/pl) margin of the soft tissue attachments, especially the insertions of the
eminences is smoothly marginated where the fibrocarti- superficial digital flexor tendon and straight distal sesa-
laginous scutum is attached. The scutum provides a gliding moidean ligament on the fibrocartilaginous scutum and
surface for the deep digital flexor tendon (DDFT) and the pa/pl eminences. With disruption of these, either
insertion for the straight distal sesamoidean ligament and through primary soft tissue injury or secondary to pa/pl
branches of the superficial digital flexor tendon. eminence fracture, weight-bearing results in pa/pl luxation
The distal articular surface is formed by two condyles or subluxation of the PIJ (Figure 18.1).
separated by a groove that articulates with the distal pha- Compared to other joints in the distal limb, the PIJ has a
lanx to form the distal interphalangeal joint (DIJ). It also relatively low range of motion. Kinematic analysis of
extends onto the pa/pl surface, where it articulates with the horses at a trot revealed flexion during the initial stance
navicular bone. phase (peak at 34%) followed by extension (maximal at
Numerous soft tissue structures lie adjacent, or attach, to about 65%) of the stance phase [3]. The range of motion
the middle phalanx. In the forelimb, the common digital from peak flexion to extension ranged from 24 to 35 ° with
extensor tendon, and in the hindlimb the long digital net movement in the pa/pl aspect of the joint [3].
extensor tendon, course distally over the dorsal aspect to
their insertion on the extensor process of the distal pha-
lanx. Collateral ligaments of the PIJ originate medially and F
racture Types
laterally from respective fossae on the distal aspect of the
proximal phalanx to insert on collateral tubercles on the Fractures of the middle phalanx occur in a variety of con-
proximal abaxial aspects of the middle phalanx. The medial figurations. Osteochondral fragments affecting the proxi-
and lateral branches of the collateral sesamoidean liga- mal articular margin occur in both the dorsal and pa/pl
ment (suspensory ligament of the navicular bone) course pouches of the PIJ. Fractures of the distal articular surface
obliquely from the dorsal distal abaxial margin of the prox- are also occasionally encountered. Major fractures include
imal phalanx to insert on the proximal abaxial aspect of the simple axial fractures extending from PIJ to DIJ but more
navicular bone. The axial and abaxial pa/pl ligaments of commonly involve the pa/pl eminences. These can be

366 Fractures of the Middle Phalanx
dorsal rim of the middle phalanx, are likely traumatic

with a pathogenesis similar to osteochondral chip frac-
tures in other joints.
Clinical Features and Presentation

When traumatic in origin, horses typically demonstrate
lameness in the affected limb although this may be mild or
intermittent [5, 6]. They may be positive to distal limb flex-
ion. The presence of PIJ distension is inconsistent, but pal-
pable asymmetry with thickening of the pastern region
may be appreciated [7].
Imaging and Diagnosis

Lameness can be localized by regional or intra-articular
anaesthesia. The latter confirms the PIJ as the source of
pain when diagnostic imaging reveals an osteochondral
fragment in the PIJ. Fragments may also be identified on
Figure 18.1 Lateromedial radiograph demonstrating severe
palmar subluxation of the PIJ secondary to disruption of the
ultrasound, computed tomography (CT), or magnetic reso-
palmar soft tissue support. nance imaging (MRI). Fragments in the dorsal compart-
ment of the PIJ can originate from the distal abaxial aspect
uniaxial or biaxial or as a component of more complex, of the proximal phalanx as well as the proximal dorsal rim
comminuted fractures involving the body of the bone and of the middle phalanx in a more axial location (Figure 18.2a).
which also often involve the DIJ. Management of most Occasionally, clinical signs are absent, and fragments are an
major articular fractures includes stabilizing the major incidental finding on survey radiographs.
fragments using an implant construct that also incorpo-
rates arthrodesis of the PIJ because of its propensity to Treatment Options and Recommendations
become degenerate following disruptive injury. The con-
figuration of the implant construct is determined by the When the fragment is an incidental finding or there is no
degree of axial instability of the PIJ, particularly disruption associated lameness, treatment may not be pursued. When
of the pa/pl support. lameness is present, options include conservative manage-
ment with systemic and intra-articular anti-inflammatories,
surgical removal or primary PIJ arthrodesis if osteoarthri-
steochondral Chip Fractures
O tis (OA) is present.
of the Proximal Articular Surface Clinicians should be cognizant that even when not
lame at the time of examination, the presence of an osteo-
Incidence and Causation chondral fragment in the PIJ may result in the develop-
ment or progression of OA. Surgical removal therefore
Osteochondral chip fractures of the proximal margin of likely provides the best prognosis for long-term soundness.
the middle phalanx are infrequently reported, but have However, if OA exists at the time of diagnosis, the owner
been documented at the pa/pl eminences and dorsally [4– should be made aware that it may progress despite
8]. Pa/pl fractures appear to be primarily avulsion injuries fragment removal [7]. In these cases, PIJ arthrodesis may
and likely occur secondary to hyperextension of the PIJ. provide the best long-term solution. When a pa/pl osteo-
They have been reported as a cause of lameness in a rop- chondral fragment is identified, it is prudent to consider
ing Quarter Horse and a Thoroughbred racehorse [4, 5]. that soft tissue injury may also exist in association with the
Osteochondral fragments in the dorsal pouch of the PIJ avulsion (Figure 18.3).
originating from the distal abaxial aspect of the proximal
phalanx have been suggested to be developmental in ori-
gin as they have been identified bilaterally in young Techniques for Treatment
horses without any history of trauma or acute onset lame- The treatment of choice for dorsal axial fragmentation is
ness [7, 8]. More axially located fragments, from the arthroscopic removal; pa/pl fragments can also be removed
Osteochondral Chip Fractures of the Proximal Articular Surfac 367
(a) (b)
Figure 18.2 (a) Lateromedial radiograph revealing an axially located fragment from the dorsoproximal articular surface of the
middle phalanx. (b) Arthroscopic view of the fragment protruding from the proximal articular margin of the middle phalanx (P2)
between the medial (M) and lateral (L) condyles of the proximal phalanx.
(a) (b)
Figure 18.3 Fragmentation of the proximal dorsal and palmar articular margins of the middle phalanx. (a) Lateromedial radiograph.
(b) Palmar arthroscopic image demonstrating associated disruption of the scutum (arrows): P1: palmar condyles of the proximal
phalanx.
arthroscopically or by an open approach through the digi- tendon. Intra-operative imaging is required to precisely
tal flexor tendon sheath. locate the fragment, and an incision is made into the pa/
Palmar/plantar fracture removal by direct dissection is pl joint capsule of the PIJ directly over the fragment.
accomplished with the patient positioned in lateral Sharp dissection is required to free the fragment from its
recumbency and the affected limb uppermost. A 5–7 cm soft attachments and allow removal. The PIJ capsule, dig-
incision is made through the skin and subcutaneous tis- ital flexor tendon sheath, subcutaneous tissue and skin
sues centred over the pa/pl aspect of the PIJ. The digital are closed routinely [4, 5].
flexor tendon sheath is incised, and the DDFT is retracted. Arthroscopic evaluation of the PIJ has been described [6,
Placing the limb in flexion facilitates retraction of the 9, 10]. A descriptive study using MRI, CT with contrast
arthrography and arthroscopy revealed that 62% of the PIJ avoid the adjacent soft tissues including the axial and abax-
perimeter can be observed from combined dorsal and pa/pl ial ligaments of the PIJ, superficial and DDFTs and the
arthroscopic approaches [10]. The dorsal abaxial portions straight sesamoidean ligament during portal placement.
of the joint were difficult to view as the joint pouch nar- Under arthroscopic observation, a needle is used to identify
rows due to the overlying collateral ligaments. Lesions in the optimum location for the instrument portal.
this region may not be accessible arthroscopically and may In most horses, the pa/pl soft tissues must be dissected to
need to be treated conservatively or by arthrotomy. allow identification and palpation of the fragment. It
Additionally, when comparing two arthroscopic approaches should be noted that pa/pl avulsion fragments may be
to the joint, the authors concluded that insertion 1.5 cm extra-articular. In these cases, the surgeon should consider
proximal to the joint allowed improved manipulation and if surgical removal and the required soft tissue disruption
observation of the medial and lateral aspects of the joint is indicated [10]. Additional imaging, including CT and/or
and reduced accidental exit of the arthroscope during MRI may aid in determining the location of the fragment.
exploration [10]. It has also been found that placement of Intra-operative radiography or fluoroscopy remains impor-
the arthroscopic portal too far proximally can limit viewing tant to identify the fragment and to confirm complete
ability, so the surgeon should be cautious not to create the removal.
portal more than the recommended 1.5 cm proximal to the After a latex specimen evaluation and arthroscopic
articulation [8]. removal of fragments from four clinical patients, several
Arthroscopic evaluation of the dorsal compartment site-specific arthroscopic challenges were identified [6]. It
requires extension of the distal limb and maximal distension was concluded that the palmar pouch is smaller than the
of the PIJ. With distension, the joint capsule is palpable plantar pouch of the PIJ, making the procedure more chal-
along the abaxial margins of the common or long digital lenging in the forelimb. Additionally, curved instruments
extensor tendon. A skin incision is made at the junction of are needed to reach the intercondylar region as straight
the middle and proximal thirds of the outpouching on either arthroscopic instruments proved inadequate. Motorized
side of the extensor tendon [9]. Others have suggested a synovial resectors are required to facilitate observation and
more distal arthroscopic portal, equidistant between the removal of fragments. The surgeon should use caution to
proximal and distal extent of the distended joint capsule; avoid the pa/pl neurovascular bundle during portal place-
however, the more proximal location may provide improved ment. The digital flexor tendon sheath and DDFT should
manipulation and evaluation [8, 9]. Using a 2.7 mm arthro- also be avoided, limiting the surgeon to an abaxial
scope facilitates intra-articular manipulations. Standard approach.
arthroscopic technique is used to identify the fragment and Post-operatively, the patient is confined for four to eight
facilitate its removal through a contralaterally positioned weeks with hand walking exercise. Turnout is typically
instrument portal (Figure 18.2b). Skin incisions should be introduced at eight weeks, and a controlled return to exer-
closed routinely and the distal limb bandaged. Arthroscopic cise begins 12 weeks post-operatively. In most patients, a
fragment removal should be considered the treatment of return to full exercise can be anticipated three to six months
choice as it allows improved identification of the fragment, after surgery; however, this is often dictated by the degree
with careful debridement of the fracture bed and any associ- of soft tissue damage.
ated soft tissues. Reduced soft tissue trauma and continued
lavage throughout the procedure also minimize post-
Results
operative complications.
For arthroscopy of the pa/pl pouch, the patient is posi- Of six horses with dorsomedial fragmentation, three were
tioned in dorsal or lateral recumbency with the limb in bilateral and three had lameness localized to the affected
moderate flexion. When examination of both the dorsal joint. Two horses were euthanized without treatment due to
and pa/pl compartments is required, it has been suggested owner concerns, two of three with incidental fragments
that the dorsal pouch be explored first, as distension may went on to race successfully and one was retired. One lame
be limited if the pa/pl pouch is penetrated first [10]. horse had the fragment removed by arthrotomy, but lame-
Following distension, the arthroscopic portal is created ness persisted [7]. Published reports of arthroscopic removal
contralateral to the fragment at a location 2–3 cm proximal of fragments are limited [6, 8]. A report of three horses doc-
to the palpable distal condyle of the proximal phalanx at umented two Standardbred horses that raced successfully
the pa/pl abaxial margin of the bone and immediately dor- and a Thoroughbred that entered race training after arthro-
sal to the neurovascular bundle. The obturator and can- scopic removal of dorsal fragments [8].
nula are directed axially and distally for introduction into Three of four horses with arthroscopically removed
the joint. The surgeon should be careful to palpate and pa/pl fragments returned to their previous level of
Axial Fracture 369
athletic performance, and one was used for trail rid-

ing [6]. Two reports described arthrotomy for removal
of fragments with return to roping in a 10-year-old
Quarter Horse and return to race training in a 3-year-old
Thoroughbred [4, 5].
Axial Fractures
Incidence and Causation

Axial fractures of the middle phalanx are rare. They are
suspected to be due to an acute traumatic incident.

Lameness is acute and initially severe. Displacement is
limited by dense ligamentous investment proximally and
overlying hoof capsule distally. Furthermore, axial frac-
tures do not disrupt the pa/pl support structures. The
inherent stability combined with the minimal displace-
Figure 18.4 Palmarolateral–dorsomedial oblique radiograph
ment result in the degree of lameness dissipating signifi- demonstrating a complete spiraling, biarticular, axial fracture
cantly within the first 24–48 hours after injury. of the middle phalanx.

screws may result in displacement along the obliquity of
Diagnosis is confirmed by radiography. Dorsopalmar pro- the fracture and cause articular malalignment. This
jections are most informative, but oblique projections and/ requires careful intra-operative imaging ideally planned by
or CT are necessary to establish configuration prior to pre-operative CT to ensure optimal implant positions and
repair. Most axial fractures are oblique in both sagittal and trajectories. Alternatively, a PIJ arthrodesis may be per-
frontal planes (Figure 18.4). formed in conjunction with lag screw fixation (Section
“Proximal Interphalangeal Arthrodesis”), which is the
authors’ preference. While the PIJ is luxated for articular
Acute Fracture Management
cartilage debridement, reduction of the proximal articular
While these injuries are usually axially stable, external coap- aspect of the fracture can be visualized to ensure anatomic
tation as described for comminuted fractures (Section “Acute reduction. Alignment of the distal articular surface is then
Fracture Management”) is recommended to minimize the expected because of the simple oblique configuration of
potential for displacement prior to definitive repair. the fracture. Additional lag screw(s) are placed in the body
of the middle phalanx to provide interfragmentary
compression.
Treatment Options and Recommendations
Complete (biarticular) sagittal fractures require internal
Results
fixation for a satisfactory long-term prognosis; options
include lag screw fixation alone or in conjunction with PIJ Published reports of axial fractures are rare [11]. The prog-
arthrodesis. nosis for long-term soundness and return to athleticism is
largely dependent on the development of OA of the PIJ and
DIJ. For this reason, the surgeon may consider primary
Techniques for Treatment
arthrodesis of the PIJ in conjunction with lag screw fixa-
Compression of non-displaced fractures can be accom- tion. When the PIJ is arthrodesed and fracture healing/
plished with multiple cortex screws in lag fashion. It is arthrodesis occurs without complication, the prognosis is
imperative to place screws precisely perpendicular to the influenced by the amount of cartilage damage and result-
fracture plane at each location otherwise tightening of the ant osteoarthritis in the DIJ.
ractures of the Palmar/Plantar

F hindlimbs [12]. In a further study 10 of 11 horses with emi-
Eminences nence fractures involved a hindlimb [13].
Incidence and Causation Clinical Features and Presentation

While the PIJ is in extension, compressive forces are con- Eminence fractures cause acute, non-weight-bearing lame-
centrated in the pa/pl aspect of middle phalanx resulting in ness. Uniaxial fractures generally do not disrupt pa/pl sup-
substantial tensile forces on the connective tissues through port and therefore do not exhibit instability. If evaluated
their attachments on the pa/pl eminences. When the ten-
sile forces are excessive, the soft tissues, or more commonly
the pa/pl eminences, fail. When bone fails under tension, a
transverse fracture oriented perpendicular to the direction
of the tensile forces results, which is the typical configura-
tion for these fractures. Such forces occur during abrupt
stops or sliding, as in reining or calf roping.
Fractures of the palmar/plantar eminences may be uni-
axial or biaxial. When uniaxial, the PIJ remains axially sta-
ble. Fragment size varies from small osteochondral
fragments (see Section “Osteochondral Chip Fractures of
the Proximal Articular Surface”) to fractures extending into
the diaphysis. When biaxial, fractures typically extend from
the junction of the middle and pa/pl thirds of the proximal
articular surface to the distal aspect of the eminences. Biaxial
fractures may occur as separate medial and lateral fragments
or as a single large fragment. Displacement occurs due to
distractive forces applied by the superficial digital flexor ten-
don and straight distal sesamoidean ligament insertions on
the fibrous scutum with the proximal phalanx displacing
distally into the fracture gap (Figure 18.5). Palmar/plantar
stability is disrupted, resulting in pa/pl subluxation or less
commonly luxation of the PIJ. The pa/pl eminences can also
Figure 18.5 Lateromedial radiograph demonstrating a biaxial,
be involved in complex fractures (Figure 18.6).
plantar eminence fracture with displacement of the proximal
Nine of 47 middle phalangeal fractures involved the pa/pl phalanx into the fracture plane and unstable subluxation of
eminences, and these occurred almost exclusively in the PIJ.
(a) (b) (c) (d)
Figure 18.6 (a) Dorsoplantar, (b) lateromedial, (c) DLPMO and (d) DMPLO radiographs of a complex fracture of a hindlimb middle
phalanx. This includes a biaxial plantar eminence fracture with additional fractures dorsally and extending into the DIJ.
Fractures of the Palmar/Plantar Eminence 371
soon after the fracture, lameness may be substantial; how- Treatment Options and Recommendations
ever, with time, it typically subsides. There are usually clin-
Delineating the configuration of the fracture is important
ically localizing signs, but in some instances regional
in selecting the most appropriate treatment. This can be
anaesthesia may be required.
accomplished with a thorough radiographic examination
Biaxial fractures are accompanied by pa/pl instability.
after removal of the emergency coaptation, while the
The pastern region is often enlarged; however, swelling is
patient is under general anaesthesia immediately prior to
limited by the density of the surrounding soft tissues.
repair. However, pre-operative CT provides superior reso-
Palpation and manipulation of the region are painful, and
lution and spatial detail [14]. An incomplete, or insuffi-
crepitus may be evident. Fractures are usually closed.
cient radiographic examination is likely to mislead the
However, with repeated attempts by the horse to bear
surgeon in pre-operative planning: comminuted fractures
weight on the limb, displacement of the fracture fragments
may appear to be biaxial eminence fractures in laterome-
may result in injury to surrounding soft tissues, particu-
dial radiographs.
larly the DDFT as it courses over the sharp distal end(s) of
Treatment options include fragment removal (Section
the displaced eminences.
“Techniques for Treatment”), lag screw fixation of uniaxial
fractures [15], and arthrodesis of the PIJ, which is the
Imaging and Diagnosis authors’ treatment of choice. Arthrodesis has been per-
Radiography is the principal diagnostic modality. However, formed using transarticular lag screws, single plate fixa-
CT provides superior three-dimensional resolution and tion, and double plate fixation [13, 16–22]. Due to the
identification of additional, sometimes occult, fractures in inherent biomechanical weakness, the authors advise
the body of the bone (Figure 18.7). against using transarticular lag screws alone. The decision
to perform a PIJ arthrodesis using a single dorsal plate
positioned axially in conjunction with abaxial transarticu-
lar lag screws or using two dorsal plates positioned abaxi-
Expedient stabilization of the limb is important to mini- ally is determined by the pa/pl stability of the joint. With
mize soft tissue damage and alleviate pain and anxiety, par- axially stable injuries (axial and uniaxial eminence frac-
ticularly in axially unstable biaxial fractures. In most cases, tures), a single plate, with additional fixation as dictated by
external coaptation should be applied prior to radiographic the individual configuration, is adequate. However, inju-
evaluation as described for comminuted fractures (Section ries accompanied by pa/pl instability (biaxial eminence
“Acute Fracture Management”). and comminuted fractures and soft tissue disruption
(a) (b) (c)
Figure 18.7 Pre-operative CT examination of the horse in Figure 18.6. Transverse (a), sagittal (b) and frontal (c) plane images provide
three-dimensional assessment and demonstrate the complexity of the fracture.
resulting in pa/pl subluxation or luxation of the PIJ) should In the authors’ opinions, performing a primary arthrode-
be repaired by double plate fixation. sis results in a better prognosis for a long-term serviceable
outcome than fracture repair alone and provides the best
opportunity for an early return to functional activity. PIJ
arthrodesis utilizing a single axial plate in conjunction
Although not advocated by the authors, re-attachment of with abaxial transarticular lag screws (Section “Proximal
uniaxial pa/pl eminence fragments to the parent middle Interphalangeal Arthrodesis”), with supplemental fixation
phalanx by lag screw fixation has been reported [12, 15]. as dictated by the type and configuration of the fracture, is
The patient is positioned in lateral recumbency with the the technique of choice.
affected eminence uppermost, and an incision is made In addition to the arthrodesis construct described below,
directly over the fracture fragment. Visualizing the articu- supplemental fixation in patients with uniaxial eminence
lar surface and fracture margins is precluded by the joint fracture includes a lag screw placed from dorsal to pa/pl
structure and dense overlying soft tissue attachments; into the fragment. Careful planning and intra-operative
therefore, intra-operative imaging is mandatory. A single imaging are necessary to minimize potential impingement
4.5 mm cortical bone screw is placed in lag fashion across with the implants used for PIJ arthrodesis. In addition, it is
the fracture. important to avoid placing the plate and transarticular
There are several limitations to this technique which screws into the fracture plane (Figure 18.9).
question its indication. Precise articular reconstruction is
difficult to achieve since the articular surface cannot be
visualized and, a single lag screw does not provide rota- roximal Interphalangeal
P
tional stability. Cast immobilization helps to mitigate, but Arthrodesis
does not eliminate bending forces at the fracture site, for
which lag screw fixation is a poor biomechanical counter. Injuries to the PIJ carry a high risk for the development of
Rotational and bending instability predisposes to incom- OA and associated chronic, progressive lameness. Insults
plete healing and places the fixation at risk of failure, either can be chronic, low-grade repetitive injury as occurs with
through screw breakage or further fracture(s) of the princi- primary OA, or acute disruptive trauma to the articular and
pal fragment (Figure 18.8). In light of imprecise articular periarticular structures. OA can also be secondary to devel-
alignment and the propensity for OA of the PIJ, persistent opmental orthopaedic conditions (subchondral bone cysts
lameness is likely. and osteochondritis dissecans) or as a sequel to infection.
Once established, OA will progress with cartilage loss that
can either be widespread throughout the PIJ or focal. Focal
loss often results in horses with pre-existing angular
deformity in the digit, exacerbating their varus or valgus
conformation (Figure 18.10). These have been noted to
exhibit the most severe lameness observed with OA of the
PIJ. Periarticular new bone formation often becomes sub-
stantial, resulting in the typical external enlargement prox-
imal to the coronary band colloquially termed high
ringbone.
When OA is not accompanied by axial instability, lameness
can usually be managed in the early phases of degeneration
by corrective farriery in conjunction with systemic and intra-
articular anti-inflammatory medications. However, progres-
sion of OA will occur, and eventually most affected horses
will suffer career-ending and sometimes life-threatening
lameness. Relief from chronic pain and debilitation, and in
many cases a return to functional use, can be achieved with
PIJ arthrodesis. Although there are anecdotal reports of
spontaneous PIJ fusion, this is the exception rather than the
Figure 18.8 Dorsoplantar radiograph of a failed attempt at lag
rule. The practice of turning out affected horses with the
screw fixation of a uniaxial plantar eminence fracture. Note loss
of reduction and secondary fracture of the fragment that expectation that they will eventually resolve their lameness
followed repair. by spontaneous fusion is questionable, and it has been the
Proximal Interphalangeal Arthrodesi 373
(a) (b) (c)
(d) (e)
Figure 18.9 Repair of a uniaxial fracture of a medial plantar eminence and concurrent PIJ arthrodesis. (a) Pre-operative DMPLO
radiograph. (b) Intra-operative photograph with reduction maintained by pointed forceps during dorsal to plantar lag screw fixation of
the fracture. (c) Intra-operative fluoroscopic image following lag screw fixation of the eminence fracture. (d) Intra-operative
photograph following lag screw fixation showing reduction of the eminence fracture (arrows). Note osteostixis of the articular
surfaces. (e) Post-operative DMPLO radiograph illustrating completed lag screw fixation and PIJ arthrodesis.
authors’ observation that most of these horses will languish into the pa/pl aspect of the middle phalanx [23]. However,
in the pasture for years without achieving significant pain this has been supplanted by a superior construct employ-
relief. ing an axially positioned dorsal plate in conjunction with
Arthrodesis is the preferred treatment for horses with cortex screws placed medial and lateral to the plate. Ex vivo
OA or injuries to the PIJ (including most middle phalanx evaluation of the plate–screw construct has demonstrated
fractures) that are likely to result in OA. Surgical removal greater stability and fatigue life than a three-screw con-
of as much articular cartilage as possible followed by inter- struct [24, 25]. Increased stability, improves post-operative
nal fixation providing compression between the subchon- comfort and allows the post-operative period of cast immo-
dral bone plates of the proximal and middle phalanges is bilization to be substantially shortened, thus reducing cast-
the only uniformly reliable method for achieving fusion. associated morbidities and time in the hospital. With
The technique originally described provided compressive increased comfort, and therefore an earlier return to full
fixation with three screws placed in lag fashion across the weight-bearing on the affected limb, the construct will be
PIJ from the dorsodistal aspect of the proximal phalanx subject to greater peak loads and loading cycles,
(a) (b) (a)
(b)
Figure 18.10 (a) Photograph of the lame right forelimb of a

13-year-old Quarter Horse gelding demonstrating varus
deformity of the pastern region. (b) Dorsopalmar radiograph
revealing advanced degenerative joint disease with varus
deformity due to collapse of the medial aspect of the PIJ.
Extensive enthesopathy associated with the medial collateral
ligament is apparent.
Figure 18.11 Surgical approach for PIJ arthrodesis. (a)
Inverted-T skin incision with skin flaps retracted and an
inverted-V incision in the long digital extensor tendon (LDE)
particularly with the reduced duration of post-operative with base of incisions at the level of the collateral ligaments:
cast support. The importance of the strong, fatigue- CB: coronary band. (b) Collateral ligament transection and joint
resistant construct afforded by the plate/screw configura- luxation expose the articular surfaces and permit eminence
tion cannot be overemphasized. fracture identification (arrows).
dissected abaxially, with care taken to include the sparse

Surgical Technique
subcutaneous tissues with the flap. The dorsal branches of
The patient is positioned in lateral recumbency with the the digital artery and vein present at the abaxial margins of
affected limb uppermost. The distal limb is clipped from the horizontal incision are avoided. The common or long
the coronary band to the mid metacarpal/tarsal region. The digital extensor tendon is incised in an inverted-V, with the
hoof is carefully prepared by thorough cleaning of the solar apex in the mid to proximal aspect of the proximal phalanx
surface and mechanical removal of the periople before the and the base near the abaxial margins overlying the PIJ
solar region of the hoof is isolated with an impervious (Figure 18.11a). The distal flap of the incised extensor ten-
adhesive barrier. A medial and lateral palmar/plantar don is sharply elevated, using an osteotome or chisel, pro-
nerve block is performed immediately proximal to the gressing from proximal to distal until the axial aspect of the
abaxial sesamoid bones, and the distal limb, including the PIJ is entered at its dorsoproximal attachment on the proxi-
proximal aspect of the hoof, is prepared for aseptic surgery. mal phalanx. A scalpel is inserted into the joint and used to
Care is taken to isolate the surgical site with appropriate sharply transect the abaxial attachments of the joint cap-
draping including an iodine-impregnated adhesive incise sule and suspensory ligaments of the navicular bone off the
drape [26]. dorsodistal end of the proximal phalanx towards the col-
Skin and subcutaneous fascia are incised longitudinally lateral ligaments. At this point, the dorsal aspect of the PIJ
on the dorsal midline extending from the proximal third of is exposed and the distal flap of the extensor tendon
the proximal phalanx to 2 cm proximal to the coronary remains attached to the dorsoproximal rim of the middle
band. A horizontal incision 2 cm proximal and parallel to phalanx (Figure 18.11b). The axial aspect of this attach-
the coronary band produces an inverted-T skin incision ment is sharply elevated to allow plate placement with care
exposing the underlying extensor tendon. Each skin flap is taken to avoid overzealous distal dissection and preserve
Proximal Interphalangeal Arthrodesi 375
the capsular attachments of the DIJ to the dorsal aspect of and facilitate soft tissue closure over the implant. Once
the middle phalanx. the region is prepared, a three-hole narrow locking com-
Complete exposure of the articular surfaces of the PIJ is pression plate (LCP) is contoured to span the PIJ with
accomplished by incremental transection of the medial the solid centre of the plate over the joint space and the
and lateral collateral ligaments at the base of the V inci- single stacked combi hole over the proximal aspect of
sion, beginning dorsally and working pa/pl, while the joint the middle phalanx.
is forced into flexion. Positioning a retractor into the articu- If the apex of the inverted-V extensor tendon incision
lation to apply leverage facilitates exposure. Generous tran- interferes with plate placement proximally, the surgeon
section of the collateral ligaments provides exposure for should avoid increasing exposure with a longitudinal ten-
removal of all but the very most pa/pl rim of articular car- don incision, i.e. converting the inverted-V into an inverted-
tilage. In addition, this degree of exposure permits observa- Y. This results in the proximal tendon incision lying directly
tion of fracture lines at the articular surface that facilitates under the longitudinal skin incision and directly over the
screw placement when treating middle phalangeal frac- implant. This is undesirable because if an incisional infec-
tures (Figures 18.9 and 18.11b). The entirety of the exposed tion occurs there is an increased likelihood for deep inva-
cartilage should be removed as remaining cartilage acts as sion and subsequent infection of the implants. Instead, the
a barrier to osseous bridging and reduces subchondral surgeon should gain additional exposure with an abaxial
bone contact which is vital for achieving maximal strength incision in the proximal tendon which provides a barrier of
and stability by compressive transarticular fixation. intact tendon between the longitudinal skin incision and
With advanced OA, periarticular new bone, soft tissue bone plate except at the apex of the inverted-V tendon
fibrosis and mineralization can impede dissection of the incision.
extensor tendon flap and opening of the PIJ for complete Positioning the solid section of the three-hole narrow
exposure of the articular surfaces. In many instances, pre- LCP directly over the joint places the distal most screw
operative radiographs will suggest that partial fusion will hole (stacked combi hole) immediately below the proxi-
completely prevent opening the joint for cartilage removal. mal subchondral bone plate of the middle phalanx. This
Although there are occasions that partial fusion will inhibit ensures that the distal end of the plate will not impinge
exposure, it has been the authors’ experience that in most on the extensor process of the distal phalanx. Although
instances it is possible to gain adequate exposure for near non-locking plates have been used successfully, the
total cartilage removal. Even though it may appear that not authors believe there are advantages of using an LCP for
attempting removal of the degenerative cartilage and simply this construct. However, special consideration must be
stabilizing the PIJ would provide a suitable outcome, remov- taken to precisely contour the LCP to ensure the distal
ing the residual cartilage is recommended. Furthermore, in plate screw in the middle phalanx, which must be inserted
cases where cartilage loss is asymmetric and has resulted in orthogonal to the plate, will be directed into the proximal
varus or valgus deformity through the PIJ, removing resid- aspect of the pa/pl eminences. The push–pull device may
ual cartilage restores sagittal alignment of the pastern. In the be applied in the second plate hole (most distal plate hole
rare instance when the PIJ cannot be adequately opened, in the proximal phalanx) prior to insertion of the most
drilling the articular margins with a 4.5 mm bit is used to distal screw to ensure that the plate is in contact with the
debride cartilage and expose the subchondral elements. underlying bone of the middle phalanx. It is important to
Passing the bit from dorsal to pa/pl in a slightly proximal to avoid a gap between the plate and the bone which will put
distal direction can be carried out with direct visualization. excessive bending stress on the screw and predispose it to
Debridement of the pa/pl aspect of the articulation is accom- fatigue failure. After placing a 5.0 mm locking screw in
plished via a lateral stab incision and facilitated by intra- the middle phalanx, the most proximal plate screw is
operative imaging. inserted with either monocortical or bicortical engage-
Following complete removal of the articular cartilage, ment based on surgeon’s preference. The authors prefer a
osteostixis of the subchondral bone of both phalanges is monocortical screw to avoid stress concentration in the
performed using a 2.5 mm drill bit (Figure 18.9d). However, pa/pl diaphysis of the proximal phalanx and to minimize
when treating middle phalanx fractures, the authors often the potential for irritating soft tissues if the tip of the
do not perform osteostixis of the middle phalanx to reduce screw protrudes. As 5.5 mm cortex screws less than 24 mm
the potential for secondary fracture. are not available, monocortical placement in horses of
Patients with advanced OA often have substantial per- small stature frequently necessitates use of a 4.5 mm cor-
iarticular new bone formation on the dorsal aspect of tex screw. The screw hole is prepared using the load guide
the proximal and middle phalanges. Much of this new to provide dynamic compression across the PIJ. However,
bone is removed to improve bone–implant apposition a gap between the bone and proximal end of the plate
The primary functions of the cast are to protect the

bone–implant construct during recovery from anaesthesia
and to immobilize the soft tissues to promote healing dur-
ing the early post-operative period. The cast is maintained
for two weeks. In patients without pre-operative pa/pl
instability, long-term post-operative cast immobilization is
unnecessary.
Patients are confined to a stall for three months follow-
ing surgery. Initially, exercise is limited to short periods of
daily grazing in hand. After six weeks, a progressive pro-
gramme of hand walking exercise is instituted. If there are
no clinical or radiographic complications, the patient is
gradually transitioned to small paddock exercise for an
Figure 18.12 Intra-operative photograph showing appropriate
countersinking (arrows) to ensure circumferential contact of the additional one to two months followed by free pasture
heads of the transarticular lag screws. (Note this arthrodesis has activity. Most patients will demonstrate lameness at a trot
been performed with a DCP.) at the three month post-operative evaluation; however, this
typically dissipates and the majority of horses will be able
to begin light work under saddle by six to eight months
should be maintained, and tightening the proximal screw post-operatively.
to effect dynamic plate compression should not be applied
until after the abaxial, transarticular screws have been
Results
placed.
Placing the abaxial transarticular screws is facilitated Lag screw fixation was initially reported in three horses
by intra-operative imaging. The screws should be directed with hindlimb uniaxial eminence fractures. Return to
to cross the pa/pl one-third of the PIJ to ensure compres- western performance was reported in two with the third
sion in this area. In addition, this trajectory ensures the horse able to compete in pleasure events [27]. In a sub-
screws exit the pa/pl cortex proximal to the navicular sequent report, only two of six horses with pa/pl emi-
bursa minimizing the potential for implant-associated nence fractures were capable of performing athletically
lameness. Adequate countersinking is required to ensure following lag screw fixation [12]. It has been the authors’
circumferential contact of the screw head with the proxi- observation, in a limited number of cases, that fracture
mal phalanx as they are tightened (Figure 18.12). After healing is unreliable, and lameness often persists as sec-
the transarticular screws are tightened, the dynamic com- ondary OA becomes established. Fracture fixation in
pression applied with the plate is maximized by tighten- combination with PIJ arthrodesis has proved superior to
ing the most proximal plate screw. Finally, a 5.0 locking lag screw fixation for uniaxial eminence fractures and
screw is placed in the open plate hole overlying the proxi- provided an improved prognosis for return to athleti-
mal phalanx adjacent to the PIJ. Prior to closure, images cism. Among 53 horses undergoing PIJ arthrodesis using
are obtained to document implant position and ensure a dorsal plate and abaxially placed transarticular lag
that screws do not extend beyond the pa/pl cortex where screws, all six with uniaxial pa/pl eminence fractures
soft tissue irritation could cause implant-associated lame- returned to their intended use [28].
ness (Figure 18.13). As previously noted, slight variations in the above con-
The extensor tendon is apposed with #1 (0.4 mm) mono- struct are necessary when incorporating PIJ arthrodesis
filament absorbable suture in an interrupted pattern. into the treatment of middle phalanx fractures. Importantly,
Tension relieving patterns are used as necessary. Extension a single plate construct requires intact pa/pl support. Axial
of the lower limb facilitates closure. Subcutaneous tissues fractures and uniaxial eminence fractures are usually can-
are apposed in a simple continuous pattern using #2–0 didates for single axial plate fixation. However, in the rare
(0.3 mm) monofilament absorbable suture in the proximal instance that a uniaxial eminence fracture is accompanied
aspect of the incision. The subcutaneous tissues typically by enough disruption of the pa/pl support structures to
become sparse distally and may prevent completing the result in significant pa/pl malalignment, single plate fixa-
subcutaneous closure in the distal aspect of the longitudi- tion is inadequate. Such unstable injuries, and pa/pl PIJ
nal incision. Skin is closed routinely, and the incision is luxations, biaxial eminence and comminuted fractures,
covered with a sterile primary layer. A distal limb cast is should be repaired using double plate fixation (Section
applied, and the patient is assisted in recovery. “Techniques for Treatment”).
Comminuted Fracture 377
(a) (b)
(c) (d)
Figure 18.13 Intra-operative fluoroscopic images confirming appropriate implant positions prior to surgical closure. (a) Dorsopalmar.
(b) Lateromedial. (c) Dorsolateral–palmaromedial oblique image for specific evaluation of the lateral abaxially located transarticular
screw. (d) Palmarolateral–dorsomedial oblique image for specific evaluation of the medial abaxially located transarticular screw.
Comminuted Fractures polo produce such complex forces. In most reports, Quarter
Horses are the predominant breed affected. Injury is most
Incidence and Causation often associated with activities involving cattle work or
arena competition; however, a number occur during free
Comminuted fractures are thought to result from a combi- paddock exercise.
nation of axial compression, bending and torsion when the Initial reports documented comminuted fractures predomi-
hoof is fixed relative to the remainder of the digit [12]. It is nantly affecting hindlimbs [12, 13]. In one report, 26 of 47
likely that abrupt, powerful stops, alone or in combination (55%) fractures of the middle phalanx involved a hindlimb [12].
with turns, common in reining, cutting barrel racing and However, another report noted that in 10 horses with
comminuted fractures, eight forelimbs and only two due to the confining nature of the overlying soft tissues;
hindlimbs were affected [22]. Most recently, in a series of 30 fractures are rarely open.
horses with disruptive injuries affecting the PIJ, fractures of
the middle phalanx occurred in the forelimbs of 12 horses of
which 11 were comminuted. In the same report, out of 18
hindlimb injuries that resulted in plantar instability of the PIJ, Standard radiographic examination, including 45° oblique
7 were comminuted and 7 were biaxial eminence fractures of views, is diagnostic. However, additional projections at var-
the middle phalanx, 3 were plantar luxations with the remain- ying degrees of obliquity are helpful to establish the degree
ing injury affecting the distal condyles of the proximal pha- of comminution and articular involvement. Biaxial emi-
lanx. It is noteworthy that of eight biaxial eminence fractures nence fractures are frequently present, resulting in pa/pl
in that report, six affected a hindlimb, and soft tissue disrup- instability, subluxation of the PIJ and distal displacement of
tion resulting in plantar luxation of the PIJ affected only the proximal phalanx. There is often severe comminution
hindlimbs [29]. of the proximal articular surface with one or more fracture
lines extending to the distal articular surface (Figure 18.14).
Careful evaluation of the DIJ will often reveal fragmenta-
tion. Particular attention should also be paid to the distal
Major fractures usually disrupt the pa/pl support of the PIJ pa/pl aspect of the middle phalanx, as comminution at the
by separating the pa/pl eminences (and attached scutum) articulation between the middle phalanx and the navicular
from the parent bone with or without additional fracture bone may also be involved. CT allows superior resolution
lines extending into the body of the bone. An audible crack and spatial recognition of fracture configuration and will
may be noted by the rider when the injury occurs, and this enhance pre-operative planning.
is followed by per acute non-weight-bearing lameness.
Instability is usually visible and easily confirmed with
manipulation of the digit. This also induces pain and, in
most cases, reveals crepitus. Soft tissue swelling is fre- Expedient stabilization of the fractured limb is of paramount
quently present, although it may be less than anticipated importance in minimizing soft tissue damage and reducing
(a) (b)
Figure 18.14 (a) Palmarolateral–dorsomedial oblique radiograph of a complex fracture with comminution at the proximal articular
surface and extension into the DIJ. (b) Intra-operative photograph of the proximal articular surface of the middle phalanx
demonstrating the comminuted fracture configuration: LDE: long digital extensor tendon; P1: proximal phalanx.
patient anxiety. Ideally, coaptation should be applied prior to With appropriate emergency stabilization, the pa/pl soft
radiographic evaluation. The distal limb should be stabilized tissues are protected and there is minimal opportunity for
in a position that aligns the dorsal cortices of the third meta- additional displacement of fragments during transport to
carpal/metatarsal bone and phalanges. Although a modified the hospital. Repair of closed fractures can therefore be
Robert Jones bandage with a dorsally applied splint in the elective, allowing the patient to recover from transport and
forelimb or a splint applied to the plantar aspect of the systemically stabilize, and provides time for the surgical
hindlimb provides a degree of immobility (Chapter 7), a team to prepare.
modified bandage cast is far superior [30]. The volume of
padding applied with a Robert Jones splint bandage allows
substantial motion at the fracture site putting the pa/pl soft
tissues at risk. Using a limited amount of padding in con- Comminuted middle phalangeal fractures have been man-
junction with a dorsal splint to maintain dorsal cortical aged with standard distal limb or transfixation casting
alignment within a fibreglass cast that encases the hoof will alone, transfixation casting in combination with internal
better immobilize the fracture and protect the pa/pl soft tis- fixation, or open reduction and internal fixation in con-
sues by neutralizing the pa/pl bending forces acting at the junction with a standard distal limb cast.
fracture. A bandage cast also (Chapter 7) provides excellent Historically, cast immobilization alone was recom-
mediolateral stability (Figure 18.15). mended [12]. Cast-immobilized fractures typically required
For the forelimb, an assistant suspends the limb while more than three months (average of 100 days) for radio-
fibreglass casting tape is applied over the bandage, splint graphic healing to occur. The major limitation of cast
and entire hoof. The cast material is most easily applied to immobilization as a solitary treatment is the inability of the
the hindlimb while the limb is positioned cranially with cast to protect the fracture from axial (weight-bearing)
the toe resting on a narrow board allowing the cast mate- compressive forces [31]. Fragment displacement and frac-
rial to be wrapped around the entire hoof except where the ture collapse are likely. As the fracture collapses, the proxi-
toe is resting on the board. Lifting the limb and suspending mal phalanx displaces distally, forcing fracture fragments
it as in the forelimb engages the reciprocal apparatus, outwards to become trapped between the overlying soft tis-
resulting in passive flexion of the digit which precludes sues and the cast. Subsequent pressure sores and necrosis
dorsal cortical alignment. Alternatively, a Kimzey Leg often result in an open or infected fracture. Malalignment
Saver splint may be applied. Immobilizing the digit in flex- secondary to contracture of the flexor tendons is also likely.
ion will protect the pa/pl soft tissues but provides negligi- Most importantly, fracture instability results in severe,
ble medial to lateral stability. unrelenting lameness, with a high incidence of supporting
(a) (b)
Figure 18.15 (a) Photograph of a
hindlimb following external coaptation
with a bandage cast applied over a dorsal
splint to provide near dorsal cortical
alignment and support to minimize
further displacement. (b) Lateromedial
radiograph following placement of the
splinted bandage cast.
limb laminitis. Standard distal limb cast immobilization is pa/pl eminence fragments. It may be necessary to increase
therefore not recommended. the abaxial extent of extensor tendon elevation to allow
Initial costs of transfixation pin casting may be less plates to be placed dorsomedially and dorsolaterally, par-
than open reduction and internal fixation, but the dura- ticularly on the rim of the middle phalanx. Cartilage
tion of hospitalization and repeated cast changes under removal from both articular surfaces and osteostixsis of the
general anaesthesia usually negate the initial economy. subchondral bone of the proximal phalanx are completed
Other disadvantages include pin breakage and loosing once the PIJ is exposed.
and the risk of catastrophic secondary fracture of the met- Fracture configurations vary, and in some cases comminu-
acarpus/tarsus (Chapter 13). There is also often an tion results in very small, irreducible fragments that prohibit
extended period of pain due to the relative instability of sufficient implant purchase. However, most comminuted
the fracture, which is often particularly evident after fractures are amenable to double plate fixation. Often, they
removal of the transfixation pins when the patient is tran- will have biaxial eminence fractures as well as multiple
sitioned to a standard distal limb cast. The above notwith- oblique fractures in the proximal body of the bone and a
standing, the technique also carries a reduced long-term major oblique fracture reaching the distal articular surface.
prognosis (particularly for athleticism) due to inevitable In some cases, there will be additional fragmentation at the
OA of both PIJ and DIJ. distal articulation which complicates fixation and may jeop-
The goals of open reduction and internal fixation are to ardize construct stability and long-term patient outcome.
re-establish alignment of the bony column and articular Fracture reduction is accomplished by bringing the emi-
surface of the DIJ while supporting arthrodesis of the PIJ nence fragments into position and aligning the major frag-
by providing a mechanical and biological environment ments at the proximal articular surface. Reduction of the
conducive to fracture union and joint fusion. Achieving eminence fragments is achieved using a combination of dis-
these objectives will provide maximal patient comfort and tal limb flexion and by applying pointed reduction forceps
encourage an early return to weight-bearing, thus mini- between the fragment(s) and parent bone (Figure 18.16). It
mizing the potential for supporting limb laminitis. is important to align the pa/pl cortices of the eminence frag-
Important considerations include the degree of comminu- ments and parent bone. Due to close proximity to the navic-
tion as well as compromise to the soft tissue envelope, spe- ular apparatus in this region, excess new bone formation
cifically concerning wounds to the region. However, the secondary to malalignment of the pa/pl cortex can cause
likelihood of an acceptable long-term outcome is enhanced. long-term lameness (Figure 18.17). Reduction of fractures
Success has been reported following open reduction and coursing through the body of the bone and into the DIJ is
internal fixation with a single dynamic compression plate assisted by direct observation at the proximal articular
(DCP) [19, 32]. However, placing two plates abaxially pro-
vides a stronger, more stable and fatigue resistant con-
struct [22]. Double plate fixation with arthrodesis of the
PIJ is the treatment of choice for injuries that disrupt pa/pl
joint support, including comminuted and biaxial eminence
fractures. In cases when internal fixation is not feasible due
to the degree of comminution or because of significant
compromise to the soft tissue envelope, transfixation pin
casting is recommended.

The approach for double plate fixation is as described for
PIJ arthrodesis (Section “Surgical Technique”), including
transection of the collateral ligaments to allow complete
exposure of the proximal articular surface of the middle
phalanx. With this exposure, the key fracture lines can be
identified enhancing the surgeon’s ability to direct implant
placement across fracture planes and ensure purchase in
the major fracture fragments (Figure 18.14). Furthermore,
Figure 18.16 Intra-operative fluoroscopic image
with the collateral ligaments transected, the body of the demonstrating reduction of a plantar eminence fracture with
middle phalanx can be manipulated to aid reduction of the pointed reduction forceps.
amount of bone in the eminences, the proximal screw tra-

jectory will need to be angled axial to abaxial and distal to
proximal in each plate. This can present technical issues,
especially when using locking implants as the locking
screws must be placed orthogonal to the plate. Careful
intra-operative adjustments must be made in the plate con-
tour to precisely engage the eminences as described. It
should be noted that the stacked combi hole of an LCP,
which is placed distal, does not allow for significant angu-
lation of a 5.5 mm cortex screw.
The PIJ is re-aligned and a 5.5 mm cortex screw is placed
in the proximal screw hole (when using a three-hole plate)
or the second hole proximal to the joint (when using a four-
hole plate) of each plate in the load position to create tran-
sarticular compression. Prior to tightening the plate screws
in the proximal phalanx, supplementary screws outside of
the plate may be placed as space allows. In large stature
horses, it is often possible to place additional transarticular
Figure 18.17 Lateromedial radiograph taken 10 months after lag screws to provide further compression across the PIJ to
repair of a highly comminuted middle phalangeal fracture and
PIJ arthrodesis demonstrating excessive plantar callus
enhance the strength and stability of the construct. In addi-
impinging on the podotrochlear apparatus. tion, it is often possible to place a screw in lag fashion in the
body of the middle phalanx across fractures coursing dis-
surface. When the DIJ is affected by a single oblique frac- tally to the DIJ. Placement of the distal screw is technically
ture, alignment of this surface is inferred by alignment of difficult, requiring a separate stab incision often through
the proximal fracture lines. Intra-operative imaging is used the coronary band and collateral cartilage. It is important
to confirm fracture reduction and alignment throughout. to place this screw as perpendicular to the fracture line as
Reconstruction begins with fixation of the largest of the possible. If the screw is not properly positioned, tightening
eminence fragments to the parent bone. Once aligned, can cause displacement. After all supplementary screws
pointed reduction forceps maintain fragment position have been tightened, the screws placed in the load position
during placement of a 4.5 mm screw in lag fashion from of the plate overlying the proximal phalanx are fully tight-
the axial aspect of the dorsoproximal middle phalanx into ened. The remaining holes are then filled using 5.0 mm
the axial aspect of the largest eminence fragment. It is locking or 5.5 mm cortex screws. When using locking com-
important to leave adequate abaxial space for a second pression technology, the holes nearest and farthest from
screw in a similar trajectory which will be placed through the PIJ should be locking screws to optimize the biome-
the distal hole of the ipsilateral plate (see below). A con- chanical advantages. Final intra-operative images are per-
toured 3–5 hole narrow DCP or LCP is applied abaxially to formed to confirm reduction and appropriate screw length.
the proximal aspect of the middle phalanx using either a The proximal and abaxial position of the plates avoids
5.5 mm cortex screw or a 5.0 mm locking screw through impingement of the DIJ capsule and extensor process of
the distal plate hole into the eminence fragment that is not the distal phalanx. Using plates of different length will pre-
engaged by the initial lag screw. Maintaining this frag- vent both plates from ending at the same transverse level of
ment in reduction with the pointed reduction forceps will the proximal phalanx and reduce stress concentration at
facilitate screw placement. The second contoured narrow this location. Closure of the soft tissue envelope over the
plate is applied abaxially with the screw in the distal hole double plate construct is as described above. Although sig-
engaging the larger eminence fragment with care to avoid nificant tension will be encountered during reconstruction
the previously placed axial lag screw. When using a cortex of the extensor tendon, in the authors’ experience, com-
screw, the authors recommend positional placement plete coverage and apposition has not been a problem. A
(Chapter 8) of the plate screws (i.e. not using lag tech- distal limb cast is applied to provide additional mechanical
nique) as drilling a glide hole may excessively weaken the support of the bone–implant construct and soft tissue
dorsal fragment. reconstruction.
Screw placement is performed with the joint opened to The double plate construct is also advocated for manag-
visualize fracture lines and thus ensure reduction and ing biaxial eminence fractures and pa/pl luxation of the
appropriate screw trajectory. To engage the maximal PIJ. Minor modifications in implant placement can be
made to address injury specific features. The technique for distal limb cast is applied and maintained for an additional
repair of biaxial eminence fractures is quite similar to the three to six weeks as determined by construct stability and
repair of comminuted fractures; however, there are no patient progress. In cases with minimal comminution and
additional fractures in the body of the middle phalanx to stable constructs, a bandage cast may be applied during the
address. In these cases, it is often possible to add additional second three to six weeks, to allow some dynamization of
transarticular compression using lag screw(s) outside of the lower limb. If a bandage cast is applied, it is changed
the plates, especially in large stature horses. Providing the every three to four days. The patient is confined to a stall
fragment is of sufficient size to allow purchase, screws are for a total of three to four months. When repeated radio-
placed from the dorsodistal aspect of the proximal phalanx graphic examinations reveal ongoing evidence of healing,
and directed pa/pl and distal into either the body of the hand walking exercise may be introduced.
middle phalanx or an eminence fragment. Care must be Radiographic healing is usually first evident about three
taken to avoid placing the lag screws into the fracture months following repair and expected to be complete four
plane, allowing screws to penetrate the pa/pl cortex of the to six months after surgery (Figure 18.18). Although resid-
middle phalanx in the region of the navicular apparatus ual lameness is usually present, a gradual transition to
and weakening the eminence fragment by excessive fixa- unrestricted exercise may be introduced through turn out
tion. Palmar/plantar luxation of the PIJ can also be effec- into a small paddock. The duration of small paddock exer-
tively stabilized using a double plate construct. Following cise is gradually increased before pasture turnout. Return
cartilage removal and osteostixsis of both subchondral to functional use should only be considered when radio-
plates, the joint is re-aligned and a transarticular lag screw graphic fracture healing is complete and lameness is
is positioned axially. Double plate fixation with abaxially minimal.
positioned plates completes the fixation. Additional fixa- Fractures not amenable to open reduction and internal
tion using transarticular lag screws, usually though the fixation due to the degree of comminution or compromise
plates, is advocated. This requires four-or five-hole narrow of the soft tissue envelope may be candidates for transfixa-
plates rather than the standard three-hole PIP plate. Care tion casting. This has also been used to support open reduc-
must be taken to avoid screw interference on the pa/pl tion and internal fixation when the bone–implant construct
aspect of the middle phalanx and weakening the bone by is suboptimal. Transfixation casting (Chapter 13) can pre-
excessive fixation. vent the distal displacement of the proximal phalanx into
The authors routinely change the cast two to three weeks the fracture and protect the area below the pins from the
post-operatively, with the patient under general anaesthe- axial compressive forces of weight-bearing [31]. Although
sia. Sutures are removed and radiographs are obtained to simple in theory, poor attention to technique can result in
evaluate stability of the fixation. In most cases, a second complications. Even when executed with technical
(a) (b)
Figure 18.18 Dorsopalmar (a) and
lateromedial (b) radiographs demonstrating
appropriate healing three months after repair
of a comminuted fracture and concurrent PIJ
arthrodesis with a lateral four-hole LCP, medial
three-hole DCP and single central lag screw.
precision, pin loosening due to remodelling at the bone– phalangeal fractures managed with transfixation casting
pin interface should be expected and limits the effective alone or more frequently in combination with internal fix-
duration of transfixation support. Pin loosening results in ation, 10 horses survived and 3 were able to be ridden at a
instability and thus increased discomfort necessitating pin reduced level. Eight had mild residual lameness and two
removal. If adequate fracture stability has not been were lame at a walk but were considered comfortable at
achieved prior to pin removal, fracture displacement, col- pasture [33]. In both reports, catastrophic secondary frac-
lapse and malalignment (as described for standard casting ture of the third metacarpal/tarsal bone caused significant
techniques) can develop. Further complications associated post-operative mortality.
with transfixation casting include ring sequestra, pin tract In a report of 30 horses with 31 unstable PIJ injuries
infection, cast sore development, pin breakage and second- repaired by double plate fixation, 29 were discharged from
ary fracture through a pin hole. The frequency of second- the hospital [29]. The group included biarticular and mon-
ary fracture through a pin hole varies, but was reported in oarticular comminuted fractures and biaxial eminence
4 of 20 horses in one report and in 14% of patients in fractures of the middle phalanx as well as pa/pl luxations
another [33, 34]. Fracture malalignment has also been seen of the PIJ. Sixteen animals with comminuted, biarticular
secondary to soft tissue contracture distal to the transfixa- fractures all survived to discharge, with 6 (38%) returning
tion pins within the cast. This can be mitigated by securely to useful function. Two with comminuted, monoarticular
anchoring the hoof within the cast. fractures survived to discharge, and one returned to useful
function. All eight patients with biaxial eminence fractures
and two of the three pa/pl PIJ luxations were discharged
Results
with seven and one, respectively, able to return to func-
In a report of 22 horses with comminuted fractures man- tional use. The average duration of standard cast immobili-
aged with casting alone, 12 of 18 with follow-up were con- zation was 28 days followed by support with a bandage
sidered successful; 2 returned to intended use and 10 were cast. Follow-up greater than two years was available for 25
salvaged for limited function [12]. Casting in combination horses, of which 15 (60%) returned to useful function.
with open reduction and lag screw fixation was reported in Radiographic healing was apparent in 28 horses (90%) six
a group of nine horses, with eight available for follow-up. months after repair.
Five horses were discharged from the hospital and had Double plate fixation as described imparts a good prog-
fracture healing. Two were able to return to athletic func- nosis for survival (salvage) and a reasonable prognosis for
tion and three were considered pasture sound. While the return to functional use. Although the cause for reduced
overall case numbers were relatively small, compared to functional outcome in the above patient population was
reports of casting alone, similar survival was achieved (63% not definitively determined, it was clear that biarticular
with surgery and casting and 67% with casting alone), but fractures were less likely to achieve post-operative func-
a greater percentage of horses returned to athletic perfor- tionality than monoarticular fractures, possibly due to the
mance when internal fixation was utilized [12]. The period development of OA in the DIJ. Other potential causes
of cast immobilization was less when lag screw fixation include callus impingement of the navicular apparatus and
was used (average of 66 days compared to 100 days with residual soft tissue injury, specifically damaged to the
casting alone). Severe degenerative joint disease was DDFT, in the pa/pl aspect of the pastern. In a report of two
observed to develop in the PIJ and DIJ regardless of treat- cases of comminuted fractures, DDFT injury was identified
ment technique. Eight of 10 horses with forelimb fractures as a significant contributor to post-operative morbid-
and 10 of 23 horses with hindlimb fractures were salvaged. ity [35]. In both cases, marked displacement of the initial
None of the horses with forelimb fractures and four of the fracture and inability to effectively reduce and stabilize pa/
horses with hindlimb fractures returned to performance. pl eminence fragments were considered important in the
Laminitis was the principal complication and was respon- progression of the DDFT injury. This was not identified as
sible for significant morbidity and mortality. a comorbidity in the report of 30 horses described above in
Among published reports of middle phalanx fractures spite of a number of patients having similar pre-operative
managed with transfixation casting, specific case details fracture displacement [29]. As noted previously, reduction
are difficult to isolate from other distal limb injuries. In one and stabilization of the pa/pl eminences fragments re-
report, eight fractures were managed with transfixation establishes tensile support of the PIJ which is important to
casting alone or in combination with orthopaedic fixa- the strength and stability of the bone–implant construct. It
tion [34]. Six were discharged from the hospital and frac- could be inferred that effective eminence fixation is also
tures healed, but none returned to their intended important to prevent post-operative progression of DDFT
performance. In a series of 14 middle and 6 proximal injury which may occur prior to definitive treatment.
(a) (b) (c)
(d) (f) (g)
(e)
(h) (i) (j)
Figure 18.19 (a–c) Radiographs of an acute displaced fracture of the distal medial condyle of the middle phalanx with dorsal
comminution. This was reduced arthroscopically: (d) before (e) after “tamping” the displaced dorsal fragment to create articular
congruency. Repair was affected with a single 5.5 mm cortex screw inserted in lag technique (an initial 4.5 mm screw failed to engage
the trans-cortex). This involved radiographic alignment, a ‘stab’ incision through the coronary band and penetration of the
underlying collateral cartilage (f, g). A cast was fitted for recovery and maintained for two weeks (h). Radiographs taken five weeks
post-operatively demonstrated good fracture healing and maintenance of articular congruency (i, j).
Fractures of the Distal Articular Surfac 385
Regardless, pre-existing DDFT injury should be considered margin. Some involve the dorsal margin only, while oth-
as a potential contributor to post-operative morbidity, and ers extend the full dorsopalmar/plantar thickness of the
appropriate imaging performed to identify its presence. bone. There may be single or multiple fragments of vary-
ing degrees of displacement. Lameness is usually propor-
tional to the degree of articular compromise. Large, full
Fractures of the Distal Articular Surface thickness fractures have been reconstructed under radio-
graphic and arthroscopic guidance (Figure 18.19).
Fractures involving the distal articular surface have been Smaller fragments can be removed arthroscopically
poorly documented in the literature [36]. They occur in (Figure 18.20). Arthroscopic approaches and techniques
forelimbs and hindlimbs and usually involve an abaxial have been described in a specialist text [9].
(a) (b) (c)
(d) (e)
Figure 18.20 Comminuted fracture (arrows) of the dorsomedial distal articular surface of the middle phalanx in a hunter. (a)
Lateromedial and (b) dorsolateral–palmaromedial oblique radiographs. The fracture was mapped by CT (c) and fragments removed
arthroscopically. (d, e) Arthroscopic images from a dorsolateral portal before and after fragment removal: F: fragment; MP: middle
phalanx; FB: fracture bed following fragment removal and debridement; DP: distal phalanx.
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389
19
Fractures of the Proximal Phalanx

M.R.W. Smith
A
natomy the third metacarpal/metatarsal bone. Tension forces occur
at the insertion of the distal sesamoidean ligaments. Due to
The proximal phalanx is a long bone, situated between the oblique orientation of the bone during weight-bearing
the distal end of the third metacarpal/metatarsal bone (proximal–palmar/plantar to distal–dorsal), bending forces
and the middle phalanx, to which there are articulations occur with compression forces dorsally and tension forces
within the metacarpophalangeal/metatarsophalangeal on the palmar/plantar aspect. The anatomy of the proximal
(MCP/MTP) and proximal interphalangeal (PIP) joints, articular surface, including orientation of the sagittal
respectively. The bone is wider proximally than distally, groove and sagittal ridge of the third metacarpal metatarsal
with expanded palmar/plantar processes medially and bone subjects the bone to torsional forces during the
laterally. The dorsal surface is convex whereas the pal- weight-bearing phase of the stride.
mar/plantar surface is flattened with central proximal
and abaxial distal concavities. The proximal articular sur-
face consists of two articular concavities separated by a F
racture Types
sagittal groove, with the medial concavity being slightly
larger than the lateral. Distally, the articular surface con- Different classification systems have been described for
sists of a shallow sagittal groove separating two condyles. fractures of the proximal phalanx. No system has gained
The bone contains a small medullary cavity in the distal widespread acceptance and, due to variations in reporting,
one-third of its diaphysis. There is a midline eminence on the relative occurrence of some fracture configurations is
the dorsoproximal aspect of the bone where the extensor difficult to define. Descriptive definitions are the most
tendons attach. Distally, further eminences are present accurate and easily communicated way of categorizing
medially and laterally immediately proximal to depres- fracture type which can be broadly grouped as:
sions where the collateral ligaments of the proximal inter-
phalangeal joint attach [1]. The common/long digital ●● Fragmentation of the dorsoproximal articular margin
extensor tendon runs over the dorsal surface of the bone ●● Short incomplete parasagittal fractures
and receives attachments from the extensor branches of ●● Long incomplete parasagittal fractures
the suspensory ligament. The latter extend obliquely ●● Complete parasagittal fractures
across the medial and lateral surfaces of the proximal ●● Comminuted fractures
phalanx from the level of the proximal sesamoid bones. –– Moderately comminuted fractures have an intact strut
The distal sesamoidean ligaments attach to the slightly of bone extending between the proximal and distal
irregular proximal two-thirds of the palmar/plantar sur- articular surfaces.
face. Additional soft tissue attachments include the proxi- –– Highly comminuted fractures have no intact strut of
mal and distal digital annular ligaments, the collateral bone between the proximal and distal articular surfaces.
sesamoidean ligaments proximally and the palmar liga- ●● Dorsal fractures (also described as frontal and lateral
ments of the proximal interphalangeal joint distally [2]. fractures)
Axial loading occurs during weight-bearing, with forces –– Central dorsal fractures
transmitted through the proximal articular surface from –– Proximal dorsal fractures

390 Fractures of the Proximal Phalanx
●● Palmar/plantar process fractures higher relative proportion of dorsal fractures in forelimbs

●● Distal articular fractures compared to hindlimbs [17].
●● Fragmentation of the distal articular margin Magnetic resonance imaging (MRI) has also identified
●● Salter–Harris fractures similar variations in fracture configuration. In eight
sports horses with subchondral bone trauma of the prox-
imal phalanx, the majority with fractures involved the
Fragmentation of the Dorsoproximal Articular central region of the bone only [18]. A unicortical dorsal
Margin fracture and a bicortical fracture were reported in two TB
racehorses [19].
Osteochondral fragmentation of the dorsal articular mar-
Periosteal new bone formation (most often on the dorso-
gin of the proximal phalanx is recognized frequently in
proximal aspect of the bone) is common [16, 17, 20], consist-
the MCP/MTP joints of racehorses [3–8] and is also seen
ent with chronicity at the time of presentation, and is most
in non-racing breeds [9]. The radiographic and arthro-
reliably detected with CT [17]. Thickening of the subchondral
scopic features can vary. Fragments may be acute and
bone plate has also been reported in several studies and is con-
sharply marginated or rounded and more chronic in
sidered to reflect prodromal pathology [17–20].
presentation. They may also be single or multiple and of
various sizes and degrees of displacement [5, 10].
Fragmentation is usually identified on standard radio- Long Incomplete Parasagittal Fractures
graphic projections of MCP/MTP joints [3]. Data on fre-
Long incomplete parasagittal fractures are generally classi-
quency distribution of fragment location has been
fied as extending in a sagittal or parasagittal plane >30 mm
published for racing Thoroughbreds [5, 6, 10] and Quarter
from the proximal articular surface [14, 15, 21], but have
Horses [5, 10] in the USA, racing Thoroughbreds in the
also been described as those extending more than half the
UK [8] and in Norwegian Standardbred trotters [7]. In all
length of the bone [13]. Long incomplete parasagittal frac-
studies, fragmentation was most common dorsomedially
tures have been reported relatively more frequently in
and in forelimbs. The treatment of choice is arthroscopic
series of fractures in UK-based Thoroughbreds (TB) [13,
removal under general anaesthesia [11], although stand-
15], and were the most common configuration in the most
ing removal has also been described [12]. Techniques are
recent report [15]. In contrast, this configuration was only
documented and discussed in detail in a specialist arthros-
the second [21] and third [14] most common configuration
copy text [11].
in series of mixed TB and Standardbred (SB) populations
from North America.
While the majority of fractures remain in a parasagittal
Short Incomplete Parasagittal Fractures
plane within the diaphysis of the bone, a proportion
One study classified fractures as short incomplete if they deviate either gradually or sharply laterally, or less com-
involved less than half of the length of the bone [13]. monly medially, usually within the middle third of the
However, the most accepted definition is for fractures bone [15]. Unsurprisingly, distraction and comminution
that extend <30 mm from the proximal articular are uncommon.
surface [14–16].
Computed tomographic (CT) imaging of short incom-
Complete Parasagittal Fractures
plete parasagittal fractures has identified differences in
fracture configuration (Figure 19.1), with limb and breed/ Complete parasagittal fractures have been reported in
discipline differences in incidence. In a series of 20 frac- series from North America [14, 21] and the United
tures in TB racehorses (author’s unpublished data), 17 were Kingdom [13, 15, 22]. A higher relative incidence was
unicortical, involving the dorsal cortex and subchondral recorded in the former, and in one series it was the most
bone only, one involved the palmar cortex and adjacent commonly reported configuration [14]. Fractures propa-
subchondral bone, one involved only the central subchon- gate distally from the sagittal groove in the proximal articu-
dral bone beneath the sagittal groove, and one fracture was lar surface. In most reports, details are limited, but two
bicortical. A group of 24 horses not used for racing reported common configurations are recognized: fractures that exit
dorsal fractures in 10 cases, palmar/plantar fractures in through the lateral cortex and fractures that exit into the
two and bicortical fractures in three cases. In nine cases, PIP joint. In a series of 14 fractures, two exited through the
fractures were confined to the subchondral bone in the lateral cortex. Both were parasagittal into the middle third
central region beneath the sagittal groove of the proximal of the bone before sharply turning laterally (Figure 19.2).
phalanx and did not penetrate either cortex. There was a The remaining 12 cases exited in the PIP joint. In 10 cases,
Fracture Type 391
(a) (b)
(c) (d)
Figure 19.1 Transverse CT images of various configurations of short incomplete parasagittal fractures of the proximal phalanx.
(a) Dorsal cortex and subchondral bone. (b) Bicortical. (c) Central subchondral bone beneath the sagittal groove. (d) Plantar cortex
and subchondral bone. Note periosteal new bone at the dorsal and palmar aspects of the fracture in (b) and the plantar aspect in (d).
fractures extended into the middle or distal third of the length of the bone [15]. Most complete parasagittal frac-
bone in a parasagittal plane, before turning into a dorsolat- tures are displaced, to varying degrees in both mediolateral
eral to palmaro/plantaromedial oblique plane, to emerge and proximodistal directions. In fractures that exit through
through the lateral condyle into the PIP joint (Figure 19.3). the lateral cortex, the lateral fragment often slides distally
Two fractures stayed in a parasagittal plane throughout the and is displaced laterally.
have no intact strut of bone (Figure 19.5). The division has

implications for both treatment options and prognosis.
In moderately comminuted fractures, the intact strut of
bone is most frequently medial [15]. Fractures commonly
consist of a complete parasagittal component extending
from the sagittal groove to the distal articular surface and
a frontal plane fracture isolating one palmar/plantar
process.
Highly comminuted fractures can occasionally be
open [13, 23]. Configuration is variable and unpredictable,
but there is frequently a parasagittal component extending
from the sagittal groove. Overriding of fracture fragments
and proximodistal shortening of the bone is common.
Dorsal (Frontal) Fractures

Fractures in a dorsal plane are relatively uncommon. Two
configurations are seen. The first extends from the central
region of the proximal articular surface into the diaphysis
of the bone. These may be incomplete or complete exiting
Figure 19.2 Dorsopalmar radiograph of a complete into the proximal interphalangeal joint (Figure 19.6) or
parasagittal fracture of the proximal phalanx that exits through
lateral cortex of the diaphysis. through the dorsal cortex in the distal diaphysis. The sec-
ond are short and usually confined to the proximal epiphy-
sis and metaphysis (proximal dorsal fractures) (Figure 19.7).
Comminuted Fractures
Information on two central dorsal (described as lateral)
For the purpose of discussion, comminuted fractures have fractures was reported in a series of proximal phalangeal
been divided into those which are moderately comminuted fractures in TB racehorses [13]. Two cases in mature pleas-
and those which are highly comminuted. Moderately com- ure horses were described in detail. Both were complete
minuted fractures are defined by an intact strut of bone fractures and exited in the proximal interphalangeal
between the proximal (MCP/MTP) and distal (PIP) articu- joint [24]. Fractures are seen in both fore and hindlimbs,
lar surfaces (Figure 19.4). Highly comminuted fractures and are commonly displaced.
(a) (b) Figure 19.3 (a) Dorsopalmar and (b) dorsal 45°
lateral–palmaromedial oblique radiographs of a
complete parasagittal fracture of the proximal
phalanx. The fracture rotates into an oblique plane in
the distal half of the bone, exiting into the proximal
interphalangeal joint through the lateral condyle.
Fracture Type 393
(a) (b) (c)
Figure 19.4 (a–c) Reconstructed 3D CT images of a moderately comminuted fracture of the proximal phalanx. There is an intact strut
of bone medially between the proximal and distal articular surfaces.
(a) (b) (c) (d)
Figure 19.5 (a–d) Reconstructed 3D CT images of a highly comminuted fracture of the proximal phalanx. There is no intact strut of
bone between the proximal and distal articular surfaces.
Proximal dorsal fractures, initially described as dorsal fragment size as the fracture extended distally towards the
frontal fractures, were reported first in five horses [14] and dorsal cortex of the bone. The majority were centred medial
then in an expanded series of nine cases [25]. All occurred to the sagittal groove, with only one located centrally and
in the hindlimbs of racehorses (eight TB and one SB); four one laterally. The medial fractures extended consistently
fractures were complete and three of these were displaced. from a point just lateral to the sagittal groove in a dorsally
Further cases have more recently been described as short concave curved plane to exit dorsomedially.
frontal plane fractures, in a series comprising 21 TB race-
horses [26]. Forelimbs (n = 5) were less commonly affected
Fractures of the Palmar/Plantar Processes
than hindlimbs (n = 16). Fractures were incomplete in six
horses and complete in 15. CT examination was performed Intra-articular fragments from the palmar/plantar margin
immediately pre-operatively in the most recent 13 cases, of the proximal phalanx are relatively common. Although
enabling accurate mapping of fracture configuration most appear in juveniles [27] and an osteochondrotic aeti-
(Figure 19.7c). Maximal fracture depth ranged from 5 to ology has been muted [28], all evidence suggests that these
15 mm, and in all cases there was a gradual tapering in are avulsion fractures [29–32]. Diagnosis and management
as a result of distracting forces transmitted through the dis-

tal sesamoidean ligaments.
Fragmentation of the Distal Articular Margin

Six cases of fragmentation of the dorsodistal articular sur-
face of the proximal phalanx have been described [34],
with osteochondrosis considered as the most likely aetiol-
ogy. Trauma has also been considered due to radiographic
and arthroscopic features [11] and is more consistent
with observations from cases in the author’s hospital
(Figure 19.9).
Distal Articular Fractures

A single hindlimb distal sagittal fracture was identified in a
series of 119 proximal phalangeal fractures in young racing
TB [13]. A further three fractures, all in hindlimbs, were
Figure 19.6 Lateromedial radiograph of a complete central reported in a mixed population of TB and SB. All were
dorsal fracture of the proximal phalanx. complete and exited the adjacent metaphysis; two were in
foals [14].
have been described comprehensively in a specialist
arthroscopy text [11] and will not be discussed further
here. Fractures can broadly be divided into articular
Salter–Harris Fractures
(Figure 19.8) and non-articular. They can occur during Salter–Harris fractures of the proximal phalanx are rare
training or racing, or while horses are at pasture, with the injuries in foals and weanlings. Two series of physeal frac-
latter common in yearlings [33]. Non-articular fractures tures in foals comprising 160 cases included only four
are more common in yearlings and may represent avulsion involving the proximal phalanx [35, 36]. In total, only
injuries of the distal sesamoidean ligaments. They occur seven cases have been documented in the literature of
laterally and medially, and hindlimbs appear over- which five involved hindlimbs. Type II, III, and IV frac-
represented. Fractures are usually complete and displaced tures have been reported [14, 35, 37, 38].
(a) (b) (c)
Figure 19.7 (a) Lateromedial and (b) dorsal 10° lateral–palmaromedial oblique radiographs. (c) Transverse CT image of a proximal
dorsal fracture of the proximal phalanx centred medially (arrows).
Incidence and Causatio 395
Figure 19.8 (a) Lateromedial and (b) dorsal (a) (b)

45° medial–palmarolateral oblique
radiographs of a complete displaced
fracture of the medial palmar process.
Figure 19.9 (a) Lateromedial and (b) dorsal (a) (b)

45° lateral–palmaromedial oblique
radiographs of a distal medial articular
fracture/fragmentation.
are lacking. In TB racehorses in the UK, the proximal pha-

Incidence and Causation lanx and the third metacarpal/metatarsal bone have been
reported as the most commonly fractured long bones [40].
Epidemiology
Age distribution is heavily biased by the populations
Fractures of the proximal phalanx are common injuries in from which case series have been reported. In series of TB
racing TBs [13–15, 21, 22] and SBs [14, 21, 39]. Less fre- racehorses in the UK, two-year-old horses were most com-
quently fractures are seen in horses not used for racing. monly affected [13, 15], and were considered to be over-
The majority of the latter are short incomplete parasagittal represented in the population from which they arose [13].
fractures [16–18], but all and any configurations are Injured horses were older in series of mixed TB and SB
encountered. A variety of configurations of fracture are populations from North America; mean ages in two studies
also seen in endurance horses, but reports in the literature were 4.2 years [14] and 3.3 years [21] .
In TB racehorses, forelimbs have been consistently from a series of 110 cases included thickening the proximal
reported as more frequently affected than hindlimbs [13, subchondral bone plate in affected compared to contralat-
15, 21], but with no left/right predisposition. No consistent eral limbs. Fractures were not associated with traumatic
fore/hind or left/right distribution has been reported in SB events, occurred during high-speed exercise, were site spe-
racehorses [14, 21, 39]. The difference may be related to the cific and followed repeatable courses. In addition, peri-
different racing gaits, with more even weight distribution osteal new bone recognized in a proportion of horses in the
between limbs in trotters and pacers. No gender predispo- affected or contralateral limb associated with the site of
sition has been identified [13–15, 21]. fracture (consistently dorsoproximal) was considered rep-
Overall, fractures have been more commonly reported in resentative of prodromal changes. These authors also sug-
horses during training than racing [13, 15, 23, 40], but com- gested that at least a proportion of parasagittal fractures
minuted fractures in SB horses have been recorded more should be considered as stress or fatigue injuries [20].
commonly when racing [23]. A study examining subchondral bone density and thick-
ness in TB horses with different training histories identified
differences in parameters across the proximal osteochon-
Aetiopathogenesis
dral surface of the bone. Subchondral bone of the sagittal
Parasagittal fractures of the proximal phalanx commence groove appears to adapt to race training by increasing in
almost invariably in the proximal sagittal groove [13–15, volumetric mineral density relative to unraced controls.
21, 41]. Debate exists regarding their aetiopathogenesis. The contralateral proximal phalanx in horses that had sus-
One of the earliest reports in the literature stated that frac- tained a fracture had more variance in subchondral bone
tures were of the result of fatigue or repeated stress [41]. It volumetric mineral density than in horses that had raced
was stated that they occur in stages, beginning as fissures but not sustained a fracture. The authors suggested that this
and extending until an apparently normal weight-bearing had potential aetiopathologic implications as subchondral
action brings about complete dehiscence. Periosteal new bone adaptation in these horses was less constrained and
bone at the dorsoproximal aspect of the proximal phalanx robust [46]. However, recent arthroscopic observations
was documented with short fissure fractures, and it was from clinical cases have identified consistent abnormalities
concluded that this feature indicates that the process is that cannot readily be explained by either previously pro-
four to six weeks old at the time of diagnosis. posed aetiopathologic mechanisms. Acute haemorrhagic
Thereafter, accounts in the literature favoured monotonic tearing of the joint capsule and dorsal plica has been identi-
(supraphysiological) loading as the preferred pathoaetiologi- fied in multiple cases with both complete and incomplete
cal theory. One theory proposed that sagittal fractures occur non-displaced fractures [47]. While this may be an epiphe-
during the second half of the stride, as the fetlock is moving nomenon, there may also be pathogenetic significance,
from an extended to flexed position. At this time, the proxi- which would be inconsistent with stress-related bone
mal phalanx is rotating from lateral to medial around its failure.
long axis, and a sudden increase or change in acceleration of At the current stage of understanding, it appears likely
the rotary movement (as may be caused by slipping of the that there is more than one pathogenetic pathway to clini-
hoof on the ground) results in the sagittal ridge of the distal cal fractures although fast exercise is a common predispos-
third metacarpal/metatarsal bone acting as a wedge [42]. ing factor.
Subsequent authors concurred and reported a pathogenesis
of longitudinal compression and asynchronous lateral to
medial rotation of the proximal phalanx in relation to the Clinical Features and Presentation
third metacarpal/metatarsal bone [43, 44].
More recently, there have been a number of clinical Longitudinal fractures typically occur during fast exercise.
observations, and experimental work, implicating repeated Horses may pull up lame acutely or develop lameness of
stress and fatigue in aetiopathogenesis. Finite-element increasing severity shortly following exercise. Development
analysis demonstrated high simulated stress levels associ- of lameness often coincides with distension of the MCP/
ated with the proximal sagittal groove [45]. Abnormalities MTP joint. Palpation of the dorsoproximal aspect of the
detected in the sagittal groove of TB racehorses with mag- proximal phalanx is frequently painful with parasagittal
netic resonance imaging, scintigraphy and radiography fractures. Complete fractures often develop a plaque of
were considered to represent prodromal fracture pathol- haemorrhage subcutaneously along the fracture line.
ogy. It was therefore proposed that some fractures of the When fractures exit in the PIP joint, this is frequently dis-
proximal phalanx may be the result of repetitive stress/ tended. With comminuted fractures, there is extensive
fatigue rather than monotonic injury [19]. Observations swelling circumferentially around the pastern, and crepitus
Imaging and Diagnosi 397
is often evident on manipulation of the distal limb. and are best imaged in the distal part of the bone with this
Overriding fractures may result in segmental shortening. radiographic projection to observe the fracture coursing
Short incomplete fractures often present as chronic through the lateral condyle to the articular surface. Some
injuries, with periosteal and/or endosteal new bone can turn sufficiently to be visible in lateromedial projections.
apparent radiographically at the time of presentation, With comminuted fractures, further oblique images can
suggesting preceding osseous compromise. In these assist in defining fracture configuration. Short proximal dor-
cases, thickening may be identified on the dorsoproximal sal fractures can often be identified in lateromedial projec-
aspect of the bone. tions, but as these most commonly involve the medial
proximal eminence of the bone are usually radiographically
most apparent on dorsal 70–80° lateral–palmar/plantarome-
Imaging and Diagnosis dial oblique views.
Short incomplete parasagittal fractures frequently display
Diagnosis is confirmed by radiography. Four orthogonal pro- thickening of the subchondral bone of the proximal pha-
jections should be obtained as a minimum standard. If the lanx in the region of the sagittal groove and periosteal and/
fracture is slightly oblique from a parasagittal plane, further or endosteal new bone at the dorsoproximal aspect of the
dorsopalmar/dorsoplantar projections angled obliquely by a proximal phalanx [16, 17]. In cases that are localized by
few degrees either medially or laterally may enable better nuclear scintigraphy, an area of focal marked increased
characterization of the configuration. Frequently, multiple radiopharmaceutical uptake is observed consistent with the
fracture lines may be observed on dorsopalmar/plantar radi- location of fracture, usually dorsoproximally (Figure 19.11).
ographs representing the fracture coursing through the dor- CT examination performed under general anaesthesia
sal and palmar/plantar cortices. It is sometimes possible to immediately prior to surgery offers superior characteriza-
discern the fracture within the dorsal and palmar/plantar tion of fracture configuration and enables more accurate
aspects of each cortex, and dense subchondral bone, result- pre-operative surgical planning. The development of a
ing in four or more parallel fracture lines in a simple fracture lightweight portable scanner (Cerotom™, Samsung) has
(Figure 19.10). The presence of periosteal and/or endosteal enabled rapid and practical acquisition of images, and in
new bone at the dorsoproximal aspect of the proximal pha- the author’s hospital this has resulted in routine CT imag-
lanx is indicative of fractures resulting from chronic fatigue ing of all repaired fractures of the proximal phalanx. The
failure. In the acute phase, some incomplete fractures may unit is used with the horse positioned on the surgical table
not be radiologically discernible. Repeating radiography with the limb either supported using a custom carbon fibre
after 7–10 days allows time for osseous resorption along the limb support or by a cup at the level of the proximal meta-
fracture line and often permits identification. Complete par- carpus/metatarsus (Figure 19.12).
asagittal fractures exiting into the PIP joint frequently spiral CT permits accurate mapping of comminuted fracture
into a dorsolateral-palmar/plantaromedial oblique plane configurations and three-dimensional visualization for the
Figure 19.10 (a) Dorsoplantar (a) (b)

radiograph of a long incomplete
parasagittal fracture. Proximally, three
fracture lines are visible representing the
fracture in the dorsal and palmar cortices
and the dense subchondral bone. (b)
Corresponding transverse CT image of the
proximal epiphysis.
(a) (b) location and thus optimal implant position are impossible to
determine from two-dimensional radiographs.
In the acute phase, horses should be administered pain

relief, which is most effectively achieved with non-steroidal
anti-inflammatory drugs (NSAIDs). If the horse is distressed
or anxious, acepromazine can be useful. External support
and immobilization should ideally be tailored according to
fracture configuration. Prior to radiographic imaging, immo-
bilization and support of suspected parasagittal fractures is
best achieved with a compression boot or a Robert Jones
bandage (Chapter 7). When comminuted fractures are sus-
pected, a bandage cast is usually most appropriate. Horses
should then be transported to a hospital facility for definitive
treatment in the acute phase following injury.
Figure 19.11 Lateral (a) and dorsal (b) nuclear scintigraphic

images of a dorsal short incomplete parasagittal fracture of the
proximal phalanx.
reatment Options
T
and Recommendations

Conservative management of short incomplete fractures
consisting of periods of stall rest and bandaging has been
widely reported. If conservative management is employed,
horses should be confined to a stable until walking sound
and then undertake a progressive programme of walking
exercise, with radiographic monitoring of fracture
healing.
Surgical management, ideally directed by CT, is recom-
mended for most cases. Following induction of anaesthe-
sia, the horse is positioned on the surgical table for CT
examination. This is performed with the horse in lateral
Figure 19.12 A portable CT scanner enables the machine to be recumbency with the affected limb uppermost. Surgical
brought to the patient positioned on the surgical table. planning is dictated by fracture configuration. Important
points of consideration include whether the fracture is uni-
operating surgeon, facilitating optimal implant placement cortical, bicortical or central and fracture length. Bicortical
and trajectory. CT studies often identify greater proximodis- and central fractures are most appropriately repaired by lag
tal length of long incomplete parasagittal fractures than pre- fashion placement of a single 4.5 mm AO/ASIF cortex
dicted radiographically with distal extension of the fracture screw from lateral to medial in the centre of the bone,
in the dorsal cortex a common observation. Radiologically immediately distal to the subchondral bone of the sagittal
undetected comminution has been identified in both incom- groove. Unicortical fractures involving the dorsal cortex
plete and complete parasagittal fractures, both at the proxi- and subchondral bone only are relatively common, par-
mal articular surface and within the diaphysis of the bone. ticularly in TB racehorses, and frequently extend only mil-
Displacement, particularly in a dorsopalmar/plantar plane, limetres beyond the subchondral bone plate. Repair is most
is more readily identified by CT than two-dimensional radi- effectively achieved by eccentric positioning of a 3.5 or
ography. Surgical planning for repair of short incomplete 4.5 mm AO/ASIF cortex screw, determined by the length of
parasagittal fractures is benefitted by pre-operative CT. the fracture, in lag fashion from lateral to medial, in the
Confident determination of dorsopalmar/plantar fracture dorsoproximal aspect of the bone immediately beneath the
subchondral bone plate. Unicortical fractures involving the lateral recumbency, the limb is supported with a cup
palmar/plantar cortex and subchondral bone are relatively attached to the surgical table at the level of the foot. The
uncommon and are repaired by eccentrically positioned proximal phalanx should be positioned horizontally.
palmar/plantar screws. Once fracture configuration has Following routine limb preparation and draping, percuta-
been mapped by CT (Figure 19.13a), and implant position neous marker needles are placed laterally (16G) and
determined, measurements should be obtained from mul- medially(19G) at the proposed site and trajectory of screw
tiplanar reconstructed images in the plane of proposed placement. Lateromedial and dorsopalmar/plantar radio-
implant trajectory. Due to the dorsal curvature of the proxi- graphs are obtained to assess and adjust needle positions
mal phalanx, when eccentrically positioned screws are to until these correspond to the planned implant placement
be placed, measurements obtained using CT will differ sig- (Figure 19.13b). The extensor branch of the suspensory
nificantly from radiographic measurements of the width of ligament is a useful anatomic landmark for the dorso-
the bone at the level of implant placement. palmar/plantar mid-point of the bone at the level of screw
For surgical repair, the horse remains in lateral recum- placement. A stab incision is made parallel to this onto the
bency with the affected limb uppermost, unless there is cortical surface of the bone. With an assistant guiding tra-
indication for concurrent arthroscopic examination of the jectory, routine lag fashion repair (Chapter 8) is performed
MCP/MTP joint, when dorsal recumbency is preferred. In using either a 3.5 or 4.5 mm AO/ASIF cortex screw. Implant
(a) (b)
(c) (d) (e)
Figure 19.13 Repair of a short, dorsal incomplete parasagittal fracture. (a) Pre-operative transverse CT image. (b) Intra-operative
lateromedial radiograph with marker needles at the proposed site of screw placement. Intra-operative dorsopalmar (c) and
lateromedial (d) radiographs following repair with a 3.5 mm cortex screw. (e) Post-operative transverse CT image confirming that the
screw has crossed the fracture, is below the sagittal groove and is of appropriate length.
position should be assessed radiographically and/or with (a)

CT at the end of the procedure (Figure 19.13c–e). The sur-
gical incision is closed with skin sutures only, and a lightly
padded bandage fitted. Horses may be allowed to recover
unassisted from general anaesthesia.
Administration of antimicrobials and non steroidal anti-
inflammatory drugs is only required peri-operatively.
Bandages are maintained until suture removal at 14 days
following surgery. Horses begin walking exercise following
discharge from the hospital, and duration is gradually
increased over one month before radiographic review. If
clinical and radiographic progress is satisfactory, trotting
exercise progressively increases for at least one further
(b)
month before increasing exercise intensity.
Long Incomplete Parasagittal Fractures

Conservative management of long incomplete parasagittal
fractures has been reported [13, 14]. It consists of stall rest
and bandaging for 6–10 weeks, followed by a gradual return
to exercise over a further six weeks. This approach can be
successful, but carries risk of fracture propagation and is
not recommended.
Surgical Repair – Dorsal Screw Configuration Figure 19.14 (a, b) Positioning of a horse in lateral recumbency
Fractures are best repaired under general anaesthesia with for repair of a long incomplete or complete parasagittal fracture.
the horse in lateral recumbency and the affected limb The limb is horizontal and supported with a cup at the foot.
uppermost. An Esmarch bandage and tourniquet are There should be as little rotation as possible, which in hindlimbs
is aided by further support at the hock. The surgeon should note
applied to the level of the proximal metacarpus/metatar- the degree of any remaining limb rotation and account for this
sus. The leg is placed in a limb support attached to the sur- during surgery. An Esmarch bandage tourniquet has been fitted.
gical table, with a cup at the level of the foot. The proximal
phalanx should be horizontal and parallel to the ground help guide drill trajectory in a proximodistal plane by
surface (Figure 19.14). viewing from directly in front of the limb (Figure 19.16).
Following aseptic preparation of the limb and draping, Limb rotation should be considered by the surgeon when
percutaneous marker needles are placed at the proposed drilling, with the aim of ensuring screws exit the mediolat-
sites of implant positioning. The extensor branch of the eral mid-point of the bone. The vast majority of long
suspensory ligament is a useful guide for the placement of incomplete parasagittal fractures remain in a parasagittal
the proximal two screws. The mediolateral mid-point of plane as they propagate distally, making lateral to medial
the bone at the level of the most proximal screw corre- positioning of screws most appropriate. The proximal
sponds to a site immediately dorsal to the extensor branch screw hole should be countersunk conservatively due to
of the suspensory ligament. At the usual site of second the relatively thin proximal cortex. Adequate screw length
screw placement, the mid-point is immediately palmar/ is required to engage the full width of the far cortex to
plantar to this. Further needles are placed at equal dis- minimize risk of screw stripping. If this occurs, in the first
tances distally according to the number of screws to be instance engagement of the full thickness of the far cortex
used for repair. Appropriate needle positioning is con- should be confirmed and if necessary, a longer screw
firmed or adjusted from a dorsopalmar/plantar radiograph inserted. A dorsopalmar/plantar radiograph is obtained
(Figure 19.15a and b). Digital radiography enables rapid following placement of all screws to confirm appropriate
acquisition and is recommended for intra-operative imag- length and positioning (Figure 19.15c) prior to closure of
ing. Following confirmation of proposed implant position- the surgical incisions with skin sutures. Horses are recov-
ing, routine lag fashion repair is performed through ered from general anaesthesia following placement of a
percutaneous stab incisions, positioning screws sequen- half limb cast, or in a padded bandage at the surgeon’s dis-
tially from proximal to distal. A non-sterile assistant can cretion. The cast is used to provide additional support to
(a) (b) (c)
Figure 19.15 Dorsopalmar radiographs during repair of a long incomplete fracture. (a) At presentation and (b) with percutaneous
needles at the proposed sites for implant placement. (c) Following screw insertion.
Rehabilitation typically involves stable rest for the first

four weeks following surgery, followed by a graduated pro-
gramme of exercise involving two months of walking and a
further six to eight weeks of trotting before cantering is
resumed. Fracture healing is monitored radiographically,
and exercise guidelines are adjusted accordingly.
Surgical Repair – Triangular Screw Configuration

Triangular screw configuration represents another option
of screw placement (Figure 19.17). It has been suggested
that this configuration reduced time to soundness and
decreased callus on the dorsal aspect of the bone [48].
Time to first race was shorter in a case series of
Thoroughbred racehorses repaired using a triangular
screw technique compared to a single proximal screw [49].
Figure 19.16 An assistant lining up for the surgeon to ensure
screws are placed perpendicular to the long axis of the bone. The An in vitro experiment demonstrated improved fracture
surgeon needs to line up in an appropriate dorsal plane, gap reduction and stability compared to use of a single
depending on the degree of limb rotation. Note the slight obliquity proximal screw [50].
to compensate for residual outward rotation in this hindlimb. The proximal screw in the triangular configuration is
placed in the dorsal half of the bone, immediately beneath
the fracture during anaesthetic recovery and is usually the subchondral bone of the sagittal groove. A second
removed within the first 48–72 hours following surgery. screw is placed parallel to the first screw and at the same
Peri-operative antimicrobial and NSAID administration proximodistal level, in the palmar/plantar half of the bone.
only is recommended. Thereafter, continued daily adminis- The latter should be positioned cautiously to avoid engage-
tration of NSAIDs is performed to maintain reasonable lev- ment of or emergence through the concave palmar/plantar
els of comfort at walk, which often extends to between five cortex. Further screws are placed distally as described in
days and two weeks following surgery. Padded bandages are Section “Short Incomplete Parasagittal Fractures,” accord-
maintained until suture removal 14 days post-operatively. ing to fracture length.
(a) (b) (c)
Figure 19.17 Pre-operative (a) and post-operative dorsopalmar (b) and lateromedial (c) radiographs of a repaired long incomplete
parasagittal fracture using two proximal screws. Source: Courtesy of Bruce Bladon.
Standing Fracture Repair comprehensive evaluation of the dorsal pouch of the joint.
Non-displaced incomplete parasagittal fractures can be Fracture displacement is assessed and under arthroscopic
repaired with the horse standing using sedation and local control, reduction achieved by a combination of limb
anaesthesia [51]. The technique is advocated to avoid gen- manipulation and torque applied to the insert drill guide.
eral anaesthesia; however, there are inherent compromises Once the fracture is aligned, it is fixed with pointed reduc-
to surgical safety and asepsis. Standing repair of complete tion forceps. Reduction usually requires a combination of
fractures is contraindicated as anatomic reduction cannot limb rotation and extension of the fetlock joint. Once
effectively be assessed or achieved. The technique is achieved, standard lag fashion insertion of the proximal
described in Chapter 12. screw is completed. The fracture is observed arthroscopi-
cally as the screw is tightened to ensure there is no loss of
reduction. In complete fractures that exit into the PIP joint,
arthroscopic examination of the distal articular surface to
Arthroscopic evaluation of the MCP/MTP joint with surgi- assess reduction may also be undertaken. Experience to
cal repair under general anaesthesia is recommended for date suggests this is most useful for fractures that remain
all complete parasagittal fractures. Horses are positioned as parasagittal in orientation and with more marked displace-
described for long incomplete parasagittal fractures, but it ment. If further reduction is required distally, then once
is important that the foot is not fixed to the limb support, achieved the distal most screw is placed next. Otherwise,
leaving it free for manipulations to assist or effect fracture placement of remaining lag screws is performed from proxi-
reduction. Individual surgeons vary in the order of surgery. mal to distal using routine technique. If the fracture spirals
The following is the author’s preferred process. into an oblique plane, screws should also be positioned
Following aseptic preparation of the limb and draping, a obliquely, perpendicular to the fracture plane. This most
marker needle is placed laterally at the proposed site for the commonly involves one or two distal screws with palmar/
proximal screw. After radiographic confirmation of appro- plantarolateral lateral to dorsomedial oblique trajectories.
priate positioning, a percutaneous stab incision is made Four screws are adequate for repair of complete fractures
onto the surface of the bone. A glide hole is drilled using a spanning the entire length of the bone.
4.5 mm drill bit to the depth of the fracture, and a 3.2 mm At the end of the procedure, a dorsopalmar/dorsoplantar
insert drill sleeve is positioned in the glide hole. Arthroscopic radiograph is obtained, and with oblique fractures and screws,
examination of the MCP/MTP joint is now undertaken. appropriate tangential images are also required (Figure 19.18).
Initial lavage is performed to clear haemorrhage before a Screw lengths should be adjusted, if necessary, before final
(a) (b) ance is mandatory, but accurate alignment at the articular

surface is enhanced by direct visualization. Arthroscopy
avoids the morbidity associated with an arthrotomy,
reduces the risk of surgical site infection and post-operative
pain and enables simpler post-operative care protocols.
When sufficient information can be gained from this
approach, it is therefore preferable. However, when there is
extensive comminution of the proximal articular surface,
limitations of arthroscopic accessibility/visibility make
arthrotomy more appropriate.
Minimally Invasive Repair

Many moderately comminuted fractures can be repaired
using a combination of radiographic, CT and arthroscopic
guidance. This includes, for example, a complete parasagit-
tal fracture, with an additional complete dorsal plane frac-
ture isolating one palmar/plantar process. Pre-operative
CT is performed immediately following induction of gen-
eral anaesthesia with the patient on the surgical table. The
Figure 19.18 Intra-operative (a) dorsopalmar and (b) dorsal entire proximal phalanx is evaluated to map fracture con-
45° lateral–palmaromedial oblique radiographs following repair
figuration and to establish a surgical plan. The patient is
of a complete parasagittal fracture. Note the distal two screws
have been angled palmarolateral to dorsomedial to be positioned in the chosen lateral recumbency (dependent
perpendicular to the fracture. on fracture configuration) with the limb supported at the
foot. An Esmarch bandage tourniquet is applied to the
tightening and closure with skin sutures. A distal limb cast is proximal metacarpus/metatarsus.
placed for recovery from general anaesthesia and is generally Following routine aseptic preparation of the limb, and
maintained for 7–10 days following surgery. surgical draping, arthroscopic examination of the dorsal
Antimicrobials are administered peri-operatively. Non- pouch of the MCP/MTP joint is performed. Initial lavage is
steroidal anti-inflammatory drugs are given daily to main- required to clear intra-articular haemorrhage and enable
tain comfortable ambulation in the stable and are typically viewing of the articular surfaces. The parasagittal compo-
continued for between two and four weeks following sur- nent of the fracture is readily visible arthroscopically and
gery. Following cast removal, padded bandages of gradu- reduced using a combination of limb manipulation and
ally decreasing size are maintained until suture removal. pointed reduction forceps to ensure accurate alignment
Rehabilitation involves stable rest for four to six weeks (Figure 19.19). The dorsal (palmar/plantar process) frac-
after surgery, followed by a graduated programme of exer- ture is reduced under radiographic control (this region is
cise similar to incomplete fractures (Section “Surgical not accessible arthroscopically) using a second pair of
Repair – Dorsal Screw Configuration”). pointed reduction forceps. If alignment is satisfactory,
reconstruction is performed by lag fashion placement of
4.5 mm AO/ASIF cortex screws, under radiographic con-
Moderately Comminuted Fractures
trol, through percutaneous stab incisions. The order and
The intact strut of bone between proximal and distal articular orientation of screw placement is dependent on fracture
surfaces of moderately comminuted fractures generally per- configuration. The author’s favoured technique is to repair
mits stable reconstruction with screws placed in lag fashion. the parasagittal fracture initially. The proximal most screw
Most configurations are complex, and accurate determi- is positioned from lateral to medial (or vice versa depend-
nation of fracture numbers, sizes, shapes and planes is ent on fracture configuration), beneath the sagittal groove
challenging with radiography alone. CT provides accurate subchondral bone plate with distal screws placed in a simi-
mapping of fracture configuration and frequently identi- lar manner to simple parasagittal fractures. Subsequently,
fies radiologically silent comminution. The information the palmar/plantar process is repaired by interdigitating
obtained from three-dimensional imaging enhances surgi- screws with those used to reconstruct the parasagittal frac-
cal planning. ture. Screws may be placed either obliquely from palmar/
Reconstruction of the articular surfaces (principally the plantar to dorsal or from dorsal to palmar/plantar. If placed
MCP/MTP joint) should be prioritized. Radiographic guid- dorsopalmar, the proximal most screw in this orientation
(a) placed and maintained for a further five to seven days. A

four week period of stable rest is typically recommended
after cast removal. At the end of this period, subject to sat-
isfactory clinical and radiographic progress, walking exer-
cise may then start. Ongoing exercise programmes are as
described for parasagittal fractures.
Open Reduction and Internal Fixation

The surgical technique is as described by Kraus et al. [52].
The patient is positioned in lateral recumbency with the
most fragmented cortex uppermost and the distal limb free
of support. The limb is prepared in a routine aseptic fash-
ion and then draped. A curved skin incision is made dorso-
laterally or dorsomedially (according to fracture
configuration) with the base orientation palmar/plantar.
The incision is made to curve from the proximal extent of
(b) the palmar/plantar pouch of the MCP/MTP joint dorsally
over the mid-dorsal proximal phalanx before curving pal-
mar/plantar over the proximal margin of the middle pha-
lanx. The subcutaneous tissues are incised sharply down to
the joint capsule and common or long digital extensor ten-
don. The skin and subcutaneous tissues are reflected as a
single flap with as little dissection as possible. To make the
deep incision, a scalpel is used to enter the palmar/plantar
pouch of the MCP/MTP joint. Varus stress is applied in a
lateral approach (or valgus stress in a medial approach) by
placing a hand on the hoof wall and applying downwards
pressure. The incision is continued distally through the lat-
eral collateral sesamoidean ligament and then around the
condyle of the distal third metacarpal/metatarsal bone to
transect the collateral ligament of the MCP/MTP joint. The
incision through the collateral ligament should leave
Figure 19.19 Arthroscopic images of the central region of the
dorsoproximal aspect of the proximal phalanx. (a) The displaced
enough tissue proximally and distally to permit apposition
sagittal component of a moderately comminuted fracture during closure. The incision is extended dorsally through
(arrows). (b) The same area following fracture reduction. SR: part of the common/long digital extensor tendon until
sagittal ridge of Mc3. reaching the dorsal fracture line and then distally through
the same tendon for the length of the sagittal fracture
can be located proximal to the first lateromedial screw, plane. Subperiosteal dissection along the margins of the
which is placed a few millimetres further distal than nor- fracture fragments is performed with a scalpel or sharp
mal to accommodate this (Figure 19.20). Following com- periosteal elevator. The MCP/MTP joint is then luxated to
pletion of surgery, final screw positioning is assessed expose the articular surface of the proximal phalanx. The
radiographically and screw lengths adjusted if necessary. fracture planes are debrided of haematoma, fibrin and
Incisions are sutured, and a distal limb cast is placed for small fragments of bone and cartilage using a sharp pick or
recovery from general anaesthesia. bone curettes before the proximal articular surface is
Peri-operative antimicrobials and NSAIDs are adminis- reconstructed with 4.5 mm AO/ASIF cortex screws placed
tered. Ongoing requirement for analgesia varies according in lag fashion. Fragments are held in reduction digitally or
to fracture complexity, and continued administration of with bone reduction forceps. The sequence of reconstruc-
NSAIDs is often required for four weeks following tion begins with attachment of the fragments deepest from
surgery. the incision and proceeding outwards, towards the inci-
Cast support is generally maintained for 10–14 days after sion. The most proximal screws are directed dorsopalmar/
surgery, and thereafter ongoing requirement is assessed plantar so that lateromedial screws can be placed distal to
radiographically. After cast removal, a padded bandage is the sagittal groove. Smaller fragments are secured with
(a) (b) (c)
Figure 19.20 Intra-operative dorsopalmar (a), lateromedial (b) and dorsal 45° lateral–palmaromedial oblique (c) radiographs
following repair of the moderately comminuted fracture illustrated in Figure 19.4.
3.5 mm lag screws. Throughout the procedure, the exposed

Highly Comminuted Fractures
soft tissues are lavaged with sterile polyionic fluid contain-
ing broad-spectrum antimicrobials. The most distal por- The aim of repair of highly comminuted fractures is sal-
tion of the fracture is reconstructed with the aid of vage for breeding purposes and/or pasture soundness.
radiography or fluoroscopy with image intensification. At Return to athletic activities is not realistic. The principal
the end of surgery, screw placement is assessed radio- goals of surgery are reconstruction of the articular sur-
graphically and lengths are adjusted if necessary. The joint faces and re-establishment of bone length and axis to per-
capsule and ligaments are apposed in a simple interrupted mit stable load bearing through the limb while fracture
pattern with size 4 metric polyglactin 910. The remaining healing occurs. To date, these goals have most reliably
tissues are apposed similarly with 3 metric polyglactin 910 been met by transfixation casting (Chapter 13). Overriding
and the skin with non-absorbable suture or stainless steel of fracture fragments and shortening of bone length are
staples. A distal limb cast is placed for recovery from gen- common, and traction is an effective means of re-
eral anaesthesia. Assisted recovery (Chapter 10) should be establishing bone length [53]. Horses are anesthetized and
considered. positioned in dorsal recumbency. A wire or metal cable is
Peri-operative antimicrobials are continued for 72 hours inserted through holes drilled in the hoof in both heels or
following surgery. Non-steroidal anti-inflammatory drugs between the shoe and the foot in the heel region. This is
are administered as required to maintain comfortable then used to suspend the limb from an electric hoist which
ambulation around the stable in the cast. The duration of must be positioned to apply perfectly straight distal to
cast coaptation varies according to fracture complexity proximal force. Traction is applied, and reduction of frag-
and healing as assessed radiographically: four weeks coap- ments is monitored radiographically.
tation is common. The period of stable rest following cast In open fractures, the wound should be debrided and any
removal is guided by clinical and radiographic progress, loose fragments presented at the wound removed. Internal
but is rarely less than one month. Walking exercise follows fixation of larger fragments with 4.5 mm AO/ASIF cortex
and is continued until there is osseous union. Thereafter, screws placed in lag fashion is employed on a case-by-case
rehabilitation varies according to clinical progress and basis and can be contributory to reconstruction of the artic-
fracture healing and may involve varied periods of pasture ular surfaces and stabilization of major fragments.
exercise Whenever possible this should be done through
ercutaneous stab incisions under radiographic control.

p cases. Complete fractures are commonly displaced, and
Transfixation pin casting follows. accurate anatomic reconstruction is imperative to pre-
Peri-operative antimicrobials are administered and con- vent implant cycling and development of degenerative
tinued for 72–96 hours following surgery. NSAIDs are given joint disease.
as required to maintain comfortable ambulation around Surgery is performed under general anaesthesia with the
the stable. horse in lateral recumbency and the affected limb upper-
Transfixation casts are usually maintained for six to eight most. The limb is supported with a cup at the foot but left
weeks and followed by a distal limb cast for a further four free to permit manipulation for reduction. Repair is per-
weeks. Fracture healing is assessed radiographically and formed through stab incisions by lag fashion placement of
used to guide the duration of casting and ongoing 4.5 and/or 5.5 mm AO/ASIF cortex screws, inserted from
rehabilitation. dorsal to palmar/plantar, under radiographic control. The
Because of the extensive disruption of the articular sur- palmar/plantar cortex of the bone is relatively thin proxi-
faces, and inability to perform accurate reconstruction, mally, and only minimal screw thread engagement is pos-
marked degenerative joint disease of both MCP/MTP and sible. As such, there are potential advantages to use of
PIP joints is a common sequel. If necessary, fetlock arthro- 5.5 mm screws proximally and/or placement of two proxi-
desis can be performed as a delayed procedure [52]. mal screws (one medial and one lateral) to enhance stabil-
Other surgical techniques for repair are under develop- ity (Figure 19.21). Reduction of the proximal articular
ment but currently insufficient experience exists to offer surface is performed under radiographic control as the
guidelines. Cast coaptation alone has resulted in survival fracture cannot be viewed arthroscopically. Reduction is
in limited numbers of reported cases [13, 23] but carries frequently difficult to achieve. Screws are placed in order
substantial mortality risk due to fracture collapse, skin from proximal to distal. A half limb cast is fitted for recov-
penetration by fracture fragments and development of ery from general anaesthesia.
overload laminitis; it is therefore not recommended. Antimicrobials are administered peri-operatively only,
and non-steroidal anti-inflammatory drugs as required to
maintain comfortable ambulation in the cast. The duration
Long Frontal Plane Fractures
of cast coaptation varies depending on fracture complexity.
Complete fractures require reconstruction, and incom- Guidelines for the duration of cast coaptation, bandaging
plete fractures are at risk of propagating to become com- and ongoing rehabilitation are similar to incomplete and
plete; surgical repair is therefore recommended in all complete parasagittal fractures.
(a) (b) (c)
Figure 19.21 (a) Pre-operative lateromedial radiograph of a dorsal fracture of the proximal phalanx. (b) Lateromedial and (c)
dorsopalmar radiographs taken 16 days after repair with two proximal 4.5 and one distal 3.5 mm cortex screws.
Short Dorsoproximal Dorsal (Frontal) Plane displaced, protected with a half limb cast for recovery from
Fractures general anaesthesia.
Antimicrobials and NSAIDs are administered peri-
Conservative management of incomplete fractures can be
operatively only. If a cast is placed for recovery, this is removed
successful, although repair shortens recovery time [25] and
48–72 hours following surgery, and bandages are maintained
improves reliability of fracture healing. Surgical repair of
until suture removal 14 days post-operatively. Rehabilitation
complete fractures is always recommended and is effected
consists of one to four weeks of stable rest, followed by a grad-
by lag fashion placement of a single 2.7 or 3.5 mm AO/
uated exercise programme consisting of three to eight weeks
ASIF cortex screw (dependent on fragment size) [26].
of walking, and three to eight weeks of trotting, before resum-
If CT is available, this assists accurate placement of the
ing canter work. Fracture healing is monitored radiographi-
screw across the centre of the fracture. Following CT, the
cally, and exercise guidelines are adjusted accordingly.
horse is repositioned in dorsal recumbency, with the fet-
lock secured in extension. Repair is performed under
arthroscopic control. In the majority of cases, the medial Fractures of the Palmar/Plantar Processes
and lateral articular margins of the fracture can be identi-
Treatment is dependent on fracture size and location. Non-
fied, and percutaneous marker needles are placed perpen-
articular fragments are usually managed conservatively
dicular to the dorsal face of the bone to define externally
with stall rest and a progressive exercise programme.
the mediolateral extent of the fracture. The distal extent of
Surgical treatment is advised for articular fractures. Smaller
the fracture is located radiographically, and a further
fragments can be removed arthroscopically, and occasion-
marker needle is placed at this site. A final marker needle
ally access for removal of extra-articular fragments may be
is placed at the location, and in the proposed trajectory, of
possible by following fracture planes and dissection from
the screw; this is assessed radiographically and adjusted as
capsular and ligamentous attachments. Larger fragments
required. A stab incision is made down to the surface of the
may require open surgical approaches for removal. Surgical
bone, and routine lag fashion placement of a single 2.7 or
repair of larger articular fractures is recommended. This
3.5 mm screw follows [26]. The screw should be unicortical
involves lag fashion placement of one or multiple 4.5 or
and extend between half and two-thirds the dorsopalmar/
3.5 mm AO/ASIF cortex screws as determined by fragment
plantar width of the proximal phalanx, staying just beneath
size (Figure 19.23). In adults, conservative management of
the proximal subchondral bone plate (Figure 19.22). At the
displaced articular fractures results in degenerative joint
end of surgery, limbs are either dressed or, if pre-operatively
disease and is associated with poor outcomes. Articular
fractures in foals can heal by osseous or fibro-osseous
union. These less frequently result in degenerative joint
disease and, particularly in hindlimbs, may not impair ath-
letic use.
Surgery is performed in lateral recumbency with the frac-
tured palmar/plantar process uppermost. An Esmarch band-
age and tourniquet applied to the level of the proximal
metacarpus/metatarsus are useful to minimize haemor-
rhage. Fragment reduction is first attempted under radio-
graphic control using pointed reduction forceps. If
satisfactory, repair is performed through percutaneous stab
incisions. Frequently satisfactory reduction cannot be
achieved in this fashion, and an open approach is then per-
formed. A vertical or curved incision is made over the affected
palmar/plantar process, dorsal to the neurovascular bundle,
which is then retracted palmar/plantar. If fragment removal
is to be performed, the incision is continued through the dis-
tal part of the annular ligament and fetlock joint capsule to
expose the articular surfaces. With the joint in flexion, the
fragment can be dissected from soft tissue attachments and
removed. Repair of larger fragments uses the same surgical
Figure 19.22 Intra-operative lateromedial radiograph
following repair of the short proximal dorsal fracture depicted approach. Reduction is challenging. Fracture margins are fre-
in Figure 19.7 with a 3.5 mm cortex screw. quently impossible to delineate arthroscopically while open
Cast coaptation is recommended for 10–14 days after sur-

gery, and radiographic examination is performed prior to
removal. Thereafter, limbs are bandaged for a further five
days and until after suture removal. Horses are confined to
a stable for one month after cast removal and, if progress is
satisfactory, walking exercise commences. Thereafter,
rehabilitation is typically similar to complete parasagittal
fractures.
Distal Joint Fractures

Lag fashion repair of complete fractures is recommended.
Reduction should be performed under radiographic and
arthroscopic guidance. Implant selection is based on frag-
ment size and fracture configuration.
Salter–Harris Fractures
Conservative management by bandage or cast coapta-
tion, and stall rest, is a reasonable approach in non-
displaced or minimally displaced cases but bandage-and
Figure 19.23 Intra-operative dorsal 45° medial–
cast-related complications are common. Effective surgi-
palmarolateral oblique radiograph following repair of the
fractured medial palmar process depicted in Figure 19.8 cal stabilization minimizes requirements for casting and
utilizing 2 × 4.5 mm and 1 × 3.5 mm cortex screws. bandaging, and prevents fracture displacement and mal-
union. Dorsally applied locking compression plates pro-
reduction allows exposure of the distal aspect of the fracture vide sufficient construct stability. Further information is
only due to proximal investment within the origin of the dis- provided in Chapter 37.
tal sesamoidean ligaments and fetlock joint capsule. The dis-
tal aspect of the fracture is exposed by reflection of the
periosteum and careful, limited reflection of ligamentous Results
and capsular attachments. Reduction is performed by frag-
ment manipulation and maintained with pointed reduction The majority of reports detailing outcome for horses sus-
forceps. Accuracy is further assessed radiographically. Lag taining fractures of the proximal phalanx relate to either
fashion repair is performed by placement of one or multiple TB or SB racehorses from the UK and North America. Most
3.5 or 4.5 mm AO/ASIF cortex screws, depending on frag- document cases with parasagittal [13, 14, 21, 22, 39, 51, 54]
ment size, angled obliquely perpendicular to the fracture or comminuted [13, 22, 23, 52] fractures. Reported out-
plane. When the fragment is of sufficient size, two screws come for other disciplines is limited and where available is
confer advantageous rotational stability to the repair. Care is discussed under each specific fracture configuration.
required to angle the screws sufficiently distal to avoid pene- Broadly similar results have been reported between
tration of the proximal articular surface. At the end of the series documenting rates of return to racing. The prognosis
procedure, the surgical incision is reconstructed in layers and following treatment of short and long incomplete parasag-
the horse is recovered from general anaesthesia with a distal ittal fractures is good, and superior to complete parasagittal
limb cast. fractures, where a lower rate of return to racing has been
When fractures can be repaired through percutaneous reported [13, 14, 21, 22]. All except relatively simple com-
stab incisions, peri-operative antimicrobials only are minuted fractures are unable to return to athletic function,
administered. Following open reduction and internal fixa- and rates of survival are considerably lower than for other
tion, antimicrobials are continued for 72 hours following fracture configurations [13, 22, 23, 52]. Horses returning to
surgery. Non-steroidal anti-inflammatory drugs are admin- racing do so typically between 200 and 400 days following
istered peri-operatively and following surgery as required injury. Time to first race is related to fracture configuration,
to maintain comfortable ambulation at walk. Requirements with short incomplete fractures taking less time than long
vary according to fracture complexity, but often extend incomplete fractures and complete fractures taking longer
only to three to five days after surgery. still [21, 22]. Time from injury to returning to racing is
Result 409
influenced not only by the duration of fracture healing and lanx two and a half years after initial diagnosis. Internal
time taken to regain fitness, but also by the seasonality of fixation was performed in the remaining five cases; all
racing, with few horses able to race again in the same sea- were sound at follow-up examinations, had radiologic frac-
son in which the fracture was sustained. ture healing and had returned to previous levels of activ-
While results are broadly similar between studies, a multi- ity [16]. The same group subsequently reported 24/27
tude of factors can influence outcome, including geographic (89%) sport horses returning to their intended uses follow-
differences in racing regulations (particularly the ability to ing lag screw fixation [55].
race while receiving non-steroidal anti-inflammatory drugs),
value of horses, breeding potential and a tendency for longer
Long Incomplete Parasagittal Fractures
racing careers in North America.
SBs have been reported to have a higher rate of return to Two papers report results of conservative management
racing compared to TBs [14], which is consistent with find- with two of two horses returning to athletic activity [14]
ings of series looking at just SB [39] or TB [13, 22] populations. and 11 of 17 horses returning to racing [13]. Results are
However, in a series of mixed SB and TB horses, similar results similar to surgical management, but propagation into com-
were reported for each breed [21] and overall with only 61% of plete fractures is a risk.
SBs returning to racing compared to 88% [39] and 77% [14] Surgical repair by screws placed in lag fashion has been
reported elsewhere. It has been suggested that more even successful in multiple reports. All five cases in one report
weight distribution during racing gaits in SBs compared to returned to athletic function [14]. In a further report, six
TBs could be relevant. cases were managed surgically, of which three returned to
Two-year-old horses have been reported as more likely to racing, two were immediately retired to stud and one did
return to racing than horses that fracture at three years of not race for unknown reasons [13]. In a series consisting of
age or older [22]. In TB racehorses in the UK, careers are predominantly SB horses, 21 of 32 (65%) horses returned to
short, with very few horses continuing to race on the flat at racing at a mean of 303 days following repair and at pre-
four years of age or older. In consideration of this, along injury levels of performance [21]. Out of 86 repaired frac-
with the period of convalescence required following injury, tures in TB racehorses in the UK, 49 (57%) raced after
and the seasonality of flat racing in the UK, it is unsurpris- surgery at a mean of 325 days from repair. Of those cases
ing that fewer horses that fracture at three years of age or that raced both before and after injury (43% and 49%), there
older return to racing. was no difference in earnings [22].
Length of fracture has been documented to be associated
with return to racing, with likelihood decreasing with
increasing fracture length [22, 39].
Outcome of 29 complete parasagittal fractures was reported
as part of a series of 69 non-comminuted fractures of the
proximal phalanx in horses from North America. All except
Eleven short incomplete parasagittal fractures were two were repaired by screw placement in lag fashion; five
included as part of a series of 69 horses with fractures of cases were lost to follow-up. One horse was euthanized
the proximal phalanx from North America. All were man- because of persistent surgical site infection, and three due
aged conservatively, of which four returned to race training to persistent lameness. Fourteen (48%) horses returned to
and one was used as a competitive show horse [14]. training or racing, three returned to pleasure or showing
A series of fractures of the proximal phalanx in UK- activities, and three were retired to breeding. More SBs
based TB racehorses included 61 cases with short incom- returned to training or racing than TBs [14].
plete fractures. Conservative management resulted in 36 of In a further series of North American racehorses, 11 out
60 horses (60%) going on to race. Three cases propagated to of 20 returned to racing following lag screw repair, at a
become complete by exiting through the lateral cortex two mean of 328 days following surgery. Horses with fractures
or three weeks following injury. The sole repaired case exiting into the proximal interphalangeal joint had worse
returned to racing following treatment [13]. In a further outcomes (46%) than fractures exiting through the lateral
series of UK-based TB racehorses reporting outcome of cortex (71%) [21].
repaired fractures, 11 of 12 cases returned to racing at an The first of two series of UK TB racehorses reported
average of 234 days following surgery [22]. results for 12 complete fractures. No case managed con-
In a report of nine non-racehorses, four were managed servatively returned to athletic use. Lag fashion repair
conservatively, of which only one became sound and one was undertaken in six horses, of which three returned to
suffered a comminuted fracture of the same proximal pha- training or racing and three were retired immediately to
stud following surgery [13]. The second series included (with an intact strut of bone between proximal and distal
12 repaired fractures of which six (50%) raced following articular surfaces) and highly comminuted fractures (with
surgery, which was comparable to long incomplete par- no intact strut). Moderately comminuted fractures were
asagittal (57%) but less than short incomplete (92%) repaired by open reduction and internal fixation. In cases
fractures [22]. with only minimal displacement and limited to three frag-
ments, repair was performed without arthrotomy. In all
other moderately comminuted fractures, an arthrotomy
Comminuted Fractures
with collateral ligament transection was performed. Highly
Many cases with comminuted fractures of the proximal comminuted fractures were treated by transfixation pin
phalanx are euthanized without treatment. Options are casting in all except one case which was managed with cast
often limited by surgical experience or financial con- coaptation alone. Thirty-three of 36 (92%) horses with
straints. While all comminuted fractures are serious, the moderately comminuted fractures survived. Seven of these
category includes a wide range of severities, from those returned to training, and four SB horses returned to racing.
which with appropriate reconstruction are able to return to Out of 20 cases with highly comminuted fractures, 12
athletic function to those in which salvage is not possible (60%) survived. Three of these underwent fetlock arthrode-
with any technique. Interpretation of reports on outcome sis as a delayed procedure for management of severe
should be viewed in this light. degenerative joint disease. The case managed with cast
A variety of treatment methods were employed in a coaptation only was euthanized [52].
series of 30 horses reported from North America. None of Outcome following transfixation pin casting has been
three horses treated by open reduction and internal fixa- reported in a series of 12 horses (10 adults and 2 foals).
tion with lag screws only survived. However, three of Fractures were reported as comminuted in 11 and articular
eight horses survived that were treated by open reduction in the remaining case. Fractures healed in 11 horses [56]. A
and internal fixation with a combination of a dorsally modified technique for transfixation pin casting was subse-
positioned dynamic compression plate and additional quently described, and outcome was reported in eight
screws placed in lag fashion. Two cases with moderate horses with comminuted fractures of the proximal pha-
comminution were treated solely by lag screws placed lanx. Four of these cases also underwent limited internal
through percutaneous stab incisions. Both survived and fixation with AO/ASIF cortex screws. Seven of eight horses
one raced following injury. Cast coaptation was used as survived to breeding or pasture activity [53].
the only method of support in three cases, of which two
survived. Transfixation casting was employed in four
Long Frontal Plane Fractures
cases, of which only one survived to discharge, but this
horse fractured the transfixed third metacarpal bone Outcome of only four cases have been reported [13, 24].
seven months post-operatively while turned-out at pas- Degenerative joint disease developed in the affected fetlock
ture. In this series, four of seven horses that had an intact joint of two pleasure horses following repair; although
strut of bone between the fetlock and pastern joints sur- both horses returned to riding activities, intermittent lame-
vived, whereas only 3 of 13 without an intact strut sur- ness was observed [24]. Two TB racehorses managed con-
vived. Infection was a major complication, particularly servatively survived, but neither returned to racing [13].
with open surgical procedures [23].
An early series of fractures in UK TB racehorses
Short Dorsoproximal Dorsal (Frontal) Plane
included outcome of 19 horses with comminuted frac-
Fractures
tures. Ten had treatment attempted, and nine were euth-
anized without treatment. Treatment approach varied In one report, two cases that underwent repair returned to
between cases and was considered successful in nine racing and were able to resume training after three months.
horses. Three cases were managed with cast coaptation There was no evidence of degenerative joint disease of the
alone due to inability to reconstruct the articular surface affected fetlock joint. In contrast, cases managed conserva-
and/or maintain longitudinal stability of the bone. The tively took longer to heal, although four of six non-
remainder underwent repair with cortex screws placed in displaced fractures returned to work. Degenerative joint
lag fashion, of which all except one survived. Severe fet- disease and intermittent lameness were observed in a case
lock and pastern joint degenerative joint disease was that presented with a chronic, displaced fracture managed
observed commonly [13]. conservatively [25].
The largest series included 64 cases from North America. In a recent series of 21 cases, radiologic fracture healing
Cases were divided into moderately comminuted fractures was consistently observed, between eight and 16 weeks
Reference 411
following surgical repair. No reactive or degenerative degenerative joint disease and may result in implant
changes were observed, and 16 of 21 (76%) horses success- cycling. If accurate anatomic reduction and stabilization
fully returned to racing [26]. can be achieved, a good outcome can be expected.
Fractures of the Palmar/Plantar Processes Salter–Harris Fractures

Non-articular fractures managed conservatively carry a Conservative management of fractures with stall rest and
good prognosis. In foals and yearlings, varying degrees of bandaging has been used successfully [14, 57], although
osseous healing may be observed, but fibrous union is outcome for athletic function has generally been advised as
expected in adult horses. The prognosis following surgical poor [37]. Surgical repair has only once been reported but
removal of small articular fractures is also good [33]. with good success [38]. There is limited contribution to
Outcome following repair of articular fractures is deter- overall limb length provided by growth in the proximal
mined by the quality of reduction achieved at surgery. phalanx [58], and premature physeal closure is therefore of
Incongruency at the articular surface results in progressive limited consequence.
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19 Ramzan, P.H.L. and Powell, S.E. (2010). Clinical and phalanx in horses. J. Am. Vet. Med. Assoc. 207: 1076–1080.
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415
20
Fractures of the Proximal Sesamoid Bones

L.R. Bramlage1 and I.M. Wright2
1
Rood and Riddle Equine Hospital, Lexington, KY, USA
2
A
natomy The SL branches become trapezoid in cross-section as
they insert on the abaxial surfaces of the PSBs. The thickest
The proximal scutum (scutum proximale) contains the two part of the insertion is distal and it tapers progressively
asymmetric pyramidal-shaped proximal sesamoid bones proximally (Figure 20.1). The intersesamoidean ligament is
(PSBs) and the thick palmar/plantar or intersesamoidean part of the fibrocartilaginous scutum in which the PSBs are
ligament (ligamentum palmare/plantare). The latter embedded. Proximally, near the apices of the PSBs it has
encloses the palmar/plantar (faces flexoria) and axial sur- little fibrillar/ligamentar form while distally, adjacent to
faces of the PSBs. The fibrocartilaginous scutum extends the bases of the PSBs, a distinct transverse fibrillar arrange-
proximal to the PSBs between the two branches of inser- ment is visible.
tion of the suspensory ligament (SL). Distally, it forms part The collateral sesamoidean ligaments arise from the
of the origin of the straight and oblique distal sesamoidean abaxial surfaces of the PSBs conjoined with the distal SL
ligaments (DSLs). The articular surface of the PSBs is two and insert principally on the abaxial third metacarpal/met-
dimensionally concave and the palmar/plantar surface, atarsal (Mc3/Mt3) bones and minimally on the proximal
which is covered by the fibrocartilaginous intersesamoid- phalanges. The paired extensor branches of the SL also
ean ligament, is convex. PSBs in the forelimb are larger and originate on the abaxial aspect of the sesamoid bones inter-
more elongated than in the hindlimb [1]. In their proximal mingled with the distal SL and collateral ligament inser-
three quarters, the abaxial surfaces of the PSBs are concave tions. They progress over the abaxial aspect of the proximal
(Figure 20.1). The apex of the lateral PSB is more pointed, phalanx dorso-axially to join with the common and long
and its abaxial margin slightly more concave than its digital extensor tendons just proximal to the proximal
medial counterpart. The medial sesamoid is significantly interphalangeal joint. These abaxial ligaments provide
larger than the lateral in both the forelimbs and hindlimbs. axial stability to the suspensory apparatus and dorsal sta-
The proximal scutum is part of the suspensory appara- bility to the proximal interphalangeal joint [4].
tus intercalated between the elastic SL proximally and The DSLs are the functional continuation of the SL to the
relatively inelastic DSLs distally [2]. As a unit, the sus- proximal and middle phalanges, but they are not contigu-
pensory apparatus functions to resist extension of the ous; they have distinct insertions and origins onto the PSBs
metacarpophalangeal/metatarsophalangeal (MCP/MTP) and each have separate stabilization functions with respect
joints, to store the kinetic energy of loading and to return the MCP/MTP joint [5]. The DSLs from dorsal to palmar/
this, in part, to the limb in the caudal weight-bearing plantar and in corresponding ascending length are: the
phase of the stride [3]. The PSBs transfer the dynamic paired medial and lateral short, cruciate, oblique and the
resistance to extension of MCP/MTP joints, which is gen- unpaired palmar/plantar straight DSLs.
erated by the SL, around the palmar/plantar angle of the The short DSLs are sub-synovial with origins and inser-
joint. All fractures of the PSBs are primarily a disease of tions from the abaxial articular margins of the PSBs and
the suspensory apparatus rather than a disease of the proximal phalanx. The paired cruciate DSLs originate on
MCP/MTP joint even though their articular surfaces are the axial dorsal aspect of the bases of the PSBs and insert
part of the joint complex. on the contralateral proximal palmar/plantar articular

416 Fractures of the Proximal Sesamoid Bones
(a) (b)
Pa
M L
Figure 20.1 (a) Left forelimb PSBs viewed proximally demonstrating concave dorsal and abaxial margins and convex palmar
surfaces. D: dorsal; Pa: palmar; L: lateral; M: medial. (b) Dorsal aspect of a PSB showing the shape of the articular surface and the
canals that contain the vessels and nerves that enter the bone (arrows). The area of suspensory ligament insertion is outlined in
yellow (shown on the lateral PSB only in (a)).
margin of the proximal phalanx. They are considerably while the highest tensile stress patterns were present proxi-
smaller than the oblique and straight DSLs. mally at the site of apical fractures.
Palmar/plantar to the above, the paired oblique DSLs The PSBs are composed of dense cancellous bone with
originate from the mid-sesamoid centrally and abaxially. two primary systems of trabeculation arranged in longitu-
Each is tripartite, and the pair fashion a large inverted dinal and radial fashions [10]. The mechanical properties
triangular-shaped insertion on the palmar/plantar surface of cancellous bone are closely related to its structure which
of the proximal phalanx [6]. The single straight DSL origi- in turn remodels (adapts) in response to changes in its bio-
nates from the bases of both PSBs and the fibrocartilage of mechanical environment. Adaptive remodelling of the
the intersesamoidean ligament. The origin is triangular to PSBs in response to training stress has been demonstrated
trapezoid in cross-section, progressing to rectangular and experimentally [8]. This included decreased porosity.
then oval distally. The straight DSL inserts axially in con- Mechanical properties of cancellous bone vary inversely
junction with the medial and lateral palmar/plantar liga- with porosity [8]. There is an increase in the amount of
ments of the proximal interphalangeal joint and the paired bone and a decrease in the amount of intertrabecular space
branches of insertion of the superficial digital flexor ten- in PSBs in response to exercise [1].
don into the scutum medium fibrocartilaginous plate of The blood supply for the PSBs arises from multiple
the proximopalmar/plantar middle phalanx. This is the branches of the medial and lateral palmar/plantar digital
largest of the DSLs. arteries [11]. Vessels enter the bones on the palmar/plantar
The PSBs are subject to complicated biomechanics with abaxial surface protected by the SL insertion and travel in
longitudinal tensile forces exerted by the SL and DSLs, an abaxial to axial, proximal to distal and palmar/plantar to
compressive force applied to their dorsal surface by the dorsal direction (Figure 20.1). It is suggested from this that
Mc3/Mt3 condyles, abaxial tensile forces created by the the axial portion of the PSBs is perfused last [12]. The
abaxial ligamentous attachments and the intersesamoid- major branches of the interosseous vessels are found in
ean ligament acting over the sagittal ridge of the Mc3/Mt3 bony canals with a radial orientation that parallels the tra-
bone [7, 8]. becular infrastructure evident on radiographs [11].
The forelimb PSBs contact 42 ± 8% of the Mc3 condyles Although marginal perfusion has been suggested as one
at a MCP extension angle of 150° and 46 ± 1% at 120° of reason for poor healing of PSB fractures, the intraosseous
extension [9]. As may be expected, the PSB subchondral blood supply is actually substantial but is disrupted by a
bone density is increased in areas of compressive contact. fracture and thus healing is compromised. Speculation that
Finite-element analysis confirmed compressive stresses on since vascular channels are oriented similarly to common
the dorsal (articular side) and tensile stresses on the pal- fracture planes that these may act at ‘stress risers’ is
mar/plantar sides of the bones [7]. The distal articular sur- unlikely to be true given the exceptional capability of bone
face of the bone experienced the largest compressive force, to respond to biomechanical stress [11].
Classificatio 417
The PSBs are innervated by the sesamoidean nerves on PSB fractures in foals has long been recognized and is
which are branches of the palmar/plantar nerves that pen- supported by experimental work which demonstrated
etrate the abaxial surface and continue into the intertra- that exercise increases bone mineral density in foal
becular spaces through the SL insertion similar to the PSBs [25]. The cancellous bone in trained horses has less
vascular supply [13]. porosity and thus, it was theorized, greater strength than
in untrained horses. But the zone just distal to the apex, a
common site for fracture, had the lowest porosity and
Aetiology therefore the greatest mineral density, contrary to the the-
ory that density of bone equals strength [8]. The quality
Bone is weakest in tension and most PSB fractures are of adaptation to training appears to be more important
ascribed to excessive tensile forces [8, 14]. However, the than the simple addition of bone mass.
bones also experience bending and compression as MCP/ Conflicting associations between use of toe grabs, sex,
MTP joint angles change; all forces peak with hyperexten- career length and exercise intensity with sesamoid frac-
sion [15]. Cyclic MCP/MTP hyperextension can result in tures and catastrophic suspensory apparatus failure make
fatigue failure and is the mechanism for creation of many causal identification and therefore prevention difficult [23,
mid-sesamoid fractures [16, 17]. No evidence of previous 26–29].
fatigue fractures was found in affected bones in one study,
but has since been documented in post-mortem studies of
horses with catastrophic injuries [16, 18]. Speculated pre- Incidence
disposing factors include musculotendinous fatigue, poor
conformation, shoeing practices, foot imbalance, track sur- Fractures of the PSBs occur in all breeds and uses but par-
faces and poor conditioning [3, 8, 15, 19, 20]. It would be ticularly racehorses. They are most common in
logical that these influences would most likely contribute Standardbreds where hindlimbs are most frequently
to cyclic fatigue rather than to single event failure. Rarely involved. In Thoroughbreds, PSB fractures are common in
abaxial fractures can be caused by external trauma. both forelimbs and hindlimbs [2]. Fracture distribution
Concurrent desmitis of the SL and/or DSLs is common and configuration is influenced by breed, use and direction
following injury and has implications for treatment, conva- of racing (clockwise vs. anticlockwise) supporting cyclic
lescence and prognosis. Ultrasonographic evaluation is fatigue as a mechanism of fracture creation [29]. Post-
helpful in most cases that have athletic expectations. mortem studies show accumulated damage in con-
Fatigue, uneven footing, accumulated strain during a race tralateral sesamoids in horses with catastrophic
and bone degeneration from chronic sesamoiditis have fractures [16, 17].
been proposed to predispose fracture [2]: clinical observa- In Thoroughbreds, fractures of the PSBs are the principal
tions do not support the latter. cause of catastrophic suspensory apparatus failure in most
Pre-existing compromise has been associated with cata- racing jurisdiction worldwide [27, 30–35] and are the com-
strophic suspensory apparatus injuries [21–24]. Pre- monest reason for on course euthanasia in the USA [33].
existing SL desmitis, use of horseshoe pads, periods of They are less common in the UK where an increased risk
≥60 days without racing or timed workout and recent on all weather surfaces has been identified [34, 36].
high intensity exercise are also associated with cata- Speculation that as the foot slides further before stopping
strophic fracture [23]. However, these factors are likely on non-turf surfaces, the degree of MCP/MTP extension
associations rather than predispositions. Horses that have increases is supported by epidemiologic studies and sug-
raced between two and five times are at most risk of cata- gests that hoof–surface interaction is important in fracture
strophic failure, suggesting a period in a horse’s training creation [32–36].
when adaptation of the PSBs lags behind its overall devel-
opment as a racehorse. It has been shown that the SL
adapts faster and/or better to exercise than the PSBs [3]. Classification
Training strengthens the SL and even though adaptive
remodelling of the PSBs occurs, it is postulated that the In addition to the standard terms of description, fractures
bone lags behind ligamentous tissue [3, 8]. The PSB is of the PSBs are classified according to their location in the
thus the weakest part of the suspensory apparatus in bone [2, 14, 37–42]. Fractures have been defined as mid-
horses that are just reaching or returning to maximum fit- body if the distal fragment measures between 25 and 75%
ness. Although growing and training are different proof the total proximodistal length of the bone as deter-
cesses, the preventative effect of graduated free exercise mined on dorsopalmar/plantar radiographs [41].
prognoses are distinct to each site and will therefore be

considered individually.
When the SL insertion is interrupted, there can be
marked displacement of the fragments proximally.
A Maintenance of the integrity of one-half of the suspensory
apparatus (SL branch, sesamoid and DSLs) preserves func-
tional weight-bearing, but biaxial disruption results in col-
Mp lapse and hyperextension of the joint.
A retrospective evaluation of 54 PSB fractures consisted
of 44 (81%) apical, 3 (7%) mid-body, 2 (4%) basilar and
5 (8%) other configurations [3]. This is a reasonable
Md
representation of clinical fracture incidence for horses in
high level exercise such as race training [3].
Apical fractures are frequently found in survey radio-
B graphs of yearlings [43]. Most occur in hindlimbs and are
not causing lameness at the time of identification, but they
create a healing response by the parent bone [43, 44]
(Figure 20.3). Previous (foal) fractures that have healed
Figure 20.2 Proximodistal divisions of the PSB for create elongation of the sesamoid (Figure 20.4a). Elongated
categorization of fractures. A: apical; Mp: proximal mid-body; PSBs as a group have not shown an association with
Md: distal mid-body; B: basilar. decreased performance [45]. However, proximal elonga-
tion is progressively problematic proportional to the degree
Fractures involving the proximal quarter of the bone are of elongation. Most clinicians consider markedly enlarged
defined as apical, and fractures involving the distal quar- bones to be a negative prognostic feature with respect to
ter of the bone as basilar (Figure 20.2). In terms of func- racing potential, and these occasionally will predispose to
tional compromise, treatment options and prognosis, this fracture (Figures 20.4). Distal elongation is less commonly
appears valid. However, there are additional configura- of concern (Figure 20.5).
tions that do not fit these categories including apical– Fracture of the PSBs in foals represent different patho-
abaxial, abaxial articular, abaxial non-articular, axial/ physiologic, healing and treatment considerations. These
sagittal and abaxial/sagittal fractures. Treatment and are discussed and described in Chapter 37.
(a) (b)
Figure 20.3 (a) Apical PSB fracture in a yearling found on survey radiographs. Note the adjacent demineralization/inflammatory
healing response. (b) Appearance six months after arthroscopic removal of the fragment. Note the increase in density and better-
defined vascular canal that originated while the bone was attempting to heal the fracture.
Apical Fracture 419
Figure 20.4 (a) Proximally elongated PSB: the (a) (b)

result of a healed foal apical fracture. (b)
Subsequent apical fracture when the horse was
in training.
In a series of 84 apical fractures in Thoroughbred horses

in training, 49% occurred in two-year olds, 26% in three-
year olds, 15% in four-year olds and 10% in older horses [43].
In this study, 64% occurred in hindlimbs with equal
left:right distribution, and 15% were bilateral: 63% of fore-
limb fractures were medial.
Diagnosis
Apical fractures are almost always articular and in the
acute phase produce distension of the MCP/MTP joint
although this generally does not persist [14, 39]. Lameness
varies and can diminish rapidly with reduced training.
Figure 20.5 Distal elongation of a PSB subsequent to a healed Acute fractures frequently exhibit pain on digital pressure
juvenile basilar fracture. and in most cases joint flexion produces pain and increased
lameness. Identification of chronic apical fractures may
require regional or intra-articular anaesthesia. Lameness
Apical Fractures from PSB fractures can be abolished by analgesia of pal-
mar/plantar nerves at an abaxial sesamoid level which can
Incidence and Location
cause misdiagnosis as lameness originating in the foot.
PSB fractures occur most commonly in the racing breeds, Local analgesia of palmar/plantar metacarpal/metatarsal
and apical fractures are the most common in both nerves at the distal end of the splint bone may improve, but
Standardbreds and Thoroughbreds [15, 42–45]. They occur usually does not abolish lameness.
most often in the hindlimbs of Standardbreds [14, 15, 44–46] Almost all apical fractures are identifiable on standard
and in the forelimbs of Thoroughbreds [35, 43–47]. No lateromedial (LM), flexed LM, dorsopalmar/plantar (DPa/
medial–lateral predisposition has been described in Pl), flexed DPa/Pl, dorsolateral–palmar/plantaromedial
Thoroughbreds; however, apical fractures of the lateral PSB oblique (DL-Pa/PlMO) and dorsomedial–palmar/plantaro-
of the right hindlimb of Standardbreds occur significantly lateral oblique (DM-Pa/PlLO) radiographic projections
more frequent than fractures of other sesamoid bones [44, (Figure 20.6). However, slightly (20°) elevated obliques
45]. Hindlimb lateral PSBs of racing Standardbreds have may improve fracture details.
been reported to have greater radiopharmaceutical uptake, Sesamoid fractures are primarily a disease of the suspen-
suggesting increased stress remodelling and histologic sory apparatus and rarely cause degenerative arthritis in
examinations support hyper-activity at the most common the associated MCP/MTP joints. In acute fractures, ultra-
site of apical fractures [48, 49]. sonographic evaluation of the SL is prudent, particularly in
within the SL is a better indication of active inflammation,

especially in sub-acute injuries. Treatment decisions are
generally based on combined clinical, radiographic and
ultrasound examinations.
Treatment
Removal of apical fragments is the preferred treatment as
non-surgical management is less successful in returning
horses to athletic performance [14, 15, 37, 39, 42]. Following
removal, there is second intention healing of the defect,
but the fibrous attachment of the SL to the PSB is stronger
than the fibrous union between the fracture fragments that
occurs if an apical fragment is left in situ [2] (Figure 20.3).
Apical fractures left in place create a healing response by
the parent bone that results in sesamoiditis. The defect cre-
ated by the removal of stable, long-standing fractures with
fibrous or fibro-osseous union is not an issue, but removal
may be unnecessary if there is no lameness or local
response by the parent bone or SL. Some large fragments
Figure 20.6 DM-PaLO radiograph illustrating an acute apical
fracture of a forelimb medial PSB. may be considered for reconstruction with a proximal–
distal-oriented lag screw (as with proximal mid-body frac-
displaced fractures, as the degree of ligament compromise tures). However, true apical fractures (involving the
is prognostically significant and dictates rehabilitation. proximal 25% of the bone) should be removed rather than
Ultrasonographic evaluation is also the best method of dif- stabilized as this results in less inflammation in the parent
ferentiating the activity/inactivity of chronic fractures that bone and a faster recovery.
may not be of clinical significance (Figures 20.7). Rounded Removal by arthrotomy was reported in 1956 and arthro-
fracture margins and lack of infrastructure in the fracture scopic removal in 1989 [50, 51]. The technique has subse-
fragments indicate longevity, but callus production is mini- quently been refined, described in surgical texts and almost
mal in sesamoid factures. In some animals, new bone may universally adopted [52]. Horses may be positioned in dor-
be evident but lysis of the parent bone and inflammation sal or lateral recumbency; one author prefers the former
(a) (b) (c)
Figure 20.7 (a) DM-PaLO radiograph of a chronic medial apical PSB fracture. (b) LPr-MDiO projection showing the fracture fragment
to be just deep (palmar) to the articular surface. (c) Transverse ultrasonograph demonstrating desmitis of the medial SL branch
associated with the fragment in (a) and (b).
Abaxial Fracture 421
(IMW) and one the latter (LRB). The use of a tourniquet is fragment does not involve more than one-fourth of the
also at surgeons’ discretion. Most surgeons employ con- abaxial (SL insertion) surface of the bone [2, 44, 45]. These
tralateral arthroscope and ipsilateral instrument portals. If guidelines are likely valid for all treatment methods and
bilateral or biaxial fractures are removed in lateral recum- breeds. Horses with apical fractures treated non-surgically
bency, ipsilateral and contralateral instrument portals are have a poorer prognosis for racing after injury and demon-
necessary. strate significantly poorer post-fracture performance [44].
Instrument portals should be positioned to allow access Decreased surgical morbidity and more rapid resolution of
to the entire circumference of the fracture fragment. Sharp the surgical trauma have led to acceptance of arthroscopic
dissection of the fragment from the fibrocartilaginous scu- removal as the treatment of choice. Concurrent suspensory
tum, intersesamoidean ligament and insertion of the SL desmitis reduces the prognosis for return to training and
branch is performed with straight and curved arthroscopy racing proportionally [15, 39, 44, 45].
knives (3.5 mm pointed knife and 3.5 mm hook knife; Karl Sixty-five out of 84 (77%) Thoroughbreds ≥two years of
Storz Veterinary Endoscopy, Goleta, CA 93117 or Beaver age from which apical fragments were removed arthro-
blades; Beaver Surgical Products, Becton Dickinson, BD scopically started a mean of 12 times after surgery. Of those
Medical Systems, Franklin Lakes, NJ 07417). Dissection that had raced previously, 31 out of 38 (82%) raced at the
should closely follow the fragment surface to minimize same or at an improved level [43]. Horses with forelimb
trauma to the SL. Once freed, the fragment can be removed medial PSB fractures were less likely to race following frag-
with appropriately sized Ferris Smith rongeurs [52]. Use of ment removal than fractures at any other locations. The
sharp elevators, arthroscopic scissors and electrocautery results in this series were better than results reported for
have also been described, but it is unlikely that the method removal by arthrotomy which is in accord with generally
of removal influences outcome providing surgical morbid- accepted surgical principles. In a further study 151
ity is minimized [46, 52]. All detached bone and soft tissue Thoroughbreds that had apical fragments removed arthro-
fibres should be removed and debris lavaged from the joint. scopically when less than two years of age, 84% (123 out of
Use of peri-operative antimicrobial and anti-inflammatory 147) raced post-operatively and there was no difference
medication is determined by surgeon preference and local between their performance and maternal siblings [53].
circumstances. Post-operative bandaging is maintained for However, similar to horses in active training, horses with
two to four weeks according to the amount of SL involve- medial apical fractures were less likely to race and had
ment and soft tissue swelling [42]. Post-operative convales- poorer performance than those with apical fractures in any
cence and exercise are determined by the size of the other location. After removal, apical fractures of the fore-
fragment and the amount of ligament insertion involved limb lateral and hindlimb medial and lateral PSBs had no
and guided by ultrasonographic monitoring of the affected effect on the horse’s performance when compared to con-
SL branch [42]. With small fragments and limited SL trol data. In a subsequent study, the geometric characteris-
involvement, exercise can resume as early as four weeks if tics of forelimb medial apical fractures were not found to
the SL is not inflamed. With concurrent desmitis, SL heal- differ. The sole negative prognostic determinant appeared
ing is the determining factor. Series of Standardbreds and to be location [54].
Thoroughbreds from which apical fragments were removed
raced at means of nine (range 3–27) and eight (range 1–23)
months post-surgery, respectively [43, 45]. However, such Abaxial Fractures
data reflects the seasonal organization of racing as well as
the degree of SL damage. Abaxial fractures are generally regarded as avulsions of the
SL, but it is likely that there is also some underlying com-
promise of the bone [15, 42, 55]. They can occur on the
Results
articular margin within the joint (Figure 20.8), in non-
Independent of method, the prognosis after removal of api- articular locations within the SL insertion (Figure 20.9) or
cal fractures is generally good. Observations made by on the palmar/plantar SL margin (Figure 20.10). Apical/
Churchill [50] and subsequent similar studies concluded abaxial and abaxial sesamoid fractures are variations of the
that following arthrotomy for fragment removal, the prog- same injury. In the acute phase, there is lameness accom-
nosis for future racing performance in Standardbreds is panied by, according to fracture location, distension of the
increased considerably if (i) the injury occurred while the MCP/MTP joint and/or soft tissue swelling adjacent to the
horse was racing or training at racing speed as opposed to affected SL branch [42, 55]. Severity of lameness and joint
before the horse reached racing speed, (ii) the fragment is distension frequently reduce in the sub-acute phase,
smaller than one-third of the total PSB volume and (iii) the although thickening of the SL branch correlating to the
(b)
(a)
(c)
Figure 20.8 (a) An articular abaxial PSB fracture (arrows). (b) Transverse (TS) and longitudinal (LS) ultrasound images documenting a
substantial hypoechoic zone in TS and the fragment (arrows) with loss of echogenicity and disorganization of the attached SL in LS.
(c) Images in the same location as (b) taken four months after arthroscopic removal of the fragment showing improved echogenicity
consistent with fibrosis re-attaching the SL to the PSB.
size of the fracture persists. All cases will have some degree proximal lateral–palmar/plantar distal medial oblique
of disruption of the associated SL branch. Abaxial fractures (DPrL-Pa/PlDiMO), and dorsal proximal medial–palmar/
most commonly involve the forelimb medial PSBs [55]. plantar distal lateral oblique (DPrM-Pa/PlDiLO) projections
Ultrasound should be used to determine the degree of are good indicators of articular involvement and help in
SL involvement which is prognostically important [2] identification of comminution [56]. Without their use, con-
(Figure 20.8). fident assessment of articular involvement frequently can-
not be made (Figures 20.7b, 20.9b and 20.10c).
Articular abaxial fractures are most common in athletic
Diagnosis
horses but can also be found on survey radiographs prior
Clinical signs with non-articular fractures generally localize to purchase. Non-articular abaxial fractures are most com-
to the insertion of the SL branch. Standard radiographic pro- monly found on survey radiographs of yearlings without
jections usually will identify the presence of an abaxial frac- clinical signs but are also found in horses actively racing.
ture. Lateral proximal–medial distal oblique (LPr-MDiO), It is difficult to project the importance of non-articular
medial proximal–lateral distal oblique (MPr-LDiO), dorsal fractures to a horse’s athletic career, but they decrease its
(a) (b) (c)
Figure 20.9 (a) DM-PaLO radiograph of an abaxial fracture within the proximal one-half of a medial PSB. (b) LPr-MDiO projection
shows the fragment to be within the SL insertion palmar (deep) to the articular surface of the bone. (c) Intra-operative DM-PaLO
radiograph confirms complete arthroscopic removal of the fragment.
sale value. When the fracture is found in a horse in active ondary bone healing response with progressive softening
training, ultrasound will determine the presence or of the parent bone, consequent compromise of SL attach-
absence of SL inflammation and therefore potential sig- ment and lameness [57]. Progressive loss of SL insertion
nificance of the fragment to the horse’s soundness can become irreversible, so early decision-making is
(Figure 20.8). Many abaxial sesamoid fractures found in recommended.
yearlings are the result of SL avulsions that occur within A direct surgical approach with longitudinal separation
the first few days of life. They may be asymptomatic at this of the SL branch insertion has been described [58]. A mod-
time but can become clinically important with increasing ification of the procedure is used for fractures that are on
performance demands. the abaxial aspect of the SL insertion. Horses are positioned
Some authors considered abaxial fractures to be asso- in lateral recumbency with the affected PSB uppermost.
ciated with some degree of sesamoiditis, but this is The exact location of the fracture is established by radio-
rarely the case in athletic horses where acute abaxial graphs with needle placement (Figure 20.10d). A one to
fractures most commonly occur in normal appearing two centimetre incision is then made parallel to the fibres
PSBs (Figure 20.8a). of the SL directly over the fragment through the annular
ligament and into the SL. The fragment is located by palpa-
tion and visualization and removed. Limited debridement
Treatment
of the fracture bed is followed by radiographic confirma-
Non-articular fractures may be allowed to heal by fibrous tion of removal (Figure 20.10e) and routine closure.
union; periods of between three and greater than six Non-articular abaxial fractures of the proximal half of
months rest have been recommended [2, 38, 42]. It has the sesamoid bone, but dorsal to the palmar/plantar mar-
been reported that these horses will often perform success- gin, can be removed arthroscopically via the fetlock joint.
fully [14], but this is frequently not the case especially in The horse is placed in lateral recumbency with the affected
horses intended to race. Assessment of abaxial fractures is sesamoid down (LRB) or in dorsal recumbency (IMW).
a judgement as to whether the healing post removal will Arthroscope and instrument portals are similar to those
improve the integrity of the SL attachment to the PSB over for apical fragment removal, with the former contralateral
the situation with the fragment left in place. If the frag- and the latter ipsilateral to the affected sesamoid.
ment is separated and the parent bone is not inflamed, this Dissection of the scutum and proximal aspect of the SL
decision must be made on experience and assessment of from the apex of the sesamoid allow access to the axial
the amount of SL involved. Fragments that interface with portion of the SL and the palmar/plantar insertional sur-
and are likely to incite a healing response by the parent face of the PSB (Figure 20.9). Most of the dissection occurs
bone should be removed. Chronic inflammation from the axial to the SL attachment, but the loss of some SL fibres
mobile fragment adjacent to the parent bone incites a sec- does not appear to cause undue morbidity. The fragments
(a) (b) (c)
(d) (e)
Figure 20.10 (a) DPa and (b) DM-PaLO radiographs of a non-articular abaxial fracture (arrows) of the medial PSB. (c) LPr-MDiO
radiograph confirming extra-articular location of the fragment at the palmar margin of the SL insertion. (d) Intra-operative needle
placement to identify the exact location and smallest approach to the fracture. (e) Intra-operative LPr-MDiO radiograph to confirm
fragment removal.
are located in the SL at the top of the fossa for its insertion margin of the palmar/plantar pouch [52]. Optimum instru-
into the PSB. Identification and removal are followed by ment portal location is determined by the fracture configura-
limited debridement of the parent bone. Radiographs are tion and assessed by a percutaneous needle placement.
mandatory to confirm complete removal. Closure and Damage to the SL insertion varies widely and determines the
bandaging follow the same guidelines as other fetlock amount of dissection necessary to permit removal. A variety
arthroscopic procedures. of fixed blade cutting instruments are suitable as determined
Articular abaxial fractures that are not amenable to repair by the surgeon’s preferences [52].
and do not totally disable the SL should be removed arthro- Post-operative management and convalescence is princi-
scopically (Figures 20.8). Horses can be positioned in dorsal pally determined by the degree of SL compromise and subse-
or lateral recumbency. Contralateral arthroscope and ipsilat- quent healing. This first assessment to determine readiness for
eral instrument portals, or ipsilateral arthroscope and instru- increasing exercise is normally done 60 days post-operatively.
ment portals, can be used [55]. The joint should be partially Reconstruction of large abaxial fractures is indicated
flexed; an Esmarch bandage and tourniquet are optional. when the entire or majority of the SL attachment is
A standard arthroscope portal is created at the proximal involved and the fragment is large enough to hold implants.
(a) (b) (c)
(d) (e) (f)
(g) (h) (i)
Figure 20.11 Repair of a large acute abaxial/mid-body fracture of a forelimb medial PSB. (a–c) Radiographs at presentation. (d)
Reconstructed 3D CT. (e, f) Ipsilateral arthroscopic images before (e) and after (f) reduction and repair. (g–i) Radiographs taken
11 months after surgery when the horse was in training.
Successful repair restores the articular surface and con- of the articular surface of the sesamoid, to accurately locate
serves the SL branch insertion. This is effected by lag screw the screws within the SL insertion while others prefer
fixation using 3.5 or 2.7 mm diameter cortical screws arthroscopic visualization. Intra-operative radiographs in
inserted through stab incisions in the SL insertion two planes are important in order to assess drill/implant
(Figures 20.11). Fracture delineation can be made by an trajectories. Between one and three implants are utilized as
ipsilateral palmar/plantar arthrotomy or arthroscopically. determined by fracture size and configuration. Following
Some surgeons prefer arthrotomy and open visualization routine wound closure, the repair should be protected by a
cast enclosing the foot and extending to the proximal meta- distal fragment is 50–75% of the total proximodistal length
carpus/metatarsus with the limb in a weight-bearing posi- of the bone and distal mid-body if it is 25–50% of the
tion for recovery from general anaesthesia. The requirement length [59] (Figure 20.2). Mid-body fractures can be trans-
for further post-operative cast immobilization is at the sur- verse (horizontal) or oblique. Proximodistal displacement
geon’s discretion. Healing is monitored radiographically can occur symmetrically or with wider palmar/plantar or
and exercise is modulated in line with the progression of abaxial fracture gaps determined by fracture configura-
osseous union. Return to training should not be anticipated tion/orientation and consequent soft tissue disruption.
in less than six months post-surgery. Comminuted fragments can also be found in or adjacent to
the principal fracture.
In a series of 25 fractures, 21 were in forelimbs and four
Results
in hindlimbs [59]. Fractures of the medial PSB were signifi-
The prognosis for abaxial fractures predominantly is deter- cantly more common in the forelimbs (20 out of 21), while
mined by the degree of disruption of the SL insertion [15, in the hindlimb they were most common laterally. Fractures
55]. Fifteen of 18 (83%) Thoroughbred and Quarter Horses were mid-proximal in 7 and mid-distal in 18 horses. They
returned to racing after arthroscopic removal; 11 showed were transverse in 18 and oblique in 7 horses. In 19 horses
the same level of performance. As logic suggests, smaller (76%), displacement was greatest on the palmar/plantar
fragments return to performance at a higher rate and are abaxial surface. Distal fractures were more likely to have
more productive than larger fragments [55]. Total detach- greater displacement than their proximal counterparts.
ment of the SL usually precludes an athletic career. For sal- In a second series, mid-body fractures occurred most
vage purposes, surgery is not always necessary as time commonly in the forelimbs of Thoroughbreds with the
alone, generally 60 days of restricted activity will stabilize highest incidence in the right fore. In Standardbreds, there
the fragment sufficiently for paddock life. was an approximately equal distribution between fore-
limbs and hindlimbs, but the left hindlimb was most com-
mon. Twenty-four out of 25 fractures (15 Standardbreds
Uniaxial Mid-body Fractures and 9 Thoroughbreds) occurred during training or
racing [60].
Mid-body fractures are primarily racehorse injuries, are Diagnosis
seen with relatively equal frequency in Standardbreds and
Thoroughbreds and can occur in training or racing Complete mid-body fractures produce marked lameness
(Figure 20.12a). with joint distension. This is frequently accompanied by
Although fractures are defined as mid-body if they rapidly developing soft tissue swelling over the affected
involve between 25 and 75% of the distal to proximal length bone and associated SL branch, particularly if the fracture is
of the bone, large complete basilar fractures are effectively displaced; digital pressure is resented. Complete fractures
the same in the approach to their treatment. Mid-PSB frac- are readily identified on standard radiographic projections
tures may be further classified as proximal mid-body if the (Figures 20.12a and 20.14a and b). Lameness is variable in
(a) (b) Figure 20.12 DM-PaLO radiographs of a

minimally displaced proximal mid-body fracture
of a forelimb medial PSB. (a) At presentation. (b)
Eight weeks after repair with a distal to proximal
5.5 mm lag screw.
Uniaxial Mid-body Fracture 427
Figure 20.13 Appropriate screw locations and trajectories (black arrows) for common mid-body fractures (red lines). Lag screws
which cross the fracture plane obliquely create shear/sliding forces that compromise reduction.
horses with incomplete fractures, and in the acute phase of six to eight months [38]. However, immobilization alone
these may be radiologically silent [42]. In this situation, does not result in osseous union and if salvage for breeding
radiographs can be repeated after 7–10 days, or alternative is the target, then simple stall rest for 60 days will result in
imaging modalities such as scintigraphy, computed tomog- a functional fibrous union that is adequate for paddock
raphy or magnetic resonance imaging can be performed. activity. Counterintuitively and, irrespective of configura-
tion, degenerative arthritis is rare after PSB fracture alone.
Treatment
Lag Screw Fixation
Incomplete fractures generally do not require fixation Although several techniques have been proposed, the best
unless they become complete. Healing of complete frac- prospect for a functional repair is lag screw fixation [61,
tures managed conservatively is poor or absent but even 63–65]. Numerous variations in surgical technique and
when treated surgically it is slow. The absence of a perios- instrumentation have been described, but none have
teum, interrupted blood supply and continuous distracting resulted in universal adoption. The anatomy of the PSB,
forces acting across the fracture have been cited as explana- the fracture configurations encountered and the anatomy
tory reasons [2, 37, 60, 61]. of the distal limb all combine to make fixation difficult.
No treatment is universally dependable. Surgical removal Fractures or repair techniques that significantly damage
of either fragment destroys or results in marked disruption the SL insertion or the DSLs will limit success.
of one-half of the suspensory apparatus [2, 60]. Non- Fracture orientation determines the ideal location and ori-
surgical management usually results in fragment distrac- entation for the lag screw (Figure 20.13). A single, ideal
tion [61]. Fibrous or fibro-osseous healing may ensue but is approach to all mid sesamoid fractures configurations does
generally inadequate for athletic endeavour [2, 14, 15, 37, not exist, and technique must be altered according to the frac-
60]. Desmotomy of the ipsilateral branch of the SL was ture and instrumentation required. The size of the fragments
described but never widely adopted and makes little bio- and orientation of the fracture plane(s) are the principal
mechanical sense [62]. Immobilization has been recom- determinant of optimum screw orientation. Thus, distal mid-
mended for non-displaced fractures using a cast or Kimzey body fractures are most logically repaired with distal to proxi-
splint for six to eight weeks and with a total convalescence mal screws and proximal mid-body fractures with proximal
to distal screws. If the fracture plane is horizontal/transverse, approximately parallel to the abaxial surface of the bone.
these rules of thumb apply. However, with oblique fracture Screws with an inappropriate trajectory result in fragment
this orientation also must be considered. A fracture coursing shift, articular incongruency and malunion. Determination
proximal and axial to distal and abaxial is most favourably of glide hole depth and approximate screw length from pre-
repaired form proximal to distal with an ipsilateral (abaxial) operative radiographs is useful.
approach; this offers the potential for placing the screw clos- When inserting screws from the base of the PSB (the
est to perpendicular to the fracture plane which cannot be most often desired approach), distal limb flexion, to
achieved from an ipsilateral basilar approach. Fractures with reduce the fracture, places the hoof in the position
a proximal abaxial to distal axial orientation can be crossed required for the drill and other instruments
by screws passing (ipsilaterally) from distal to proximal or (Figures 20.14). Extension tends to distract fractures and
contralaterally from proximal to distal following trajectories never completely removes the foot as an obstruction to
(a) (b)
(c) (d)
(e) (f)
Figure 20.14 Arthroscopically guided repair of a medial forelimb mid-body fracture. (a, b) Radiographs at presentation. (c, d) Limb
positioning and draping including sterile foot wrap to permit circumferential access. A spinal needle has been inserted to determine
implant location and trajectory. (e, f) LM and DP radiographs corresponding to (c) and (d). (g) Surgeon view demonstrating close
proximity of the drill and the heel bulbs. The surgeons left hand grips the apex of the PSB to provide stereotactic assistance.
(h) Arthroscopic image following creation of the glide hole. A 3.2 mm insert sleeve containing a 3 mm Steinmann pin is inserted into
the glide hole (arrow) to manipulate the distal fragment. (i) Radiograph following creation of the glide hole with the 3.2 mm sleeve
and Steinmann pin inserted. (j) Arthroscopic image and radiographs (k, l) at completion of surgery. Source: Nixon, 2020, Adapted from
Figures 21.13, pp. 360–361. Reproduced with permission from Wiley & Sons.
(g) (h)
(i) (j)
(k) (l)
position and angulation of instruments. Surgical tech- separate stab incision or by extending the arthrotomy inci-
niques to avoid the foot and to insert functional implants sion. Proximal screw insertion is accomplished by retrac-
must be devised and adapted on an individual fracture tion of the arthrotomy skin incision and making a stab
basis. Various instruments have been suggested to aid and incision through the SL branch to position the drill approx-
maintain reduction and assist fixation, but none com- imately 5 mm palmar/plantar to the articular surface.
pletely overcomes the problem [64, 66, 67]. The most useful tool for reduction and temporary fixa-
Most reports describe open approaches that access the tion is the pointed Wagner A-O reduction forceps. These
articular surface via a standard palmar/plantar arthrotomy. can be placed at differing locations to manipulate and
This avoids subcutaneous fluid and is technically easier in reduce the fragments and to rotate the sesamoid for easier
visualizing optimal screw location and trajectory. An access to its apex or base for screw insertion. Location and
arthroscopic approach to reduction and fixation reduces orientation of the screw is under radiographic, or fluoro-
soft tissue disruption and is preferred by some surgeons. scopic, control. One method is to reduce the fracture and
Both require additional intra-operative radiographic or insert a 2 mm drill bit to maintain temporary fixation and
fluoroscopic guidance. Open and arthroscopic approaches reduction and to act as a radiographic guide for screw loca-
all require access to the base of the PSB. This can be via a tion and orientation. Other surgeons drill the glide hole
and then use the insert sleeve to reduce the fracture and Additional stability for this process can be provided by prior
guide the pilot hole into the far fragment. Techniques have application of large AO/ASIF reduction forceps. Standard
to be adapted for insertion of proximal to distal or distal to lag screw insertion technique follows. The base of the PSB
proximal screws and individual surgeons have to develop a is concave dorsal to palmar/plantar and (centrally) concave
range of techniques that they are comfortable with: no sin- mediolaterally. The authors did not report or discuss the
gle procedure is suitable for all mid-body fractures. desirability of countersinking for the screw head. This is
The natural fossa in the base of the PSB has been advo- necessarily a balance between optimizing the conditions for
cated as the best location for the screw [39, 61]. A case the implant and minimizing trauma to the DSLs. The depth
can be made to locate the screw just palmar/plantar to of soft tissue precludes accurate use of a depth gauge. In
this at the junction of the straight and oblique DSL, non-displaced fractures the length of the affected PSB and
which is the least noxious location to the DSL. Fracture in displaced fractures the length of its intact contralateral
orientation dictates how axial or abaxial the screw is counterpart measured on radiographs along the trajectory
placed, but it is always oriented to exit the apex of the of the implant are the best determinants of screw size.
PSB palmar/plantar to the articular surface. Proximal to Intra-operative radiographic monitory is essential through-
distal screws are placed similarly but in the opposite out. At the end of the procedure, the joint is lavaged and
direction. Even in what appears to be ideal reduction, the skin portals closed routinely. The reporting authors
fixation is perilous and subject to cyclic fatigue. When described use of this technique in 10 horses with lag screw
the fragment is thin and 3.5 mm screws are used, multi- fixation by arthrotomy in a further 6 animals. Thirteen
ple screws are generally needed. Single 4.5 mm screws horses had single 4.5 mm cortical screws, one horse
will maintain fixation in the majority of horses, but will 2 × 4.5 mm screws, one horse 1 × 3.5 mm screw and one
be subjected to cyclic fatigue in horses with disrupted horse 3 × 3.5 mm screws. The principles of the technique
palmar/plantar soft tissue support. In this situation, it is can also be applied to repair other fracture configurations
advisable to use two 4.5 mm or a single 5.5 mm screw (Figures 20.15 and 20.16).
(Figures 20.12). It is also helpful to place the screw as Autologous cancellous bone grafts aid in overcoming the
palmar/plantar as practical as this surface of the bone is lack of periosteum, limited blood supply and biomechani-
under tension. Specialized screws have been reported, cally tenuous fixation. Some surgeons use them in all
but have not gained acceptance [66]. defects and in fractures in which duration, reduction and
The originally reported arthroscopic technique involved or fixation are not ideal [2, 61, 68, 69].
insertion of a single distal to proximal oriented 4.5 mm AO/ Osseous union is necessary for return to athletic activity.
ASIF cortical screw [59]. The centre of the base of the PSB Accomplishing this is difficult, and even then it is not a
is located and drill trajectory determined by a percutaneous guarantee of soundness due to concomitant damage to the
needle (e.g. 18 gauge/1.2 mm × 3.5 in./85 mm passed pal- other structures. Comorbidity of either the attachment of
mar/plantar to the neurovascular bindle through the DSLs. the SL or the DSLs can result in permanent performance
Its position is assessed and modified by radiographic/fluor- limiting lameness [60] (Figure 20.17).
oscopic examinations in dorsopalmar/plantar and LM
planes (Figure 20.14). A short (stab) incision is then made Transfixation/Hemi-circumferential Wire
along this trajectory to the base of the bone before a 4.5 mm Repair of mid-body fractures with wire was initially reported
drill guide is passed and, if required, its position and trajec- as circumferential and later as hemi-circumferential/
tory also confirmed radiographically. A glide hole is then transfixation techniques. These have been adjusted over
created to the fracture plane, a 3 mm Steinmann pin inserted time to alter the technique of insertion and in many instances
and a 3.2 mm sleeve is passed over the pin. A long sleeve is to use it as an adjunct to other fixation methods [42, 70, 71].
useful as, in the correct trajectory, the skin to fracture plane The open approach involves a palmar/plantar
distance in adult horses is often >50 mm. The articular sur- arthrotomy, similar to open lag screw fixation, fol-
face is evaluated from an ipsilateral proximal arthroscopic lowed by desmotomy of the palmar/plantar annular
portal. Removal of comminuted fragments and debride- ligament to open the digital flexor tendon sheath. The
ment of the fracture can be performed as necessary through digital flexor tendons are retracted to expose the fibro-
an instrument portal created at the level of the fracture. cartilage covered palmar/plantar surface of the frac-
Reduction is achieved by a combination of joint flexion and tured PSB. The technique of insertion to maximize
manipulation utilizing the 3.2 mm drill sleeve and purchase and stability must be sequenced precisely as
Steinmann pin. Once satisfactory, the pin is withdrawn, and described [42, 70, 71]. Some surgeons use a similar
a 3.2 mm hole drilled in the apical fragment taking care to technique which substitutes arthroscopic guidance for
minimize protrusion of the drill bit into the SL insertion. MCP/MTP arthrotomy.
(a) (b)
(c) (d) (e)
Figure 20.15 Repair of a medial forelimb distal mid-body fracture. (a, b) Radiographs at presentation. (c, d, e) Radiographs five
months after surgery.
Figure 20.16 DPa radiograph of a healed proximal mid-body Figure 20.17 DM-PaLO radiograph of a distal mid-body
fracture repaired with a proximal to distal 4.5 mm lag screw. fracture repaired with a 5.5 mm distal to proximal screw. The
fracture has healed, but the sesamoiditis and disruption of the
SL insertion are significant.
With open surgery, the joint and digital flexor tendon should therefore be used cautiously. Horses are confined to
sheath incisions are closed. Cast support is recommended a stall for eight weeks and assessed radiographically at that
for recovery and is maintained for varying periods post- time. Some horses require up to 90 days of stall confine-
operatively as per surgeon’s preference. Wire breakage ment. Once the fracture is bridged, a gradually ascending
occurs but, with 1.25 mm wire, is rare [71]. The malleable controlled exercise programme facilitates remodelling. The
fixation produced permits anatomic alignment as the average time for return to training is 10–12 months [15, 60,
articular surface adapts to the opposing Mc3/Mt3 joint 70]. Implant removal is not required unless infection or
surface, but because the wire is not rigid an inevitable gap implant breakage and migration dictate the need.
at the joint surface requires secondary bone healing with
resultant elongation of the PSB [67, 72]. Damage to the
articular surfaces of Mc3/Mt3 is rare [71]. Experimentally Results
wire fixation of osteotomized PSBs resisted equal or Regardless of technique, the prognosis for racing following
greater loads than screw fixation, but loss of reduction single mid-body PSB fractures remains guarded and those
occurred under load [67, 72]. Wire fixation complications returning to racing usually compete in a lower class of
include irritation of the tendon sheath, wire migration race [2, 15, 60]. Lag screw fixation augmented by autolo-
and impingement on adjacent soft tissues [59]. One mil- gous cancellous bone grafts were used in a series of 25
limetre ultra-high molecular-weight polyethylene cable horses with 27 mid-body fractures. Nine of 15 Standardbreds
was found to be stronger than 1.25 mm (16 gauge) (all racing) and 6 of 9 Thoroughbreds returned to athletic
stainless-steel wire in repair of mid-body osteotomies in performance (five racing and one in Horse Trials)
cadaver forelimbs, but to date this has not been tested 10–12 months post-surgery [60]. Seventeen fractures were
in vivo [73]. repaired with single 4.5 mm AO/ASIF cortical screws, 16 in
a distal to proximal direction and 1 with a proximal to distal
trajectory. 3.5 mm AO/ASIF cortical screws were used in
Autologous Cancellous Bone Grafts
eight cases of abaxial fractures. Radiographic evidence of
Autologous cancellous bone grafts aid fracture healing
pre-operative sesamoiditis was a negative prognostic indi-
by osteoinduction and osteoconduction and improve vas-
cator. Post-operative of performance was diminished by
cularization of healing callus (Chapter 6). They have
prolonged healing times and by subsequent sesamoiditis,
been described for treatment of basilar fractures and are
but outcome was not affected by fracture duration or pre-
also used to augment internal fixation of mid-body frac-
injury starts. Post-operative infection disabled two horses.
tures [60, 68]. The bone graft harvest site is pre-prepped.
Of 15 horses with mid-body or large basilar fractures
Reduction and fixation are accomplished and then evalu-
repaired by circumferential (5) or hemi-circumferential
ated. If there is concern, the screw is loosened and a thin
transfixation (10) wiring techniques, 5 returned to com-
layer of graft is inserted through the dorsal or the pal-
petition [70]. In a further series of 25 horses with mid-
mar/plantar margin into the fracture gap and/or any
body fractures repaired using hemi-circumferential
defects [60]. The screw is then retightened. Only a small
wiring, wiring and bone grafting, or interfragmentary lag
amount of bone graft is needed and can be harvested
screw fixation, 7 of 16 horses (44%) with screw fixation
through a 5.5 mm drill hole from the most accessible
raced after surgery but none of the nine horses with wire
donor site [42, 60]. Bone grafts have been described as
repairs raced. Lag screw fixation resulted in the most
the sole treatment but have not persisted as a preferred
accurate reduction, and this positively influenced the
technique [38, 68, 69]. In non-displaced fractures, or in
outcome [59].
displaced fractures when reduction is perfect and the
fixation is stable, no graft is used.
Basilar Fractures
Post-operative Care
All authors agree that horses should receive cast support
for anaesthetic recovery to prevent over-extension of the Basilar fractures are much less common than their apical
fetlock joint [2, 39, 41, 42, 60, 61]. However, the period of counterparts accounting for between 6 and 24% of all PSB
cast immobilization varies among surgeons from two to fractures [37, 74, 75]. They are usually uniaxial, occur pri-
four weeks to next day removal [42]. Prolonged cast immo- marily in racing horses and are more common in
bilization causes flexor tendon laxity and when the cast is Thoroughbreds than Standardbreds [2, 42, 74, 75]. The
removed the load on the suspensory apparatus and there- majority (88 and 100%) occur in the forelimbs, and medial
fore the fixation is increased: external immobilization PSBs are more often affected than lateral [74, 75]. A wide
Basilar Fracture 433
range of configurations are encountered, but most articu-

lar fractures are variations of two types, small dorsal chips
and transverse fractures that involve the whole distal mar-
gin of the bone. Non-articular palmar/plantar fragments
are also occasionally encountered. Most are DSL avulsion
injuries and thus are embedded within ligamentous attach-
ments: infrequently these can result from direct trauma.
Small articular fragments may involve little of the origins
of the DSLs, but as the fracture extends further palmar/
plantar corresponding amounts of the ligament origins are
compromised. Axial fragments are commonly found in
yearling survey radiographs and occasionally occur in
racing horses (Figure 20.18).
Large basilar fractures can be accompanied by, and may
be caused by, palmar distal Mc3 disease and subsequent Figure 20.19 DPa radiograph of a displaced basilar fracture
change in the shape of its articular surface [57]. that is also split axially, precluding lag screw fixation.
Identification of this is important because the combination
carries a poor prognosis for return to racing. Comminution
of complete basal fractures is common. Many have a sagit- cal concern to result in primary radiographic examination
tal fracture that bisects the distal fragment: irrespective of without further investigation, but some small chronic frac-
treatment, these are poor candidates for return to athletic tures may be found following local analgesic techniques.
activity (Figure 20.19). Most fractures are recognized on standard radiographic
projections, but L20°Pr-MDiO and M20°Pr-LDiO projec-
tions will better profile the articular margins of lateral
Diagnosis and medial PSBs, respectively [76]. Nonetheless, some
If the Mc3 is unaffected, the degree of lameness accompa- small, axial fragments can be radiologically silent in all
nying basilar fractures is roughly proportional to the projections.
amount of compromise of the associated DSLs. Articular Ultrasonographic evaluation of DSLs is prudent in all
fractures are accompanied, in the acute phase, by joint dis- basilar fractures as injury is a prognostically limiting factor.
tension. Pain on MCP/MTP joint flexion is a consistent sign, Occasionally, full thickness fractures will extend into the
and digital pressure sometimes can localize pain to the area. digital flexor tendon sheath: these are poor candidates for
Large fractures which disrupt significant portions of the treatment unless they are large enough to repair by lag
origins of the DSLs usually result in swelling palmar/plan- screw fixation.
tar to the proximal phalanx. With time, acute inflammation
subsides and is replaced by firm thickening at the base of
the affected PSB. Most acute fractures raise sufficient clini- Repair
For basal fractures that are thick enough to hold a screw,
the approach and technique for fixation are as described
for distal to proximal lag screw fixation of mid-body frac-
tures. Careful evaluation of radiographs is important as
comminution may preclude safe or efficacious repair.
Surgeons must take into account the concave base of PSBs
because fractures less than 5–6 mm in thickness will have a
‘donut’ profile providing very little bone in the centre of the
fragment to support the screw and allow compression.
Chronic fractures can also become osteopaenic/osteoporo-
tic and may not tolerate compression [14]. In these circum-
stances, hemi-circumferential/transfixation wiring may be
considered but rarely returns horses to athletic activity. In
any less than ideal fixations, autologous cancellous bone
grafting is logical but has met with limited documented
Figure 20.18 Axial basilar fracture (arrow) causing lameness in success [68]. A cast is recommended for recovery from
a racehorse: this was removed arthroscopically. general anaesthesia. Osseous union is determined by
r adiographic monitoring, and post-operative rehabilitation decreases which is likely the result of increasing DSL dam-
is tailored by individual horses’ progress. age [39, 74, 75].
Results of Repair
Non-articular Basilar Fragments
The prognosis for basilar fractures with normal distal can-
non bones is inversely proportional to the amount of dam- Management of non-articular fractures is based on their like-
age to the DSLs [74]. Loss of significant DSL attachment lihood of causing future problems. It has generally been con-
increases load on the remaining ligaments which results in sidered that surgical trauma, and damage to adjacent intact
overload, desmitis and lameness. If DSL loss is marked, DSLs, outweighed any potential advantages that accrued
PSB instability can occur. from fragment removal [2, 14]. Fractures that are in close
Cancellous bone grafts have been successfully used in apposition and interact with the parent bone create a healing
experimentally induced basilar fractures, but in clinical response that results in softening of the PSB and progressive
cases results were less favourable [68, 74, 77]. compromise of DSL attachments [57]. These fractures there-
fore require a risks-v-benefits debate as to whether the loss of
fibre attachment due to the surgical procedure or the pres-
Removal of Articular Fragments
ence of the fragment and loss of fibre attachment due to the
Arthroscopic removal may be performed with the horse in secondary bone healing response represents the greater limit-
dorsal or lateral recumbency as per the surgeon’s preference, ing factor to athletic soundness. Non-articular fragments that
generally using contralateral arthroscope and ipsilateral are separated from the parent bone by fibrous tissue and can-
instrument portals in the former and ipsilateral arthroscope not produce a response by the parent bone do not represent
and instrument portals in the latter. Biaxial fractures can further risk to the horse. Providing they are accessible with-
effectively be visualized from a single arthroscopic portal out undue trauma, removal of fragments in close apposition
and removed through biaxial instrument portals. The arthro- to the parent bone may represent an opportunity to prevent
scope is inserted with the joint semi-flexed and an instru- future problems determined by the DSLs involved and the
ment portal is created just distal to the collateral sesamoidean available surgical options [57].
ligament parallel to the base of the PSB [52]. An approach for removal of non-articular fragments
Large fragments involving the whole dorsopalmar/plantar from the origin of the oblique DSLs has been described
thickness of the bone contain the origins of all of the DSLs, including results of 11 forelimb and 5 hindlimb fragments
and removal is contraindicated as loss of the oblique or in 11 performance horses [78]. All were lame and 5 of the
straight DSLs carries a poor prognosis. The concave base of 11 had been rested for ≥six months without resolution of
the PSB contains the oblique DSL origins and should not be lameness. Surgery was performed in lateral recumbency
significantly invaded if the horse is to have a good prognosis. with the affected limb uppermost. A direct approach was
Dorsal margin fragments are attached to the cruciate or short made through the digital flexor tendon sheath with frag-
DSL origins, which can be removed with little morbidity. ments located by palpation and radiographic control. After
Radiographically, these fragments will be half of the width removal, horses received 60 days of stall rest followed by
and half of the depth of the bone. Axially, which is the most graduated return to athletic activity
common site, these involve the cruciate and abaxially the
short DSL origins. Arthroscopic removal of these fragments is Results
effective in resolving lameness associated with their presence. Racing success has been documented following conserv-
If the extent of the lesion is in doubt, then ultrasonographic ative management of fragments resulting from DSL avul-
evaluation can help definition. Fragment dissection, removal sions in yearlings (Figure 20.20) [79]. Surgical treatment
and debridement are carried out using the same instruments, is therefore rarely elected without lameness. Removal
principles and aftercare described for apical fractures [52]. resulted in 9 of 10 horses with follow-up returning to per-
formance in non-racing disciplines [78].
Results with Removal
Although the prognosis for basilar fractures has been con-
sidered to be guarded to poor irrespective of treatment Sagittal/Axial Fractures
modality [38, 39, 75], if the fragment(s) involves only the
cruciate or short and has minimal involvement of oblique Sagittal fractures are generally axial but occasionally also
DSLs there is a good prognosis for athletic performance occur abaxially. Axial fractures range from narrow slivers
with arthroscopic removal. In one series, 59% (30/51) of into the intersesamoidean space to fractures in the middle
horses raced after sustaining basilar fractures and horses one-third of the bone. They most commonly occur in asso-
treated by fragment removal were more likely to race and ciation with displaced fractures of the lateral condyle of
performed better than horses that had reconstruction [74]. Mc3/Mt3, although they occasionally occur alone [57]. The
As fragment size and displacement increases, the prognosis former are thought to result from MCP/MTP joint instability
Destabilizing Fractures of the Proximal Sesamoid Bone 435
c ontaminated and contused. The palmar/plantar annular lig-

ament and digital flexor tendon sheath may also be involved.
These injuries follow the same pathologic pathway as other
traumatic wounds and are treated using similar principles of
surgical debridement, systemic antimicrobials and intra-
osseous or intravenous perfusion techniques [14, 82–84].
estabilizing Fractures of the

D
Proximal Sesamoid Bones
Biaxial disruption of the suspensory apparatus destabi-

lizes the MCP/MTP joint. The majority of such injuries
occur in the forelimbs, and the description that follows
will be ascribed to these although the principles apply
Figure 20.20 Non-articular basilar fragments found on
yearling survey radiographs.
equally to the hindlimbs. The injury can occur with biax-
ial fracture of the PSBs or any combination of sesamoid
fracture, ruptured SL or ruptured DSLs that destroy
with dorsal displacement of the fractured lateral condyle suspensory apparatus support of the MCP joint. Uniaxial
and loss of an articular interface for most of the PSB. This disruption (i.e. one-half of the suspensory apparatus)
creates a bending force against the margin of the fractured does not cause collapse of the MCP joint. If one of the SL/
Mc3/Mt3 resulting in fracture of the supported axial margin PSB/DSL complexes remains intact, the joint will retain
from the unsupported abaxial PSB. Radiographs of all horses sufficient stability to restore the opposite disrupted half
with displaced lateral condylar fractures should be scruti- of the suspensory apparatus by fibrosis adequate for pad-
nized carefully with multiple views for the potential pres- dock activity, but not for athletic use.
ence of an axial PSB fracture (Chapter 21). Horses with axial
fractures usually have articular damage that precludes Diagnosis
return to racing [80, 81]. All displaced condylar fractures
should be examined arthroscopically to assess the degree of Identification of a ruptured suspensory apparatus is possi-
cartilage damage to the lateral PSB and the potential pres- ble on clinical examination alone. Biaxial mid-body and/or
ence of an axial fracture. The treatment of choice for abaxial comminuted PSB fractures cause acute, severe lameness.
sagittal fractures is stabilization with a 3.5 mm lag screw [60] The limb usually is non-weight-bearing, but if loaded
(Figure 20.21). results in marked hyperextension of the MCP joint.
Destruction of the suspensory apparatus and palmar dis-
ruption of the MCP joint and digital flexor tendon sheath
Fractures Caused by External Trauma result in marked soft tissue swelling. Fracture fragments
can frequently be palpated subcutaneously, and occasion-
Fractures caused by external trauma usually involve the ally these will penetrate the skin. The palmar neurovascular
palmar/plantar abaxial surfaces of the PSBs. They commonly bundle is rarely lacerated by the fracture fragments but can
are accompanied by open wounds and so frequently are be stretched beyond physiologic limits as the MCP joint
Figure 20.21 DPa radiographs (a) (b)

of an abaxial sagittal fracture of
a medial PSB. (a) At presentation.
(b) Following repair with a single
3.5 mm cortex screw.
Figure 20.22 DP and LM radiographs of unsupported comminuted biaxial mid-body fractures with LM dehiscence indicative of
fibrocartilaginous scutum disruption. Note the degree of PSB distraction and hyperextension of the MCP joint even through the limb
is non-weight-bearing illustrating the danger to the palmar soft tissues when unsupported by first aid.
hyperextends. Excessive elongation of the vessels results in without joint collapse is rare because the Mc3/proximal
thrombosis, and if biaxial, results in irreversible avascular phalangeal articulation is generally intact. Surgical arthro-
necrosis. Even a period of reduced vascularity can result desis is the option most likely to minimize the risk of con-
in reperfusion injury and irreversible damage to the tralateral overload laminitis and result in a functional limb.
metabolically demanding laminae of the foot. Assessment If this is neither possible nor affordable, then euthanasia on
of vascularity is critical to prognostic assessment. Standard humane grounds is justified and preferred to subjecting the
radiographic projections, obtained after emergency support horse to a long painful convalescence that rarely results
has been applied, define the fracture configurations. in saving its life. The expedient pain relief produced by
Proximal displacement of proximal fragments on a recoiled surgical arthrodesis protects the contralateral limb. Before a
SL occurs in proportion to the amount of concurrent soft satisfactory technique for MCP arthrodesis was developed,
tissue disruption (Figure 20.22). the complication rate associated with such injuries was
high and resulted in euthanasia of 16 of 18 Thoroughbred
horses with traumatic disruption of the suspensory appara-
First Aid
tus [85]. External skeletal fixation with a cancellous bone
Emergency support of a limb with suspensory apparatus graft has been reported as an alternative but has not been
rupture is critical, second only to control of the horse itself. consistently successful [86]. Surgical arthrodesis that
The distal limb should be fixed in a flexed position included palmar support of the fetlock joint solved the bio-
(Figure 7.22). Even a few unprotected minutes of weight- mechanical limitations of dorsal plate fixation alone [85, 87,
bearing can permanently destroy the potential for survival. 88]. The technique is technically demanding and necessarily
Detailed description is provided in Chapter 7. expensive but is the treatment of choice (Figures 20.23–20.25).
Treatment Arthrodesis of the Metacarpo/

Metatarsophalangeal Joint
Most biaxial fractures begin with a mid- or comminuted
fracture of the medial PSB and subsequent disruption of the The currently recommended surgical technique is illus-
lateral half of the suspensory apparatus either through, trated in diagrammatic form in Figure 20.24 and is
above or below the lateral PSB [16, 17]. Repair of biaxial described for the MCP joint. The horse is anesthetized
fractures has been reported but has not been consistently and placed in lateral recumbency with the affected limb
successful [15]. Spontaneous ankylosis of the MCP joint uppermost. Systemic antimicrobial and anti-inflammatory
Figure 20.23 DPa and LM radiographs of a MCP joint

following biaxial mid-body PSB fracture. A 4.5 mm
broad DCP has been applied dorsally with a
combination of 4.5 and 5.5 mm cortex screws. Palmar
tension band support has been provided by two figure
of eight wires through the mid-diaphysis of the
proximal phalanx and distal Mc3. Note the single
lateromedially oriented 4.5 mm cortex screw in the
metaphysis of Mc3 used to repair the condylar
osteotomy. The hole in the dorsal cortex of Mc3
proximal to the plate was used to fit a tension device.
One screw was used to support the fractured medial
PSB and proximal interphalangeal joint.
therapy should be started prior to surgery. The limb is pression plate (LCP) provides greater rigidity but is not
prepped for aseptic surgery from the coronary band to the essential [89, 90] and a broad dynamic compression plate
carpus. A tourniquet is not used. In an open technique, a can be employed (Figures 20.23–20.25). Between 10- and
dorsolateral skin incision is made from 6 cm below the 16-hole plates are used, depending on the size of the horse
carpus following the path of the lateral digital extensor and the surgeon’s preference. The length of the plate is
tendon to the MCP joint and then is curved dorsally along determined by the purchase needed in MC3. In some situ-
the extensor branch of the SL to the midline, just proximal ations, leaving a stress concentrator directly in the middle
to the proximal interphalangeal joint. The incision is car- of Mc3 or ending the plate immediately under the top of
ried through the skin and subcutaneous tissue. The ten- the cast are undesirable. Three or four holes of the plate are
don of the lateral digital extensor, the MCP joint capsule used to insert screws into the proximal phalanx; the
and the extensor branch of the SL are split longitudinally. remaining holes extend up the Mc3. The most distal plate
The periosteum, transected tendon and ligament, joint screw and those immediately proximal and distal to the
capsule, subcutaneous tissue and skin are then reflected as MCP joint are exposed to the greatest stressed. It is there-
a unit from lateral to medial, exposing the dorsal surface fore recommended that 5.5 mm cortical screws are used in
of the MCP joint and dorsal cortices of Mc3 and proximal these locations with 4.5 mm cortical screws in the remain-
phalanx. Minimally invasive plate insertion without expo- ing plate holes.
sure of the MCP joint has also been described [89, 90]. After the plate is fitted to the proximal phalanx, it is
The chosen plate is bent to produce an extension angle of removed. The joint surface is then approached to remove
15–20° at the MCP joint. It is fitted to the dorsal surfaces of the articular cartilage from Mc3 and proximal phalanx.
Mc3 and proximal phalanx as accurately as possible: it is This can be carried out by surgically transecting the joint
especially important to determine that the long axis of the capsule and lateral collateral ligament, by creating a condy-
plate aligns with the long axis of the Mc3. A locking com- lar osteotomy or by drilling the joint blindly to destroy the
(c)
Skin incision Fetlock luxated
(a)
Split lateral extensor tendon
2 mm drill bit
(d)
Tension-band wire
Common digital
extensor tendon Wire passer
(b)
Condylar osteotomy
Condyle osteotomy lag screws

Tension-band wire
(e)
14-hole dynamic
Sesamoid lag screw compression plate
Figure 20.24 Technique for MCP joint arthrodesis. (a) Surgical approach. (b) Lateral condylar osteotomy. (c) Medial joint luxation and
subchondral osteostixis. (d) Creation of a palmar tension band. (e) Implant positions at completion. Source: Nixon, 2020, Figure 23.6,
p. 430. Reproduced with permission from Wiley & Sons.
cartilage. Osteotomy is the first author’s preference. An tiple holes across the articulation rather than the more
oscillating bone saw is used to mimic a complete fracture of invasive disarticulation.
the lateral condyle that exits the distal diaphysis of Mc3 The next step is provision of palmar support to stabi-
proximal to the collateral ligament attachments. This lize the MCP joint. If the PSBs and DSLs are intact, then
allows medial luxation of the joint and maximizes room for fixation of the PSBs to Mc3 with lag screws and resultant
removal of the articular cartilage and insertion of the pal- tightening of the DSLs will provide palmar support to
mar support (when needed). After removal of articular the plate in resisting extension of the MCP joint. If the
cartilage, usually with a combination of curettes and PSBs are to be used for lag-screw fixation, then their
motorized equipment, the subchondral bone is fenestrated articular surfaces must also be denuded of articular
with multiple small (2.0, 2.7 or 3.2 mm) drill holes to pro- cartilage before realignment of the MCP joint. If the sus-
mote vascular ingrowth and access for mesenchymal cells pensory apparatus has been disrupted, then its support
in the epiphyseal spongiosa. In order to minimize the soft must be replaced by a palmar ‘figure-eight’ tension band
tissue disruption, some surgeons prefer to simply drill mul- wire or cable. A transverse hole is drilled in the middle
(a) (c)
(b)
(d) (e) (f) (g) (h)
Figure 20.25 Arthrodesis for biaxial PSB fractures in a three-year-old Thoroughbred filly using the lateral collateral ligament
desmotomy technique. (a) LM radiograph demonstrating fracture distraction with dorsal subluxation of the proximal interphalangeal
joint despite a cast fitted in a straight distal limb position. (b) Pre-operative Doppler ultrasonography to assess integrity of distal limb
blood supply. (c) Flexion splint fitted after cast removal producing straight Mc3/proximal phalangeal loading and reducing distraction.
(d) Post-operative LM radiograph. (e, f) LM and DP radiographs three months after surgery confirming construct stability and
demonstrating early Mc3/proximal phalangeal bridging. (g, h) LM and DP radiographs 20 months after surgery. Arthrodesis is complete
with organized cortical and trabecular bone crossing the previous MCP joint where the subchondral bone plates are no longer
discernible. The PSBs have also been incorporated into an organized palmar osseous continuum. The animal leads a normal
broodmare life and has bred successfully for five consecutive years.
of the proximal phalanx, and in the Mc3 a similar dis- are in place, the MCP joint is reduced, placed in slight
tance proximal to the MCP joint. These holes are drilled flexion and the wires are twisted or cables are fixed to
between the holes of the plate to avoid intersecting the create the tension band. The limb is placed in slight flex-
wire/cable with later screw placement. The wire/cable is ion to pre-tighten the tension band, ensuring that maxi-
then threaded through the proximal phalanx, passed mum tension is created when the MCP joint is extended
proximally up the palmar aspect of the leg by means of a by subsequent plate attachment. Good pre-operative
wire passer, crossed behind the MCP joint and threaded planning and three-dimensional thinking avoids wire
through Mc3 to exit laterally. A second wire is then impingement, and likely resultant failure, when drilling
inserted to follow the same path. When the wires/cables adjacent plate holes.
If the PSBs are to be used without wires (which is not degree of healing (Figure 20.25). If progress is satisfactory,
possible with biaxial PSB fractures), the luxation is reduced, a period of hand walking is used before graduated free
and the limb is held in slight flexion. Two 4.5 mm cortical exercise is allowed. The most important aspect of the grad-
bone screws are inserted, in lag fashion, through the distal uated return to exercise is the accommodation of the adja-
end of Mc3 to the centre of each PSB, thereby tightening cent articulations, particularly the proximal interphalangeal
the DSL palmar tension band. If required, tension wires or joint, as these will absorb additional stress normally
cables can also be combined with sesamoid fixation. absorbed by the MCP joint.
Whenever possible, it is desirable to fix the sesamoids in Implant removal is indicated only in instances when
some fashion because this also stabilizes the palmar pas- implant infection causes persistent drainage and should be
tern joint (Figure 20.23). considered only after functional ankylosis is established.
Once the tension band has been established and the
joint reduced, the plate is re-attached to the proximal pha-
Complications
lanx and depressed to the surface of Mc3. A tension device
is used to increase the tension on the plate and place com- The most significant complication is laminitis in the con-
pression across the MCP joint by creating tension in both tralateral limb (Chapter 14). This principally results from
the palmar tension band support and the plate. The lack of comfortable weight-bearing in the injured limb,
appropriate locking or cortical screws are inserted sequen- which may have numerous causes, including instability
tially using all of the holes in the plate. As in other loca- and/or infection. Successful arthrodesis with resultant sta-
tions, if a locking plate is used then cortical screws should bility is critical to prevention.
be inserted first to create bone–plate contact. Avascularity of the injured distal limb may occur because
Two additional lag screws, one on each side of the plate, of arterial damage. Lack of adequate perfusion is seen in two
are then placed across the joint from the proximal phalanx forms. Immediate avascular necrosis causes the limb to
into the distal Mc3, to increase and broaden the area of become and remain cold, whereas transient avascularity can
compression and increase rotational stability of the fixa- result in reperfusion injury to the foot with loss of skin or
tion. When employed, the condylar osteotomy is repaired hoof wall approximately two weeks after the injury. The first
with one or more lateromedially oriented lag screws that is easily diagnosed and should be assessed clinically and
interdigitate with the dorsopalmar plate screws. ultrasonographically pre-operatively and the surgery
At the discretion of the surgeon, a suction drain may be delayed or declined. The second is impossible to predict.
placed alongside the plate to exit proximally. Closure Occasionally, the first cast change will reveal some or all of
occurs sequentially using the digital extensor tendon, sub- the tissues undergoing reperfusion inflammation. The most
cutaneous tissue and skin over the plate. A cast is placed on devastating result is loss of the hoof capsule because the
the distal limb for recovery from surgery and to protect the laminae are the most metabolically demanding tissues of the
implants against cyclic loading. Assisted recovery from distal limb. Avascular loss of the hoof capsule is
general anaesthesia is recommended. irreversible.
Rupture of the DSLs disables the straight DSL support to
the proximal interphalangeal joint, creating instability and
Post-operative Care
in turn partial or complete palmar subluxation. This causes
Post-operative intravenous antimicrobials are maintained discomfort and increases the risk of laminitis in the con-
for a period appropriate for the amount of soft tissue dam- tralateral limb.
age, surgeon preference and the amount/time of exposure
to contamination [88]. Phenylbutazone at 2.2–3.3 mg/kg
Results
q24h is used post-operatively following similar guidelines.
The first cast is usually maintained to protect the fixation In a retrospective study, 34 of 52 horses with MCP arthro-
for two weeks before being replaced. This can be performed desis survived to have unrestricted activity [88]. Results
standing with sedation in most horses. Often, the second were better when arthrodesis was the primary treatment
cast is placed as a cylinder, allowing the toe to exit the bot- than when this followed unsuccessful non-operative treat-
tom of the cast. This allows the horse to tension the flexor ment and for horses with intact distal suspensory appara-
tendons, helping to prevent flaccidity that often accompa- tus compared to those with loss of the DSL support. The
nies cast immobilization. The second cast is kept in place prognosis was also better for horses with degenerative
for two weeks. arthritis than for horses with disruption of the suspensory
Horses are normally restricted to stall rest for two months apparatus presumably because of reduced pre-surgery
with follow-up radiographs at that time to determine the trauma to the limb [88].
Reference 441
Blanket prognostication is difficult and must be modified as vascular compromise and proximal interphalangeal sub-
for each injury. Stable internal fixation can negate the effects luxation, then become the primary determinants of out-
of the primary injury and is achievable but demands strict come. After successful arthrodesis, horses can be treated
adherence to internal fixation principles, careful attention to normally with free unrestricted paddock or field exercise
technique, surgical skill and experience. In their absence, and used as breeding animals (Figure 20.25), but athletic
the risk of technical failure is high. Secondary injuries, such work is precluded by the lack of a functional MCP joint.
R
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445
21
Fractures of the Distal Condyles of the Third Metacarpal

and Third Metatarsal Bones
I.M. Wright
A
natomy proximal sesamoid bones (PSBs) when the joint is maxi-
mally extended. Immediately abaxial to the pa/pl sagittal
The third metacarpal (Mc3) and metatarsal (Mt3) bones ridge are the parasagittal condylar grooves. These are
develop from three ossification centres: epiphyses proxi- inconsistent and variable indentations that run parallel to
mally and distally with an intervening body. The proximal the sagittal ridge pa/pl to the transverse ridge.
epiphysis unites with the body before birth [1]. The diaphy- The distal articular surfaces cover an angle of approxi-
ses are dorsally convex semi-cylinders, but Mt3 has greater mately 220° [5]. Normal movement is restricted almost
dorsal and abaxial convexity than Mc3. Distal to the second entirely to the slightly laterally angled parasagittal plane in
and fourth metacarpal/metatarsal bones, the diaphyses of line with the sagittal ridge, i.e. flexion and extension [6]. As
Mc3/Mt3 become mediolaterally wider and the dorsal con- the limb is loaded and the metacarpophalangeal/metatar-
tour flatter. sophalangeal (MCP/MTP) joint extends, the proportion of
The anatomical relations of Mc3 and Mt3 are of greater Mc3/Mt3 that contacts the PSBs increases while that con-
importance to the management of diaphyseal fractures tacting the proximal phalanx decreases [7]. At a MCP angle
(Chapter 22), but surgeons must be cognisant of the posi- of 120°, which approximates to the degree of extension
tions of the second and fourth metacarpal and metatarsal produced in the stance phase of a galloping horse, 46% of
bones and adjacent neurovascular elements [2–4] in the the condyles and the sagittal ridge are contacted by the
repair of proximally propagating fractures of the condyles. PSBs and intersesamoidean ligament, and the remainder
Aside from the digital extensor tendons, the dorsal and by the proximal phalanx. The purported site of origin of
abaxial surfaces of both bones have no soft tissue covering fractures of the Mc3/Mt3 condyles is pa/pl in the contact
except skin and thin metacarpal/metatarsal fascia. area of the PSBs and, as speed increases, the proportion of
Periosteal haemorrhage associated with fractures therefore load borne by the suspensory apparatus rather than the
often can be seen and usually can be palpated. Displaced axial skeleton increases [8]. The pa/pl subchondral bone is
fractures may also be identified by palpation alone. thicker than the dorsal, although this varies between and
The metaphyseal and epiphyseal anatomy for Mc3 and within both the condyles and individual horses. The under-
Mt3 is similar. The distal epiphyses consist of two condyles lying trabeculae are oriented in a converging manner
separated by a sagittal ridge which is angled slightly laterad towards the centre of the epiphysis [8].
from palmar/plantar (pa/pl) to dorsal. The medial condyle The abaxial surface of both condyles is an irregular fossa
is larger in both mediolateral and dorsopalmar/plantar from which the majority of the collateral ligaments of the
(DP) planes. Its distal articular surface is perpendicular to MCP/MTP joints originate. This is bordered proximally by
the long axis of the bone while that of the lateral condyle an epicondylar eminence which is situated at the level of
has a slight proximal axial incline. The articular surfaces of the distal metaphyseal growth plate and represents an
both condyles bear a slight lateromedial transverse ridge at important palpable landmark in fracture repair. Complete
their most distal point. This marks a change in the radius closure of the growth plate occurs between 10 and
of curvature such that the pa/pl articular surfaces are flat- 18 months with radiographic, which is generally thought to
ter than the dorsal surfaces. The latter represent the con- represent functional, closure between six and eight
tact area for the proximal phalanx and the former for the months [1]. The irregular osseous contour continues over

446 Fractures of the Distal Condyles of the Third Metacarpal and Third Metatarsal Bones
the epicondyle and onto the metaphysis where the collat- conjoin to exit through the periosteal surface of the meta-
eral ligaments gradually thin. physis or diaphysis of the bone and incomplete if this has
Computed tomography (CT) has demonstrated that the not occurred. Displacement has been variously and
pa/pl subchondral bone of both Mc3 and Mt3 is most inconsistently defined. The author’s favoured definition
dense particularly in their axial one-half. The lateral con- is that displacement involves a change in the anatomic
dyle usually is more dense than its medial counterpart. A axis of one fragment with respect to another. In distrac-
narrow zone of less dense bone separates the pa/pl axial tion, orientation is maintained and fragments simply
regions of the condyles from the sagittal ridge which is separate [19]. Displacement can involve abaxial, proximo-
also less dense. This juxtaposition creates a substantial distal, DP or rotational movement; frequently, there is a
mediolateral density gradient [9], and similar variations combination of these. In some fractures, this can only be
in mechanical properties including elastic modulus, determined arthroscopically. It should also be recognized
yield stress and energy to failure (toughness) [10, 11]. In that unstable fractures can also move from distracted to
the distal epiphysis of Mc3, the trabecular infrastructure displaced, for example a fracture which is radiographi-
is anisotropic [8, 12] with the principal trabeculae run- cally distracted may be displaced by joint flexion and vice
ning in a sagittal plane with fewer and less substantial versa. Incomplete fractures can distract at the articular
mediolateral connections [12]. This structure gives maxi- surface but cannot displace. Fractures that extend into
mum strength in the sagittal plane in which the bone is the diaphysis are described as propagating. These are of
principally loaded but offers minimal resistance to frac- two types. The first remain in a sagittal or parasagittal
ture propagation. It was concluded that this arrangement plane, and the second begin in this plane and then change
could explain the course of many fractures of the lateral orientation to oblique or frontal planes; the latter are
condyle [13]. Fractures of the lateral condyle which are generally referred to as spiral [18, 20–30]. Propagating
abaxial often curve towards the epicondylar eminence or fractures are much more common medially than later-
metaphyseal cortex – the orientation of abaxial epiphy- ally [18, 20–24], but this is not invariable. Comminution
seal trabeculae. By contrast, fractures that originate close can be articular (subchondral) and/or proximal (meta-
to the sagittal ridge, in common with the vertically ori- physeal or diaphyseal) [18]. It is usually only seen with
ented axial trabeculae, commonly remain sagittal and complete fractures [25].
have a greater propensity to proximal propagation. Differentiation between fracture types is not clear cut,
The major forces acting on the epiphysis of the Mc3 can and definitions employed have varied. Many apparently
be resolved into two components, transmitted through the radiographically incomplete fractures, at least in the acute
proximal phalanx and the PSBs. The distribution varies phase, may in reality be complete [26]. Additionally, radi-
with speed and phase of the stride [8]. The principal loading ography may not always identify displacement in a DP
forces are sagittal [8], but there is evidence of transverse plane [21, 31]. Classification has merits in permitting
tensile force between the distopalmar condyles and sagittal grouping for management decisions and in order to com-
ridge [14]. Epiphyseal trabecular bone volume (density) pare treatment protocols but should always be interpreted
increases distally towards the subchondral bone, particu- with these shortcomings in mind.
larly in the pa/pl quadrants [9, 12]. Exercise increases min- Fractures of the lateral condyle vary in position from the
eralization and subchondral bone density and is associated sagittal ridge to narrow fragments less than 10 mm from
with trabecular thickening [12, 15, 16]. The increase in vol- the abaxial margin [18, 21]. Fractures that commence axi-
umetric bone density that accompanies training has been ally whether medial or lateral are usually longer than those
shown to occur in a pattern that runs obliquely from dis- which arise abaxially [18, 26, 27]. Thus, propagating frac-
topa/pl dorsoproximally [17]. The disparity in density tures of the lateral condyle usually originate close to the
between the dorsal and pa/pl halves of the epiphyses sagittal ridge [18, 22].
increases with intense training [12]. Fractures of the medial condyles almost invariably arise
immediately adjacent to the sagittal ridge [18, 21, 23], and
either are confined to the pa/pl subchondral bone or are
Fracture Types bicortical and propagate proximally into the diaphysis.
Fractures of the lateral condyle also feature in complex
Fractures are generally classified from radiographic fea- usually catastrophic fractures centred on the MCP/MTP
tures [18] (Figure 21.1). They may be unicortical (although joint. These generally manifest as racing injuries and com-
this usually involves pa/pl subchondral compacta rather monly include a displaced fracture of the lateral condyle,
than cortical bone) or bicortical. Fractures are classified proximal sesamoid fractures and markedly comminuted
as complete if the fractures in dorsal and pa/pl cortices fracture of the proximal phalanx.
Incidence and Causatio 447
(a) (b) (c) (d)
(e) (f) (g)
Figure 21.1 Fractures of Mc3/Mt3 condyles imaged by transverse (a) and reconstructed 3D (b)–(g) CT. (a) Short palmar ‘unicortical’
fracture of the lateral condyle. (b) Bicortical incomplete fracture of the lateral condyle. (c) Complete non-displaced fracture of the
lateral condyle. (d) Displaced fracture of the lateral condyle. (e) Parasagittal propagating fracture of the medial condyle. (f) ‘Spiral’
propagating fracture of the lateral condyle. (g) ‘Spiral’ propagating fracture of the medial condyle.
Incidence and Causation training [18]. They occur less frequently in Standardbreds
and occasionally in Quarter Horses. They are also seen in
Fractures of the condyles of Mc3 and Mt3 are the most polo ponies [25], endurance horses [32] and occasionally in
common long bone fracture of Thoroughbred horses in other disciplines in which the horse moves at speed. These
fractures have attracted more research and generated more MRI, the percentage of dense bone volume was similar in
publications than any other injury in equine athletes which both fractured and intact condyles of limbs with fractures
reflects their welfare and financial importance. and in contralateral limbs, but was greater than the legs of
The fractures are not associated with traumatic events, control horses [50]. Bone marrow lesions were identified in
occur during high speed exercise, are site specific and fol- all limbs with catastrophically fractured condyles and 27%
low repeatable courses, thus answering the criteria for clas- of contralateral limbs, but only 7% of condyles from control
sification as stress or fatigue fractures [33] (Chapter 3). horses. However, fissures in the parasagittal groove were
They are usually uniaxial; 1 in 167 (0.6%) fractures in rac- found in 27% of legs contralateral to fractures, none in frac-
ing Thoroughbreds was biaxial [18]. tured legs and 8% of control limbs [50].
An association with suspensory apparatus injury has Quantitative CT demonstrated that 54% of Mc3 condylar
been reported [34], and biomechanical hypotheses fractures had no evidence of subchondral porosity which
relating loss of soft tissue support to fracture pathogen- led the authors to conclude that these can occur in the
esis raised [35]. It is currently accepted that fatigue fail- absence of remodelling [42]. Additional work has shown
ure occurs through intense focal remodelling that bone mineral density in the Mc condyles of racehorses
bone [36–43]. It has been suggested that the injury appears similar between horses with and without frac-
starts in the calcified cartilage layer of the pa/pl condy- tures [53], i.e. this appears to be a response to training
lar groove [12, 41]. There are numerous reports docu- rather than representing a predisposition to fracture per
menting the presence of coalescing cracks in the se. Similarly, there was no evidence of higher bone volume
calcified layer and subchondral bone in the region of fraction in Mc3 condyles of horses with condylar fractures
the condylar grooves of horses in training [12, 37, 39, than in racehorses with other fatal musculoskeletal inju-
41, 44, 45]. It has been reported that these are a precur- ries [54]. It therefore remains unclear whether all condy-
sor to development of a fracture and that accumulation lar fractures are the result of cumulative adaptive
and coalescence of micro-cracks results in propagation failure [44].
of a critical crack in the compacta (subchondral and Fractures most commonly present in two- and three-
cortical) shell. It is reasoned that remodelling of the year-old flat racing Thoroughbreds [18, 21, 26], but ani-
subchondral bone targeted at micro-crack repair may, mals of all ages may be affected. Fractures can occur at
paradoxically, facilitate crack propagation by increasing any stage of training or at any time during a racing sea-
porosity [41] and producing density gradients that con- son. In one study, the frequency of fractures in two-year
centrate stress [9, 10, 12, 37]. Increased thickness of olds increased month on month as the racing season pro-
dense palmar subchondral/trabecular bone [46] and gressed, but this may reflect only the numbers of animals
qualitative focal increases with more heterogeneous involved in training at these times [18]. In this study, 139
bone density [47] have been identified by magnetic res- of 174 (80%) of fractures involved the lateral and 35 of
onance imaging (MRI) and CT, respectively, adjacent to 174 (20%) involved medial condyles. Thirty-one (60%)
catastrophic fractures of the lateral condyle of Mc3. medial fractures occurred in two-year-old horses. When
However, there are no longitudinal studies to determine using combined data from comparable UK [18, 21] and
temporal association, and the specificity of risk has not USA [25, 26, 55–57] studies, 220 of 298 (74%) fractures in
been established [48]. the UK and 391 of 455 (86%) fractures in the USA were
Other features of pa/pl subchondral compromise such as lateral. One hundred and eighty-eight of 298 (63%) frac-
palmar osteochondral necrosis (POD) do not appear to tures involved forelimbs, and 110 (37%) involved
have a parallel incidence. A report describing MRI findings hindlimbs in the UK which is similar to 310 (68%) and
in horses euthanized on racecourses found the greatest 145 of 455 (32%) involving forelimbs and hindlimbs in
incidence of POD in limbs of horses with no fractures the USA, respectively. In the UK, 153 (81%) forelimb frac-
(12%) followed by the contralateral limb in horses with tures were lateral and 35 (19%) were medial compared
fractures (9%) and the lowest incidence in limbs with frac- with 39 (35%) medial and 71 (65%) lateral fractures in
tures of the lateral condyle of Mc3 (4%) [49]. Similarly, in hindlimbs. Thirty-three of 80 (41%) lateral and 12 of 13
an MRI cadaver study of Mc3s, no POD lesions were identi- (92%) medial fractures originated in the region of the
fied in fractured condyles, and the incidence in control condylar grooves [18]. Although sidedness has been
limbs (33%) was significantly greater than in fractured reported [21, 37], pooled UK and USA data has shown no
limbs (4%) [50]. As a result of these and other negative cor- evidence of this either for all condylar fractures or for
relations between POD and condylar fractures, it has been any specific type [18].
suggested that different patterns of loading in individual In the pooled data, 109 of 298 (37%) UK fractures were
horses may predispose to fracture or to POD [51, 52]. On classified as radiographically complete compared to 221 of
Clinical Features and Presentatio 449
389 (57%) in the USA. In a single study, 88 of 139 (63%) Clinical Features and Presentation
fractures of the lateral condyle were complete and of these
68 (77%) were displaced, comprising 68 of 139 (49%) of all Fractures of the Palmar/Plantar Subchondral
fractures of the lateral condyle [18]. This compares to 149 Bone
of 221 (67%) complete fractures which were displaced in
the pooled USA data. Propagation was identified in 28 of Some horses with fractures that involve only the pa/pl sub-
35 (80%) medial and 12 of 139 (9%) lateral fractures. chondral bone present with lameness of acute onset and
Twenty out of 28 (71%) medial and 11 of 12 (92%) lateral moderate severity after completing a race or training work.
propagating fractures had spiral configurations. The other Others are found in lameness investigations of horses in
fractures remained parasagittal. Articular comminution training. It is a rare injury in other horse sports. Either fore-
was identified in 20 of 174 (11%) fractures, and proximal limbs or hindlimbs can be affected, but in a series of 45
(non-articular) comminution was reported in 17 of 174 Thoroughbred racehorses 35 (78%) were in Mc3 and 10
(10%) fractures [18]. (22%) were in Mt3 [59]. Distension of the MCP/MTP joint
Fractures of the medial condyles are less common than was documented in only 1 (2%) of these cases. It is fre-
lateral accounting for 26% and 14% of reported cases in the quently not marked but, when present, is often greatest in
UK and USA, respectively [18, 21, 25, 26], but are more the pa/pl pouch. Increased arterial pulse amplitudes may
likely to propagate into the diaphysis [18, 20, 21, 26, 56]. be detected in pa/pl arteries at an abaxial sesamoid level;
Fractures of the medial condyle of Mt3 have been reported this is frequently misinterpreted as indicative of a more
to be more common than those of Mc3 [55], but in two fur- distal lesion but, unlike the latter, the arterial pulse ampli-
ther series there was no significant difference in inci- tudes in the pa/pl digital arteries in the pastern region are
dence [18, 26]. There are also varying results in the usually not increased. In the hindlimb, there can be an
literature with respect to the propensity for spiral propaga- increased arterial pulse amplitude in the great metatarsal
tion between limbs. In one series, 21 of 22 (95%) fractures artery. In some animals, digital pressure over the affected
of the medial condyle of Mt3 adopted a spiral configura- distal pa/pl Mc3/Mt3 is resented. These fractures are
tion compared to 11 of 21 (52%) in Mc3 [21]. By contrast, in entirely intra-articular, and there is thus no periarticular
another report six spiral fractures of the medial condyle haemorrhage or swelling. When local analgesic techniques
were all in Mc3 [26]. In 15 propagating fractures of the are employed, lameness is usually responsive to intra-
medial condyle of Mt3 in six Standardbreds and nine articular anaesthesia of the MCP/MTP joint and/or to
Thoroughbreds, left and right limbs were equally affected regional blocks at a distal metacarpal/metatarsal level [59].
in the Standardbreds, but in the Thoroughbreds six out of As a general rule, lameness is not improved by local anal-
nine were left and three out of nine were right; it was sug- gesia of the pa/pl digital nerves at or distal to a mid-pastern
gested that this may reflect anticlockwise training and rac- level. However, a positive response can be obtained follow-
ing regimes [30]. Two studies reported a lower mean age of ing local analgesia of the pa/pl nerves at an abaxial sesa-
horses suffering fractures of the medial condyle of Mt3 moid level. Either medial or lateral condyles can be
than lateral counterparts [20, 21], but they are encountered affected, and fractures can be bilateral but clinically asym-
in horses of all ages. metric. In one report, 44 of 45 cases were unilateral [59].
Proximally propagating fractures of the lateral condyles Nonetheless, bilateral radiographic examination is always
are less common than those occurring medially, but clini- recommended. Some unicortical fractures will be radio-
cians should be alert to their potential and associated clin- logically silent in the acute phase and clinical signs, includ-
ical signs. Like their medial counterparts, they originate ing lameness, can resolve rapidly with only a few days of
close to the sagittal ridge [18]. Incidences of 12 of 139 box rest. If possible, suspicious cases therefore should be
(8.6%) [18] and 2 of 81 (2.5%) [21] fractures of the lateral assessed scintigraphically by MRI or monitored radio-
condyle and 11 of 31 (35%) [18] and 2 of 8 (25%) spiral graphically to minimize the risk of fracture propagation.
fractures [26] have been reported. They were also recorded Two cases that were not recognized at initial evaluation
in 6 of 75 (7%) catastrophic fractures of lateral continued to train and progressed to complete, catastrophic
condyles [58]. fractures [59].
No single pathogenetic theory explains all of the clinical
presentations. It is possible that there may be a number of
Bicortical Incomplete Fractures
causes and/or that failure may be multifactorial. There is
anatomic commonality, but fractures occur at different Most bicortical fractures present with acute, severe lame-
locations within the condyles, follow differing paths and ness following a race or training session. Forelimbs are
occur at differing times. more commonly affected than hindlimbs, and occasionally
fractures can be bilateral. Some horses also have fractured Within a short time, some spiral fractures (medial and lat-
lateral condyles of both Mc3 or Mt3 as successive injuries. eral) produce pitting soft tissue swelling over the palmar/
There is usually progressive distension of the affected plantar lateral diaphysis as the pa/pl fracture extends later-
MCP/MTP joint due to intra-articular haemorrhage. With ally adjacent to the fourth metacarpal/metatarsal bone.
short fractures that do not progress beyond the proximal The key to distinguishing this from haemorrhage associ-
capsular reflections, this may be the only palpable abnor- ated with complete fractures of the lateral condyle is that
mality. Proximally, longer fractures can result in periosteal this swelling is palmaro/plantarolateral rather than lateral
haemorrhage that may be clinically evident in the distal and is centred adjacent to the dorsal border of the fourth
lateral metacarpus/metatarsus. Digital pressure at this site metacarpal/metatarsal bone (fractures of the lateral con-
may be resented. Flexion of the MCP/MTP joint usually, dyle usually exit distal to this point).
but not invariably, is painful. With the above history and In the middle one-third of the diaphysis, where spiral frac-
clinical features, immediate radiographic examination is tures change planes, they can become complete when
mandatory. exposed to bending and torsional forces. The principal excit-
ing force to the former appears to be an animal’s rising which
presumably exerts maximal bending force on the bone.
Complete Non-displaced Fractures
Unstable displacement is instantaneous and usually cata-
In the acute phase, the clinical presentation of complete, strophic. Occult (radiographically silent) fractures can pre-
non-displaced fractures is similar to their incomplete coun- sent, sometimes with catastrophic consequences, at almost
terparts, but in addition there is usually clinically discern- any time in the first four to six weeks following injury.
ible haemorrhage at the exit point on the distal lateral Previously identified fractures also appear to be capable of
diaphysis or metaphysis. Initially, this can be quite subtle, both acute and insidious propagation during this period.
but it is generally readily apparent within an hour or so.
Complex Fractures
Displaced Fractures of the Lateral Condyles
Complex fractures almost always occur when horses are
Affected animals usually exhibit severe lameness, although galloping at racing speeds. Horses are unable to continue
paradoxically some are less lame at presentation than and can fall particularly with forelimb involvement. If
incomplete fractures [60]. In most cases, there is rapidly horses do not ‘pull up’ quickly, fractures can become open.
developing soft tissue swelling of the distolateral metacar- Clinical presentation reflects the severity of the injury. The
pus/metatarsus and distension of the MCP/MTP joint due MCP/MTP joint and proximal phalanx are unstable, and
to haemorrhage. the fractured lateral condyle is palpable with marked crepi-
Abaxial displacement is often palpable. Most displaced tus at all locations.
fractures remain closed, but the instability of some is suf-
ficient, particularly when the horse does not pull up
promptly, to become open as the thin overlying skin can be
perforated by the sharp proximal edges of displaced
fragments.
Fractures of the Palmar/Plantar Subchondral
Bone
Propagating Fractures
Fractures confined to the pa/pl subchondral bone are situ-
Propagating fractures almost invariably present with acute, ated immediately adjacent to the sagittal ridge in the region
severe lameness either during or immediately following of the condylar groove. Most are identified on DP radio-
training or racing. Generally, affected horses are more dis- graphic projections and variations thereof. The ‘standard’
tressed than those which have suffered non-propagating DP projection of the MCT/MTP joint is a dorsal 20° proxi-
fractures, and the limb is often guarded markedly with mal-pa/pl distal oblique which profiles the most distal
minimal loading that usually involves toe-only foot–ground articular margin of Mc3 and Mt3. The palmar/plantar con-
contact. Rapid distension of the MCP/MTP joint is com- dyles may be imaged in a dorsopalmar/plantar plane by
mon, and in the per acute phase there may be little else to flexing the MCP/MTP joint sufficiently for a horizontal
see or feel. Horses with medial fractures will frequently X-ray beam to be at approximately 125° to the long axis
resent digital pressure dorsomedially in the distal one-third of Mc3/Mt3 [61]. However, these are superimposed on
of the bone and sometimes both medial and lateral to the the PSBs. A preferred technique is the flexed dorsal 35°
extensor tendons in the middle one-third of the diaphysis. distal-pa/pl proximal oblique (flexed D35°Di-Pa/PlPrO)
rojection [62]. An alternative is the dorsal 25° distal-pa/pl

p results in horses in training must be interpreted cautiously;
proximal oblique projection. Until the advent of flexed DP nuclear scintigraphy is a sensitive indicator of changes in
techniques, many of these fractures were unrecognized. subchondral bone activity but lacks specificity in discerning
They are therefore under-represented in published series normal osseous remodelling from damage [15] (Chapter 5).
of condylar fractures. However, even with these projec- MRI can identify fractures of the pa/pl subchondral bone
tions, fractures are frequently radiographically silent for that may not readily be identified radiographically [59, 63,
7–10 days and sometimes for 2–4 weeks. 64] (Figure 21.3). It has also been suggested that MRI may
Some fractures are imaged only in flexed DP projections. identify prodromal fracture changes [59, 64].
However, CT has demonstrated that previous assumptions
that fractures imaged in DP projections were bicortical and
those imaged only in flexed DP projections involved the
palmar/plantar subchondral bone and adjacent dense Most bicortical fractures are apparent in DP and flexed
spongiosa only [18] are incorrect (Figure 21.2). DP projections in the per acute phase. However, at this
Although confined to subchondral bone of the Mc/Mt. time, the full extent and precise configuration of the
condyle (they do not extend further proximal), these frac- fracture may not be known. The majority are lat-
tures are commonly referred to as unicortical [18, 59]. When eral [18], and frequently a dorsal 5–15° medial-pa/pl
radiographically apparent, acute fractures are usually linear, lateral oblique (D5–15°M-Pa/PlLO) projection corre-
parasagittal and sharply marginated. Fractures of longer sponds with, and therefore will highlight, the fracture
duration or which manifest after a period of progressive sub- plane. The fracture can originate immediately adjacent
chondral failure are poorly marginated. These are com- to the sagittal ridge or at any point abaxial to this.
monly accompanied by a zone of osteolysis immediately Axially situated fractures propagate further proximad;
adjacent to the fracture and a more peripheral area of the more abaxial the fracture the shorter its length and
increased opacity in the palmar/plantar half of the condyle. generally the greater its lateral obliquity [18]. Some
In a series of 45 cases, 32 (71%) were lateral and 13 (29%) fractures are bicortical distally and unicortical (pa/pl)
medial; there was no difference in laterality between fore- proximally. Radiographically, incomplete fractures do
limbs and hindlimbs. Thirty-five (78%) fractures were only not extend to the periosteal surface of the lateral cor-
evident on flexed DP radiographs [59]. tex. Differentiation from complete non-d isplaced frac-
Nuclear scintigraphic evaluation can reveal increased tures is radiographic and temporally d ependent as,
radiopharmaceutical uptake which precedes radiographic with time, evidence of complete disruption of the lat-
identification. This is usually confined to the affected con- eral cortex often becomes apparent; it is therefore
dyle and is generally greatest on the pa/pl side. However, imprecise. Cross-s ectional imaging, principally CT, has
(a) (b) (c)
Figure 21.2 Fracture of the medial palmar subchondral bone and adjacent dense epiphyseal spongiosa. (a) Transverse CT image at
the level of the base of the proximal sesamoid bones (with the MCP at a neutral angle). Fracture (arrow) identified in flexed (b) and
standard (c) DP radiographs.
(a) (b) Figure 21.3 Transverse MRI (a) and CT (b)

images of a plantar fracture of the lateral
condyle of Mt3. The differences in
proximal sesamoid bone location are
produced by a combination of slice angle
and differences between extension of the
MTP joint for standing image acquisition
(a) and a neutral position under general
anaesthesia (b).
(a) (b)
Figure 21.4 Short bicortical fracture of the lateral condyle of Mc3. (a) DP radiograph demonstrating an abaxial fracture course. (b) Fracture
location in a transverse CT image at the level of the epicondylar fossa.
also demonstrated that fractures that were considered Complete Non-displaced Fractures
incomplete on standard two-dimensional radiographs
Complete non-displaced fractures almost invariably occur
were in fact complete. Some authors consider that frac-
laterally. Most are readily identified on the previously
tures that extended ≥75% of the distance from the dis-
described radiographic projections (Figure 21.6). However,
tal articular surface to their projected metaphyseal or
the classification should be made with caution. Arthroscopy
diaphyseal exit point should be considered complete
has demonstrated the inaccuracy of radiography in consist-
even if radiographic evidence of such is lacking [26].
ently identifying displacement. Relatively subtle displace-
Almost all incomplete fractures are simple. As the
ment in a dorsopalmar/plantar plane is usually
majority present acutely, fracture lines are sharply
radiographically silent. CT, presumably due to image sum-
marginated (Figures 21.4 and 21.5). In the author’s
mation, may also not identify subtle displacement/articular
practice, radiographic evidence of pre-existing changes
incongruency (Figure 21.7). Until evaluated arthroscopi-
such as opacification and loss of trabecular organiza-
cally, a better term may be complete radiographically
tion is uncommon.
Figure 21.5 Long incomplete fracture of the lateral condyle of Mc3 imaged on a DP radiograph and in transverse CT images at the
depicted levels (hashed lines).
(a)
(b) (c)
Figure 21.6 Complete radiographically non-displaced fracture of the lateral condyle of Mc3 identified on (a) a DP radiograph and
(b, c) transverse CT images at the levels of the epicondylar fossa and close to its distal diaphyseal point of emergence respectively.
(a) (b) Figure 21.7 A radiographically non-displaced

fracture of the lateral condyle of Mc3 (a). Subtle
displacement is difficult to discern on a CT image
(b) but is identified at the dorsal fracture margin
(circle) arthroscopically (c). P1: proximal phalanx;
SR: sagittal ridge and LC: lateral condyle of Mc3;
arrow: fracture line.
(c)
non-displaced fractures. Scrutiny of flexed DP and/or displaced fractures of Mc3 and in 24% of similar fractures
D35°Di-Pa/PlPr oblique projections is important to detect of Mt3 [58]. In one series, the site of comminution was
pa/pl comminution which usually takes the form of a dis- almost equally distributed between dorsal and pa/pl
tally based wedge. articular surfaces [48]. Incidence of radiographic predicta-
bility has varied between 24 and 42% [18, 56, 67].
A comparison of CT with orthogonal radiographs in
Displaced Fractures of the Lateral Condyle
assessing catastrophic condylar fractures found that the
DP, lateromedial (LM), dorsolateral-palmar/plantarome- latter (including flexed DPa/Pl projections) failed to iden-
dial oblique (DL-PMO), dorsomedial-palmar/plantarolat- tify pa/pl comminution in 42% and diaphyseal propagation
eral oblique (DM-PLO) and flexed DP projections will of fractures in 63% of limbs which were recognized by
identify and define most displaced fractures. Careful scru- CT [48]. In the author’s hospital, CT has also identified
tiny is necessary to identify the potential presence of com- radiographically undetected articular and non-articular
plicating injuries such as axial fracture of the lateral PSB comminution (Figure 21.9). It has also identified fragmen-
(Figure 21.8) [65, 66]. tation trapped in the fracture plane, which requires removal
Displaced fractures may be simple or comminuted. before reduction is possible, and axial fractures of the PSB
Comminution can occur at the proximal margin where (Figure 21.10).
cortical fragments of varying sizes can detach
(Figure 21.8) [18, 21]. This was recorded post-mortem in
44% of catastrophic fractures [58] and with a clinical inci-
dence of 20 and 24% [25, 26] in two further series. Propagating fractures arise close to the sagittal ridge, are
Distal, articular comminution can also occur. Careful bicortical, divide the condyle and metaphysis and extend
scrutiny of radiographs sometimes will reveal fine radi- into the diaphysis. Their course is not predicted accu-
odensities in dorsal and/or pa/pl compartments which are rately by two-dimensional radiography. Two forms of
usually indicative of intra-articular osseous or osteochon- propagation are recognized. In the first, the fractures in
dral debris. Macroscopic comminution was found at post- both dorsal and pa/pl cortices remain sagittal or parasag-
mortem examination in 86% [58] and 52% [48] catastrophic ittal and, in the second, these change orientation to
Figure 21.8 Proximally comminuted displaced (a) (b)

fracture of the lateral condyle of Mc3. An axial fracture
of the lateral proximal sesamoid bone is obscured by
the fracture in the DP image (a) but identifiable
(arrows) in a D10oM-PaLO projection (b).
Figure 21.9 DPl radiograph and transverse CT

images taken at the depicted levels (hashed lines) of
a displaced fracture of the lateral condyle of Mt3. The
CT images identify proximal dorsal and distal plantar
comminution together with displaced fragmentation
abaxially between the medial proximal sesamoid
bone and condyle of Mt3.
oblique and/or frontal planes; the latter are generally

termed ‘spiral’ fractures [20, 21, 23, 28, 36]. In a series of
18 propagating medial fractures, 6 (33%) remained par-
asagittal. These all terminated within the middle one-
third of the diaphysis. The remaining 12 (67%) had spiral
configurations beginning sagittally and turning into an
oblique frontal plane in the middle one-third of the dia-
physis. Spiral fractures that extended into the proximal
one-third of the diaphysis had a less predictable course;
seven remaining in a frontal plane and four turning back
into an oblique configuration [23]. Occasionally, fractures
will extend into the carpometacarpal or tarsometatarsal
joint [20] (Figure 21.11).
Figure 21.10 Transverse CT image of a displaced fracture of Other fracture configurations have been reported includ-
Mc3 demonstrating comminuted fragments dorsally and ing proximomedial propagation of the fracture in the pal-
entrapped within the palmar fracture plane. There is also an
mar/plantar cortex and a mid-diaphyseal ‘Y’ course [21, 29,
axial fracture of the lateral proximal sesamoid bone which
was not identified radiographically. 30]. However, CT has demonstrated that this is commonly
(a) (b) Figure 21.11 Spiral fracture of the lateral condyle

of Mc3 (arrows) propagating to the carpometacarpal
joint imaged in (a) DP and (b) DM-PaLO radiographic
projections.
a two-dimensional radiographic phenomenon produced by 10% [18]. Other fractures of the lateral PSB have been
superimposition of fracture lines in dorsal and pa/pl corti- recorded in clinical imaging and at post-mortem concur-
ces rather than a genuine configuration. rent with fractures of the lateral condyle of Mc/Mt3 [25,
In addition to the standard radiographic projections 26, 48, 58].
described previously, complete radiographic assessment The most common complex fractures include PSB
of the entire diaphysis is necessary with all suspected fracture(s) and/or dehiscence together with comminuted
propagating fractures. Multiple radiographic projections, fracture of the proximal phalanx.
to follow the fractures in both dorsal and pa/pl cortices by
slightly varying the angles of incidence, can aid in map-
ping the fracture course. These should include D10-
20°L-Pa/PlMO and D10-20°M-Pa/PlLO projections.
Fractures of the pa/pl subchondral bone generally have lit-
However, radiologic accuracy is limited: one study
tle ambulatory compromise and require no specific acute
reported that correct configurations were only identified
care. Temporary immobilization may not be necessary for
in 1 out of 12 (8%) spiral and 5 out of 6 (83%) parasagittal
bicortical incomplete fractures. However, in the acute
propagating fractures [23].
phase, confident determination that fractures are incom-
Cross-sectional imaging, principally CT, has demysti-
plete is not possible. Additionally, most horse will gain
fied determination of configurations and whenever pos-
analgesic benefit from appropriate support and this is
sible should be advocated to permit rational treatment.
therefore recommended (Chapter 7).
Fractures of the medial condyles have two basic configu-
Temporary support should be applied to complete frac-
rations. The first remains parasagittal and may terminate
tures at diagnosis and maintained through induction of
in the mid or proximal one-third of the diaphysis. The
general anaesthesia. Limbs are placed in an extended
second is parasagittal into the distal one-third of the dia-
(weight-bearing) position. Support systems that fix the limb
physis where the fracture in the pa/pl cortex deviates lat-
in a flexed position are contra-indicated (Chapter 7)
erally and passes through the interosseous space between
(Figure 7.23).
Mc/Mt3 and Mc/Mt4 to continue proximally in the dor-
External support should be applied to all cases in which
solateral cortex. The fracture in the dorsal cortex courses
a propagating fracture is a differential (Chapter 7). In the
in a parasagittal plane to a mid-diaphyseal level. At this
author’s opinion, repair of propagating fractures should be
point, in fractures which propagate proximad, the frac-
undertaken with minimal delay. In most cases, analgesics
ture in the dorsal cortex deviates medially so that the
offer minimal relief until the fracture is surgically repaired.
fracture plane now approaches a dorsal (frontal) orienta-
Horses should remain supervised and/or cross-tied until
tion. Fractures which extend to the proximal one-third of
repair has been performed as rising presents a major risk
the diaphysis can remain in a dorsal plane, or the frac-
for catastrophic failure.
ture in the lateral cortex may deviate pa/pl to create a
dorsomedial to plantarolateral fracture plane of varying
obliquity. Propagating fractures originating in the lateral
condyle more commonly adopt the ‘spiral’ configuration reatment Options
T
with the fracture in the pa/pl cortex also proximally devi- and Recommendations
ating laterally, dorsally and then medially, while the frac-
ture in the dorsal cortex deviates medially, palmarly and In addition to the insult to the diarthrodial environment that
then laterally. CT has also identified spiral configura- is common to many equine fractures, the clinician also must
tions that were not predicted by planar radiographs. consider factors that are pertinent to the Mc3 and Mt3 con-
Proximal fracture lines can become evident some weeks dyles. These include varying contact (determined by loading
post-injury and repair. These are not identifiable, even ret- conditions) with the proximal phalanx and PSBs and the com-
rospectively, on radiographs taken in the acute phase and, promise to articular stability that accompanies disruption of
in some cases, are also not recognizable on CT images the origin of the collateral ligament and joint capsule.
taken at the time of surgery. Healing of fractures is a complex biological process
involving the mechanical environment, growth factors,
scaffolds and mesenchymal stem cells – the diamond con-
Concurrent Lesions
cept [68]. Primary bone healing refers to a direct attempt of
Axial sagittal fractures of the lateral PSB have been identi- the cells and cortical (and by inference also subchondral)
fied with fractures of the lateral condyle of Mc/Mt3 [18, bone to re-establish the disrupted continuity. This requires
21, 56, 65, 66] with reported incidences of 4% [56] and absolute reduction (contact) of the fragments and almost
complete stability with minimal interfragmentary strains. suggested [73]. Therefore, when considering risks versus
Secondary bone healing occurs in the presence of a frac- benefits, repair is usually the treatment of choice.
ture gap, involves intramembranous and endochondral If a non-invasive approach is selected, then confine-
ossification and leads to callus formation [69, 70]. In real- ment is necessary. There are no demonstrable benefits to
ity, and at a microscopic level, repair aims to achieve a bandaging or other support. Clinical monitoring is neces-
combination of the above with the balance moved as far as sary, and follow-up radiographic examinations are recom-
possible towards primary healing (Chapter 6). mended to monitor healing and thus guide ongoing
management.
It has been suggested that horses receive stall rest for 90 days
and, if radiographic examination at this time indicates heal-
Bone
ing, that a rehabilitation exercise programme is commenced.
Palmar/plantar fractures can heal without interven- If healing is unsatisfactory, then a further 30–60 day confine-
tion [59, 71], and if horses are removed from training it is ment was recommended [27]. Current thinking suggests that
rare for the fracture to progress. In some individuals, fol- this is excessive and indeed may be counterproductive since
low-up radiographs may reveal apparent proximal exten- micromovement promotes healing. In the author’s view, frac-
sion and mediolateral widening of the fracture that is likely tures that do not exhibit radiographic evidence of progressive
to result from osseous resorption rather than progressive healing after four to six weeks are delayed unions, and surgi-
discontinuity. A number of empiric regimens have been cal repair should be reconsidered. While healing may occur
employed. Most involve an initial period of box rest; 30 to with further time and/or exercise modulation, it is optimized
60 days has been recommended [71]. This is followed by a by lag screw fixation.
graduated exercise programme with resumption of train-
ing at not less than 120 days. Radiographic healing of pa/pl
subchondral bone can be protracted and is generally not a Complete Non-displaced Fractures
useful guide to timing return to exercise.
Complete fractures are inherently unstable, and repair is
Some fractures become delayed unions, and others recur
always recommended. This applies even if horses are
on resumption of exercise. Such cases frequently respond
intended for retirement and/or breeding purposes. The
well to compression with a single 4.5 mm AO/ASIF cortical
consequences of contralateral limb overload and, with
screw. Insertion in the centre of the epicondylar fossa places
displacement, malunion often are sufficiently severe to
screws in a dorsally eccentric position with respect to the
preclude long-term humane preservation of life. The
fracture. Recently, and with the benefit of pre-operative CT,
articular deficit and resulting osteoarthritis are mini-
the author has placed screws further distal and palmar/
mized by compression. In the largest published series, all
plantar to engage fractures. Assessment of benefit is
(43 out of 43) complete non-displaced fractures were
pending.
repaired [67].
There are anecdotal suggestions that repair reduces
convalescence time. Additionally, it is possible that a
transcondylar screw may be effective in protecting cracks Displaced Fractures
from cyclic stresses, thereby preventing progression into
a complete fracture [39]. This is logical but clinically There are no circumstances under which displaced frac-
unproven. tures can satisfactorily be managed without reduction and
repair. Animals treated conservatively remain painful, and
the severe degenerative changes that occur in the MCP/
Incomplete Fractures MTP joint limit humane life expectancy.
Some incomplete fractures will heal satisfactorily without
repair. However, radiographic examination does not, at Propagating Fractures
least in the acute phase, reliably differentiate between
complete and incomplete fractures. Surgical immobiliza- When exposed to bending and torsional forces propagat-
tion and compression of the fracture will minimize the ing, fractures can become complete often with catastrophic
articular deficit, improve the quality of cartilage repair [72] consequences, at almost any time in the first four to six
and reduce risk of progression. Importantly, repair offers weeks following injury. The principal exciting force appears
the most effective and expedient analgesia and should min- to be an animal’s rising which presumably exerts maximal
imize the period of necessary immobilization and/or con- bending force on the bone. When failure occurs, it is not
finement. Reduced risk of re-fracture has also been generally by propagation of the original fracture (whether
Techniques for Treatmen 459
or not repaired) but by failure through the narrowest, often begins to sink to the ground. Hindlimbs should be kept
mid-diaphyseal strut of bone. under the horse’s body, preventing abduction.
Some propagating fractures can heal without surgical
intervention [30, 56, 74] but is associated with high mor-
bidity and mortality rates and cannot generally be recom-
Bone
mended. Rigid external support may be provided by a cast
that extends to the level of the third carpal or central tar- The majority of fractures extend through the subchondral
sal bones or alternatively a full-limb cast may be applied. bone and adjacent dense epiphyseal spongiosa less than or
Analgesics are necessary with the choice and dose rate equal to 50% of the pa/pl to dorsal distance through the
determined by response. Despite these, contralateral limb affected condyle. They are also usually situated in the distal
overload is common. In the short and medium terms one-third of the condyle. Engagement requires a screw posi-
(days to weeks), laminitis is the principal concern. In the tion that is correspondingly distal and pa/pl in the epicondy-
medium to long terms (weeks to months), degenerative lar fossa. This ideally requires cross-sectional imaging,
joint disease in the proximal interphalangeal and/or preferably CT, to accurately determine optimal implant loca-
MCP/MTP joint is a common complication [21, 30, 56]. tion. Insertion technique is as described in “Surgical
Both can be seriously debilitating, usually preclude future Technique” section of “Bicortical Incomplete Fractures” but
athletic function and frequently result in permanent horses are positioned in dorsal recumbency to facilitate
lameness. Laminitis is often sufficiently severe and intrac- accurate drill/implant targeting. This also requires good
table to require euthanasia. intra-operative lateromedial radiographs or fluoroscopy to
Repair of propagating fractures is almost universally rec- safely and appropriately locate the site. In most circum-
ommended as the treatment of choice but owners, trainers, stances, a single 4.5 mm AO/ASIF cortical screw is placed in
insurers, etc. should be counselled regarding inherent risks. lag technique (Figure 21.12). Protective dressings are applied
for recovery from general anaesthesia, and the author gives
peri-operative antimicrobial and non steroidal anti-
Techniques for Treatment inflammatory drugs. Confinement is minimal (usually
7–14 days) with increasing periods of walking exercise to fol-
Anaesthesia for Repair low. Thereafter, exercise is titred in line with radiographic
healing.
All fractures can be repaired under general anaesthesia.
Incomplete and complete non-displaced fractures can be
repaired under sedation and local analgesia [75–77].
Techniques and applications are discussed in Chapter 12.
Standing repair is contra-indicated in displaced fractures in Pre-operative Planning and Preparation
which reduction cannot be achieved or assessed. In the The timing of surgical intervention is a matter of contin-
author’s opinion, it is also not recommended for complete ued debate. Some surgeons advocate a short delay in order
radiographically non-displaced fractures as undetected dis- to minimize perceived increased anaesthetic risks that may
placement or instability is common. Standing repair may accompany an anxious horse that recently has raced or
also compromise repair of some incomplete fractures in trained and has travelled to the hospital. In the author’s
which CT may redirect surgical plans made on the basis of opinion, the risks of fracture propagation and the relief of
pre-operative two-dimensional radiographs. Additionally, in pain and anxiety that accompanies repair outweigh the
the author’s hospital, the complication rate associated with above concerns. No increase in complications has been
anaesthesia and recovery of horses with fractures of the Mc/ encountered, and unless specific risks are identified
Mt condyles are less than the published risks for standing prompt fracture repair is recommended.
repair. A comprehensive assessment of a complete series of
For induction of anaesthesia (Chapter 10), the author’s orthogonal radiographs is important in order that the
preference is to position the horse with the non-fractured surgeon can create an accurate three-dimensional men-
side against the wall of the induction box. As induction tal model of the bone and fracture. CT represents the
agents are given two assistants, push from the fractured current gold standard, and in theatre mobile units as
side in order that the horse can slide down the induction described in Chapter 19 are ideal. Once the configura-
box wall while a third person controls the fractured limb. tion has been determined, the optimum site and trajec-
Loading can be removed entirely from a forelimb by flexing tory of implants can be assessed and marked on
the carpus and supporting the distal limb as the animal radiographs.
(a) (b) (c) (d)
Figure 21.12 Pre-operative (a) and post-operative (d) transverse CT images and intra-operative DP (b) and LM (c) radiographs
illustrating repair of a palmar fracture of the lateral condyle of Mc3. A single 4.5 mm cortical screw has been placed in a distal, palmar
location in the epicondylar fossa to engage the fracture.
Surgical Technique Pre-operative planning is important to optimize implant

Repair is effected using classical minimally invasive (per- location. Digital radiographs permit accurate and reliable
cutaneous) lag screw technique. Horses can be positioned measurement. Measurements made at the chosen sites for
in dorsal or lateral recumbency. The author usually uses screws also determine the depth of the glide holes, obviating
the latter with the affected limb uppermost. Use of an the need for this to be determined by intra-operative radiog-
Esmarch bandage and tourniquet to the level of the proxi- raphy. Since the majority of screws will be placed with
mal metacarpus/metatarsus is optional. In lateral recum- straight lateral to medial trajectories, measurements of the
bency, the limb should be perfectly horizontal, i.e. parallel bone width at these points are a good guide to required screw
with the operating room floor, with no rotation to optimize lengths (Figure 21.13a). Comparison of the radiographically
drill (and therefore implant) alignment. The distal limb determined hole depth with that measured at surgery also
can be supported at the foot or pastern. The natural ten- acts as a check on drill trajectory. Drill tracts with measure-
dency for hindlimbs to rotate outwards is reduced by plac- ments that differ more than 2 or 3 mm from the predeter-
ing support beneath the calcaneus. mined depth warrant cautious consideration before
(a) (b) (c)
Figure 21.13 DP radiographs of repair of an incomplete fracture of the lateral condyle of Mc3 using 2 × 4.5 mm cortical screws.
(a) Pre-operative plan including measurements of bone width and glide holes at the proposed sites of screw placement.
(b) Determination of drill sites using percutaneous needles. (c) End of surgery confirmation of correct screw placement.
(a) (b)
Figure 21.14 Intra-operative DP radiographs in repair of a short bicortical fracture of the lateral condyle of Mc3. (a) Incongruity of
the screw head and epicondylar fossa due to inadequate countersinking and (b) good bone head congruency following the further use
of the countersink.
proceeding. During surgery, it is helpful to keep all images in use of the countersink to remove osseous debris that inter-
the same plane and orientation, preferably aligned with the feres with the depth gauge and subsequent screw insertion.
horse/limb position. Swathe left in the soft tissues also can result in enlarging
The distal screw is positioned centrally, at the junction of mineralized foci.
the proximal and middle one-thirds of the epicondylar In light of the density of the epiphyseal bone, threads
fossa. It is approximated as the mid-point between the pal- should be cut cautiously with frequent backwards move-
pable proximal pa/pl process of the proximal phalanx and ment of the tap. Power tapping is not advocated at this site.
dorsal margin of the lateral condyle [60]. Correct location A finger placed over the contralateral epicondylar fossa
is determined by percutaneous needle placement and radi- will help determine protrusion of the tap as the bone den-
ography or fluoroscopy (Figure 21.13b). Compression of sity is such that a lack of resistance when the tap emerges
the fracture is optimized if the screw is mid-way between is often not appreciated. If thread holes are not fully tapped,
the dorsal and pa/pl articular surfaces and perpendicular then screws may prematurely tighten, and if the surgeon
to the bone in both proximodistal and lateromedial planes. persists in advancing the screw, then it may shear in the
This demands surgical skill, aided by experienced operat- dense bone. Self-tapping screws can be difficult to insert in
ing room assistants, and meticulous limb positioning. this location, tighten prematurely and hence are at
Placing the forefinger of the non-drilling hand at the pro- increased risk of shearing. Although some surgeons use
jected site of drill emergence in the contra-axial epicondy- 5.5 mm screws in this location [67, 79], implant strength is
lar fossa is a simple but useful stereotactic aid. rarely, if ever, a limiting factor to repair; the author there-
A longitudinal 10 mm skin incision is followed by a lon- fore uses 4.5 mm cortical screws throughout. By contrast,
gitudinal stab incision using a number 11 blade through correct implant placement is critical to outcome.
the collateral ligament to the bone surface. Standard lag Proximal screws are placed as the individual fracture dic-
screw technique (Chapter 8) follows. The epiphyseal bone tates at 20–25 mm intervals. Short fractures may need only
is dense, and frequent clearing and cleaning of the drill a single lag screw in the epicondylar fossa, while others
flutes and continual use of irrigating fluid over the bit are may extend sufficiently proximad to require up to four
important. The surgeon also should not allow the drill to screws for adequate compression and fixation
protrude excessively into, and thus to traumatize, the (Figures 21.13–21.16). These screws should also be central
medial collateral ligament. in the bone and the drill aligned in the same manner as the
It has been suggested that, due to the bone’s concavity, most distal screw. Outwith the epicondylar fossa, the bone
use of a countersink is not necessary and can damage the is convex. Once the dorsopalmar/plantar centre has been
collateral ligament [73, 78]. However, without its use, there identified, the drill should be placed on the surface of the
is marked incongruity between screw head and bone sur- bone and advanced a few revolutions. This creates a groove
face. Point contact not only compromises compression, but in which the drill tip can be located, preventing slippage
also predisposes to screw breakage when this is tightened. and permitting dorsopalmar/plantar and proximodistal
A countersink therefore should be used (Figure 21.14). The alignment. Use of a nurse or assistant to direct and/or con-
drill tract should be flushed with irrigating fluid following firm drill alignment, which almost invariably should be
(a) (b) and trajectories are confirmed radiographically.

Adjustments can be made as necessary. Appropriately
placed implants will usually compress acute fractures well.
Skin closure only is necessary.
In the absence of other intra-articular lesions, arthro-
scopic evaluation of the MCP/MTP joint during repair of
incomplete fractures is optional. Incomplete fractures usu-
ally do not result in intra-articular debris, and cartilage dis-
ruption is usually minimal. Many have acute haemorrhagic
tearing of the dorsal and/or palmar/plantar joint capsule:
some surgeons also believe that articular lavage to remove
haemorrhage is logical and contributory.
Variations in Technique
Mechanical properties of conventional 4.5 and 5.5 mm cor-
tical screws have been compared with similar screws with
20 and 25 mm shafts in blocks of cadaver epiphyses of Mc3
and Mt3. Screws with shafts provided greater resistance to
shear, but there was no significant difference between 4.5
Figure 21.15 DP radiographs of an incomplete fracture of the
lateral condyle of Mc3 repaired with 3 × 4.5 mm cortical screws: and 5.5 mm screws [80].
(a) at presentation and (b) at completion of surgery. Despite previously expressed caution [27], abaxial frac-
tures that have a width of less than 10 mm can beneficially
(a) (b) be repaired with 3.5 mm cortical screws in a lag technique.
Screw location, use of countersink, etc. are all similar. The
thread hole should be drilled cautiously as excessive pres-
sure can break the 2.5 mm bit in the dense epiphyseal bone.
However, the bone density allows good repair without
engagement of the whole medial condyle. The 3.5 mm screw
should be inserted carefully to avoid shearing the head as the
implant tightens; fingertip pressure only is applied. Narrow
proximal ‘spikes’ (in all fracture types) can also be com-
pressed with similar 3.5 mm lag screws (Figure 21.17).
Irritation of the collateral ligament by the head of the
screw has been suggested as a cause of lameness, although
vcausation has not been demonstrated. In attempts to cir-
cumvent this, use of headless bi-pitched Herbert [81] and
variable pitch [82–84] compression screws have been
reported. However, with variable pitch, compression is
reduced in proportion to fragment thickness making the
implant unsuitable for the majority of cases [85]. Neither
Figure 21.16 DP radiographs of an incomplete fracture of the
lateral condyle of Mc3 repaired with 4 × 4.5 mm cortical screws: have been adopted widely.
(a) at presentation and (b) at completion of surgery.
Post-operative Care
biaxially perpendicular to the bone, ensures correct The requirement for, or potential benefits from, use of a
trajectory. cast for recovery from general anaesthesia have not been
Closure of the fracture gap is optimized by proximal to determined definitively. The author uses a half-limb
distal compression. Distal screws are usually inserted first combination cast (Chapter 13). It is rationalized that,
but should not be tightened. When all have been placed, correctly applied, there are no demonstrable disadvan-
then screws are tightened in proximal to distal order with tages, the cost makes a modest contribution to the over-
finger torque force. Increasing the force will not compen- all budget and disruption of the repair in recovery is
sate for a suboptimal implant position or trajectory. Once likely to be catastrophic. If no complications arise, casts
all the screws have been placed, their lengths, locations usually can be removed within the first 24–48 hours
(a) (b) (d)
(c)
Figure 21.17 A complete radiographically non-displaced fracture of the lateral condyle of Mc3. (a) Pre-operative DP radiograph. (b, c)
Dorsal arthroscopic views of the fracture (b) revealing dorsopalmar displacement and (c) following reduction and compression. (d)
Radiographic appearance at completion of surgery.
post-surgery. A compression (Robert Jones or similar) end of surgery or, alternatively, apparent widening of a
bandage is fitted at this time. Other surgeons use band- fracture line that remained at this level. This palmar/
ages or compression boots for recovery from general plantar subchondral bone, at least radiographically, is
anaesthesia. slowest to heal. Complete disappearance of the fracture
Skin sutures are generally removed 10–12 days post- at this level can take months and, if the remaining frac-
operatively. The author usually maintains bandages for ture heals with good osseous reorganization, then this
two to three weeks after surgery. Subjectively, this appears should not be considered a limiting factor in progressing
to reduce swelling, subsequent scar tissue formation and to with convalescence.
provide a degree of analgesia. Most repaired fractures will heal with minimal callus
Post-operative exercise is modulated by clinical and radi- formation. Periosteal callus sometimes will be identified
ographic progress. If both are satisfactory, then gradually post-operatively proximal to the previously identified limit
increasing periods of walking exercise can begin three to of the fracture. This is thought to indicate that the fracture
four weeks after surgery. Trotting usually can be intro- was complete, but that its lateral cortical exit was not radio-
duced after six weeks of walking and cantering six weeks graphically discernible.
later. However, with careful clinical and radiographic mon-
itoring, some horses have successfully returned to training
Complications
with shorter convalescent periods.
The most serious complication is articular trauma caused
by surgical error. Poor drill alignment can result in pene-
Fracture Healing tration of the medial condyle. Surgeons should be alerted
Post-operatively, there is commonly osseous resorption to this possibility by lack of correlation between the meas-
adjacent to the fracture in the pa/pl subchondral bone. ured drill hole depth and the lateromedial width of the
Radiographically, this may manifest as the reappearance bone determined on pre-operative radiographs. This sce-
of a fracture line, usually distal to the most distal screw, nario demands immediate multiplanar radiographic
which appeared obliterated on radiographs taken at the investigation.
Premature tightening, usually of the most distal screw, Infection is a rare complication with percutaneous tech-
can result from an inadequately tapped thread hole or from niques although there are anecdotal reports of increased fre-
osseous debris within the tract. As soon as this is recog- quency when surgery is performed standing, presumably as
nized, the screw should be backed out and the hole flushed; a result of consequential aseptic compromise.
the screw can then be reinserted. Once the thread hole is
engaged, advancing this screw two times followed by one-
Implant Removal
half turn back (in a tap-like manner) can assist insertion. If
Unless there are implant related complications, screws
this fails, then the hole should be re-tapped using a finger
rarely require removal [67]: two studies concluded that
over the medial condylar fossa to feel for emergence. The
there was no difference in post-operative performance
screw should never be forced as the dense bone will cause
between horses that had screws removed and those which
it to shear and break.
were left in situ [25, 56].
Screw breakage invariably is due to insertional error.
Broken screws are non-contributory and if possible should
be substituted. Inadequate or suboptimal fracture com- Complete Non-displaced Fractures
pression can result from errors in screw location or more
commonly by an incorrect (oblique) trajectory. The author advocates arthroscopic evaluation of com-
Periosteal new bone can occur adjacent to screw heads plete non-displaced fractures because radiographs do not
with no obvious cause. Sometimes this can be sufficient to predict instability or detect slight articular displacement,
produce visible swellings at the screw site. Similar exos- particularly in a dorsopalmar plane (Figures 21.17
toses can be present medially, particularly if the tail of the and 21.18). This can then be reduced prior to fixation.
screw(s) protrudes. Although unsightly, these are not gen- Arthroscopy has also revealed radiographically unde-
erally of functional significance. tected intra-articular comminution and identified joint
(a) (c)
(b) (d)
Figure 21.18 Complete radiographically non-displaced fracture of the lateral condyle of Mt3. (a) Pre-operative DP radiograph. (b)
Transverse CT image at the level of the epicondylar fossa. (c) Arthroscopic evaluation of the dorsal articular portion of the fracture
demonstrating distraction and articular deficit. (d) Arthroscopic appearance following compression of the fracture (arrows).
capsule and articular cartilage lesions that otherwise lar lesions such as fragmentation and/or cartilage defects
would not be recognized. In most circumstances, it can be on the lateral PSB and tearing of the joint capsule and/or
performed expediently and has little or no associated dorsal plica that can accompany displaced fractures can
morbidity. also be identified, assessed and appropriately dealt with at
Once articular congruency is ensured, repair may be this time.
effected percutaneously as described in repair of incom- The author advocates repair as soon as surgical and
plete fractures. CT has identified comminution that has anaesthetic circumstances permit. Displaced fractures are
not been predicted by pre-operative radiographs. This unstable and highly destructive to articular tissues until
most commonly involves the distal pa/pl articular surface reduced and stabilized. Repair is also the most effective
and frequently has a palmar/plantar based wedge shape. means of providing analgesia and reducing anxiety.
Such fragments can be compressed with the principal
fracture. They appear to be viable and can heal. It has Surgical Technique
been suggested that some might resorb [56]. This has not Lateral recumbency with the affected limb uppermost is
been the author’s experience, although they may go recommended. Limb positioning and draping must pro-
through a period of reduced radiopacity followed by reduce sterile circumferential access. The limb can be supported
mineralization over a period of weeks following repair proximally with a cupped limb support into which the
(Figure 21.19). proximal Mc3/Mt3 fits and which permits manipulation of
Individual surgeons vary in their use of external support the limb during surgery that is important in all, and essen-
for recovery from general anaesthesia. Logical arguments tial in some, cases to effect reduction. Alternatively, the cup
can be made in favour of casts, bandage casts, compres- support can be at the level of the foot or distal pastern with
sion boots or Robert Jones bandages. All have their pro- the limb positioned in but not secured to the cup to permit
tagonists and are employed successfully in varying reduction. A perfectly horizontal (parallel with the ground)
circumstances. limb position aids perpendicular drill and therefore
implant trajectories. Use of an Esmarch bandage and tour-
Fracture Healing niquet can expedite surgery. Occasionally, it can reduce
All of the comments made with respect to healing of limb mobility sufficiently to inhibit fracture reduction, but
incomplete fractures are pertinent to complete non- if this arises it can be removed.
displaced fractures. Reduced radiodensity (osteopenia) in Displacement is usually proximal and rotational such
the fractured lateral condyle is more commonly encoun- that the articular portion of the lateral fragment is most
tered in complete than incomplete fractures. This can per- commonly pa/pl and the proximal portion dorsal
sist for many months and appears unrelated to the fracture (Figures 21.20 and 7.23). Reduction is generally effected
gap. It generally resolves, often proximally to distally, by extension of the MCP/MTP joint together with adduc-
with time and appears unrelated to ultimate outcome. It tion of the foot and pastern. The application of torque
is possible that this is associated with interrupted blood (usually inwards rotation) by twisting the foot is frequently
supply. also of assistance (Figures 21.21 and 21.22). This process
should be viewed, monitored and directed by concurrent
arthroscopic evaluation of the dorsal articular surface of
Displaced Fractures of the Lateral Condyle
the lateral condyle. An arthroscope positioned in the
The overriding goal in all circumstances is restoration of standard dorsolateral portal [86] will permit this
articular congruency. This is critical to resumption of an (Figures 21.22 and 21.23). To establish accuracy of reduc-
athletic career and is desirable for other (salvage) cases to tion, the fracture should be viewed from a number of
minimize ongoing articular trauma and therefore inevita- angles by rotating the arthroscope. Sometimes edges of
ble, consequential degenerative joint disease. Arthroscopy articular cartilage and/or small comminuted fragments
directs accurate reconstruction including reduction or can be displaced dorsally as the fracture is reduced.
removal of comminuted fragments. Whenever possible, the Complete articular congruency can be further evaluated
fracture gap should be eliminated and cartilage surfaces by introduction of a probe through a lateral instrument
apposed as closely as possible to minimize articular deficits. portal. If necessary, additional adjustment can be made
Additionally, displaced fractures usually result in intra- following creation of the distal glide hole by manipulation
articular osseous debris. Occasionally, this is radiographi- with a 3 mm Steinman pin inserted through the 3.2 mm
cally identifiable but often it is silent. Arthroscopic removal, drill sleeve (Figure 21.24) [87]. An alternative technique is
piecemeal for larger fragments and by directed lavage for to place sleeves into two distal screw holes which permits
smaller debris, is considered highly desirable. Other articu- movement of the fragment en bloc.
(a) (b) (c)
(d) (e) (f)
(g) (h) (i)
Figure 21.19 Palmar comminution in a complete non-displaced fracture of the lateral condyle of Mc3. (a) DP and (b) flexed DP
radiographs failed to identify comminution evident on a transverse CT image at the level of the base of the proximal sesamoid
bones (c). (d) DP radiograph at completion of surgery in which the comminution was conserved. (e–i) Flexed DP radiographs at 3, 4,
7, 12, and 16 weeks following repair demonstrating initial resorption in the area of comminution followed by restoration of
radiopacity.
(a)
(b)
Figure 21.20 (a) DP radiograph and (b) dorsal arthroscopic image of a displaced fracture of the lateral condyle of Mc3. Displacement
is proximal and rotational so that the articular portion of the fragment (LC) is palmar to the parent bone. SR: sagittal ridge of Mc3; P1:
proximal phalanx.
Figure 21.21 Reduction of proximal and rotational displacement usually requires MCP/MTP extension and a combination of
adduction and inwards rotation of the phalanges.
Once articular congruency has been obtained, the frac- as determined by fracture length (Figure 21.23). At least
ture can be fixed by application of large AO/ASIF reduc- two screws should be inserted before reduction forceps are
tion forceps. The first (most distal) pair should be applied removed. Screws are not tightened until all have been
at the level of the epicondylar eminence. This allows place- placed and this then proceeds from proximal to distal,
ment of the distal screw in the epicondylar fossa. A second thereby closing the wedge-shaped (wider distally then
pair of reduction forceps can be applied further proximad proximally) distraction.
(a) be carried out judiciously as this can, of itself, result in frac-

ture displacement. Pa/pl comminution almost invariably is
distal on the Mc/Mt condyle, and access usually will
require an instrument portal through the collateral sesa-
moidean ligament [86]. Large pyramidal, fragments that
are non-displaced or can be reduced should be conserved
and compressed in the principal repair. These remain via-
ble, heal and remodel and carry only a slightly reduced
prognostic outlook compared with simple fractures [67].
Others, which create incongruity, should be removed. Full
thickness defects in the articular cartilage of the lateral
PSB are commonly found with displaced fractures of the
(b) lateral condyle.
Once adequately reduced, repair follows as previously
described for non-displaced fractures. Glide hole/fragment
depth can be measured on pre-operative radiographs, and
the full thickness of the bone can be determined at these
sites from radiographs of the contralateral limb. In the
absence of articular comminution, arthroscopically guided
reduction can usually be followed by percutaneous lag
screw fixation, particularly if fractures have been mapped
by CT (Figure 21.23). However, soft tissue (principally
skin) healing is rarely a limiting factor and in the absence
Figure 21.22 Arthroscopically guided reduction of a
of CT visualization of the extra-articular portions of the
displaced fracture of the lateral condyle of Mc3. (a) The fracture can be valuable. The whole extra-articular portion
arthroscope is held by a surgical assistant to maintain a of the fracture is exposed by a skin incision that extends
consistent view of the dorsal articular portion of the fracture. from the lateral epicondylar eminence to a point just proxi-
The surgeon’s hands are positioned to effect and control
reduction. (b) Reduction stabilized by application of reduction
mal to the radiographically identified fracture exit. In some
forceps: percutaneous needles are inserted at the proposed cases, a shorter incision over the fracture’s proximal exit
sites of screw placement. may be adequate (Figure 21.24). This permits removal of
small proximal comminuted fragments: larger fragments
can be repaired with small (3.5 or 2.7 mm) frequently uni-
Comminuted fragments that can be reduced should be cortical screws in a lag technique. Placement of 2 x 4.5 mm
conserved and incorporated into the principal repair. An screws in the epicondylar fossa with a third screw proxi-
arthroscopic probe can be used to maintain or to tamp frag- mally in a triangular pattern has been suggested [60]:
ments into congruency. Surgeons should ensure that this is potential benefits are unproven.
maintained when screws are tightened. Fragments that Open approaches are closed in continuous patterns of
preclude reduction, create articular incongruency or are absorbable material in the Mc/Mt fascia and subcutis fol-
unstable should be removed. Removal of some fragments lowed by stainless-steel staples in the skin. Despite the
can be performed utilizing a standard ipsilateral instru- paucity of overlying soft tissues, wound healing is gener-
ment portal [86]. In some cases, fragmentation precludes ally uneventful.
reduction. In this situation, arthroscope and instrument
portals are made dorsally, directly over the fracture in order Post-operative Care
to identify and remove comminuted fragments and to evac- Application of a half-limb cast (Chapter 13) for recovery
uate the fracture gap. This permits access to the pa/pl mar- from general anaesthesia is prudent. The optimum period
gins of the fracture and is considerably superior to open of cast immobilization is debatable. The fracture repair is
removal [88]. Arthroscopic examination of the pa/pl com- not reliant on external immobilization, but soft tissue
partment is usually performed after dorsally monitored healing may be enhanced by a short period of cast
fracture reduction and fixation. However, if there are con- support.
cerns regarding reduction and/or there is evidence of pa/pl Peri-operative antimicrobial drugs are given to horses
comminution, then arthroscopic evaluation should be per- with closed fractures in accord with individual surgeons’
formed prior to implant placement. Flexion for this should preferences and the pertaining surgical and hospital
(a)
(b) (e)
(c) (d)
Figure 21.23 Repair of a displaced fracture of the lateral condyle of Mt3. (a) DP radiograph and transverse CT images at the sites of
proposed screw placement. (b) Dorsal arthroscopic appearance of the fracture with plantar displacement of the fragment (LC). (c) DP
radiograph of reduced fracture secured with reduction forceps. The arthroscope remains in situ and needles have been inserted at the
sites of proposed screw placement. (d) DP radiograph at completion of repair. (e) Arthroscopic image following fracture reduction and
repair (arrows: fracture line).
e nvironment (Chapter 9). Acutely treated open fractures hand walking exercise may be introduced from 30 days
are contaminated, and administration is necessary. In such post-surgery and a gradually ascending controlled exercise
circumstances, a mixture of contaminating organisms is programme follows as determined by the features of the
inevitable and therefore antimicrobials or combinations of individual case. In general, convalescence is longer than
antimicrobials with a broad spectrum of activity are indi- with non-displaced fractures. A more protracted convales-
cated (Chapter 9). Skin staples or sutures are removed at cence has been recommended for horses with pa/pl com-
12–14 days. minution or osteolytic lesions [67].
Post-operative stall confinement has been recommended
for a minimum of 90 days [27]. However, current under-
standing of osseous healing, articular pathobiology and Fracture Healing
athletic rehabilitation protocols suggest that this is exces- Primary union should be anticipated. Healing characteris-
sive. With satisfactory clinical and radiographic healing, tics are similar to complete non-displaced fractures.
Figure 21.24 Displaced fracture of the

lateral condyle of Mt3 with dorsal and
plantar articular comminution. (a) DP
radiograph. (b) Transverse CT image at the
level of the epicondylar fossa. (c) Dorsal
arthroscopic image revealing
displacement of the lateral condyle (LC)
and comminuted fragment (F). (d)
Intra-operative DP radiograph. The
fracture has been reduced with the aid of
a 3.2 mm insert and Steinman pin in the
(b) distal glide hole and then secured by
proximally placed reduction forceps. A pair
of Gelpi self-retaining retractors had been
inserted into a short incision over the
(a) (d) proximal diaphyseal spike: the
arthroscope remained in the dorsal MTP.
(e) Arthroscopic image following
reduction. (f) DP radiograph at completion
of repair. (g) DP radiograph 13 weeks after
surgery.
(c)
(e)
(f) (g)
Secondary healing and callus formation can be present in CT-directed Minimally Invasive Repair
areas of proximal comminution but appears limited by In the author’s opinion, CT-directed minimally invasive
conservation and repair. Non-displaced distal palmar com- repair is now the technique of choice. This permits accu-
minution can retain viability, heal and remodel if com- rate three-dimensional determination of fracture courses
pressed adequately in the primary fixation. and planes and permits safe percutaneous lag screw
Osseous resorption in the distal subchondral bone and repair. It also means that all implants are placed at opti-
adjacent epiphysis frequently can be greater than seen mal positions and trajectories throughout the whole
with non-displaced fractures. In some cases, this will per- length of the fracture.
sist for a protracted period (multiples of months). Horses are positioned in lateral recumbency with, in the
Occasionally, a lucent defect (often described as a cyst or majority of circumstances, the affected limb uppermost
osseous cyst-like lesion) may become evident in the adja- extended and horizontal. Bone density is such that there is
cent subchondral bone of the proximal phalanx. Causation no perceptible difference in technique or compression
is obscure, but it carries a poor prognosis for return to obtained by the reversed glide–thread hole ratio in medial
training and racing. fractures. Utilizing a surgery-based CT system
(Chapter 19), the MCP/MTP joint and whole of the meta-
carpus/metatarsus are imaged and the fracture is evalu-
ated in its entirety. This sometimes can involve changes in
Accurate identification of fracture planes is central to safe, brightness and contrast of the viewing window in order to
effective management of propagating fractures. This is ide- identify confidently subtle cortical fractures that fre-
ally provided by CT, and the author now considers this quently differ in visibility between dorsal and pa/pl corti-
critical to rationalizing and optimizing repair. Adoption ces. All three-dimensional image options should be
has completely changed the previously recommended sur- evaluated and in areas of doubt oblique planes selected to
gical approach [79]. define changes in fracture orientation. When the entirety
of the fracture has been fully determined and considered, recovery from anaesthesia and 3 of 12 horses within four
a surgical plan can be formulated. This aims to direct a days of surgery using a similar technique [30]. All of the
series of percutaneously placed bicortical 4.5 mm AO/ post-operative catastrophic fractures were reported to have
ASIF cortical screws in lag technique perpendicular to mid-diaphyseal ‘Y’ configuration with varying degrees of
individual fracture planes at 20–25 mm intervals through- comminution. A hybrid technique of distal percutaneous
out the fracture length. At each planned screw location, a and proximal open lag screw fixation of propagating frac-
transverse plane CT image can be used to determine the tures was described in 9 Standardbreds and 17
precise trajectory required and to accurately measure the Thoroughbreds. Catastrophic failure occurred post-
associated width of the bone and glide hole depth. operatively in two horses [89].
Percutaneous needles are inserted at the anticipated sites As radiographic prediction of fracture configuration
of screw placement. Radiographs are used to check and using two-dimensional radiography is poor [23, 30], percu-
adjust as necessary to comply with the CT-directed plan. taneous fracture repair under general anaesthesia is only
Short (stab) skin incisions are then made at these points. recommended if CT is available.
As the epiphyseal and metaphyseal components of the
fracture invariably are parasagittal, at least the distal three Open Lateral Approach
screws are placed with lateromedial trajectories. Further An open lateral approach is appropriate if cross-sectional
proximally, the fracture configuration will determine screw imaging is not available. With spiral fractures, this allows
trajectory. In fractures that remain parasagittal, all screws the surgeon, in most cases, to see the fracture as it propa-
are placed in a similar manner to the level of the proxi- gates in the dorsal cortex and from the pa/pl cortex into the
mally identified fracture. This usually requires four or five lateral cortex [23]. It directs the entry point for screws and
screws (Figure 21.25). In spiral fractures of both medial provides an estimate of the likely fracture plane at these
and lateral condyles, screw orientation most commonly points in order that screws can be placed in biomechani-
involves increasing dorsolateral to pa/pl medial oblique cally appropriate positions along the visible length of the
trajectories in the distal and middle one-thirds of the dia- fracture. It is important to emphasize that this is entirely
physis, and in fractures which progress further proximad, dependent on identification of haemorrhage in the diaphy-
implants may be dorsopalmar/plantar (Figures 21.26– seal cortex. Additionally this sometimes is visible on only
21.28). The second metacarpal/metatarsal bone is valuable one side of the fracture: laterally more frequently than
in orienting oblique drill tracts. The surgeon can place the dorsally.
fore finger of the non-drilling hand on, dorsal or palmar/ The horse is positioned in lateral recumbency with the
plantar to this, as an aiming guide. Screws should avoid affected limb uppermost and horizontal. Accurate identifi-
engagement of the second metacarpal/metatarsal bone. cation of fracture lines requires exsanguination of the
This can result in lameness and, even with subsequent limb with an Esmarch bandage and application of a tour-
removal, bridging of the interosseous space and fixation niquet in the distal antebrachium or crus. The limb should
which can result in subsequent fracture of the second met- be fixed in an extended position prior to this procedure as
acarpal/metatarsal bone. Proximally, screws which emerge the tourniquet will cause limb flexion. Surgical skin prep-
through the pa/pl cortex should not protrude from the sur- aration and draping should permit access to the MCP/
face of the bone in order to avoid impingement on the sus- MTP joint and the whole length of the Mc/Mt including
pensory ligament. Spiral fractures may require between 5 medial, dorsal and lateral cortices. A distolateral to proxi-
and 10 screws as determined by their proximodistal length. modorsal curvilinear incision is made from the level of the
Following radiographic verification of screw positions and MCP/MTP joint to a point on the diaphysis proximal to the
lengths, skin portals are closed with simple interrupted radiographically determined termination of the fracture.
sutures. Proximal to the joint capsule and collateral ligament and
lateral to the extensor tendons, the incision is continued
Percutaneous Repair through the metacarpal/metatarsal fascia and periosteum.
Two series have reported percutaneous lag screw repair of This is reflected to permit close inspection of the metacar-
eight [20] and nine [24] propagating fractures with pal/metatarsal cortex for fracture lines. Preservation of the
medial [20] and lateral [24] approaches. The former periosteum in so-called ‘biological osteosynthesis’ tech-
involved three spiral Mt3 and four sagittal Mc3 fractures niques has demonstrable advantages to bone healing in
and the latter series comprised spiral fractures in three Mc3 some circumstances [90, 91]. However, in this situation, it
and six Mt3 bones. Neither group experienced catastrophic is not possible to identify the fracture lines without reflect-
post-operative failure. By contrast, another study reported ing the periosteum. This is required up to the lateral inter-
complete fractures occurring in 2 out of 12 horses during osseous space and beneath the lateral and common or
(a)
(b) (c) (d)
Figure 21.25 Sagittally propagating fracture of the medial condyle of Mc3. (a) DP radiograph and transverse CT images at proposed
sites of screw placement. (b–d) DP radiographs taken at completion of surgery and at 3 and 14 weeks post-operatively, respectively.
(a) (b) (c)
Figure 21.26 Spiral propagation of a fracture of

the medial condyle of Mc3. (a) DP, (b) LM and (c)
DM-PaLO radiographs at presentation. Arrows:
identifiable fracture lines. (d) Transverse CT
images taken at the levels of proposed screws as
depicted on the DP radiograph. Note the changes
in brightness and contrast necessary to identify
the fracture lines. (e) DP and (f) LM radiographs at
completion of surgery. (g) DP and (h) LM
radiographs three weeks after repair. (d)
(e) (f) (g) (h)
long digital extensor tendons. Handheld retractors are

(a) necessary to reflect the tendons, and sometimes separa-
tion of the former is necessary. Dissection extends proxi-
mally until normal dorsal and lateral cortices are
identified; fracture lines are frequently found proximal to
the radographically determined limits [23]. Subperiosteal
and intracortical haemorrhage are common distally, but
proximally fracture lines are frequently identified only as
fine linear defects in the cortex.
Using standard AO/ASIF lag screw technique, 4.5 mm
(b) cortical screws are inserted bicortically at approximately
25 mm intervals from the epicondylar fossa to the proximal
limit of the identifiable fracture. When the fracture is visible
in both cortices, screws are placed halfway between the frac-
ture lines and angled perpendicular to the anticipated frac-
ture plane. If the fracture is visible in the dorsal cortex only,
screws are angled dorsolateral to palmar/plantaromedial to
follow the spiral configuration of the fracture. Intra-operative
radiography may be used as required but should be per-
Figure 21.27 Intra-operative dorsal (a) and lateral (b) views of formed at least before wound closure commences to check,
percutaneous needles at sites of proposed screw placement for and if necessary amend, screw lengths and trajectories.
repair of a spiral fracture of Mt3. Note distal lateromedial Wound closure is usually in three layers: Mc/Mt fascia,
orientation progressing through increasing dorsolateral to
subcutis/intradermal and skin. The former may include
plantaromedial oblique to dorsoplantar trajectories proximally
in line with CT determination of the fracture plane. reflected periosteum, but this is fragile and attempts at
(a)
(b) (c) (d) (e)
Figure 21.28 Spiral fracture of the lateral condyle of Mc3. (a) DP radiograph and transverse CT images demonstrating the fracture
orientation at proposed sites of screw placement. Note the changes in brightness and contrast to assist in identification of fracture
lines. (b & c) DP and LM radiographs taken 10 days after surgery demonstrating screw trajectories in line with the CT-determined
fracture orientation. Cast support is applied to the level of the third carpal bone. (d & e) DP and LM radiographs taken four months
after surgery demonstrating fracture healing at the time of proximal implant removal.
repair are counterproductive. The extensor tendon should (a)

be avoided as incorporation will result in the formation of
binding adhesions.
Plate Fixation
Some authors advocate plating techniques for all propagat-
ing fractures with an oblique diaphyseal component [60].
Application of a neutralization plate to resist bending
forces and thus catastrophic propagation has been recom-
mended for fractures with a mid-diaphyseal ‘Y’ or more
complex configuration [22, 92, 93]. The plate is used to
increase the stability of the repair and therefore a reduc-
tion in catastrophic post-operative fracture propagation.
However, restoration of distal articular congruency with
lag screw fixation remains critical. A second surgery for (b)
plate removal is required if the horse is intended to race.
Reports involving dorsolateral [22, 92–94], dorsal [67, 94],
dorsomedial [93, 94], lateral [94], medial [94] and twisted/
spirally contoured [93, 94] broad dynamic compression
plates (DCPs) and locking compression plates (LCPs) have
been described. It is difficult to rationalize such diversity.
Dorsal and dorsolateral plates are applied with the horse
in lateral recumbency and affected leg uppermost. Distally,
fractures are repaired with lateral to medial lag screws as
described previously. A 10–12 hole (Mc3) or 12–14 hole
(Mt3) broad DCP, broad limited contact DCP or LCP have
been used. This can be applied by an open approach or by
a skin sparing technique following creation of a subcuta-
neous tunnel [22, 79]. The LCP does not rely on bone plate
friction (contact) and is superior but costly. The initial Figure 21.29 MIPPO dorsolateral plate insertion from a distal
portal. (a) Use of a plate passing device. (b) Threaded drill guides
description of minimally invasive percutaneous plate oste- used as a handle in an LCP. Source: Photographs courtesy of Dr D.
osynthesis (MIPPO) involved proximal to distal insertion, W. Richardson.
although distal to proximal generally is easier. The plate is
inserted through a 2–3 cm skin incision at its intended
distal or proximal end. A plate passing device can be fash-
ioned by shaping the end of the broad DCP and fixing a
handle to the opposite end to create a tunnel for the plate
in the required location and orientation [22]. Locking
head screw (LHS) drill guides can be inserted into two
holes at the end of a LCP to create a handle for insertion
(Figure 21.29). Alternatively, the tunnel can be created
with a pair of stout artery forceps [79]. Most plates are at
least partially subtendinous with respect to the common
or long digital extensor tendons. Screw holes are located
by palpation, aided by an overlying plate used as a guide
and confirmed by radiography or fluoroscopy which is
also required to monitor screw placement. Drill guides,
taps (for cortical screws) and screws are inserted through Figure 21.30 Proximal to distal MIPPO in a Mc3. Six-plate
stab incisions made over individual screw holes screws have been inserted but not tightened. The process is
monitored fluoroscopically. Note deviation of the common
(Figure 21.30). At the completion of surgery, skin portals
digital extensor tendon to access the plate and distal lateral
only are closed. DCPs have been considered easier to apply stab incisions for lag screws. Source: Figure courtesy of Dr D. W.
than LCPs, but the mechanical advantages of the latter are Richardson.
(a) (b) (c) (d) (e)
Figure 21.31 Repair of a spiral fracture of the medial condyle of Mt3 with two distal lateral to medial 4.5 mm cortical screws and a
dorsolateral LCP fixed with both 5.5 mm cortical screws and 5 mm LHS. (a)–(c) Post-operative radiographs and (d, e) radiographs taken
at plate removal 75 days after repair. Source: Figure courtesy of Dr D. W. Richardson.
considerable (Figure 21.31). Cortical screws that may reported to receive stall rest with hand walking for two months
cross the fracture in lag technique are inserted first. These followed by one month of restricted paddock turnout.
should also be employed at any sites in which there is risk A second series included fractures of the medial con-
of intrusion into the fracture plane from fixed angle lock- dyles of 16 Mc3 and 14 Mt3 [93]. Twenty-two fractures had
ing screws. spiral, four had straight propagating and four had ‘Y’ con-
Of two series in the literature, the first documented (MIPPO) figurations. All were repaired by open approaches. In 29
of 22 propagating fractures [22]. These comprised 10 medial horses, 10–16 hole broad DCPs or low contact DCPs were
Mt3, 9 medial Mc3 and 3 lateral Mc3 fractures. The distal par- employed and in one horse a narrow DCP was used. All
asagittal portion of the fracture was repaired with between two were applied as neutralization plates. These were posi-
and four lateral to medial 4.5 mm cortical screws in a standard tioned extraperiosteally, dorsomedially or dorsolaterally in
lag technique. A 10–14 hole broad DCP or limited contact DCP accord with individual fracture configurations. The plates
was then fixed to the dorsolateral surface of the bone. When were twisted distomedial to proximodorsal or distolateral
the fracture configuration permitted, distal plate screws were to proximodorsal to follow the fracture spiral in 15 horses
placed in a lag technique. Robert Jones bandages were fitted at and applied as straight plates in 15 horses. Application of a
the end of surgery. Sixteen horses recovered from general cast and use of assisted recovery systems varied.
anaesthesia in a pool-raft system [95] and six in an Anderson CT has increased accuracy of fracture mapping, permit-
sling (CDA Products, Potter Valley, CA, USA). They were ted safer percutaneous repair and decreased the numbers
of cases which require or may benefit from plate fixation. may benefit from limiting bending forces by cast support,
Current evidence also suggests that the “Y” configuration use is recommended for two to four weeks. By this time,
is a two dimensional radiographic artefact occult fracture lines are likely to be radiographically recog-
nizable through the cast. Reporting authors have main-
Standing Repair tained casts for means of 5 [24] and 16 days
Standing repair with radiographically guided percutaneous post-operatively [23]. Peri-operative antimicrobial drugs
lag screws has been reported as described in Chapter 12. are given with a similar rationale to other repairs.
The limitations described above for percutaneous screw Marked symptomatic improvement should be
repair still apply. One group repaired only the radiographi- expected immediately post-operatively. Non steroidal anti-
cally identifiable portions of the fracture in the epiphysis inflammatory drugs provide adequate analgesia, and post-
and metaphysis [75], while another included the diaphy- operative administration can be titred on an individual
sis [76]. A few horses required implant removal. case basis. Phenylbutazone is the drug of choice.
Compromises in the surgical environment and tech- Following cast removal, horses are usually confined to
niques available are marked. The principal benefit is their box for a period of not less than four weeks. Fracture
avoiding general anaesthesia (particularly recovery). In the healing is monitored radiographically. Walking exercise
author’s opinion, this is outweighed by confident assess- commences when there is reasonable osseous union and
ment of fracture configuration and hence appropriate then gradually increases in intensity over an eight-week
repair that is afforded by CT. period. Commencement of walking exercise should not be
delayed until osseous reorganization is established. This is a
Post-operative Care slow process that takes multiples of months and requires
A pool system has been reported to reduce the complica- the stimulus of exercise. Reorganization includes reforma-
tion rate associated with recovery from general anaesthe- tion of uniform cortical density, remodelling and corticali-
sia [95]. In the absence of a suspended, pool or similar zation of callus with re-establishment of medullary
system (which create their own problems; Chapter 11), cancellous organization. If clinical and radiographic pro-
recovery represents the principal risk period for the gress is good at this time, then gradually ascending periods
repaired fracture. Fractures that spiral are particularly sus- of ridden trotting are recommended as a further stimulus to
ceptible to dorsopalmar/plantar bending forces. These are adaptation. Canter exercise usually can commence from
inevitable as the horse rises. Efforts therefore should be approximately six months post-surgery.
made to limit them and their transmission to the bone.
Whatever else is done, a quiet recovery with as few as pos- Complications
sible attempts to stand, is highly desirable. Instrument or implant breakage was recorded in 4 out of
Full-limb casts have been suggested for recovery from 23 (17%) cases during MIPPO [22]. In a series of 30 cases
general anaesthesia [25, 30]. In the author’s experience, the repaired with plates, morbidity was significant: two horses
difficulty in rising that these impose and biomechanical had catastrophic failure of repairs in recovery; four horses
complications that they create preclude their safe use. had surgical wound infections; one horse developed sup-
Half-limb casts minimize bending forces on Mc3/Mt3 dur- porting limb laminitis necessitating euthanasia one week
ing recovery from general anaesthesia [27], and although post-operatively; one horse required implant removal due
some authors have suggested that these are contra- to joint impingement; three horses developed jugular phle-
indicated in Mt3 fractures [60], they have been used suc- bitis of which one died. Although receiving little attention
cessfully [23, 24]. The author recommends use of a in the literature, fibrosis of common/long digital extensor
half-limb cast (Chapter 13) which extends to the level of tendons and substantial restrictive adhesion formation [93]
the third carpal or central tarsal bones, respectively. It is can be athletically limiting.
believed that this proximal location of the casts contributes Post-operative fracture propagation following percutane-
by transferring force from the Mc/Mt to the distal carpus/ ous lag screw fixation was reported in 21.4% of cases in
tarsus. There were no failures using this technique in 27 one [21] and 42% in a second series [30] of propagating frac-
reported cases [23, 24]. The author does not cross-tie horses tures of Mt3. These studies preceded digital radiography and
with repaired fractures supported by a cast. CT. Nonetheless, fracture lines have been identified, often
No clear directives can be given on the duration of cast weeks after surgery, proximal to implants in both parasagittal
immobilization. Restoration of osteochondral homeostasis and spirally propagating fractures that were not identified on
requires this to be minimized. Nonetheless, some fractures acute phase radiographs or CT. These include evidence of
will extend beyond the radiographically and surgically propagating fractures being complete. To date, none have dis-
identified, and therefore repaired, proximal level. As these placed and/or resulted in catastrophic failure.
Result 479
In 2 of 18 fractures repaired by lag screw fixation, an Results

oblique mid-diaphyseal dorsolateral to palmaromedial
screw engaged the second metacarpal bone [23]. Both Fracture classification has important prognostic implica-
horses were lame post-operatively with clinical signs local- tions – all authors agree that non-displaced fractures have
izing to this site, and both became sound after screw a better prognosis than displaced fractures [21, 56, 67]. A
removal. Iatrogenic (screw) damage to the second metacar- note of caution should be made with respect to interpreta-
pal/metatarsal bone and/or suspensory ligament has also tion of results with respect to racing Thoroughbreds. The
been recognized in plate repairs [60]. nature of the Thoroughbred industry is such that a number
of animals, particularly females, which would be capable
Implant Removal of racing following injury are, for economic reasons, retired
Screws placed in lateromedial trajectories do not require to stud. All results therefore are skewed towards lower
removal unless associated with complications. Screws that return to racing in this subgroup [67].
inadvertently impinge on the second Mc/Mt bone require
removal. Screws that engage dorsal and pa/pl cortices may
require removal as fixation of these can result in lameness Fractures of the Palmar/Plantar Subchondral Bone
when horses return to training [23]. If animals are in less
athletically demanding pursuits, then these are of little or One report documents 8 out of 12 (67%) [21] and a second
no consequence. Timing is determined by fracture healing 32 out of 45 (71%) [59] returning to racing post-injury. The
and osseous reorganization including (re)corticalization of first group were all manged conservatively. The second
defects and re-establishment of corticomedullary demarca- group comprised 40 with conservative treatment and 5
tion. Neither have to be complete, but both should beestab- repaired with single 4.5 mm lag screws. The conservatively
lished. Removal can be performed standing or under managed horses received varying periods of box rest fol-
general anaesthesia as determined by individual lowed by a graduated exercise programme, all determined
circumstances. by radiographic monitoring of the healing process. Five
Plates are removed from horses that are intended to (12.5%) re-injured the original fracture; four had repeated
return to work (Figure 21.31); standing removal three unicortical fractures and one became complete and
months following implantation has been recom- catastrophic [59].
mended [22, 67, 93]. Under sedation and regional analge-
sia, the screws are removed percutaneously. An incision is Incomplete Fractures
made at the proximal margin of the plate to permit eleva-
tion. It is then grasped (with vice grips or similar) and All authors have reported favourable outcomes for the
pulled out. In a series of 30 horses, plates were removed in majority of horses with bicortical incomplete fractures
16 of 18 cases either standing or under general anaesthesia whether the fractures are repaired or managed conserv-
8–19 weeks post-operatively [93]. atively. Pooled data reports 28 of 31 (90%) of horses
managed conservatively and 106 of 132 (80%) of
repaired horses [25, 56, 67] returning to racing. A more
Complex and Complicated Fractures favourable outcome has been reported for repaired
Mt3 in which 28 out of 30 (93%) compared to 43 out of
On occasions, and usually with conservatively managed 56 (77%) fractures of Mc3 raced post-operatively [25]. In
fractures, only the proximal part of a propagating fracture a series in which incomplete and complete non-
may heal; radiographic non-union or delayed union displaced fractures were combined, 14 of 23 (61%) con-
remaining in the epiphysis. Clinical signs associated with servatively managed and 17 of 28 (61%) repaired
these are highly variable but lag screw repair is advocated, fractures raced after injury [21].
particularly if resumption of athletic activity is required in It has been suggested generally that horses that have not
order to minimize the risk of propagation and re-fracture. raced before fracturing are less likely to do so after than
Uncommonly, fractures of the Mc/Mt condyles can be horses with similar injuries that had previously run. This
biaxial. These usually are comminuted, complicated by was not borne out in a major study which found that 65% of
additional lesions and, when displaced, may become open. horses that were starters pre-injury and 64% of horses that
Fractures of the Mc/Mt condyles can also present in con- had not raced previously were able to race following their
junction with other severe, frequently catastrophic frac- fractures [67]. The latter had more prolonged convalescent
tures. Salvage in such circumstances can be surgically periods as may be expected for overall training/
challenging and is commonly unsuccessful. conditioning.
Complete Non-displaced Fractures is anticipated that its contribution will be reflected in future
case series.
In one series, 4 out of 6 (67%) [56] and in another 24 out of
40 (58%) [67] fractures raced following repair. In the latter,
more fractures of Mt3 raced and their time to first race was Propagating Fractures
shorter than similar fractures of Mc3. A further study The mean time from surgery to the first race has varied lit-
reported that 19 out of 25 (76%) and 16 out of 47 (34%) tle between published techniques (11.6–14.5 months) [22–
Thoroughbreds with complete fractures of the lateral con- 24, 76, 89].
dyles of Mt3 and Mc3, respectively, raced after surgical Of 60 horses repaired by plate application, 18 of 38 (47%)
repair [25]. However, this paper made no distinction repaired by an open technique [67, 93] and 10 of 22 (45%)
between non-displaced and displaced fractures. repaired by MIPPO [22] raced following surgery. In the lat-
ter series, 14 of 22 cases (64%) returned to training. Of
Displaced Fractures horses repaired using standing lag screw techniques, 4 out
of 4 [75] and 8 out of 13 (62%) [76] raced following surgery.
The articular insult that accompanies displaced fractures Six of nine (67%) horses with fractures repaired by percuta-
results in a higher incidence of subsequent degenerative joint neous lag screws returned to training with five (56%) rac-
disease than with non-displaced fractures [56]. Articular ing [24], while an open technique resulted in 14 of 18 (78%)
incongruity is the most common complication. Before arthro- of horses returning to training and five (28%) racing after
scopic evaluation and guidance of reduction was routine, this surgery [23]. A hybrid percutaneous and open lag screw
frequently, and despite intra-operative radiographs, was fixation technique resulted in 15/26 (58%) of horses racing
unrecognized. It is possible to have good reduction of the after repair [89].
extra-articular portion of the fracture and for radiographs to
fail to identify slight, usually dorsopalmar/plantar or
rotational displacement. The prognostic significance of carti- Concurrent Lesions and Complications
lage defects on the lateral PSB has not been documented but
Concurrent fractures of the PSBs [25, 56, 67], particularly
is likely to contribute to the reduced return to racing.
axial/sagittal fractures of the lateral PSB, diminish mark-
The extensive osteochondral and subchondral changes
edly the prospects of athletic soundness [21, 65, 66]. When
found in post-mortem examinations of displaced frac-
these extend the full dorsopalmar/plantar thickness of the
tures [39, 96, 97] are likely to contribute to reported modest
PSB, they compromise a substantial amount of intersesa-
success rates. In a series published in 1983, 12 of 38 (32%)
moidean ligament/scutal insertion. A number of dorsal
repaired and none of 6 conservatively managed displaced
(articular) partial thickness fragments have also been iden-
fractures raced following injury [56]. In a 1994 publication,
tified on CT and removed arthroscopically. Numbers are
only 3 of 17 (18%) of such fractures raced following
limited, but in the author’s experience the prognosis asso-
repair [21]. An improved success rate was reported in
ciated with these appears better.
1999 [67] when 25 of 43 (60%) displaced fractures raced fol-
The presence [25, 56] and loss [67] of comminuted frag-
lowing surgery. However, the definition of displacement as
ments have been associated with diminished post-
distraction >1 mm is liberal. In this series, more horses with
operative performance. These have not consistently been
fractures of Mt3 raced and these had a reduced convales-
recorded in the literature but were found in 33 of 75 (44%)
cent period compared with similar fractures of Mc3. All of
horses with catastrophic fractures of the lateral condyle of
the current data is based on results of repairs undertaken
Mc3/Mt3 [58].
before arthroscopically guided reduction was introduced; it
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repair of propagating condylar fractures of the third
485
22
Diaphyseal Fractures of the Third Metacarpal and Third Metatarsal Bones

C. Lischer and C. Klaus
Diaphyseal and metaphyseal fractures of the third meta- side of the bones is dorsolateral which makes this the
carpal (Mc3) or metatarsal (Mt3) bones, colloquially preferred side for plate application [1]. The straight shape
termed cannon, occur in all types of horses. These can be of the bones necessitates usually only minimal plate
monotonic as a result of external trauma such as a kick or contouring.
can be repetitive cyclic fatigue injuries. Complete diaphy- The digital extensor tendons course over the dorsal sur-
seal fractures usually require anatomical reduction and faces of Mc3/Mt3. This aside the bones have little soft tis-
double plate fixation. Incomplete fractures are often man- sue coverage, except for their palmar/plantar aspect where
aged conservatively unless there is joint involvement or the tendons, ligaments and major neurovascular structures are
fracture plane is clearly identified. In these cases, lag screw located. These features increase the risk of skin damage
fixation improves healing. and creation of open fractures. They also create difficulties
in skin closure after plate application, particularly in foals
where adequate soft tissue closure after double plating is
natomy and Biomechanical
A sometimes not possible. The lack of muscles and conse-
Considerations quent sparse vascularization of the distal limb often results
in a poor blood supply at fracture sites, which can be detri-
Mc3 and Mt3 are the most intensely loaded bones of the mental to fracture healing.
appendicular skeleton and have the thickest cortices of all
long bones. Mt3 is approximately one-fifth longer and has
a rounder cross-section than Mc3 which is oval shaped [1]. Fracture Types
The nutrient foramen is usually located in the proximal
palmar/plantar cortex and should be avoided by screws. In adults, simple complete diaphyseal fractures can occur
The nutrient artery of Mc3, a branch of the medial palmar at all levels of Mc3/Mt3 and are usually transverse or
metacarpal artery, is accompanied by a corresponding vein slightly oblique (Figure 22.1). Comminuted fractures
and a branch of the palmar metacarpal nerve [2]. which are most common in older horses can exhibit all lev-
Neurovascular supplies to the dorsal periosteal surface of els of complexity. Some of these have one larger butterfly
Mc3 are provided by small medial and lateral dorsal meta- fragment on either the medial or lateral side. Reconstruction
carpal arteries and the medial cutaneous antebrachial and and reduction can be difficult, and it is important to place
dorsal branch of the ulnar nerves [3, 4]. The nutrient artery one plate over the fragment as a buttress in order to maxi-
and satellite vein of Mt3 are from the proximal deep plan- mize stability of the repaired construct. Long oblique and/
tar arch, the former arising from the medial plantar and or spiralling fractures encompassing the whole diaphysis
perforating tarsal arteries. The periosteal blood supply of are rare. These are good candidates for plate repair because
the dorsal Mt3 comes from branches of the dorsal metatar- multiple lag screws can be placed across the long fracture
sal arteries [3, 4]. Age and stress adaptation by training plane, which increases substantially the stability of the
change the cross-section of the bone. The dorsomedial cor- construct.
tex becomes thicker, while stress fractures occur more fre- Distal physeal fractures in foals most communally have a
quently in the thinner dorsolateral cortex [5]. The tension type II configuration with a variable length of the meta or

486 Diaphyseal Fractures of the Third Metacarpal and Third Metatarsal Bones
Incidence and Aetiology
In non-racehorse populations, fractures of the Mc3/Mt3

diaphyses are relatively common, with almost the same fre-
quency as tibial, radial and ulnar fractures [6]. They are
most frequently kick injuries, with Mt3 at least twice as
commonly affected as Mc3, but can follow other traumatic
I II III IV events such as collisions, traffic accidents or falls.
In racehorses, fractures of the Mc3/Mt3 condyles, most
commonly medially, can propagate into the diaphysis
(Chapter 21). Other stress-related injuries in racehorses
can lead to incomplete fractures, including the dorsal (usu-
ally lateral) diaphyseal, proximal (usually palmar metaphy-
seal) and distal palmar metaphyseal cortices.
Figure 22.1 Common configuration of complete fractures of Dorsal Cortical Stress Fractures
Mc3/Mt3 in adult horses. (I) Distal metaphyseal, (II) simple
diaphyseal, (III) comminuted diaphyseal and (IV) proximal Dorsal metacarpal disease (DMD) describes a range of
metaphyseal. pathological changes colloquially termed ‘bucked’ or ‘sore’
shins which manifest clinically as pain over the dorsal
diaphyseal spike (Figure 22.2) (Chapter 37). Simple mid- aspect of the diaphysis. DMD has been reported as the
shaft fractures are usually transverse. In very young foals, most common cause of days lost to training and racing in
these may be unicortical, which is thought to be the result young Thoroughbred racehorses [7]. It usually occurs in
of a thin cortex of soft bone covered by strong thick perios- the early period of training and was claimed to have
teum. Bending forces applied to such bones result in failure reached a prevalence up to 70–80% in some racehorse pop-
on the tension side: the fracture line will run transversely ulations in the 1970s and 1980s [8], although a decreased
but will not enter the cortex at the compression side. incidence has been reported more recently [7]. Modelling
However, stress/fracture planes can change direction in and remodelling of the dorsal cortex of Mt3 occur similarly
the middle of the bone and propagate in a proximal or dis- to that of the Mc3, but the relative lack of clinical signs in
tal direction. These are sometimes referred to as greenstick the hindlimb is explained by the difference in the load dis-
fractures (Figure 22.2). Occasionally, simple diaphyseal tribution between forelimbs and hindlimbs [9].
and metaphyseal fractures, as described for adult horses, Stress fractures in the dorsal cortex occur in approxi-
also occur in older foals or weanlings. mately 12% of horses with DMD and are typically seen
Figure 22.2 Common Mc3/Mt3 fractures in foals.

(I) Salter–Harris type II. (II) Incomplete, unicortical,
simple transverse mid-diaphyseal. (III) Simple,
transverse/slightly oblique mid-diaphyseal. (IV)
Simple, transverse proximal metaphyseal.
I II III IV
Dorsal Cortical Stress Fracture 487
months after the initial episode of bucked shins. Horses Non-surgical management includes anti-inflammatory
experiencing high strain cyclic loading on inadequately therapy and rest until fracture healing is confirmed radio-
remodelled bone are at highest risk. The dorsolateral cortex graphically. The best candidates for conservative manage-
of Mc3 is thinner and most likely to be affected. Osseous ment are fractures in either the distal or proximal
failure usually manifests as an incomplete stress fracture or metaphyses. Bridging periosteal callus appears to develop
less commonly as a catastrophic mid-diaphyseal frac- more rapidly at these sites than the more common dia-
ture [10]. Dorsal cortical fractures in the Mt3 are rare but physeal fractures. Delayed union fractures can be treated
occasionally occur in both Thoroughbred and Standardbred surgically, but some clinicians advocate surgical treat-
racehorses [9]. ment of all.
Surgical treatment options include osteostixis alone or in
combination with a unicortical screw which can be inserted
Diagnosis
as a position screw or in lag fashion. The surgery can be
The most common clinical signs are unilateral or bilateral performed with local analgesia in the standing sedated
lameness with a swelling on the dorsal diaphysis which is horse [12] or under general anaesthesia in lateral or dorsal
sensitive to local pressure. Lameness usually reduces with recumbency. The authors prefer lateral recumbency with
rest, but recurs with resumption of work. the affected limb uppermost to facilitate intra-operative
The diagnosis is confirmed radiographically. It is impor- imaging which is crucial to locate the exact site of the frac-
tant to image the entire fracture length, so multiple oblique ture and the position of the screw.
projections are required. The vast majority (97%) course A 4–6 cm incision is made directly over the fracture down
from dorsodistal to palmaroproximal (Figure 22.3) [11]. to the bone, which usually involves splitting the common
Nuclear scintigraphy can identify suspect fractures before or lateral digital tendons. A periosteal elevator is used to
fissures become radiographically apparent (Chapter 5). expose the bone surface. The edges of the incision are
parted with a self-retaining retractor. The actual fracture
can rarely be seen although callus may be visible or palpa-
Treatment
ble. Screws can also be inserted percutaneously under radi-
Several treatment options are available. All require a period ographic or fluoroscopic guidance.
of rest from training, but there are no benefits from Some surgeons use 4.5 mm cortical screws inserted in lag
immobilization. fashion but, as dorsal cortical stress fractures are not dis-
placed, the effect of compression is controversial [8, 13].
(a) (b) The authors’ preference is insertion of a 3.5 mm cortical
screw in neutral technique.
Using radiographic guidance, a 3.5 mm cortical screw is
placed perpendicular to the fracture plane at the junction of
its middle and distal thirds. As this is a position screw, the
entire hole, i.e. through the full thickness of the dorsal cor-
tex, is drilled with a 2.5 mm drill bit. In dorsolateral frac-
tures, it is important to aim towards the centre of the bone
to be perpendicular to the dorsal cortex, to remain unicorti-
cal and not to drill towards the palmar cortex. Countersinking
is not recommended because screw removal is easier if the
head is not recessed. Subsequently, the hole is tapped by
hand and a unicortical screw inserted. The screw is not
excessively tightened to avoid bending when the head
engages the bone.
Screw insertion is often combined with osteostixis, but
drilling the dorsal cortex alone can also be effective [14].
Using a 2 or 2.5 mm three-flute drill bit, approximately
eight holes are drilled in a grid pattern approximately
10 mm apart through the dorsal cortex in the area of the
Figure 22.3 (a) Incomplete stress fracture in the dorsolateral
estimated fracture plane. Although in vitro biomechanical
Mc3 cortex with a typical dorsodistal to palmaroproximal course
(black arrows). (b) Surgical treatment with a unicortical 4.5 mm tests revealed that clustered drill holes in the dorsal cortex
cortex screw and osteostixis (white arrows). of the distal diaphysis of Mc3 act as a stress concentrator
and significantly reduce the stress for failure [15], no cast is Various configurations have been reported. These
needed for recovery. include incomplete longitudinal fractures of the proximo-
Post-operative management consists of box rest and palmar medial aspect of Mc3 [17–19], frontal (dorsal) plane
hand walking exercise. Elective screw removal is usu- fracture of proximal Mc3 [20, 21] and proximal Mt3 [22]
ally performed two months post-operatively in the and mid-diaphyseal fractures of Mc3 in which lines tend to
standing sedated horse. If follow-up radiographs con- spiral around the cortex (Figure 22.4) [23].
firm healing, the horse can resume training 45 days
after screw removal.
Diagnosis
The prognosis after surgical intervention is good. It has
been reported that 80–90% of horses returned to racing [11, Clinical features have not been well documented, but are
13, 16]. Complications include broken drill bits and taps, strongly related to the extent and location of the fracture.
local infection and re-fracture or further stress fracture in There is often an initial episode of severe lameness that
the same location. Catastrophic failure has only been improves after a few days of rest or treatment with non-
reported in horses that had repeated osteostixis following steroidal anti-inflammatory drugs (NSAIDs). During clini-
unsuccessful first treatment [16]. cal examination, lameness may deteriorate the further the
horse trots [17]. Following kicking injuries, there is typi-
cally an acute onset lameness, a skin mark, swelling and
Incomplete Longitudinal Fractures pain on palpation [24]. Even if radiographically incom-
plete cases should be managed as complete fractures for
Incomplete longitudinal fractures that are independent of the first two weeks until this can confidently be deter-
the distal condyles occur more frequently in the Mc3 than mined. This should include putting the horse in a sling or
in the Mt3. They have been attributed to both fatigue dam- cross ties, and immobilizing the cannon bone with a full-
age secondary to repetitive loading (stress fracture) or a limb bandage cast.
single non-catastrophic traumatic event, such as a bad step, Radiographically, fractures appear as a longitudinal
a jump or a kicking injury. Stress fractures seem to be more radiolucent line extending a variable distance along Mc3/
common in performance or racehorses whereas acute Mt3. Multiple projections are necessary because these
trauma is more likely in pleasure horses. fractures have a tendency to spiral and propagate into the
(a) (b) Figure 22.4 Acute, incomplete longitudinal

spiralling fracture of the Mc3 crossing the nutrient
foramen and continuing into the carpometacarpal
joint (arrows). Multiple radiographs in different
projections are necessary to follow the fracture
plane.
Avulsion Fractures Associated with the Origin of the Suspensory Ligamen 489
carpometacarpal or tarsometatarsal joint (Figure 22.4). In injury. Close monitoring of comfort level and radiographic
some horses, fractures are not radiographically visible change is mandatory. If there is a risk of fracture propaga-
until there is adjacent osteoclastic resorption and/or sur- tion, then lag screw fixation is the treatment of choice.
rounding increased radiopacity (Figure 22.5). Understanding the orientation of the fracture plane is
Differentiation between healing of an acute traumatic critical but can be challenging in spiralling fractures.
fracture and a stress-related bone injury is not always pos- Long fractures require rigid support for induction and
sible. In inconclusive cases, further imaging modalities recovery from general anaesthesia. To avoid risk of propa-
such as scintigraphy, magnetic resonance imaging (MRI) gation at these times, standing fracture repair can be con-
or computed tomography (CT) are strongly recommended. sidered (Chapter 12).
For obvious reasons, techniques that can be performed in
the standing sedated animal are preferred.
vulsion Fractures Associated
A
Treatment with the Origin of the Suspensory
Incomplete sagittal fractures of the proximopalmar aspect
Ligament
of the Mc3 are managed conservatively with periods of
Avulsion fractures can be solitary injuries or associated
stall rest and have an excellent prognosis [17].
with proximal suspensory desmitis (PSD). They occur in
Frontal plane fractures that extend from the carpometa-
Standardbred racehorses, less frequently in Thoroughbreds
carpal/tarsometatarsal joint distally into the diaphysis or
and occasionally in sport horses.
metaphysis can be managed conservatively [20] or surgi-
cally. With long fractures, the horse should be prevented
from lying down for the first six to eight weeks after the Diagnosis
There is usually an acute onset, moderate to severe unilat-
(a) (b)
eral lameness and local pain on palpation. Diagnosis is
made on the basis of clinical signs often in combination
with scintigraphy, radiography and ultrasonography
(Figure 22.6). Longitudinal images are often most useful
with the latter. An avulsion fracture may be detected radio-
graphically in dorsopalmar/plantar or slightly obliqued
views and in lateromedial, or flexed lateromedial, projec-
tions. Occasionally, fractures are identified as an almost
straight or saucer-shaped lucent line (with the base proxi-
mal or distal) or a ‘punched out’ lesion [25]. More com-
monly, less well-defined areas of radiolucency and/or
increased radiopacity are seen.
In horses with more chronic fractures, local analgesia
techniques suitable for the localization of pain at the origin
of the suspensory ligament are useful. Scintigraphy, MRI or
CT may be required because chronic fractures are more dif-
ficult to identify radiographically.
Treatment
Conservative management using a progressive increase in
exercise without turnout is usually successful. Recurrence
is common and most likely in horses that have associated
PSD. Successful treatment of chronic fractures by percuta-
neous osteostixis has been described (Figure 22.6).
Resolution of the fracture and associated ligament pathol-
Figure 22.5 An acute, incomplete, longitudinal fracture of Mc3
(arrows) (a) two days after the injury and (b) 14 days later ogy took up to six months, and 59% of horses returned to
consistent with osteoclast activity. full athletic function [26].
(a) (b)
(c) (d)
Figure 22.6 Nine-year old shows jumper with an avulsion fracture of the proximal plantar Mt3. (a) Bone phase caudal scintigraphic
images of both limbs show a focal area of IRU in the right Mt3. (b) A subtle saucer-shaped radiolucent line (black arrows) around an
area of increased radiopacity. (c) Longitudinal sonograph of the lateral lobe of the proximal suspensory ligament shows a
hyperechogenic line indicating the displaced bone fragment (white arrows). (d) Intra-operative DP radiograph during osteostixis of the
area. Needles demarcate the area of the suspensory ligament origin.
ransverse Stress Fracture of the

T of corticomedullary definition and increased endosteal
Distal Diaphysis radiopacity or periosteal callus palmar, palmaromedial
and/or palmarolateral are useful indicators (Figure 22.7). In
These fractures have only been reported in the forelimbs of the absence of radiographic changes, alternative imaging
Thoroughbred racehorses and Arabian endurance horses [8, modalities such as scintigraphy, standing MRI and CT can
27–29]. Approximately 40% are bilateral and they are con- be useful. In more severe cases, there are distinct fracture
sidered to be stress fractures. They invariably involve the lines and variable comminution. Complete fractures can
palmar cortex but can extend varying distances dorsad. displace and in some the metacarpal condyles can rotate.
Diagnosis Treatment
A distinct fracture line in the palmar cortex is not always Conservative management is appropriate for incomplete
obvious on radiographic evaluation, particularly in the fractures and stable complete non-displaced fractures. A dis-
acute phase. However, endocortical changes such as loss tal limb Robert Jones bandage and strict stall confinement
Complete Diaphyseal Fracture 491
Figure 22.7 Lateromedial (a) and oblique (b) (a) (b)

radiographs of a Thoroughbred racehorse with
a transverse stress fracture in the distal
metaphysis of Mc3. Note the palmar callus
formation and incomplete fractures of palmar
(white arrows) and dorsal (black arrows)
cortices. Source: Courtesy Chris Riggs, Hong
Kong.
for eight weeks followed by a similar period of hand walking (a) (b)
exercise can be sufficient for healing. Some extensive frac-
tures produce abundant callus; however, this does substan-
tially remodel (Figure 22.8). If pain is persistent, stability
must be questioned and a distal half-limb cast is required.
Displaced and demonstrably unstable fractures require
immediate surgical intervention to stabilize the fracture
and to prevent necrosis of the epiphyseal component. The
more distal the transverse fracture is located the more dif-
ficult the repair. Minimal invasive locking compression
plate (LCP) technology using special plates such as variable
angle LCP (VA-LCP), curved condylar plate [8] or a 4.5 mm
LCP T-plate might be considered. In some cases, arthrode-
sis of the metacarpophalangeal joint is the only option to
salvage the animal. Post-operative rehabilitation includes
box rest and half-limb cast support for four to six weeks.
In all cases, catastrophic failure remains a serious risk
during the acute and subacute phases. However, horses Figure 22.8 Lateromedial radiographs of a transverse fracture
with fractures that heal conservatively have a good progno- of the distal diaphysis of Mc3 in a two-year-old Thoroughbred.
sis to regain athletic function [8, 28]. (a) Two months after acute onset lameness demonstrating
abundant periosteal and endosteal callus and (b) 15 months
later. The filly had trained and raced in the interim.
Complete Diaphyseal Fractures
Diagnosis
In racehorses, the most common major long bone fractures
involve the distal condyles of Mc3 and Mt3 (Chapter 21). Complete fractures usually displace and are therefore
However, diaphyseal fracture are occasionally encoun- clinically apparent. Almost all present acutely. Affected
tered [30]. In horses used for other purposes, Mc3 and Mt3 horses are usually distressed and the primary focus should
account for 17% of all major long bone fractures and rank be to effectively immobilize Mc3 or Mt3 as soon as possible
behind tibia, radius and ulna [31]. Complete diaphyseal (Chapter 7). In light of the paucity of soft tissue coverage, it
fractures occur in all breeds, at any age and irrespective of is of utmost importance to reduce the risk of a closed frac-
activity. In non-racehorses, more than 50% are the result of ture becoming open. The authors’ preferred immobiliza-
a kick by another horse [31]. tion is a full-limb splint bandage or bandage cast applied to
a sedated horse. Open fractures should be cleansed and axial collapse of a mid-diaphyseal third metacarpal 30°
covered with a sterile dressing; systemic antimicrobial osteotomy site when the bone was placed under axial com-
medication should also be initiated. In most circumstances, pression [32]. However, prolonged periods of external fixa-
it is advisable to take radiographs following external coap- tion are associated with substantial risks such as skin sores,
tation, when the horse has calmed down. This should osteopenia, joint stiffness as well as pin-related problems
include a minimum of four orthogonal views ideally which can result in fracture instability and severe lame-
including the proximal and distal joints. Further projec- ness [33] (Chapter 13). Application of external skeletal
tions may be necessary to plan surgery. fixation techniques may be considered in highly commi-
nuted, open fractures that are not amenable to internal
fixation and fractures with considerable soft tissue
Treatment
trauma [34, 35].
Non-surgical management with external coaptation alone The recommended surgical treatment of complete dia-
is rarely an acceptable approach in unstable diaphyseal physeal fractures is reduction and stable fixation using two
fractures, either in adult horses or foals. Sliding of the frac- LCPs positioned at a 90° angle to each other (Figure 22.10).
ture ends in oblique fractures or rotational displacement in In an in vitro study of osteomized equine Mc3, LCP fixation
transverse fractures generally results in an open fracture in combination with locking head screws (LHS) was supe-
and life-ending outcome. In the few cases in adult horses in rior to the 4.5 mm limited contact dynamic compression
which stability is maintained, a minimum period of plate (LC-DCP) in resisting static overload forces (palmaro-
12 weeks of external coaptation would be required which, dorsal four-point bending and torsional) and cyclic fatigue
of itself, carries significant morbidity risks. under palmarodorsal four-point bending [36]. Fixed angle
External skeletal fixation techniques using transfixation constructs (LCP) increase stability and allow fractures to
pins have been used alone or in addition to internal fixa- heal even when open and infected [37].
tion (Figure 22.9). Biomechanical studies demonstrated Surgery is performed with the horse in lateral recum-
that a full-limb transfixation cast provided significantly bency and the affected limb uppermost. In open fractures,
greater resistance than a standard full-limb cast against the pre-existing skin wound is debrided, rinsed and closed
(a) (b)
Figure 22.9 Comminuted fracture of the Mc3 in a 200 kg pony. (a) Dorsopalmar and lateromedial radiographs. The fracture was
reduced following an open approach with multiple lag screws. A DCP plate was applied dorsally and included engagement of the third
carpal bone. A transfixation cast was then applied utilizing metaphyseal and distal diaphyseal pins in the radius. (b) Radiographs
taken at the end of surgery before application of the cast.
(a) (b)
Figure 22.11 Dorsolateral approach to an Mt3 fracture in a

foal. Splitting the long digital extensor tendon provides a solid
layer for closure after repair.
screw insertion is beneath a plate, interference can be pre-

vented by using a deeply countersunk 3.5 mm cortical
screw. Transverse fractures can be more difficult to stabi-
Figure 22.10 Dorsopalmar radiographs of a long, oblique Mc3
lize before plate application as placement of effective lag
fracture in a 500 kg Thoroughbred mare. (a) At presentation and
(b) two months following repair with a 12-hole broad LCP screws across the fracture plane may be precluded. In this
dorsally and a 13-hole broad LCP -medially which was selected situation, bone holding and reduction clamps, e.g. a
because the leading edge of the fracture was medial. Verbrugge bone clamp which maintains reduction by com-
pressing the plate onto the bone, may be useful.
with instruments and gloves that are removed after this Two plates are necessary for adequate stabilization in
procedure. The bone is then exposed by a gently curved adults and in most foals. Only young foals with transverse
dorsolateral skin incision followed by splitting the long, or short oblique mid-diaphyseal fractures may be treated
common or lateral digital extensor tendon to provide a with a single plate. The dorsolateral aspect of the bone is
solid layer for closure after repair (Figure 22.11). To reduce the tension side; hence, plates are usually applied dorsally
risk of infection, areas of poor vascularization or open and laterally. Uncommonly with specific fracture configu-
wounds should be avoided. The incision is carried directly rations, such as a medial butterfly fragment that requires
to the Mc3 and Mt3 periosteum. As far as possible, it is bridging, a buttress plate may need to be applied to the
important to preserve this: the periosteum is elevated just medial surface, which would affect the position of the
enough to visualize the fracture, when necessary to debride horse on the surgery table. Alternatively, plates may be
the fracture gap and to control reduction. placed dorsolaterally and dorsomedially (Figure 22.12). In
Once the fracture configuration has been determined, both situations, it is important to check intra-operatively
fracture debris is removed. Displaced fractures are reduced that the plates are placed at 90° to each other. They should
either by applying tension on the limb or by tenting the two extend along the entire proximodistal length of the diaphy-
main fragments out of the incision. In multifragment frac- sis and metaphysis without involving the joints or physis.
tures, it is preferable to lag large butterfly fragments back to However, plates should be of different lengths and end at
the major fragments before reduction is attempted. Once different levels on the bone to mitigate stress concentration
the fracture is aligned, reduction is maintained using large and subsequent fracture at the end of the plates. The longer
pointed reduction forceps. Preliminary fracture fixation of plate should be placed on the dorsal surface to facilitate
oblique fractures is achieved with interfragmentary lag wound closure. Areas of comminution should be spanned
screws, using 3.5 mm or 4.5 mm cortical screws. The posi- with the stronger plate because this has a buttress function
tions of interfragmentary screws should be planned strate- (Chapter 8). The two plates should also be staggered to
gically to avoid interference with subsequent plates and ensure that screws placed perpendicular to the plate will
plate screws. If the only useful or appropriate site for the not interfere with those in the other plate.
Figure 22.13 Intra-operative photograph and radiograph of a

transverse mid-diaphyseal fracture after reduction and
placement of dorsal and lateral LCPs. The fracture is temporarily
fixed with a lag screw and both plates are compressed to the
bone with cortical screws. Drill guides for LHSs are inserted at
the proximal and distal end of the lateral plate to assess the
direction of the screws near the joint.
Figure 22.12 Open, displaced transverse diaphyseal fracture of Variations in technique include consideration of
Mt3 in a foal and repair with LCPs dorsolaterally and 3.5 mm broad LCP implants with 3.5 screws in foals or
dorsomedially.
small ponies because more screws can be inserted and
skin closure is facilitated. In cases with large cortical
Following reduction, a template can be used to help con- defects, an autologous cancellous bone graft or a cortical
tour the plates. Usually, a 4.5 mm broad LCP is placed dor- allograft [39] may be considered. To reduce the risk of
sally and a 4.5 mm narrow LCP medially or laterally. In bacterial adherence to the implants, polymethylmeth-
large adult horses, two broad LCPs may be used if skin clo- acrylate impregnated with antimicrobials may be used
sure is still achievable. Generally, a combination of LHS near the plate and in the empty space of the combi holes
and cortical screws is employed. Whenever possible, of the LCP. However, care should be taken not to fill in
5.5 mm cortical screws are recommended because of their the socket of the screw head because this complicates
greater holding power and tensile strength in adult implant removal. In some fracture configurations in
bone [38]. The cortical screws are placed first in order to which there is little proximal or distal bone stock, a
press the plate against the bone and to use the dynamic 4.5/5.0 LCP T-plate may be useful to obtain purchase in
compression unit to create compression across the fracture this segment. The T-part is slightly curved and fits well to
plane. the dorsoproximal aspect of the bone (Figure 22.14).
Once the first plate is fixed with the two cortical screws, Before closure, intra-operative radiographs are taken at
the second plate is placed and fixed onto the bone. It is 90° to all implants to assess the fracture repair, plate
advisable to take two radiographs at this point, to assess placement and screw length. Particular care should be
reduction and plate placement (Figure 22.13). In oblique taken to avoid engagement of the splint bones and injury
fractures, surgeons should place as many lag screws across to the physis. Intravenous regional limb perfusion with
the fracture plane as possible. Significantly increased stiff- antimicrobials may be performed during wound closure
ness of fracture constructs can be achieved by strategic use to reduce the risk of infection. The extensor tendon is
of 5.0 mm LHS. In each plate, bicortical LHS screws are apposed with No. 1 (five metric) monofilament synthetic
placed in the two most proximal and distal holes, with two absorbable suture material in a continuous suture pat-
bicortical LHS as close as possible proximal and distal to tern before the subcutaneous tissue and skin are closed
the fracture plane. routinely.
(a) (b) (c) (d)
Figure 22.14 (a, b) Oblique fracture in the proximal diaphysis of Mc3 in a three-month-old foal. (c, d) Stable repair with a dorsal
8-hole 4.5/5.0 LCP T-plate and a lateral 10-hole narrow 4.5/5.0 LCP.
When fractures require little or no reduction, then mini- there is a potential for ischaemic bone failure which is pre-
mally invasive repair can be considered. If good intra- sumed to result from their greater dependence on peri-
operative imaging is available, the strength and stability of osteal blood supply (Chapter 37).
the LCP allows surgeons to slide plates through small inci- During anaesthetic recovery, the repair is protected with
sions between periosteum and skin. Screws are then a full-limb cast or a splint bandage, depending on the size
inserted through stab incision under fluoroscopic guid- of the patient, the affected limb and the stability of the
ance. It is premature to claim that most Mc3/Mt3 fractures repair. Assisted recovery as determined by availability, per-
in foals might be treated this way, but the complications sonnel and horse size and temperament can be beneficial
associated with open techniques are sufficient to justify (Chapter 10). External coaptation should be maintained
further efforts. The bones are particularly well suited to for two weeks in order to protect the skin incision. The cast
percutaneous implant placement because of the minimal can then be removed and replaced with a bandage. It is
overlying soft tissue and their relatively straight diaphyses. advisable to keep adult horses cross-tied or in a sling that
If the periosteal sleeve, its contained fragments and the prevents them from lying down for six to eight weeks after
fracture haematoma are undisturbed by two extra- surgery. Peri-operative medication includes antimicrobial
periosteal plates, it seems probable that the normal pro- treatment and analgesic medication as determined by indi-
gression of fracture healing will be unimpaired [40]. vidual case circumstances.
However, substantial experience of fracture fixation is nec- The principal complication is infection with consequen-
essary to minimize risk of technical errors in implant tial implant loosening, delayed or non-union, excessive
placement. Some fractures in young foals can be repaired new bone formation and laminitis in the contralateral
using single plates (Figure 22.15). With multiple implants, limb [33, 41]. If anatomic reduction is achieved and selection
(a) (b) (c) (d)
(e) (f) (g) (h)
Figure 22.15 Minimally invasive repair of an oblique mid-diaphyseal fracture of Mt3 in a neonate. (a) Dorsoplantar and (b)
lateromedial radiographs taken in a splinted bandaged on arrival demonstrating valgus displacement and overriding. (c) The foal is
positioned in dorsal recumbency with traction applied by an overhead hoist. (d, e) DP radiographs in surgery demonstrating
progressive reduction with increasing traction. (f) Haemostats inserted dorsodistally to create a sub tendinous tunnel. The long digital
extensor tendon is gripped in the surgeons left hand. (g) Stacked LHS drill guides used to create a handle for insertion of the LCP.
(h) LCP location confirmed in a LM radiograph (i) Plate/bone contact created by insertion of 2 × 4.5 mm cortical screws. (j) Construct at
the end of surgery with the remaining plate holes filled with 4 mm LHS. (k, l) DP radiographs and (m) clinical appearance 12 days after
surgery. Source: Courtesy of William Barker, Newmarket Equine Hospital.
of implants and application technique is appropriate, cata- vascularization after surgical treatment of Mc3/Mt3 frac-
strophic implant failure is uncommon. tures [42]. Implant removal is recommended in foals
Healing is assessed clinically and radiographically. after complete healing of the fracture but not earlier than
Serial scintigraphy has been used to evaluate fracture three months after repair. Staged removal is safest, with
(i) (j) (k) (l) (m)
Figure 22.16 Removal of a laterally placed (a) (b)

LCP in a standing sedated Icelandic horse. (a)
Use of an identical plate to aid screw location
(b) Following screw removal the end of the
plate is exposed and grasped with pliers.
the first plate removed after three months and the second screw location (Figure 22.16). Staged removal is manda-
two months later (Chapter 37). tory and generally should not commence earlier than six
Implants are not removed routinely from adult horses months after repair. The second plate is removed four to
unless there are associated problems. If possible, six months later (Figure 22.17). Plate removal under gen-
implants are removed in the standing sedated horse eral anaesthesia with an open approach should be
using local analgesia and a minimal invasive approach. A reserved for cases with exuberant callus formation
plate of similar design and size acts as a useful guide to (Figure 22.18).
(a) (b) (c) (d)
Figure 22.17 Dorsoplantar radiographs of an open, oblique fracture of the mid-diaphysis of Mt3 in an Icelandic horse. (a) At presentation.
(b) Repair with dorsal and lateral LCPs. Implants were removed due to chronic low grade lameness. (c) The dorsal implant was removed
one year after repair and the lateral plate six months later. Lameness resolved after implant removal. (d) 3.5 years after fracture repair.
(a) Figure 22.18 Implant removal in a foal with a chronic

infected Mt3 fracture which required an open approach
because of exuberant callus formation and ingrowth of
bone into empty plate holes. (a) Dorsoplantar radiograph
and (b) appearance at surgery.
(b)
The overall prognosis for survival and soundness after 43]. Age (foals have a better prognosis than adult horses),
double plate repair of complete Mc3/Mt3 fractures has increasing body weight, soft tissue damage and open frac-
been reported as 60–80% from specialist hospitals [33, 41, tures have negative effects on prognosis.
Reference 499
References
1 Auer, J.A. (2000). Metacarpal (−tarsal) shaft. In: AO 14 Hanie, E.A., Sullins, K.E., and White, N.A. (1992).
Principles of Equine Osteosynthesis (eds. G.E. Fackelman, Follow-up of 28 horses with third metacarpal unicortical
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(ed. R. Getty), 665–688. Philadelphia, USA: WB Saunders. fractures of the third metacarpal bone in thoroughbred
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New Jersey, USA: Wiley Blackwell. fractures and fatigue injury of the proximopalmar medial
5 Nunamaker, D.M., Butterweck, D.M., and Provost, M.T. aspect of the third metacarpal bone in 55 horses. Equine
(1989). Some geometric properites of the third metacarpal Vet. J. 44: 64–70.
bone: a comparison between the thoroughbred and 18 Pinchbeck, G.L. and Kriz, N.G. (2001). Two cases of
standardbred racehorse. J. Biomech. 22: 129–134. incomplete longitudinal fracture of the proximopalmar
6 Hug, S. (2009). Epidemiologische Untersuchungen der aspect of the third metacarpal bone. Equine Vet. Edu. 13:
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Schlagverletzungen als Ursache von Frakturen. Doctoral 19 Pleasant, R.S., Baker, G.J., Muhlbauer, M.C. et al. (1992).
Thesis Vetsuisse-Fakultät Zürich: Zurich. Stress reactions and stress fractures of the proximal
7 Couch, S. and Nielsen, B.D. (2017). A review of dorsal palmar aspect of the third metacarpal bone in horses: 58
metacarpal disease (bucked shins) in the flat racing cases (1980-1990). J. Am. Vet. Med. Assoc. 201: 1918–1923.
horse: prevalence, diagnosis, pathogenesis, and 20 Paschke, C.T. and Walliser, U. (2016). Unusual
associated factors. J. Dairy Vet. Anim. Res. 5: 228–236. incomplete frontal plane third metacarpal fracture in a
8 Richardson, D.W. and Ortved, K.F. (2019). Third dressage horse. Pferdeheilkunde 32: 316–322.
metacarpal and metatarsal bones. In: Equine Surgery, 5e 21 Ross, M.W. and Martin, B.B. (1992). Dorsomedial
(eds. J.A. Auer, J.A. Stick, J.A. Kümmerle and J.M. articular fracture of the proximal aspect of the third
Prange), 1618–1635. St Louis: Missouri: Elsevier. metacarpal bone in Standardbred racehorses: seven cases
9 Ross, M.W. (2011). The metatarsal region. In: Lameness in (1978-1990). J. Am. Vet. Med. Assoc. 201: 332–335.
the Horse, 2e (eds. M.W. Ross and S.J. Dyson), 499–508. 22 Cillán-Garcia, E., Reardon, R.J.M., Schiavo, S. et al.
St. Louis, Missouri: Elsevier Saunders. (2018). Standing repair of a proximal, incomplete,
10 Boston, R.C. and Nunamaker, D.M. (2000). Gait and speed articular fracture of the third metatarsal bone. Equine Vet.
as exercise components of risk factors associated with onset Edu. https://doi.org/10.1111/eve.12939.
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thoroughbred racehorses. Am. J. Vet. Res. 61: 602–608. Incomplete oblique sagittal fractures of the dorsal cortex
11 Dallap, B.L., Bramlage, L.R., and Embertson, R.M. (1999). of the third metacarpal bone in six horses. Vet. Surg. 27:
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for treatment of dorsal cortical stress fractures of the 24 Derungs, S.B., Fuerst, A.E., Hässig, M., and Auer, J.A.
third metacarpal bone in 56 thoroughbred racehorses. (2004). Frequency, consequences and clinical outcome of
Equine Vet. J. 31: 252–257. kick injuries in horses: 256 cases (1992–2000). Wien.
12 Sullins, K.E. (1990). Drilling of dorsal metacarpal stress Tierärztl. Monatsschr. 91: 114–119.
fractures: technique in the standing horse. AAEP. 35: 25 Dyson, S. (2007). Diagnosis and management of common
333–339. suspensory lesions in the forelimbs and hindlimbs of
13 Jalim, S.L., McIlwraith, C.W., Goodman, N.L., and sport horses. Clin. Tech. Equine Pract. 6: 179–188.
Anderson, G.A. (2010). Lag screw fixation of dorsal 26 Launois, T., Desbrosse, F., and Perrin, R. (2006).
cortical stress fractures of the third metacarpal bone in Percutaneous osteostixis as treatment of the palmar/
116 racehorses. Equine Vet. J. 42: 586–590. plantar third metacarpal/metatarsal cortex at the origin
of the suspensory ligament in 29 cases. Equine Vet. Educ. horses (1994-2004). J. Am. Vet. Med. Assoc. 230:
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27 O’Sullivan, C.B. and Lumsden, J.M. (2002). Distal third 36 Sod, G.A., Mitchell, C.F., Hubert, J.D. et al. (2008).
metacarpal bone palmar cortical stress fractures in four in vitro biomechanical comparison of locking
thoroughbred racehorses. Equine Vet. Edu. 14: 70–76. compression plate and limited-contact dynamic
28 Ramzan, P.H.L. (2009). Transverse stress fractures of the compression plate fixation of osteotomized equine third
distal diaphysis of the third metacarpus in six metacarpal bones. Vet. Surg. 37: 283–288.
thoroughbred racehorses. Equine Vet. J. 41: 602–605. 37 Levine, D.G. and Richardson, D.W. (2007). Clinical use of
29 Riggs, C.M. (2002). Fractures – a preventable hazard of the locking compression plate (LCP) in horses: a
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30 Wright, I.M. (2020). Racetrack fracture management and 39: 401–406.
emergency care. In: Equine Fracture Repair, 2e (ed. A.J. 38 Yovich, J.V., Turner, A.S., and Smith, F.W. (1985). Holding
Nixon), 44–82. New York: Wiley Blackwell. power of orthopedic screws in equine third metacarpal
31 Donati, B., Furst, A.E., Hassig, M., and Jackson, M.A. and metatarsal bones: part II. Adult Horse Bone. Vet. Surg.
(2018). Epidemiology of fractures: the role of kick injuries 14: 230–234.
in equine fractures. Equine Vet. J. 50: 580–586. 39 Cassotis, N.J., Stick, J.A., and Arnoczky, S.P. (1997). Use
32 Hopper, S.A., Schneider, R.K., Johnson, C.H. et al. (2000). of full cortical allograft to repair a metatarsal fracture in a
in vitro comparison of transfixation and standard foal. J. Am. Vet. Med. Assoc. 211: 1155–1157.
full-limb casts for prevention of displacement of a 40 James, F.M. and Richardson, D.W. (2006). Minimally
mid-diaphyseal third metacarpal osteotomy site in horses. invasive plate fixation of lower limb injury in horses: 32
Am. J. Vet. Res. 61: 1633–1635. cases (1999-2003). Equine Vet. J. 38: 246–251.
33 Bischofberger, A.S., Furst, A., Auer, J., and Lischer, C. 41 Beinlich, C.P. and Bramlage, L.R. (eds.) (2002). Results of
(2009). Surgical management of complete diaphyseal plate fixation of third metacarpal and metatarsal diaphyseal
third metacarpal and metatarsal bone fractures: clinical fractures. Proc. Am. Assoc. Equine Prac. 48: 247–248.
outcome in 10 mature horses and 11 foals. Equine Vet. J. 42 Markel, M.D., Snyder, J.R., Hornof, W.J., and Meagher,
41: 465–473. D.M. (1987). Nuclear scintigraphic evaluation of third
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cast to repair fractures in horses and ponies. Equine Vet. J. J. Am. Vet. Med. Assoc. 191: 75–77.
23: 32–36. 43 McClure, S.R., Watkins, J.P., Glickman, N.W. et al. (1998).
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metacarpal, third metatarsal, and phalangeal fractures in Assoc. 213: 847–850.
501
23
Fractures of the Second and Fourth Metacarpal and Metatarsal Bones

A
natomy to the head and proximal diaphyses. The superficial loca-
tion of the small Mc/Mt bones makes them particularly
The small metacarpal (Mc2 and Mc4) and metatarsal susceptible to external trauma, especially the laterally
(Mt2 and Mt4) bones (splint bones) are considered to be located Mc4 and Mt4.
vestigial; however, they play an important role in intrinsic
limb stability. They are all similar in shape with a larger
proximal end (head), diminishing diameter through the F
racture Types
middle and distal diaphyses and a small distal bulb (‘but-
ton’). Despite these similarities, there are important dif- Fractures can occur anywhere along the length of the bone
ferences in the weight-bearing functions of these bones. and are usually classified by location into distal, mid-body
The medially positioned Mc2 and Mt2 play significant and proximal (Figure 23.1). Distal fractures are most
roles in articulation and stability of the carpometacarpal common and tend to be simple. Mid-body and proximal
and tarsometatarsal joints, respectively. Mc2 articulates fractures are more common in Mc4 and Mt4. These have a
with the second and third carpal bones, while Mt2 articu- tendency to be open and comminuted, and are often
lates with the fused first and second tarsal bones. Mc4 complicated by osteomyelitis, sequestrum formation and if
and Mt4 have smaller articulations with the fourth carpal articular can result in infected arthritis.
bone and fourth tarsal bone, respectively. However, proxi-
mal Mc4 and Mt4 are sites of insertion of several support-
ing ligaments of the carpus and tarsus. The head of Mt4 is Incidence and Causation
also substantially larger than the other splint bones. The
diaphyses are triangular in cross-section and exhibit vary- Distal fractures occur more commonly in older horses (five
ing degrees of axial convexity. The bones are attached to seven years of age) with less common occurrence in
over their proximal two-thirds to the third metacarpal horses less than two years of age. They can be a direct
(Mc3) and metatarsal (Mt3) bones by a dense interosse- result of trauma or due to tension applied by the
ous ligament. These have varying morphology between interosseous and suspensory ligament during exercise.
horses, between limbs and within limbs including zones Distal fractures can also occur secondary to suspensory
of ossification [1]. A separate ligament-like structure ligament desmitis in which the enlarged suspensory branch
extends from the distal end of the bones towards the leads to abaxial displacement of the distal small Mc/Mt
medial and lateral condyles of Mc/Mt3 [1, 2]. In their bone [4, 5]. Mid and proximal fractures generally result
proximal halves, the palmar/plantar metacarpal/metatar- from external trauma and are frequently comminuted and
sal fascia runs between the respective second and fourth open. In Mc/Mt2, this can include interference injuries
splint bones. This encloses all of the palmar/plantar soft from the contralateral foot/shoe although some diaphyseal
tissue structures in the region. Proximally, it merges fractures of Mc2 can also occur in the absence of external
imperceptibly with the palmar carpal and tarsal fasciae. trauma and are likely to be the result of mal-loading,
The latter is thicker than the former [1, 3]. These fascial fatigue or adaptation failure. Proximal fractures particularly
attachments have to be divided in all surgical approaches of Mt4 are often articular.

502 Fractures of the Second and Fourth Metacarpal and Metatarsal Bones
(a) (b) (c)
Figure 23.1 (a) Distal, (b) mid-body and (c) proximal fractures of the small Mc/Mt bones.
Clinical Features and Presentation plantarolateral oblique (DMPLO) and dorsolateral–palmar/

plantaromedial oblique (DLPMO)). Oblique projections
Distal fractures are usually associated with swelling, are usually most informative, and small-angle variations
pain on palpation and mild–moderate lameness in the can assist in fracture assessment. Ultrasonography of the
acute phase. The degree of lameness can also be con- suspensory ligament can provide information on concur-
founded by concurrent suspensory desmitis. With rent pathology, which may affect prognosis. It can also be
chronic fractures, palpation of the limb may be normal. useful in identifying osseous discontinuity and potential
Horses with mid and proximal fractures tend to have communication of fractures with wounds and tracts.
more swelling and pain on palpation. Lameness is gener- Computed tomography (CT) can be useful in complicated
ally greater depending on the severity of the fracture and cases and particularly for surgical planning in mid-body
acuteness of the injury. Wounds frequently accompany and proximal fractures.
acute fractures, while draining tracts are common with
chronic fractures in which osteomyelitis and sequestrum
formation have ensued.
T
reatment
Proximal Fractures
Imaging and Diagnosis As proximal fractures are usually due to external trauma,
they are commonly complicated by comminution and
Radiography should be performed whenever fracture is contamination or infection. The adjacent Mc3 and Mt3
suspected. Radiographs can help differentiate between should also be carefully examined for concurrent fractures
exostoses (‘splints’) and fractures but summation of or fissures [2]. Treatment is determined on an individual
densities of an exostosis can appear very much like a case basis and may include medical management,
fracture. Four views of the affected area should be obtained debridement, internal fixation and, in some Mt4 fractures,
(lateromedial, dorsopalmar/plantar, dorsomedial–palmar/ ostectomy.
Treatmen 503
Medical Management proximal fractures with an intact axial cortex, excision of

Open, proximal fractures can be treated with wound the tract with curettage and lavage of the infected bone is
debridement and if articular with lavage of the usually sufficient. A Penrose drain exited distal to the site is
carpometacarpal or tarsometatarsal joint [6, 7]. Additional often used when a large dead space results.
management should include systemic antimicrobial and When infected fractures involve the entire thickness of
anti-inflammatory therapy. Local antimicrobial therapy via the bone, restoring the integrity of the proximal portion of
intravenous regional limb perfusion can also be the bone, especially Mc2/Mt2, is desirable but internal fixa-
advantageous and may be administered for several days tion with metal implants can clearly be problematic. In this
following injury. The horse should be maintained in a situation en bloc excision of the infected bone with autolo-
compressive bandage and on box rest with follow-up gous cancellous bone grafting of the gap is a useful tech-
radiographs obtained at regular intervals to monitor nique (Figures 23.2 and 23.3). The horse is placed in lateral
healing. If the wound heals, drainage does not recur recumbency, preferably with an Esmarch bandage and
following discontinuation of antimicrobials, the fracture tourniquet in place. An incision is made directly over the
shows radiographic signs of healing and the horse remains fracture. If needed, this can be fusiform to excise a draining
sound, then further treatment is rarely indicated. The horse tract. Using an osteotome and mallet or an oscillating saw,
should be maintained on box rest for at least six to eight the infected segment of bone is removed en bloc leaving
weeks followed by one month of hand walking. In one transverse healthy bone ends. The abaxial edge of the sus-
series, medical management of open proximal fractures pensory ligament is then directly visible in the depth of the
resulted in return to soundness in 12/14 horses [6]. Another incision. A collagen sponge is positioned on the axial side
multicentre study found that medical management of open of the bony gap, and autologous cancellous bone is placed
Mt4 fractures produced similar outcomes to surgical to anatomically ‘fill’ the gap. The collagen sponge helps
management and was associated with less morbidity [7]. It prevent extrusion of the graft into the axial soft tissues.
is presumed that successful conservative management of Intra-operative imaging should be considered to ensure
even comminuted proximal fractures of Mt4 results from that no loose/unstable fragments are missed. The incision
the inherent stability afforded by the substantial soft tissue is closed routinely, and pressure bandages maintained for
attachments. not less than two weeks. Bandaging is important to
minimize swelling and more extensive fibrosis at the site.
Surgical Debridement Post-operative management includes administration of
Sequestrum formation can occur in open proximal and systemic and/or local antimicrobials as needed.
mid-body fractures. In this situation, removal of sequestra Following uncomplicated fragment removal, horses can
and surgical debridement of infected bone are indicated. In be back in light work in as little as four to six weeks if the
(a) (b) (c) (d) (e)
Figure 23.2 En bloc excision of infected bone in a horse with a fracture of Mt2. DMPLO radiographs (a) demonstrating sequestrum/
involucrum formation. (b–e) Immediately, two months, three months and five years post-operatively showing excellent long-term
healing.
(a) (b)
(c) (d)
(e) (f)
Figure 23.3 Surgical treatment of the fracture depicted in Figure 2. (a) An Esmarch bandage/tourniquet exsanguinates the surgical
field and provides good visibility. The wide rubber bandage is secured above the tarsus/carpus and ‘unspiralled’ from the foot upwards.
(b) En bloc excision of the entire segment of infected and devitalized bone including the draining tract. (c) Following removal, the soft
tissues on the axial side of the bone are clearly visible. (d) A rectangular piece of collagen foam is placed on the axial side of the
osseous defect between the bone, suspensory ligament and flexor tendons. (e) The sponge can be soaked with an antimicrobial
solution (usually amikacin). (f) Freshly harvested autologous cancellous bone is loosely packed in the bone gap.
Internal Fixation
adjacent suspensory branch is unaffected. More complex Internal fixation should be recommended for unstable
injuries, particularly those undergoing grafting, may proximal fractures in adult horses. Younger animals, par-
require three to six months. ticularly foals, can heal and remodel remarkably well
Treatmen 505
(a) (b) this repair because it is easy to contour, allows an angled

lag screw through the plate and, very importantly, is thin
enough to cover easily with the limited soft tissue available
in this location. It is possible, but rarely necessary, to use
more expensive small locking plates. However, they are
nearly always used in larger horse with more complex frac-
tures. It is preferable to reconstruct the fractured splint
bone without placing screws into Mc/Mt3. Plates with
screws engaging the Mc/Mt3 frequently need to be removed
if the horse is returning to athletic activity (Figure 23.5).
For all repairs, the horse is placed in lateral recumbency
with the affected bone uppermost. For proximal fractures,
a curved skin incision is helpful to allow implant place-
ment on the palmar/plantar surface of the bone, but the
distal part of the incision should be made along the abaxial
margin of the bone. Proximal dense collateral ligament
attachments should be elevated enough to allow plate posi-
Figure 23.4 Radiographs of a displaced Mt4 fracture in a foal.
tioning but not transected. Occasionally, comminuted
(a) At presentation and (b) eight months following conservative proximal fragments are amenable to reconstruction with
management including stall rest followed by a gradual return to 3.5 mm screw(s) before applying the plate (Figure 23.6).
normal pasture turnout. The plate is contoured and placed appropriately to ensure
that it does not extend proximally to interfere with the
(Figure 23.4). Open fractures can be treated medically to adjacent joint or carpal/tarsal bones. If the fracture is
resolve infection prior to implant placement. The goals of oblique and allows it, 3.5 mm cortex screws in lag fashion
internal fixation are to (i) anatomically reconstruct articu- should be used for reduction and stabilization. The small
lar and peri-articular fractures, especially those involving size of the proximal fragment demands accurate place-
proximal Mc2, (ii) restore axial stability, (iii) minimize exu- ment, and it is easier to exactly position the lag screw and
berant callus formation and (iv) afford a consistent time then position and contour the plate so that the screw can be
frame for healing. Plate fixation can also help fuse an placed through the plate (Figure 23.7). Because of the col-
unstable splint bone to the cannon bone following fracture lateral ligament attachments, a plate on the proximal splint
or exostosis excision that involved removal of a large por- bone acts as a tension band so it is possible to use only a few
tion of the distal bone. screws through the plate on the distal side of the fracture.
Luxation or subluxation of the proximal fragment can Intra-operative imaging is essential for accurate plate posi-
occur when substantial distal portions of the bones are tioning and to assess screw length, especially if the goal is
removed. Although removal of up to two-thirds of splint to keep all screws within the splint bone.
bones has been advocated, our experience is that removal The incision is closed routinely, and a compression band-
of the distal two-thirds of all but Mt4 can lead to instability. age applied. Horses are recovered from general anaesthesia
This can result in abaxial displacement of the proximal routinely and maintained on box rest for six to eight weeks
fragment or excessive callus formation. Lag screw fixation with hand walking for an additional one month. Following
alone has been described in which cortical bone screws are three months of rest, horses can be turned out in a small
applied in lag fashion from the small Mc/Mt bone to Mc/ paddock for one month before returning to work. Implants
Mt3. This is biomechanically illogical and is not recom- that engage the cannon bone may need to be removed.
mended. Lag screw fixation has been associated with Plates placed with the intention of fusing the mid-portion
implant failure, excessive callus formation and persistent of the splint to the cannon bone can often be left in place.
lameness [8, 9], although recently successful use of tapered The prognosis following plate fixation of closed fractures is
absorbable (polylactic acid) screws has been reported [10]. excellent. The prognosis following plate fixation of open
Plate fixation is superior. Appropriate implants include fractures also appears to be good but can be complicated by
3.5 mm locking compression plates (LCPs) or limited implant infection and exuberant callus formation [6].
contact-dynamic compression plates (LC-DCPs), semitu-
bular plates and 3.5 mm reconstruction plates. In the Ostectomy of Mt4
authors’ opinions, the thinner plates are suitable for most Complete removal of Mt4 can be successful, but is chal-
simple fractures. A 3.5 mm reconstruction plate is ideal for lenging with significant risk of complications. The horse is
(a) (c) (d)
(b)
Figure 23.5 Comminuted, proximal Mc4 fracture. (a) DLPMO radiograph at presentation. (b) Transverse CT images of the proximal
metacarpus demonstrating the severity of comminution. (c) DLPMO and DP radiographs obtained immediately post-operatively. The
fracture was repaired with a 3.5 mm reconstruction plate and 3.5 mm cortex screws. The palmarolateral cortex of MC3 was engaged
due to the highly comminuted nature of the fracture. (d) DLPMO radiographs obtained four months post-operatively before and after
removal of the plate.
placed in lateral recumbency with the affected limb up. closed in two layers. Recovery from anaesthesia should be
Some surgeons use an Esmarch bandage and tourniquet assisted or a full-limb cast should be placed due to the risk
placed proximal to the tarsus for haemostasis. This of luxation of the tarsometatarsal joint [2]. Removal of Mt4
improves visibility and reduces surgical time. An incision for treatment of proximal fractures resulted in 5/8 horses
is made over the lateral aspect of the entire bone. The distal returning to working soundness, while 2/8 horses were
end of the bone is isolated and elevated with a towel clamp pasture sound [11].
or tissue forceps. The soft tissue attachments are dissected
using scissors or a #15 scalpel blade freeing the bone from
Mid-Diaphyseal Fractures
distal to proximal. Care is taken to avoid the dorsal meta-
tarsal artery located between Mt4 and Mt3. In the proximal Medical Management
half of the metatarsus, this is on the dorsal side of the Mt4. Conservative management can be successful in many mid-
It is most iatrogenically vulnerable just distal to this as it body fractures. Fractures near the middle of the bone tend to
passes through the interosseous space to lie plantar to the be stable enough that a bridging callus forms relatively reliably.
Mt4. Sharp transection of the insertion of the long collat- Indications for surgical treatment include exuberant callus for-
eral ligament, long plantar ligament and tarsometatarsal mation due to instability at the fracture site and sequestrum
joint capsule are necessary to release the proximal end of development which is more likely in open injuries. Closed
the bone. The surgical site is lavaged, and the incision fractures can generally be treated with anti-inflammatories,
Treatmen 507
(a) (b)
(a)
(c) (d)
(c)
Figure 23.6 Repair of a proximal Mt4 fracture. (a) LM radiograph revealing a comminuted but minimally displaced fracture.
(b) Surgical exposure. (c) Repair with a lateromedial 3.5 mm lag screw and plantar 3.5 mm LCP. (d) DLPMO radiograph illustrating
repair, stable fixation and early healing.
bandaging and stall rest. Conservative management for open s egment is removed using scissors or a #15 scalpel blade to
fractures is as described above for proximal fractures. dissect soft tissue, principally interosseous ligament,
attachments. The incision is then closed routinely. Partial
Surgical Management ostectomy of the entire bone distal to the fracture is a more
Segmental ostectomy of the fractured bone can be per- invasive alternative. In a series of 17 horses treated with
formed with the horse in lateral recumbency. An incision is segmental ostectomy, all horses returned to normal activity
made directly over the affected portion of the bone. An within eight weeks of surgery [12]. There were no post-
osteotome or oscillating saw is used to obliquely transect operative complications, and cosmesis was considered
the bone proximal and distal to the fracture. The affected good in all cases.
(a) (b)
(c) (e)
(d)
Figure 23.7 Repair of a proximal Mc2 fracture. (a) DMPLO radiograph revealing a displaced simple, oblique fracture. (b) Intra-
operative image; the fracture (arrow) has been reduced with pointed forceps. (c) The hole for the interfragmentary lag screw is drilled
prior to application of the plate. (d) The plate is contoured and applied to Mc2. (e) Post-operative DMPLO radiographs showing
anatomic reduction and repair of the fracture with a 3.5 mm LC-DCP.
Treatmen 509
(a) (b) (c)
(d) (e)
Figure 23.8 Removal of a distal fracture of Mc4. (a) DLPMO radiograph of the fracture. (b) After sectioning the distal ligament, the
bone is elevated to facilitate cutting the interosseous ligament on the axial side of the bone. The dissection continues proximal to the
fracture site or callus. (c) An osteotome is used to obliquely cut the bone approximately 1 cm proximal to the fracture site. (d) A narrow
Penrose drain can be inserted if there is excessive dead space. (e) The skin is apposed over the Penrose drain which exits from a
separate distal skin incision.
they can be easily cut. Further elevation of the distal frag-

Distal Fractures ment allows interosseous connections on the axial side of
Removal of displaced distal fragments is generally recom- the bone to be cut with scissors or an osteotome. Finally, the
mended as these rarely heal (Figure 23.8). However, con- dissection is carried up through and above the callus at the
servative treatment can be considered as non-union fracture site. An osteotome can be used to cut the healthy
fractures often become quiescent and may not cause long- splint bone obliquely approximately one centimetre proxi-
term lameness, especially in horses doing less intensive mal to the callus. If removal results in a large dead space, a
work. Removal of the distal fragment can be performed narrow Penrose drain can be used in conjunction with nor-
with the horse under general anaesthesia or standing using mal pressure bandaging. Otherwise, the incision is closed
local anaesthesia and sedation. Using the former, the horse routinely in two layers and a compression bandage is
is placed in lateral recumbency with the fracture positioned applied. Peri-operative antimicrobials are administered for
up. A skin incision is made from just proximal to the 24 hours, and horses are given anti-inflammatories for three
fracture/callus to a point slightly distal to the bulbous tip of to five days to limit swelling and pain. Horses are main-
the bone. The incision should be in one plane and directly tained on box rest for two weeks to allow incisional healing.
onto the bone. This makes it easy to accurately elevate the Hand walking is performed for an additional four weeks
soft tissues dorsally and palmarly/plantarly with an oste- before returning to exercise. Concurrent pathology should
otome or sharp periosteal elevator. When operating on Mt4, be taken into consideration when designing a rehabilitation
care is taken to avoid the dorsal metatarsal artery which at programme. The prognosis is generally excellent, but it will
this level is axial (medial) to Mt4. The button of the splint be significantly affected by concurrent disease including
bone is grasped and elevated with Allis forceps or a towel suspensory desmitis, sesamoiditis and/or metacarpo/meta-
clamp. This tenses the distal ligamentous structures so that tarsophalangeal osteoarthritis [13].
R
eferences
1 Jackson, M., Geyer, H., and Fürst, A. (2005). Anatomy of comminuted fractures of the fourth metatarsal bone in
the splint bones and their surrounding area particularly in horses. Equine Vet. Educ. 20: 373–379.
consideration of fascial attachments. Schweiz. Arch. 8 Peterson, P.R., Pascoe, J.R., and Wheat, J.D. Surgical
Tierheilkd. 147: 473–481. management of proximal splint bone fractures in the horse.
2 Jackson, M. and Auer, J. (2019). Vestigial metacarpal Vet. Surg. 16: 367–372.
and metatarsal bones. In: Equine Surgery, 5e 9 Harrison, L., May, S., and Edwards, G. (1991). Surgical
(eds. J. Auer, J. Stick, J. Kümmerle treatment of open splint bone fractures in 26 horses. Vet.
and T. Prange), 1636–1647. St Louis, Rec. 128: 606–610.
Missouri: Elsevier. 10 Mageed, M., Steinberg, T., Drumm, N. et al. (2018).
3 Lischer, C.J. (2008). Fractures of the splint bones: the Internal fixation of proximal fractures of the 2nd and 4th
importance of soft tissue attachments. Equine Vet. Educ. metacarpal and metatarsal bones using bioabsorbable
20: 380–382. screws. Aust. Vet. J. 96: 76–81.
4 Jones, R.D. and Fessler, J.F. (1977). Observations on small 11 Baxter, G.M., Doran, R.E., and Allen, D. (1992). Complete
metacarpal and metatarsal fractures with or without excision of a fractured fourth metatarsal bone in eight
associated suspensory desmitis in Standardbred horses. horses. Vet. Surg. 21: 273–278.
Can Vet J. 18: 29–32. 12 Jenson, P.W., Gaughan, E.M., Lillich, J.D., and Bryant,
5 Verschooten, F., Gasthuys, F., and Moor, A. (1984). J.E. (2004). Segmental ostectomy of the second and
Distal splint bone fractures in the horse: an fourth metacarpal and metatarsal bones in horses:
experimental and clinical study. Equine Vet. J. 16: 17 cases (1993-2002). J. Am. Vet. Med. Assoc. 224:
532–536. 271–274.
6 Jackson, M., Fürst, A., Hässig, M., and Auer, J. (2007). 13 Bowman, K.F., Evans, L.H., and Herring, M.E. (1982).
Splint bone fractures in the horse: a retrospective study Evaluation of surgical removal of fractured distal splint
1992–2001. Equine Vet. Educ. 19: 329–335. bones in the horse. Vet. Surg. 11: 116–120.
7 Sherlock, C. and Archer, R. (2008). A retrospective study
comparing conservative and surgical treatments of open
511
24
Fractures of the Carpus

C.W. McIlwraith
Colorado State University, Fort Collings, CO, USA
A
natomy The second carpal bone is described as an irregular
hemisphere [1]. Its proximal articular surface is convex
The equine carpus contains seven consistent and two with a long palmar extension for articulation with the
inconsistent cuboidal bones arranged in proximal and radial carpal bone. The distal articulation with the second
distal rows. The former contains from medial to lateral, metacarpal bone is flat but obliquely oriented. Axially,
radial, intermediate and ulnar carpal bones that articulate there is a smaller facet for articulation with the third meta-
with the distal radius. The accessory carpal bone is situated carpal bone. The third carpal bone which dominates the
palmar to and articulates with the ulnar carpal bone and distal row has a rounded triangular shape with the base
radius. Second, third and fourth carpal bones are consistent dorsally. The dorsal surface is irregularly convex produced
in the distal row. A first carpal bone of varying sizes and by a broad transverse ridge that increases from lateral to
shapes is sometimes present palmar to the second; fifth medial. The proximal articular surface has a shallow broad
carpal bones are rare. concavity for articulation with the radial carpal bone and
The radial carpal bone is described as hexagonal [1]. immediately palmar to this is a fossa for insertion of the
Both proximal and distal articular surfaces have convex medial palmar intercarpal ligaments. The articular surface
dorsal and concave palmar contours for articulation with for the intermediate carpal bone is delineated from the
the radius and both second and third carpal bones, radial facet dorsally by a shallow dorsopalmar-orientated
respectively. Proximal and distal axial facets articulate with ridge. This is concave dorsally and becomes convex in its
the intermediate carpal bone. The intermediate carpal palmar half over the body of the bone. Additional abaxial
bone is wider dorsally than palmarly. It has a saddle-shaped facets are present for the second and fourth carpal bones.
proximal articular surface. Distally, the articular surface is The distal articular surface undulates slightly but is rela-
also convex dorsally and concave palmarly. It articulates tively flat for articulation with the proximal third metacar-
with both third and fourth carpal bones. Abaxial facets pal bone. The fourth carpal bone is irregularly shaped with
articulate with the ulnar carpal bone. The ulnar carpal a convex proximal surface for articulation with ulnar and
bone is irregularly shaped. Its proximal articular surface is intermediate carpal bones. Distally, it articulates with the
concave and on its palmar side is an obliquely orientated second and third metacarpal bones. A palmar protuber-
articular surface for the accessory carpal bone. The distal ance is considered to be the phylogenetic remnant of the
articular surface has an undulating articulation with the fifth carpal bone.
fourth carpal bone. Proximal concave and distal flatter The carpal bones are interconnected by a complex of
articular surfaces on the accessory carpal bone correspond extra-articular, peri-articular and intra-articular liga-
with surfaces of the radius and ulnar carpal bones. The ments [2]. These do not appear to be of pathogenetic sig-
bone is strongly curved dorsal to palmar creating convex nificance but can be involved in repair and/or removal of
lateral and concave medial surfaces. A substantial portion individual fractures. The motion and biomechanics of the
of the latter forms part of the lateral wall of the carpal carpal joints are complicated [3‑5]. Differential movement
canal. An oblique groove is present dorsally in the lateral of the proximal row in flexion and extension has implica-
surface of the bone which contains the long tendon of tions for arthroscopic procedures. The absence of move-
insertion of ulnaris lateralis. ment in the carpometacarpal joint provides an important

512 Fractures of the Carpus
point of surgical orientation in repairing third carpal bone Table 24.1 Location of carpal chip fractures in 591 racehorses
fractures. (principally TB and QH).
Various factors may lead to non-physiologic loading of
Midcarpal (intercarpal) (540) joints
the carpal bones, including fatigue, conformation, shoeing
and racing surfaces. Abnormal loading can lead to Distal radial carpal bone 475
synovitis, capsulitis and articular damage, osteochondral Distal intermediate carpal bone 106
fragmentation, slab fractures of an individual carpal bone Proximal third carpal bone 60
or collapsing comminuted fractures of the carpal bones, Total 641
which can in turn cause instability of the carpus. Horses Antebrachiocarpal (radiocarpal) (460) joints
that sustain osteochondral chip fractures or simple slab Proximal intermediate carpal bone 273
fractures are commonly treated with arthroscopic surgery
Proximal radial carpal bone 168
and return to full athletic soundness. Injuries that cause
Distal lateral radius 167
destabilization are also indications for surgery, but the aim
is to restore axial weight-bearing ability and salvage the Distal medial radius 96
animal for breeding rather than athletic activity [3]. Proximal ulnar carpal bone 1
Total 705
Source: Adapted from McIlwraith et al. [6].

steochondral Chip Fractures
O
(Fragments) of the Dorsal Articular
latter and the proximal third carpal bone more frequently
Margins in the former.
These data [6] do not support earlier statements that chip
fractures are breed-related with TB being more prone than
Osteochondral chip fractures of the equine carpus are QH [9]. Carpal chip fractures are very common in racing
common in racehorses. In a series published by the author, QH [6]. Further, our data contrasts with a study from New
580 of 591 (98%) horses were racehorses (349 Quarter Zealand in which the third carpal bone was reported as the
Horses [QH], 220 Thoroughbreds [TB], 5 Appaloosas and 6 most common site in TB [10], but that study was only in 57
Standardbreds [SB]) [6]. SB are rare in the author’s surgical horses. Previous studies reported that antebrachiocarpal
referral practice, so this is not a true reflection of the overall joint fractures were three times more common on the left
incidence of osteochondral fragmentation in these horses than the right, whereas fractures involving the middle car-
which has been documented in two series [5, 7]. The most pal joint were seen twice as frequently in the right limb [5].
notable difference between SB and other racehorses is that This has been related to stresses induced with anticlockwise
while they are predisposed to fragmentation of the distal racing. Although there were more fractures in the right
portion of the radial carpal bone and proximal portion of middle carpal joint than the left in the author’s study, there
the third carpal bone, they rarely develop fragments in the was no difference in fracture frequency between antebra-
antebrachiocarpal joint [5, 7]. The specific locations of chiocarpal joints in either breed [6]. This is interesting
osteochondral fragments are depicted in Tables 24.1 when it is considered that most QH do not race through a
and 24.2 [6]. As previously reported [5, 8, 9], the most turn. It is suspected that the protocol of radiographing both
common location for fragmentation was the distal radial carpal joints and arthroscopy of suspicious lesions could
carpal bone. This was followed by the proximal intermediate nullify left versus right differences.
carpal bone, proximal radial carpal bone and distal lateral A recent report documented the frequency distribution of
aspect of the radius. Fractures were equally distributed osteochondral fragments in the carpi of racing TB in the UK
between the left and right joints of QH, but significantly and compared these to studies in the USA, Australia, New
were more frequent in the right carpus of TB. Previous Zealand and Japan [11]. A total of 229 sites of fragmenta-
reports describe an increased incidence of fractures in the tion were identified arthroscopically in 174 horses. This
right forelimb in TB [8, 9]. There were significantly more involved 135 (75%) middle carpal and 44 (25%) antebrachio-
fractures in the right middle carpal joint compared with carpal joints. Most common sites of fragmentation were
the left middle carpal joint, but no significant difference dorsodistal radial carpal bone (49%), dorsoproximal third
between the left and right antebrachiocarpal joints. carpal bone (22%), dorsodistal radius (15%), dorsoproximal
Significant differences exist between TB and QH in the radial carpal bone (5%) and dorsoproximal intermediate
relative frequency of fracture location; the proximal intercarpal bone (4%). Comparisons with pooled data from other
mediate carpal bone was fractured more frequently in the studies indicated that TB in the UK are more likely to have
Osteochondral Chip Fractures (Fragments) of the Dorsal Articular Margin 513
Table 24.2 Specific location of carpal chip fractures in racing TB and racing QH.
Thoroughbreds Quarter Horses
Left Right Left Right

Midcarpal
Distal radial carpal bone 64 (34.4%) 85 (36.3%) 136 (32.7%) 158 (37.3%)
Distal inter-mediate carpal bone 15 (8.1%) 14 (6.0%) 29 (7.0%) 36 (8.4%)
Proximal third carpal bone 10 (5.4%) 22 (9.4%) 8 (1.9%) 19 (4.5%)
Subtotal 89 121 173 213
Antebrachiocarpal
Distolateral radius 30 (16.1%) 35 (15.0%) 53 (12.7%) 37 (8.7%)
Distomedial radius 17 (9.1%) 21 (9.0%) 32 (7.7%) 26 (6.1%)
Proximal intermediate carpal bone 30 (16.1%) 36 (15.4%) 97 (23.3%) 100 (23.6%)
Proximal radial carpal bone 20 (10.7%) 21 (8.9%) 60 (14.4%) 48 (11.3%)
Proximal ulnar carpal bone 0 (0.0%) 0 (0.0%) 1 (0.2%) 0 (0.0%)
Subtotal 97 113 243 211
Total 186 234 416 424
Source: Adapted from McIlwraith et al. [6].
fragmentation in the middle carpal than antebrachiocarpal osteoarthritis (OA) [13]. It has been proposed that chip
joints, specifically from the dorsodistal radial carpal bone fractures of the joint margin arise from at least two differ-
and dorsoproximal third carpal bone compared with TB ent processes: (i) fragmentation of the original tissue of the
and QH in the United States. There was also no evidence of joint margin which starts as progressive subchondral bone
sidedness. There were similar sites of distribution of carpal damage induced by repetitive trauma of training and
fragmentation in the UK and Australian racing TB. The sin- racing, leading to compromise of articular cartilage because
gle most common site of fragmentation in Japanese TB was of non-compliant subchondral bone before eventually the
the dorsodistal radius [12] which differed from racing TB sclerotic bone undergoes ischemic necrosis; (ii) arise
everywhere else in the world. within the base of developing periarticular osteophytes [13].
More recently, research has recognized that pathologic
Clinical Signs changes that precede fragmentation are not simply those of
subchondral bone sclerosis. Studies on horses receiving
Affected horses present with synovial effusion and varying fast treadmill exercise have demonstrated microdamage in
degrees of lameness. Fragmentation of the intermediate subchondral bone [14]. In addition, post-mortem
facet of the radius can extend into the attachments of the examination of racehorse joints (euthanized for
fibrous joint capsule which in the acute phase results in pit- catastrophic injury in another limb) has demonstrated the
ting swelling dorsolaterally between extensor carpi radialis range of microdamage to include not only microfracture,
and common digital extensor tendon sheaths. Occasionally but also primary osteocyte death [15]. Not only is the
back in the knee conformation will be noted. In cases of mechanical support of overlying cartilage lost when
osteochondral fragmentation with minimal associated subchondral microdamage progresses to macrodamage,
damage, the main clinical sign is that the horse jogs with a but cytokine release from the bone also has the potential to
wide based stance. Bilateral fragments are common, par- influence the state of the articular cartilage [16].
ticularly in the QH. Deficiencies have been noted in the Other possible early events leading to microdamage in
radiographic demonstration of some fragments and the exercising horses have been assessed by comparing mineral
amount of associated cartilage damage (Figure 24.1) [6]. components and post-translational modifications of the
collagenous matrix alongside changes in biomarkers of
collagen remodelling and bone formation in radial and
Pathogenesis
third carpal bones from raced and non-raced TB [17].
It has been suggested that chip fractures are generally a Horses that had raced had a net increase in bone formation,
secondary complication affecting joint margins altered by bone collagen synthesis and remodelling, particularly
(b)
Figure 24.1 Radiographic appearance (a)
(a) and arthroscopic appearance before (b) and
after (c) removal of distal radial carpal bone
fragmentation that is barely discernible on
pre-operative radiographs (arrow).
Diagnostic arthroscopy was performed
because of return of lameness referable to
the middle carpal joint after the horse went
back into training following lag screw
fixation of a sagittal fracture of the third
carpal bone. The case was referred for
screw removal (not usually done), but the
(c)
new fragmentation was the real indication
for arthroscopic surgery.
(a) (b) (c)
Figure 24.2 (a) Arthroscopic view of distal radial carpal bone fragmentation prior to removal. (b) Fragment removal revealed
diseased subchondral bone. (c) Debridement to organized healthy bone.
within the trabecular regions of the bone. Increase in bone arthroscopically and it certainly exists at a microscopic
density would lead to greater stiffness, particularly of sub- level [18].
chondral bone. Concurrent lack of support from the rap- Fatigue of supporting soft tissues causing hyperexten-
idly remodelling and structurally weakened underlying sion, extreme speed, poor racing surfaces, faulty conforma-
trabecular bone may then lead to failure of the stiffer sub- tion, improper hoof trimming and shoeing, have all been
chondral compacta. cited as contributing to the development of abnormal com-
It is now generally accepted that microdamage leads to pression on the dorsal surface of the carpal bones. in vitro
clinical osteochondral fragmentation and observations at kinematic studies have suggested that the radial carpal
arthroscopic surgery confirm the presence of subchondral bone moves as an independent unit and that a concentra-
bone disease associated with and often appearing to have tion of kinetic energy along the distal and medial aspect of
preceded fragmentation (Figure 24.2). The author now pre- the carpus during weight-bearing predisposes the region to
fers using the term ‘fragment’ rather than ‘fracture’ for the injury [5, 7]. It has also been suggested that the articulations
osteochondral pieces that are created; they are truly patho- of most carpal bones allow some axial load to be transmit-
logic fractures. In some instances, the lesion appears as a ted to intercarpal ligaments [4]. It was hypothesized that the
‘fresh’ fracture line through an articular surface with no hinge nature of the middle carpal joint prohibits hyperex-
visible subchondral change; in most instances, it is seen tension, and therefore chronic supraphysiological loads are
incriminated in injuries to this joint. On the other hand, osteochondral fragments from either carpal joint involves
acute supraphysiological loads are more likely to injure the triangulation techniques using two portals that remain
antebrachiocarpal joint due to its susceptibility to hyperex- consistent for all fracture locations. A lateral arthroscopic
tension as a rotating joint [4]. As an extension of these theo- portal is made between the extensor carpi radialis and
ries, it was suggested that if palmar soft tissues aid in common digital extensor tendons and their associated
counteracting hyperextension that jogging several miles a sheaths. A medial portal is made approximately 5 mm
day could protect the antebrachiocarpal joint of medial to extensor carpi radialis. These portals are also
Standardbreds from fragmentation [7]. made halfway between the articular surfaces of the bones.
The ability of chronic carpal fragmentation to result in Skin incisions are made in the appropriate location prior to
progressive OA is not just mechanically based. Both distension of the joint to avoid any compromise to the
synovitis and diseased cartilage and bone release cytokines extensor tendon sheaths. Generally, for a fragment on the
and other inflammatory mediators that can cause medial side of the joint, the arthroscope passes through the
progression of the disease. This has mainly been a clinical lateral portal and the instruments enter through a medial
observation, but more recently recognition of elevated portal. For lesions on the lateral side of the joint, the arthro-
interleukin-6 levels [19] in synovial fluid of horses with scope is generally placed through a medial portal and the
osteochondral fragments reflects an upregulation of the instrument is positioned through a lateral portal. The posi-
interleukin-1 cascade that has been demonstrated to tion of the arthroscope and instrument relative to the
promote OA in the horse [20]. appropriate lesion is illustrated in Figure 24.3, using the
distal radial carpal bone as an example.
A diagnostic arthroscopic examination is always per-
Treatment
formed first. An egress cannula is placed through the
Arthroscopic removal of osteochondral fragments is instrument portal and then opened to allow flushing of the
indicated to relieve clinical signs and to prevent or limit joint if visualization is less than optimal. After the view is
further development of OA. Fragments cause pain by cleared, the egress cannula is closed. The initial diagnostic
tugging on synovial membrane attachments, induction of examination is carried out with closed distention (care is
synovitis from release of debris and inflammatory needed to maintain the ingress fluid pressure at a relatively
mediators and by damaging opposing articular surfaces. low level as there is no free flow from the instrument portal
These factors contribute to a cycle of OA which can become at this stage). A complete examination of each joint can be
self-perpetuating if surgical intervention is not timely, made through a single arthroscopic portal; however, the
although it is recognized that fragmentation of the distal
radial carpal bone produces secondary OA quickly, whereas
fragments in the antebrachiocarpal joint are more forgiving.
Inevitably, other factors enter into case selection for surgery
including economics and the athletic ability of the horse.
The ideal surgical candidate is a proven racehorse that has
recently sustained an osteochondral fragment.
Unfortunately, ‘the economics of the industry’ preclude
some horses being operated. The judicious use of intra-
articular short-acting corticosteroids can be defended on a
one or two time basis if this involves either triamcinolone
acetonide (Vetalog™) [21] or betamethasone esters
(Celestone™) [22]. However, repeated injection of
corticosteroids and long-term continued racing without
surgical intervention is difficult to defend. Use of
6-alpha-methylprednisolone acetate (Depo-Medrol™) in
carpal joints with fragmentation can no longer be
defended [23].
Figure 24.3 Diagram illustrating the arthroscopic approach to

Surgery remove a fragment from the distal aspect of the radial carpal
bone. The arthroscope is placed through the lateral portal with
Techniques for arthroscopic removal of fragments have the lens angled proximad and instruments are brought through
been described in detail in a specialist text [24]. Removal of the medial portal. Source: McIlwraith et al. [24].
(a) (b)
(c)
Figure 24.4 Osteochondral fragment from the proximal intermediate carpal bone. (a) Pre-operative radiograph. (b, c) Arthroscopic
views of direct removal (with Ferris–Smith rongeurs) (b) and after debridement (c).
arthroscope may be exchanged to the opposite portal if 4) Fragments with a proliferative bony response and exten-
lesions are being treated on both sides of a joint. Evaluation sive osseous reattachment. The osseous proliferative
should include palpation of fragments and other areas of response usually consists of osteophytosis and in many
concern using an arthroscopic probe. instances this can be removed [24]. If these cases have
Fragments can be divided into four categories and the progressed to the point that there is extensive loss of
techniques used for their removal vary accordingly. articular cartilage, the prognosis is poor and the bene-
fits of surgery are questionable. That said, there is a dif-
1) Recent fragments that are mobile on palpation. The frag-
ference between such changes in the middle carpal joint
ment is grasped with appropriately sized arthroscopic
compared to the antebrachiocarpal joint. In the former,
(Ferris–Smith) rongeurs, if necessary these are rotated to
these are most commonly secondary to chronic distal
free soft tissue attachments, and the fragment is removed.
radial carpal bone fragmentation (Figure 24.7) and the
Nearly all proximal intermediate carpal bone fragments
prognosis for continued racing is poor. The antebrachio-
are removed in this fashion as prior elevation can easily
carpal joint is much more forgiving, and chronic frag-
lead to them becoming loose bodies (Figure 24.4).
mentation and spurring can be present without
2) Fragments with synovial membrane and fibrous capsu-
significant articular cartilage loss. Osteophytes can be
lar attachments preventing displacement with initial
removed with Ferris–Smith rongeurs (if the bone is rel-
probing. A periosteal elevator is used to dislodge the
atively soft), but in other instances a motorized burr is
fragment from the parent bone (Figure 24.5) ideally
more appropriate. These cases should be a small part of
without being completely separated as it then becomes
an arthroscopic surgeon’s caseload.
a loose body and is more difficult to retrieve.
3) Longstanding fragments with early bony reattachment.
These are uncommon, but in most the bone is soft and Once the fragment is removed, the defect is debrided
the fragments are still removed with Ferris–Smith ron- (Figures 24.4–24.6). Undermined cartilage or flakes of carti-
geurs. If it is not possible to separate the fragment, an lage at the edge of the lesion are removed using arthroscopic
elevator or 4 mm osteotome can be placed at the junc- curettes and rongeurs. Soft defective bone in the base of the
tion of fragment and parent bone and orientated along defect is common and is also removed. Kissing lesions are
the cleavage plane while assistant taps this with a mal- evaluated and only debrided if there is separated or defective
let. Routine removal follows (Figure 24.6). articular cartilage and bone. Debridement of articular
(a) (b) (c)
Figure 24.5 Arthroscopic views of a displaced fragment of distal lateral radius. (a) Prior to elevation. (b) During elevation of the main
fragment. (c) Fracture bed following fragment removal and debridement.
(a) (b) (c)
Figure 24.6 Arthroscopic views of a chronic distal lateral radius fragment. (a) Prior to elevation. (b) Tapping an elevator with a mallet
to separate the fragment. (c) Following removal of fragmentation and debridement of the defect.
defects is based on current knowledge of articular cartilage trophy are removed for visualization rather than therapeutic
healing [18, 25]. While there is no healing of a partial thick- reasons. At the completion of surgery, the portals are closed
ness defect, a simple partial-thickness defect in the articular using skin sutures only. The carpus is bandaged with a sterile
cartilage with the deeper zone firmly attached to subchon- non-adhesive dressing and adhesive gauze before a padded
dral bone is not an indication for debridement. Defects gen- bandage is applied for anaesthetic recovery.
erally heal with fibrocartilage in the base but fibrous tissue
at the surface. It has also been recognized on follow-up data
Post-operative Care
that significant articular cartilage loss can be sustained with-
out compromising return to athletic activity [6]. To further There are no special requirements for recovery from anaes-
define how articular cartilage loss affects prognosis, four thesia. At the first bandage change, a light bandage such as
grades of articular damage in the carpus have been defined a Telfa pad, sterile 4″ Kling and Elasticon is used. Horses
and their significance evaluated [6] (Figure 24.8). Grade 1, are placed on phenylbutazone preoperatively and this is
minimal additional cartilage loss (extending less than 5 mm continued for three to four days postoperatively.
from the edge of defect left by osteochondral fragments); Postoperative antimicrobials are not usually administered
grade 2, loss of 30% of articular cartilage from the visible unless there is concern about recent intra-articular injec-
articular surface of affected bone; grade 3, loss of 50% or tion. Inoculation of only 100 Staph aureus organisms can
more of articular cartilage from the visible surface of affected result in infection [26], so if the joint has been injected/
bone; grade 4, significant, usually dorsal, loss of subchondral medicated within two to three weeks, the use of prophylac-
bone and consequential support. tic antimicrobials is considered appropriate.
After debridement, the joint is flushed by opening the Skin sutures are removed 10–12 days after surgery, when
egress cannula and manipulating the tip both in the area of hand walking for five minutes a day commences. The
the lesion and also to the opposite side of the joint where author generally recommends that walking is increased
debris will commonly accumulate. Extensive synovectomy is 5 minutes each week up to 30 minutes a day after two
contra-indicated. Occasionally, small areas of villous hyper- months. At this time, the horse may be turned out or in
(a) (b) Figure 24.7 (a) Pre-operative radiograph

showing severe osteophyte formation on distal
radial and intermediate carpal bones in a roping
horse with chronic change following untreated
osteochondral fragmentation. Arthroscopic views
before (b) and after (c) removal of osteophytosis
from the radial carpal bone, and (d) post-
operative radiograph.
(d)
(c)
(a) (b)
(d)
(c)
Figure 24.8 Arthroscopic views of the four grades of damage after removal of osteochondral fragmentation and debridement:
(a) Grade 1, (b) grade 2, (c) grade 3 and (d) grade 4.
cases with a fresh single fragment, training may recom- When horses were separated into four categories of artic-
mence. Rehabilitation using underwater treadmilling has ular damage, the performance in the two most severely
become increasingly popular (Chapter 15) and is now com- affected groups was significantly inferior: 71.1% horses
monly used by the author. This generally commences with grade 1, 75% horses with grade 2, 53.2% horses with
30–45 days after surgery and continues for a similar period. grade 3 and 54.1% horses with grade 4 damage returned to
Physical rehabilitation techniques that are currently used racing at a level equal to or better than before injury [6].
in equine joint disease and following arthroscopic surgery Refragmentation, osteophytosis and enthesitis on the dor-
have recently been reviewed [27]. Aquatic therapy research sal aspect of the carpal bones are quite common in grade 3
has focused on use of underwater treadmills [28, 29]. and 4 cases. Although there have been no specific follow-
Clinical and postural [28] with concomitant biomechani- up studies in the last 30 years, a study on palmar osteo-
cal and histologic [29] improvements have been reported chondral fragments in 31 horses recognized a similar
in a fragmentation model of carpal OA. relationship to dorsal lesions in which 53–54% of horses
The total time from surgery to training varies from two with grade 3 or 4 damage raced successfully [36].
to four months, depending on the amount of associated Interestingly, in this study 52% of the cases had grade 1 or
damage to the joint. However, the trend has been to ear- 2 damage dorsally and 48% had grade 3 or 4 damage, mak-
lier return to training due to various factors, including ing the overall prognosis worse than reported previously in
low surgical morbidity, understanding that convales- horses without palmar fragmentation.
cence is not dependent on cartilage repair and appreciat- Results of surgery have also been assessed in relation to
ing the risk of other injuries following a long lay-up the location of the fragments. In horses (187 QH and 133 TB)
period [30]. with a single site involved (or the same site bilaterally), the
Complications from arthroscopic surgery are rare. distal aspect of the radial carpal bone had the poorest prog-
Subcutaneous infections are usually associated with a nosis in TB, which is considered to relate to the amount of
horse losing a bandage and getting the incisions contami- secondary damage commonly associated with these frag-
nated soon after surgery and are treated by suture removal. ments. The worst prognosis in QH was seen with fragmen-
Intra-articular infection is very rare. Synovial effusion, tation of the proximal surface of the third carpal bone
usually with low viscosity, haemorrhagic fluid will persist followed by the distal aspect of the radial carpal bone [6].
post-surgically when there is extensive cartilage dam- In a retrospective study of 176 SB horses, fragments of
age [24]. Such cases have been successfully managed with the proximal third and distal radial carpal bones occurred
intra-articular polysulphated glycosaminoglycan with equal frequency (49.2 and 49.6%, respectively) while
(PSGAG) [31] which can inhibit acute synovitis [32]. fragmentation in the antebrachiocarpal joint was rare [7].
Hyaluronan (HA) has also been used to treat persistent Trotters had significantly more third than radial carpal
effusion and has been demonstrated to have long-term bone lesions compared to pacers. Seventy-four percent of
chondroprotective effects [32]. horses had at least one start following surgery. Pacers were
significantly more likely to race after surgery than trotters.
Median earnings per start significantly decreased after
Results
surgery, while median race marks significantly increased
Post-surgical follow-up has been reported for 445 (TB and after surgery. It was concluded that the majority of SB
QH) racehorses [6]. After arthroscopy, 68.1% raced at a would be useful racehorses following carpal arthroscopy;
level equal to or better than pre-injury, 11.0% had decreased however, most earn less money per start and many race at
performance or problems referable to the carpus, 5.2% a lower class. There was no evaluation of prognosis in rela-
were retired without returning to training, 6.3% sustained tion to fragment location or grade of lesion.
another chip fracture, 7.2% developed other problems, and The author has recently completed a 10-year retrospec-
2.2% sustained career ending collapsing slab fractures tive study of racing TB and racing QH [37]. In total, 828
while racing. Similar returns to racing were subsequently horses underwent 880 surgical events (416 QH and 412
reported from other geographically remote groups [12, 33, TB). Sixty-five percent and 27% of the lesions were bilat-
34]. Comparing the results of arthroscopic surgery with the eral in QH and TB, respectively (p < 0.01). In both breeds,
results of arthrotomy is difficult because of the variable the most common site of fragmentation was the dorsal dis-
methods used to assess success [35]. Using a single race tal radial carpal bone. Overall, 82% of horses raced post-
start as the criterion for success would be 88.6% for TB and surgery including 86% QH and 79% TB of which 57% (228
88.8% for QH [6]. The author believes that return to racing QH and 248 TB) horses that had raced pre-surgery ran at
at the same level or higher is a more realistic criterion as the same or higher level post-surgery. The odds of not rac-
this eliminates variations in horses’ ability. ing post-surgery was associated with increase in age,
female horses, and a grade 4 lesion, while racing pre- f ixation [24, 38]. The technique is a modification of that
surgery was protective. There were significant differences described for a repair of small slab fractures. The horse is
between the location and severity of lesions in QH, when positioned, and the joint evaluated arthroscopically as
compared to TB. described earlier for each fracture location. Suitable frac-
tures are either non- or minimally displaced (Figure 24.9a
and b). When necessary, reduction can be effected by
rthroscopic Surgery for the Repair
A increasing joint flexion or by manipulation using the 2 mm
of Carpal Chip Fractures drill sleeve after creation of the glide hole or both. The
medial and lateral margins of the fracture are defined by
Chip fractures of the carpal bones that are of sufficient size placement of percutaneous needles (Figure 24.9c). It is
can be repaired by arthroscopically guided internal important that these are inserted perpendicular to the skin
(a) (b)
(c)
(e) (f)
(d)
Figure 24.9 Repair of a chip fracture of the dorsal distal radial carpal bone using a 2.7 mm screw. (a) Dorsolateral–palmaromedial
oblique. (b) Flexed lateromedial radiographs. (c) Medial and lateral margins of the fracture demarcated with percutaneous needles
and (d) mediolateral midpoint in the distal margin of the fragment identified by a spinal needle placed midway between these
needles along the distal articular surface of the bone in the trajectory chosen for the implant. (e) Dorsolateral–palmaromedial oblique
and (f) Flexed lateromedial radiographs taken eight weeks post-surgery. Source: McIlwraith et al. [24].
Osteochondral Fragments in the Palmar Compartments of the Carpal Joint 521
to avoid erroneous assessment of fracture size and location.

These are followed by an 18 gauge × 89 mm spinal needle
placed mid-way between the marker needles adjacent and
parallel to the articular surface of the fracture (Figure 24.9d).
This acts as a guide for drill direction. A further needle is
then used to mark the proposed site of screw placement
immediately adjacent to the capsular attachment which
places the screw close to the endosteal side of the subchon-
dral bone plate. It also means that the repair process can be
visualized arthroscopically. A stab incision is made at this
point with a number 11 blade and a 2.7 mm glide hole cre- Figure 24.10 Avulsion fragment from the radial carpal bone
ated through the fragment until it passes the fracture plane (RC) associated with the MPICL in a horse being treated for a
(monitored radiographically). The 2 mm drill guide (insert) frontal plane slab fracture involving both radial and
is then located and a 2 mm hole is drilled into the parent intermediate facets of the third carpal bone (C3).
bone. The hole is countersunk, measured and then tapped
to cut a thread before a 2.7 mm cortical bone screw of
selected length is inserted and tightened. A lateral to is the most common problem encountered arthroscopi-
medial radiograph is taken to confirm appropriate implant cally [39], avulsion fragments involving the proximal attach-
placement. If necessary, small loose osteochondral fragment to the radial carpal bone occasionally occur [18]. The
ments and detached cartilage flaps are debrided. majority are recognized during repair of slab fractures of the
The results obtained with 35 fractures in 33 TB race- third carpal bone, most frequently frontal plane fractures
horses including the dorsal distal radial carpal bone involving both radial and intermediate facets (Figure 24.10).
(n = 25), dorsal proximal third carpal bone (n = 9) and Many of these are collapsing slab fractures in which surgical
dorsal distal radius (n = 1) have been reported [38]. Horses repair is a salvage procedure. Avulsion fragments of the
were confined to their stable for one to four (mean 2) weeks MPICL have been removed, but are usually left in situ as
followed by 4–12 (mean 8) weeks of walking and a similar they are a minor part of the total joint pathology.
period (mean 6 weeks) of trotting exercise. The LPICL runs from the distal palmar aspect of the
Fractures healed in 18 of 19 horses with radiologic fol- ulnar and intermediate carpal bones to the palmar aspect of
low-up (Figures 24.9e and f). Twenty-three of 28 (82%) the third and fourth carpal bones. The dorsal aspect of the
horses with follow-up returned to racing with 19 (68%) rac- LPICL can be examined arthroscopically. Tears of this liga-
ing at a level equal to or better than pre-surgery and four at ment occur occasionally but not nearly as commonly as
a reduced level. The mean time between surgery and the those of the MPICL [24]. A series of 37 cases of lateral pal-
first race was 10 (range 3–22) months [38]. mar intercarpal ligament avulsion fragments have been
described [41]. These involved discreet fragments from the
ulnar carpal bone. Avulsions were associated with lameness
with clinical signs referable to the carpus; fragments were
vulsion Fragments Associated
A identified radiographically and confirmed arthroscopically.
with the Palmar Intercarpal Twenty of 22 (91%) horses in which fragments were
Ligaments removed arthroscopically returned to work, compared to
five of nine horses treated conservatively. Twelve horses
Two palmar intercarpal ligaments (PICLs) connect the prox- had LPICL avulsion without concurrent osteochondral
imal and distal rows of carpal bones: one medial (MPICL) fragmentation in the same or additional joints; and of nine
and one lateral (LPICL). The MPICL runs from the radial horses with follow-up, eight returned to athletic work [41].
carpal bone to the second and third carpal bones. Although
described initially as a single entity [39], it has since been
recognized as consisting of two branches [40]: a medial steochondral Fragments in the
O
branch extends from the palmar aspect of the radial carpal Palmar Compartments of the
bone to the palmar fossa of the second carpal bone and a Carpal Joints
lateral branch with the same origin inserts in the palmar
synovial fossa of the third carpal bone. The dorsal aspect of Osteochondral fragments can be found in or associated
the MPICL can be evaluated arthroscopically, but the major- with the palmar compartments of the carpal joints [24, 36,
ity of the ligament is inaccessible. While injury to the MPICL 42–44]. The most important consideration at the time of
identification is to determine, as far as possible, if these 31 cases were considered to have originated from the pal-
have originated from the palmar articular margins or have mar aspect of the carpal bones [46]: six from the proximal
dorsal origins and have migrated to this site. Clinical pres- aspect of the radial carpal bone and one from the proximal
entation, together with the size and location of the frag- aspect of the third carpal bone. Fragmentation in the
ments and other radiographic features, provide important remaining 24 horses was considered to have originated in
differential information [36, 42–44]. Sites for arthroscopic the dorsal aspect of the joint.
access to the palmar aspects of both middle and antebra- In the most recent paper, a known traumatic event
chiocarpal joints and description of the fields of view and caused the fragmentation in 17 of 25 (68%) horses: 17 (68%)
visible carpal bone surfaces for each approach have been involving the antebrachiocarpal joint, 7 (28%) middle car-
documented [24, 45]. pal joint and 1 (4%) the carpometacarpal joint. The proxi-
mal aspect of the radial carpal bone was the single most
common site followed by the accessory carpal bone with 12
Incidence and Diagnosis
(40%) and 6 (20%) of 30 fragments, respectively [44].
Fragmentation can originate from the palmar surfaces of Clinical signs are referable to the carpal joints, and defin-
any of the carpal bones, but the radial carpal bone is most itive diagnosis is made by radiographic examination
frequently involved [44]. The dorsal articular surfaces of (Figure 24.11a).
the accessory carpal bone and the palmar surfaces of the
ulnar and fourth carpal bones are involved less frequently.
Treatment
Large partial slab fractures of the palmarolateral surface of
the intermediate carpal bone also occur and are largely Arthroscopic surgery in the palmar compartments of the
accessible for arthroscopic removal or reattachment [42]. carpal joints involves triangulation using ipsilateral arthro-
Avulsion injuries associated with anaesthetic recovery can scope and instrument portals. Lateromedial passage of
result in multiple and frequently larger fragments. A series instruments is not possible and there are central areas of
of 10 such fragments involved the palmaromedial aspect of inaccessibility. As an example, arthroscopic removal of
the radial carpal bone [43]. In another series, only seven of proximal palmar radial carpal fragments is performed
(a) (b)
(c)
Figure 24.11 (a) Dorsomedial–palmarolateral oblique radiograph demonstrating fragmentation of the proximal palmar aspect of
radial carpal bone (circled) recognized following recovery from anaesthesia for colic surgery. Arthroscopic views before (b) and after
(c) removal and debridement. R: articular surface of the radius.
Carpal Slab Fracture 523
through a palmaromedial approach to the antebrachiocar- considered pasture sound and two were euthanized. Eight of
pal joint, which gives access to the palmar perimeter of the 14 (57%) horses with pre-operative evidence of OA return to
radial carpal bone and medial the radius (Figure 24.11b function after surgery. Twelve of 17 (71%) horses with ante-
and c). Prior (dorsal) distension of the joint facilitates brachiocarpal and six of seven (86%) horses with middle car-
creation of an arthroscope portal proximally in the dis- pal joint fragments returned to their previous use [44].
tended palmaromedial out pouching. An instrument portal
is developed adjacent (usually distal) to the arthroscopic
portal. Motorized equipment may be necessary to remove Carpal Slab Fractures
synovial proliferation and provide better visualization of
the fragment. Details on the arthroscopic approaches for Slab fractures extend from proximal to distal articular sur-
removal of fragments in the different locations have been faces of a bone and in the carpus may occur in frontal (dor-
provided in another text [24]. sal) or sagittal planes. They are, by a large majority, most
In one series, osteochondral fragments were removed in common in the third carpal bone. Radial, intermediate and
13 of 31 (41.9%) horses [36]. Horses with primary lesions fourth carpal bones are less frequently affected. From both
on the dorsodistal aspect of the radial carpal bone or dorsal surgical (middle carpal joint) and pathogenic perspectives,
aspect of the third carpal bone were more likely to have the third carpal bone is usually described as comprising
multiple palmar fragments. All horses with slab fractures radial and intermediate facets with a palmar body that lies
of the third carpal bone had multiple palmar fragments of behind the latter. Incomplete slab fractures involve only
a smaller grade. Horses with the largest dorsal lesions one (almost invariably the proximal) subchondral bone
(grades 2 and 3) were significantly more likely to have the plate and extend varying distances into the cuboidal spon-
smallest (grade 1) palmar fragments than horses with giosa. Fractures that extend through the proximal sub-
larger palmar fragments, while horses with two or three chondral bone into the spongiosa and then exit the dorsal
dorsal lesions were significantly more likely than horses surface of the bone distal to joint capsule attachments are
with no dorsal lesions or one dorsal lesion to have the sometimes referred to as partial slab fractures but are more
smallest grade of palmar fragments. Horses with primary correctly termed chip fractures; management is usually as
lesions of only the proximal palmar aspect of the radial car- described in “Arthroscopic Surgery for the Repair of Carpal
pal bone were significantly more likely to have one palmar Chip Fractures” section.
fragment than two or multiple fragments [36]. Frontal plane slab fractures are commonly differentiated
into displaced or undisplaced, and this has been considered
relevant to surgical management. However, it is also impor-
Results
tant to distinguish slab fractures that retain axial stability
Results in 10 horses with fractures of the palmar aspect of from collapsing slab fractures, where the radial carpal bone
the radial carpal bone suggest that simple fractures should displaces distally into the fracture gap and progressive col-
be removed as soon as they are identified. Cases in which lapse of the carpus ensues [46]. The radial facet is the most
damage was confined to only the area of the fragment and common location for both frontal and sagittal plane slab
where the fragment was removed soon after injury tended to fractures of the third carpal bone. This has been related to
have less OA and did better after arthroscopic surgery [43]. the hinge-like function of the middle carpal joint, in which
In a second series in which 50% of horses had multiple the radial carpal bone impacts onto the radial facet of the
palmar fragments, 52% returned to racing, 48% earned third carpal bone when the limb is loaded in the close
money and 32% had at least five starts. All horses with mul- packed extended position [47]. It has been suggested that
tiple fragments had significantly less earnings per start and the medial location of the radial facet exposes it to larger
lower performance index values after surgery than those forces during exercise and the intermediate facet is pro-
with one fragment. Horses with palmar fragments less than tected by expansion of the articulation between the third
3 mm in diameter were significantly less likely to return to and fourth carpal bones when the intermediate carpal bone
racing, have five starts or to win money after surgery than is locked against the distal row of carpal bones [3, 4].
horses with larger fragments. It appeared that multiple small
fragments had a poorer prognosis because they resulted
Incidence
from more severe damage in the dorsal compartment. When
one or two large fragments were evident, these had usually In a survey of 371 third carpal bone fractures in 313 horses,
originated from the palmar articular margins [36]. 157 were classified as slab fractures, 93 (59.2%) were in the
In a later paper, 19 of 25 horses (76%) were sound after frontal (dorsal) plane and confined to the radial facet, and
surgery and returned to their intended use. Four (16%) were 35 (22.3%) were in the frontal plane and involved both
radial and intermediate facets. Seventeen fractures (10.8%) Sagittal fractures are inherently more stable than frac-
were sagittal and situated on the medial side of the radial tures in the frontal plane. There may be displacement of
facet. Nine (5.7%) frontal and three (1.9%) sagittal fractures comminuted fragments, but there is rarely displacement of
involved the intermediate facet. These authors also identi- the principal fracture. Dorsal displacement of complete
fied 39 incomplete fractures involving the proximal sub- frontal plane fractures is common. This is usually, at least
chondral bone of the radial facet; of these, 59.5% were partially, rotational with greater dorsal displacement of the
identified only in flexed dorsoproximal–dorsodistal oblique proximal articular surface. Most displaced fractures are
projections of the distal row of carpal bones [47]. reduced in flexion. Flexed lateromedial projections are
In a series of 72 TB and 61 SB, 87% of slab fractures were therefore a useful pre-surgical guide to the ease of intraop-
in the frontal plane and involved the radial facet [48]. The erative reduction and repair.
forelimbs were equally affected in SB; however, the right Radiographs of frontal plane fractures should be scruti-
third carpal bone predominated in TB (48 right and nized carefully for the presence of proximal palmar com-
34 left) [48]. In a survey of the author’s cases, both TB and minution. This is usually identified as a wedge shaped
QH had more slab fractures in the right third carpal bone fragment(s) in DL-PaMO projections. In the author’s
(70% and 67.7%, respectively), which is consistent with experience, comminution at this site is common with
increased loading of the medial side of the right carpus. In collapsing slab fractures of both radial and intermediate
a fourth group of frontal fractures, the right third carpal facets. Configurations of complex fractures may be better
bone was affected in 24 of 31 (77.4%) TB. The fractures typi- defined by computed tomography [53].
cally occurred at high speed (racing or training). Twenty
(65%) of horses had previously been administered intra-
Treatment
articular corticosteroids [49].
A series of 125 horses with 128 slab fractures of the third All carpal slab fractures in racehorses are considered to be
carpal bone included 113 (88%) TB and 15 (12%) in SB. In surgical candidates. Previous statements that undisplaced
unilateral fractures, the right leg was affected in 62% of TB third carpal bone slab fractures do not require surgery need
and the left in 60% of SB. Fractures were bilateral in 3% of qualification [54]. Healing may occur in some cases, but
TB. Fractures were in frontal in 76 and 87% and sagittal in progressive osteoporosis of the fragment and development
24 and 13% planes in TB and SB, respectively [50]. of OA are seen commonly. In one report, where undisplaced
In a report of 71 third carpal bone slab fractures in racing was defined as a fracture line of less than 1 mm, 12 SB were
TB in the UK, 65 (96%) were unilateral and of these 43 treated with rest and 10 raced; 8 of the 10 raced well [48].
(66%) involved the left leg. Fractures were in a frontal plane In the author’s experience, such fractures are uncommon,
in 52 (73%) and parasagittal in 19 (27%). The radial facet and conservative management of carpal slab fractures in
only was involved in 62 (87%) of fractures. Displacement TB is not recommended.
was most common with frontal plane fractures (63%) and Undisplaced frontal plane slab fractures of the third car-
uncommon (21%) with parasagittal fractures [51]. pal bone are excellent candidates for surgery. Frontal slab
fractures with some displacement are definite candidates
for surgery, and when fractures involve both facets, surgery
Diagnosis
is essential for restabilization. Whether the horse can
Clinical signs vary from mild to severe non-weight-bearing return to athletic activity is related to the amount of associ-
lameness. Joint distension is consistent and in the acute ated articular damage. Sagittal slab fractures are also candi-
phase is the result of intra-articular haemorrhage. A full dates for lag screw fixation [55]. Arthroscopic examination
series of radiographs, including a skyline view of the third has shown that these fractures are mobile. Conservative
carpal bone, is essential (Figure 24.12). The projections in management of a series of 12 of these fractures resulted in
which individual slab fractures of the third carpal bone return of function in seven [56]. The author has treated
are usually recognized are given in Table 24.3. A recent cases that had not healed with conservative therapy but
report recommended use of a flexed dorsoproximal 15–35° later were successfully treated with lag screw fixation. A
lateral–dorsodistal medial oblique (DPr15-35oL-DDiMO) 1976 case report described a filly with a sagittal slab frac-
projection to identify sagittal fractures of the radial facet ture of the medial aspect of the third carpal bone treated
that may not be identified in conventional sagittally orien- conservatively with four months rest [57]. Follow-up radio-
tated DPr-DDiO (skyline) projections [52]. Slab fractures graphs revealed OA in the midcarpal joint, and when an
involving both radial and intermediate facets are usually attempt was made to train the filly, a chip developed in the
situated further palmad than their single facet antebrachiocarpal joint, ending in retirement from racing.
counterparts. In 1983, lag screw fixation of a sagittal slab fracture in the
(a) (b)
(c)
(d)
Figure 24.12 Radiographs of a displaced frontal plane slab fracture of the radial facet of the third carpal bone: (a) lateromedial, (b)
dorsolateral–palmaromedial oblique, (c) flexed lateromedial and (d) flexed dorsoproximal–dorsodistal oblique (skyline) projections.
Note the fracture reduction produced by carpal flexion. The dorsopalmar depth of the fracture and bone thickness have been
determined (c) in preparation for surgery. Source: McIlwraith et al. [24].
Table 24.3 Radiographic projections in which individual slab fractures of the third carpal bone are most frequently recognized.
Projection
Flexed
Fracture DPa LM Flexed LM DL-PaMO DM-PaLPO DPr-DDiO
Frontal radial facet ✓ ✓ ✓ ✓

Frontal radial and intermediate facets ✓ ✓ ✓ ✓ ✓
Sagittal radial facet ✓ ✓
Frontal intermediate facet ✓ ✓ ✓ ✓
Sagittal intermediate facet ✓ ✓
DPa: dorsopalmar; LM: lateromedial; DL-PaMO: dorsolateral–palmaromedial oblique; DM-PaLO: dorsomedial–palmarolateral oblique;
DPr-DDiO: dorsoproximal–dorsodistal oblique.
third carpal bone was described in a single case report [58]. of the fracture (Figures 24.13 and 24.14). The tip of this
More recently, a report of surgical and non-surgical man- needle is usually located in the palmar fossa in the third
agement of sagittal slab fractures of the third carpal bone carpal bone. It can be pressed into the bone at this point
in 32 racehorses concluded that horses treated surgically which ensures that it is a reliable guide for drill trajectory.
were more likely to race after treatment than horses man- Finally, another needle is placed, in mediolateral align-
aged without surgery [55]. ment with the spinal needle, in the carpometacarpal joint,
and a flexed lateral radiograph is obtained. The needle
placement as visualized in the joint determines the latero-
Surgery
medial site of screw placement (halfway along the slab).
Frontal Plane Slab Fracture of the Radial Facet The needle placement on the radiograph dictates proximo-
of the Third Carpal Bone distal location and trajectory to ensure that it is approxi-
Both 4.5 mm and 3.5 mm cortex screws are used [24, 50, 51, mately at the mid-point and parallel with the articular
59]: for larger fragments (≥10 mm dorsopalmar depth) the surfaces. A stab incision is made with a number 10 scalpel
author prefers 4.5 mm screws; for smaller fragments, a blade, and a 4.5 mm glide hole is drilled through to the frac-
3.5 mm screw is more appropriate. The smaller head ture plane. During this, the drill must maintain biplanar
requires less depth of countersink groove and results in alignment with the spinal needle. As an additional guide,
less prominence. The technique used for 4.5 mm screw the surgeon can ensure that the drill is perpendicular to the
insertion will be described. When a 3.5 mm screw is third metacarpal bone. A 3.2 mm drill sleeve is inserted
employed, all stages remain the same, only the instruments and, if further reduction is necessary, this can be used to
sizes vary. manipulate the fragment. A 3.2 mm hole is then drilled
Repair in all cases uses the arthroscopic technique devel- into the body of third carpal bone. A countersink groove is
oped by Richardson [59], with some modifications [24]. made in the convex prominence of the bone before the
Surgery is performed with the horse in dorsal recumbency. depth of the hole is measured, tapped and a screw of
A lateral arthroscopic portal and a medial instrument por- appropriate length is selected. The 4.5 mm screw is then
tal are used, and a diagnostic examination of the joint is inserted to compress the fracture (Figures 24.14 and 24.15).
performed. The fracture is visualized, and if necessary, This is re-evaluated arthroscopically and any additional
fragments are removed and the margins debrided before debris removed. Finally, repair is assessed radiographically
the fracture site and joint are irrigated. If the fracture is before sutures are placed in the skin incisions.
displaced, the carpus is then placed in maximal flexion to The use of a cannulated Herbert screw has been described
effect reduction. Under arthroscopic visualization, two for compression of experimentally created third carpal
narrow gauge needles are placed percutaneously into the bone slab fractures (osteotomies) [60], and more recently
middle carpal joint at the medial and lateral margins of the the use of the Acutrak™ (AT) screw has been reported as
fracture adjacent and parallel to the third carpal bone. A successfully treating frontal slab fractures of the third car-
spinal needle is then placed midway between the two nee- pal bone [61]. Like the Herbert screw, the AT screw is can-
dles, close and parallel to the proximal articular surface nulated which facilitates accurate placement over a guide
and directed as close to 90° as possible across the midpoint pin and helps maintain reduction during drilling, tapping
(a) (b)
(c) (d)
(e)
Figure 24.13 Diagram (a) and external view (b) demonstrating arthroscope position and placement of needles for fixation of a
frontal plane slab fracture of the third carpal bone. (c) Arthroscopic view of the fracture prior to the placement of needles (d).
Arthroscopic view of the needle at the medial margin of the fracture and placement of the spinal needle. (e) Spinal needle lodged in
the palmar fossa of the third carpal bone. Source: McIlwraith et al. [24].
(a) (b) (e)
(c) (d) (f)
(g) (h)
Figure 24.14 Repair of a frontal plane slab fracture of the radial facet of the third carpal bone using a 3.5 mm cortex screw. (a, b)
Pre-operative radiographs. (c) Arthroscopic evaluation reveals an acute slightly displaced fracture. (d) Fracture reduced by increased
carpal flexion. Medial, lateral and bisecting guide needles inserted. (e) Lateromedial radiograph following fixation confirming central
implant location and trajectory parallel to the articular surfaces. (f) Arthroscopic view of the fracture following repair. (g, h)
Radiographs nine weeks after surgery demonstrating good fracture healing.
(a) (c)
(b)
Figure 24.15 Repair of a displaced slab fracture of the radial facet of the third carpal bone using a 4.5 mm cortex screw. (a)
Dorsolateral–palmarolateral oblique. (b) Flexed dorsoproximal–dorsodistal oblique radiographs at presentation. (c) Flexed
lateromedial projection at completion of surgery.
and screw implantation. The AT screw is a titanium alloy, the fracture. The arthroscopic technique is quite difficult as
cannulated, headless, variable pitch, self-tapping, taper visibility is limited. A curved blade is necessary to sever the
compression screw (Acumed, Beaverton, OR). An in vitro most distal attachments.
study on simulated third carpal bone slab fractures repaired
with either 4.5 mm AO cortical (AO) or AT compression Frontal Plane Slab Fractures of the Intermediate
screws found that insertion variables such as drilling Facet of the Third Carpal Bone
torque, tapping (AO) versus screw insertion (AT) torque These fractures are less frequent. When encountered, the
and maximum screw torque were comparable. The technique is similar to that described for radial facet frac-
mechanical shear testing variables recorded for yield and tures except the arthroscope is placed in the medial portal
failure were also comparable; however, the AO-repaired and instruments through the lateral arthroscopic portal. A
constructs had significantly greater initial shear 3.5 mm screw is favoured (Figure 24.16) [24].
stiffness [62].
In clinical cases, the cannulated screw was reported to Frontal Plane Slab Fractures of Radial
facilitate accurate screw placement, prevent the need for and Intermediate Facets of the Third Carpal Bone
countersinking, decrease the possibility of fragment split- In general, these fractures occur in a more palmar position
ting and eliminate screw head impingement on dorsal soft than those involving the radial facet only and as a result are
tissues while achieving stable fixation. Possible disadvan- sometimes less readily imaged in skyline radiographs
tages of the AT system were cited as less potential for initial (Figure 24.17a–d). They are usually not comminuted, do not
fracture compression compared with screws appropriately involve a collapsing component and can be repaired using a
placed in lag fashion, the probable difficulty of removing modification of the technique used for slab fractures involving
screws if implant-related complications required and the the radial facet only [24]. The fracture is approached, prepared
necessity to learn a new insertion technique for dense and reduced as described in “Frontal Plane Slab Fracture of
equine bone [61]. the Radial Facet of the Third Carpal Bone” section. Needles
In rare cases, removal of the slab fracture fragment is are placed at the medial and lateral margins of the fracture
considered when the fragment is thin, too comminuted for which is often at the articulations with the second and fourth
reconstruction, or there is a large separated wedge of bone carpal bones. Repair may involve two 4.5 mm, two 3.5 mm or
at the fracture site which precludes reduction and safe sometimes 1 × 4.5 mm and 1 × 3.5 mm screws (one through
repair. Removal is most easily achieved with an arthrotomy each facet) to provide stabilization and compression. To
medial to the extensor carpi radialis tendon. Sharp dissec- achieve this, the spinal needles used to guide drill/implant
tion is required to sever the joint capsule attachments to location and trajectory are placed at approximately one-third
(a) (b) (c)
Figure 24.16 Repair of a displaced frontal plane slab fracture of the intermediate facet of the third carpal bone. Fracture identified
on dorsomedial–palmaromedial oblique (a) and flexed dorsoproximal–dorsodistal oblique (b) radiographs. (c) Post-operative
dorsomedial–palmarolateral oblique projection following repair with a single 3.5 mm cortex screw.
and two-thirds points along the mediolateral length of the with comminuted fractures of the distal row of carpal
fracture. These should be as perpendicular as possible to the bones. Both T-plates and dynamic compression plates
fracture, but a degree of palmar convergence is required to (DCPs) were employed. Two animals with fractures sur-
engage the body of the bone (Figure 24.17e–i). vived and functioned as broodmares [63]. Ranges of flexion
possible following partial carpal arthrodesis of the middle
Comminuted Collapsing Fractures (with carpometacarpal) joint (43° ± 73.6°) and antibrachio-
There are two common forms of collapsing fractures of the carpal (25° ± 6.3°) have been determined in an ex vivo
carpus. The first are large markedly displaced and fre- model [64]. Use of the locking screw plate (LCP) system
quently comminuted frontal plane fractures of the third offers improved stability. The use of partial carpal arthro-
carpal bone which create a deficit into which the proximal desis to preserve antebrachiocarpal joint mobility has also
row of carpal bones descends (Figures 24.18 and 24.19). If been described for repair of a comminuted fourth carpal
these fractures can be reduced and stabilized, then recon- bone fracture associated with carpal instability [65]. The
struction using modifications of the technique described in repair was also facilitated by computed tomographic
“Frontal Plane Slab Fractures of Radial and Intermediate documentation.
Facets of the Third Carpal Bone” section is appropriate. Pancarpal arthrodesis is indicated when there are frac-
The second group are slab fractures of multiple carpal tures and instability involving both proximal and distal
bones (Figure 24.20). Horses are usually unable to bear sig- rows of carpal bones. The initial technique described using
nificant weight on the limb, and there is instability often two broad DCPs [66]. Lewis reported use of two long DCPs
with dorsopalmar and/or mediolateral deformity. Carpal applied dorsomedially and dorsolaterally in 14 pan and 14
destabilization can also be caused by carpometacarpal partial carpal arthrodeses. Peri-operative morbidity due to
subluxation. Treatment aims to re-establish axial stability implant failure (4) and contralateral limb laminitis (4) was
and is a salvage procedure. Return to athletic activity is not significant [67]. More recently, pancarpal arthrodesis using
expected. two LCPs for treatment of a comminuted ulnar carpal bone
Constructs to re-establish load bearing require arthrode- fracture associated with carpal instability has been
sis. Partial arthrodesis leaving the antebrachiocarpal joint reported [68]. The filly was maintained in a full-limb cast
functional is the best option if there is confidence that in for 15 days, followed by a tube cast for 14 days and subse-
the antebrachiocarpal joint is stable and unaffected. quently a full-limb bandage with a caudal splint for 21 days.
Figure 24.20 illustrates a case where partial arthrodesis This resulted in a pasture sound filly six months after sur-
using locking compression plates (LCP) was performed. gery. Three horses with carpal instability due to commi-
The concept was introduced in 1990 with a report of partial nuted second carpal bone fracture (cases 1 and 3) and
carpal arthrodesis in six animals including three horses fracture of the head of the second metacarpal bone (case 1)
(a)
(b)
(c)
(d)
(e) (f)
(g)
(h) (i)
Figure 24.17 Frontal plane slab fracture of radial and intermediate facets of the third carpal bone. (a) Lateromedial. (b) Flexed
lateromedial. (c) Flexed dorsoproximal–dorsodistal oblique radiographs demonstrating the fracture that is more palmarly situated
(arrows) than those involving the radial facet only. (d) Transverse CT image at the proximodistal mid-point of the third carpal bone
confirming fracture location and configuration. Arthroscopic views of the radial facet (e) and intermediate facet (f) of the third carpal
bone with fracture arrowed. (g) 18-gauge spinal needles placed along the proximal margin of the third carpal bone to determine
trajectory of implant placement. A smaller (blue) needle is placed in the carpometacarpal joint. (h) Skyline. (i) Lateromedial
radiographs following insertion of 2 × 3.5 mm screws. The needles used for trajectory determination remain in situ.
(a) (b) (c)
(d)
(e)
Figure 24.18 Radiographs (a–e) of a collapsing frontal plane slab fracture involving both facets of the third carpal bone.
or comminuted fractures of the fourth carpal bone, ulnar period of protective external coaptation [70]. Six cases
and intermediate carpal bones (case 2) have recently been including two pan and four partial carpal arthrodesis were
reported. These were treated by partial (cases 1 and 3) or described. A minimally invasive approach was used in
pancarpal (case 2) arthrodesis with two (x2) or three (x1) three cases, a partially minimally invasive technique in two
LCPs using a minimally invasive approach [69]. This main- cases and open surgery in one case. Autologous cancellous
tains substantially intact skin over the implants and bone grafts were also instilled in five horses. Radiographic
reduces exposure of the surgery site to contamination. It is ankyloses followed in all. Horses were reported to be sound
technically challenging and requires good aseptic intra- at the walk and restricted only by mechanical
operative radiography or fluoroscopy. All cases recovered lameness [70].
well, were lame-free at the walk, were able to trot and gal- Post-operative support with a fibreglass sleeve cast
lop and could be used for leisure and pasture activities in (Chapter 13) (Figure 24.21) is necessary following all sur-
the cases of partial carpal arthrodesis and for breeding in geries for collapsing fractures of the carpus.
the case of pancarpal arthrodesis [69]. It has been sug- Figure 24.22 illustrates an unusual case in which stabili-
gested that employing three LCPs further increases stabil- zation was achieved by lag screw fixation of a slab fracture
ity thus allowing use of shorter implants and reducing the of the radial carpal bone into the intermediate carpal bone
(a) (d) (b)
(c)
(e) (f)
(i)
(g)
(h) (j)
Figure 24.19 Lag screw fixation of a collapsing frontal slab fracture involving both facets of the third carpal bone (a), partial
reduction with carpal flexion (b) arthroscopic view down the medial portion of the fracture after debridement and before reduction;
the proximal articular surface of the third metacarpal bone is visible (c), arthroscopic view across both facets with fracture unreduced
(d, e) radiographs with fracture reduced and needles placed in preparation for repair. Loss of comminution produced a gap on the
medial side so the screw in the radial facet was placed more laterally than usual (f), 3.2 mm drill guide placed through first glide hole.
(g, h) Intraoperative radiographs after fixation with two 4.5 mm cortical bone screws. Arthroscopic views medially (i) and laterally (j)
after reduction and fixation demonstrating articular congruency but deficits due to loss of fragmented bone.
(a) (b) (c)
(d) (e)
Figure 24.20 Multiple collapsing fractures of the distal row of carpal bones. (a–c) Pre-operative radiographs. (d, e) Post-operative
radiographs after partial carpal arthrodesis using two broad LCPs.
because of comminution of the palmar fragment in the the second–third carpal articulation. The treatment of
radial carpal bone. This illustrates that there are various choice for complete fractures is lag screw fixation using a
alternatives to creating stability with internal fixation in 3.5 mm cortical bone screw (Figure 24.23). The fracture is
the carpus, but it is critical that stability is obtained; other- defined preoperatively using a skyline radiograph. It has
wise, there will be failure and breakdown generally into been suggested that it is important that the fracture line
carpal varus when the sleeve cast is removed. should be seen to traverse the third carpal bone from
proximal to distal articular surfaces on a dorsomedial-
Sagittal Fractures of the Third Carpal Bone palmarolateral radiographic projection to confirm it as a
Sagittal slab fractures are most commonly in the radial sagittal slab fracture and to avoid confusion with other
facet and either have a straight course or curve towards sagittal plane injuries of the third carpal bone, including
contralateral (lateral) joint capsule to provide reliable

t rajectory alignment (I. M. Wright, personal communica-
tion). Intra-operative monitoring of screw placement is
difficult and careful arthroscopic assessment of direction
is critical for compression. A skyline radiograph confirms
repair and safe implant location (Figure 24.23e).
Following the fixation of the fracture, the joint is lavaged
and the skin portals are closed.
Simple partial slab fractures can be repaired using a
hybrid of this technique with that employed in the repair
of chip fractures described in “Arthroscopic Surgery for the
Repair of Carpal Chip Fractures” section. Alternatively,
and if comminuted, these can be removed
arthroscopically.
Sagittal Slab Fractures of Other Carpal Bones

Sagittal slab fractures may also occur in the intermediate,
radial and fourth carpal bones. These fractures have gen-
erally broken into the adjacent articulation and have been
treated using arthroscopic techniques [24]. An open surgi-
cal approach was employed in two horses with principally
sagittal but comminuted fractures of the fourth carpal
Figure 24.21 Use of a sleeve cast for post-operative bone. Repair was effected by lag screw fixation with
management of partial arthrodesis. 2 × 3.5 mm cortex screws which also engaged the third car-
pal bone. Walking casts (Chapter 13) were fitted post-
operatively. Both horses returned to pleasure riding albeit
subchondral lucencies, corner fractures and comminuted with reduced carpal motion [71]. Sagittal fractures of the
fractures [55]. However, experiences with computed fourth carpal bone were reported in five horses; all of
tomography (CT) have demonstrated that this is unrelia- which were comminuted and three had concurrent frontal
ble (I. M. Wright, personal communication). The arthro- plane fractures of the intermediate carpal bone. None
scope is placed through the dorsolateral portal and the were acute. All were repaired by lag screw fixation. In four
fracture line visualized (most are non-displaced). The cases, this also included engagement of the third carpal
screw is placed immediately dorsal to the junction of the bone. Only one intermediate carpal bone fracture was
second and third carpal bones. The location and trajec- repaired. The results were unsatisfactory [72]. However,
tory are defined by a medially placed percutaneous nee- the paper is over 30 years old and both imaging (princi-
dle immediately adjacent and parallel to the articular pally CT) and surgical (arthroscopic) techniques have
surface of the third carpal bone. This is directed to cross since evolved, and there is greater understanding of bio-
the fracture at an angle as close as possible to 90°, but in mechanics. Sagittal fractures also occur along with com-
practice this is sometimes a compromise between the minuted fractures and/or carpometacarpal luxation. In
fracture plane and the narrow window of entry to avoid these instances, the fourth carpal fracture is not always
impingement on the second carpal bone. The distal mar- specifically addressed.
gin of the third carpal bone is determined by placing a
needle into the carpometacarpal joint. For complete slab Frontal Plane Slab Fractures of Other Carpal Bones
fractures, a stab incision is then made in the proximodis- Frontal slab fractures in locations other than the third
tal middle of the bone. Unlike frontal plane slab fractures, carpal bone are uncommon, but the most usual site is the
there is no point of fixation for the tip of the trajectory radial carpal bone. They are generally non- or minimally
determining spinal needle. To ensure correct drill align- displaced and can be treated by arthroscopically guided
ment, this can be visualized by an assistant holding the lag screw fixation [24]. The middle carpal and antebra-
arthroscope while the surgeon manipulates the spinal chiocarpal joints are both examined arthroscopically
needle and aligns the drill parallel to this and along the using a lateral portal to assess the amount of joint dam-
appropriate course. Alternatively, and more reliably, a age, remove debris and to ascertain the position of the
178 mm (7 inch) spinal needle can be passed through the fracture in both joints. Needles are placed in both joints to
(a) (b) (c) (d)
(e) (f) (g)
Figure 24.22 Slab fractures of radial and third carpal bones. Comminution precluded insertion of a lag screw into the palmar
fragment of the radial carpal bone. This was therefore lagged to the adjacent intermediate carpal bone (a–f). Although the mare was
quite lame in the initial post-operative period, she became able to canter around the pasture without any problems. A follow-up
radiograph is shown in (g).
demarcate fracture margins and select an appropriate Post-operative Care and Results
drill/implant position and trajectory. A 4.5 mm cortical
bone screw is then placed in lag fashion using the tech- Slab fractures treated with arthroscopy which do not have evi-
niques described above (“Frontal Plane Slab Fracture of dence of instability are recovered from anaesthesia in a pad-
the Radial Facet of the Third Carpal Bone” section). A ded bandage and treated as for other arthroscopic surgeries.
more palmar variation of a frontal plane slab fracture has External support with a sleeve cast is used routinely for slab
been encountered in the radial carpal bone. There is less fractures of both facets of the third carpal bone and other col-
bone for the threaded portion of the lag screw, and accu- lapsing fractures when there has been significant instability
rate placement into the palmar portion of the radial car- within the carpus (Figure 24.21). The cast is usually main-
pal bone is critical. The author’s experience with frontal tained for four to six weeks. When the repair is more exten-
slab fractures other than third carpal bone has been lim- sive, the use of perioperative broad spectrum antimicrobials is
ited to the radial carpal bone. also appropriate. All patients receive non-steroidal anti-
A frontal plane slab fracture of the second carpal bone inflammatory agents in the immediate perioperative period.
with concurrent subluxation has been reported following Most horses with lag screw fixation of slab fractures
surgical arthrodesis (by fanned drilling) of the carpomet- undergo similar exercise and physical therapy protocols to
acarpal joint. Precise causation was not identified [73]. those which follow fragment removal.
(e)
(a)
(b) (d)
(c)
Figure 24.23 Skyline radiograph (a) and arthroscopic view (b) of slightly displaced sagittal fracture of medial aspect of third carpal
bone. There is some comminution at the surface. (c) Fracture after debridement and placement of a spinal needle guide; (d)
arthroscopic view following fixation and (e) post-operative radiograph with the fracture compressed.
The first two reports with follow-up data for the treat- In the second study of 31 TB racehorses surgically treated
ment of (non-collapsing) third carpal bone slab fractures for frontal slab fractures of the third carpal bone, 21 (67.7%)
did not generally involve arthroscopic surgery and care raced at least once after surgery. The mean convalescent
should be taken in extrapolating results. The first evaluated time was 9.5 months. Claiming value declined from means
the race records of 72 TB and 61 SB [46]. A number of fac- of $13 900 to $6500 (n = 11; p < 0.05) based on two races
tors in addition to fracture characteristics or method of before and four races after injury: the mean finish position
treatment affected outcome, for example, females of both was 5.8 ± 3.16 before and 5.8 ± 3.30 after (n = 11). Horses
breeds were less likely to race after injury than males. The that did not race after recovery had significantly larger
percentage of Standardbreds racing (77%) was significantly fractures. The authors noted the inferior post-operative
higher than TB (65%). All 38 SB horses with racing starts performance as determined by reduced percentage return-
before fracture were able to race again. Prior racing starts ing to racing and post-fracture level of racing, of horses
were not related to outcome in TB. Convalescent time was with slab fractures compared to horses following removal
not correlated with any variable (including treatment) or of osteochondral fragments [49].
related to outcome. Fracture characteristics were an impor- Fixation of third carpal bone frontal plane slab fractures with
tant determinant of outcome. None of the TB treated by the Acutrak screw system was reported in 17 racing
screw fixation with fragment thickness >9 mm raced well. Thoroughbreds [61]. Twelve of 15 horses that raced before
None of the four TB with fragment thickness >7 mm raced injury returned to racing. Average days to first start was
after fragment removal. Horses treated by fragment 349.3 ± 153.9 days. Horses that returned to racing had more
removal performed similarly to horses treated via screw starts after repair (median 6.5 vs. 3.5; p = 0.04) and did not have
fixation in both breeds despite increased associated dam- decreased earnings per start (median $2432 vs. $3061; p = 0.3).
age and fracture displacement. Based on their findings, the In the initial description of arthroscopic repair of third
authors felt that the optimal range of fragment thickness carpal bone slab fractures [59], 17 horses had six months or
for removal was <8 mm for TB and <14 mm for SB [48]. longer follow-up. Of these, 10 returned to race successfully.
One other horse was reported to be training soundly and geldings [51]. The studies reported similar results for return
two trained well but were retired because of other injuries. to racing following repair of sagittal fractures of the third
One horse was unable to return to training because of carpal bone in TB: 17/27 (63%) [50] and 12/18 (66%) [51].
another injury. Two horses did not recover well enough to Comminuted fractures can be salvaged if stability can be
train or race and one horse was lost to follow-up. At the established and post-operative complications avoided.
time of writing, six horses had less than six months follow- Pancarpal arthrodesis has complications similar to fracture
up; five were progressing well and the sixth horse was fixation of any long bone. Additionally, the author has had
reported to trot well, but radiography revealed degenera- one horse with pancarpal arthrodesis later fracture above
tive changes involving the radiocarpal joint. Except for the plates while galloping at pasture.
horses requiring two screws for repair, the cosmetic appear-
ance was reported to be good with only a small swelling
over the screw [59]. Accessory Carpal Bone Fractures
Two recent papers have reported results of arthroscopic
repair, the first a multicentre study of TB and SB from the Fractures of the accessory carpal bone are less common
USA [50] and the second a single centre series of TB in the than other carpal fractures [74]. Available reports suggest
UK [51]. The former documented 36/86 (35%) TB and 10/13 that these occur most frequently in horses that race over
(79%) SB racing after repair of frontal plane fractures. fences and therefore are more commonly seen in the UK.
Displacement, osteolysis and cartilage damage were nega- Some are also seen in event horses [75]. Frontal (dorsal)
tively associated with outcome, while horses with fractures plane fractures occurring through the mid-portion of the
repaired with single 3.5 mm screws were more likely to race bone are most common and may be simple or slightly com-
than horses in which 4.5 mm or multiple screws were minuted. Horizontally oriented fractures are much less
used [50]. In contrast, the UK study, in which the majority common [76]. In a series of 19 accessory carpal bone frac-
(75%) of fractures were repaired with single 3.5 mm screws, tures, 17 were frontal with 13 of these being comminuted,
recorded 31/49 (63%) frontal plane fractures returning to one was an avulsion fracture from the palmarodistal border
racing. There was a small but significant reduction in per- of the bone and one was a comminuted fracture of the dor-
formance after injury. Horses that had raced before sustain- sal articular surface [77]. The author has also seen frag-
ing fractures were more likely to race subsequently, but ments off the dorsoproximal aspect of the bone in the
females were less likely to return to racing than males and palmar pouch of the antebrachiocarpal joint (Figure 24.24a).
(a)
(b)
Figure 24.24 Fragmentation from the proximal articular surface of the accessory carpal bone in a TB yearling. (a) Lateromedial
radiograph. (b) Arthroscopic image of the fragment prior to removal.
Accessory Carpal Bone Fracture 539
Theories to explain the pathogenesis of vertical frac- Diagnosis

tures in the accessory carpal bone include the bowstring
Lameness associated with a fracture of the accessory carpal
effect of ulnaris lateralis, flexor carpi ulnaris and the digi-
bone is usually acute in onset. There is often some swelling
tal flexors on the accessory carpal bone when the horse
on the palmar aspect of the carpus and the horse resents
lands on a partially flexed leg, and also the accessory car-
flexion. Fractures are identified radiographically. The lat-
pal bone being caught in a ‘nutcracker’ between the meta-
eromedial view will demonstrate most fractures, but a full
carpus and the radius [78]. It is logical to assume that the
series should be taken to evaluate the fracture fully and to
biomechanical forces associated with the ligamentous
identify concurrent problems. Unstable frontal plane frac-
attachments, together with normal movement of the
tures are usually displaced by flexion. Lateromedial radio-
accessory carpal bone during carpal flexion, are involved.
graphs taken with a small amount of flexion will separate
A retrospective series reported nine frontal plane frac-
fragments and often allow more complete identification of
tures, which all communicated with the carpal sheath. In
comminution (Figure 24.25a and b). The mid-metacarpus
these horses comminuted fragments and/or protruding
should also be imaged with a lateromedial radiograph as
fracture margins lacerated the lateral margin of the
comminuted fragments can descend to the most distal lim-
enclosed deep digital flexor tendon (DDFT). This was
its of the carpal sheath. Ultrasonographic examination
identifiable ultrasonographically and confirmed at tenos-
allows assessment of the effects of fractures on the carpal
copy in seven cases [79].
sheath and its contents [79] (Figure 24.25c).
(a) (b) (c)
(d) (e) (f)
Figure 24.25 Comminuted frontal plane fracture of the accessory carpal bone. (a) Lateromedial. (b) Flexed lateromedial radiographs
demonstrating fracture distraction with flexion. (c) Ultrasonographic image demonstrating impingement of the deep digital flexor
tendon (DF) by the fractured accessory carpal bone (arrows) within the carpal sheath. (d-f ) Tenoscopic images of the protuberant
fracture fragment (F) into the carpal sheath to lacerate the lateral margin of the deep digital flexor tendon (DF). In (d) the carpus is
slightly flexed and in (e) extended demonstrating impingement of the fragment into the tendon. (f) Following removal of the
impinging bone and lacerated flexor tendon. The carpus is extended to ensure the removal of the impingement.
Treatment there is no data to support a positive contribution. A

series of cases of frontal plane fractures in which com-
Fragments from both proximal and distal aspects of the
minuted fragments and/or protruding fracture margins
accessory carpal bone have been reported to respond well
lacerated the lateral margin of the DDFT were evaluated
to either conservative treatment or surgical removal with
tenoscopically. Treatment consisted of removal of torn
return to full athletic function [75]. The author recom-
tendon tissue together with impinging fragmentation
mends arthroscopic removal of dorsoproximal fragments
and protuberant fracture edges (Figures 24.25d–f). Seven
that involve the antebrachiocarpal joint (Figure 24.24b),
of seven cases treated in this fashion returned to work.
while distal avulsion fragments are generally treated con-
One horse with a non-displaced fracture was managed
servatively. The author also recommends a conservative
with immobilization; the fracture healed and the horse
approach to the treatment of vertical and horizontal frac-
returned to work and one horse with a displaced fracture
tures that do not disrupt the carpal sheath and/or
was retired to stud [79].
impinge the DDFT. In a series of 19 conservatively man-
Articular fragmentation is removed arthroscopically with
aged fractures, all of the 11 cases followed up, became
the horse in dorsal recumbency. Distension of the antebra-
sound and six returned to competition [77]. In six cases
chiocarpal joint results in visible outpouching of the palmar
radiographed between six months and three years after
pouch, and the arthroscope is inserted centrally. If fragments
the fracture occurred, none showed evidence of bony
can be recognized by visualization and manipulation, they
union. The usual outcome is a fibrous union, but clinical
are removed. In some instances, fragments will be buried
soundness will commonly result [75]. There has been a
within soft tissue under the synovial membrane. Removal
report of a bony union in a horizontal fracture [76].
can be challenging as the working space is small. Some will
Although carpal canal syndrome has been reported as a
require dissection from the accessorioradial ligament supple-
common sequela to accessory carpal bone fracture [78],
mented with judicious use of a motorized synovial resector.
in the author’s experience this is relatively infrequent,
In conservative management, horses are confined to a stall.
and if it does result, it can be treated by retinaculectomy.
Although maintaining the horse in a standing position and
Various surgical treatments, including lag screw fixation,
the use of external splinting has been described, the author
bone grafting and removal, have been advocated [80–82].
restricts treatment to support bandaging and confinement.
The use of ulnar neurectomy has been described, but
R
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545
25
Fractures of the Radius

A.J. Ruggles
A
natomy the respective carpal collateral ligaments. Laterally, this
has narrow vertical groove for the lateral digital extensor
The adult radius appears an archetypical long bone with tendon. The distal articular surface of the radius is shaped
proximal and distal epiphyses and metaphyses and an for congruency with the radial, intermediate and ulnar car-
elongated intervening diaphysis. However, it develops from pal bones and palmarolaterally the articular surface con-
four centres of ossification as its lateral styloid process is tinues for articulation with the accessory carpal bone.
phylogenetically the distal ulna. Fusion with the distal epi- The radius is prone to injury from external trauma due to
physis of the radius usually occurs during the first year of its location and limited medial soft tissue coverage. Disruption
life, but occasionally incomplete closure has been identi- of structural integrity leads to axial instability and inability to
fied in older animals [1]. The line of fusion usually remains bear weight. Secondary to axial instability fractures are sus-
arthroscopically evident [2]. There is some breed and indi- ceptible to becoming open on the medial aspect of the ante-
vidual variation, but the proximal and distal metaphyseal brachium. In addition, proximal injuries may result in radial
growth plates are generally radiologically closed at approx- nerve dysfunction; affected horses have difficulty in extend-
imately 14 and 24 months of age, respectively, although ing the digit for placement, but once placed the animal can
microscopic evidence of activity can persist for longer [1]. usually bear weight. This occurs most commonly with Salter–
The proximal epiphysis is mediolaterally wide. It has Harris (SH) type II fractures of the proximal lateral aspect of
larger medial than lateral articular surfaces for the humerus the radius in the area of the extensor muscle complex. The
separated by a sagittal ridge; all are covered with hyaline cephalic vein is located superficial to the radius on the medial
cartilage. Caudally, there are two facets for articulation aspect of the limb and is subject to injury from both external
with the ulna and immediately distal to these is a wide and surgical trauma. The cranial and lateral aspects of the
irregular area for insertion of the strong radio-ulnar liga- limb provide soft tissue coverage with the complex of exten-
ment. Craniomedially, the epiphysis is dominated by the sor carpi radialis, common digital extensor and lateral digital
radial tuberosity for insertion of biceps brachii. Abaxially, extensor muscles. The convex cranial cortex is markedly
there are large lateral and small medial tuberosities for loaded in tension. This is of significant practical value in frac-
insertion of the respective cubital collateral ligaments. ture repair as placement of a plate on the tension surface is of
The cranial surface of the diaphysis is mediolaterally flat biomechanical importance. The concave caudal surface is
which provides a stable surface for plate application. The loaded in compression. Thus, failure to anatomically reduce
bone is craniocaudally convex, slightly concave laterally the caudal cortex in fracture repair leads to collapse and is a
and relatively straight medially. significant technical error.
The cranial distal epiphysis bears three prominent proxi-
modistally orientated ridges creating grooves for the com-
mon digital extensor tendon laterally and extensor carpi Fracture Types and Causation
radialis medially. A further oblique groove medially marks
the course of extensor carpi obliquus. There are marked Fractures of the radius are most common in foals and year-
medial and lateral prominences, usually referred to as the lings but can occur in horses of all ages and uses. They are
styloid processes, which mark the centre of attachment of usually the result of direct trauma rather than failure of

546 Fractures of the Radius
adaptive remodelling. Foals getting kicked by another foal’s ment is being considered, it is important to evaluate the
dam when in a group situation is a common cause of proxi- limb radiographically to assess the fracture configuration
mal diaphyseal fractures. Fissure fractures occur more before making a decision about potential management
commonly in adults but can progress to become complete. options. On occasion, horses will suffer fractures of the col-
Fracture configuration is dependent on the biomechanical lateral ligament attachment to the proximal lateral radius
forces applied and the age of the animal [3–5]. An experi- from a direct blow. This injury may be associated with a
mental model revealed medial impacts to the centre of the wound into the cubital joint and protocols for an open and/
radius mimicked clinical fractures [4]. Physeal injuries can or infected joint including systemic, local and intra-
be seen throughout animals’ yearling year. Pathological articular antimicrobial agents, articular lavage and poten-
fracture through an aneurysmal bone cyst has been tial debridement of the affected bone all need to be
reported [6]. considered (Figure 25.1). Development of degenerative
In foals, most fractures are closed [7]. Occasionally, soft joint disease is a potential sequela of these injuries.
tissue loss may result in SH type II or III open fractures
which is likely to complicate surgical outcomes. Adults are
more likely to have open diaphyseal fractures as the distal Imaging and Diagnostics
end of proximal fragments tend to displace medially perfo-
rating the forearm soft tissues as the horse attempts to bear Diagnostic imaging chiefly consists of a well-exposed set
weight and the distal limb abducts (Chapter 7). of standard radiographic views at 45° angles to the entire
radius. With the availability of digital radiography, the
identification and evaluation of the extent of the fracture
Clinical Features and Presentation can usually be made stall side. Images can then be sent to
a referral centre for further assessment, consideration of
Horses with radial fractures are usually severely lame and treatment options, first aid advice and determination of
most are non-weight-bearing. There is often soft tissue potential outcome. Some subtle fractures including fis-
swelling and potentially a skin injury or defect typically on sure fractures, non-displaced SH fractures and develop-
the medial side of the antebrachium. If the fracture is coming sequestra may initially be difficult to detect and
plete, there may be deviation of the limb in dorsal, sagittal require serial radiographic studies. Additionally, all radi-
or in both planes. Instability and crepitus may be palpated ographs should be carefully evaluated to check for addi-
and deformity may be exacerbated with abduction of the tional fissure lines distant to the most obvious fracture
limb. All complete fractures will feel unstable so, if treat- which may complicate repair. Stressed views to highlight
(a) (b) Figure 25.1 A three-day event horse that

suffered a kick wound two weeks prior to
presentation. (a) Purulent fluid drained from a
small lateral wound on the antebrachium. (b)
Craniocaudal radiograph demonstrating an
intra-articular fracture of the proximal lateral
radius. Synoviocentesis confirmed infection of
the cubital joint which was treated
arthroscopically. The fragments were removed
by an open surgical approach.
medial to lateral instability can be especially useful in the Fissure Fractures

diagnosis of SH fractures of both proximal and distal
Fissure fractures of the radius occur typically in adults.
radial physes. Nuclear scintigraphy and ultrasound are
Generally, the horse is moderately to severely lame. It may
not typically required except in cases of undiagnosed fis-
be associated with wound from a blow or kick. For this rea-
sure fractures or evaluation of draining tracts which may
son, any horse with a wound to the antebrachium, clinical
be associated with sequestra formation. The author has
signs consistent with sequestrum formation or persistent
not used pre- or intra-operative computed tomography
lameness is at risk of having a fissure fracture and should
for the evaluation and treatment of radial fractures.
be radiographed to identify potential fissure lines.
However, as technology evolves and equipment with ade-
Fissure fractures carry a risk of progression to cata-
quate bore diameter becomes available, this has the
strophic failure and use of overhead restraints, cross-ties or
potential to be contributory.
slings have been advocated to prevent the horse from lying
down and potentially disrupting the fracture when rising
from recumbency. The use of these devices varies between
Acute Fracture Management clinicians and is somewhat dependent on the nature of the
horse, the ability to monitor the horse in the restraint and
First aid depends on whether fractures are complete or risk avoidance. In the author’s experience, many horses
incomplete. Incomplete or fissure fractures are not usually can be managed without overhead restraints with stall rest
splinted. For complete fractures, first aid is aimed at pre- alone which should be considered a reasonable option of
venting the fracture from becoming open on the medial itself. A period of at least eight weeks of stall rest is recom-
aspect of the forearm or limiting soft tissue injury. Splinting mended prior to any hand walking or turnout. Judicious
consists of a light bandage with caudal and lateral splint- use of analgesics is recommended in an effort to provide
ing, extending from the ground to elbow and the ground to comfort but to prevent overactivity while confined or
proximal scapula, respectively (Chapter 7). Heavy bandag- restrained [8–12].
ing makes keeping the splints in place more difficult. This
type of splint will allow the horse some awkward use of the
limb but will reduce anxiety and allow transport. Horses Repair of Simple Diaphyseal Fractures
with forelimb injury are generally better hauled backwards
These fractures occur most commonly as a result of a kick.
in the van or trailer to allow the hindlimbs to absorb the
The limb is unstable and soft tissue swelling is variable.
force when the vehicle stops which is more difficult to con-
Most fractures in foals are closed.
trol than during acceleration. First aid should also include
pain management in the form of non-steroidal anti-
Implant Selection
inflammatory agents (Chapter 7), dressing of any wounds
Cortex screws placed in lag fashion reduce shear forces and
and the administration of antimicrobial agents if the frac-
provide inter fragmentary compression of fracture frag-
ture is open or there is a concern that it will become open
ments. They should be used whenever possible for both
during transport to a surgical facility. Not all equine surgi-
fracture reduction and in plate application. In the radius
cal facilities are equipped to deal with radial fractures so a
because of the high torsional, bending and compressive
clear understanding of facilities, implant inventory and
forces present, screws applied in lag fashion are relatively
surgical experience should be taken into account prior to
weak compared to plate fixation. Ideally, four bi-cortical
referring or accepting the referral.
screws should be placed above and below the fracture line
in each plate, but it is acknowledged that some fracture
configurations do not allow this.
reatment Options
T Bone plates are used for the repair of nearly all radial
and Recommendations fractures in the horse. They have advantages over other
methods of repair by their ability to counteract axial com-
Radial fractures occur in a variety of configurations, and pression, bending and torsion loads that are applied to the
repair methods vary according to type and location. Some bone. The bending stiffness of a plate is related to the third
non-displaced fractures can be treated with rest alone. power of its thickness and directly proportional to its mod-
Other small cortical fractures can lead to sequestra forma- ulus of elasticity. It is therefore easiest to increase the stiff-
tion and require removal. Although fractures in adults are ness of the implant–bone construct by choosing thicker or
often open, comminuted and catastrophic, some are multiple plates. Anatomic reconstruction of the fractured
amendable to internal fixation. bone is an absolute requirement for successful repair.
Failure to properly reconstruct the bone prevents load ing within the plate hole providing increased stability [17].
sharing between implants and bone and quickly leads to A disadvantage of fixed angle technology in the LCP is
failure of the construct. Double plate fixation is the method increased difficulty in avoiding other screws, especially
of choice for the management of most radial fractures in when double plating. This can also result in screws being
the horse [13, 14]. Some simple diaphyseal fractures in placed in a single cortex without crossing the medulla
foals can be managed with a single cranial plate, and use of which causes a stress riser and can lead to catastrophic fail-
a single plate and cerclage cables to repair a proximal radial ure [18]. In adults, particularly with proximal or distal frac-
fracture has been reported in a small (395 kg) horse [15]. tures, the use of a dynamic condylar screw (DCS) system
One report describes the use of screws alone for distal should be considered [19, 20]. This allows adequate pur-
radial fractures in the sagittal plane [16]. Application chase in the proximal or distal aspect of the bone which
guidelines for single plate fixation have not been estab- might be difficult with other plating techniques. In gen-
lished. The author routinely places a shorter secondary eral, the larger plate is used on the cranial aspect of the
plate on the medial or lateral side of the bone to improve radius which is the tension surface of the bone and the sec-
construct stiffness and patient comfort and to reduce the ondary plate, which is typically shorter and possibly of nar-
likelihood of cyclic fatigue of the implants. The ultimate rower profile, is placed 90° to the broad plate. Placement of
site for plate placement is determined by fracture configu- a plate on the tension surface is biomechanically advanta-
ration, relevant tension and compressive surfaces of the geous since the plate-bone construct has its greatest stiff-
bone, adjacent soft tissue anatomy and the presence of any ness when placed in tension compared to compression.
associated wounds. Placing a second plate at 90° to the first optimizes resist-
In most foals, a combination of a broad, 4.5 mm dynamic ance to axial compression, bending and torsional loads.
compression plate (DCP) and a narrow, 4.5 mm DCP are One of the plates can have both compression and neutrali-
used for double plate fixation (Figure 25.2). Limited con- zation functions, whereas the second plate is typically used
tact dynamic compression plates (LC-DCP) or locking as a neutralization plate. This technique of bone-plate
compression plates (LCP) can be substituted for DCP placement optimizes load sharing, diminishes compres-
plates. LCPs have the advantage of not requiring the screw sion forces and reduces cyclic fatigue. The tension surface
holes to be tapped and prevent the screw head from mov- of the radius can be altered by coaptation. Placement of a
(a) (b) (c) (d)
Figure 25.2 Pre-operative (a, b) and post-operative (c, d) radiographs of a five-day old Saddlebred with a complete transverse
mid-diaphyseal fracture of the radius treated with a broad 4.5/5.0 LCP on the cranial cortex and a narrow 4.5 mm DCP on the medial
surface. A combination of locking and cortex screws was used in the former with cortex screws in the latter.
full-limb cast from foot to elbow converts the caudal sur- radialis (Figure 25.4). If there is a wound associated with
face of the bone, which is normally compressive into a ten- the fracture, this influences the decision regarding surgical
sion surface [21]. Such casts weaken the repair and are not approach. It is recommended that incorporating the wound
recommended. in the surgical incision is avoided. Similarly, separate
instruments should be used to debride and if possible close
Surgical Techniques the wound prior to commencing the primary repair. In the
Surgical approach and position of the horse/leg can be var- medial approach and when dealing with medial wounds,
ied according to surgeon preference. There are two com- care should be taken to isolate and avoid the cephalic vein.
mon approaches that can be used alone or in combination. The fracture is identified and minimal periosteum is dis-
The first is medial to the extensor carpi radialis muscle. rupted. In young animals, identification of the proximal
This approach allows access to the entire medial and cra- and distal growth plates with hypodermic needles is help-
nial aspects of the radius. The second approach is between ful to prevent the implants from crossing these. Fracture
the extensor carpi radialis and common digital extensor reduction is aided by a combination of traction, tenting (in
muscles which gives access to the lateral and cranial transverse fractures) and walking (in oblique fractures) the
aspects of the radius. fracture ends. After tenting the facture ends out of the inci-
This author prefers positioning most radial fractures in sion, the caudal cortices of the fracture are engaged before
dorsal recumbency with the distal limb attached to an over- pressing the cranial cortices back into position to achieve
head hoist (Figure 25.3). This allows access to the cranial, reduction. ‘Walking’ to reduction involves pushing the fac-
medial and lateral aspects of the radius and permits trac- tures ends down the incline plane of an oblique fracture
tion to aid reduction. It is important to securely tether the while using reduction forceps to secure alignment. Axial
distal limb to the hoist so that by dropping the table trac- traction can be accomplished in dorsal recumbency by low-
tion can be applied. The limb should be positioned directly ering the table if the limb is tethered to the ceiling. If neces-
under the hoist to improve axial and dorsal plane align- sary, a mediolaterally placed Steinmann pin in the distal
ment. For most fractures, the author typically uses the fragment can act as a handle to apply axial traction.
approach along the medial border of the extensor carpi Alternatively, a calf jack or similar device can be used.
Once reduction is obtained, it can be maintained with
Figure 25.3 TB foal in dorsal recumbency prior to repairing a Figure 25.4 Intra-operative photograph of a medial approach
distal diaphyseal fracture of the radius. It is important to to the radius of the foal in Figure 25.2 after placement of broad
position the animal such that the limb remains straight in all (cranial) and narrow (medial) LCPs. Note the extensor carpi
planes to facilitate reduction and implant placement. radial muscle over the proximal aspect of the cranial plate.
c ortex screws in lag fashion or reduction forceps while a

plate(s) is applied. Care must be taken to ensure accurate
anatomic reduction and alignment. It is imperative that
good cortical contact is achieved on the caudal surface as
this is the compressive side of the bone. Failure to achieve
complete reduction of the caudal cortex is likely to result in
fixation failure. In most fractures in foals and all fractures
of the diaphysis in adults two plates are applied at 90° to
each other (Figure 25.5).
Occasionally, fractures of the radius are accompanied by
ulnar fractures. If they are very distal in the ulna, surgical
repair is not usually needed. One exception to this is the
combination of proximal radial physeal and mid-ulnar
fractures. In this circumstance, counteracting the caudal
tension forces on and through the ulna is required for suc-
cessful fixation.
The use of DCP, LCP or DCS plate/screw system (typi-
cally more distal or proximally located fractures in adults)
is based on the size of the animal, fracture configuration
and location and surgeon preference (Figure 25.6). Adult
radial fractures are typically distal and are often open.
Difficulty in obtaining enough purchase on the distal seg- Figure 25.6 Post-operative radiograph of a 550 kg Warmblood
gelding with a distal radial fracture repaired using a
ment of bone can be overcome with the use of the DCS combination of a laterally placed DCS plate and cranial broad
plate system. Care must be taken to stagger the plates and 4.5 mm DCP.
avoid interference with screws especially in fixed angle
implant systems. Screws should traverse the medulla to lead to fracture. Typically, a longer broad plate is placed on
prevent stress concentration in a single cortex which may the tension side of the radius which is cranial and a shorter
and possibly narrow plate placed on the medial or lateral
side depending on the fracture configuration. Another rea-
son for the longer cranial plate is the difficulty in keeping
the plate on the entire medial or lateral cortex of the radius
due to its bowed shape. Antimicrobial beads and closed
suction drainage are commonly used. Standard soft tissue
and skin closure with minimal bandaging are recom-
mended. Hand assisted recovery, slings or pool recovery
systems have all been used for recovery. In young animals
and ponies, hand recovery is usually sufficient (Chapter 10).
Comminuted fractures occur most commonly in adults
and often require alterations in surgical approach and tech-
nique. The guiding principle is to try to make the fracture
into two major components and then reconstruct the bone
as for a simple diaphyseal fracture. Careful pre-operative
planning including placement of separate cortex screws in
lag fashion can accomplish this but avoiding interference
with additional implants is important.
Physeal Fractures
Figure 25.5 Post-operative radiograph of a diaphyseal radial
Physeal fractures occur both at proximal and distal ends of
fracture in a 425 kg Tennessee Walking Horse gelding repaired
with two broad 4.5 mm DCPs using a combination of 4.5 and the radius. Salter–Harris (SH) type II fractures are com-
5.5 mm cortex screws. monest and frequently involve the proximal growth plate.
Physeal Fracture 551
SH type I fractures are less common and, in the author’s ulnar plate should avoid engaging the caudal cortex of the
experience, are most frequent distally. Other SH fractures radius to prevent subluxation of the elbow joint caused by
can occur but are less common then types I and II. linkage of the ulna to the radius and subsequent distal dis-
traction of the ulna as the radius lengthens [22]
(Chapter 26). A closed suction drain is used if significant
Proximal Radius
haematoma/seroma is anticipated. Typically, antimicrobial
Animals with SH type II fractures of the proximal radius impregnated beads are placed within the wound whether
often have fractures of the ulna that are situated distal to the fracture is closed or open [23]. The incisions are closed
the growth plate. When ulnar fractures are seen in this in multiple layers of muscle bellies, muscular fascia, sub-
location, it is important to look carefully for SH II fractures cutaneous tissues and skin. Stent bandages are usually
of the proximal radius. Proximal fractures characteristi- applied. Implant removal is recommended in an attempt to
cally have a medial metaphyseal spike. These are usually allow the growth plate to resume function and prevent
closed but soft tissue swelling is variable and can be severe. development of angular deformity. In foals, implant
Some animals have a degree of peripheral radial nerve removal is usually performed 45–90 days post-operatively
injury that may affect use of digital extensors pre-and post- depending on the animal’s age and radiographic healing.
operatively. Radiographs typically reveal distraction of the Prior to implant removal, it is recommended that the ani-
lateral aspect of the physis. Fracture biomechanics require mal is given at least 30-day pasture activity so that the bone
the lateral side of the fracture to be fixed rather than the undergoes loading and the risk of re-fracture is reduced.
tendency to place implants medially over the metaphyseal
spike using screws in lag technique. This fails to counteract
Distal Radius
the tension force on the proximal lateral radius. A second
construct, usually consisting of plates and screws over the SH type I fractures of the distal radial growth plate usually
ulna, is usually added but in young foals’ figure of eight present with soft tissue swelling, lameness and if displaced
wires are occasionally used. On occasion, SH II fractures of deformity of the limb in the sagittal and occasionally frontal
the proximal radius are non- or minimally displaced and planes. Radiographs generally reveal physeal incongruity
can be managed non-surgically based on the horse’s com- but in some cases a mediolaterally stressed cranial–caudal
fort (Figure 25.7). If displacement occurs, surgical manage- view is needed to demonstrate the fracture. The degree of
ment can be instituted. lameness and soft tissue swelling depend on the degree of
The foal is positioned with the affected limb up. The fore- displacement. The principles of first aid immobilization are
arm region is prepared for aseptic surgery. Two incisions similar to adults (Chapter 7), but foals have limited toler-
are needed: one between the extensor carpi radialis and ance of bandage/splint bulk and weight. A light cast can be
common digital extensor for the proximal lateral construct useful for transport, to protect soft tissues and to allow nurs-
and a second over the caudal lateral ulna for repair of the ing while management decisions and arrangements are
ulnar fracture. The fracture hematoma is removed and made. However, external coaptation alone is not generally a
reduction effected by applying traction and trying to tent viable treatment method due the inherent instability of the
the proximal lateral aspect of the parent radius into the fracture, risk of it becoming open and the complications of
fracture gap. flexor laxity and pressure sores secondary to cast applica-
Reduction can be difficult with chronic fractures or tion. Methods of fixation include use of single or multiple
extreme swelling. Time and care should be taken to ensure transphyseal bridges (TPB) with cortex screws and figure of
that anatomic reduction is achieved. A transphyseal screw eight wire and/or plate/screw fixation. Technique decisions
can be placed caudal to the expected site of the plate to are based on the configuration of the fracture and size of the
maintain reduction and provide initial compression across animal [24]. An understanding of the biomechanics par-
the fracture plane. A five to six hole narrow 4.5/5.0 mm/ ticularly the distracting tension forces (typically on the side
DCP, LCP or LCP T-plate is then fashioned to the proximal away from the metaphyseal spike) guides implant location.
lateral radius. Depending on the plate, 4.5, 5.5 mm cortex In a growing animal, the placement of a TPB on both the
or a combination of these with 5.0 mm locking screws are medial and lateral aspects of the distal radius should be
used to repair the fracture. The ulnar fracture is repaired considered to prevent the development of angular limb
using an DCP or LCP plate with appropriate cortex or lock- deformity. Use of a sleeve cast or splinting for recovery from
ing screws (Figure 25.8). Care should be taken to ensure general anaesthesia and in at least the immediate post-
that the plate extends proximally on to the ulnar apophysis operative period is recommended.
to prevent a stress riser effect and fracture at the top of the TPB can be placed through stab incisions with the wires
plate. In horses less than one year of age, screws in the tunnelled subcutaneously. The animal is placed in dorsal
Presentation 2 Weeks
6 Weeks 9 Weeks
6 Months 14 Months
Figure 25.7 Non-surgical management of a Salter–Harris type II fracture in an eight-week-old TB foal. Lateromedial and
caudocranial radiographs obtained at presentation and at 2, 6 and 9 weeks, 6 months and 14 months after injury. The animal grew
normally and raced as a two-year old.
recumbency for ease of reduction and to enable medial and one or two 5–6-hole DCP or LCP plates can be placed at 90°
lateral placement of TPBs. Reduction can be performed to each other to increase construct stability (Figure 25.9).
closed and confirmed radiographically, but if necessary a Care should be taken to avoid ending plates at the same
small incision over the physis can be used to aid and con- level or in the mid-diaphysis of the bone.
firm reduction. A 4.5 mm cortex screw is placed in the dis- SH type III fractures of the distal radius cause lame-
tal epiphysis and metaphysis and linked with a 1.25 mm ness and swelling but do not typically cause angular
figure of eight wire tunnelled subcutaneously. In addition deformity. These fractures can involve either medial or
to preventing angular deformity placing TPBs medially and lateral aspects. Treatment principles include accurate
laterally improves fixation. In most animals, more than anatomic reduction of the antebrachiocarpal joint sur-
one TPB can be placed at each site if required. If larger face and use of a tension band to counteract distracting
implants are needed for stability and in SH type II fractures, forces from the collateral ligaments. The screws placed in
Post-operative Managemen 553
Post-operative Management
The use of sling or pool recovery systems is advantageous

with radial fractures in adults, although in foals and wean-
lings these are difficult to employ and are not generally
necessary (Chapter 10). In the author’s practice, horses of
all sizes are attended in recovery using a head and tail rope
with the animal on a well-padded mat with good footing.
Minimal bandaging consisting of light adhesive or sutured
stent bandages are usually used and changed as needed
until suture/staple removal 10–12 days post-operatively.
The use of a closed suction drain system is typically discon-
tinued 48–72 hours post-operatively. Antimicrobials are
generally given for 5 days post-operatively, and non-
steroidal anti-inflammatory use is tapered down over a 10-
day period. Anti-ulcer medication, limited use of opioid
Figure 25.8 Post-operative radiographs of an 18-month-old transdermal patches and probiotics are at the surgeon’s dis-
Quarter Horse gelding with an SH type II fracture of the
proximal radius and a distal ulnar fracture repaired with a cretion. Exercise instructions are dependent on the type of
narrow 4.5 mm DCP on the ulna and a 4.5/5.0 mm human narrow fracture and age of patient. In general, foals will have
proximal tibial LCP on the lateral radius. period of four to six weeks of strict stall confinement
whereas adults would more likely have a period of at least
the epiphysis act to both reduce and compress the articu- eight weeks. Following progressive controlled exercise or
lar fracture and as anchors for figure of eight wires limited outdoor activity will be based on age, comfort, and
secured proximally with a single or multiple metaphyseal degree of healing. Implants are generally removed if the
screws. The use of washers is recommended to prevent horse is to be athletic. Most important is the removal of the
wires from slipping over distal screw heads where they cranial plate and any implants that join the cranial and
also have a compressive function. Washers should also be caudal cortices. It may not be important to remove implants
placed under the proximal screw head if it is anchoring on the lateral or medial aspect of the radius for athletic use.
multiple wires (Figure 25.10). If plate removal is elected, the author recommends at least
(a) (b) (c)
Figure 25.9 Pre-operative (a) and post-operative (b, c) radiographs of a 400 kg Warmblood with a displaced SH type II fracture of the
distal radius repaired with two broad 4.5/5.0 mm LCPs fixed with a combination of locking and cortex screws.
(a) (b) Figure 25.10 Pre-operative (a) and post-operative

(b) radiographs of a two-year-old Standardbred
gelding with a distal medial articular fracture of
the radius. The two distal cortex screws function to
reduce and compress the articular fracture and act
as an anchor for the tension band to counteract the
distracting forces of the medial collateral ligament.
Note the use of washers on all screws to enhance
the compressive function of the distal screws and
to prevent wire slippage.
30 days of turnout to stress the radius prior to plate removal. come. Displaced radial fractures can be amendable to
Staged plate removal is also advocated to reduce the risk of surgical management. In one study, 18/22 (82%) repairs in
refracture. Specific guidelines that address implant removal animals less than two years of age were successful whereas
in the horse have not been established but this programme only 6 of 18 (33%) horses greater than two years of age
has worked well. If the animal is to have low level activity survived. Transverse fractures, of which seven of seven
or to be pasture sound for breeding, then implant removal (100%) were treated successfully, only occurred in animals
is not required unless this is to deal with post-operative six months old or less. Comminuted fractures were most
infection or to prevent limb deformity. likely to occur in adults but were only successfully treated
in two foals. Open fractures became infected post-
operatively in 3 of 4 cases (75%), and infection was a com-
Results plication of 7 of 24 (29%) repaired fractures [7]. In a study
of post-operative orthopaedic infections, radial and femo-
There are few publications detailing outcomes for radial ral fractures and fetlock arthrodesis procedures were most
fractures; most consist of case reports. In general terms, as likely to develop an infection post-operatively and less
with most fractures, closed, simple mid-diaphyseal frac- likely to be discharged [25].
tures in small animals do best [14, 25]. Non-displaced frac- In another report of adult horses, two of nine (22%)
tures can be treated successfully non-surgically. Successful horses with complete fractures treated with internal fixa-
management of physeal fractures in foals requires an tion using plates and screws survived, highlighting the dif-
understanding of pertinent biomechanics and considera- ficulty in treating adults with complete, displaced radial
tion of future growth needs for successful athletic out- fractures [26].
References
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2 McIlwraith, C.W., Nixon, A.J., and Wright, I.M. (2005). J. 44: 714–720.
Diagnostic Arthroscopy of the Carpal Joints in Diagnostic 5 Fuerst, A.E., Oswald, S., Jäggin, S. et al. (2008). Fracture
and Surgical Arthroscopy in the Horse, 3e, 56. Edinburgh: configurations of the equine radius and tibia after a
Mosby. simulated kick. Vet. Comp. Orthop. Traumatol. 1: 49–58.
3 Schroeder, O.E., Aceto, H.W., and Boyle, A.G. (2013). A 6 Ordidge, R. (2001). Pathological fracture of the radius
field study of kick injuries to the radius and tibia in 51 secondary to an aneurysmal bone cyst in a horse. Equine
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Reference 555
7 Sanders-Shamis, M., Bramlage, L.R., and Gable, A.A. 18 Kuemmerle, J.M., Kühn, K., Bryner, M. et al. (2013).
(1986). Radius fractures in the horse: a retrospective Equine ulnar fracture repair with locking compression
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Conservative management of minimally displaced radial 19 Janicek, J.C., Wilson, D.A., Carson, W.L. et al. (2009). An
fractures in three horses. Aust. Vet. J. 80: 44–47. in vitro biomechanical comparison of dynamic condylar
9 van Veen, L. and de Greef, R.J. (2005). Conservative screw plate combined with a dorsal plate and double
treatment of open incomplete radial fracture in an adult plate fixation of distal diaphyseal radial osteotomies in
horse. Tijdschr. Diergeneeskd. 130: 375–377. adult horses. Vet. Surg. 8: 719–731.
10 Martin, B.B. and Reef, V.B. (1987). Conservative 20 Rodgerson, D.H., Wilson, D.A., and Kramer, J. (2001).
treatment of a minimally displaced fracture of the radius Fracture repair of the distal portion of the radius by use
of a horse. J. Am. Vet. Med. Assoc. 191: 847–848. of a condylar screw implant in an adult horse. J. Am. Vet.
11 Derungs, S., Fuerst, A., Haas, U. et al. (2001). fissure Med. Assoc. 218: 1966–1969.
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14 Stewart, S., Ricahrdson, D., and Boston, R. (2015). Risk 23 Schneider, R.K., Andrea, R., and Barnes, H.G. (1995). Use
factors associated with survival to hospital discharge or of antibiotic-impregnated polymethyl methacrylate for
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15 Bolt, D.M. and Burba, D.J. (2003). Use of a dynamic 24 Rutherford, D.J., Textor, J., and Fretz, P.B. (2007). Surgical
compression plate and a cable cerclage system for repair management and outcome of a type-III Salter-Harris
of a fracture of the radius in a horse. J. Am. Vet. Med. fracture of the frontal plane of the distal radial physis in a
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557
26
Fractures of the Ulna

I.M. Wright
A
natomy the radius and remaining ulnar cortex imperceptibly blend.
The bulk of the ulnar diaphysis forms a fibrous syndesmo-
The equine ulna develops from three principal ossification sis with the caudolateral radius that ossifies distally. The
centres: one for its diaphysis, one for its proximal (olecra- osseous union progresses proximally with age but leaves a
non) tuberosity and a distal epiphyseal centre that unites large interosseous space just distal to the radio-ulnar artic-
with the radius as its lateral styloid process. Closure of the ulation through which the interosseous artery passes from
proximal (olecranon) apophysis occurs between 30 and medial to lateral. In most individuals, the ulna terminates
40 months of age [1], although effective growth slows by complete union with the radius at approximately the
markedly between 15 and 18 months [2] which is an impor- mid-point of the radial diaphysis. Occasionally, as a normal
tant consideration in fracture repair. variant it will extend further distal.
The olecranon tuberosity forms the bulk of the equine The cubital joint is purely ginglymus permitting unipla-
ulna (Figure 26.1). It is convex laterally and concave medi- nar sagittal flexion and extension only. Interdigitation of the
ally. Its proximal (apophyseal) portion is irregular at sites of deep semilunar notch and anconeal process of the ulna
musculotendinous insertions. The remaining periosteal sur- with the olecranon fossa of the humerus provides substan-
faces are smooth. A cranial eminence, the anconeal process, tial lateromedial stability. Biomechanically, the dominant
forms the caudal boundary of the semilunar (trochlear or force experienced by the olecranon and ulna are from tri-
ulnar) notch and articulates with the humerus. Occasionally, ceps brachii whose insertions envelope the rough proximal
the anconeal process can have a separate centre of ossifica- apophysis. This creates a near-perfect tension band trans-
tion. The humero-ulnar articular surface is separated by a mitting cranioproximal force from the muscle through the
synovial fossa from the two facets of the immovable radio- ulnar diaphysis to the radius. The anconeus also inserts on
ulnar articulation which, in mature animals, can at least the lateral aspect of the ulna beneath the lateral head of tri-
partially ossify. The caudal surface of the ulna is narrow, ceps brachii. Heads of flexor carpi ulnaris and deep digital
mediolaterally sharply convex, and at the junction with the flexor originate from the medial surface of the olecranon.
irregular apophysis there is a variably protuberant promi- The cubital joint has well-developed collateral ligaments
nence. The caudal profile of the ulna, including the olecra- medially and laterally. The medial collateral ligament
non, is straight in foals and concave in adults [3]. The ulna is attaches proximally to an eminence on the medial epicon-
proximomedial to distolateral oblique with respect to the dyle of the humerus. A short, deep part inserts on the
radius. Distally, the ulna is situated on the caudolateral medial tuberosity and a long, superficial part further dis-
aspect of the radius with which, in most horses, it blends. tally on the radius. The lateral collateral ligament extends
The lateral surface of the body of the ulna is flat, and the between a depression on the lateral epicondyle of the
medial surface slightly concave [1]. The apophysis consists humerus and the lateral tuberosity of the radius. The radio-
of dense cancellous bone with more conventional cortico- ulnar articulation consists of two small convex facets on
cancellous organization in the bulk of the olecranon. A the ulna and corresponding facets on the caudal surface of
medullary cavity is found at the junction of the olecranon the radius. This is enclosed within a common fibrous
and the diaphysis of the ulna. Distal to this point, the capsule with the cubital joint. Between the radio-ulnar
medulla progressively narrows until the caudal cortex of articulation and interosseous foramen, the bones are

558 Fractures of the Ulna
(a) (b) (c) (d)
(e)
Figure 26.1 Anatomical specimen viewed from cranial (a), caudal (b), lateral (c), medial (d) and proximal (e) illustrating the osseous
anatomy of the ulna and its relationship to the radius in a skeletally mature horse.
c onnected by a short strong radio-ulnar ligament that in fractures are occasionally seen. However, the majority of
mature horses can partially ossify. Distal to the interosse- fractures result from trauma. Falls and kicks from other
ous foramen in foals, radius and ulna are connected by an horses are most common [7–11, 14–17]. The latter are fre-
interosseous ligament that undergoes osseous metaplasia quently accompanied by a wound or abrasion [10, 15, 18].
before skeletal maturity [4]. Most fractures are transverse or oblique to the long axis of
the bone. Fractures occasionally are encountered in recov-
ery from general anaesthesia: these usually are commi-
I ncidence nuted and displaced (Figure 26.2).
Fractures of the ulna are common [5–10]; they are probably

the most common non-racehorse long bone fracture. They Fracture Types and Classification
are seen in horses of all ages [10, 11] and types, but young
animals appear over-represented [2, 12, 13]. In one study, 34 Fractures of the ulna may be simple, comminuted, articular
of 49 (79%) cases were in horses less than two-years old [6]. or non-articular and can exhibit varying degrees of displace-
In another, 11 out of 25 fractures (44%) were in foals six- ment [15]. They have been classified into five broad types, but
months old and 9 out of 25 (36%) were in animals between there are several variations on the classification system [5, 10,
six-months and three-years old [11]. Comminuted fractures 11, 14, 17, 18]. Fracture classifications can be useful but,
appear to be more common in adults than juveniles [8]. particularly with trauma-induced monotonic fractures, fail to
encompass the spectrum of configurations encountered in
Aetiology clinical practice. They will therefore be referred to but, in the
author’s opinion, description of the individual fractures is
Fractures of the ulna are considered to be monotonic. In more accurate and optimizes management decision-making.
young foals, apophyseal avulsion (Salter–Harris type I) Additionally, although the Salter–Harris scheme for
Fracture Types and Classificatio 559
c lassification of fractures involving the proximal ulnar

growth plate has been used, this is an apophysis, not a meta-
physeal growth plate, and this system has been
questioned [19].
Apophyseal avulsion (Salter–Harris type I) also referred
to as Type 1 [18] or Type 1a fractures [5, 10, 14, 19] are usu-
ally seen in neonates (Figure 26.3a). Displacement is highly
variable. It can range from a subtly altered angle between
the apophyseal centre of ossification and body of the olec-
ranon to substantial proximal and cranial displacement.
Foals with the latter are unable to fix the elbow while cases
with the former present with lameness.
Salter–Harris type II fractures, classified as Type 1a if non-
articular and 1b if articular [5], as Type 2 [18] or Type 1b [10,
14, 17], are seen in older foals and yearlings [9, 10, 17] and
have been reported to be the most common configuration in
animals less than one-year old [14]. Such fractures can be
articular and exit through the trochlear notch or, less com-
monly, exit proximal to the anconeal process and remain non-
articular [17] (Figure 26.3b). In one series of 24 cases, 19 (79%)
involved the articular surface, 12 (50%) were comminuted and
of these 4 (17%) had fragmentation of the anconeal pro-
Figure 26.2 Comminuted and widely displaced fracture of the cess [14]. They usually result from impact trauma [10]. When
olecranon tuberosity sustained by a broodmare in recovery from
present, displacement is usually cranial [14].
general anaesthesia for dystocia.
Transverse, oblique and comminuted humero-ulnar
articular fractures entering the trochlear notch are most
frequently encountered in animals over one-year old [17]
but are also seen in foals. Simple transverse and oblique
(a) (b)
Figure 26.3 Apophyseal fractures. (a) Salter–Harris type I avulsion with proximal and cranial displacement of the apophysis in a foal.
(b) Salter–Harris type II fracture with marked cranial displacement in a yearling.
fractures have been classified as Type 2 [5, 10, 14, 17] or Fractures involving the ulnar diaphysis commencing at
Type 3 [18] (Figure 26.4). Comminuted fractures almost or distal to the radio-ulnar articulation have been classified
invariably have an articular component and have been as Type 5 and described as entering the distal part of the
classified as Type 4 [5, 10, 14, 17]. These can exhibit a wide trochlear notch [10, 14, 17]. In one study, 30 out of 32 (94%)
range of comminution and complexity (Figure 26.5). were found to involve the distal semilunar notch at the
(a) (b)
(c) (d)
Figure 26.4 Variations in simple humero-ulnar articular fractures in foals (a) and (b) and in skeletally mature animals (c and d) .
Fracture Types and Classificatio 561
(a) (b) (c)
(d) (e) (f)
Figure 26.5 Variations in comminuted fractures involving the humero-ulnar (a–d) and radio-ulnar (e, f) articulations in foals (a, b)
and in skeletally mature horses (c–f).
level of the synovial fossa [15]. In the author’s experience, est with fractures at and distal to the level of the articular
a further group enter the radio-ulnar articulation. These notch and is usually minimal with fractures further distad
fractures may be transverse, comminuted or caudodistal to which are stabilized by the radio-ulnar ligament.
cranioproximally oblique (Figure 26.6). Integrity of at least On rare occasions, the traumatic insult will be sufficient
a portion of the radio-ulnar ligament appears an important to result in concomitant fracture of the radius and/or
indicator of stability and thus propensity to displace. d isrupt cubital support resulting in concurrent luxa
Displacement is therefore often less marked than with tion or subluxation [20]. In foals, failure generally
more proximal fractures. In a series of 32 cases, 20 were occurs through the proximal radial metaphyseal growth
nondisplaced, 9 mild and 3 moderately displaced; none plate [18] (Chapter 25). These are often referred to as
were severely displaced [15]. Monteggia fractures.
Transverse and oblique fractures confined to the proxi- The frequency distribution of fractures is in large part
mal, non-articular olecranon, classified as Type 3 frac- influenced by geography which, in turn, is a major deter-
tures [5, 10, 14, 17], are uncommon (Figure 26.7). minant of breed, age and use of catchment horses. The
Proximal fractures have a propensity to displace which, largest single centre data available gives incidences of 7, 31,
due primarily to traction from triceps brachii, is proximal 9, 1, 16, and 36% for fracture types 1a, 1b, 2, 3, 4, and 5,
with cranial rotation. Displacement is generally more mod- respectively, in a series of 77 horses [14].
(a) (b)
(c) (d)
Figure 26.6 Variations in simple fractures involving the radio-ulnar articulation.
Clinical Signs adjacent to the radio-ulnar articulation [15]. This posture

results from displaced fractures that disarm the triceps
Acute severe lameness accompanies most cases. Although apparatus such that the cubital joint cannot be fixed. It
described as usually resulting in a ‘classic dropped elbow’ often causes marked anxiety and is usually accompanied by
appearance (Figure 26.8) [8, 9], this is not consistent [10]. It repeated lifting and placing activity. The further distal the
was recorded in 13 of 22 horses (59%) with mixed fracture fracture location the more likely it is to retain stability. Local
types [21], 15 of 23 (65%) animals with Salter–Harris type II soft tissue swelling due to haemorrhage and contusion is
fractures [14] and 4 of 19 (21%) of animals with fractures common [9, 10, 17]. In the acute phase, the degree of swelling
Emergency Car 563
Figure 26.7 A simple transverse proximal fracture of the

olecranon in a skeletally mature horse.
Figure 26.8 ‘Dropped elbow’ posture adopted by a
is generally proportional to the amount of displacement. Thoroughbred yearling with a Salter–Harris type II fracture.
Marked displacement is usually accompanied by disruption
of the ulnar heads of the deep digital flexor (laterally) and II fractures, the degree of rotational displacement may
ulnaris lateralis (medially). Horses with ulnar fractures usu- be marked and can, on first view, mislead orientation.
ally resent digital pressure and limb manipulation. Wounds Alignment of the apophyseal growth plate and considera-
at the site of impact are common and frequently communi- tion of segmental length are useful guides. Displacement of
cate directly with the fracture, and thus with the cubital articular fractures is predominantly rotational, greater cau-
joint [17]. Sanguineous synovial fluid will sometimes exude. dally than cranially [10]. Images should always be scruti-
nized carefully for evidence of comminution including
integrity of the anconeal process (Figure 26.11) which in
Radiography and Radiology young animals can occasionally appear as a separate centre
of ossification: radiographs of the contralateral limb can
Mediolateral images obtained with the standard non-weight- assist in assessment. In acute phase evaluation of open frac-
bearing protracted limb technique [22] are most useful in tures, the presence of air in the cubital joint is consistent
making a diagnosis and in establishing the fracture configu- with articular contamination (see Figure 26.18a).
ration. Craniocaudal projections are important to identify
sagittal and parasagittal comminution but also to alert the
surgeon to rotational, almost invariably proximal medial– Emergency Care
distal lateral displacement (Figure 26.9). Apophyseal avul-
sion (Salter–Harris type I) fractures sometime are not The majority of ulna fractures require surgical repair.
immediately apparent, and radiographic evaluation of the Associated wounds should therefore be cleaned of gross
contralateral limb provides an important control. The apo- debris and antimicrobial drugs given. Although some
physeal centre of ossification changes radiographic shape in surgeons advocate pre-operative wound interference [17],
the first months of life. In the neonate it is small, ovoid and the author favours a conservative approach. Detailed wound
separated from the body of the olecranon. With growth, it exploration can be more satisfactorily performed later in a
becomes progressively rectangular and closer to the olecra- hospital environment. Horses that can fix their elbow and
non body with the radiographic appearance of a growth control the limb should not be splinted as this increases
plate between them (Figure 26.10). With Salter–Harris type dependent limb weight, acts as a pendulum and merely adds
(a) (b)
Figure 26.9 (a) Mediolateral and (b) craniocaudal radiographs of an oblique fracture involving the humero-ulnar articulation and
exiting the diaphysis of the ulna. Rotational displacement undetected in (a) is evident in (b).
Figure 26.10 Radiographic development of the ulnar apophysis in the first 18 months of life.
Conservative Treatmen 565
use of a locking compression plate (LCP) is appropriate to

bridge the fracture and reduce the potential for collapse and
consequent failure. An AO/ASIF hook plate has been used
to engage the apophysis in foals before compressing frac-
tures in a conventional caudal tension band technique [23],
but this implant is no longer available.
Some mechanical properties of transverse ulnar osteoto-
mies in adult cadaver limbs repaired with a caudal narrow
DCP, tension band wire and Steinmann pins and a bone grip
system have been compared [24]. Constructs were evaluated
for single load to failure and cyclic failure by forces applied
in line with triceps brachii. Osteotomies were made in the
olecranon just proximal to the anconeal process. Ten-hole
DCPs were applied with 4.5 mm screws. Two Steinmann
pins (1 × 3.1 mm and 1 × 4.7 mm diameter) were inserted in a
proximal to distal technique with two pieces of 1.25 mm
stainless-steel wire wrapped around each pin proximally
before being passed through transverse holes in the ulna dis-
tally. One wire was placed in a figure of eight and one as a
simple loop before being tightened in a standard twist knot
technique. In single load to failure tests, all constructs failed
Figure 26.11 Fracture of the anconeal process (arrows) in a by displacement of the proximal fragment; no implants
comminuted Salter–Harris type II fracture. broke. The grip system proved unsuitable and will not be dis-
cussed further. Load to failure with DCP repair was 50%
to the horse’s encumbrance. Inability to extend the elbow greater than pins and wires and was associated with less
disarms the forelimb stay apparatus and afflicted horses are angular displacement. In cyclic fatigue tests, implant failure
then unable to extend the carpus [17]. There is a loss of con- led to fragment displacement. Constructs repaired with
trol of the distal limb, and the horses are distressed and fre- DCPs withstood a mean of 87% more cycles than pins and
quently exhibit lifting and placing behaviour. Protraction is wires. The authors concluded that the pin and wire tension
only achieved by hopping and use of shoulder muscles. band technique appeared to be approximately half as strong
However, if the carpus is fixed into an extended position, the as DCP application and is therefore likely to be suitable for
limb can be loaded and controlled. This relieves markedly the smaller individuals only.
horses stress, permits ambulation and enables animals to be
transported. Details of techniques are given in Chapter 7.
Conservative Treatment
T
reatment Options It has been reported that horses with non-displaced non-
and Recommendations articular [5, 6, 9, 17] and minimally displaced articular [9]
fractures can be managed conservatively. Bandaging with
A small number of fractures can be managed conservatively an elbow to ground caudal splint has been recom-
with simple confinement or supplemented with a splint mended [5, 9] with radiographic monitoring to ensure that
fixing the horse’s carpus into extension (Chapter 7) [5]. progressive displacement is not occurring [5, 6]. All frac-
Techniques for reconstruction are based on the strong cau- ture types can, and frequently do, displace and distract days
dal tension surface created by triceps brachii and facilitated to weeks following injury (see Figures 26.20 and 26.21). In
by the uniplanar movement of the elbow joint. The tension a review of 43 horses with fractures of the ulna which were
band may be produced by application of a dynamic com- managed conservatively, 10 (23%) were euthanized as a
pression plate (DCP) or insertion of wires bridging the cau- result of the fracture or resultant complications, 19 (44%)
dal surface of the fracture. The latter may be supplemented survived but were lame and 14 (33%) became sound. The
by intramedullary pins or screws. Comminution can pre- latter group included 7 of 10 fractures distal to the semilu-
clude effective creation of a stable compressible column. In nar notch, 1 of 2 apophyseal avulsions and 6 of 12 Salter–
some cases, this can be reconstructed usually by screw fixa- Harris type II fractures. No fractures involving the
tion. However, when this cannot safely be achieved, then semilunar notch became sound [6]. The authors concluded
that surgical repair offered the best prognosis for sound- The time between injury and repair has been associated
ness and that conservative management should only be with poorer outcomes [11]. This was not statistically sig-
considered for non-displaced fractures distal to the semilu- nificant in other studies but may simply be an effect of
nar notch. Other studies have reported poor results with insufficient numbers [8]. Delay in repair has resulted in
conservative management of other fracture configura- overload lesions in the contralateral limb and progressive
tions [5], leading to the general recommendation that con- osteoarthritis in affected legs.
servative management is appropriate only for minimally Horses are operated under general anaesthesia in lateral
displaced fractures distal to the level of the radio humeral recumbency with the affected limb uppermost and parallel
articulation [5–7, 10]. The radio-ulnar ligament appears to to the ground. Use of dorsal recumbency has been dis-
limit displacement [10]. However, some fractures distal to cussed but has not yet been described in the literature
the olecranon notch will distract during convalescence, (F. Rossginol 2018, personal communication). In the for-
resulting in delayed or non-unions. mer, a semi-flexed position with the leg supported at the
With conservative management healing is slow, lameness metacarpus gives good access and is suitable for non- or
protracted [17] and a number of conservatively managed minimally displaced fractures (Figure 26.12). If fracture
fractures also exhibit progressive distraction and become displacement is marked, then surgery should commence
delayed unions. Disuse flexural deformity and cubital with the limb in extension or provision made to extend it as
degenerative joint disease with persistent lameness are necessary in order to facilitate reduction during the proce-
common in affected limbs [5]. The morbidity in overloaded dure. Diathermy is useful for haemostasis. Following surgi-
contralateral limbs is also high and includes angular cal skin preparation, waterproof drapes can be applied and
deformity, suspensory apparatus breakdown, laminitis and secured to allow free access to the caudal aspect of the limb
other ill-defined contralateral limb lameness [5, 6, 11]. In from the junction of the middle and distal thirds of the
contrast, surgical repair not only improves the prognosis antebrachium to a point over the triceps muscle masses
but is generally the most humane way of managing ulnar approximately 10 cm proximal to the olecranon. A long,
fractures; pain relief is swift [5, 14, 15]. In most circum- caudal incision is made distally directly over the groove
stances, it is therefore the treatment of choice [17]. between ulnaris lateralis and the ulnar head of the deep
digital flexor and curves proximally over the lateral aspect
of the olecranon tuberosity (Figure 26.13a and b). The
F
racture Repair
thick antebrachial fascia is then incised along the same
line. Ulnaris lateralis and the ulnar head of the deep digital
Principles and Surgical Approach
flexor are separated by blunt (digital) dissection to expose
Surgical repair utilizes, in various forms, the tension band the ulnar diaphysis (Figure 26.13c and d). In acute cases,
principle. This is the purest site of its application in horses. haemorrhage from the fracture and, with articular frac-
The first reported rationalization and repair using the ten- tures, sanguineous synovial fluid frequently emerge at this
sion band principle appears to be Johnson and Butler in time. Exposure of the distal caudal ulna, when necessary,
1971 [25]. A slightly more detailed report by Fretz followed reveals an overlying thin layer of muscle which is the small
in 1973 [26]. This included removal of the sharply convex
caudal margin of the ulna to produce a flat ‘stable seat’ for
the plate. The first series of four cases treated using this prin-
ciple was published in 1976 [27]. The surgical approach has
changed little from the original description [28]. Although
the tension band principle can be applied with wires, either
alone or in combination with screws or pins, in most cases
caudal plate application is the treatment of choice.
Accurate pre-operative planning is important. Intra-
operative radiography is not readily achieved, and good
pre-operative planning to direct fracture repair is critical.
This includes accurately measured bone depths and hence
screw lengths to ensure adequate engagement without
impingement on the cubital joint and, when appropriate,
to ensure that screws engage only the ulna. In most
circumstances, radiographs are then only necessary at the Figure 26.12 Horse positioned in lateral recumbency in
completion of surgery. preparation for repair of a fracture of the left ulna.
Fracture Repai 567
(a) (b)
(c) (d)
(e) (f)
Figure 26.13 Surgical approach to the left ulna demonstrated on a cadaver limb. (a) Palpation of the groove between the muscles of
ulnaris lateralis (lateral) and ulnar head of the deep digital flexor (medial) on the caudal antebrachium distal to the olecranon. (b) A
linear incision over the groove, extending from the level of the distal ulnar diaphysis proximally before curving laterally over the
olecranon tuberosity and terminating at the caudal insertion of triceps brachii. (c) Division of the thick antebrachial fascia revealing
the fascial plane between ulnaris lateralis and the ulnar head of the deep digital flexor. (d) Ulnaris lateralis and the ulnar head of the
deep digital flexor are separated by blunt (digital) dissection to expose the caudal surface at the ulna. Self-retaining retractors are
inserted between the two muscles proximally and distally. The thin muscle overlying the caudal distal diaphysis of the ulna is the
ulnar origin of the radial head of the deep digital flexor. (e) For demonstration purposes, the ulnar nerve is demonstrated (arrow) by
partial division of the origin of the ulnar head of the deep digital flexor. This is usually protected by reflection with the ulnar head of
the deep digital flexor. (f) Surgical view of the exposure required to repair the majority of fractures. The ulnar nerve is not exposed.
The caudal olecranon tuberosity has been amputated with an oscillating saw to provide a flat proximal seat for a caudally placed
plate. The periosteum has been reflected through a short distance on the lateral surface of the olecranon which can be useful for
visualizing fracture planes and/or reducing fractures in this region.
ulnar origin of the radial head of the deep digital flexor. At will be necessary. There is no single technique that is suit-
this level, the ulnar head of the deep digital flexor is tendi- able for reduction of mediolateral and/or caudocranial dis-
nous and immediately caudal to it is the ulnar nerve placement. Use of reduction forceps is an attractive concept
(Figure 26.13e). Insertion of self-retaining retractors but generally impractical, although as a means of gripping
between the ulnar head of the deep digital flexor and the apophysis to assist in correcting medial rotational dis-
ulnaris lateralis assists with exposure and ensures preser- placement these can be helpful. A surgical assistant tuck-
vation of the nerve (Figure 26.13d). Access to the caudal ing fingers medial to the olecranon and providing lift
ulnar diaphysis and olecranon to the level of the proximal (apophyseal abduction) is also effective. Fractures of some
cubital joint can be achieved by muscle separation. If standing may have caudally protuberant callus that
exposure is needed proximal to this, division of part of the requires removal, usually from this margin only, to permit
origin of the ulnar head of the deep digital flexor becomes good plate/bone contact. In adult horses with large caudal
necessary (Figure 26.13e). However, this should be judi- protuberances at the level of the closed apophyseal growth
cious not only as a general principle of minimizing surgical plate, this can be removed with an oscillating saw to create
trauma but also because it results in medial (or further a stable flat surface for plate application (Figure 26.13f).
medial) displacement of the proximal olecranon fragment. Further flattening of the caudal surface of the ulna has
If it is necessary to access the proximal surface of the olec- been suggested [9] but is not advocated.
ranon (usually to place a plate), then the triceps tendon can Plate length is determined on a case-by-case basis accord-
be split longitudinally minimizing disruption of its inser- ing to the site, type and configuration of the fracture together
tion. Unless there are displaced fragments or additional with the animal’s age and size. The tension band principle
fractures are identified, further exposure of the lateral sur- relies on establishing a stable link between proximal and dis-
face of the olecranon is not necessary. tal fragments along the caudal surface of the ulna. This, in
Comminuted fractures may benefit from exposure of turn, requires mediolateral stability of entrapped fragments
the lateral aspect of the olecranon. This can be obtained and sufficient screw purchase to anchor the tension band
by a second incision in the antebrachial fascia between plate on each side of the bridged defect.
ulnaris lateralis and lateral digital extensor muscles dis- As a general rule, plates lying on the caudal aspect of the
tally with proximal extension over the lateral aspect of ulna should be contoured as little as possible to maintain
the olecranon. Alternatively, and in most cases prefera- bone contact. Substantial plate contouring is necessary if
bly, the lateral surface of the olecranon can be exposed by this is curved over the proximal margin of the olecranon.
sub-periosteal dissection of ulnaris lateralis and the Fractures in foals almost always require incorporation of
insertion of the lateral head of triceps brachii the apophysis in this manner. An aluminium template can
(Figure 26.13f). Exposure of the lateral diaphysis of the be used if required. The plate should be positioned on the
ulna is rarely necessary or of benefit and surgeons should caudal surface of the olecranon to optimize the tension
be cognisant that this additionally causes the risk of band and to ensure safe screw trajectories. Establishing
trauma to the common interosseous artery and adjacent this when the plate is fitted and maintaining it until there
muscular branch of the radial nerve as they emerge from are screws proximal and distal to the fracture is important.
the interosseous foramen [28]. Maintaining a small gap between the concave caudal sur-
Haemorrhage in acute cases, granulation in subacute face of the ulnar diaphysis and plate prevents the compli-
cases or fibrocallus in chronic cases are removed together cation of cranial fracture distraction that can result from
with small comminuted fragments if these are not reduci- over contouring [10]. It has been suggested that screws
ble. Non- or minimally displaced fractures can then be should engage a minimum of five cortices proximal and
repaired. Displaced and distracted fractures require reduc- distal to the fracture [17]. The proximal medial concavity of
tion. If displacement is proximodistal only, i.e. the fracture the olecranon necessitates slight caudomedial to craniolat-
is distracted and if the fracture gap is narrow, the use of eral trajectories of screws proximal to the radioulnar artic-
offset screws usually will suffice. These should not be ulation to avoid emergence through the medial cortex.
placed immediately adjacent to the fracture. Inserting Distally, when screws need to engage, the caudal cortex of
them proximally and distally assists with maintaining plate the radius holes should be created with caudolateral to cra-
alignment with the ulna (Chapter 8). One offset screw on niomedial trajectories to avoid location in and weakening
each side of the fracture produces 2 mm of compression. It of the lateral cortex of the radius. Screws should not engage
is possible to place a second screw in the plate in an offset the cranial cortex of the radius. As far as possible, screws
location on each side of the fracture (after slight loosening should be inserted perpendicular to the long axis of the
of the first screw) to produce a further 2 mm of compres- plate and angled only to avoid fracture planes.
sion. The maximum reduction/compression effected by the It has been suggested that a broad DCP should be used in
offset screw technique is therefore 4 mm. If the fracture gap horses weighing over 500 kg [10]. This presents a technical
is wider, then manipulation and use of the tension device difficulty because distal to the apophysis the plate is
Fracture Repai 569
Figure 26.14 A gauze stent bandage sewn over the wound and secured with vertical mattress sutures of sheathed braided
polyamide.
s ubstantially wider than the caudal ulna. Additionally, the ment synthetic absorbable material; five metric is suitable
offset screw positions in a broad DCP and do not readily for the deeper layers and 3.5 metric in the subcutis of adults
engage with the sharply sloping caudal margin of the ulna. whilst 3.5 metric is adequate for the fascial layer with
Finally, in the author’s experience, constructs do not fail by 3 metric for the subcutis in foals. The skin can be sutured,
plate bending or breakage. Narrow DCPs have been but staples are expeditious. Over sewing a stent bandage
employed in animals weighing up to 600 kg [7]. Use of with tension-relieving (the author uses vertical mattress)
5.5 mm cortical screws has been advocated in adult sutures is recommended (Figure 26.14). This will provide
horses [10]. However, screw bending and pull-out strength physical protection for the surgical wound, impart counter-
are not considered to be limiting factors and these may pressure and anchoring sutures can relieve tension on the
therefore be reserved for replacement of non-engaged wound margins. The placement of a suction drain adjacent
4.5 mm screws. 6.5 mm cancellous screws should be used to the plate has been advocated, but these are rarely pro-
only when cortical screw insertion has failed. ductive [18]. Bandaging is also not generally contributory.
In horses ≥two-year old, the ulna and radius can be bridged
by screws without consequence to the elbow joint. Growth in
Locking Compression Plate Repair
the proximal radial metaphyseal growth plate begins to slow
at 12 months of age but continues until 18 months [2]. It has The LCP can be used in compression, in bridging fashion
been estimated that on average the equine radius will grow a or in combination for the repair of ulnar fractures. Its
further 8 mm after the animal is 12-month old. When screws mechanical properties and principal advantages are dis-
engage the radius, plate removal is therefore recommended cussed in Chapter 8. It has been suggested that locking
in all animals up to two years of age [10]. screws are placed at each end of the plate with one or two
Surgical wounds are closed in layers. The approach others on proximal and distal sides of the fracture [17].
leaves substantial potential dead space in fascial/intermus- Cortical screws are inserted first to effect reduction and
cular planes. The divided ulnar head of the deep digital compression. In most circumstances, these are placed
flexor is satisfactorily re-apposed with loosely applied eccentrically in plate holes to utilize the offset screw tech-
interrupted horizontal mature sutures that resist tearing nique. All intended cortical screws should also be inserted
the muscle. The antebrachial fascia is then closed in a sim- before any locking screws to compress the plate against the
ple continuous pattern. In adult horses, this frequently can bone. Once locking screws are inserted, the construct is
be carried out in two layers: a thick inner and a thinner fixed and further or additional fracture compression is pro-
outer layer. In foals, this is usually completed with one row hibited. When locking screws are employed, a disadvan-
of sutures. Closure of the subcutis follows; a continuous tage is the fixed, perpendicular trajectory that is necessary
locking vertical mattress (far near–far near) pattern works for the conically threaded screw head to correspond with
well. All are accomplished satisfactorily with multifila- the threads in the combi hole, i.e. threaded screws cannot
be inserted at an angle. This is desirable proximally in the Longitudinal growth in the radius and ulna of foals up to
olecranon tuberosity and in the distal portion of the ulnar 72 weeks (approximately 18 months) has been measured [2].
diaphysis. There are three reports of their use in the litera- Growth continued at similar rates (3.5 and 3.4 cm, respec-
ture [16, 29, 30]. Repair is based on caudally positioned tively) in each bone through this period. However, growth
LCPs, although second lateral plates have also been from the apophyseal growth plate of the ulna contributed
employed with comminuted fractures [16, 30]. The major- only to the length of the olecranon; it did not contribute to
ity of the repairs utilized combinations of conventional ulna growth distal to the cubital joint. As growth occurred at
cortical and locking screws; the former were employed the proximal radial metaphyseal growth plate, this moved
whenever the need for angulation was recognized and are distally, i.e. in a sliding motion, in relation to the ulna. Thus,
inserted first to optimize plate–bone contact [16, 30]. In transfixion of ulna and radius has the potential to result in
one series, inadvertent placement of a distal locking screw cubital dysplasia until there is functional closure of the proxi-
in the lateral cortex of the radius precipitated catastrophic mal radial metaphyseal growth plate at approximately
fracture of the same 11 days post-surgery [16]. 18 months of age. However, growth follows a logarithmic pat-
The ulna is proximomedial–distolaterally oblique with tern so the potential for disproportionate growth and conse-
respect to the radius (Figure 26.1). Distally, the ulna is situ- quent cuboidal dysplasia decreases progressively with age
ated on the caudolateral aspect of the radius with which, in through this time. In short, the younger the foal the greater
most horses, it blends. Thus, if fracture fixation necessi- the risk. At 1, 5 and 12 months of age, foals had completed
tates extension of an LCP distally on the ulna, then cortical means of 12, 46, and 78% of growth from the proximal radial
screws should be employed in order that these may be metaphyseal growth plate, respectively.
angled medially. Stover and Rick [34] described cubital dysplasia (humero-
Risk of inadvertent penetration of the lateral cortex of ulnar subluxation) following the development of radio-ulnar
the radius by locking head screws in the distal holes of an synostosis and rationalized the pathogenesis including the
LCP has been evaluated in a cadaver model [31]. Transverse suggestion that its severity was likely to be more severe in
osteotomies were performed to mimic simple articular younger animals with greater growth potential. It had also
(type II) fractures in 16 limbs. The fractures were repaired been noted following radio-ulnar fixation as part of ulna
using LCPs with cortex screws or locking head screws in fracture repair in juveniles [11]. Radiographically, this
the distal three holes of eight limbs. The cortex screws were manifests as distal displacement of the trochlear notch and
inserted at the surgeons’ chosen angle which was caudola- coronoid process of the ulna resulting in step like incon-
teral–craniomedial (mean angle of 17.6°). No cortex screws gruity between radius and ulna.
penetrated the lateral cortex of the radius. However, 6 of Cubital dysplasia was produced experimentally by fixing
24 locking head screws damaged this. These all involved the radius and ulna with 4.5 mm cortical screws placed
the distal three screws. Thus, combining the cortex screws through a narrow DCP mimicking ulna fracture repair [12].
and locking head screws in ulnar fracture repair appears The growth disparity and consequential dysplasia were
logical and allows the advantages of the LCP system to be inversely related to the age at which fixation was performed
applied to fractures that might benefit from such [30, 32]. (one > five > seven months). Growth disparity was not cor-
Combining published data provides a total of 33 ulnar rected by implant removal after 16 weeks (in the one and
fractures repaired with LCPs; 27 were single caudally posi- five month old foals in which this was performed). Clinical
tioned plates and 6 had additional lateral LCPs. Twenty-six signs, when evident, included lameness and distal limb
of 33 (79%) recovered and returned to their intended use. flexural deformity. Cubital dysplasia was accompanied by
Further details are discussed with regard to individual frac- visible radio-ulnar incongruity with cartilage defects in the
ture configuration. intercondylar grove of the humerus and trochlear notch of
the ulna. After radio-ulnar fixation, continued growth at
the proximal radial metaphyseal growth plate produced a
Fixation of the Ulna to the Radius in Foals
disparity in growth between the two bones which, in turn,
Longitudinal growth of the radius accounts for greater than leads to radio-ulnar subluxation. The anconeal process is
20% of the total increase in height of animals from birth to forced into contact with the humerus resulting in abrasion,
two years of age. The proximal metaphyseal growth plate of cartilage loss and subsequently progressive subchondral
the radius contributes approximately 40% of total radial damage and development of degenerative joint disease.
growth with 53% of this occurring by three months of age. Although, in this study, there was reduced dysplasia in
Growth then continues at a reduced rate until approxi- foals in which radio-ulna fixation occurred at 7 months of
mately 18 months of age [33]. The proximal apophyseal age, continued growth of the proximal radial metaphyseal
growth plate of the ulna contributes to longitudinal growth, growth plate until closure at approximately 18 months of
but this appears to have little effect on the elbow [12]. age suggests that this remains possible until at least this
Fracture Repai 571
time. On the basis of this study, screws transfixing ulna and ally successful, but failing this, a 5.5 m screw can be inserted
radius should, whenever possible, be avoided in young without further drilling. Both are preferable with respect to
foals. If they are necessary for stable fixation, then they subsequent removal than use of cancellous screws. There
should be removed as soon as fracture stability is not reli- is usually adequate bone stock distal to the fracture to cre-
ant on their support and certainly earlier than 16 weeks ate a stable construct while restricting screws to engage-
post-operatively. If cubital dysplasia develops, a degree of ment of the ulna only. However, if this is questioned, then
improvement can follow implant removal [10], but avoid- engagement of the caudal radius and early elective implant
ance by diligent case management is strongly advised. removal is the preferred option. Implants are generally
removed 8–12 weeks post-operatively even if the ulna is not
Repair of Apophyseal Avulsion (Type 1a) Fractures fixed to the radius in order to allow normal force transmis-
sion and bone development. Premature closure of the apo-
In young foals the apophysis consists of a relatively small
physeal growth cartilage does not appear detrimental [10].
centre of ossification surrounded by a large zone of carti-
Multiple wire sutures can be placed caudally to create a
lage that has limited ability to hold screws. Additionally, it
tension band supplemented with one or more screws or
carries the entire insertion of triceps brachii [10].
pins placed from proximal to distal through the apophysis
Apophyseal avulsions can be repaired in a number of ways
and into the body of the ulna to maintain axial align-
including pins and screws in combination with tension
ment [21]. In most circumstances, the quality of reduction
band wires or the application of bone plates. Apophyseal
and stability are inferior to those achieved with plate appli-
disintegration and catastrophic failure remain a risk [10].
cation (see also Chapter 37).
Hook plates have been described [23] but are no longer
available. The current treatment of choice is a markedly
contoured 4.5 mm narrow DCP cupping over the apophy- Repair of Salter–Harris Type II (Type 1b) Fractures
sis [10] (Figure 26.15). This is applied through a longitudi-
Salter–Harris type II fractures are most common in older
nal split in the tendon of insertion of triceps brachii. The
foals when there is a greater degree of ossification of the
most proximal screw hole can be left blank. Use of cancel-
apophysis. The ‘spike’ of the olecranon tuberosity also pro-
lous screws in the apophysis has been recommended [10],
vides additional bone stock than is available with apophy-
but the author’s preference is to use, at least initially,
seal avulsions. Nonetheless, some proximal contouring of
4.5 mm cortical screws. These are inserted after minimal
plates over the apophysis is still recommended [10, 14].
tapping; sufficient only for the screw to engage the thread
The plate can be fixed to the apophysis with three or some-
and it is then inserted in a self-tapping manner. This is usu-
times four screws [14] (Figure 26.16). If possible, screws
Figure 26.15 Repair of the Salter–Harris type I fracture seen in

Figure 26.3a with a 4.5 mm narrow DCP curved over the Figure 26.16 Repair of a Salter–Harris type II fracture with a
apophysis. This is secured with 4.5 mm cortical screws engaging 4.5 mm narrow DCP contoured to entrap the apophysis proximally
the apophysis and restricted to the ulna distally. and secured with 4.5 mm cortical screws confined to the ulna.
immediately distal to the apophysis should engage the radius, this should be restricted to engagement of the
cranial fragment and may be placed in lag technique [14]. ulna only. Once this has been achieved, then additional
Distal to the cubital joint to avoid the risk of cubital dyspla- distal screws can engage the caudal radius which is
sia screws should be confined to the ulna. These should be generally considered to be contributory to stable fixation
bicortical, but if this is considered to compromise stability in adults [5, 10] (Figure 26.18).
then distal screws should penetrate the caudal cortex of When the fracture gap is wide reduction can be aided and
the radius. Implants can then be removed when fracture in some cases, requires use of the tension devise (Chapter 8).
healing allows (generally 10–12 weeks post-operatively). This necessitates exposure of the distal ulna and adjacent
This should not be delayed unduly as development of a caudal radius. The plate is fixed to the olecranon proximal
radio-ulnar synostosis can have the same effect as implant to the fracture before the tension device is employed. The
restriction [12, 34, 35]. Premature closure of the apophy- plate is therefore contoured before the fracture is com-
seal growth plate does not appear to be clinically signifi- pletely reduced. This is not generally a problem as minimal
cant. In the largest series in the literature, 20 fractures were distal contouring is necessary or indicated. However, it is
repaired without recourse to engagement of the radius [14]. critical when fixing the plate to the proximal fracture frag-
ment to produce and maintain perfect longitudinal align-
ment with the ulna distal to the fracture. If this is not
Simple Humero-ulnar Articular (Type 2)
performed, adequate reduction and repair are impossible.
Fractures
In young foals, the apophysis should be included in the
A caudally applied narrow DCP is the treatment of construct in order to reduce the risk of avulsion which can
choice. It usually requires minimal contouring or bend- occur post-operatively. In the neonate, the bulk of the apo-
ing. Adequate bone stock is available proximally to per- physis is cartilaginous. The plate can be bent markedly to
mit stable fixation; however, almost invariably, such entrap this, if necessary, leaving the proximal hole empty
fractures require incorporation of the caudal radial cor- but fixing its centre of ossification with screws in the
tex into the repair (Figure 26.17). Screws should not second and third holes. These sometimes will partially
engage the cranial cortex of the radius. When reducing ‘back out’ a few weeks after surgery. This is of no conse-
and compressing such fractures utilizing the offset screw quence as by this time the apophysis is secure and they can
technique in the DCP, if the distal screw overlies the be removed electively with the remaining implants. In
(a) (b)
Figure 26.17 Repair of the fracture seen in Figure 26.9. (a) Pre-operative plan and measurements of bone depth at proposed sites of
screw insertion. (b) Completed repair utilizing a 13-hole 4.5 mm narrow DCP secured with 4.5 mm cortical screws. The distal five
screws engage the caudal radius.
Fracture Repai 573
(a) (b)
Figure 26.18 Repair of a simple humero-ulnar articular fracture accompanied by a lateral wound. (a) Mediolateral radiograph at
presentation. Note air in the cranial compartment of the cubital joint. (b) Repair with a 14-hole 4.5 mm narrow DCP secured with
4.5 mm cortical screws. The distal six screws engage the caudal radius including a screw crossing the interosseous foramen.
(a) (b)
Figure 26.19 Repair of the simple humero-ulnar articular fracture seen in Figure 26.4a. (a) Radiograph at completion of surgery.
Repair was effected with a 4.5 mm narrow DCP curved over and engaging the apophysis. 5.5 mm cortical screws were utilized in plate
holes 1 and 4 when 4.5 mm cortical screws, used at the remaining sites, failed to adequately engage. All screws were confined to the
ulna. (b) Radiographic healing eight weeks after repair at the time of implant removal.
(a) (b) (c)
(d) (e) (f)
Figure 26.20 Simple humero-ulnar articular fracture in a foal. (a–c) Distraction and resorption along the fracture plane in
mediolateral radiographs: (a) at diagnosis, (b) four days and (c) eight days later. (d) Surgical plan and bone depths measured at
proposed sites of screw insertion. (e) Radiograph at the end of surgery. The fracture was repaired with a 4.5 mm narrow DCP contoured
over the apophysis and secured with 4.5 mm cortical screws. The proximal screw hole was left blank and the next two screws engaged
the apophysis. The two distal plate screws engaged the caudal radius. (f) Radiograph nine weeks after surgery at the time of implant
removal demonstrating fracture healing at this time.
some cases, distal screws can be confined to the ulna sually sufficient bone stock proximal to the fracture
u
(Figure 26.19), but if additional purchase is required for that the plate can be positioned on the caudal ulna with
stability, then the caudal radial cortex can be incorporated minimal contouring and often without requirement for
in the construct (Figure 26.20). Implants can be removed proximal dissection. In oblique fractures, it may be pos-
8–10 weeks after repair avoiding risks of cubital dysplasia. sible to place one or two screws across the fracture in lag
technique [15], but the contribution to stability and
fracture healing is uncertain and it does not appear to be
Fractures Commencing at or Distal to the
necessary. Screws are confined to the ulna at the level of
Radio-ulnar Articulation (Type 5 Fractures)
the radial epiphysis. Ideally, screws at the level of the
Some fractures at this level can heal with conservative intraosseous foramen are also restricted to the ulna to
management [6, 10], some will displace and some will avoid damage to the artery (Figure 26.22). However, if
become delayed or non-u nions presumably as a result crossed, any resultant haemorrhage is controlled by
of persistent distracting forces and/or instability. screw insertion and no untoward sequelae appear to fol-
Application of a caudal plate is therefore considered the low (Figure 26.23). Further distally, the caudal cortex of
treatment of choice (Figure 26.21). In adults there is the radius is also engaged.
Fracture Repai 575
(a) (b)
(c) (d)
Figure 26.21 Fracture at the level of the radio-ulnar articulation in a foal. (a) At presentation. (b) Comminution recognized eight days
later together with fracture distraction. (c) Fracture repaired with a 4.5 mm narrow DCP contoured to enclosed the apophysis. The
proximal screw hole was left blank. Two screws engaged the apophysis. Three distal screws also engaged the caudal radius.
(d) Mediolateral radiograph nine weeks following repair at the time of implant removal. The heads of the proximal two screws
protrude slightly from the plate.
c onsequent loss of stability, fracture collapse and repair

Comminuted (Type 4) Fractures
failure, usually during recovery from general anaesthesia.
Whenever possible, comminuted fragments should be con- LCPs are an indication for such fractures.
served, reduced with independent fixation if necessary and Some comminuted fragments can simply be incorporated,
incorporated into the definitive construct. When there is with judicious screw placement, into the principal repair.
substantial comminution, the surgeon should be careful Others may require or benefit from lateromedially placed
to avoid excessive proximodistal compression as this inter-fragmentary screws which can be placed in lag or
can result in extrusion of comminuted fragments with neutral position techniques as determined by individual
(a) (b)
Figure 26.22 (a) Simple oblique fracture at the level of the radio-ulnar articulation. (b) Radiograph at the end of surgery
demonstrating repair with a 4.5 mm narrow DCP secured with 4.5 mm cortical screws. The interosseous foramen has not been crossed
but four screws engage the caudal radius.
(a) (b)
Figure 26.23 Repair of a simple displaced fracture at the level of the radio-ulnar articulation depicted in Figure 26.6b (a) Pre-
operative plan. (b) Lateromedial radiograph taken at the end of surgery. Repair was effected with a 14-hole 4.5 mm narrow DCP
secured with 4.5 mm cortical screws throughout. All screws distal to the fracture engage the caudal radius. The screw tract for a
tension device is seen distally (arrow).
Fracture Repai 577
(a) (b)
Figure 26.24 Repair of the comminuted articular fracture seen in Figure 26.5d. (a) Pre-operative plan and bone depths.
(b) Lateromedial radiograph at the end of surgery following repair with a 13-hole 4.5 mm narrow DCP secured with 4.5 mm
cortical screws at all locations.
circumstances. Small, 3.5 mm or less commonly 2.7 mm, plate on the lateral aspect of the ulna has also been
screws are generally most suitable. The lateral cortex is rela- documented [29].
tively thin, but the small head of these screws can usually Comminuted fractures in which the anconeal process
safely be countersunk to optimize screw/bone contact. becomes a separate fragment require particular considera-
Occasionally, lateral comminution can be bridged and tion. Fragments that are of sufficient size to tolerate a
entrapped by a laterally applied 3.5 mm narrow DCP. On rare cranioproximal to caudodistal lag screw and which are
occasions, wire sutures can also be employed. If augmentation perfectly reducible should be repaired. The latter is an abso-
of the principal repair can be achieved in a timely manner, lute prerequisite as any incongruity will both compromise
then it can be contributory. However, non-displaced com- stability and thus implant integrity and lead to persistent
minuted fragments commonly can be entrapped, com- lameness with articular degeneration. If these criteria can-
pressed and stabilized within the primary repair and this not confidently be met, then fragment removal is preferred
should be prioritized (Figure 26.24). Fractures can be com- and does not appear to adversely influence prognosis [8, 14,
plex but, in the author’s experience and opinion, repair 29, 36]. Fragmentation of the anconeal process can be
should whenever possible be kept simple (Figure 26.25). removed arthroscopically using lateral caudoproximal
Attempts to repair all components can be counterproductive arthroscope and ipsilateral instrument portals [37]. This
in prolonging surgery time which is key to anaesthetic provides superior visibility and is substantially less invasive
recovery. than removal by arthrotomy. The principal fracture(s)
It has been suggested that in highly comminuted frac- should be reduced and repaired before arthroscopy to avoid
tures plates are applied in neutral technique [9] to avoid compromised visibility from extravasated fluid. Additionally,
collapse of unstable central fragments. This is often a increased elbow flexion which can result in distracting
difficult judgement call; if fragments can be secured, forces on comminuted fractures is sometimes contributory
then the construct will benefit substantially from max- to arthroscopic access to the anconeal process. Although
imising bone:bone contact. An LCP therefore provides a visibility is modest, some fragments can be removed
logical alternative approach. Use of the second shorter through the fracture plane following distraction [14, 17].
(a) (b)
(c) (d)
Figure 26.25 Mediolateral radiographs of a comminuted fracture. (a) There is slight displacement of one fracture and multiple
fracture lines are visible throughout the olecranon tuberosity and extending into the diaphysis of the ulna. (b) Pre-operative plan and
bone depths. (c) Lateromedial radiograph at the end of surgery. No attempt was made to secure the individual fractures. All were
compressed within the primary repair. Offset screws were inserted first in holes three and eight and the remaining screws were placed
in neutral positions. 4.5 mm cortical screws were used throughout with the distal four screws engaging the caudal radius, two of
which traversed the interosseous space. (d, e) Mediolateral radiographs taken three and 16 weeks post-surgery.
Fracture Repai 579
(e) infection and associated sinus tracts usually resolve follow-

ing implant removal.
Repair with Wire

Wire can be used either alone or in combination with other
implants such as pins and screws to achieve tension band
repair [21, 38]. However, this is suitable only in selected
circumstances. Although adult horses have been managed
in this manner, in the original report three of four treated
animals were foals [38] and in the principal series the
median age of treated animals was four months [21].
Wires alone have been recommended for fractures at or
distal to the humeroradial articulation, supplemented
with pins or screws in more proximal fractures [13].
Proximodistally placed intramedullary Steinmann pins or
5.5 mm cortical bones screws aid in maintaining axial
alignment and reducing rotation. Three millimetre diame-
ter pins may be adequate for small foals but 5 mm pins
should be used for larger animals. Fractures are reduced by
manipulation facilitated by extension of the elbow and
may be held manually or with AO/ASIF large reduction
forceps. Trochar tipped Steinmann pins are introduced
with a Jacob’s chuck and directed past the fracture as far as
possible into the distal fragment without emerging. Screws
are inserted using lag technique. In the original descrip-
Open Fractures tion, these were used to effect reduction and provide com-
In general, wounds associated with fractures of the ulna pression [38]. More recently, it has been recommended
have less prognostic significance than at other sites. Caudally that screws are not tightened and the wire is used to com-
located wounds can often be excised in the surgical approach. press the fracture [13]. The tension band is created with
Laterally located wounds are avoided and after the fracture multiple (2–6) 1.2 or 1.5 mm monofilament stainless-steel
is repaired should be cleansed and debrided in line with wire either in a figure of eight or a simple loop fashion.
standard surgical principles. Creation of a clean contami- Reduction of displaced fractures lacks control and is rarely
nated wound is usually achievable therefore closure can complete. Fracture compression and construct rigidity are
follow. Cubital lavage may be beneficial in acute or contami- also less than achieved with plate application. A degree of
nated cases and is indicated in the presence of infection. It instability is therefore likely and consequent pin/screw
should be performed through both cranial and caudal com- bending is common [21]. In proximal fractures, wires are
partments [37]. Additional reported techniques with open looped around the proximal tips of the pins or screw heads.
fractures include continuous suction drains, lavage systems, Distal to the fracture, wires are passed through laterome-
antimicrobial infusion pumps and cancellous bone grafts [8]. dial drill tracts in the ulna. In distal ulnar fractures, this
Antimicrobial medication in open and infected fractures technique can also be used proximally. When the wires
should be tailored according to individual case circum- have all been placed, each is pulled straight before being
stances. Systemic administration of broad spectrum antimi- alternatively tightened with a wire tightener or pliers.
crobial drugs is indicated (Chapters 9 and 14). Local depot Protruding proximal pins can then be cut and tapped down
techniques can be considered [10], but in the author’s expe- with a mallet to leave 6–8 mm above the proximal surface
rience have not been considered contributory. Occasionally, of the olecranon [13]. Of a series of 22 cases repaired with
with protracted infection, sinus tracts can develop. These are wire combined with pins and/or screws, 7 fractures were
usually associated with glycocalyx formation adjacent to also augmented by 4.5 mm cortical screws placed in lag
implants. Nonetheless, fractures will usually heal (unlike technique to assist in reduction of oblique or comminuted
other sites in the horse) providing stability is retained [5, 15]. fractures. Implants were removed in five animals at a
Symptomatic treatment is appropriate until fracture healing median of 12 weeks post-operatively to minimize risks
is no longer dependent upon implant support. Chronic associated with premature closure of the ulnar apophysis.
In a further animal, these were removed due to distal pin muscular effort with a semi-flexed elbow to pull itself up)
migration. exposes the olecranon to massive forces perpendicular to its
The technique has been considered a suitable alternative long axis and probably markedly in excess of normal slow
in animals weighing up to 250 kg [21] and/or less than six ambulation. Constructs fail through the bone and/or proxi-
months of age [9, 13]. Tension band wiring has been mal pull-out and are catastrophic commonly becoming open.
considered the technique of choice for repair of apophyseal Manual or pool recovery systems have been advocated [9,
avulsion (Salter–Harris type I) fractures [13]. 14–16, 21]. Sedation and hand-controlled/restrained recovery
A study in adult cadaver limbs concluded that DCP reduces markedly the risk but, particularly in adults, requires
application was more biomechanically sound than pins a team of experienced personnel (Chapter 10). Rope-assisted
and wires [24]. The principal advantages of the latter were recovery systems add an element of control, but horses still
cited as technical simplicity and reduced cost [21]. These load the elbow in a flexed position. In one series, all 14 frac-
must be considered carefully and balance against the previ- tures repaired with LCPs recovered from anaesthesia in a pool
ously documented disadvantages. It is rarely the technique system without complications [16].
of choice. Adult horses treated in this manner survived
only with the availability of a recovery pool. Comminuted
fractures appear to be a contraindication [21]. Post-operative Care and Convalescence
A study comparing tension band wire and plate repair of
olecranon fractures in dogs and cats documented a greater All authors report the use of peri-operative antimicrobial
frequency of complications associated with the former. The drugs. The duration of administration should be deter-
authors concluded that, if technically feasible, plate osteo- mined by the state of soft tissues, the presence of wounds
synthesis should be performed [39]. and the nature and degree of contamination present at the
time of surgery [9]. Peri-operative non steroidal
anti-inflammatory medication is indicated. Phenylbutazone
Fractures with Cubital Luxation
is the author’s drug of choice. This provides good analgesia
Fracture of the ulna with concurrent cubital luxation and may assist in limiting post-operative swelling.
(Monteggia fracture) is an uncommon injury in horses. A poor Post-operative/surgical site swelling is inevitable but var-
prognosis has been ascribed [27], but case reports have iable in degree. This is commonly maximal three to four
documented successful management [20, 40, 41]. In one case, days after surgery and then gradually subsides as fluid
there was a concurrent Salter–Harris type IV fracture of the gravitates distally before dissipating. Stent sutures fre-
caudoproximal radius [41]. In all three cases, reduction quently act as a litmus for the process, first exhibiting an
required traction supplemented by neuromuscular blockade increase in tension in the anchoring skin and then losing
with succinylcholine [20], administration of guaifenesin [41] this sequentially from proximal to distal. The stent bandage
or use of a mechanical distractor [40]. In all cases, the ulna can usually be removed between 7 and 10 days and staples
fracture was repaired with a caudally positioned DCP includ- 14 days after surgery. Wound healing is usually good.
ing engagement of the radius. Cubital joint stability was main- Some horse will develop patchy sweating adjacent to the
tained in all three case reports, and the horses were salvaged. wound presumably as a result of sympathetic irritation or
trauma; a branch of the caudal cutaneous antebrachial
nerve is close to the incision [28]. This can take some time
Fragment Removal to resolve but appears to be of little consequence.
If fractures are reduced and stabilized, the majority of
Removal of a large proximal displaced non-articular fracture horses are immediately more comfortable following sur-
fragment has been reported in a polo pony [42]. This was gery. Historically, protracted periods of box rest have been
chosen due to economic constraints but, as the animal had recommended [9], but with simple fractures this is not gen-
sufficient triceps brachii integrity to load and fix the elbow, it erally necessary or advantageous. The amount of post-
was considered potentially viable. A favourable outcome operative confinement necessary is determined by a number
with return to polo 12 months post-surgery was reported. of factors and therefore should not be comprehensively pre-
scriptive. In adults, confinement for greater than four weeks
Recovery from Anaesthesia is generally unnecessary. However, radiographic review at
this time is recommended as a number of fractures that, in
The recovery from general anaesthesia is critical and is the the acute phase and at surgery, appear to be simple are not.
principal time when the construct can fail. The horse’s normal Radiographic evidence of comminution is sometimes not
action in standing (placing its forelimbs in front and using apparent until weeks post-surgery. Comminuted fractures
Result 581
with compromised stability may benefit from a longer without this. Re-fracture following a fall in anaesthetic
period of confinement. Hand walking is the preferred first recovery for removal of two LCPs one year after reparative
exercise with control enhanced by low-dose acepromazine surgery has been documented [16]. An increased incidence
as necessary. If, after two weeks, the horse is settled then, if of re-fracture in yearlings has been mentioned in the litera-
available, a horse walker can be introduced. Empirically, ture [18]. Lameness associated with implant presence per
horses are given six weeks of increasing walking exercise se has also been mentioned [18] but appears uncommon.
followed by a similar period of trotting and/or restricted A mean time between surgery and competition of
area (up to 10 × 10 metres) turnout. The time at which free 9.5 months (average 4–12 months) was reported for a series
exercise can be allowed has not been determined and of repaired distal (type V) fractures compared to 12 months
should be decided on a case-by-case basis determined by (average 6–18 months) for conservatively managed cases [15].
clinical progress, radiographic fracture healing and the
horse’s temperament together with available facilities and Results
personnel. Atrophy of triceps brachii is common post-
operatively and can take several months to resolve. There are sufficient publications relating to fractures of the
Fractures in foals heal quickly (Chapter 37); if fractures ulna for data to be pooled in order to increase confidence of
are stable, not only is there no advantage to prolonged con- interpretation. However, this should be tempered with the
finement; there is substantial clinical and experimental caveats that techniques and corporate expertise continue to
evidence that restricted exercise in the first few months of evolve and develop and the definitions of ‘success’ frequently
life is a major predisposing factor in the development of vary between studies. Similarly, results obtained from a genu-
osteochondrosis [43]. Controlled exercise is usually impos- ine centre of excellence cannot be extrapolated or applied
sible to deliver effectively in foals and unhandled yearlings. elsewhere. In short, they are relevant to the reporting group
Gradually increasing areas of free exercise are a practical using the reported techniques in the reported time frame only.
and well-tolerated alternative. Graduating from a large
(4 × 4 m) stable to a 10 m diameter cage/playpen followed
Apophyseal Avulsions
by 20 × 10 m and then 20 × 20 m nursery paddocks at 10-day
intervals is generally achievable at a well-designed stud. There are six papers from which results can reasonably be
Implant removal in foals and yearlings is generally con- combined [5, 6, 21, 23, 38, 44]. These report a total of 19
sidered the norm even if the radius has not been transfixed. fractures of which 13 were repaired and 6 were managed
The optimum time for removal in foals has been suggested as conservatively. Eight of the 13 foals that underwent surgery
three months after repair [18], but controlled studies are and 2 of 6 animals that were managed conservatively
lacking. Radiographic monitoring of healing is helpful in recovered to soundness. Five of the successfully treated
yearlings and, when the radius has been transfixed, should be fractures were repaired with pins and wires [21, 38, 44],
balanced against the progressive risk of cubital dysplasia. one with a 4.5 mm narrow DCP [5] and one with a hook
Unless there are clinical indications, implant removal in plate [23]. Of the animals that did not become sound, two
adults is not usually necessary. The principal indication is repaired with pins and wires survived but had athletically
infection. Chronic bacterial infection is frequently associ- limiting lameness [21] and two hook plate repairs failed [23,
ated with the formation of a granulomatous calyx adjacent 44]. Two of the conservatively managed foals were eutha-
to the plate and, in some cases, screw tracts. Such infec- nized due to persistent carpal flexural deformity, and two
tion usually results in draining tracts, and while a degree survived but remained lame [5, 6].
of symptomatic improvement may follow antimicrobial
administration, resolution requires implant removal.
Salter–Harris Type II Fractures
Radiographic evidence of osteolysis adjacent to one or
more implants is strongly indicative of an infective process Seventy fractures are available for review in the literature
but is temporally dependent and inconsistent. Similarly, including 40 that were managed surgically and 24 conserv-
particularly in the chronic phase, haematologic parameters atively [5–7, 14, 21, 23, 38, 44, 45]. Two were euthanized
and acute phase proteins are not always indicative of an without treatment and four were lost to long-term follow-
infective process. Providing construct stability is not com- up. Overall, 27 of 40 animals (68%) treated surgically
promised, most ulnar fractures will heal in the presence of became sound and functional compared to 8 of 24 (33%)
low-grade infection [5, 7, 16]. Implants should therefore be that were managed conservatively. In 34 cases, fractures
left in situ until fracture healing is considered sufficiently were repaired by plate application of which 29 were DCPs,
advanced to be independent of implant support and capa- 4 hook plates and 1 LCP [5, 7, 14, 23, 30, 44, 45]. Pins and
ble of withstanding recovery from general anaesthesia wires were used in four animals [21, 38], and screws and
wires in two animals [21]. One hook plate [23] and one loaded articulations [14]. This is supported by pub-
wire [20] repair failed in recovery from anaesthesia. One lished data.
animal re-fractured post-operatively [5]. Flexural contrac- Results of 51 comminuted articular fractures are availa-
ture was a commonly reported sequel to conservatively ble in the literature. These include fractures repaired by
managed animals [5, 6]. DCPs in 31 [5, 7, 8, 11, 44, 45], LCPs in 10 [16, 29, 30] and a
The most useful information comes from a single centre hook plate in 2 horses [23]. Eight conservatively managed
study in which a consistent technique of repair with 4.5 mm horses were either lame or euthanized. Twenty-five of 43
narrow DCPs was reported in 20 animals. No constructs (58%) horses whose fractures were repaired returned to
failed. Nineteen horses were discharged from the hospital; soundness included 8 of 10 fractures repaired with
one died as a result of post-operative colic. Thirteen of 16 ani- LCPs [16, 29, 30] and 17 of 31 fractures (55%) repaired with
mals (81%) available for long-term follow-up returned to DCPs [5, 7, 8, 11, 44, 45]. Constructs in six (15%) fractures
athletic use making a strong case for adoption of the repaired by DCPs failed in recovery from general anaesthe-
technique [14]. sia or in the immediate post-operative period. All LCPs
constructs retained integrity.
Fracture biomechanics and principles of repair suggest
Proximal Non-articular (Type 3) Fractures that in the presence of comminution, use of an LCP should
There is a relative dearth of reports in the literature which be considered. This is supported by the data available to date.
likely reflects the uncommon nature of this injury. Of six
reported cases, five were repaired and one managed con- Fractures Commencing at or Distal to the
servatively with the application of a caudal limb splint. Radio-ulnar Articulation
Four of five cases that were repaired by application of a
tension band plate became sound; the fifth horse con- Sixty-one fractures have been reported of which 38 were
tracted pneumonia one week post-operatively [5, 23, 27]. managed surgically and 18 in a conservative manner. The
The animal managed conservatively also became former consisted of application of a tension band plate in
sound [5]. 28, LCP in 5 and repair with wire in 5 horses. Overall, 26 of
33 horses (79%) with long-term follow-up became athleti-
cally sound. These consisted of 18 of 21 fractures (86%)
Simple Humero-ulnar Articular Fractures repaired with DCPs [7, 15, 44], all 5 LCP repairs [30] and
The outcomes of 48 fractures are available for review in the 3 of 5 (60%) fractures repaired by tension band wires
literature. Of these, 42 were repaired and 6 were treated (only) [21]. Eleven of 18 (61%) horses managed conserva-
conservatively [5–7, 16, 23, 30, 44]. Thirty-five (83%) of the tively returned to soundness [6, 7, 15].
surgically managed cases returned to working soundness The most illuminating data comes from a single centre study
compared with none of those managed conservatively. of 32 horses in which 20 were repaired with DCPs, 7 managed
Twenty-four fractures were repaired with DCPs [5, 7, 44], conservatively and 5 were euthanized for economic reasons.
17 with LCPs [16, 30] and 1 with a hook plate [23]. One Thirteen horses managed surgically were available for long-
fracture repaired with a DCP failed in recovery from anaes- term follow-up of which 11 were sound in athletic activity,
thesia [7] and a technical error precipitated a radial frac- 1 was pasture sound and 1 was lame. Comminution was pre-
ture in one horse repaired with an LCP [16]; one other sent in 10 cases and did not appear related to outcome. Three
horse died of post-operative enteritis. Twenty of 24 (83%) of five individuals with follow-up available, which were man-
horse repaired with DCPs were sound which is similar to aged conservatively, became athletically sound [15].
14 of 17 horses (82%) repaired with LCPs. Failure of fixation was recorded for one wire repair, but
there was no recorded construct failure of fractures that
underwent plate fixation.
Comminuted Articular Fractures
Comminution in the ulnar notch has been considered Open Fractures
a negative prognostic sign due to the potential for sub- Although the presence of wounds is reported in a number
sequent degenerative joint disease [18]. However, this of publications, the follow-up data is sporadically recorded
is not inevitable and disruption of the ulnar portion of and therefore quantifying this as a complication risk is not
the cubital joint can be more tolerant than axially currently possible.
Reference 583
R
eferences
1 Getty, R. (1975). Equine Osteology. In: Sisson and 16 Jackson, M., Kummer, M., Auer, J. et al. (2011).
Grossman’s the Anatomy of the Domestic Animals Horse, Treatment of type 2 and 4 olecranon fractures with
5e, 255–348. Philadelphia, USA: WB Saunders. locking compression plate (LCP) osteosynthesis in horses:
2 Smith, B.L., Auer, J.A., Taylor, T.S. et al. (1991). Use of a prospective study (2002-2008). Vet. Comp. Orthop.
orthopaedic markers for quantitive determination of Traumatol. 24: 57–61.
proximal radial and ulnar growth in foals. Am. J. Vet. Res. 17 Watkins, J.P., Glass, K.G., and Kümmerle, J.M. (2018).
52: 1456–1460. Radius and ulna. In: Equine Surgery, 5e (eds. J.A. Auer,
3 Fackelman, G.E. (2000). Ulna (olecranon): plate fixation. K.A. Stick, J.M. Kümmerle and T. Prange). St. Louis,
In: AO Principles of Equine Osteosynthesis (eds. G.E. Missouri, USA: Elsevier.
Fackelman, J.A. Auer and D.M. Nunamaker), 159–169. 18 Nixon, A.J. (1996). Fractures of the ulna. In: Equine
Stuttgart: Thieme. Fracture Repair (ed. A.J. Nixon), 231–241. Philadelphia,
4 Sisson, S. (1975). Equine Syndesmology. In: Sisson and USA: Saunders.
Grossman’s the Anatomy of the Domestic Animals, 5e, 19 Watkins, J. (2006). Etiology, diagnosis and treatment of
349–375. Philadelphia, USA: Saunders. long bone fractures in foals. Clin. Tech. Equine Pract. 5:
5 Donecker, J.M., Bramlage, L.R., and Gabel, A.A. (1984). 296–308.
Retrospective analysis of 29 fractures of the olecranon 20 Levine, S.B. and Meagher, D.M. (1980). Repair of an ulnar
process of the ulna. J. Am. Vet. Med. Assoc. 185: 183–189. fracture with radial luxation in a horse. Vet. Surg. 9: 58–60.
6 Wilson, D.G. and Riedesel, E. (1985). Nonsurgical 21 Martin, F., Richardson, D., Nunamaker, D. et al. (1995).
management of ulnar fractures in the horse: a Use of tension band wires in horses with fractures of the
retrospective study of 43 cases. Vet. Surg. 14: 283–286. ulna: 22 cases (1980-1992). J. Am. Vet. Med. Assoc. 207:
7 Denny, H.R., Barr, A., and Waterman, A. (1987). Surgical 1085–1089.
treatment of fractures of the olecranon in the horse: a 22 Butler, J.A., Colles, C.M., Dyson, S.J. et al. (2016). Clinical
comparative review of 25 cases. Equine Vet. J. 19: Radiology of the Horse, 4e. Wiley.
319–325. 23 Murray, R.C., DeBowes, R.M., Gaughan, E.M., and Bramlage,
8 Anderson, D., Allen, D., and DeBowes, R. (1995). L.R. (1996). Application of a hook plate for management of
Comminuted, articular fractures of the olecranon process equine ulnar fractures. Vet. Surg. 25: 207–212.
in horses: 17 cases (1980 to 1990). Vet. Comp. Orthop. 24 Hanson, P.D., Hartwig, H., and Markel, M.D. (1997).
Traumtol. 8: 141–145. Comparison of three methods of ulnar fixation in horses.
9 Hubert, J. and Stashak, T.S. (2011). The antebrachium, elbow Vet. Surg. 26: 165–171.
and humerus. In: Adams and Stashak’s Lameness in Horses, 25 Johnson, J.H. and Butler, H.C. (1971). The tension-band
6e (ed. G.M. Baxter), 687–707. New Jersey, USA: Wiley. principle in fixation of an equine ulnar fracture. Vet. Med.
10 Nixon, A.J. (2020). Fractures of the ulna. In: Equine Small Anim. Clin. 66: 552–556.
Fracture Repair, 2e (ed. A.J. Nixon), 545–568. New Jersey, 26 Fretz, P.B. (1973). Fractured ulna in the horse. Can. Vet. J.
USA: Wiley. 14: 50–53.
11 Easley, K.J., Schneider, J.E., Guffy, M.M., and Boero, M.J. 27 Denny, H.R. (1976). The surgical treatment of fractures of
(1983). Equine ulnar fractures: a review of twenty five the olecranon in the horse. Equine Vet. J. 8: 20–25.
clinical cases. J Equine Vet Sci. 3: 5–12. 28 Milne, D.W. and Turner, A.S. (1979). An Atlas of Surgical
12 Clem, M.F., DeBowes, R.M., Douglass, J.P. et al. (1988). Approaches to the Bones of the Horse. Toronto, Canada:
The effects of fixation of the ulna to the radius in young Saunders.
foals. Vet. Surg. 17: 338–345. 29 Levine, D.G. and Richardson, D.W. (2007). Clincal use of
13 Richardson, D.W. (2000). Ulna (olecranon); tension band the locking compression plate (LCP) in horses: a
wiring. In: AO Principles of Equine Osteosynthesis (eds. retrospective study of 31 cases (2004-2006). Equine Vet. J.
G.E. Fackelman, J.A. Auer and D.M. Nunamaker), 39: 401–406.
171–177. Stuttgart: Thieme. 30 Jacobs, C.C., Levine, D.G., and Richardson, D.W. (2017).
14 Swor, T.M., Watkins, J.R., Bahr, A., and Honnas, C. Use of locking compression plates in ulnar fractures of 18
(2003). Results of plate fixation of type 1b olecranon horses. Vet. Surg. 46: 242–248.
fractures in 24 horses. Equine Vet. J. 35: 670–675. 31 Kümmerle, J.M., Kühn, K., Bryner, M., and Fürst, A.E. (2013).
15 Swor, T.M., Watkins, J.R., Bahr, A. et al. (2006). Results of Equine ulnar fracture repair with locking compression plates
plate fixation of type 5 olecranon fractures in 20 horses. can be associated with inadvertent penetration of the lateral
Equine Vet. J. 38: 30–34. cortex of the radius. Vet. Surg. 42: 790–794.
32 Gordon, S., Moens, N.M., Runciman, J., and Monteith, G. 39 Fournet, A., Boursier, A.-F., Corbeau, S. et al. (2018).
(2010). The effect of the combination of locking screws and Stabilization of olecranon fractures by tension band
non-locking screws on the torsional properties of a wiring or plate osteosynthesis: a retrospective study of 41
locking-plate construct. Vet. Comp. Orthop. Traumatol. 33: cases. Vet. Comp. Orthop. Traumatol. 31: 53–61.
7–13. 40 Trostle, S.S., Peavey, C.L., King, D.S., and Hartmann, F.A.
33 Cambell, J.R. and Lee, R. (1981). Radiological estimates (2001). Treatment of methicillin-resistant Staphylococcus
of differential growth rates of the long bones of foals. epidermidis infection following repair of an ulnar
Equine Vet. J. 13: 247–250. fracture and humeroradial joint luxation in a horse. J.
34 Stover, S.M. and Rick, M.C. (1985). Ulnar subluxation Am. Vet. Med. Assoc. 218: 554–559.
following repair of a fractured radius in a foal. Vet. Surg. 41 Jalim, S.L., McKinnon, A.O., and Russell, T.M. (2009).
14: 27–31. Repair of type IV Monteggia fracture in a foal. Aust. Vet. J.
35 Klopfenstein Bregger, M.D., Jackson, M.A., Kummer, M. 87: 463–466.
et al. (2011). Ulnar osteotomy for treatment of cubital 42 Elliot, C. and Middleton, B. (2016). Standing removal of
subluxation, following locking compression plate the proximal aspect of an olecranon fracture in a mature
osteosynthesis of a radius fracture in a foal. Equine Vet. Educ. horse. Equine Vet. Educ. 28: 492–496.
23: 455–461. 43 Barnweld, A. and van Weeren, P.R. (2010). Conclusions
36 Baxter, G.M. (2008). Making the rounds: surgical regarding the influence of exercise on the development
treatment of an ulna fracture – case notes and of the equine musculoskeletal system with special
commentary. Compend. Equine Archive 3: 147–150. reference to osteochondrosis. Equine Vet. J. 531:
37 McIlwraith, C.W., Nixon, A.J., and Wright, I.M. (2015). 112–119.
Diagnostic and surgical arthroscopy of the cubital 44 Janicek, J.C., Rodgerson, D.H., Hunt, R.J. et al. (2006).
(elbow) joint. In: Diagnostic and Surgical Arthroscopy in Racing prognosis of horses following surgically repaired
the Horse, 4e (eds. C.W. McIlwraith, A.J. Nixon and I.M. olecranon fractures. Can. Vet. J. 47: 241–245.
Wright), 292–307. Philadelphia, USA: Elsevier. 45 Colahan, P.T. and Meagher, D.M. (1979). Repair of
38 Monin, T. (1978). Repair of physeal fractures of the tuber comminuted fractures of the proximal ulna and
olecranon in the horse, using a tension band method. J. olecranon in young horses using tension band plating.
Am. Vet. Med. Assoc. 172: 287–290. Vet. Surg. 8: 105–111.
585
27
Fractures of the Humerus

A
natomy glides within the intertuberal groove aided by the large
synovial sac of the bicipital bursa interposed between the
The humerus is compact bone and relatively short com- tendon and the underlying fibrocartilage covered bone.
pared to other equine long bones. Its proximal end is com- The bicipital bursa ends at the level of the deltoid tuberos-
posed of the humeral head which articulates with the ity. This serves as the attachment of the deltoideus muscle
glenoid of the scapula in forming the scapulohumeral joint. which aids in shoulder flexion and forelimb abduction. The
Cranioproximal to the articular surface are the bifid greater superficial pectoral muscle also attaches to the deltoid
(lateral) and lesser (medial) tuberosities that form the tuberosity and contributes to forelimb adduction. The bra-
respective margins of the cranially situated intertuberal chialis muscle which serves to flex the cubital joint courses
(bicipital) groove. This is divided by an intermediate ridge. from its origin caudoproximally on the humerus to insert
Between the head of the humerus and the tubercles is the craniomedially on the proximal radius. It lies within the
humeral fossa. A caudally concave deltoid tuberosity is pre- musculospiral groove with the radial nerve immediately
sent on the craniolateral surface of the humerus at the junc- adjacent to its caudal border. Superficially, the brachioce-
tion of its proximal and middle one thirds. This is joined to phalicus muscle inserts on the osseous ridge of the
the lateral tuberosity by the humeral crest that is a promi- humerus that extends distally from the deltoid tuberosity
nent rough edge. Distally, the humerus terminates with and serves to protract the forelimb. The extensor carpi radi-
medial and lateral condyles which articulate with the head alis muscle, which is a major extensor of the carpus and
of the radius and trochlear notch of the olecranon to form supports flexion of the cubital joint, originates from a broad
the cubital joint. Proximal to the condyles are lateral and attachment on the cranial aspect of the lateral epicondyle.
medial epicondyles. The latter extends distal and caudal to The principal vascular structures are predominantly
the medial condyle with the space between the epicondyles medial to the humerus. The axillary artery and vein con-
forming the olecranon fossa. The superficial locations of the tinue distal to the shoulder joint as the brachial artery and
lateral osseous prominences (greater tubercle, deltoid vein. The external jugular vein continues distal in the
tuberosity and lateral epicondyle) serve as palpable land- groove between the brachiocephalicus and descending
marks but also places them at risk for traumatic injury. pectoral muscles as the cephalic vein.
The bulk of the humerus is deeply invested in soft tissues The radial nerve innervates the extensor muscles of the
and serves as a major site of attachment for many of the limb distal to the shoulder. It travels with the brachial artery
large muscles of the scapulohumeral region. The greater and passes between the medial and long heads of the triceps,
tubercle serves as the principal insertion for supraspinatus to lie along the caudal aspect of the brachialis muscle within
and infraspinatus muscles that course over the lateral the musculospiral groove of the humerus. It passes from
aspect of the shoulder joint. The joint has no collateral liga- caudolateral in the proximal to mid-diaphyseal region com-
ments so these muscles are responsible for lateral stability, ing to the lateral aspect of the brachium proximal to the lat-
and if disabled, either by injury to the suprascapular nerve eral epicondyle before continuing distally over the cranial
or loss of humeral insertion, lateral instability of the joint aspect of the cubital joint. Injury to the radial nerve proximal
will result . The tendon of origin of biceps brachii, which to the triceps branches precludes effective weigthbearing on
serves to flex the cubital and extend the shoulder joint, the affected limb due to inability to extend the elbow and

586 Fractures of the Humerus
lock the carpus in extension. However, radial nerve injury are caused by blunt trauma, usually the result of a kick by
distal to the triceps branches results in less severe clinical another horse, falls or collision with a fixed object.
signs. Affected horses can extend the elbow and carpus but
not the digit. Patients affected with low radial nerve paresis
will typically rest the dorsal surface of the hoof on the
ground and hold the carpus and digit in the flexed position. Pain on palpation and during manipulation of the limb are
If the hoof is placed in a normal position, either with assis- consistent findings. Swelling is usually evident, the degree
tance or by the patient flipping it forwards or setting back determined by the severity of the injury. Depending on the
over the toe, a normal weight-bearing stance can be main- inciting cause, some cases will also have an overlying
tained. Such low radial nerve injury is a typical complication wound. Crepitation in the region of the greater tubercle
in foals with diaphyseal fractures of the humerus and can may be identified, particularly when the fracture is dis-
negatively impact convalescence and outcome. placed. In the immediate post-injury period, lameness will
The musculocutaneous, median and ulnar nerves supply typically be severe, but dependent on the degree of instabil-
the flexors of the free limb. The musculocutaneous nerve ity usually dissipates with time. The gait is typified by
joins the median nerve proximally after supplying the cora- marked reluctance to protract the limb, resulting in a pro-
cobrachialis and biceps brachii muscles. The median nerve nounced decrease in the cranial phase of the stride. Lateral
courses along the cranial border of the brachial artery instability and potential luxation of the scapulohumeral
before moving to the caudal margin of the artery at the joint may be present in displaced fractures that completely
level of the elbow. The ulnar nerve courses along the cau- disarm the insertions of supraspinatus and infraspinatus
dal border of the brachial artery before passing over the muscles [2] (Figure 27.1). In cases accompanied by lateral
medial epicondyle of the humerus and entering the fore- instability, it is important to differentiate greater tubercle
arm. Injury to these structures is uncommon. Because of fractures from acute suprascapular nerve paresis. This is a
the shared innervations, it is unlikely that damage to either frequent sequel to blunt trauma to the cranial aspect of the
alone would significantly affect gait or limb function. shoulder region and can also occur when a horse collides
with a fixed object.
Fractures of the Greater Tubercle Imaging and Diagnosis

Radiographic evaluation of horses with suspected greater
tubercle fractures should include craniomedial to caudola-
Greater tubercle fractures are uncommon with publica- teral and caudolateral to craniomedial oblique projections.
tions restricted to case reports or small series [1–7]. Most Complete, displaced fractures are usually readily apparent
(a) (b) Figure 27.1 (a) Caudolateral–craniomedial

oblique radiograph revealing marked proximal
displacement of a greater tubercle fracture.
(b) Craniomedial–caudolateral radiographic image
demonstrating concurrent scapulohumeral
luxation.
Fractures of the Greater Tubercl 587
in the latter. The most common fracture is obliquely ori- tional information regarding the osseous margins of the
ented with its cranial aspect within the bicipital groove fracture (Figure 27.3).
exiting the lateral cortex caudally and extending distally to
the region of the deltoid tuberosity [7]. Complete fractures
tend to displace proximally due to the pull of the infraspi-
natus and supraspinatus muscles (Figure 27.2). Management of acute fractures primarily aims to address asso-
Identification of incomplete or minimally displaced ciated soft tissue injuries, especially open wounds. Wounds
fractures may require additional radiographic views. A overlying fractures should be managed aggressively as deep
cranioproximal–craniodistal oblique (skyline) projection infection will not only invade the fracture, complicate bone
of the proximal humerus was useful in defining long healing and increase morbidity associated with surgical repair,
oblique fractures in one series [3] (Figure 27.2c). However, but may also result in infection of the bicipital bursa. Immediate
fractures that were clearly identified on the mediolateral and appropriate wound care is essential and should include
projections and those located more caudally were not well both systemic and local antimicrobial therapy.
defined with this projection [3]. Targeted projections can Axial instability of the limb can accompany severe frac-
sometimes be contributory. Ultrasound is indicated to tures that compromise the lateral support of the shoulder
evaluate surrounding soft tissues and to provide addi- by disrupting the insertions of the supraspinatus and
(a) (b)
(c)
Figure 27.2 (a) Caudolateral–craniomedial oblique radiograph of the left proximal humerus confirming a complete, proximally
displaced, greater tubercle fracture in a 14-year-old Standardbred gelding that exhibited lateral instability of the scapulohumeral
joint. (b) Similar image two days later (a), after transportation to the referral facility for repair, demonstrating marked progressive
proximal displacement of the fragment. (c) Cranioproximal–craniodistal oblique (skyline) radiograph. Source: Images courtesy of
Dr Ashlee Watts, Texas A&M University, College Station, TX.
(a) (b) (c)
Figure 27.3 Fragmentation of the caudal eminence of the greater tubercle. Difficult to identify on a mediolateral radiograph (a)
but profiled in cranioproximal medial–caudodistal lateral oblique projection (b). The fracture was accompanied by a wound and
ultrasonography confirmed articular communication and quantified infraspinatus insertional involvement (c).
infraspinatus muscles. Unfortunately, there is no external the fracture shows evidence of healing and the lameness
coaptation that can effectively reduce instability and has improved to an acceptable degree, small paddock turn-
improve limb function prior to definitive therapy. out is recommended for an additional 8–12 weeks prior to a
gradual reintroduction to training.
In a series of five cases, two horses managed non-
Non-surgical Treatment
surgically were able to return to their previous level of ath-
Fractures with minimal displacement and adequate com- letic performance, one remained lame but was able to
fort to allow shared weight-bearing between affected and function as a broodmare, one was euthanized due to severe
support limbs are potential candidates for conservative muscle atrophy and one was lost to follow up [3]. Two addi-
management. In such cases, this can offer a fair prognosis tional case reports describe conservative management and
for return to athletic function. Patients selected for nonsur- both patients, an 8-year-old Tennessee walking horse and a
gical treatment should be confined to a stall. Non-steroidal 16-month-old Thoroughbred filly, were able to perform
anti-inflammatories are administered to improve comfort their intended functions [1, 5].
as needed. Surgery should be considered in patients who
are not or who do not quickly become sufficiently comfort-
Surgical Treatment
able to place substantial weight on the affected limb as they
are at increased risk of supporting limb complications Techniques described for surgical management include
including laminitis. fragment removal, open reduction and internal fixation
Fracture displacement during the initial weeks of con- (ORIF) and minimally invasive internal fixation. Fragment
finement is the major risk when electing non-surgical size, degree of displacement and soft tissue considerations
management. This may be reduced by discouraging recum- influence the choice. Removal is indicated in patients with
bency through cross-tying or utilizing a sling support sys- small fragments involving only a minor portion of the
tem for four to six weeks. Careful monitoring of patient insertions of supraspinatus and/or infraspinatus and mini-
comfort and sequential radiographic evaluations are cru- mal involvement of the intertubercular groove, particu-
cial to identify patients whose fracture may be displacing. larly in cases complicated by communicating wounds
With careful monitoring, fracture displacement can be (Figure 27.3).
identified prior to complete avulsion, simplifying surgical Displaced fractures with larger fragments or those that
reduction and fixation. extend axially and involve a significant portion of the inter-
Patients whose fracture remains non-displaced and have tubercular groove are candidates for internal fixation.
an acceptable level comfort should be confined for Repair re-establishes stability and once this is restored,
12 weeks. During the last weeks of confinement, a progres- patient comfort will improve. This promotes a rapid return
sive programme of hand walking is instituted. Providing to weight-bearing on the affected limb and reduces the risk
Fractures of the Greater Tubercl 589
of supporting limb complications. Anatomic reconstruc-

tion of the fibrocartilaginous surface of the intertubercular
groove also minimizes impingement injuries and conse-
quent biceps tendonitis that can result from incongruity.
Furthermore, it is the authors’ opinion that repair should
be advocated for nondisplaced fractures if subsequent dis-
placement would result in regional instability or disrupt a
significant portion of the intertubercular groove. Fixation
can be accomplished in the anesthetized, laterally recum-
bent or standing, sedated patient using local anaesthe-
sia [3, 4]. General anaesthesia with an open approach is
advisable when the fragment is significantly displaced.
Exposure of the fracture permits fragment manipulation,
visualization for anatomic reduction and allows the
surgeon to choose implant placement by direct observation
rather than reliance on imaging.
A lateral curvilinear incision centred over the scapulo-
humeral joint and extending distally to the level of the
deltoid tuberosity with deep dissection between brachio-
cephalicus and deltoideus muscles provides access to the Figure 27.4 Post-operative medial to lateral radiograph of the
case illustrated in Figure 27.1 confirming reduction of the
greater tubercle. To expose the fracture line within the scapulohumeral luxation with fracture reduction and fixation
intertubercular groove, the brachiocephalicus muscle is utilizing 5.5 mm cortex screws placed in lag fashion. Tension
incised directly over the greater tubercle and its edges band wire fixation is utilized to counteract the distractive forces
retracted. The deep fascia is transected between the lat- of supraspinatus. Washers are placed to increase cortical contact
for the lag screws, preventing the screw heads from over-
eral border of the biceps brachii and the cranial aspect of penetrating the underlying bone, and to increase wire security.
the greater tubercle, opening the bicipital bursa and
allowing the tendon to be retracted medially. Reduction
of the proximally displaced fracture fragment may be post-operatively. Recovery from anaesthesia should be
facilitated by use of pointed reduction forceps. assisted, as difficulty in standing, or falls place the fixa-
Alternatively, a 5.5 mm glide hole can be made in the frag- tion at risk of failure [3, 6].
ment at an appropriate location and the 4.0 mm drill Fractures that are not markedly displaced may be stabi-
guide placed in the hole can be used as a handle to pro- lized through a minimally invasive approach in the stand-
vide distal traction on the fragment. Following reduction, ing, sedated, locally anaesthetized patient. Radiographic
compressive fixation is achieved using multiple 5.5 mm control is mandatory as the fracture will not be visualized
cortex screws placed in lag fashion with washers. directly and implants will be positioned through stab inci-
Distractive forces acting at the fracture place substantial sions. Radiopaque markers are placed to aid in identifica-
bending forces on the screws, therefore large orthopaedic tion of appropriate screw locations (Figure 27.5a). Mild
wires or cables should be applied in a figure-of-eight pat- displacement can be reduced by using the 4.0 mm insert as
tern from the screws in the greater tubercle to screws a handle to lever the fragment into position. Multiple
placed distally in the parent bone (Figure 27.4). The wires 5.5 mm cortex screws with washers are then placed in lag
are necessary to neutralize bending forces on the screws fashion to accomplish compressive fixation (Figure 27.5b
and the washers will aid in retention of the wires/cables and c). The addition of wire/cables to counteract tensile
on the screw heads. Alternatively, a bone plate can be forces acting on the fracture fragment may be less impor-
used in place of the wires/cables. A plate may provide tant since the fixation will not be subject to the additional
more uniform compression; however, the alignment of forces associated with recovery from general anaesthesia.
the holes when using a plate may increase the risk of sec-
ondary fracture through the screw holes. In addition, the Post-operative Care
number of screws that can be placed through the fracture Management after surgical fixation should follow a similar,
fragment may be limited. If such a tension band plate is if somewhat abbreviated, protocol as described for non-
used, fracture compression by prior placement of lag surgical treatment. With stable fixation, the length of time
screws may be prudent. Wound closure is routine and a the patient needs to be prevented from recumbence can be
stent bandage is sutured in place to protect the incision reduced. Radiographic monitoring of the construct is
(a) (b) (c)
Figure 27.5 Repair of a fractured greater tubercle in a standing sedated horse. Intra-operative caudolateral–craniomedial oblique
radiographs (a) demonstrating needle placement to localize screw positions and positioning of the 4.0 mm insert sleeve to facilitate
fragment manipulation and reduction and (b) following fixation with three, 5.5 mm cortex screws in lag fashion. Washers are placed
on all screws to increase cortical contact. Gas is present within the subcutaneous tissues. (c) Post-operative mediolateral radiograph
demonstrating triangular orientation of screws to optimize compression and minimize risk of weakening the fragment by placing
screws in the same plane. Antimicrobial impregnated PMMA beads are visible cranially.
advisable to determine the patient’s readiness for free stall follows. Affected horses frequently have evidence of wounds
movement and then when additional activity can be or soft tissue swelling over the lateral aspect of the humerus
allowed. Implants remain in situ unless complications dic- or are presented with a draining tract in the region of the
tate otherwise. tuberosity. Lameness is variable but is often evident at walk
and characterized by reduced protraction (cranial phase) of
the affected limb. Clinical signs are usually adequate to local-
Results ize the region of interest.
Reports of surgical fixation are limited but the progno- Several imaging modalities have been reported as use-
sis for survival was excellent and was good for return to ful to establish a diagnosis. Radiographically, fractures
previous athletic function in a variety of disciplines [3, were identified on cranial 45° medial–caudolateral
7]. In the largest series, eight of nine horses treated sur- oblique projections in one report [8]. Only 32% were
gically returned to their previous level of activity with identified on mediolateral radiographs. Ultrasonography
only one performing at a lower level [3]. In four other may show discontinuity of the deltoid tuberosity.
case reports, horses undergoing ORIF, ranging in age However, this may not be possible in the presence of a
from 8 to 13 years, successfully returned to previous wound when gas accumulates within soft tissues. In
performance levels by six months post-operatively [2, 4, cases presented with a draining tract, sonographic evi-
6, 7]. In two cases with athletic outcomes, the fracture dence of communication with the deltoid tuberosity can
line remained evident radiographically five months be diagnostic and aid in identifying additional fluid accu-
post-operatively [6, 7]. mulation associated with more extensive soft tissue
infection. Nuclear scintigraphy has been performed
when there is concern regarding the integrity of the
humeral shaft. Increased radiopharmaceutical uptake
Fractures of the Deltoid Tuberosity may be identified as early as four days post-injury [8].
There are few reports of deltoid tuberosity fractures in the

Treatment and Results
literature [8, 9]. However, its superficial location places it at
risk of external trauma resulting in fracture, usually of a por- Wounds should be treated by debridement, lavage and
tion of the tuberosity. Often these are open and sequestration removal of loose comminuted, contaminated or obviously
Stress Fracture 591
distinct locations in the humerus [11, 12]. These areas

are at risk for stress fracture which may in turn lead to
catastrophic bone failure. In a series of 54 Thoroughbred
racehorses, there was a greater risk of complete humeral
fracture after a ≥two-month period of rest followed by
an increase in exercise. The majority (65%) sustained a
complete humeral fracture within 10 days of resuming
race training [13]. Osteopenic change within the
humerus during the rest period was considered the
likely cause of bone failure since it occurred so soon
after the horses returned to training. However, it is also
possible that a pre-existing stress fracture or pathology
in the humerus may have been responsible for initiating
the rest period and predisposed the humerus to com-
plete fracture once the horse became free of pain and
returned to training. Understanding the risks, clinical
signs and modalities for diagnosis are critical to identify-
ing at-risk individuals.
Figure 27.6 Craniomedial–caudolateral radiograph Clinical Features and Diagnosis

demonstrating osseous trauma to the deltoid tuberosity of the
humerus associated with a wound. Subcutaneous gas is Acute, moderate to severe lameness following exercise
apparent within a large wound in the cranial shoulder and which may be exacerbated by manipulation of the upper
pectoral regions.
limb are nonspecific indicators typical of humeral stress
fracture. Lameness usually resolves with rest [14]. Humeral
stress fractures appear to occur most frequently in horses
devitalized fragments. Broad spectrum antimicrobial ther-
of three years of age and those with more extensive race
apy is indicated. Judicious use of non-steroidal anti-
histories. This is in contrast to those affected by tibial stress
inflammatory therapy to improve patient comfort is also
fracture, which are typically younger (two years of age) and
recommended. Failure of the wound to heal or unresolving
without or light race records [14]. There does not appear to
lameness suggests possible sequestration, and additional
be a sex, limb or seasonal predisposition [10, 11].
investigation and treatment are warranted (Figure 27.6).
When clinical findings are suggestive of humeral stress
Deltoid tuberosity fractures accompanied by fracture of the
fracture, radiographic evaluation is indicated. Periosteal
greater tubercle are treated as described above (“Surgical
new bone formation and medullary sclerosis, in locations
Treatment” section).
known to be at risk, are highly suggestive [11]. However, it
Isolated deltoid tuberosity fractures, treated by wound
is important to note that immature periosteal callus may
care and stall rest, have a good prognosis for return to
not be visible, and the lack of radiographic findings does
athletic function [8, 9]. In a series of 19 horses, lameness
not rule out the presence of a stress fracture [11]. When
resolved and athletic function was restored in 13 of 14
localizing clinical signs or significant radiographic abnor-
patients. The remaining horse experienced repeated
malities are lacking, nuclear scintigraphy is advocated and
sequestration of a comminuted fracture, and further
is frequently needed for diagnosis. Increased radiopharma-
surgical treatment was declined [8]. In another report, a
ceutical uptake identified on nuclear scintigraphy should
single horse recovered completely following a period of
be considered diagnostic [11].
rest [9].
Four locations have been identified where most humeral
stress remodelling and subsequent stress fracture formation
occur: caudoproximal, cranioproximal, caudodistal and
S
tress Fractures
craniodistal [12, 14]. Caudoproximal stress remodelling
lesions are typically more severe and are associated with
most complete fractures [12]. Horses training and racing on
Stress fractures are a common cause of lameness in rac- synthetic surfaces experience a greater proportion of distal
ing Thoroughbreds [10] and stress remodelling, charac- humeral stress remodelling lesions compared to horses at
terized by periosteal callus, has been identified at racetracks with dirt surfaces where a greater proportion of
caudoproximal lesions are identified [12]. In a series of 26 also the most common sites in the UK (Figures 27.7 and 27.8)
Thoroughbred racehorses with 27 stress fractures, 12 horses (I. M. Wright, unpublished data), which are similar to the
(13 fractures) involved the humerus. Ten involved the proxi- two ends of the catastrophic spiral diaphyseal fracture seen
mal caudolateral cortex and three the distal craniomedial in racing Thoroughbreds. It has been suggested that caudo-
cortex; one horse had lesions at both sites [15]. These are distal fractures may have a different pathogenesis [10].
(a) (b)
(c) (d)
Figure 27.7 (a) Scintigraphic images from investigation of acute left forelimb lameness in a Thoroughbred colt revealing increased
radiopharmaceutical uptake (IRU) in the caudoproximal humerus. (b–d) Mediolateral radiographs taken respectively 1, 35 and 68 days
later demonstrating (circle) loss of margination (b), a cortical defect with adjacent periosteal and endosteal callus (c) and cortical
healing with adjacent organizing new bone (d).
Stress Fracture 593
(a)
(b)
(c) (d) (e)
Figure 27.8 (a) Scintigraphic images investigating acute left forelimb lameness in a Thoroughbred filly revealing IRU in the cranial
distal humerus. (b–e) Mediolateral images of the distal humerus and cubital joint taken 1 day (b), 5 weeks (c), 9 weeks (d) and
14 weeks (e) later. In (b), there is a discrete fracture in the cranial distal metaphyseal cortex with adjacent endosteal and periosteal
new bone. (c–e) Progressive fracture healing and remodelling to a normal contour and osseous organization.
A recent study of 131 Thoroughbreds recorded 52 (40%) cau- the need for accurate diagnosis and management to avoid
doproximal, 43 (33%) craniodistal and 36 (27%) caudodistal catastrophic injury [11]. Two studies concluded that
humeral stress fractures [10]. with early diagnosis using nuclear scintigraphy, progres-
sion to complete, catastrophic fracture can be completely
avoided [12, 14].
Treatment and Results
Affected horses should be stall rested for at least one
Humeri from 10 of 13 horses with complete unilateral month. Once lameness at the walk is resolved, hand walk-
humeral fractures occurring during races or race training ing exercise is instituted. The horse may be allowed small
in California established an association between complete paddock turnout after lameness at a trot is no longer
fracture and pre-existing stress remodelling emphasizing evident. Following one month in a small paddock, an
additional one to two months of pasture turnout should be

allowed. A minimum of three to four months rest and
rehabilitation is required before a gradual return to race
training [14]. Recurrence rates of 15% (6 of 39 horses) have
been reported which in all but one horse involved the cor-
responding location in the contralateral limb [14]. The
importance of continued clinical observation and appro-
priate management of horses returning to training cannot
be over-emphasized. However, the prognosis is good: 110
of 131 (84%) Thoroughbreds raced after suffering humeral
stress fractures. The median time to first race was 244 days
and earnings for horses which had raced previously were
not significantly different. In this series, there were no
recurrences although two horses suffered humeral stress
fractures in the contralateral limb [10].
Physeal Fractures
The humerus has four physes, one each associated with

the epiphyses of the head and the condyles, together with
Figure 27.9 Craniocaudal radiograph of a minimally displaced
the apophyses of the greater tubercle and medial epicon- Salter–Harris type II distal humeral physeal fracture. The case
dyle. Fractures involving the humeral physes are relatively was managed conservatively with a favourable outcome.
uncommon compared to other long bones. In a survey of Source: Courtesy of Dr Nick Carlson, Steinbeck Country Equine
Clinic, Salinas, CA.
70 equine physeal fractures, 11 (16%) were humeral; one
affected the proximal physis, one affected both the proxi-
mal physis and greater tubercle, two affected the physis of
the medial epicondyle, and seven affected the distal phy-
sis [16]. Uncommonly fracture can involve more than one
humeral physis, and one was reported in conjunction
with ulnar apophyseal avulsion (Salter–Harris type I)
fracture [17].
The only reported fracture involving the proximal
(humeral head) physis did not survive following con-
servative management by stall confinement [16].
Fractures of the distal (condylar) physis are typically
either Salter–Harris type II (Figure 27.9) or IV, and
rarely type III (Figure 27.10). When displaced, these
have a poor prognosis due the complex surface contour
of the bone and limitations of implants available for
fixation. Five cases have been reported in a series of
humeral fractures, three treated by surgical fixation and
two by stall confinement. Only one of the group, man- Figure 27.10 Craniocaudal radiograph of a chronic Salter–
aged by stall confinement, survived [19]. Harris type III distal humeral physeal fracture in a weanling
Quarter Horse. Source: With permission from Auer and
Of two cases of avulsion fracture through the physis of Watkins [18].
the medial epicondyle managed with stall confinement,
one survived and became sound. A case report documented
repair of a comminuted distal humeral Salter–Harris type LCP. The filly was given an assisted recovery from
II fracture in a 161 kg two-month-old Standardbred filly. anaesthesia and exhibited extensor deficits post-
This was accessed by ulnar osteotomy and repaired with a operatively. These were managed by splinting and at six
seven-hole broad locking compression plate (LCP). The months post-surgery the animal was reported to be com-
osteotomy was then repaired using a seven-hole narrow fortable and in normal management [20].
Diaphyseal Fracture 595
Diaphyseal Fractures

Diaphyseal fractures in horses in race training can result
from repetitive, high intensity exercise with accumulated
stress remodelling preceding catastrophic failure. However,
they can also be monotonic and result from a traumatic
event, such as falling onto the affected limb, which is most
common in foals. Complete diaphyseal fractures secondary
to a kick injury are infrequent, but have been noted in
foals.

Affected horses have non-weight-bearing lameness with a
dropped elbow appearance and the limb held in flexion,
similar to displaced fractures of the olecranon tuberosity of
the ulna or radial nerve injury (Figure 27.11). Diaphyseal
fractures of the humerus typically have marked swelling of
the humeral and shoulder region which is best viewed
from a cranial vantage (Figure 27.12). Additional localizing
signs include instability, crepitation and, with displaced
fractures, substantial discrepancy in the palpable distance
Figure 27.12 Left humeral diaphyseal fracture in a three-
month-old Appaloosa filly with marked swelling of the brachial
region extending to the antebrachium.
between the point of the shoulder and point of the elbow

when compared to the contralateral limb (see Figure 7.9).

Diagnosis is established by radiography. Extending the
limb cranially and obtaining a medial to lateral projection
with a slight cranial to caudal obliquity best defines frac-
tures [21] (Figure 27.13). Further characterization of the
fracture is possible by obtaining an orthogonal caudoproxi-
molateral to craniodistomedial (CauPrL-CrDiM) projec-
tion [21] (Figure 27.14). Most fractures affect the mid to
distal diaphysis, and in foals they are usually simple oblique
or spiral in configuration.

Once a fracture of the humerus is confirmed, a decision
should be reached regarding the feasibility for repair and
the client’s willingness to pursue therapy. There are
many instances when euthanasia is the selected option.
Fixation is often successful in foals weighing less than
Figure 27.11 A six-month-old Quarter Horse colt with a left
humeral diaphyseal fracture demonstrating the typical dropped 250 kg with simple, closed fractures. Open and/or more
elbow and flexed limb posture. complex fractures and animals weighing over 250 kg are
(a) (b)
Figure 27.13 (a) Position of the limb and image detector for medial to lateral radiographic projection of the humerus. (b) Medial to
lateral radiograph demonstrating a complete, short oblique, diaphyseal humeral fracture.
(a) (b)
Figure 27.15 Craniocaudal radiograph of an articular, highly

comminuted, distal humeral fracture in an eight-year-old, 636 kg
Warmblood mare. Due to the size of the patient, configuration
and comminution of the fracture, the animal was not considered
Figure 27.14 (a) Position of image detector and photograph a surgical candidate and was humanely euthanized.
taken from tube position for CauPrL-CrDiM radiographic
projection. (b) CauPrL-CrDiM radiograph of the patient shown in
Figure 27.12. cated. Encouraging use of the axially unstable limb causes
additional movement of the sharp, highly mobile fracture
fragments and further trauma to adjacent soft tissues, par-
more problematic and are not ideal candidates for repair ticularly the brachialis muscle and radial nerve.
(Figure 27.15). When treatment is elected, attempts at Wounds in the area should be investigated for evidence
emergency coaptation prior to transport are not recom- of communication with the fracture and managed appro-
mended. It is not possible to stabilize fractures because the priately. Fortunately, the vast majority of humeral fractures
elbow and shoulder joint cannot be immobilized with are closed because the humerus is deeply invested in the
external coaptation. Splinting the carpus in extension, to soft tissue envelope, reducing the likelihood of fracture
allow weight-bearing on the affected limb, is contraindi- fragments penetrating the skin.
The physiologic status of an equine patient with an axi-

ally unstable fracture can vary widely and in worst cases is
characterized by a shock-like state resulting from a combi-
nation of exertion, hypovolaemia, extreme pain and anxi-
ety. Weight-bearing on three legs while managing an axial
unstable limb during transport to a hospital can exacerbate
these problems. Pain and anxiety should be addressed with
the judicious use of analgesics and anti-inflammatories.
Hypovolaemia, often related to profuse sweating, as well as
blood loss into the fracture haematoma, should be corrected
with fluid therapy appropriate for the patient’s status.

Options for therapy include conservative management or
surgical reduction and fracture stabilization with metallic
implants. In general, complex fractures in animals greater
than 250 kg are not good candidates for surgical repair.
With simple fractures of the diaphysis in foals, good to
excellent results can be obtained in a high percentage of
Figure 27.16 Mediolateral radiograph of a seven-month
cases using appropriate implants and fixation methods. Quarter Horse gelding demonstrating a diaphyseal humeral
fracture that healed with exuberant callus in a malunion;
overriding resulting in a shortened overall humeral length.
Conservative Management
Conservative management entails confining the patient
to a stall for an extended time. Horses which may have a verlying the fracture. Additionally, when splinting is
o
reasonable chance of success with conservative manage- employed, it is important to reduce the amount of bedding
ment include incomplete and complete fractures that are in the stall to reduce the effort needed for the patient to
non-displaced or long oblique fractures in which the advance the limb with the carpus immobilized.
overriding fragments interdigitate and provide some Support limb complications, ongoing fracture displace-
degree of stability. Cases where the distal spike of the ment with associated soft tissue injury and/or radial nerve
proximal fracture segment impacts the distal segment at paralysis, malunion and non-union are all commonly
the proximal aspect of the condyles are also candidates as encountered in patients managed conservatively [19, 22].
this provides some resistance to continued axial displace- In adults, the most common complication is supporting
ment. However, the only resistance to the forces of bend- limb laminitis. In foals, varus deformity of the supporting
ing and rotation is provided by soft tissue swelling and the limb fetlock and/or carpus are frequent scenarios.
fracture haematoma. As the haematoma matures, stabil- Hyperextension of the supporting limb fetlock can also
ity gradually increases and eventually second intention result from excessive overload during the prolonged conva-
fracture healing can occur. However, the humerus is typi- lescence. In the affected limb, flexural deformity of the car-
cally malaligned and shorter than its contralateral coun- pus, fetlock and/or coffin joints and tendon contracture
terpart (Figure 27.16). can result from insufficient weight-bearing (Figure 27.17).
Initially, the patient should be confined in a deeply bed- Carpal contracture can also result from extensor deficits as
ded stall. As the fracture haematoma consolidates and the a consequence of radial nerve injury from unstable fracture
limb gains stability, it is expected that partial weight- fragments.
bearing, with full extension of the carpus at rest, becomes Favourable outcomes have been reported following
possible. Careful monitoring and judicious use of a splint conservative management in young horses. Seven of
over the caudal aspect of the carpus to maintain full exten- 10 horses aged four months to three years were reported
sion may enhance recovery and limit the degree of carpal to attain riding soundness after confinement ranging
contracture which is a common occurrence during the pro- from 4 to 12 months [22]. In another report, 7 of 14 horses
tracted convalescence. It is important to delay use of a (aged three months to five years) with non-physeal
carpal splint until partial stability at the fracture has been fractures had favourable outcomes with four becoming
restored to avoid further damage to the soft tissues athletically sound [19].
which is favoured by the authors [26]. Skin is incised begin-

ning approximately 4 cm proximal to the greater tubercle and
extending distally to the level of the lateral epicondyle.
Proximally, the brachiocephalicus muscle is incised along its
fibres exposing the craniolateral surface of the greater tuber-
cle and proximal humeral metaphysis. The bicipital bursa is
opened laterally, allowing medial retraction of the tendon of
biceps brachii to expose the cranial aspect of the proximal
humerus. The deltoideus muscle is transected from its inser-
tion on the deltoid tuberosity exposing the lateral aspect of
the humeral diaphysis. Distally, caudal retraction of triceps
exposes the origin of extensor carpi radialis muscle for eleva-
tion from the craniolateral aspect of the lateral epicondyle.
The radial nerve should be identified along the caudal border
of brachialis to confirm its integrity prior to fixation.
Successful repairs using stacked pin, Rush pin, plate and
intramedullary interlocking nail (IIN) fixations have been
reported in foals [18, 19, 21, 22, 24–26]. Technique is deter-
mined by patient size, fracture location and configuration,
Figure 27.17 Clinical appearance of the animal in Figure 27.16. available instrumentation/implants and experience of the
Marked varus deformity of the supporting limb has developed surgeon.
secondary to the protracted period of lameness during fracture Stacked pin fixation requires minimal instrumentation
healing. The affected leg exhibits a substantially shortened but the construct provides limited resistance to bending
brachial length, distal limb flexural deformity, marked muscle
atrophy and a narrow (contracted) hoof. forces and affords only minimal axial and rotational stabil-
ity (Chapter 8) [19, 27]. Non-locked intramedullary fixa-
tion is best suited to fracture sites where pins can establish
Surgical Management
substantial contact with the medullary cortical bone proxi-
Displaced, diaphyseal fractures are typically short oblique mal and distal to the fracture. Unfortunately, the anatomy
to spiral, markedly overriding, and highly unstable mak- of the foal’s humerus, combined with the typical location
ing them extremely poor candidates for conservative man- of most humeral fractures, precludes a strong interface
agement. With appropriate case selection, patient between implants and bone on both sides of the fracture.
outcomes can be markedly improved with ORIF [22–25]. Without this, stability is lacking and pins typically migrate.
Simple fractures in patients weighing up to 250 kg are Further instability results and there is a high risk that pins
good candidates for repair with appropriate instrumenta- will be extruded, leading to construct failure. Additionally,
tion and implants. if pins penetrate the skin, the construct becomes contami-
Definitive fracture fixation providing a stable bone– nated and infection is likely. Instability and/or infection
implant construct will prevent further fracture-associated result in protracted lameness, impede healing and contrib-
damage to the bone and surrounding soft tissues and encour- ute to failure.
age early weight-bearing on the fracture limb. The sooner Plate fixation using a cranial approach to the humerus
this can be achieved, the better. However, as with all major has been reported with favourable results in a small num-
fracture fixations in the horse, many factors must be taken ber of patients, including one foal [26]. Single-plate appli-
into consideration including timing of surgery. The patient’s cation to the cranial humerus proximally and the
physiologic status, which is often compromised in the imme- craniolateral humerus distally may allow adequate fixation
diate post-injury period, will negatively impact anaesthesia in small foals with simple mid-diaphyseal fractures. Large
and recovery. Although additional fracture-induced soft tis- patients or patients whose fractures are not mid-diaphyseal
sue damage can occur, it has been the authors’ experience benefit from double plate fixation, with the second plate
that short delays to allow physiologic stabilization of the applied to the lateral aspect of the bone. However, the com-
patient, assemble the surgical equipment needed and allow plex surface topography of the distal humerus makes it dif-
the surgical team to plan the repair have seldom had a major ficult to achieve substantive purchase in the distal fracture
negative consequence. Many successful repairs have been segment with the lateral plate. Since the initial report of
accomplished in the days immediately following the injury successful plate fixation in a foal, there have been no other
rather than on the same day. reports to further substantiate the technique. The authors
Exposure for reduction and fixation can be accomplished are aware of numerous attempts at plate repair that have
using a cranial or modified lateral approach to the humerus, ended with construct failure. In the majority of these,
a dequate purchase in the distal segment could not be (a) (b)

achieved due to the distal location of the fracture.
Limitations with conservative therapy, stacked pin fixa-
tion and plate fixation provided the impetus for the first
author to seek an innovative method for humeral fracture
repair using IIN fixation. Repair using an IIN provides addi-
tional purchase in the distal fracture segment by engage-
ment of the medial epicondyle, and using screws to lock the
proximal and distal fracture segments to the intramedullary
nail prevents implant migration and provides axial and rota-
tional stability. in vitro testing of the IIN revealed superior
rotational stability than stacked pin fixation [28]. The
intramedullary location of the implant is biomechanically
advantageous as it is near the neutral axis of the bone rather
than eccentrically on the cortex as with a bone plate.
Intramedullary implants may also be at less risk for implant
associated infection compared to implants applied to the
external cortical surface [21]. IIN fixation is the authors’
technique of choice for repair of diaphyseal humeral frac-
tures in foals [24]. Using the modified lateral approach, the
medullary cavity is reamed allowing introduction of a cus-
tom fabricated IIN. Proximal and distal fracture fragments Figure 27.18 Post-operative mediolateral (a) and CauPrL-CrDiM
are transfixed to the IIN using 5.5 mm cortex screws placed oblique (b) radiographs demonstrating fixation of a mid-
diaphyseal short oblique humeral fracture with an IIN.
transcortically using a rigid targeting device which obviates Antimicrobial impregnated beads are present adjacent to the
the need for intra-operative imaging. An ideal IIN construct fracture, and skin staples are evident.
consists of three interlocking screws in both proximal and
distal fracture fragments (Figure 27.18). If the fracture loca-
tion or configuration precludes such a construct and in
larger patients, the addition of a plate to the cranial aspect of
the humerus is recommended (Figure 27.19). Cerclage with
wire(s), or preferably large orthopaedic cable, can be used to
augment the fixation in oblique fracture configurations.
Following repair, patients should be confined to a stall
for a minimum of 60–90 days. Repeat radiographic exami-
nation documents healing identified by remodelling at the
fracture site and periosteal and endosteal bridging callus.
At 30–45 days post-surgery, animals may begin a daily regi-
men of controlled hand walking and at 90 days the foal may
be allowed small paddock turnout. Typically, animals are
returned to their normal housing and turnout routine by
four months post-operatively. Implants are not removed
unless complications occur.
Complications of repair are similar to those of other
long bones and include surgical site and/or implant infec-
tion, construct failure, malunion, non-union, and support-
ing limb complications. Low radial nerve paresis is often
present in the immediate post-operative period as a conse-
quence of the proximity of the nerve to fracture sites in the
musculospiral groove. This often occurs pre-operatively,
either from the insulting traumatic event or from the Figure 27.19 Immediate post-operative mediolateral
unstable sharp fracture fragments, but may also occur radiograph of a diaphyseal humeral fracture repaired with an
IIN, cranial LCP and cerclage cable. Gas is present within the soft
intra-operatively during surgical manipulations. Radial
tissues secondary to the surgical approach. Antimicrobial
nerve paresis, and/or pain resulting in reduced weight- impregnated PMMA beads are present adjacent to the fracture,
bearing and the inability or unwillingness of the patient to and skin staples can be seen.
completely extend the carpus, predispose to carpal con- the humerus [26]. Rush pin fixation has been reported in
tracture in affected limbs. This is common and, if severe, three foals, one with a successful outcome at 10 months post-
may require surgical transection of the ulnaris lateralis fixation [19, 22]. Five foals, all less than two months of age at
and flexor carpi ulnaris insertions for correction. If carpal the time of repair, were treated with stacked pin fixation and
contracture is recognized early, bandaging and a caudally three achieved athletic outcomes [19].
applied splint to fix the carpus in extension may resolve Fixation of a humeral fractures in a large number of
the issue. cases employing an IIN alone or in combination with a cra-
nial bone plate has recently been presented [24, 25, 29].
Twenty-five foals ranging in age from one week to nine
Results
(mean four) months and weighing 68–295 (mean 177) kg
Reports detailing repair of diaphyseal fractures are limited were repaired with an IIN alone [24]. Fifteen patients, aged
and, for the most part, dated [19, 21, 22, 26]. Plate fixation of 2–12 (mean six) months and ranging in weight from 113 to
non-physeal fractures has been attempted in four foals, with 377 (mean, 242) kg, were repaired with an IIN in combina-
one reported success [17, 25]. The patient with a favourable tion with a cranial bone plate [25]. Overall, 29 patients
outcome was sound 21 months after repair of a long oblique (73%) survived to discharge and 25 of 27 (93%) patients
fracture using a single DCP applied to the cranial aspect of were able to perform their intended use as adults [29].
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Assessment and treatment of equine humeral fractures: Cranial approach to the Humerus for repair of fractures
retrospective study of 54 cases (1972–1990). Equine Vet. J. in horses and cattle. Vet. Surg. 20: 1–8.
25: 203–207. https://doi.org/10.1111/j.2042-3306.1993. 27 Markel, M.D., Nunamaker, D.M., Wheat, J.D. et al. (1988).
tb02944.x. in vitro comparison of three fixation methods for
20 Ahern, B.J. and Richardson, D.W. (2010). Distal humeral humeral fracture repair in adult horses. Am. J. Vet. Res.
Salter Harris (type II) fracture repair by an ulnar 49: 586–593. https://doi.org/10.1017/
osteotomy approach in a horse. Vet. Surg. 39: 729–732. CBO9781107415324.004.
21 Watkins, J.P. (2006). Etiology, diagnosis, and treatment of 28 Watkins, J.P. and Ashman, R.B. (1991). Intramedullary
long bone fractures in foals. Clin. Tech. Equine Pract. 5: interlocking nail fixation in transverse humeral fractures:
296–308. https://doi.org/10.1053/j.ctep.2006.09.004. an in vitro comparison with stacked pin fixation. Proc.
22 Zamos, D.T. and Parks, A.H. (1992). Comparison of surgical VOS 18: 54.
and nonsurgical treatment of humeral fractures in horses: 29 Watkins, J. and Glass, K. (2017). Repair of 40 humeral
22 cases (1980–1989). J. Am. Vet. Med. Assoc. 201: 114–116. fractures in horses less than one year of age (1989–2013).
http://www.ncbi.nlm.nih.gov/pubmed/1644630. AAEP Proc. 63: 476.
603
28
Fractures of the Scapula

A
natomy cranioventral displacement due to tension applied by the
biceps brachii and coracobrachialis muscles. Comminuted
The scapula is a large, flat, triangular bone that articulates fractures of the supraglenoid tubercle occur uncommonly.
with the humeral head via the glenoid cavity. A long scapu- Fractures of the neck and body are variable and depend on
lar spine extends longitudinally from dorsal to ventral on the inciting cause. Transverse fractures of the neck have
the lateral aspect of the bone. This creates a division been reported [5–7]. Comminuted fractures of the neck
between the cranial supraspinous fossa where the supraspi- and body can be monotonic, caused by direct trauma such
natus muscle originates and the caudal infraspinous fossa as a kick or a fall, or subsequent to exercise-induced stress
where the infraspinatus muscle originates. Just dorsal to the fractures in racehorses.
mid-point of the spine, there is a variably sized caudally Stress fractures in the neck, spine and body occur with
angled tuber spinae. The region between the distal margin some frequency in Thoroughbred (TB) and Quarter Horse
of the spine and glenoid is termed the neck of the scapula. (QH) racehorses and can lead to complete catastrophic
The subscapular muscle originates on the subscapular fractures during high-speed work [8, 9]. Stress fractures
fossa, the slightly concave medial aspect of the scapula. The have been reported at the middle or distal aspect of the
dorsal boarder is continued as a large scapular cartilage. scapular spine and/or supraspinous fossa [10], caudal
The supraglenoid tubercle extends cranially from the distal aspect of the neck (Figure 28.1) and infraspinous fossa [11]
scapula forming a palpable prominence. It is convex later- and medial aspect of the glenoid [8]. A post-mortem study
ally and concave medially where the coracoid process is a of racehorses with complete scapular fractures demon-
small but pronounced protuberance. The tubercle serves as strated a typical configuration in which a transverse frac-
the origin for the biceps brachii (craniolateral) and coraco- ture occurred across the neck of the scapula at the level of
brachialis (craniomedial) muscles. The supraglenoid tuber- the distal aspect of the spine with a dorsal plane fracture
cle and cranial glenoid form as two separate centres of extending distally through the cranial glenoid. In this
ossification, uniting radiographically at approximately nine study, all horses had periosteal callus consistent with a pre-
months of age [1]. This epiphysis then fuses with the parent existing stress fracture in the neck of the scapula where the
scapula by 12 months of age. These separate centres of ossi- complete transverse fracture had occurred. These horses
fication likely explain the increased frequency of supragle- were also noted to have similar periosteal reaction in the
noid fractures in horses <two years of age [2]. contralateral scapulae. Other areas of periosteal callus
included the lateral aspect of the neck, middle of the spine,
distal subscapular fossa and medial glenoid [8].
F
racture Types
Overall, fractures of the scapula occur infrequently. Incidence and Causation

Fractures of the supraglenoid tubercle are most common,
but fractures of the neck, body and spine have also been Although the supraglenoid tubercle is the most commonly
reported [1, 3, 4]. Fractures of the supraglenoid tubercle reported site of scapular fracture, they represent a small
are usually simple, complete and articular with variable number of total equine fractures. Supraglenoid fractures

604 Fractures of the Scapula
(a) occur most commonly in young horses (<two years) either

as a result of direct trauma or as avulsion fractures associ-
ated with excessive tension applied by the biceps brachii
and coracobrachialis tendons [3, 12]. These fractures may
be over-represented in younger animals due to the pres-
ence of the physes. Supraglenoid fractures, although
uncommon, do occur in adult horses.
Stress fractures of the scapula represent approximately
4% of overall stress fractures in TB racehorses [13]. They
are secondary to maladaptive stress remodelling and cause
variable lameness. Complete catastrophic scapular frac-
tures have been reported to account for 2% of TB and 6% of
QH racehorse fatalities in California [14]. Racehorses in
early high-speed training but behind that of their training
cohort, QH that had a prolonged lay-up and TB that had
received greater high-speed training than cohorts were
considered at increased risk [15].
In the acute phase, horses with fractures of the supragle-

noid tubercle generally display severe lameness. There is
usually a markedly shortened cranial phase of the stride
and reluctance to fully extend the limb. Swelling over
the point of the shoulder and pain on palpation are
common; crepitus can be appreciated in some horses.
Lameness often improves within 48 hours, which can
delay time to surgical referral [3, 4]. Horses with chronic
(b) fractures of the supraglenoid tubercle often have sec-
ondary atrophy of the infraspinatus and supraspinatus
muscles and can develop osteoarthritis of the scapulo-
humeral joint [16].
Stress fractures of the neck and body cause variable
lameness, with increased severity during speed work.
Horses with complete fractures involving the neck and
body are unable to bear weight. Swelling, pain on palpation
and crepitus are common; over-riding can also result in
segmental shortening (see Figures 7.5 and 7.10). Damage
to the suprascapular nerve can occur secondary to the
injury leading to denervation and atrophy of supraspinatus
and infraspinatus muscles. Suprascapular nerve function
can be assessed using electromyography; however, this is
only reliable at least 7–10 days post-injury [17]. Axillary
nerve injury can also occur leading to atrophy of the del-
toid muscles and/or cleidobrachialis [12].

Figure 28.1 (a) Nuclear scintigraphic images of a three-year-old
Thoroughbred colt with a history of right forelimb lameness Radiography
following speed work. There is intense, focal increased
Radiographic evaluation of the scapula is challenging in
radiopharmaceutical update in the scapular neck caudal and distal
to the scapular spine. (b) A mediolateral radiograph revealed new the horse due to the large surrounding muscle mass and
bone (arrow) in the same location consistent with a stress fracture. superimposition of the contralateral scapula and ribs.
Treatmen 605
High-output machines are required for diagnostic images. luxation of the scapula [16]. Fragment removal is carried
Radiographs of the distal scapula, including the glenoid out with horses placed in lateral recumbency with the
and supraglenoid tubercle, can be obtained by extending affected limb up. A skin incision is made from the distal
the limb forward such that the area of interest is superim- aspect of the scapular spine over the cranial aspect of the
posed over the air-filled trachea in the caudal neck. Once scapulohumeral joint extending distally to the deltoid
the limb is extended, a mediolateral projection can be tuberosity. The brachiocephalicus muscle is retracted cra-
obtained. A cranial 45° medial–caudolateral oblique nially and ventrally with hand-held retractors, and the
(extended) view can provide additional information. supraspinatus muscle is incised in the direction of its fibres
Radiographs of the scapula can also be obtained under over the supraglenoid tubercle. Self-retaining retractors
general anaesthesia with the horse placed in lateral recum- placed in the supraspinatus muscle incision may be helpful
bency, the cassette placed under the affected limb and the to expose the fracture. Care should be taken to identify and
contralateral limb either protracted or retracted. gently retract the suprascapular nerve, artery and vein tra-
versing the neck of the scapula. The fracture fragment is
then dissected from the robust tendinous attachments
Ultrasonography
using a combination of blunt and sharp dissection.
Ultrasonography can be useful for detecting fractures of Dissection can be challenging even when the fragment is
the body and spine that are not easily detected radiographi- small. The surgical site should be thoroughly lavaged, and
cally. Complete ultrasonographic evaluation of the scapula the incision closed in multiple layers including supraspina-
has been described and used to successfully evaluate scap- tus and brachiocephalicus muscles, fascia, subcutaneous
ular fractures [18, 19]. In the absence of hospital facilities, tissue and then skin. If possible, recovery from anaesthesia
this can be highly contributory. should be assisted. Horses are maintained on box stall rest
for 60 days post-operatively to allow fibrous adhesion of the
Nuclear Scintigraphy amputated biceps tendon and fracture bed. During this
time, range of motion exercises can be performed. Return
Nuclear scintigraphy is especially useful for identification to work generally occurs 6–12 months post-operatively.
of scapular stress fractures (Figure 28.1) [11, 13]. Areas of Internal fixation of supraglenoid tubercle fractures
increased radiopharmaceutical uptake are readily identi- should be performed in horses with fragments involving
fied on lateral images. >1/3 of the articular surface of the glenoid. Historically, this
involved lag screw fixation with or without tension band
wiring (Figure 28.3) [1–3, 16, 20]. The surgical approach for
T
reatment
lag screw fixation is similar to that described for fragment
removal. In order to achieve successful repair using lag
Supraglenoid Tubercle Fractures
screws, tension from the biceps tendon must be neutralized
Conservative and surgical management of supraglenoid to prevent implant failure. Partial or complete biceps tenot-
tubercle fractures have both been reported. Conservative omy has been described [21] with moderate results.
management consists of stall rest for three to four months Following tenotomy, the fracture is reduced ensuring con-
followed by pasture turnout for three to nine months. Due gruity at the articular surface. Reduction can be maintained
to the risk of osteoarthritis of the scapulohumeral joint sec- using large pointed bone reduction forceps. Two or three
ondary to incongruity of the articular surface, conservative 5.5 mm cortical bone screws or 6.5 mm cancellous bone
management is only recommended for horses with small screws are placed cranial to caudal across the fracture in lag
fracture fragments or horses in which surgery is not an fashion. The use of 7.3 mm diameter cannulated screws
option. Overall, conservative therapy has been associated appears appealing because the equipment allows the entire
with a poor prognosis for return to athletic soundness, procedure (drilling, tapping and screw insertion) to be per-
although the prognosis for breeding or pasture soundness formed with a guide pin in place. Unfortunately, the can-
is generally good [16]. Conservative management usually nulated screws, despite their larger diameter, break more
results in fibrous or fibro-osseous malunion. Horses fre- easily than a solid screw and are not strong enough in larger
quently develop more upright conformation and a ‘con- yearlings. Screws should be placed in slightly diverging
tracted foot’ on the affected leg. directions to increase resistance to pull-out. A tension band
Surgical treatment can involve fragment removal can be created using 1.25 or 1.5 mm stainless-steel wire or
(Figure 28.2) or internal fixation. Fractures involving more 1.7 mm cable. In order to place the tension band, a 2.5 or
than one-third of the glenoid should be repaired to main- 3.2 mm hole is drilled lateral to medial through the cranial
tain congruity of the scapulohumeral joint. Removal of scapular neck proximal to the supraglenoid tubercle. A sec-
large fragments causes instability and can lead to caudal ond hole is then drilled through the supraglenoid tubercle
(a) (b) (c)
Figure 28.2 Mediolateral radiograph of a 13-year-old Warmblood gelding with a comminuted, displaced fracture of the supraglenoid
tubercle. (a) At presentation. (b) Immediately after fracture fragment removal. (c) Ten months post-operatively. Mild to moderate
osteoarthritis of the scapulohumeral joint is noted, but the horse was in work.
and the wire or cable is placed in a figure-of-eight pattern rest for three to four months following surgery followed by
and securely tightened. Following lavage of the surgical six to nine months of pasture turnout before returning to
site, a closed suction drain can be placed in the incision to work. The authors postulated that complete tenotomy may
decrease post-operative seroma formation. The incision is provide better results than a partial tenotomy because ten-
closed as described above, and assisted recovery from anaes- sion from the intact medial portion of the tendon is main-
thesia is performed. Box stall rest for two months followed tained with partial tenotomy.
by box stall rest with hand walking for one month is recom- More recently, plate fixation of supraglenoid tubercle
mended. Following 12 weeks of stall rest, horses can be fractures has been described. The earliest description
turned out into a small paddock for two to three months involved a distal femoral locking compression plate
before returning to work. Complete tenotomy with lag (LCP) [22]. In this report of three horses, the LCP was
screw fixation was reported in three cases with two of three applied longitudinally either cranial or caudal to scapular
horses returning to work. Horses were maintained on stall spine. Although fractures healed in all horses, two required
(a) (b) Figure 28.3 Mediolateral radiographs of a

two-year-old Warmblood filly. (a) A large
moderately displaced fracture of the
supraglenoid tubercle which demonstrates
typical rotational displacement associated with
traction from biceps brachii. (b) Post-operative
image following repair with 5.5 mm cortical
screws placed in lag fashion and two strands of
1.25 mm wire used as a tension band. Note that
the distal screw is too long.
Treatmen 607
standing plate removal due to persistent mild lameness Complete Fractures of the Scapular Neck
and muscle atrophy presumed to be associated with com- or Body
pression of the suprascapular nerve. In a follow-up study,
Complete fractures of the scapular neck and body are
the authors found that cranial placement of a plate that
uncommon. Few are amenable to internal fixation,
was overbent over the suprascapular nerve gave the best
although successful repair of transverse fractures of the
results [23]. In the authors’ opinions, longitudinal plate
neck [4, 5, 7] and of a longitudinal fracture of the body [19]
placement is much more difficult and not mechanically
have been reported. Successful repair of complete, commi-
superior to a transversely positioned plate.
nuted fractures in adult horses has not been reported.
Internal fixation using one or two narrow LCPs placed
Incomplete or stable, complete fractures can be managed
transversely across the scapular neck has been described
conservatively [1, 3].
in four horses with three returning to athletic sound-
For transverse or oblique fractures of the neck, a skin inci-
ness [24]. Following the surgical approach described for
sion is made just cranial to the spine of the scapula and cen-
fragment removal, the fracture plane is debrided and
tred over fracture. The caudodorsal fascia of the
reduced using large pointed reduction forceps
brachiocephalicus muscle is incised, and the muscle is
(Figure 28.4). If the fragment is large enough, two locked
retracted cranially and ventrally. The fascia attaching the
screws are placed in the tubercle then the fragment is
supraspinatus and infraspinatus muscles to the scapular
reduced accurately. The scapula is very nearly flat across
spine are incised, and the muscles are elevated from the
the neck so minimal plate contouring is required. A 5.5
scapular body using a periosteal elevator. The suprascapular
cortex screw is placed in load position in hole three and
nerve should be identified and isolated. Following fracture
tightened to compress the fracture. The fourth hole is
debridement and reduction, an appropriately sized LCP or
filled with a locked screw. In larger horses, two plates can
dynamic compression plate (DCP) is contoured and posi-
be used with similar screw placement. The more proximal
tioned to maximize the number of screws in the thicker dis-
plate can be a three-hole proximal interphalangeal (PIP)
tal aspect of the scapula [5, 6, 7]. The plates can be applied at
arthrodesis LCP. At least one hole on each side of the frac-
90° to each other with one plate cranial and one plate caudal
ture should have a locked screw. The plating can be com-
to the spine [4]. Narrow 4.5 or 3.5 mm plates can used
bined with a tension band wire that goes through one of
depending on the size of the horse (Figure 28.5). Following
the plate’s cranial combi holes and through a lateral-to-
plate application, the fascia of the supraspinatus and
medial hole drilled through a more proximal segment of
infraspinatus muscles are closed followed by closure of the
the cranial scapula, but more recent cases suggest that
brachiocephalicus with adjacent fascia, subcutaneous tis-
this is unnecessary. There are significant advantages to
sues and skin. Recovery from general anaesthesia should be
transverse lateral plating. It is technically easier, the self-
assisted.
compressing capacity of the plate is appropriate to stabi-
Internal fixation of longitudinal fractures involving the
lize the fracture and the fixed angle nature of the implants
glenoid, neck and/or body is challenging. A case report
can strongly resist the tension of biceps brachii.
described successful repair of a longitudinal fracture
Theoretically, stable reconstruction of the joint with pres-
extending from the caudal glenoid proximally to the dorsal
ervation of the origin of biceps brachii should be the best
cartilage in a two-year-old Paint Horse [19]. This appears
technique. Closure and recovery from anaesthesia are as
to be a rare fracture. Following reduction, repair was
previously described. Post-operative management and
effected with four 4.5 mm narrow DCPs applied across the
return to training follow that described for lag screw
fracture line along the length of the fracture. Ten months
fixation.
post-operatively the horse was sound at the trot.
Overall, the prognosis for return to athleticism follow-
ing internal fixation of supraglenoid tubercle fractures
largely depends on the degree of cartilage damage and Fractures of the Scapular Spine
articular congruity achieved at surgery. Horses that
develop secondary osteoarthritis will have continued Closed fractures of the spine have a good prognosis with
lameness despite fracture healing. Only a small number adequate rest. Open, contaminated fractures may require
of cases have been followed up to date, but five out of debridement, which can often be performed in the stand-
seven have become athletically sound using the trans- ing, sedated horse [4]. With resolution of infection, the
verse plating technique. prognosis is generally good.
(a) (b)
(c) (d)
(e)
Figure 28.4 (a) Mediolateral radiograph of yearling Standardbred colt with a displaced fracture of the right supraglenoid tubercle.
(b) Intra-operative photograph of the surgical approach. The horse is positioned in left lateral recumbency with cranial to the right of
the image. The skin incision is made from the distal aspect of the scapular spine over the cranial aspect of the scapulohumeral joint.
The brachiocephalicus muscle (B) is retracted cranioventrally, and the supraspinatus muscle (S) is incised along its muscle fibres to
expose the supraglenoid tubercle. (c) The fracture is exposed with Hohmann retractors. (d) Repair with two four-hole narrow 4.5 mm
LCPs. In a larger horse like this, two 5.0 locking head screws are placed in the fragment followed by a 5.5 mm cortex screw in load
position into the hole adjacent to the fracture in the parent bone and then a final locked screw. (e) Mediolateral post-operative
radiograph demonstrating two LCPs placed transversely across the fracture.
Treatmen 609
(a) (b)
(c) (d)
(e) (g)
Figure 28.5 (a) Mediolateral and (b) cranial 45° medial–caudolateral oblique radiographs of a two-month-old Thoroughbred filly
who sustained a complete, transverse fracture of the neck of the scapula (arrows) while out on pasture. (c) Prior to plate application,
the suprascapular nerve was identified and isolated using a Penrose drain. (d) The fracture was repaired using two LCPs placed at 90°
to each other on either side of the scapular spine. (e) Mediolateral and (f) cranial 45° medial–caudolateral oblique radiographs
obtained post-operatively demonstrating implant placement and fracture reduction. (g) Mediolateral radiograph obtained two months
following surgery. The fracture had healed, and a well-organized bony callus is evident. The horse subsequently raced.
R
eferences
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611
29
Fractures of the Tarsus

I.M. Wright
A
natomy of the lateral talus. It is taut during extension of the tar-
socrural joint and loose in flexion. The horizontally ori-
The equine tarsus consists of six and occasionally seven ented short lateral collateral ligaments (superficial, middle
bones [1]. Movement is substantially uniplanar (flexion and deep) are axial to the long [5]. They are partly fused at
and extension) and occurs through the tarsocrural articula- their proximal attachments on the lateral malleolus but
tion [2], although the 12–15° proximomedial to distolateral have distinct and separate insertions predominantly on the
orientation of the trochlear ridges of the talus and corre- talus. They arise dorsal to the groove for the lateral digital
sponding grooves in the distal tibia [1] results in outwards extensor tendon. The superficial short lateral collateral lig-
rotation of the distal limb as the tarsus is flexed [2]. The ament has superficial fibres that are taut in extension and
remaining joints are planar and are bound by inelastic deep fibres taut in flexion, although maximal stretching of
intertarsal ligaments permitting only minimal gliding the entire ligament occurs when the tarsocrural joint snaps
motion [3]. Their function has been described as absorbing into or out of maximum extension. Middle and deep short
concussion and neutralizing twisting forces [4]. lateral collateral ligaments are both under maximum ten-
The distal tibial epiphysis is irregularly quadrilateral in sion during flexion and loose in extension of the tarsocru-
cross-section [1]. Its articular surface consists of two dorso ral joint. The short lateral collateral ligaments are
lateral to plantaromedial grooves that interdigitate with the subsynovial within the tarsocrural joint and can be visual-
trochlear ridges of the talus. These are bordered by the lat- ized arthroscopically enveloping almost the entire articular
eral and medial malleoli and divided by the similarly ori- surface of the lateral malleolus of the tibia [6].
ented sagittal (intermediate) ridge. The medial malleolus The long medial collateral ligament is again approxi-
of the tibia is more abaxially protuberant than the lateral mately vertically orientated but is broader and less well
and the distal intermediate ridge of the tibia has a beak-like defined than its lateral counterpart. It originates on the
dorsodistal protuberance. The lateral malleolus, as the phy- medial malleolus proximal to the groove of the medial digi-
logenetic distal fibula, develops as a separate centre of ossi- tal flexor tendon and its sheath and inserts over a broad
fication with fusion to the distal tibial epiphysis occurring area on the distal tuberosity of the talus, central, third and
in the first year of life [1]. It has a greater dorsoplantar (DP) fused first and second tarsal bones and on the second and
depth than its medial counterpart. A shallow groove is evi- third metatarsal bones. The short medial collateral liga-
dent on its surface which marks the line of the lateral digi- ments are more obliquely orientated than laterally. Their
tal extensor tendon which, in turn, occupies a groove in the origins are on the medial malleolus dorsal to the groove of
long collateral ligament. The tibial malleoli serve as origins the medial digital flexor tendon. They are more abaxially
of the collateral ligaments of the tarsus; there is one long situated than the short lateral collateral ligaments such
and three short collateral ligaments medially and laterally. that a larger portion of the medial malleolus is visible
The well-defined approximately vertically orientated arthroscopically in the dorsal tarsocrural joint. Their prin-
long lateral collateral ligament originates on the lateral cipal insertions are on the medial talus on and adjacent to
malleolus plantar to the groove for the tendon of the lateral its proximal medial eminence and on the sustentaculum
digital extensor and inserts on the distal calcaneus, fourth tali. The long medial collateral ligament is under tension
tarsal, third and fourth metatarsal bones and a small area during extension of the tarsocrural joint and is loose during

612 Fractures of the Tarsus
flexion. The superficial short medial collateral ligament is protuberant coracoid process. The proximal margin (apo-
under tension in flexion, the middle is tense in extension physis) is irregularly convex. This forms from a separate
and the deep portion has mixed fibres, some of which are centre of ossification which fuses to the parent bone at
tense in extension and some which are tense during approximately 20 months of age [1]. Its plantar surface is
flexion [5]. covered by fibrocartilage and forms the dorsal wall of the
The dorsal tarsal ligament is broad and flat attaching congenital subtendinous calcaneal bursa. Dorsal to this
proximally to the distal medial tuberosity of the talus and the bone is substantially enveloped by the insertion of
fanning dorsally to insert on the central and third tarsal and gastrocnemius and abaxial to this the complex insertions
the third and second metatarsal bones. There are in addi- of the superficial digital flexor, biceps femoris and sem-
tion a number of short intertarsal ligaments connecting itendinosus [7]. The plantar surface of the calcaneus dis-
individual bones around and within the tarsus which are tal to the fibrocartilaginous surface serves as origin for
not of specific concern with respect to fracture diagnosis the long plantar ligament. Distally, the calcaneus has a
and management. The complex of tarsal joints has a com- relatively small, shallow concave articulation with the
mon fibrous capsule that is thin dorsally and in the proxi- fourth tarsal bone. The body of the calcaneus extends
mal plantar pouch of the tarsocrural joint, but thick in the medially from the distal half of the bone as the susten-
distal plantar tarsus. Here, it is intimately attached to the taculum tali. This has a long smooth plantar margin cov-
tarsal bones, is in part cartilaginous and forms the dorsal ered by fibrocartilage that acts as a trochlear for the
wall of the tarsal sheath. The intertarsal ligaments preclude tendon of insertion of the lateral digital flexor in its
significant motion at all but the tarsocrural joint where the course through the tarsal canal. The medial wall of the
collateral ligaments ensure that the tarsus/tarsocrural joint associated tarsal sheath reflects off the medial margin of
is bistable, i.e. in both flexion and extension [2]. the sustentaculum tali.
The body of the talus has an irregular shape dominated The central tarsal bone has large proximal and distal
proximally and dorsally by medial and lateral trochlear articular surfaces for the talus and third tarsal bone,
ridges and a deep intervening intertrochlear groove respectively. Distally and medially, it articulates with the
which interdigitate and articulate with the tibia. The dor- second tarsal bone and at its plantarolateral margin there
sal aspect of the intertrochlear groove commonly con- is a small articular facet for the fourth tarsal bone. The
tains a synovial fossa. Distally, the talus has an undulating bone is described as having an irregular quadrilateral
but predominantly convex articular surface principally cross-sectional shape [1]. It is mediolaterally widest dor-
for the central tarsal bone but with a small lateral facet sally where it is approximately four times its proximodistal
for the fourth tarsal bone. On its plantar surface, the depth. The proximal articular surface is concave with a
talus has four articular facets for the calcaneus. The larg- radius of curvature that decreases towards its plantarome-
est is proximolateral and occupies the abaxial surface of dial margin. The distal surface is undulating and articu-
the proximal lateral trochlear ridge and proximal lateral lates primarily with the third tarsal bone but with a
body of the talus. This articulates with the coracoid pro- smaller, convex facet plantaromedially for the conjoined
cess of the calcaneus. Distal and medial to this, a second first and second tarsal bones. The dorsal surface of the
articular facet has a steep dorsoproximal to plantarodis- central tarsal bone is slightly convex in its lateral one-half
tal orientation that articulates with the body of the calca- before becoming irregularly convex and protuberant to its
neus. Laterally, there are two smaller articular facets for medial margin.
the distal calcaneus. An irregular, concave fossa occupies The third tarsal bone has a roughly triangular cross-
the space between the articular facets and with a similar sectional shape with a wide convex dorsal margin and irreg-
concavity in the calcaneus forms the sinus tarsi. The ularly indented concave medial and lateral margins
medial body of the talus has large distal and small proxi- extending to an irregularly truncated plantar surface. Both
mal tuberosities at the points of insertion of the long and proximal and distal articular surfaces, for the third tarsal
short collateral ligaments, respectively. The lateral body and third metatarsal bones respectively, are undulating, but
has an irregular contour to which long and short collat- the former is predominantly concave and the latter convex.
eral ligaments attach. The bone is widest dorsally where it is approximately four
The calcaneus articulates with the plantar and lateral times it proximodistal depth. The dorsal surface is smooth
surfaces of the talus with facets that correspond in size and slightly convex medially and irregularly protuberant
and location to those described above. Proximal to these and convex laterally. In the mature Thoroughbred, the third
is the large tuber calcanei that has straight lateral and tarsal bone has a proximodistal depth of approximately
plantar, concave medial and slightly concave dorsal 15 mm with 8 mm between proximal and distal subchondral
surfaces [1]. At the distal end of the latter is the dorsally bone plates [8]. The first and second tarsal bones are usually
Fractures of the Medial Malleolus of the Tibi 613
fused into an irregularly shaped bone that forms the medio- ractures of the Medial Malleolus
F
plantar part of the distal row of tarsal bones distal to the of the Tibia
central and plantar to the third tarsal bones. It has articula-
tions with central and third tarsal bones and second and Fractures of the tibial malleoli occur medially and laterally.
third metatarsal bones. The latter are most frequent and the single most common
The fourth tarsal bone bridges proximal and distal rows tarsal fracture in horses. A 2012 review of the refereed lit-
of tarsal bones laterally. It articulates proximally with the erature published in English cited 42/44 (95%) lateral,
calcaneus and talus, distally with the third and fourth met- 1 medial and 1 biaxial fracture [9]. Fractures of the medial
atarsal bones and axially with the central tarsal bone. An malleolus generally have a traumatic aetiology, are usually
axial groove and corresponding abaxial concavities in the larger than their lateral counterparts and can be articular
central and third tarsal bones form a canal for the perforat- or non-articular. The latter are commonly caused by kicks
ing tarsal artery. or similar trauma and may be accompanied by a wound
The proximal metatarsal epiphysis fuses to the diaphysis and/or contusion. Articular fractures are frequently the
before birth [1]. Its principal articular surface with the result of falls or similar insults. Both result in lameness,
third tarsal bone is slightly concave. There is a large cen- but joint distension is a dominant clinical feature of articu-
tral, non-articular depression that communicates with a lar fractures. They are generally recognized, and configura-
lateral notch axial to the fourth metatarsal bone. Dorsal to tion determined in DP and dorsolateral–plantaromedial
this is a slightly slopping articular surface for the fourth oblique (DL-PMO) radiographs. Articular fractures exhibit
tarsal bone with a confluent vertical facet for articulation varying degrees of displacement (Figure 29.1a and b) and
with the fourth metatarsal bone. Plantar to the notch is a require a minimum of four orthogonal projections for
second smaller vertical facet for articulation with the assessment and identification of displaced comminution.
fourth metatarsal bone. Small confluent horizontal and Open, usually non-articular fractures, frequently become
vertical facets are present plantaromedially for articulation infected and can sequestrate (Figure 29.2). Distal, articular
with the conjoined first and second tarsal bones and for the fractures usually disarm entirely the origins of the short
second metatarsal bone, respectively. A small, non- collateral ligaments whereas proximal, non-articular frac-
articular groove separates the latter from a second, smaller tures involve varying amounts of the long collateral liga-
articular facet for the second metatarsal bone at the plantar ment origin. All should be assessed ultrasonographically in
aspect of the metatarsal bone. A slightly protuberant irreg- order to evaluate collateral ligament compromise and thus
ular ridge running around the dorsal epiphysis is the site of assess surgical risks and potential benefits of support in
insertion of tibialis cranialis [1]. recovery from general anaesthesia.
The proximal fourth metatarsal bone (head) is approxi- Fractures that are of sufficient size to require reconstruc-
mately twice the size of the second metatarsal bone. It has tion and repair are more common medially than laterally.
consistent dorsal and inconsistent plantar articular facets Dorsal recumbency is recommended utilizing a limb sup-
for the fourth tarsal bone. The bulk of its proximal surface port system that will allow varying degrees of flexion in
is non-articular for insertion of the long collateral and order to facilitate reduction. Use of an Esmarch bandage
plantar ligaments. The proximal second metatarsal bone and tourniquet can improve visibility and reduce surgical
has two confluent proximal articular facets for the con- time.
joined first and second tarsal bones and two separate, verti- Reconstruction of articular congruency is critical [4, 10]
cal facets axially for articulation with the third metatarsal and is evaluated using a standard dorsomedial arthro-
bone. scopic portal [6]. Lag screw fixation is generally advocated,
with implant(s) (3.5, 4.5 or 5.5 mm cortical screws) deter-
mined by fragment size [10]. Reduction can be guided
Fractures of the Tarsal Bones arthroscopically utilizing a Steinmann pin in a glide hole
insert. However, a concurrent open approach exposing the
Both monotonic and repetitive stress fractures occur within proximal, non-articular, portion of the fracture may also
the tarsus. The former include fractures of the tibial malle- be necessary. The screws, which may be inserted percuta-
oli, talus, calcaneus and proximal (articular margins) of neously or through a short incision, must be directed
the fourth metatarsal bone. Slab fractures of the third tarsal obliquely in distal medial to proximal lateral trajectories to
bone and dorsoproximal third metatarsal bone are work avoid impingement on the articular surface [4]. Intra-
related. Causation of slab fractures of the central bone is operative radiographic monitoring is essential. Fractures
less clear. that are of sufficient size to require repair will compromise
(a) (b) (c)
(e)
(d)
Figure 29.1 Large comminuted fracture of the medial malleolus of the tibia resulting from an unseen paddock accident in a
three-year-old Thoroughbred filly. (a) DP and (b) DL-PMO radiographs demonstrating loss of the entire abaxial portion of the medial
malleolus (circle). The fracture disarmed entirely the short and disrupted substantially the long medial collateral ligaments. (c)
Dorsolateral arthroscopic view demonstrating protrusion of the most axial fragment (arrows) through disrupted short medial
collateral ligaments (arrow heads). (d) Exposure of the principal fragment (F) with torn short collateral ligaments attached (arrow
heads) and debrided defect in the long collateral ligament visible proximally (arrows). (e) Principal fragment following removal:
articular surface to the left with portions of short collateral ligaments (arrow heads) adjacent and resected long collateral ligament
further proximal (arrows). The filly recovered from general anaesthesia in a hock cast. Recovery was eventful, and the animal
ultimately led a normal broodmare life.
(a) (b) Figure 29.2 A non-articular fracture of

the medial malleolus of the tibia in a
five-year-old gelding that sustained a
wound from a kick seven weeks prior to
referral. It had been given varying
antimicrobials during the intervening
period and was presented with a
discharging granulated wound (a) DP and
(b) DL-PMO radiographs demonstrating
fragmentation (circle) with an irregular
defect in the parent bone and adjacent
soft tissue swelling. This was treated by
surgical excision, sequestrum removal and
debridement followed by primary wound
closure. The wound healed by first
intention and the animal returned to work
normally.
the origin of the long medial collateral ligament and there- thirds of the metatarsus) which resists well mediolateral
fore cast application, at least for recovery from general movement but permits limited proximal and distal joint
anaesthesia, is indicated. A full-limb cast has been recom- flexion (Chapter 13).
mended, but many horses find these a major encumbrance Smaller fragments and those which cannot be reduced
in rising. The author utilizes a short hock cast (extending completely should be removed. This is usually accom-
from the junction of the middle and distal one-thirds of plished arthroscopically utilizing dorsolateral arthroscope
the tibia to the junction of the proximal and middle one- and dorsomedial instrument portals, but in some cases
Fractures of the Lateral Malleolus of the Tibi 615
dorsomedial arthroscope and instrument portals will be mal and also involve the origin of the long collateral
necessary [6]. It will require dissection of the short medial ligament (Figure 29.4a and b). In such cases, ultrasonogra-
collateral ligaments from the fragment (Figure 29.1c–e) phy is recommended to assess integrity of the same and
utilizing similar techniques to the lateral malleolus, but thus to guide any concerns with tarsocrural stability.
there is a greater working space medially. Although good results were reported with removal of
Acute surgical removal and appropriate wound care are fragments via arthrotomy [11], arthroscopic surgery is cur-
advocated for fragmentation of the protuberant non- rently recommended (Figure 29.3b–f) [6, 12, 13]. A sub-
articular portion of the medial malleolus. When infection stantial level of technical skill and experience is required to
is established and/or fragments have sequestrated, then do this safely and efficiently. Horses are operated in dorsal
excision of wounds and associated draining tracts is recom- recumbency. Use of an Esmarch bandage and tourniquet
mended. Following fragment removal and appropriate applied to the proximal crus is recommended. A tarsal
debridement of the osseous defect and adjacent soft tis- angle of approximately 130° is generally utilized [13],
sues, a clean contaminated wound can usually be obtained. though on occasions, it can be useful to vary this for access.
This permits closure. Tension-relieving sutures in an over Surgery is most readily performed with the surgeon stand-
sewn stent bandage can be contributory. ing on the medial aspect of the limb facing across the leg to
view the arthroscopic monitor craniolaterally [6, 13]. If
necessary, the tarsocrural joint can be inflated further
ractures of the Lateral Malleolus
F before an arthroscopic portal is made at the proximodistal
of the Tibia mid-point of the dorsolateral outpouching, just abaxial to
the extensor tendon bundle. Positions of instrument por-
Fractures of the lateral malleolus appear to be monotonic. tals are determined by percutaneous needle placement
Falls in jump racing are the most commonly reported aeti- abaxial to this site such that instrument trajectories are
ology but falls in other situations and external trauma such approximately perpendicular to the long axis of the tibia.
as kicks have also been recorded [11–13]. In the acute In acute cases, joints containing sanguineous fluid and
phase, lameness is marked but the severity usually reduces blood clots may require evacuation. In longer standing cases,
with time. Distension of the tarsocrural joint is consistent fractures can be covered by granulation tissue and/or vary-
and is frequently accompanied by a periarticular swelling ing degrees of disorganized fibrous tissue. This frequently
which is usually greatest laterally [11–13]. Palpable thick- obscures immediate recognition of the fracture, but the frac-
ening and/or lack of definition of the long lateral collateral ture plane can usually be delineated with an arthroscopic
ligament is common and crepitus may be palpable adjacent probe. Fragment removal always requires dissection of the
to the lateral malleolus at its dorsal or, less commonly, insertions of the short lateral collateral ligaments from its
plantar margins [11, 13]. distal abaxial margin. Fixed blade arthroscopic knives and
Fractures are generally recognized in DP radiographs but scissors are recommended [13], and a radiofrequency probe
frequently are profiled best in dorsal 10° medial–plantaro- can also be employed [12]. During this procedure, it is neces-
lateral oblique views [11–13]. Nonetheless, a minimum of sary to remove intermittently divided material in order to
four orthogonal radiographs is recommended as commi- maintain visibility in the dissection plane. This is achieved
nuted fragments can displace widely in both dorsal and with a motorized synovial resector in an oscillating mode
plantar compartments of the tarsocrural joint. with suction applied. Complete division of the short lateral
Fragmentation can also descend dorsally into the talocen- collateral ligaments is necessary for removal of the
tral articulation where this is frequently seen adjacent to fragment(s) and this requires frequently that the fragment or
the centrodistal articular margin. Comminution is com- most plantar fragment is pushed into the plantar pouch of
mon [12, 13]. Entheseous new bone associated with the the tarsocrural joint in order to visualize the ligamentous
capsular attachments to the tibia is commonly seen in attachments. Dissection at this point can be continued by
cases that present weeks (generally greater than six) after passage of the arthroscope between the long collateral liga-
injury [11, 13]. A number of fracture configurations are ment and talus or via a plantarolateral instrument portal.
encountered. The most common involves the full DP thick- Fragments can then be retrieved usually, through the same
ness of the lateral malleolus with distal rotational displace- dissection plane, but on occasions, this can most readily be
ment of the principal fragment which results from traction performed through an ipsilateral plantar instrument portal.
by the intact insertions of the short collateral ligaments on Large (6 × 10 mm) arthroscopic rongeurs are generally neces-
the talus (Figure 29.3a). Such fractures generally disarm sary for large fragments and similar smaller instruments for
the entirety of the tibial origins of the short collateral liga- the removal of comminution. Frayed short collateral ligaments
ments. Less commonly fractures may extend further proxi- can then be debrided with a motorized synovial resector.
(a) (b) (c) (d)
(e) (f)
Figure 29.3 Fracture of the lateral malleolus of the tibia in a four-year-old Thoroughbred gelding with acute lameness following a
jump race fall. (a) DP radiograph demonstrating a complete fracture with rotational displacement (circle). Soft tissue swelling is
evident medially and laterally. (b) Initial arthroscopic view of the fracture (arrows) from a dorsolateral portal. (c) Dorsal aspect of the
fragment (F) exposed following partial resection of the short collateral ligaments from its distal margin. (d) Fragment following
arthroscopic removal. The ruler lies along the fragment’s proximal dorsoplantar articular margin. (e) Arthroscopic view following
fragment removal. (f) Visualization of the plantar compartment of the tarsocrural joint following fragment removal and debridement
of the amputated talar attachments of the short collateral ligaments (SCL); LTR: lateral trochlear ridge of the talus; FB: fracture bed;
C: coracoid process of calcaneus.The horse ran 64 times post-operatively between 5 and 9 years of age with 11 wins and 18 places.
Large fragments frequently expose the long collateral liga- cise and/or restricted free turnout. The prognosis for return
ment and, on occasions, the tendon of insertion of the lateral to athletic function is good. Two reports of arthroscopic
digital extensor and its synovial sheath. The fracture bed is removal of fragments record 11 out of 13 [12] and 18 out of
generally debrided using arthroscopic curettes. Loose osteo- 22 [13] horses returning to work. These included 10 out of
chondral fragments that may have displaced in either dorsal 11 [12] and 16 out of 16 [13] racehorses returning to train-
or plantar compartments of the joint can be removed utilizing. Surgical complication rate was low. In one series, a
ing appropriately placed instrument portals. Routine lavage small extra articular fragment remained in situ and a sec-
and the closure of skin portals follows before sterile band- ond horse developed a plantar synovial fistula both of
ages are applied. If there is concurrent damage to the long which were treated and resolved [12]. In the second series,
collateral ligament, and ultrasonography raises concerns tarsocrural infection followed suture removal in one horse
regarding joint stability, then a short hock cast can be which again resolved with treatment [13].
applied. This extends from the junction of the middle and Large fractures of the lateral malleolus which extend
distal thirds of the tibia to the junction of the proximal and from its axial articular margin proximally to the tibial met-
middle one thirds of the metatarsus (Chapter 13) and is fit- aphysis are occasionally encountered. These are usually
ted with the tarsus in a passively extended position. complete and can have varying degrees of displacement.
Horses are generally given peri-operative antimicrobial They disarm the origins of both short and long lateral col-
and anti-inflammatory drugs according to surgeon prefer- lateral ligaments and thus destabilize the tarsocrural joint.
ence. Dressings should be maintained for 14 days after sur- When the limb is loaded, the joint is reduced but removal
gery at which point sutures are also removed. The tarsocrural of load and abductory forces placed on the distal limb can
joint is subcutaneous and maintenance of sterility is consid- produce subluxation. Such fractures require repair to resta-
ered important for this period. It has been recommended bilize the joint. They are managed as described for similar
that horses are confined to their stables until sutures are fractures of the medial malleolus of the tibia, but surgeons
removed. Increasing walking exercise is advised for a period should be cognisant of differences in the shape and size of
of two months followed by a similar period of trotting exer- the malleoli (Figure 29.4). A case report described complex
Fractures of the Lateral Malleolus of the Tibi 617
(a) (b) (c)
(f)
(d) (e)
Figure 29.4 A six-year-old gelding with acute lameness at the end of a jump race. (a) D10°M-PLO radiograph demonstrating fracture
of the lateral malleolus of the tibia extending from the articular surface to the metaphysis. (b) Stressed D10°M-PLO radiograph with
an abductory force applied to the distal limb demonstrating instability of the tarsocrural joint and the fracture. (c) Transverse CT
image at the level of the tibial epiphysis confirming complete fracture of the lateral malleolus and demonstrating plantar
comminution. (d) Protrusion of long medial collateral ligament (arrow heads) into the dorsal tarsocrural joint. (e) Plantarolateral
trochlear ridge of the talus (LTR) denuded of cartilage. (f) Fracture repaired with 2× distolateral to proximomedial oriented 4.5 mm
cortex screws inserted in lag technique. The hock was supported in a sleeve cast for recovery from general anaesthesia and in the
immediate post-operative period. The horse survived but was retired.
tarsal fractures in a broodmare that included a large frac- with single 4.5 mm AO/ASIF cortex screws inserted with
ture of the lateral malleolus which extended proximally to oblique distal abaxial to proximal axial trajectories under
involve the long collateral ligament. This resulted in unsta- fluoroscopic guidance. The lateral repair was reinforced with
ble luxation of the tarsocrural joint. The principal fragment a 1.25 mm stainless-steel wire in a figure of eight to create a
was removed by arthrotomy and luxation reduced by trac- tension band. This was inserted through 2 mm drill holes in
tion and manipulation before a full-limb cast was fitted. the fragment distal to the screw head and through the tibial
The horse initially required assistance to stand, but the metaphysis proximally. A bandage cast was applied from the
hock remained stable and it ultimately was able to con- proximal tibia to the metatarsophalangeal joint, and the filly
tinue as a broodmare [14]. received a hand-assisted recovery from anaesthesia. There
Biaxial fractures of the tibial malleoli have been reported in were no peri-operative complications. The filly received box
a yearling Arab filly. These extended sufficiently proximal to rest for two months followed by a similar period of walking
include the origins of the long collateral ligaments. The lat- exercise before commencing restricted turnout. It was ulti-
eral fracture was displaced, and the medial fracture was non- mately able to train and race successfully [15].
displaced. The lateral fracture was reduced and secured with Non-articular fragmentation of the lateral malleolus is occa-
AO/ASIF reduction forceps. Both fractures were repaired sionally encountered and has similar causation, presentation
and sequelae as non-articular fractures of the medial malle- was reported to be absent in three, mild in four and moder-
olus. Injuries at this site can, in addition to involving the ori- ate in four cases [16]. In the acute phase, many non-
gin of the long collateral ligament, also disrupt the lateral displaced sagittal fractures of the talus are not identifiable
digital extensor tendon and its sheath. Fragmentation is usu- on radiographic examination. In one study, 9 of 11 frac-
ally identified in DP and/or D10° L-PMO and dorsal 10° tures were not identified on initial radiographic examina-
medial-plantarolateral oblique (DM-PLO) radiographs. tion [16]. Increased radiopharmaceutical uptake (IRU) in
Ultrasonographic evaluation is also necessary to assess con- the proximal talus is commonly evident scintigraphically
current tendinoligamentar injury. Cases are managed in the (Figure 29.6), and flexed lateromedial (LM) images are
same manner as their medial counterparts. considered important in anatomical differentiation [16].
Intense IRU was reported in an endurance horse in which
a sagittal fracture of the talus was subsequently identified
ractures of the Distal Intermediate
F
by magnetic resonance imaging (MRI) [17].
Ridge of the Tibia Radiographs taken at a later date will frequently confirm
the fracture (Figure 29.7). Sagittal fractures of the talus can
Fractures of the distal intermediate ridge of the tibia are
be identified on DP radiographs but D10-20° L-PMO
uncommon but occasionally encountered following
images usually optimize visibility [16]. In a series of 11
trauma such as falls. Plantar fractures appear to be most
such fractures in racehorses (eight Standardbreds [SB] and
frequent (Figure 29.5). The tarsal sheath, and enclosed lat-
three Thoroughbreds [TB]), all were incomplete extending
eral digital flexor tendon, preclude safe access for repair;
from the inter-trochlear groove distally into the proximal
smaller fragments should be removed arthroscopically.
one-third of the talus in six and to the middle one-third of
the bone in five horses [16].
Sagittal Fractures of the Talus Fractures can be managed conservatively or repaired but
before embarking on the latter, surgeons should be cog-
Sagittal fractures of the talus are uncommon [10]. Lameness nisant that these may be components of more complex
is usually acute in onset, but a frequent history of previous fractures [10], and computed tomography (CT) is therefore
low-grade lameness has been reported [16]. Distension of considered critical for assessment of potential surgical can-
the tarsocrural joint is common but not invariable. This didates (Figure 29.7).
(a) (b)
Figure 29.5 Fracture of the plantar distal intermediate ridge of the tibia in a seven-year-old Thoroughbred following a jump race
fall. The horse presented with acute, severe lameness and marked distension of the tarsocrural joint. (a) LM radiograph identifying the
fracture (arrows). Small fragments from the dorsal medial trochlear ridge of the talus displaced distally into the talocentral
articulation (circle). (b) Arthroscopic view of the fracture (arrows) from a plantarolateral portal; LTR: lateral trochlear ridge of the talus.
The dorsal fragments were removed arthroscopically, and the principal plantar fragment dissected from the joint capsule, pulled to
the plantarolateral surface of the joint and removed through a short (cut down) arthrotomy. The horse raced and won nine months
post-operatively and subsequently was a multiple winner over four seasons.
Fractures of the Trochlear Ridges of the Talu 619
(a) (b)
Figure 29.6 Parasagittal fracture of the talus in a seven-year-old flat race gelding. The animal was lame after racing with no
localizing clinical signs. Lameness was unaffected by local analgesic techniques up to and including subtarsal blockade but was
abolished by local anaesthesia of tibial and peroneal nerves. A tarsometatarsal block was subsequently negative, but a positive
response was obtained with local analgesia of the tarsocrural joint. Serial radiographs over a four-week period were unremarkable.
There was persistent marked (7/10) lameness, and scintigraphic evaluation after five weeks revealed marked increase
radiopharmaceutical uptake (IRU) in the body of the talus (a). Routine orthogonal radiographic projections were unremarkable with an
ill-defined radiolucency (arrow) identifiable in dorsal slightly lateral–plantaromedial oblique projections (b).
Lag screw repair has been advocated [18, 19] and in ractures of the Trochlear Ridges
F
simple fractures can carry a favourable prognosis for of the Talus
working soundness. Dorsal recumbency is recom-
mended. The tarsocrural joint should be evaluated Fractures of the trochlear ridges of the talus are generally
arthroscopically. Medial to lateral trajectory for the lag monotonic and usually caused by external trauma [10] but
screw(s) is preferred as this permits access to the centre can result from falls. The most common single cause is a
of the body of the talus; laterally, it is adjacent to the kick from an other horse producing fractures of the dorso-
talocalcaneal articulation. Fortunately, the majority of distal, and usually lateral trochlear ridge when the limb is
fractures are incomplete and/or non-displaced as reduc- loaded (Figure 29.8), and of the proximal, and frequently
tion of displaced fractures is challenging. Non-displaced medial plantar trochlear ridge when the limb is flexed
fractures can be repaired by percutaneous 4.5 mm AO/ (Figure 29.9) [4, 20]. These are commonly accompanied by
ASIF cortical screws inserted, under radiographic guid- wounds creating an open fracture into the tarsocrural joint
ance, in lag technique. It requires intra-operative align- necessitating urgent surgical interference. Distention of
ment in both DP and LM planes. Careful DP alignment the tarsocrural joint is inevitable but may not be marked if
is important to ensure placement of screws in the body there is drainage through an open wound. Fractures of the
of the talus avoiding impingement of the sagittal groove proximal plantar medial trochlear ridge may not readily be
(Figure 29.7). identified on conventional radiographic projections and
A SB with a complete parasagittal fracture returned to may be imaged in profile in flexed LM, flexed oblique
racing nine months after fixation with two lateral to medial images or flexed DP projections [4, 10, 21]. Sometimes frag-
4.5 mm lag screws [18]. The implants were left in situ. In a ments from the dorsal trochlear ridges can be displaced
series of 11 cases managed conservatively, seven of eight into the plantar compartment (Figure 29.10).
animals with follow-up raced post-injury. All received box In most circumstances, arthroscopic removal of the frag-
rest for one month followed by a further one month of ments is advocated [4, 6, 10, 19]. Even large distal frag-
restricted area turnout and then two months of unre- ments can be removed without compromising joint stability
stricted paddock exercise to provide a total of four months and with good clinical outcomes [19]. Arthroscopy is
convalescence [16].
(a) (b)
(c)
(d) (e)
Figure 29.7 The horse illustrated in Figure 29.6 was managed conservatively for a further six weeks and remained lame at a level of
5/10. (a) Similar DL-PMO radiograph demonstrated a linear lucency in the sagittal groove of the talus (arrow). (b) Transverse CT
confirmed an oblique parasagittal fracture (arrows). (c) Medial and lateral needle placement to guide repair. (d) Repair of the fracture
with a single 4.5 mm cortex screw. (e) DL-PMO radiograph taken 12 weeks post-operatively. At this time, the horse was sound and
returned to canter exercise. It subsequently ran 16 times for one win and five places.
undertaken using standard approaches for dorsal and/or Dorsal recumbency and use of an Esmarch bandage and
plantar compartments as appropriate for the individual tourniquet are recommended (Figures 29.8 and 29.9).
injury [6]. Fragmentation of the proximal trochlear ridges Large fragments can be repaired by lag screw fixation,
is arthroscopically accessed via the plantar compartment but absolute reduction and articular congruency are pre-
with variation in the degree of flexion as required; increas- requisites and thus is only generally considered for non-or
ing flexion exposes greater amounts of the trochlear ridges. minimally displaced fractures [19]. Arthroscopic guidance
Fractures of the Calcaneu 621
(a) (b) (c)
Figure 29.8 A 12-week-old Thoroughbred foal was found in the paddock with acute hindlimb lameness and marked tarsocrural joint
distension six days prior to referral. (a) DM-PLO radiograph demonstrating fragmentation of the distal dorsal lateral trochlear ridge of
the talus. (b) Arthroscopic evaluation of the joint from a dorsomedial portal. Fragments (F) are frequently substantially larger in foals
than are predicted by radiographs due to incomplete ossification of primordial subchondral bone; DIR: distal intermediate ridge of
tibia; S: synovial fossa in the sagittal groove of the talus. The fragment was removed with minimal debridement of the fracture bed.
(c) DM-PLO radiograph taken six weeks post-operatively demonstrating smooth margins at the fracture site. The colt ran 14 times
with five wins and three places.
is necessary, and screw heads should be countersunk advocated. Both are accessed arthroscopically via dorsome-
beneath the articular surface. This is most readily achieved dial arthroscopic and ipsilateral instrument portals. An
utilizing AO/ASIF 3.5 mm cortical screws [10, 19], although Esmarch bandage and tourniquet can be helpful. A case
cannulated screws have also been suggested [19]. If large report described fragmentation of the distal medial tuber-
fragments have to be removed, the joint is evaluated arthro- cle [23] with concurrent fragmentation of the fused first
scopically and any necessary dissection performed before and second tarsal bones. This followed limb entrapment
marking fragment margins with percutaneous needles. A and was considered to represent a long medial collateral
short arthrotomy can then be made directly over the frag- ligament avulsion injury. The horse was managed conserv-
ment for removal. atively and returned to Standardbred racing but developed
tarsometatarsal and centrodistal osteoarthritis.
ractures of the Medial Tubercles

F
of the Talus Other Fractures of the Talus
Fragmentation of the proximal medial tubercle of the talus Fractures of the distal medial or lateral body of the talus
is an uncommon but recognized lesion [22]. It is the site of are occasionally encountered. These usually exhibit a
insertion of portions of the short collateral ligaments, pro- degree of rotational displacement which produces incon-
vides a groove for the tendon of insertion of the medial gruity in the respective talocentral or taloquaternal joints
digital flexor and its sheath and is substantially extrasyno- (Figure 29.13). In simple fractures, reduction and repair
vial. In a series of nine cases, seven occurred in Warmbloods using one or two lagged 3.5 mm AO/ASIF cortex screws is
(WB). The aetiology was unknown. The majority (9 out of the treatment of choice. Conservative management appears
10) of horses were not lame in affected limbs. Interference to be unrewarding [10].
in these circumstances is generally considered contraindi-
cated (Figure 29.11). Occasionally, traumatic avulsion inju-
ries of the short medial collateral ligaments with Fractures of the Calcaneus
fragmentation of the proximal medial eminence are
encountered. Such fragments can be intra-articular Fractures of the articular surface of the calcaneus are rare
(Figure 29.12). Removal with the disrupted ligament is and usually of indeterminate aetiology (Figure 29.14).
(a) (b) (c)
(d) (e)
Figure 29.9 Fragmentation of the plantaromedial trochlear ridge of the talus in a four-month-old Thoroughbred foal with an open
infected tarsocrural joint. The fracture and adjacent fragmentation were identified in flexed LM (a), DM-PLO (b, c) and flexed
dorsoplantar radiographs (d) (circle). (e) Arthroscopic appearance from a plantaromedial portal; MTR: medial trochlear ridge; F:
fragment; P: pannus covering fracture bed and adjacent synovium. The fragmentation and pannus were removed, the fracture bed
debrided and the joint lavaged. The traumatic wound was excised before primary closure. The foal received intravenous sodium
benzyl penicillin and gentamicin sulphate, and an uneventful recovery ensued. The horse ran at two and three years.
(a) (b) Figure 29.10 Four-year-old flat racehorse

that fell while leaving a swimming pool
10 day before presentation. (a) LM radiograph
demonstrating a defect in the dorsal medial
ridge of the talus (circle). (b) DM-PLO
projection demonstrating a fragment
plantaromedially (circle). This was confirmed
at arthroscopic removal to have displaced
from the dorsal defect. The horse returned to
training, had its first race nine months
post-operatively and ran a further three
times in the same season with one win.
Figure 29.11 (a) LM and (b) DM-PLO (a) (b)

radiographs of an eight-year-old sports
horse gelding demonstrating fracture/
fragmentation of the proximal medial
eminence of the talus (circled).
Figure 29.12 Fragmentation of the (a) (b)

proximal medial eminence of the
talus in a four-year-old flat racehorse
with acute lameness following a fall.
(a) DP radiograph demonstrating
fragmentation (circle). (b) Arthroscopic
image from a dorsomedial portal
demonstrating fragmentation in
avulsed and recoiled short medial
collateral ligaments (F) adjacent to
the abaxial surface of the medial
trochlear ridge of the talus (T). The
fragmentation and avulsed short
collateral ligaments were removed
arthroscopically, and the horse raced
and won nine months after surgery.
Most calcaneal fractures are extra-articular, traumatic, fre- sustentaculum tali and if this is not involved then the risk
quently the result of kick injuries or falls on hard abrasive of tarsal infection is reduced (Figure 29.16). Fragments at
surfaces [19] and are commonly accompanied by wounds. all sites can become infected and frequently form
Open fractures of the calcaneal tuberosity can result in sequestra.
contamination of the calcaneal bursae with subsequent In addition to DP, LM, D45° L-PMO and D45° M-PLO
infection of these (Figure 29.15) [24]. Open fractures of the radiographic projections, a D30° M-PLO view will profile
sustentaculum tali can similarly result in infection of the the medial margin of the sustentaculum tali. Flexed DP
tarsal sheath [25, 26]. Risk is largely determined by loca- (skyline) projections will provide valuable further informa-
tion. The tarsal sheath reflects off the medial margin of the tion of both the calcaneal tuber and sustentaculum
The majority of traumatic fragments require removal

sometimes by surgical enlargement of associated wounds;
elliptical excisions are often most suitable. Endoscopic
removal is recommended for intra-thecal fragmentation
involving the calcaneal bursae (Figure 29.15) or tarsal
sheath (Figure 29.17). Contamination or infection of these
cavities can be managed at the same time. Although
guarded [24] and poor [10] prognoses have been reported
with infected foci in the calcaneus, the author’s experience
with meticulous endoscopic surgery has been more encour-
aging and the majority of horses can be expected to return
to working soundness. The prognosis following removal of
calcaneal fragments generally is good [4]. The outlook for
infected fractures of the sustentaculum tali with or without
concurrent involvement of the tarsal sheath is also favour-
able with surgical removal and debridement; 7 out of 10
horses survived and 6 were reported to return to previous
use [26].
In foals, calcaneal fractures can involve the epiphyseal
growth plate (Chapter 37). A case report detailed the repair
of a Salter–Harris type II fracture in a two-month-old foal
with a plantarolateral 4.5 mm AO/ASIF narrow dynamic
Figure 29.13 DL-PLO radiograph of a nine-year-old warmblood compression plate. This extended distally beyond the calca-
gelding that sustained a paddock accident including entrapment
neus to engage third tarsal and fourth tarsal and third and
under a gate. This demonstrates fracture of the distal medial
talus (arrow) in conjunction with other intraarticular fractures fourth metatarsal bones. External support was provided in
that produced the comminuted fragments (circles). The proximal the form of a full-limb bandage cast, and implants were
intertarsal joint was unstable, and the horse was euthanized in removed five months after repair [27]. The requirement for
light of the poor prognosis for athletic soundness.
extra calcaneal fixation is questioned.
Transverse and oblique fractures of the calcaneus may be
tali [21]. Ultrasonographic examination of all potential
amenable to repair. The gastrocnemius and calcaneal inser-
fractures of the sustentaculum tali and calcaneal tuber is
tions of the superficial digital flexor and distal support of
recommended as a routine both to assess potential involve-
the plantar ligament create a strong tension band for appli-
ment of adjacent synovial cavities and soft tissues but also
cation of a plantar or a plantarolateral plate. Occasionally,
to identify osseous disruption in acute cases that may not
oblique fractures of the calcaneal body can be amenable to
be imaged in profile on radiographs (Figure 29.17).
(a) (b) Figure 29.14 (a) DM-PLO radiograph

of a yearling Thoroughbred filly found
lame in a paddock. There is a fracture
of the distal dorsal calcaneus. (b)
Transverse CT at the level of the
proximal intertarsal joint confirming
the site of fragmentation (circle)
dorsally from the calcaneus (C); T:
distal talus. At arthroscopy, there was
substantial tearing of the dorsal joint
capsule that exposed the fragment.
The animal raced 13 times at two and
three years.
(a) (b) (c)
(d)
Figure 29.15 Infected fragmentation of the calcaneal apophysis in a seven-month-old Thoroughbred colt that had sustained a
wound to the plantarolateral tarsus two weeks before referral. At admission it exhibited marked lameness and there was profuse
foetid discharge from a granulating wound. Congenital and acquired calcaneal bursae were distended. Fragmentation and irregular
osteolysis of the calcaneal apophysis (circle) in DL-PMO (a) and flexed DP (b) radiographs. (c) Tenoscopy of the calcaneal bursa
revealed abundant pannus (P). The fragment (F) which involved approximately 50% of the lateral insertion of the superficial digital
flexor tendon was removed. (d) Partial debridement of the fracture bed (arrow heads) demonstrated substantial foreign material
embedded within the bone which was subsequently removed. FC: fibrocartilaginous cap of the superficial digital flexor tendon. The
granulating wound was left open, and a hock cast was fitted for three weeks post-operatively. The colt received penicillin and
gentamicin for two weeks, and good second intention wound healing ensued. It ran and won as a two-year old and had a further
seven runs and two places.
Figure 29.16 Transverse schematic

illustrating areas of the sustentaculum tali
which communicate with (red) or are out Tarsocoural
with (yellow) the tarsal sheath. Source: Cranial tibal joint cavity
Adapted from McIlwraith et al. [6]. artery
Long medial
collateral
ligament
Talus
Long
lateral
collateral Medial (long)
ligament digital flexor
tendon
Calcaneus Sustentaculum
tali of calcaneus
LDFT
Mesotenon
Tarsal sheath
Long plantar caudal pouch
ligament
SDFT Medial plantar a.,v.,n.
Lateral plantar a.,v.,n.

(a) (b)
(d)
(c)
(e) (f) (g)
Figure 29.17 Images of a Thoroughbred yearling filly that presented with a draining wound adjacent to the chestnut on the medial
aspect of the tarsus for 16 days. It had been treated with systemic antimicrobial and non steroidal anti-inflammatory drugs in the
interim. At presentation, there was toe-only foot–ground contact with diffuse swelling centred on the tarsal sheath. (a) DM-PLO and
(b) flexed DP radiographs demonstrating fragmentation of the plantar proximal surface of the sustentaculum tali (circle). (c)
Transverse ultrasonograph confirming marked distension of the tarsal sheath with layered echogenic material (E) within; LDFT: lateral
digital flexor tendon; arrows: sustentaculum tali. (d) Transverse CT image demonstrated fragmentation (circle) on the plantar axial
margin of the sustentaculum tali. (e) Tenoscopic image from a proximal medial portal demonstrating fragmentation (F) covered
partially by pannus displaced from the fracture bed (arrow heads) in the sustentaculum tali (ST); LDFT adjacent lateral digital flexor
tendon. (f) Abundant hair embedded within fragmentation following removal of overlying pannus. (g) Fracture bed (FB) and
osteochondral junction (arrow heads) following debridement. Traumatic wounds were excised before primary closure. The filly
received penicillin and gentamicin for 10 days post-operatively. A small amount of distal dehiscence occurred, but the majority of the
wound healed by first intention. The animal raced 18 times at two and three years of age including seven wins.
lag screw fixation (Figure 29.18) [28]. Use of the tension repaired with a plantarlly located narrow dynamic com-
band principle was first reported for repair of an oblique pression plate to create a tension band. 4.5 mm AO/ASIF
fracture of the calcaneus. This incorporated fixation of the cortical screws were used at all plate locations. Concomitant
third and fourth metatarsal bones and positioned the plate fragments were either repaired with single lag screws or
beneath the superficial digital flexor tendon [29]. If possi- removed. The repair was protected in a full-limb cast for six
ble, this should be avoided and placing the plate plantaro- weeks post-surgery. The plate was removed three months
laterally adjacent to the superficial flexor tendon has been after surgery, and a functional limb was achieved [30].
advocated [10, 19] (Figure 37.22). A case report documented a large oblique fracture of the
A case report described a displaced comminuted fracture calcaneal body in a four-month-old SB foal [28]. This ini-
of the calcaneus with concomitant medial subluxation of tially was non-displaced and was managed conservatively,
the superficial digital flexor tendon in a brood mare. The but after seven days displacement, consistent with traction
principal fracture was reduced with a tension device and by gastrocnemius and other musculotendinous units
(a) (b) (f)
(c) (d) (e)
Figure 29.18 An oblique fracture of the calcaneus in a three-year-old Thoroughbred colt that occurred during a race. The fracture
(arrows) was initially non-displaced (a), and the horse was cross-tied. However, the fracture displaced 18 days later (b). At this stage, it
was mapped by CT (c–e) that guided repair with 3 × 4.5 mm AO/ASIF cortical screws in lag technique (f). The transverse CT images
(c–e) illustrate the fracture from proximal to distal at the sites of screw placement. The horse ran four times in the following season.
inserting on the calcaneal apophysis, was noted. The frac- f requently a history of acute onset severe lameness [33].
ture was then repaired with two 4.5 mm cortical screws Distension of the tarsocrural joint though frequently not
inserted, percutaneously, under radiographic guidance in marked is common [33–36]. Lameness is usually improved
lag technique. Good fracture healing and resolution of by intra-articular anaesthesia of the tarsocrural joint [36].
lameness ensued. One implant was removed post- In some cases, localizing signs are absent or subtle and
operatively due to impingement on the tarsal sheath. In suspected fractures are identified by scintigraphy
this case, the fracture appears to have been sufficiently (Figure 29.19) [37]. IRU has been recorded in a central tar-
oblique to permit re-establishment of the plantar calcaneal sal slab fracture that was not identified on radiographs at
tension band by interfragmentary compression alone. two weeks but was radiologically evident four weeks after
A combination of interfragmentary compression and onset of lameness [38]. Fractures have also been identified
figure-of-eight tension band wiring has been used in two on MRI following scintigraphic localization [37].
miniature horses [20]. Fracture configurations vary and appear to differ in race-
There are inadequate numbers of documented repairs to horses and non-racehorses. Fractures can also be commi-
be objective in prognostication. nuted or complex [10, 39]. Three groups all reported central
tarsal bone fractures in racehorses in a frontal plane, which
were best identified in LM projections [34, 35, 40]. All sus-
Fractures of the Central Tarsal Bone pected central tarsal bone fractures require radiographic
evaluation with standard DP, LM, DL-PMO and DM-PLO
Fractures of the central tarsal bone are usually proximo- projections, often supplemented by additional oblique
distally complete, i.e. slab fractures. It appears that they views. Nonetheless, accurate two-dimensional radio-
can be monotonic or a result of fatigue failure, and they graphic determination of fracture configuration is often
are seen in all horse types. Slab fractures of the central tar- not possible and CT is necessary to assess fractures in order
sal bone have also been identified, albeit uncommonly, in to determine the potential for and to direct repair [33]. In
screening radiographic examinations of Thoroughbred some cases, MRI can also be contributory.
weanlings and yearlings [31]. In a series of 24 horses (18 In the author’s case load, which is dominated by racing
SB, 5 TB and 1 QH), there was no left versus right differ- TB, slab fractures of the central tarsal bone are substantially
ence in distribution [32]. Resultant lameness is variable less common than third tarsal counterparts. They do occur
and influenced by the time of presentation, but there is in similar dorsolateral locations (Figure 29.20), but this is
(a) (b) (c)
Figure 29.19 A two-year-old Thoroughbred filly in flat race training with acute onset hindlimb lameness with no localizing signs.
Scintigraphy (a) performed one week post-injury revealed marked increase radiopharmaceutical uptake (IRU) dorsally in the region of
the central tarsal bone. (b) Multiple radiographic projections including DM-PLO projections at varying angles failed to reveal
significant abnormality. (c) Computed tomography (CT) revealed an oblique dorsolateral slab fracture (arrows). T4: fourth tarsal bone.
Fractures of the Central Tarsal Bon 629
less predictable and other configurations are also encoun- 4.5 and 3.5 mm AO/ASIF cortical screws have been
tered (Figure 29.21). However, slab fractures of the central employed [10, 33], but the latter reduce the risk of engage-
tarsal bone can also be complex and this occasionally is suf- ment of subchondral bone. It is also important that surgeons
ficiently severe to preclude reconstruction (Figure 29.22). are cognisant of the proximodistal undulating shape of the
Repair of amenable fractures is by lag screw fixation, and central tarsal bone. Implants must be proximodistally central
there are a number of reports in the literature [4, 33, 35, and perfectly perpendicular to the long axis of the limb to
41–43]. Conservative management has also been reported [32, avoid risk of articular interference.
34, 40]. Screws are inserted percutaneously under radio- The first case in the literature reported repair of a medi-
graphic control using a modification of the technique ally bias sagittal slab fracture of the central tarsal bone in a
described for slab fracture of the third tarsal bone horse used for jumping. A single 4.5 mm AO/ASIF cortical
(Figures 29.20 and 29.21) (“Fractures of the Third Tarsal screw was placed percutaneously in lag technique. The frac-
Bone” section). Lateral recumbency is preferred; the fracture ture healed and the horse returned to training. The screw
configuration determines whether the affected limb is up or was removed 10 months after surgery following mild lame-
down. Application of an Esmarch bandage and tourniquet is ness, and the horse subsequently returned to work [41].
strongly recommended. The leg should be positioned parallel The first series involved 12 cases of slab fractures of the
with the ground, and the distal limb secured in an extended central tarsal bone predominantly in SB trotters [35]. These
position into a support before this is applied as the tarsal flex- were repaired by lag screw fixation, but the precise fracture
ion produced compromises radiography and therefore surgi- location and technique are open to debate. Results were
cal alignment. Needles are placed in the centrodistal and combined with eight slab fractures of the third tarsal bone,
talocentral joints, and the drill is positioned midway between and it was reported that 15 of the 20 horses returned to
these in a trajectory appropriate for the individual fracture. athletic careers but unfortunately the division between v is
(a) (b) (e)
(c) (d)
Figure 29.20 A two-year-old Thoroughbred with acute onset lameness after racing. It presented five days after injury, and there was
moderate distension of the tarsocrural joint. (a) DM-PLO radiograph demonstrating a slab fracture of the dorsolateral aspect of the central
tarsal bone. (b) Transverse CT image demonstrating fracture configuration. (c) Intra-operative DM-PLO radiograph with needle placement to
guide repair. (d) Intra-operative DM-PLO radiograph following screw placement. (e) DM-PLO radiograph 10-months post-operatively
demonstrating fracture healing. The colt first raced five months post-operatively and subsequently seven times with three wins and one place.
(a) (b) (c) (d)
Figure 29.21 Oblique slab fracture of the central tarsal bone in a three-year-old racing Thoroughbred filly with history of intermittent
hindlimb lameness followed by acute lameness after galloping. There were no localizing signs but IRU on scintigraphy. A slab fracture
was identified on LM (a) and DL-PMO (b) projections only. Fracture configuration was determined by CT (c) that guided repair (d) with a
single 3.5 mm cortex screw. The filly raced five-months post-operatively and on two further occasions before retiring to stud.
(a) (b)
Figure 29.22 Comminuted slab fracture of the central tarsal bone in a two-year-old Thoroughbred colt. (a) Orthogonal radiographs.
(b) Transverse CT image demonstrating severity of comminution.
Fractures of the Third Tarsal Bon 631
not given. Screw heads were not countersunk which in the developed mild periarticular osteophyte formation without
author’s opinion is incorrect. other radiographic evidence of degenerative articular
A series of six central tarsal bone fractures were identified change. Unless clinical problems arise that are referable to
following intense IRU. Subsequent radiographs identified the implants, these are left in situ [33]. In this series, CT
the fractures in D25° M-PLO projections. Four fractures was critical in determining confidently fracture configura-
were repaired using a 4.5 mm variable pitched, cannulated tions and to directing repair.
headless Herbert compression screw. The screws were A series of six central tarsal fractures in SB racehorses were
inserted percutaneously under radiographic guidance in managed conservatively, but only one returned to racing and
dorsolateral to plantaromedial trajectories. The horses with with poor results [34]. The authors concluded that conserva-
repaired fractures all returned to working soundness. One tive treatment was inadequate for athletic function. Another
conservatively managed horse also worked successfully, group reported a series of 11 central tarsal slab fractures, 6 in
and one was retired to stud [42]. SB, 3 in TB and 2 in QH. The authors rationalized that the
A case report documents a nondisplaced sagittal slab limited motion in the talocentral and centrodistal joints and
fracture of the central tarsal bone in a QH used for jump- substantial intrinsic ligamentar support would provide ade-
ing. This was repaired with a single 4.5 mm AO/ASIF corti- quate stability for healing. All were therefore managed con-
cal screw placed in a medial to lateral trajectory in lag servatively. Two of seven (29%) racehorses that received box
technique, and the horse returned to working soundness. rest for periods of between three and five months won more
An additional medial fracture was identified by CT, but in than five times after injury [40]. In a review of conservative
the images published this is questionable. CT also demon- management of 24 horses with slab fractures of the central
strated pre-fracture opacification of the fractured bone [43]. tarsal bone, 8 out of 10 SB raced after injury. The results of
Six slab fractures of central tarsal bones were reported in five TB and one QH were not provided [32].
five WB used for showjumping and a QH used for reining. Slab fractures of the central tarsal bones were reported in
Fractures were identified on DP radiographs in two, DP four non-racehorses [36]. All were simple, non-displaced
and LM views in one and DM-PLO projections in two and had dorsomedial to plantarolateral orientation.
horses. All were described as subtle. The fractures were all Fractures were identified on DM-PLO radiographs only,
non-displaced, and the central tarsal bones exhibited but frequently multiple slightly different angles were nec-
opacification which was interpreted as likely representing essary. Configurations were confirmed by CT in two horses.
prodromal failure or stress adaptation. CT identified sub- Increased dorsomedial radiopacity of the affected tarsal
stantial commonality of fracture configurations. All were bones was considered to represent pre-existing stress
parasagittal commencing dorsally and extending in a plan- remodelling [44, 45]. Two cases in which scintigraphy was
tar or a plantaromedial direction to exit just medial to the performed had marked focal IRU in the region of the cen-
articulation with the conjoined first and second tarsal tral tarsal bone. The fractures were all managed conserva-
bones in five and adjacent to the plantar articulation with tively, and one horse returned to working soundness.
the fourth tarsal bone in one horse. The fracture was com- The current balance of evidence indicates that in horses
minuted in one horse with the second fracture plane that are required to work and in which fracture configura-
extending from the parasagittal fracture laterally in a fron- tion confidently can be determined repair by lag screw fixa-
tal plane to produce an inverted ‘Y’ configuration [33]. It tion is indicated. However, CT appears to be an important
was therefore considered that repair in most cases was logi- prerequisite. Salvage for breeding or companion purposes
cal with mediolaterally orientated lag screws as determined may be possible with conservative management.
by individual fracture configurations. This, in turn, was
directed by CT. Horses were operated in lateral recum-
bency with the affected limb down. Under fluoroscopic Fractures of the Third Tarsal Bone
guidance, fractures were repaired by percutaneous place-
ment of 1 × 4.5 mm (4), 2 × 4.5 mm (1) or 1 × 4.5 mm and The majority of fractures of the third tarsal bone are proxi-
1 × 3.5 mm (1) cortical screws in lag fashion. No external modistally complete slab fractures. In TB racehorses, these
support was given. Horses were given peri-operative anti- occur in similar locations and configurations, are associ-
microbial and nonsteroidal anti-inflammatory medica- ated with high speed exercise, occur in the absence of spe-
tions. Post-operatively horses received box rest for 4 weeks cific trauma and therefore may be considered as stress
followed by 12 weeks of walking and gradually increasing fractures [8]. A study of racing TB in the UK (10 with and
exercise thereafter. The five WB all returned to working 10 without fractures) concluded that loss of parallel proxi-
soundness. The QH had persistent post-operative lameness mal and distal articular margins with converging and
but had other areas of orthopaedic compromise. The frac- diverging subchondral bone plates, previously termed
tures appeared to heal radiographically, but three horses ‘wedging’ [46] of the third tarsal bone, was associated with
the development of slab fractures [47]. These findings were In TB racehorses, fractures occur with similar orienta-
not upheld by a subsequent study in which only 3 out of 17 tions obliquely through the dorsolateral aspect of the third
cases exhibited ‘wedging’ [8] or in juvenile TB screening tarsal bone [8]. They are therefore most commonly identi-
radiographs when 70% of fractures occurred in the absence fied in DM-PLO images [8, 40, 48]. A D50°M -PLO projec-
of wedge deformation [31] which questions whether bone tion has been recommended [47]. However, variations in
shape is the sole or principal predisposing factor for frac- fracture planes require subtle changes in the angulation of
ture. The ‘wedged’ bone shape is considered a likely conse- DM-PLO projections to align the primary beam with the
quence of neonatal cuboidal hypoplasia which, in some fracture (Figure 29.24) [8]. Most fractures are complete,
cases, may include juvenile fractures at a similar location but displacement is generally modest and proximodistal
[Chapter 37]. In one study of survey/screening radiographs articular congruency is maintained [8]. Occasionally frac-
in weanling and yearling TB, slab fractures of the third tar- tures may be proximodistally incomplete.
sal bone were identified in 2.5% of studies [31]. CT has confirmed commonality of locations and configu-
Slab fractures of the third tarsal bone appear to be an rations in racing TB in the UK. All fractures encountered to
injury exclusive to racehorses. All reports have been in date involve the dorsolateral aspect of the third tarsal bone
TB, SB and QH racing or training [8, 34, 35, 40, 47, 48]. with a curvilinear fracture plane in a dorsomedial to planta-
Four studies have documented an increased incidence in rolateral direction (Figure 29.25). This consistent configura-
left limbs [8, 35, 40, 47], but this was not found in other tion permits a minimally invasive approach to repair.
case series [32, 34]. Lameness varies in severity according Slab fractures of the third tarsal bone are amenable to
to the time of presentation, but it is usually acute in onset repair by lag screw fixation. The goal is to provide fracture
and frequently follows fast work or racing [34, 35, 48]. compression and stability in order to optimize direct (pri-
Sometimes a small amount of soft tissue swelling is evi- mary) bone healing and to limit joint incongruity. A mini-
dent dorsolaterally, which in the author’s experience is mally invasive technique using radiographic guidance has
between the long and lateral digital extensor tendons, at been reported [8]. Surgery is performed under general
the level of the tarsometatarsal joint [35, 48]. Sensitivity anaesthesia in lateral recumbency with the affected limb
to digital pressure at this site is common but inconsist- uppermost. The limb is fixed in extension with support pro-
ent [34, 35, 40, 47]. A positive response following intra- vided at the level of the pastern to ensure that the long axis
articular local analgesia has been reported [19, 34, 40]. In of the limb is horizontal. Use of an Esmarch bandage and
cases in which there are few clinically localizing signs tourniquet at a distal crural level is recommended but
and sometimes in horses in which radiographs are unre- should not be applied until the limb is fixed in an extended
warding, scintigraphy can assist in identifying fractures position. DM-PLO radiographs are then taken to ensure
of the third tarsal bone (Figure 29.23) [19, 38, 40, 49]. It is repeatability of the precise previously determined projec-
recognized that fractures may not be radiographically evi- tion aligned with the fracture plane. This must also align
dent in the acute phase [19, 47]. accurately with the centrodistal and tarsometatarsal joints.
(a) (b) Figure 29.23 Acute lameness with no

localizing signs in a two-year-old
Thoroughbred colt in training. (a)
Scintigraphic examination one week
after injury demonstrating marked IRU
dorsolaterally in the region of the third
tarsal bone. (b) DM-PLO radiograph
demonstrating slab fracture of the
dorsolateral third tarsal bone.
Fractures of the Third Tarsal Bon 633
(a) (b) (c) (d)
Figure 29.24 DM-PLO radiographs demonstrating consistent dorsolateral locations of slab fractures of the third tarsal bone in four
horses.
spinal needle is then placed at the centre of this window

with a dorsolateral proximal to plantaromedial distal orien-
tation in line with the required implant trajectory. The pre-
selected DM-PLO radiograph is then repeated, and the
needle adjusted until the orientation is correct. This requires
alignment of the long axis of the needle parallel to the cen-
trodistal and tarsometatarsal joints and, in this respect, it is
critical that the X-ray beam is perfectly aligned with the
joint spaces. The needle point, with the radiographs pre-
cisely aligned with the fracture plane, should be located on
(not radiographically overlapping) the dorsal surface of the
third tarsal bone to ensure central location of the implant in
a LM plane (Figure 29.26a). The combination of these two-
dimensional parameters provides the necessary three-
dimensional assessment for safe and appropriate repair.
When this is achieved, a vertical stab incision (less than
1 cm in length) is made using a number 11 blade at the site
of the spinal needle, through the skin and directly onto the
surface of the third tarsal bone. A 3.5 mm glide hole is then
created along the line of the spinal needle (dorsolateral
proximal to plantaromedial distal) to the fracture plane.
Figure 29.25 Transverse CT images demonstrating relatively This is determined by pre-operative radiographic measure-
consistent locations and configurations of slab fractures of the ments and verified by intra-operative radiographs. A
dorsolateral aspect of the third tarsal bone in six Thoroughbred 2.5 mm thread hole is then drilled to a depth determined
racehorses.
from pre-operative radiographs and checked with a depth
gauge. The length of the drill tract depends on fragment
Percutaneous marker needles (22 gauge × 40 mm) are then size but is restricted to the body of the bone. The screw hole
placed, under radiographic guidance, perpendicular to the is countersunk and tapped to an appropriate length before
long axis of the limb, into the dorsolateral aspect of the cen- a 3.5 mm cortex screw is inserted and tightened. Fracture
trodistal and tarsometatarsal joints to define the proximal compression is assessed radiographically using the same
and distal margins of the fracture. The area between these DM-PLO projection (Figure 29.26b). The skin incision can
needles and between the long and lateral digital extensor then be closed, and a protective dressing applied. There is
tendons provides a window of direct access to the dorsolat- no benefit or requirement for additional external support.
eral surface of the third tarsal bone. An 18-gauge × 89 mm Bandages are maintained until sutures are removed
(a) (b) (c)
Figure 29.26 Repair of a slab fracture of the third tarsal bone in a three-year-old Thoroughbred colt. DM-PLO radiographs. (a)
Intra-operative needle alignment. (b) Following screw placement. (c) Ten weeks post-surgery. The colt raced five months post-
operatively and for five subsequent years winning each year.
10–14 days after surgery. In the reported series, horses were between four and six months post-surgery (Figure 29.26c).
stabled for a median of four weeks post-operatively before In cases where there was a loss of trabecular pattern, density
commencing walking exercise for a further four weeks. If and/or loss of definition of subchondral bone, these param-
horses were sound at the end of this period, trotting exer- eters all improved progressively in line with fracture healing.
cise was introduced and gradually increased for a further Pre-existing capsular and peri-articular new bone progressed
four weeks. Fracture healing can be monitored radiograph- in five cases and developed post-surgery in one horse.
ically, and the horses exercise titred in line with clinical Previous surgical reports in the literature have described
and radiographic progress. open approaches that are not applicable [35, 48]. The first
The majority of fractures have depths of less than 10 mm, study utilized single 4.5 mm AO/ASIF cortical screws in
so use of a 3.5 mm screw is logical to minimize the risk of two horses. Both fractures healed and the horses returned
fragmentation of the fracture fragment following counter- to training and racing. Peri-articular osteophyte formation
sinking and screw tightening. A 3.5 mm screw also mini- was reported, but articular impingement by the implants
mizes the risk of subchondral bone impingement and was identified [48]. In the second study, eight fractures
stiffening compared with a 4.5 mm screw. Additionally, the were repaired ‘in most cases’ using 4.5 mm cortical screws.
3.5 mm screw has a 6 mm diameter head that can be located The results were reported in conjunction with slab frac-
between the proximal and distal subchondral bone plates tures of 12 central tarsal bones. Fifteen of a total of 20
unlike the 8 mm head of 4.5 mm screws. Compression from horses returned to racing [35].
a single centrally located screw in a curved fracture plane Conservative management of fractures identified in TB
will produce interdigitation of the fracture fragment and weanlings and yearlings did not impact negatively on sale
parent bone and prevent rotation. price or subsequent racing performance [31]. Conservative
A report of 17 horses recorded no post-operative complica- management of fractures occurring during training and
tions. Long-term follow-up was available for 14 animals of racing has also been reported [32, 34, 40, 48]. Three race-
which 11 raced post-operatively, 1 was retired to stud and horses that were treated with prolonged (four to six months)
2 had returned to training but had not raced. The mean time box rest all had persistent lameness and did not return to
from repair to first race was seven months, and of five horses work. Delayed or non-unions accompanied by articular
that had raced before and after injury, the number of races degeneration were reported [48]. A second group reported
and levels of performance were comparable. Radiographic fractures in three SB and two TB. Once horse was eutha-
follow-up information was available for 15 horses at inter- nized, one fracture was repaired and three were managed
vals between 1 and 18 months after surgery including 5 conservatively. The horse with the repaired fracture raced,
horses with two or more radiographic follow-up studies. All but none of the three conservatively managed animals
fractures healed with radiographic healing occurring returned to racing. The authors concluded that conservative
Fractures of the Proximal Third Metatarsal Bon 635
management may be adequate to salvage mares for breed- progressive failure through remodelled bone. The degree of
ing purposes [34]. A group of 17 horses (3 TB, 11 SB and lameness varies accordingly. There are frequently few
3 QH) were given prolonged (three to five months) box rest. localizing clinical signs, and diagnostic anaesthesia and/or
Ten out of 13 horses with follow-up raced greater than or scintigraphy may be necessary to localize [50]. The injury
equal to five times post-injury. The authors recognized that has been described dorsolaterally in five SB [51] and dorso-
some horses successfully returned to athletic performance laterally in one and dorsomedially in two TB race-
despite persistence of the fracture on follow-up radiographs. horses [50]. Fractures are usually most readily imaged in
The mean convalescent time for SB was eight months and LM and DM-PLO projections. The fractures are generally
for TB six months [40]. Outcomes were also reviewed for 28 wedge-shaped, mediolaterally and dorsoplantarlly widest
horses with slab fractures of the third tarsal bone (11 TB, 16 proximally in the subchondral bone of the third metatarsal
SB, and 1 QH) following conservative management. Of bone and exit the dorsal cortex distally. Fracture lines may
these, 12 of 13 SB and 5 of 7 TB raced after injury. The mean appear sharply marginated, but adjacent osseous disrup-
time between diagnosis and first race was eight months [32]. tion and new bone deposition indicate prodromal failure.
In the author’s hands, minimally invasive repair offers a Some horses will resent digital pressure, and a small
substantially better prognosis for racing in TB, particularly amount of swelling may be palpable between the long and
in jurisdictions in which medication is prohibited. lateral digital extensor tendons of the proximal third meta-
tarsal bone. Most fractures are non-displaced [50, 51], but
occasionally displacement is encountered [51].
ractures of the Proximal Third
F The prognosis for racing has been considered to be
Metatarsal Bone guarded, but there was wide case variability and manage-
ment [51]. In the author’s experience, repair of non-
Fractures of the proximal dorsal aspect of the third meta- displaced fractures carries a good prognosis for return to
tarsal bone usually are intra-articular with respect to the racing. In racing, TB fractures appear to have a consistent
tarsometatarsal joint. These are seen as training and racing dorsal location and to be curved in a frontal plane. The
injuries. Some present as acute injuries and others follow size and configuration are identified by CT (Figure 29.27),
(a) (c) (d)
(b)
Figure 29.27 Fracture of the dorsoproximal third metatarsal bone in a two-year-old Thoroughbred colt with acute onset lameness in
training that persisted for six weeks prior to referral. (a) DM-PLO radiograph at presentation. (b) Transverse CT image. (c) Post-
operative radiograph. (d) Radiograph taken six months after surgery. The animal raced and won post-operatively.
and this directs accurate, minimally invasive repair. (Figure 7.3c&d). Repair of these is key to re-establishing
Horses are positioned in lateral recumbency and prepared stability. Techniques used include open reduction and
in the same manner as slab fractures of the third tarsal application of limited contact dynamic compression plates
bone (“Fractures of the Third Tarsal Bone” section). A in a pony and closed reduction followed by application of a
marker needle is placed proximally in the tarsometatarsal transfixation cast in a miniature horse [55]. A horse with
joint and at the distal exit point of the fracture as meas- proximal intertarsal subluxation was stabilized with lateral
ured on pre-operative radiographs and/or CT images. A and plantarolateral locking compression plates (LCPs) [56].
needle is then placed along the proposed line of repair Closed reduction under general anaesthesia followed by
with the needle point at the pre-determined centre of the cast support was reported to be effective in re-establishing
fracture. Repair is effected by the insertion of a single stability and promoting ankyloses including a return to rid-
3.5 mm AO/ASIF cortical screw along this line in lag tech- den work in four of six individuals [53] and in a further
nique. Radiographic monitoring is performed in a manner case report [54]. A paper reported three cases of DP proxi-
similar to repair of slab fractures of the third tarsal bone mal intertarsal and two cases of tarsometatarsal subluxa-
described above (“Fractures of the Third Tarsal Bone” section [56]. The plantar aspect of the tarsus provides a strong
tion). The skin portal is closed with skin sutures only, and and reliable tension surface and all were stabilized with
a protective dressing applied. Sutures are generally plantarolaterally applied plates extending from proximal
removed 10–12 days post-operatively. Horses are confined calcaneus to mid-metatarsus. Four horses were treated
for two weeks, and this is followed by four weeks of gradu- with broad 4.5 mm dynamic compressions plates and one
ally increasing walking exercise with clinical and radio- with a 4.5 mm broad LCP. All were fitted with full-limb
graphic review to follow. Thereafter, exercise is determined casts and received assisted recoveries from general anaes-
by radiographic and clinical progress. thesia. The casts were maintained for 14–48 days, although
the authors concluded that the shorter period only was
likely necessary. One horse developed surgical site infec-
tion and was euthanized and two horses ruptured peroneus
Other Tarsal Fractures tertius (10 and 17 days post-operatively). The four surviving
horses were serviceable for light riding (three) and breed-
Fractures of the second and fourth tarsal bones are uncom- ing (one). In a report of five cases (three horses and two
mon. The second tarsal bone is shielded from external ponies), four medial and one plantar tarsal subluxations
trauma, but fractures of the fourth tarsal bone can result were repaired/stabilized by application of LCPs [57]. These
from kicks [52]. No specific management recommenda- were applied to the medial, dorsomedial or plantarolateral
tions occur within the literature. The proximal fourth met- aspects of the limb as determined by the compromised sta-
atarsal bone is a common site of fracture resulting from bility of the individual cases. All plates were applied in
kicks. These are commonly open, comminuted and some- neutral fashion. Medially, these extended from the talus or
times articular. Although ostectomy has been reported, in central tarsal bone (according to the level of instability
the author’s hands surgery, if necessary, should be conserv- within the tarsus) to the proximal one-third of the metatar-
ative and confined to removal of non-viable/or infected sus. Plantarolateral LCPs extended from the proximal cal-
fragments (Chapter 23). caneus to mid-metatarsus. Fixation included trans-articular
Complex fractures and fracture luxations are occasion- screws in three animals, but there was no attempt to
ally encountered in the tarsus. These are unpredictable include surgical arthrodesis of affected joints. Locking
monotonic injuries that generally result from severe head screws only were used in four cases, and a combina-
trauma such as falls, limb entrapment, collisions and road tion of locking head and cortical screws was used in one
traffic accidents. Instability can produce subluxation which horse. Following routine wound closure, ponies were fitted
most commonly involves the tarsometatarsal and proximal with full-limb casts and received a hand-assisted recovery
intertarsal joints; the fourth tarsal bone spanning the cen- from general anaesthesia. Water repellent bandages was
trodistal joint appears to be protective [53–57]. In some applied to horses before these recovered in a pool system.
cases, ligamentar compromise may be sufficient to create All horses were managed for varying times post-operatively
tarsal instability but stressed (usually abducted) DP radio- in a sling system to prevent them from lying down. Two
graphs may be necessary for identification [54, 57]. Most horses suffered ruptured peroneus tertius muscles appar-
horses with tarsal instability will have associated fractures ently as a result of post-operative tarsal cast or splint immo-
that can range from marginal fragmentation of the bones bilization; both recovered uneventfully from this. Most
involved [57] to substantial fractures of the proximal meta- horses commenced hand walking exercise six weeks post-
tarsus resulting in tarsometatarsal instability [55, 56] operatively. All horse survived, and the two ponies returned
Reference 637
Figure 29.28 Complex fracture of the talus following a fall in a Thoroughbred yearling and resulting in tarsocrural luxation.
to previous use. The horses had reduced activity due to using a dorsally located 5.5 mm LCP [58]. The biomechan-
persistent lameness. Radiographic signs of osteoarthritis ical shortcomings of a dorsally applied plate have been
developed or progressed in all cases [57]. A case report highlighted [59]. Some complex fractures of the talus can
documented severely comminuted and unstable tarsal displace to produce irreducible fracture luxation
fractures in a pony managed by pantarsal arthrodesis (Figure 29.28) necessitating euthanasia.
R
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horses. Equine Vet. J. 14: 55–58. Lopez, J.M. (2013). Surgical treatment of distal tarsal joint
49 Poulin Braim, A.E., Bell, R.J.W., Textor, J.A. et al. (2010). luxations in three horses. Vet. Comp. Orthop. Traumatol.
Computed tomography of proximal metatarsal and 3: 304–310.
concurrent third tarsal bone fractures in a Thoroughbred 56 McCormick, J.D. and Watkins, J. (2014). Plate fixation for
racehorse. Equine Vet. Educ. 22: 290–295. management of plantar instability of the distal tarsus/
50 Pilsworth, R.C. (1992). Incomplete fracture of the dorsal proximal metatarsus in 5 horses. Vet. Surg. 43: 425–429.
aspect of the proximal cortex of the third metatarsal bone 57 Keller, S.A., Fürst, A.E., Kircher, P. et al. (2015). Locking
as a cause of hind-limb lameness in the racing compression plate fixation of equine tarsal subluxations.
Thoroughbred: a review of three cases. Equine Vet. J. 24: Vet. Surg. 44: 949–956.
147–150. 58 Vlahos, T. (2020). Pantarsal arthrodesis in a pony using a
51 Ross, M.W., Sponseller, M.L., Gill, H.E., and Moyer, W. locking compression plate. Equine Vet. Educ. 32: 358.
(1993). Articular fracture of the 59 Auer, J.A. and Fürst, A.E. (2020). Tarsal arthrodesis in
dorsoproximolateralaspect of the third metatarsal bone in horses. Equine Vet. Educ. 32: 359–364.
641
30
Fractures of the Tibia

A
natomy articulates with the trochlear ridges of the talus forming
the tarsocrural joint. The distal tibia is undulating with lat-
The tibia is the major weight-bearing bone in the crus eral and medial malleoli and a conspicuous centrally
(gaskin) of the horse [1]. It develops from three principal located intermediate ridge.
centres of ossification for proximal and distal epiphyses Important neurovascular structures that require consid-
and the diaphysis. There are also separate centres for the eration when planning surgical approaches include the cra-
tibial tuberosity and lateral malleolus: the latter is nial tibial artery, a branch of the popliteal artery, that
phylogenetically fibular. The proximal and distal courses distally along the lateral diaphysis of the tibia before
metaphyseal growth plates close at approximately 3.5 and moving cranially in the mid-diaphyseal region. The com-
2 years of age, respectively [2]. The triangular-shaped mon peroneal nerve courses around the lateral aspect of the
proximal tibia articulates with the femoral condyles proximal fibula and tibia before branching into deep and
forming the lateral and medial femorotibial joints. The superficial branches mid-proximal tibia and extending dis-
proximal articular surface of the tibia is flat and divided by tally. The major muscles overlying the tibia are the aptly
medial and lateral intercondylar eminences to create named tibialis cranialis, the craniolateral long and lateral
separate articular surfaces for the respective condyles of digital extensors, and the caudoproximal gastrocnemius
the femur. The axial sides of each intercondylar eminence and the superficial and deep digital flexors. Peroneus tertius
are covered by hyaline cartilage and are intra-articular with is a dense fibrous band lying between the tibialis cranialis
respect to the medial and lateral femorotibial joints. The and the long digital extensor muscles.
medial eminence is cranial to the lateral, taller and has a
more acute lateromedial proximal angle. The eminences
are separated by a fossa that extends to the axial side of the F
racture Types
medial eminence for insertion of the cranial cruciate
ligament. Smaller fossae are present cranial to each Fractures of the tibia occur at multiple locations, may be
eminence for insertion of the cranial ligaments of the complete or incomplete and are of several types. Proximal
respective menisci. Caudally, the condyles are separated by and distal physeal fractures have been reported in foals;
the deep popliteal notch with a blunt caudomedial proximal injuries occur fairly often, but distal fractures are
eminence for insertion of the caudal cruciate ligament. The uncommon [3]. Proximal physeal fractures are almost
rudimentary fibula articulates with the lateral proximal always Salter–Harris type II injuries and have a highly
tibia. A prominent laterally oblique tibial tuberosity and stereotypical configuration with a lateral metaphyseal
conjoined tibial crest protrude from the cranial proximal component and medial fragment separation (Figure 30.1).
portion of the bone and serve as the attachment for all Distal physeal fractures are more variable (Figure 30.2),
three patellar ligaments. The tendon of origin of the long but the Salter–Harris type II also tend to have a lateral
digital extensor and peroneus tertius courses through a metaphyseal fragment [3]. Diaphyseal fractures occur in
long deep sulcus lateral to the tibial tuberosity. The tibia horses of all ages and can be secondary to external trauma
changes to an oval shape through its diaphysis before (monotonic) or result from fatigue failure (stress fractures).
becoming irregularly quadrangular distally. Here, it Monotonic diaphyseal fractures usually have oblique or

642 Fractures of the Tibia
(a) (b) (c)
Figure 30.1 Caudocranial radiographs of three proximal Salter–Harris type II fractures. These stereotypically involve medial
separation of the physis with variable sized lateral metaphyseal fragments.
(a) (b) (c)
Figure 30.2 Radiographs of distal physeal fractures. (a, b) Salter–Harris type II fractures with lateral metaphyseal spikes.
(c) Salter–Harris type III fracture.
spiralling configurations, and comminution is common extend caudally and involve the joint surface. Tibial
(Figure 30.3). In adults, this is due, at least in part, to the tuberosity fractures can be minimally displaced or dis-
energy required to fracture an adult tibia (Figure 30.4). placed proximally and cranially due to traction by the
Diaphyseal fractures also have a tendency to become open patellar ligaments [5]. Stress fractures of the tibia were first
due to the minimal soft tissue coverage on the medial reported in 1987 [6]. They result in substantial loss of train-
aspect of the limb. Fractures of the tibial tuberosity are also ing time and can become complete during high-speed work
usually associated with external trauma (Figure 30.5) (Figures 30.6–30.8) [7–9]. Post-mortem evidence suggests
[4, 5]. They are usually non-articular but will occasionally that horses with stress fracture which continue with
Fracture Type 643
Figure 30.3 Examples of four oblique diaphyseal fractures in foals that are suitable for double-plate fixation.
Figure 30.4 Three severely comminuted diaphyseal fractures in adult horses. To date, successful repair has been seen only with less
comminuted fractures.
(a) (b) (c)
(d) (e) (f)
Figure 30.5 Fractures of the tibial tuberosity have a variety of configurations. The majority (a–d) do not compromise the entire
patellar ligament insertions, but long fractures (e, f) may do so.
(a) (b) Figure 30.6 Stress fracture of the caudal distal

medial cortex identified by scintigraphy (a).
Subsequent radiography (b) demonstrated extensive
periosteal and endosteal new bone consistent with
chronic failure.
Fracture Type 645
(a) (b) (c)
Figure 30.7 Caudal diaphyseal stress fracture localized by nuclear scintigraphy (a, b) and subsequently identified in the caudal
lateral cortex on craniolateral–caudomedial oblique radiographs (c).
Figure 30.8 Stress fracture of the (a) (b)

proximolateral tibia in a three-year-old
Thoroughbred. (a) Lateral and caudal
scintigraphic images. (b) Periosteal new
bone (arrows) with loss of margination of
the underlying cortex.
t raining and racing are at risk of complete catastrophic diagnostic criteria. The caudal mid-diaphyseal cortex was
fracture [10], although these are relatively uncommon [11, 12]. reported to be the most frequent location in a population of
In Thoroughbreds, tibial stress fractures are most common Standardbreds [15]. Incomplete fractures in non-racehorses
in the proximolateral, mid-diaphyseal and distal caudal are generally secondary to external trauma (Figure 30.9):
cortices [6, 9, 13, 14]. However, the most frequent site var- these tend to have a spiralling configuration and are also at
ies between publications with differing populations and/or risk of catastrophic failure [16].
Figure 30.9 Multiple fracture lines identified in the proximal diaphysis and metaphysis of an incomplete fracture in an adult mare
caused by a kick.
Fractures of an intercondylar eminence are uncommon It has been suggested that fractures of the medial emi-
injuries. Most osseous fragments seen on the caudocranial nence are avulsions of the cranial cruciate ligament, but
view in the intercondylar area are free fragments, but occa- this is anatomically incorrect. Axially, these usually involve
sionally true fractures of the eminences are seen. only a small amount of its insertion [23] and instability or
other clinical consequences appear rare. Fractures are usu-
ally associated with traumatic events [23], and shear forces
Incidence and Causation have been suggested as causative [24]. Avulsions associated
with the caudal cruciate ligament are generally monotonic
Physeal fractures occur from the neonatal period up to and commonly result from unseen paddock accidents.
16–18 months of age. Salter–Harris type II proximal phy-
seal fractures are probably the single most common tibial
fractures in foals. They can be caused by a kick on the lat- Clinical Features and Presentation
eral aspect of the limb while this is bearing weight or if a
foal attempts to rise with the limb caught under an object. Both proximal and distal physeal fractures tend to be
Fractures of the tibial tuberosity result from impact trauma closed. There is usually marked soft tissue swelling over
usually with the stifle in flexion. They are most common in the medial physis, and the foal is usually (but not always)
event horses that hit a solid jump with the stifle flexed [4, 5]. non-weight-bearing. Loading of the limb leads to an obvi-
Diaphyseal fractures are most often caused by external ous valgus deformity. Horses with tibial tuberosity frac-
trauma such as a kick. tures generally display an acute, severe lameness with
Stress fractures are presumed to be caused by repetitive limited weight-bearing and a marked decrease in the poste-
cyclic loading, and changes consistent with fatigue injury rior phase of the stride [25]. There is usually local swelling
have been recognized in the caudal distal tibia [17]. They with or without crepitus, and synovial effusion is generally
are common in young Thoroughbred racehorses [7, 18–20], evident in horses with fractures that are articular.
occur at lower frequency in racing Standardbreds and Horses with complete, displaced fractures of the tibia pre-
Quarter Horses [15, 21] and are seen uncommonly in horses sent with severe, non-weight-bearing lameness. Marked
used for other purposes [22]. There is evidence of increased swelling is usually present and these fractures are often open
risk of tibial stress fractures with training and racing on on the medial side, especially in adult horses. Instability of
synthetic surfaces [8]. They can be unilateral or bilateral the limb is usually obvious, and like physeal fractures load-
although commonly one leg is clinically dominant: bilateral ing leads to valgus deformity. Urgent first aid is required to
evaluation/imaging is always recommended. limit the risk of the fracture becoming open (Chapter 7).
A caudal splint extending to the point of the hock and a lateral c audolateral–craniomedial oblique and craniolateral–
splint extending to the hip should be applied over a moder- caudomedial oblique projections, should be performed to
ately padded full-limb bandage. Excessive padding should be fully assess fracture configuration. For diaphyseal frac-
avoided because it increases the weight of the coaptation and tures, use of a long detector plate in order to capture as
moves the splint farther from the limb surface. much of the length of the bone as possible on one image is
Horses with incomplete fractures will generally display recommended. Cortical defects associated with stress frac-
severe, unilateral lameness. Focal pain may be present on tures in racehorses can sometimes be identified on radio-
palpation. Presentation of horses with stress fractures varies graphs or may later become radiographically evident,
widely. Lameness can range from mild to marked. Horses although several views at slightly different angles are often
with unilateral stress fractures often present with acute, required. Endosteal and/or periosteal reaction usually is,
severe lameness, but lameness may be variable in horses or becomes, evident, and in some cases may be the only
with bilateral stress fractures. Lameness is often exacerbated identifiable radiographic feature [9]. This is consistent
by high-speed work but dissipates after several days of rest. with chronicity and/or prodromal bone failure. Positive
Some horses will have focal pain on palpation of injury sites. identification of radiographic abnormalities is diagnosti-
Fractures of the medial eminence usually produce an ini- cally important but reported to be an unreliable measure
tial acute, severe lameness with rapid onset distension of the of clinical severity or stage of progression of lesions [26].
medial femorotibial joint. Acute caudal cruciate avulsion Incomplete fractures often require several projections at
fracture generally results in marked lameness accompanied slightly different angles in order to highlight the fracture
by distension of the medial femorotibial joint. The lateral plane(s). They frequently have a spiral proximolateral to
femorotibial and sometimes femoropatellar joints can also distomedial configuration [25].
be distended: this may be the result of concurrent soft tissue Most fractures of the medial tibial eminence are identi-
injuries or lesions resulting from consequent instability. fied on caudocranial and lateromedial projections.
Flexed lateromedial projections often assist in profiling
fractures (Figure 30.10). Caudal cruciate avulsion frac-
tures are generally evident on lateromedial radiographs
Imaging and Diagnosis and with careful scrutiny can be identified on caudocra-
nial projections.
Radiography
Fractures of the tibial tuberosity are usually identified in
Although physical examination of horses with complete lateromedial projections, but because of its oblique
fractures usually establishes a diagnosis, radiographs are orientation a caudal 35° lateral–craniomedial oblique
used to confirm and characterize the injury. For physeal projection is often the most useful in visualizing the frac-
and diaphyseal fractures, a complete radiographic evalua- ture line and accurately determining the configuration [5].
tion of the tibia, including a lateromedial, caudocranial, Radiography of the contralateral tibia can be useful in
Figure 30.10 Caudocranial and flexed

lateromedial radiographs illustrating
fracture of the medial tibial eminence in
a yearling Thoroughbred.
young horses with suspicion of a non-displaced fracture of incomplete fractures that cannot be confirmed or configu-
the tibial tuberosity. The physis of the tibial tuberosity rations identified on standard radiographs.
should be radiographically closed by 36–42 months of age,
but before closure the appearance can vary considerably on
different radiographic projections. T
reatment
Nuclear Scintigraphy Proximal Physeal Fractures
Nuclear scintigraphy is the most useful diagnostic modal- A variety of techniques for repair of proximal physeal
ity for detection of tibial stress fractures [6, 27], although fractures have been described including cross-pinning [25,
it does not quantitatively correlate with clinical sever- 29, 30], lag screw fixation [31], and bone plate fixa-
ity [26, 28] or outcome [28]. Areas of increased radiophar- tion [32, 33]. Use of cross-pins requires biaxial surgical
maceutical uptake (IRU) are identified on lateral and approaches and usually is supplemented by lag screw fix-
caudal images. Typical locations include the distal medial, ation of the lateral metaphyseal fragment [25]. Although
mid-diaphysis, and proximal caudolateral tibia considered to have less detrimental impact on subsequent
(Figures 30.6–30.8). The major differential for IRU is an physeal growth, cross-pinning and simple lag screw repair
enostosis-like lesion, but orthogonal views help discrimi- lack strength and stability and are only appropriate for
nate. True stress fractures involve at least one cortex, neonates. Reduction is also less effective. Supplementing
while IRU in enostosis-like lesions should be centred these simple techniques with a transphyseal screw and
within the medullary cavity on perpendicular views. wire as a tension band may enhance construct strength,
Elongated zones of IRU merit caution as these can signal but medial plate fixation is currently the repair technique
the presence of propagating and/or bicortical stress frac- of choice.
tures that can initially be radiographically undetected Plate fixation is recommended for the repair of most
(Figure 5.10). proximal physeal fractures and definitely should be done
in larger foals and yearlings (Figure 30.12). The animal is
positioned with the affected leg down, and a slightly
Computed Tomography
curved (caudal concavity) incision is made directly over
The advent of standing computed tomography (CT), the medial physis. The incision is made just long enough
although not yet widely available, allows partial three- to accommodate a four- or five-hole plate. With less
dimensional imaging of the mid to distal tibia (Figure 30.11). severely displaced fractures, a minimally invasive
This is particularly useful in horses suspected of having approach can be used. (Figure 30.13) The commonly
Figure 30.11 Multiplanar reconstructed slices from a standing CT scan of a diaphyseal stress fracture identified with scintigraphy.
Treatmen 649
(a) (b) (c) (d)
Figure 30.12 Caudocranial radiographs of a minimally displaced proximal Salter–Harris type II fracture: (a) at presentation,
(b) post-operative image following repair with a locking T-Plate and (c) eight weeks after surgery. It is common to leave the plate
bridging the medial physis long enough to correct any persistent valgus. (d) Following plate removal.
available three-hole locking pastern arthrodesis plate can illimetres off the surface of the medial metaphysis.
m
be used in small foals (Figure 30.14), but in larger foals or Fully inserting and tightening the epiphyseal screw(s)
fractures with marked instability a locking ‘T’-plate has a before a cortex screw is placed through the distal part of
number of advantages. After the medial physis is exposed, the plate will further reduce the medial side of the frac-
the fracture is displaced by abducting the distal limb and ture and ensure tensile loading of the plate. The proximal
the fracture line is gently debrided of any large fibrin clots portion of the plate must be contoured such that the
or folded fragments of physeal cartilage. Large fragments screw going across the epiphysis is meticulously centred.
of healthy-looking physeal cartilage should be left in The epiphysis is a narrow target so this must be done
place. Adduction of the distal limb with traction will usu- carefully. It is easy to inadvertently aim the screw(s)
ally reduce the fracture. Reduction of fractures which are slightly proximally which can result in undesirable pene-
a few days old may require more forceful manipulation tration of the articular surface and necessitate a shorter
and even introduction of a Hohmann retractor or other than ideal screw. The current locking T-plate has three
instrument to lever the fragment. In some cases, achiev- screw holes in the top (Chapter 8), but it is probably not
ing and holding reduction is facilitated by inserting a desirable to use all three, especially in smaller foals. The
screw in the medial epiphysis, another in the metaphysis medial position of the plate in the proximal tibia puts the
and placing a figure-of-eight wire around the screw heads. plate in tension because of the foal’s tendency to abduct
These should be placed caudal to the intended site of the distal limb. With plating techniques, it is not essential
plate application. Following reduction, a malleable tem- to lag the lateral metaphyseal spike although it may pro-
plate is fitted and a locking T-plate or narrow 4.5 mm vide additional stability. In yearlings (>250 kg), the
locking compression plate (LCP) is appropriately con- authors prefer to use two narrow 4.5 plates placed side by
toured. Non-locking plates can be satisfactory, but the side (Figure 30.15).
locking element adds stability. Twisting should not be Soft tissues overlying the plate are apposed with inter-
necessary if the plate is positioned medially, but ‘under- rupted tension sutures (cruciate or near–far–far–near) of
contouring’ the plate affords a solid tension band and absorbable synthetic material. The skin is closed with inter-
more correction of the valgus alignment. This means fit- rupted simple or vertical mattress sutures before a well-
ting the plate such that its more distal part is several adhered bandage is placed directly over the incision. Recovery
(a) (b)
(c) (d)
(e) (f)
Figure 30.13 Minimally invasive repair of a proximal Salter–Harris type II fracture with a locking T-plate. (a) Needle used to
identify physis. (b) A transverse incision is made over the epiphysis and a plate passing device used to make a subcutaneous/
extraperiosteal tunnel. (c, d) A plate contoured to match the medial contour of the contralateral tibia is passed into the tunnel. (e)
The distal positioning of the plate is checked digitally. (f) The plate is clamped in position and a locking drill guide is placed in the
‘T’ portion of the plate. (g) Two 5.0 mm locking screws tightened in the ‘T’. (h) A #10 blade is used to make a stab incision in the
palpable hole in the vertical portion of the plate. (i) A cortex screw is placed to lag the plate against the bone and to apply a
tension band effect over the medial physis. (j, k) Additional locking screws are inserted. (l) Skin sutures only are necessary for most
of the closure.
is always assisted. Foals are maintained on box stall rest for perfectly reduce the fracture resulting in persistent slight
four weeks, following which radiographs are obtained. If post-operative valgus. In such cases, the medial transphyseal
healing is adequate, exercise can be progressively increased plate is left in longer to help correct the deformity. Plate
to unlimited by eight weeks. Implant removal is recom- removal through a less invasive technique is facilitated by
mended in foals because the plate crosses the physis. In foals using a matching plate as an external template (Figure 30.16).
<one month of age, fractures heal quickly, and the plate can In yearlings, the plate(s) can be left in situ.
be removed in 20–30 days. Before doing so, it is important to Complications include failure of fixation, surgical site
assess alignment of the proximal tibia. It is often difficult to infection and wound dehiscence. These incisions are
Treatmen 651
(g) (h)
(i) (j)
(k) (l)
articularly prone to problems because soft tissues are tight

p joint is not involved, implants can be removed later and the
providing minimal coverage of the plate(s), and it is a chal- site will heal with a moderate blemish.
lenging area to keep well bandaged. It is worth noting that Proximal physeal fractures are straightforward to
dehiscence of the incision and exposure of the plates do repair and have an excellent prognosis for healing but
not necessarily augur failure. These fractures can heal well not necessarily for athletic function [30–33]. Trauma
even with the plate exposed and draining. Providing the associated with the fracture can permanently injure the
(a)
(b) (c)
(d) (e)
(h)
(g)
(f)
(i) (j) (k)
Figure 30.14 (a) Moderately displaced proximal Salter–Harris type II fracture in a young foal. (b) Needles are used to mark the medial
edge of the epiphysis. (c) A 4.0 mm drill is used to make a precisely positioned hole across the epiphysis. (d, e) A three-hole locking plate
roughly contoured to the medial surface of the contralateral tibia is attached with a 5.0 mm screw. The plate is intentionally ‘under-
contoured’ to diverge from the metaphysis. (f, g) Two 5.5 mm cortex screws are tightened to pull the plate down and reduce the fracture.
(h, i) Radiographs taken 21 days after repair: rapid healing in young animals permits early plate removal. (j, k) Caudocranial radiographs
following plate removal (j) and 60 days after repair (k). At the time of writing, the animal was sound and racing.
Figure 30.15 Medial side-by-side DCPs
used to enhance construct strength in a
16-month-old 300 kg yearling.
Figure 30.16 Less invasive plate removal (a) (b)

of a T-plate. (a, b) The transverse incision
overlying the ‘T’ is easy to see and replicate
to remove the proximal screws through an
open approach. (c) A matching plate is used
to make accurate stab incisions over each
screw. (d) In order to avoid confusion, it is
helpful to loosen all screws to skin level,
count them and then remove.
(c) (d)
physis and reduction is frequently imperfect; growth fractures is good, but complex or displaced fractures are
problems can therefore result regardless of repair very challenging [34].
technique.
Fractures of the Tibial Tuberosity
Distal Physeal Fractures
Decisions on conservative management, removal or repair are
Non-displaced or minimally displaced fractures in younger largely determined by the integrity of patellar ligament inser-
foals can often be treated with coaptation in a cast for tions and thus, in turn, by the proximodistal length of the frac-
three to six weeks. Internal fixation should be strongly ture. Horses with non- or minimally displaced fractures and
considered in larger foals and all displaced fractures. Lag some with small displaced fractures can be treated conserva-
screw fixation with or without tension band wiring can be tively with box stall rest. Limiting recumbency with cross-
used to stabilize the fragment; however, the undulating tying or sling support has been recommended to decrease the
nature of the distal tibial epiphysis makes screw place- risk of displacement. A prolonged recovery period is required,
ment challenging. Displaced fractures can also be aston- but good prognoses for return to performance have been
ishingly difficult to reduce because the epiphyseal reported with 12/15 (80%) horses returning to working sound-
fragment moves so much over the talus. In complex distal ness [35]. Small fragments that involve limited amounts of
physeal fractures, multiple short locking plates can be patellar ligament insertion can safely be removed
used (Figure 30.17). The prognosis for minimally displaced (Figure 30.18) which may shorten the convalescent period.
(a) (b) (c) (d)
(e) (f) (g) (h) (i)
Figure 30.17 Repair of a complex distal physeal and epiphyseal fracture. (a, b) Pre-operative dorsoplantar and dorsomedial–
plantarolateral oblique radiographs. (c, d) Reduction forceps allowed a lag screw to be placed through the distal hole of a narrow
locking plate. (e) The remaining three holes are filled with two cortex screws and a single locked screw. (f, g) A highly contoured
narrow plate is held with pointed reduction forceps before a lag screw is directed sharply proximally to avoid the articular surface.
(h, i) After filling the medial plate, a three-hole PIP arthrodesis plate was placed dorsally to further stabilize the epiphysis Source::
Courtesy of Bruce Bladon.
Treatmen 655
Internal fixation by application of a tension band is recom- amenable to repair. Exceptions are encountered [36], and the
mended for larger displaced fractures [4, 5]. Horses can be reduced mechanical demands in ponies and miniature horses
positioned in lateral recumbency with affected limb up or in improve prospects. Surgical reconstruction is more frequently
dorsal recumbency. A straight or slightly curvilinear incision feasible in foals in which simple oblique or minimally com-
is made over the fracture site. Some sharp dissection of the minuted mid-diaphyseal fractures are more common.
patellar ligament insertions may be needed for plate applica- Repair of diaphyseal fractures requires two plates. The
tion but should be minimized. Arthroscopy or a small femo- surgical approach can be either craniolateral or craniome-
rotibial arthrotomy can be used to facilitate reduction of dial; in both the majority of the skin incision is centred
articular fractures, but most do not involve the articular sur- over the tibialis cranialis muscle (Figure 30.21) [25, 32]. If
face. Fixation can be achieved using a dynamic compression the fracture configuration allows, the authors prefer to
plate (DCP) with cortex screws placed in lag fashion position the animal with the affected limb down as this
(Figure 30.19) or using an LCP with a combination of locking readily allows a plate to span the entire length of the bone.
head screws and 5.5 mm cortex screws placed in lag fashion. Plates on the medial or craniomedial surface of the tibia
Although this repair is very stable, there is a risk of cata- require less overall contouring than lateral plates. The lat-
strophic fracture through the screw holes with proximal tib- eral musculature is also more complex and difficult to
ial plates, especially when they are aligned in the same plane. retract. The margins of the muscles are separated and vig-
Another option for repair is screws and a tension band wire. orously elevated from the tibia using Hohmann retractors.
Washers under the screw head are helpful to prevent wire The cranial/craniolateral plate is placed by levered retrac-
displacement (Figure 30.20). Horses should be assisted dur- tion of the tibialis cranialis muscle with the Hohmann
ing recovery from general anaesthesia. Box stall rest for eight retractors. In larger foals or when there is difficulty placing
weeks with radiographic evaluation of healing performed the craniolateral plate, it is possible to make a second deep
prior to introduction of small paddock turnout is recom- incision between tibialis cranialis and long digital extensor
mended. Overall, the prognosis for performance should be muscles followed again by strong Hohmann retractor use
fair to good. In one report, two of four [4], and in another four to move the former medially and the latter laterally. A cran-
of four [5], horses were sound and returned to work. iolateral approach is preferred by other surgeons [25] and
It should be noted that published images [4, 5, 35] and does have the advantage of maintaining more soft tissue
measurements [35] suggest that removed fragments were over the implants. The craniolateral approach also makes it
substantially smaller than those repaired. easier to position the more difficult of the two plates.
Nonetheless, the ease of placing the full length medial
plate and acceptance of a slightly shorter craniolateral
Diaphyseal Fractures
plate cause the authors to prefer the craniomedial approach.
Locations, configurations and frequent comminution are Following exposure, fractures are debrided of any fibrin,
such that complete diaphyseal fractures in adults are rarely clots or loose fragments interfering with reduction. Periosteal
(a) (b) (c)
Figure 30.18 Removal of a small displaced fragment from the tibial tuberosity associated with a kick wound. (a, b) Pre-operative and
(c) 11-day post-operative radiographs.
(a) (b) (c)
(d) (e) (f)
Figure 30.19 Radiographs illustrating repair of a minimally displaced fracture of the tibial tuberosity with a narrow DCP. (a, b) At
presentation. (c, d) Ten days. (e, f) Eight weeks after surgery. Note the plate twisting necessary to follow the contour of the tuberosity
and crest and consequent changes in screw trajectories.
stripping and intramedullary disturbance are minimized. where neither plate will need to be positioned. Smaller
Many foal fractures are comminuted. In common with other (3.5 mm) screws can be helpful. They will hold well enough
sites, the goal is to reconstruct fragments that are large to allow final manipulation of the reconstructed two pieces
enough to allow fixation back to one of the two major ele- into alignment, interfere less with the definitive fixation by
ments of the fracture. This is usually done with independent the plate screws, and if it is the only option, the screw heads
lag screws (Figure 30.21d), but occasionally cerclage wiring can be countersunk to fit directly under a plate. The goal is
is suitable. Reconstruction of the comminuted fracture with to convert a multipiece fracture into a two-piece fracture and
lag screws demands planning as the screws are best placed then put those two pieces together.
Treatmen 657
(a) (b) (c)
Figure 30.20 Radiographs illustrating lag screw and tension band wire repair of a displaced comminuted fracture of the proximal
tibial tuberosity. (a) Pre-operative and (b, c) post-operative images. Washers are used to resist slippage of the wire over the screw
heads Source:: Courtesy of Bruce Bladon.

As in other locations, more transverse plane fractures are feasible in non- or minimally displaced diaphyseal frac-
easiest to reduce by ‘tenting’, i.e. folding them outward until tures, especially on the medial surface but such cases are
their ends are engaged before gradually straightening into rare. A combination of an open approach and a less inva-
alignment. This is a dangerous technique if there is substan- sive approach should be considered in any double-plating
tial obliquity to the fracture due to the risk of fracturing the procedure.
ends of either fragment. Direct intermittent traction is then Screw interference is a major challenge in the tibia because
more suitable. To do this, pull the aligned but overlapping the necessary plate contouring makes the simple half-hole
oblique ends apart, clamp in position, rest and repeat. This staggered placement of the two plates that works in a more
can take quite a long time but usually will be successful. If at uniformly tubular bone inadequate. The surgeon usually has
all possible once alignment/reduction is achieved, temporar- to optimize placement of the larger and longer plate and then
ily securing reduction with one or more independent (out- work out how to position screws in the second plate. When
side of a plate) screws is highly desirable. Wires or cable ties possible, lag screws should be applied through the plate in spi-
are alternative options. It is very difficult to place plates on an ral or long oblique configurations but surgeons must be cog-
unstable tibia or one being held with clamps so the effort to nisant that the ability to angle larger screws through larger
hold reduction even with tenuous fixation is worthwhile. plates is progressively limited. If feasible, locked screws should
Two plates are essential in all equine diaphyseal frac- be placed in the end holes of each plate. When possible,
tures because there is no strong tension surface, and the implants crossing proximal and distal physes should be
tibia is both complexly and heavily loaded each time the avoided but engaging and crossing the tibial tuberosity is not a
animal rises from recumbency. The plates should be as major concern. Cancellous bone usually harvested from the
long and as close to right angles to one another as possible, tuber coxae can be used in fractures with major cortical defects.
i.e. medial and cranial or craniomedial and craniolateral. Closure of the deep incision using interrupted absorba-
Plates should be positioned to cover any cortical gaps. Most ble synthetic sutures should be meticulous. Because the
foal fractures are repaired with two broad 4.5 mm LCPs tibia can be adequately bandaged, closed suction drains are
affixed with a combination of 5.0 mm locking and 5.5 mm only used if there is extensive bleeding or muscle injury. A
cortex screws (Figure 30.21). In smaller foals, one can be a lightly padded bandage is placed for recovery which is
narrow plate (Figure 30.22), but if there is any question always assisted. Usually, the hock and metatarsus are not
about construct stability, two broad plates are used. In bandaged for recovery to make it easier for the foal to move
larger horses although rarely attempted, the 5.5 mm broad the limb. Antimicrobials are given for 48–72 hours in sim-
plate should be considered. Contouring the latter can be ple cases, but many surgeons administer antimicrobials for
daunting. Less invasive plating techniques should be longer periods because of concerns about soft tissue injury
(a) (b) (c)
(d) (e) (f)
Figure 30.21 Repair of a mid-diaphyseal spiral oblique fracture in a foal. (a, b) Pre-operative radiographs. (c) The fracture is exposed
by a craniomedial approach and reduced with large bone holding clamps that are applied, released and reapplied as forceful
longitudinal traction is applied. (d) Independent 4.5 mm lag screws (arrows) are inserted across the oblique fracture plane to maintain
alignment/reduction and to apply compression while plates are applied. (e) A long medial broad LCP is applied. The saphenous vein is
isolated and protected with a Penrose drain. (f) A second broad plate is placed as close as possible to 90° on the craniolateral aspect
of the bone.
Treatmen 659
(a) (b) (c) (d)
(e) (f) (g) (h)
Figure 30.22 Repair of an oblique mid-diaphyseal fracture in a foal. (a–d) Immediate, (e, f) 8-week and (g, h) 14-week post-operative
radiographs. In this foal, one broad and one narrow LCP were applied with 5.0 locking screws in most holes. Two 4.5 mm cortical lag
screws (arrows in (a)–(d)) were used to maintain reduction while the plates were applied. Abundant bridging callus is evident at
follow-up. A locking screw has partially disengaged from the craniolateral plate.
(a) (b) (c) (d)
(e) (f) (g) (h)
Figure 30.23 Repair of a diaphyseal fracture in a four-year-old Standardbred. A non-displaced fracture was sustained while racing,
and the mare was hospitalized and placed into a sling. Radiographs taken after 48 hours (a–d) demonstrated progressive
displacement, and the fracture was repaired with two broad minimal contact LCPs with 5.0 LHS and independent 5.5 mm cortical
screws (e–h). Source: Courtesy of Fabrice Rossignol.
and incisional complications. Post-operatively, foals should for future racehorses. The decision to remove one or both
be kept confined to a stall that is not too deeply bedded so plates at the same time is difficult: there is more risk with
that it can move around easily, as some degree of transient simultaneous removal, but more expense with staged
peroneal paresis is common. removal. Plate removal should be discussed with the owner
Healing is monitored by radiographs taken at regular well before the appropriate time (usually three to four
intervals. Most foals require six to eight weeks of box stall months after repair in foals). It is far more difficult to
rest. Sling support should be strongly considered in adult remove tibial plates after the bone starts to enclose them.
horses. Although plate removal does not appear to be Prognosis is highly dependent upon the age of the patient
essential for athletic soundness, it is still generally advised and the complexity of the fracture. Major complications
Treatmen 661
(a) (b) (c)
Figure 30.24 Arthroscopic removal of the fractured medial tibial eminence illustrated in Figure 30.10. (a) Sharp dissection from the
axially located cranial cruciate ligament using a curved knife. (b) Division of the attached portion of the cranial ligament of the
medial meniscus using arthroscopic scissors. (c) Fracture bed (arrows), cranial cruciate ligament (CC) and cranial ligament of the
medial meniscus (CLMM) viewed from a craniomedial arthroscopic portal following fragment removal and debridement.
include breakdown of the fixation due to bone or implant exercise increased with clinical and radiographic monitor-
failure, surgical site infection and overload of the contralat- ing. A total of four to six months of rest from intense race
eral limb. Simple diaphyseal fractures in young foals have a training is recommended to reduce the risk of catastrophic
favourable prognosis for life and a reasonable outlook for failure. Horses with tibial stress fractures have a good
athletic function. Open or severely comminuted fractures prognosis for soundness and return to racing, provided
have a guarded prognosis. Although successful reports they are allowed an adequate period of rest. Two reports
exist [36], an effective repair of diaphyseal fractures in document 49/61 (80%) [9] and 27/35 (77%) [7]
adult horses is very challenging and expensive even under Thoroughbreds returning to racing at means of 7 and
optimal circumstances (Figure 30.23). 4.5 months, respectively. Similarly, 10 of 13 (77%)
Standardbreds raced after injury [15]. Early recognition
and appropriate management have subjectively reduced
Incomplete Fractures
the incidence of catastrophic fractures.
The reported incidence of fracture disruption is <50% so
most incomplete fractures are managed conservatively due
Fractures of the Medial Eminence
to risks associated with internal fixation [16]. Horses
should be restricted with cross-ties or slings to prevent Most fragments are amenable to arthroscopic removal [23,
recumbency. Serial radiographs allow assessment of heal- 37], but large fractures that may involve greater portions of
ing. Horses can often begin hand walking after eight weeks the cranial cruciate and/or cranial ligament of the medial
of stall rest and then resume small paddock turnout at meniscus insertion(s) or which extend axially and caudally
three months. towards the lateral eminence may benefit from internal
fixation [37, 38].
The technique for removal has been discussed and illus-
Stress Fractures
trated in a specialist arthroscopy text [37] (Figure 30.24). A
Propagating and bicortical stress fractures are managed in similar craniolateral arthroscopic portal is employed for
cross-ties to prevent lying down and the risks associated repair. Visibility is aided by resection of the interarticular
with rising. The necessary time is subjective but, unless septum. Fragment size usually permits only a single crani-
circumstances preclude, generally should not be less than oproximal- to caudodistal-oriented 4.5 mm cortical screw
four weeks. Traditionally, the treatment recommendations placed in lag technique. Orientation is directed by a combi-
for racehorses with unicortical tibial stress fractures nation of radiography or fluoroscopy and arthroscopy
include 60 days of box stall rest and 30 days of small pad- (Figure 30.25).
dock turnout prior to return to training. More recently, the Following arthroscopic removal, 15/20 horses returned
period of confinement has been reduced and controlled to previous use [23].
(a) (b) (c)
(d) (e)
Figure 30.25 Radiographs of a comminuted fracture of the medial tibial eminence in a two-year-old Thoroughbred. A subchondral
bone cyst in the medial condyle of the femur had not prevented training and racing prior to fracture. (a–c) At presentation
demonstrating a displaced proximal fragment with a further fracture extending into the epiphysis (arrows). (d) Intraoperative image
following arthroscopic removal of the proximal fragment. A spinal needle is used to determine implant location and trajectory.
(e) Repair with a single 4.5 mm cortical screw.
Caudal Cruciate Avulsion Fractures ate proximity of the popliteal artery thwart safe dissection for
removal but, this aside, it is likely that loss of the caudal cruciate
There are no reports of safe surgical access either for recon-
insertion would be incompatible with return to soundness.
struction or removal. Compromised visibility and the immedi-
R
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665
31
Fractures of the Patella

K.F. Ortved1 and I.M. Wright2
1
2
A
natomy f unctional insertion these dominate biomechanical influ-
ences on the bone. From a surgical perspective, the four
The patella is the largest sesamoid bone in the body. It heads of quadriceps femoris (rectus femoris, vastus later-
develops from a single centre of ossification within quadri- alis, vastus intermedius and vastus medialis) envelope the
ceps femoris [1]. In the neonate, it is ovoid. As ossification proximal half of the patella, including the cranial proximal
proceeds, it becomes irregularly quadrilateral in the fron- sloping margins of the medial and lateral surfaces as far as
tal plane and convex cranially with an undulating caudal their respective angles. Medially, this also includes the
articular surface. The adult patella has approximately the patellar fibrocartilage. Tendons of insertion are short.
same proximodistal and lateromedial dimensions but is a The lateral patellar ligament extends from the lateral
complex shape (Figure 31.1). Its cranial surface is irregu- margin of the patella to the craniolateral aspect of the tibial
larly convex with greater lateromedial than proximodistal tuberosity. The middle patellar ligament has its origin on
curvature. The articular surface is proximodistally shorter the cranial aspect of the apex of the patella, runs through a
and proximolateral to distomedially oblique. It is divided pronounced groove in the tibial tuberosity and inserts just
by a proximodistal ridge into a mediolaterally broader distal to this. The medial patellar ligament is weaker than
medial concavity and narrower, slightly undulating lateral the other two. It may be considered a continuation of the
surface that articulate with the respective femoral troch- medial patellar fibrocartilage (or vice versa) and inserts on
lear ridges. The articular surface of the patella is substan- the craniomedial margin of the tibial tuberosity. Its caudal
tially smaller than the trochlear ridges and groove of the margin is confluent with the common aponeuroses of sar-
femur reflecting its range of proximodistal gliding move- torius and gracilis muscles [2]. Proximally, the patellar liga-
ment. The distal half of the medial articular (caudal) sur- ments are subsynovial with respect to the femoropatellar
face flares abaxially; at this site, the curved fibrocartilage joint. Further distad, the patellar fat pad separates them
of the patella blends with the medial margin and contin- from the joint capsule [2].
ues distally as the medial patellar ligament. A large medi- Other insertions that will have biomechanical influ-
olaterally comma-shaped, proximodistally irregularly ences on the patella include tensor fascia lata and biceps
concave, surface is found between the proximal cranial femoris laterally and sartorius and gracilis medially.
and caudal (articular) surfaces. This provides a substantial Lateral and medial femoropatellar ligaments attach the
area of insertion for quadriceps femoris (principally rectus patella to the femur. The lateral ligament is most substan-
femoris and vastus intermedius). Cranial and caudal sur- tial and extra-articular; the medial ligament is thinner and
faces converge distally. The patella is generally referred to peri-articular [2].
having proximal (base), distal (apex), medial and lateral The permanently flexed angle of the equine stifle creates
angles. a strong cranial tension surface to the patella. Its medial
Quadriceps femoris is the principal muscular attach- patellar fibrocartilage also functions as part of the stay
ment and together with the patellar ligaments as its apparatus.

666 Fractures of the Patella
(a) (b)
Proximal Proximal
Caudal Cranial Medial Lateral
Distal Distal
Figure 31.1 Lateral (a) and articular (b) profiles of the patella.
F
racture Types of the medial patella are most common [3, 5, 7, 8, 10, 14,
16]. It is suggested that parasagittal fractures of the medial
The majority of patellar fractures involve the articular sur- patella result from cranial impact with the stifle flexed. At
face. Complete fractures of the patella may be parasagittal this time, the patella is located in the trochlear groove of
or horizontal. Most parasagittal fractures involve the the femur and is forced against the large medial trochlear
medial one-third of the bone, but lateral fractures have also ridge [3, 6, 9, 17]. This is consistent with horses’ histories
been reported [3]. Incomplete fractures generally involve and supported by observations of contusion injuries on the
the articular surface and can be parasagittal or consist of medial trochlear ridge.
fragmentation of the articular margins. With all articular Horses with articular fragmentation can present with
fractures, comminution is common and fragments can be histories of traumatic incidents similar to parasagittal frac-
of varying sizes. Fractures involving the medial patellar tures, but this is not invariable. Extra-articular fragmenta-
fibrocartilage only are also encountered. Traumatic articu- tion is usually caused by kicks and therefore commonly
lar fragmentation can occur on all margins. Fragmentation involves the craniolateral aspect of the patella. It is fre-
of the distal articular margin is most commonly seen in quently accompanied by an open wound. Such lesions
association with upward fixation of the patella and medial commonly are contaminated and become infected.
patellar desmotomy. Non-articular fragmentation of the Sequestration can also occur.
cranial or proximal margins is occasionally seen. Fragmentation of the distal margin of the patella is usu-
ally a consequence of medial patellar desmotomy [18–20],
although it has been observed in horses with untreated
Incidence and Causation upward fixation of the patella [21]. It appears to be part of
an enthesopathy involving the origin of the middle patellar
Parasagittal and horizontal fractures of the patella are ligament [2], although degenerative change can extend
monotonic injuries and usually associated with external proximally into the subchondral bone of the patella [18,
trauma. The two most common aetiologies, determined by 19]. Altered loading appears to be causative, but whether
practice case load, are impact injuries when horses jump or this is a degenerative process or cumulative fatigue is
attempt to jump fixed obstacles [4–10] and kicks from unknown.
other horses [4–9, 11–14]. However, other impact trauma
including falls can also be responsible [4, 9, 14, 15]. Some
fractures of the medial pole (angle) have been described as Clinical Features and Presentation
avulsion injuries [16]. There is little evidence for this, and
the configurations illustrated are similar to those which are In the acute phase, lameness associated with complete par-
caused by impact trauma. Most fractures are closed but asagittal fractures is usually severe. Horses most commonly
concomitant contusions are common. Traumatic fractures are unable or are unwilling to extend the stifle. The limb is
can have variable configurations, but parasagittal fractures therefore maintained in a semi-flexed position [5, 6].
Treatmen 667
Initially, horses will usually make toe-only foot–ground Articular fragmentation can occur at any of the patellar
contact; later the sole may contact the ground, but the leg margins and is usually identified on LM or oblique radio-
will remain semi-flexed so that a ‘crouched’ posture is graphs. It is inconsistently profiled in skyline projections
maintained as the limb is loaded. Haemorrhage results in (Figures 31.5–31.7). Fragments from the articular margins
rapid onset distension of the femoropatellar joint. In com- of the patella can also displace (Figure 31.5).
plete fractures, this can soon be masked by haemorrhage Although displaced fragments may be seen in other radio-
into adjacent fascial planes, muscles and the subcutis result- graphic projections, non- or minimally displaced parasagit-
ing from traumatic contusion of the same and leakage from tal fractures are often only recognized in skyline radiographs.
the femoropatellar joint through the fracture plane. Before This is also necessary in order to establish fracture site and
soft tissue swelling develops, a deficit in the cranial (usually configuration, the presence of comminution and fragment
medial) surface of the patella can sometime be palpated and sizes. Limb positioning (flexion) in order to obtain these
in some cases there may be appreciable crepitus. Due to the images is frequently resented and requires sedation, analge-
aetiology of patellar fractures, skin wounds, excoriations sia, patience on behalf of personnel and sympathetic han-
and contusions are common [4]. Skin abrasions are more dling of the horse. Medial deviation of the distal limb, which
common than wounds. produces outward rotation of the stifle, can sometimes assist.
Most incomplete parasagittal fractures involve the artic- Concurrent impact injuries of the femoral trochlear ridges
ular (caudal) surface of the bone. Lameness is usually less (usually medial) are occasionally seen (Figure 31.2d) but can
severe. Distension of the femoropatellar joint is a consist- take several weeks to be identifiable radiographically.
ent finding, but there is usually substantially less peri-
articular swelling. Other sites of articular fragmentation
and fractures of the medial patellar fibrocartilage have a Ultrasonography
similar clinical presentation.
Ultrasonography can identify and delineate fractures of
Horizontally oriented fractures are rare, but when
the patellar fibrocartilage which may be primary or con-
complete they disarm the quadriceps apparatus. When
current with fractures of the bone. Ultrasonographic evi-
afflicted horses attempt to load the limb, there is hyperflex-
dence of avulsion lesions and desmitis of the lateral
ion of the stifle so that the horse appears to collapse on
collateral ligaments have been reported in three horses
the leg.
with parasagittal fractures of the patella, and therefore
merits evaluation [9].
Imaging and Diagnosis T

reatment
Radiography
Management of patellar fractures has recently been
A complete radiographic evaluation of the stifle is necessary reviewed [10]. It has been suggested that some marginal,
in all cases of trauma. This should include lateromedial particularly proximal (basal), fragmentation can be suc-
(LM), flexed LM, caudocranial, caudolateral–craniomedial cessfully managed conservatively [23], and this has been
oblique (CaL-CrMO), craniolateral–caudomedial oblique advocated for non-displaced fractures [6, 16]. There are
(CrL-CaMO) and flexed cranioproximal–craniodistal occasional reports of successful management of complete
oblique (skyline) projections (Figures 31.2–31.8). In addi- fractures [9, 16, 17], although most of these horses were
tion to the standard projection angles [22], subtle different not tested athletically. Additionally, fractures which at
beam angles and/or limb positions can sometimes highlight presentation in the acute phase may appear incomplete
lesions that may otherwise be unrecognized or poorly rec- and/or non-displaced can also displace days to weeks
ognized. Clinicians should also be aware that fractures can later [5]. In most cases, surgical intervention is considered
involve multiple bones: in particular, patellar fractures can to optimize outcome.
be accompanied by fragmentation of the trochlear ridges of Surgery has been recommended for parasagittal frac-
the femur [5]. Fragmentation of the origin of the lateral col- tures if the fracture gap is >5 mm or if there is articular
lateral ligament, identified in caudocranial projections, has malalignment [8]. As positive indications for surgery, these
also been reported [9]. Complete parasagittal fractures of are perfectly reasonable. However, the degree of displace-
the medial pole of the patella frequently distract medially ment is subjective and temporally dependent as fragment
(Figures 31.3, 31.4 and 31.8). This varies in degree, and distraction can be progressive. It should not therefore be
some lie abaxial to the medial trochlear ridge of the femur. considered absolute.
(a) (b)
(c) (d) (e) (f)
Figure 31.2 Fracture of the distal medial pole of the patella in a Thoroughbred yearling. Fracture (arrows) identified in LM (a), flexed
LM (b) and skyline (c) radiographs. (d) Fracture (arrows) viewed from a craniolateral arthroscope portal. Note concurrent impact injury
(arrowhead) on the adjacent medial trochlear ridge of the femur. (e) Fracture bed (arrows) following dissection and removal of the
fragment from its attachment to the medial patellar fibrocartilage (FC). (f) Articular surface of the fragment following removal.
also been reported following poor recovery from general

Subtotal Patellectomy and Removal anaesthesia in a horse with a fracture involving the medial
of Intra-Articular Fragments quarter of the bone. Pre-operative muscle pathology was
Fragments resulting from parasagittal fractures of the implicated as causative or contributory [5].
patella which involve up to one-third of the bone mass can The timing of surgical intervention is important [5, 6, 8].
be removed [5]. Fractures that involve greater than one- Sufficient time should be allowed for haemorrhage asso-
third of the axial dimensions extend into the inter-trochlear ciated with the fracture and traumatized soft tissues to
groove. On removal, there is no effective medial anchor cease, i.e. swelling should start to reduce. Non steroidal
and inadequate congruency between patella and femur to anti-inflammatory drugs (NSAIDs) are indicated to assist
maintain stability. Lateral muscular contraction can then but are also required as analgesics. Femoropatellar joint
result in lateral luxation or subluxation of the patella. The distension will not resolve, but peri-articular swelling
greatest risk is in recovery from general anaesthesia. should reduce substantially before surgery is
Luxation and subluxation are generally irreducible and undertaken.
catastrophic. Affected horses are distressed and unable to Horses are positioned in dorsal recumbency. This per-
load or effectively control the limb. Euthanasia is indicated mits arthroscopic evaluation of the femoropatellar joint
as soon as the condition is recognized. Lateral luxation has and guidance of surgery. Lateral recumbency with the
Treatmen 669
(a) (b)
Figure 31.3 Parasagittal fracture of the medial pole of the patella in a three-day event horse. (a) Skyline radiograph. (b) Fracture
(arrows) viewed from a craniolateral arthroscope portal demonstrating little disruption of the articular cartilage.
affected limb down [5, 6] is no longer recommended. Removal of intra-articular fragments in other locations
Initial arthroscopic evaluation of the femoropatellar joint generally involves similar initial arthroscopic evaluation of
and inspection of the fracture site are made from a con- the joint. Instrument portals are selected following percu-
ventional craniolateral arthroscope portal [3, 24]. taneous needle placement (Figures 31.5 and 31.6). These
Irrespective of the fragment size or surgical plan, compre- can be distal to the patella between or abaxial to the patel-
hensive examination is important to locate and remove lar ligaments or proximally into the suprapatellar pouch
displaced fragments and to identify and manage concur- (Figure 31.7) as determined by fragment location. The lat-
rent lesions. Instrument portals for these are made at ter requires perforation of quadriceps femoris which is tol-
appropriate sites determined by percutaneous needle erated well. Sometimes fragments from and fracture beds
placement. Fractures of the medial pole are usually in the proximal articular margin can be best visualized and
accessed via an instrument portal made at the cranial mar- accessed using suprapatellar arthroscope and instrument
gin of the medial patellar ligament. Instrumentation and portals, although this generally follows the use of an initial
techniques for dissection of intra-articular fragments from (standard) distal craniolateral arthroscope location. The
the distal medial margin have been described in a special- ideal arthroscope portal is proximolateral to the patella
ist arthroscopy text [24]. Following arthroscopic removal through the intermuscular septum between bicep femoris
of fragments, thorough evaluation of the fracture site is and vastus lateralis muscles [25].
important as all fragments may not readily be visible from Large full thickness parasagittal fractures completely dis-
a standard craniolateral arthroscope portal and can mis- arm the patellar attachment of the fibrocartilage and thus the
takenly be left in situ [9]. Inspection should include use of medial patellar ligament. The osseous fragment can be dis-
a craniomedial arthroscope portal (usually the previous sected from the fibrocartilage, but the authors’ preference is
instrument portal) in order to evaluate the more proximal to divide the medial patellar ligament immediately adjacent
aspects of the fracture plane (Figure 31.4e). to the fibrocartilage before removing this and the patellar
Fragments up to one-quarter the size of the patella have fragment en bloc. In most cases, the dissection at least can be
been removed entirely arthroscopically [3] (Figures 31.2 achieved arthroscopically which minimizes the requirement
and 31.4). This requires patient dissection and frequent use for open surgical exposure and more extensive soft tissue dis-
of motorized apparatus to clear the visual field. Large frag- section and thus reduces trauma. Once dissection is com-
ments can be removed piecemeal, sometimes after being pleted, an alternative to piecemeal arthroscopic removal,
divided with an osteotome and/or through an enlarged which is particularly applicable to large fragments, is removal
instrument portal. through a restricted open approach. The margins of the
(a)
(b)
(c) (d) (e)
Figure 31.4 Long-standing comminuted fracture (arrows) of the medial pole of the patella in a racing Thoroughbred. (a) LM and
(b) skyline radiographs. Osseous bridging (large arrow) of the cranial portion of the fracture, (c) arthroscopic appearance of the
fracture (arrows) visualized from a craniolateral portal, (d) the proximal portion of the medial patellar fibrocartilage (FC) was intact
and therefore preserved and (e) fracture bed (arrows) and articular deficit (D) viewed from a craniomedial arthroscope portal
following fragment removal.
Treatmen 671
(a) (b)
(c) (d) (e)
(f) (g)
Figure 31.5 Complex patella injury in a two-year-old Thoroughbred that includes fractures of the medial pole and lateral and
proximal margins with fragment displacement. (a) Caudocranial, (b) LM, (c) CaL-CrMO and (d) skyline radiographs with fragments
arrowed. Arthroscopic appearance of fractures from (e) medial, (f) lateral and (g) proximal margins.
(a) (b)
(c)
Figure 31.6 Fragmentation of the proximal lateral margin of the patella in an event horse. Fragments (circle) are visible on LM (a)
and skyline (b) radiographs. (c) Arthroscopic appearance of the site (arrows) viewed from a craniolateral portal. S: suprapatellar pouch.
f racture fragment can be marked under arthroscopic guid- Soft tissue trauma is generally sufficient, that in the authors’
ance by percutaneous needles (Figure 31.8). It is important opinions, peri-operative antimicrobial medication is justified.
that these are placed perpendicular to the skin. A short medial A degree of post-operative swelling is inevitable. This usually
incision can then be made slightly longer than the distance begins immediately after surgery suggestive of haemorrhage
between the needles, through the subcutaneous fascia and and can take multiple days or weeks to resolve. However, the
aponeuroses of sartorius and gracilis. Fluid will then emerge degree of swelling with the technique described is, in the
from the joint. The fragment can be grasped with bone hold- authors’ experience, substantially less than that resulting
ing forceps and dissected free from vastus medialis and any from conventional open approaches which, by necessity, are
remaining fibrocartilage or medial patellar ligament rem- both longer and require far greater dissection.
nants before being removed. All other fragments should be A direct open approach for removal of fractures of the
removed, and any necessary debridement of the parent bone medial pole of the patella was first reported by Colbern and
performed arthroscopically before the open approach is Moore [11]. In a subsequent series of 14 cases, one horse
made. Visibility through the open surgical wound is poor, and was euthanized in recovery from general anaesthesia due to
subsequent arthroscopy is generally futile. The open surgical lateral luxation. Two had pre-existing degenerative joint
wound is closed with absorbable material using a continuous disease and did not return to working soundness and 10
pattern. It is usually possible to close the sartorius/gracilis returned to athletic function at the same or higher level
aponeurosis and stifle fascia in separate layers followed by than pre-injury [5]. No surgical or post-operative complica-
subcutaneous/intradermal closure. The skin edges can then tions were encountered with arthroscopic removal of frag-
be apposed with stainless-steel staples. Arthroscopic portals ments, ranging from 1/8 to 1/4 of the size of the patella,
are closed with interrupted skin sutures in a routine manner. from four medial and one lateral parasagittal fractures. All
Wounds are protected by stent bandages secured by tension horses returned to their previous levels of work three to five
sutures to provide physical protection, relieve distracting months after surgery [3].
forces and apply counterpressure. Assisted recovery from Return to soundness occurs gradually during rehabili-
general anaesthesia is logical but of unproven contribution. tation. Most horses lose significant muscle in affected
Treatmen 673
Figure 31.7 Fragmentation of the (a) (b)

proximal articular margin of the patella in
an event horse. (a) Flexed LM radiograph
with injury site circled. (b) Enlarged image
from (a) with the fracture arrowed.
(c) Fracture site viewed from a
craniolateral arthroscope portal with the
probe introduced proximolaterally through
the suprapatellar pouch (S).
(c)
limbs, particularly quadriceps femoris. Recovery is aided is necessary to visualize the distal margins of the fracture
by active rehabilitation aimed at restoring muscle and to allow digital palpation proximally. Both are neces-
(Chapter 15). In the immediate post-operative period, sary to guide reduction. This is achieved by manipulation
horses that have had the entire medial pole and fibrocar- and application of large bone holding forceps [14].
tilage removed commonly walk with the stifle partially Alternatively, a glide hole can be prepared and an appropri-
flexed. However, with appropriate (NSAID) analgesia ately sized sleeve and pin inserted and then used to manip-
and controlled exercise, this gradually corrects: it is not a ulate the fragment into reduction. Surgeons should be
negative prognostic indicator. No horses appear to have cognisant that a combination of techniques may be neces-
developed fragmentation of the apex of the patella post- sary. Once the fracture has reduced, separate stab incisions
operatively despite functional loss of the medial patellar may be necessary for screw placement. Lag screw fixation
ligament which is difficult to rationalize in light of with 4.5 mm [15] or 5.5 mm [14] cortical screws have been
reports detailing such following medial patellar desmot- described. In adult horses, the latter are recommended due
omy [18, 19]. to their superior bending strength (Figure 31.9). As a sesa-
moid, the patella has no cortical compacta and washers are
recommended to prevent screw heads sinking into the
Repair of Parasagittal Fractures
bone [14, 15]. Accuracy of screw placement is enhanced by
Internal fixation is not commonly performed but should be the use of an aiming device (Chapter 8); a C-clamp has also
considered in horses with sagittal fractures that involve been used [14]. Hemi-cerclage wire has been used to stabilize
greater than one-third of the patella which are therefore repair [15]. In all circumstances, intra-operative radiography
not safe candidates for subtotal patellectomy. Dorsal is critical to assess fracture reduction and safe, appropriate
recumbency is recommended to allow medial and lateral implant placement. Wounds should be closed in layers;
access and for ease of intra-operative limb movement/posi- there is substantial independent fascial movement in the
tion. Extension facilitates reduction while flexion allows area. If the fascial planes and subcutis are not apposed
use of skyline radiographs to guide screw placement [14]. independently, closure will fail as soon as the horse moves.
Most fractures are accessed through a large curvilinear Following skin closure, stent bandages over sewn with ten-
(S-shaped) incision [14, 15]. Alternatively, a linear incision sion relieving sutures are recommended. Assisted recovery
can be made directly over the fracture guided by percutane- from general anaesthesia is also advocated. A pool system
ous needles and in theatre radiography. A cranial arthrot- is ideal for minimizing trauma to the surgery site but con-
omy, usually between middle and medial patellar ligaments, tamination of the wound is a concern. Inflatable mat or
(a) (b) (c)
(d) (e)
(f)
Figure 31.8 Displaced fracture of the medial pole of the patella that followed impact with a cross-country fence. (a) Skyline
radiograph. (b, d, and e) Arthroscopic images from a craniolateral portal. (b) Identification of the fracture (arrows) and attached medial
patellar fibrocartilage (FC). MTR: medial trochlear ridge of the femur. (c) Intra-operative photograph. The proximal and distal margins
of the fracture and the level of dissection of the FC are marked with percutaneous needles (arrows). The remaining needles permit
fluid egress from the suprapatellar pouch and lateral sulcus. (d) Arthroscopic view of the proximal two needles within the fracture
plane. (e) Fracture margins (arrows) with a proximal bridge of FC remaining following fragment removal. (f) Craniomedial arthroscopic
view of the fracture bed (FB) remaining FC and residual joint defect (D) at the end of surgery.
sling recovery systems are also good, but if these are not In the first reported repair of a parasagittal fracture,
available then head and tail ropes should improve control reduction could not be achieved until a medial patellar
and reduce trauma. desmotomy was performed [15]. These authors used
Arthroscopically guided reduction and fixation has been three diverging medial to lateral 4.5 mm cortex screws,
performed (Figure 31.10). this required good anatomic washers and hemi-cerclage wire. The horse received an
knowledge, substantial arthroscopically guided internal assisted recovery from general anaesthesia and was
fixation experience and three-dimensional stereotactic then cross-tied to prevent it from lying down for three
skill. With these caveats, the rewards that accrue from weeks. A further six weeks of box rest followed. The
accurate articular reconstruction and minimally invasive yearling was reported to be sound three months after
surgery are encouraging. surgery.
Transverse Fracture 675
(a) (c) (e)
(b) (d) (f)
Figure 31.9 Radiographs of a five-year-old Thoroughbred mare with a displaced sagittal plane fracture of the patella. Pre-operative
(a), LM and (b) skyline radiographs. Intra-operative LM (c) and skyline (d) radiographs following fracture fixation with two 5.5 mm
cortical screws placed with washers in lag fashion. The mare was maintained in a sling for 14 days post-operatively and then
introduced to hand walking. (e) LM and (f) skyline radiographs three months post-operatively demonstrating good fracture healing.
The mare was sound at the trot at this time. Source: Courtesy of Dr Fabrice Rossignol.
In a second report, two parasagittal fractures were in both cases, although the authors acknowledged the
repaired in adult horses [14]. One of these was commi- potential advantage of reinforcing repair with cranial ten-
nuted with the sagittal fracture close to the mid-point of sion band wires.
the patella and a second horizontal fracture dividing the
medial fragment. In both horses, repair was effected by
the insertion of 2 × 5.5 mm cortical screws with mediolat- Transverse Fractures
eral trajectories in lag technique. The transverse fracture
in the first horse was repaired with a proximal to distal Transverse fractures are most commonly complete and thus
oriented (6.5 mm) cancellous screw. Washers were placed disrupt the quadriceps apparatus. Although healing of
over the heads of all screws. Wound dehiscence occurred transverse fractures which do not disrupt the quadriceps
in one horse after it lay down 11 days following surgery. apparatus with conservative management has been inti-
The second case was kept in a sling for 14 days post- mated in the literature [6], this has not been the authors’
operatively to prevent this. Functional healing occurred experience.
(a) (b) (c)
(d)
(e) (f) (g)
(h) (i) (j)
Figure 31.10 Comminuted fracture in a warmblood foal. (a–c) Radiographs at presentation revealed a complex multiplanar fracture with
lateromedial and proximodistal displacement of fragments. (d) The fracture configuration was determined by computed tomography (CT).
(e–g) Arthroscopic images, (e) in the middle one-third of the patella, (f) arthroscopic probe used to manipulate fragments and create articular
congruency, (g) proximal margin of the fracture following application of reduction forceps, (h) intra-operative lateromedial radiograph with the
arthroscope in situ following screw placement. Reduction forceps remain in position. Spinal needles mark articular, cranial and proximal
margins of the bone. (i, j) Radiographs 13 days following repair with a single 4.5 mm cortical screw and washer demonstrating fracture stability.
Reference 677
Horses are operated in dorsal recumbency. This allows insertion of 2 × 5.5 mm cortical screws with distal to proxi-
biaxial access and facilitates extension which is necessary mal trajectories in lag technique. These were reinforced by
for fracture reduction. Soft tissue dissection should be two 1.6 mm wires placed around the screws over the cra-
minimized. Reduction is achieved by manipulation and nial aspect of the patella to create a tension band. Early
guided by intra-operative radiography and, if possible, fracture healing was documented radiographically, and the
arthroscopy. Large proximodistally oriented reduction horse was able to be used for riding one year after surgery.
forceps can assist in securing fragments [6]. Two or three
distal- to proximal-oriented 5.5 mm cortical screws have
been recommended [6]. Placement of a cranial tension Extra-articular Fragmentation
band is also indicated. This can be created with 1.25 mm
diameter orthopaedic wire [12] or application of bone Extra-articular fragmentation is relatively uncommon but
plates [8]. There are few reports in the literature and cor- is recognized and reported [4, 13, 16]. There is frequently a
porate experience is small. history of trauma. Lameness is usually less marked than in
In the first report, a displaced transverse fracture in a horses with articular fractures and characteristically there
Thoroughbred yearling was repaired in a cranial open is no distension of the femoropatellar joint. Treatment usu-
approach [26]. This was effected with 3 × 6.5 mm cancel- ally involves fragment removal [4, 13]. The timing of this is
lous screws with distal to proximal trajectories in lag tech- generally determined by presenting features, including the
nique. Reduction was incomplete and a fibro-osseous presence of wounds, contamination and/or infection and
union appeared to result. Nonetheless, a satisfactory clini- concomitant injuries.
cal recovery was recorded. These injuries carry a good prognosis. Two horses in the
A minimally displaced transverse fracture in a foal was original series of patellar fractures returned to work follow-
repaired with two oblique proximal to distal oriented ing surgery [4]. Other authors have reported a large proxi-
6.5 mm cancellous screws. The fracture healed, and the mal (basilar) fragment removed by an open cranial
animal was reported to have raced [17]. A third case report approach with the horse in dorsal recumbency. Dissection
described a comminuted transverse fracture in a three- from quadriceps femoris insertion was necessary. Following
year-old horse [12]. An open cranial surgical approach was debridement and wound lavage, closure was effected in
made with the horse in dorsal recumbency. Marginal com- layers. An uneventful recovery and favourable outcome
minuted fragments were removed. A C-clamp was used to were reported [13].
reduce the principal fracture, and repair was effected by
R
eferences
1 Getty, R. (ed.) (1975). Equine Osteology. In: Sisson and 8 Fowlie, J.G., Stick, J.A., and Nickles, F.A. (2012). Stifle. In:
Grossman’s the Anatomy of the Domestic Animals, 5e, Equine Surgery, 4e, 1419–1442. St Louis, Missouri: Elsevier.
255–348. Philadelphia: WB Saunders. 9 McLellan, J., Plevin, S., and Taylor, E. (2012). Concurrent
2 Wright, I.M. (1995). Ligaments associated with joints. Vet. patellar fracture and lateral collateral ligament avulsion
Clin. North Am. Equine Pract. 11: 249–291. as a result of trauma in three horses. J. Am. Vet. Med.
3 Marble, G.P. and Sullins, K.E. (2000). Arthroscopic Assoc. 240: 1218–1222.
removal of patellar fracture fragments in horses: five 10 Auer, J.A. and Kümmerle, J.M. (2018). Fractures of the
cases (1989-1998). J. Am. Vet. Med. Assoc. 216: 1799–1801. patella. Equine Vet. Educ. 30: 37–40.
4 Parks, A.H. and Wyn-Jones, G. (1988). Traumatic injuries 11 Colbern, G.T. and Moore, J.N. (1984). Surgical
of the patella in five horses. Equine Vet. J. 20: 25–28. management of proximal articular fracture of the patella
5 Dyson, S., Wright, I., Kold, S., and Vatistas, N. (1992). in a horse. J. Am. Vet. Med. Assoc. 185: 543–545.
Clinical and radiographic features, treatment and 12 Hunt, R.J., Baxter, G.M., and Zamos, D.T. (1992).
outcome in 15 horses with fracture of the medial aspect Tension-band wiring and lag screw fixation of a
of the patella. Equine Vet. J. 24: 264–268. transverse comminuted fracture of a patella in a horse. J.
6 Hance, S.R. and Bramlage, L.R. (1996). Fractures of the Am. Vet. Med. Assoc. 200: 819–820.
femur and patella. In: Equine Fracture Repair (ed. A.J. 13 Wilderjans, H. and Boussauw, B. (1995). Treatment of
Nixon), 284–293. Philadelphia: WB Saunders. basilar patellar fracture in a horse by partial patellectomy.
7 Walmsley, J.P. (2011). The stifle. In: Diagnosis and Equine Vet. Educ. 7: 189–192.
Management of Lameness in the Horse, 2e (eds. M.W. Ross 14 Vautravers, G., Brandenberger, O., Vitte, A., and
and S.J. Dyson), 532–549. St Louis, Missouri: Elsevier. Rossignol, F. (2018). Articular sagittal and medial
parasagittal patellar fracture repair using lag screws in 21 Fowlie, J.G., Richardson, D.W., and Ortved, K.F. (2019).
two mature horses. Equine Vet. Educ. 30: 31–36. Stifle. In: Equine Surgery, 5e (eds. J.A. Auer, J.A. Stick,
15 Aldrete, A. and Meagher, D.M. (1981). Lag screw fixation J.M. Kummerle and T. Prange), 1747–1777. St Louis,
of a patellar fracture in a horse. Vet. Surg. 10: 143–148. Missouri: Elsevier.
16 Dik, K.J. and Nemeth, F. (1983). Traumatic patella 22 Butler, J.A., Colles, C.M., Dyson, S.J. et al. (2017). Clinical
fractures in the horse. Equine Vet. J. 15: 244–247. Radiology of the Horse, 4e. Chichester, West Sussex: Wiley
17 Pankowski, R.L. and White, K.K. (1985). Fracture of the Blackwell.
patella in horses. Comp. Cont. Educ. Pract. Vet. 7: 23 Dyson, S. (1994). Stifle trauma in the event horse. Equine
566–573. Vet. Educ. 6: 234–240.
18 Gibson, K.T., McIlwraith, C.W., Park, R.D., and Norrdin, 24 McIlwraith, C.W., Nixon, A.J., and Wright, I.M. (2015).
R.W. (1989). Production of patellar lesions by medial patellar Diagnostic and Surgical Arthroscopy in the Horse, 4e,
desmotomy in normal horses. Vet. Surg. 18: 466–471. 175–242. Elsevier.
19 McIlwraith, C.W. (1990). Osteochondral fragmentation of 25 Vinardell, T., David, F., and Morisset, S. (2008). Arthroscopic
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20 Riley, C.B. and Yovich, J.V. (1991). Fracture of the apex of 26 DeBowes, R.M. and Chalman, J.A. (1980). Fractured
the patella after medial patellar desmotomy in a horse. patella in a horse. Equine Pract. 2: 49–53.
Aust. Vet. J. 68: 37–39.
679
32
Fractures of the Femur

A
natomy The distal femur is characterized by two large trochleae
separated by a groove, forming the gliding articular surface
The femur is the largest of the equine long bones. The fem- for the patella at the femoropatellar joint. The medial
oral head articulates proximally with the acetabulum of trochlear ridge is wider and extends more proximally than
the pelvis to form the coxofemoral joint. It is anchored in the lateral, providing a location for the medial patellar liga-
the acetabulum through the ligament of the femoral head ment to engage the stay apparatus. The medial and lateral
(also known as the round ligament) which extends from femoral condyles articulate with the proximal tibia and
the subpubic groove close to the acetabular notch and menisci to form the femorotibial joints. The intercondylar
inserts in the notch of the head of the femur. Unique fossa serves as the femoral attachment site for the cruciate
among domestic species, it is also secured in the acetabu- ligaments. An extensor fossa, located proximal to the lat-
lum by an accessory ligament, which originates from the eral condyle, is the origin of the long digital extensor and
prepubic tendon of the abdominal muscles, passes through peroneus tertius muscles.
the acetabular notch and inserts caudal to the ligament of The femur develops from four centres of ossification.
the femoral head in the notch of the head of the femur. The proximal femur has separate centres of ossification
A relatively short, wide neck connects the femoral head (and therefore physes) for the femoral head and greater tro-
to the proximal femur. The junction of the femoral neck chanter. The former closes at 24–36 months and the latter
and proximal metaphysis is characterized by a large, later- at 18–30 months. A distal physis is situated proximal to the
ally located greater trochanter with smaller cranial and trochlea and condyles and closes at 24–30 months of
larger caudal parts separated by a palpable notch. The cra- age [1]. A final separate centre of ossification is present for
nial part of the greater trochanter serves as the insertion for the third trochanter [2].
the deep gluteal muscle. The middle gluteal muscle inserts
on the larger, caudal part of the greater trochanter. The
smaller, third trochanter of the femur is located laterally at Proximal (Capital) Physeal Fracture
the junction of the proximal and middle thirds of the dia-
physis and serves as the attachment site for the superficial Incidence and Causation
gluteal muscle. Medially, at approximately the same level,
the minor trochanter serves as the insertion for the iliop- The proximal (capital) femoral physis was the most com-
soas muscle. mon fracture location in a retrospective evaluation of 67
The femur courses distocranially, often approaching a horses with 70 fractures affecting physes [3]. These
nearly vertical position, towards articulations with the occurred in 11 foals with configurations including four
patella and proximal tibia at the stifle. The diaphysis nar- Salter–Harris (SH) type I, four SH type II and two SH type
rows distally and has a marked supracondylar fossa located III fractures. Fracture of the femoral capital physis has not
caudolaterally. The largely tendinous superficial digital been reported in horses older than 16 months [3–6]. In
flexor originates from the supracondylar fossa under the another study of 25 capital physeal fractures, it was noted
course of the more proximal origin of the gastrocnemius that 56% were accompanied by other coxofemoral injuries,
muscle from the supracondylar tuberosities. including luxation and fractures of the acetabulum and

680 Fractures of the Femur
femoral neck [5]. Traumatic events such as a fall onto the which is highly suggestive of disruptive injury of the cox-
affected side, flipping over backwards or severe abduction ofemoral region. Depending on the duration of the injury,
of the limb are often reported. muscle atrophy may be appreciated. Rectal palpation,
when patient size and compliance allow, is unremarkable.
Clinical presentation can be variable. If examined in the
immediate post-fracture period, severe lameness is evident Radiographic evaluation provides a definitive diagnosis.
associated with acute pain and instability at the fracture The most complete, diagnostic images are obtained with
site. With separation at the physis, the proximal femur dis- the patient anesthetized for recumbent positioning.
places into the overlying musculature of the gluteal region. Ventrodorsal and oblique pelvic views are most diagnos-
This relationship limits the degree of displacement and pro- tic. In some instances, images obtained by standing radio-
vides a degree of stability that allows the patient to bear par- graphic examination can be diagnostic. This entails
tial weight on the limb once the acute fracture-associated positioning the image detector vertically against the
pain subsides. In many instances, this results in a delay in affected side of the pelvis with the X-ray tube angled
definitive diagnosis as dissipation in the degree of lameness approximately 30° ventrally from horizontal for evalua-
in the first few days following fracture gives a false impres- tion of the proximal femur and coxofemoral regions [7]
sion that the injury is resolving. (Figure 32.2a). Alternatively, a slightly oblique ventral to
On presentation, there may be swelling of the proximal dorsal projection can be obtained by placing the radio-
femoral region and crepitus may be palpable over the hip graphic image detector over the gluteal region and pro-
and or stifle regions as the limb is manipulated. The distal jecting the X-ray beam from beneath the horse while an
limb is often externally rotated due to contraction of the assistant holds the limb in abduction [8] (Figure 32.2b).
gluteal musculature through their insertions on the greater In the authors’ experience, the latter technique has been
trochanter [4]. Overall length of the fractured limb may more reliable in delineating injuries in the coxofemoral
appear shortened, with the tuber calcis proximal to the region. However, to fully appreciate the extent of injury if
unaffected limb, particularly when coxofemoral luxation is surgical repair is to be attempted, it is imperative to have
also present. Pelvic symmetry is typically altered, with the high-quality images, which are best obtained in the
tuber coxa appearing lower than the contralateral limb [5]. recumbent patient using general anaesthesia. As noted
Most notably, the greater trochanter of the affected limb is previously, a high percentage of capital physeal fractures
proximal to the contralateral limb (Figure 32.1). If swelling are accompanied by either fracture of the acetabular rim,
is substantial, this may be difficult to discern. However, in separation of the greater trochanter, subluxation or luxa-
many cases, deep palpation delineates the discrepancy tion of the femoral head or evidence of avascular necrosis
of the femoral head [5].
Additional imaging modalities include ultrasound and
computed tomography. With ultrasound, discontinuity of
the femoral neck or malalignment of the femoral neck and
head may be appreciated. However, ultrasound is associ-
ated with a significant risk of false negative results due to
the anatomic location of the fracture [4, 7]. Computed
tomography, when available, will provide the most sensi-
tive and specific images. If the patient can be accommo-
dated in the machine, this is the modality of choice.

The proximal location of these fractures precludes effective
temporary stabilization. Early surgical intervention to
reduce and stabilize the fracture should be considered in
patients who are candidates for repair. Important consider-
ations when selecting cases for repair include patient size,
Figure 32.1 Photograph of a weanling age foal with a left hind
capital femoral physeal fracture demonstrating more proximal fracture configuration, accompanying injury(ies), duration
location of the greater trochanter on the affected side. of injury and client expectations.
Proximal (Capital) Physeal Fractur 681
(a) (b)
Figure 32.2 (a) Photograph demonstrating the placement of the X-ray generator and image detector for acquisition of a lateral
oblique radiograph of the coxofemoral joint in the standing horse. (b) Photograph demonstrating the placement of the X-ray generator
and image detector for acquisition of a ventrodorsal oblique radiograph of the coxofemoral joint in the standing horse.
Physeal separation and coxofemoral luxation may also patient is small (less than 150 kg) with a Salter–Harris type
result in avascular necrosis of the femoral head [5]. It is not I fracture occurring within the past 48 hours.
uncommon for definitive diagnosis of a capital femoral Methods of transphyseal fixation include multiple
physeal fracture to be delayed which increases the risk of intramedullary pins, large cancellous bone screws, cortex
eburnation of the physeal margins and promotes muscle screws placed in lag fashion, cannulated screws and the
contraction and fracture displacement, all of which com- dynamic hip screw plate system [4, 5, 10, 11]. Intramedullary
plicate reduction and fixation. pinning does not provide compression and is often compli-
cated by pin migration with ongoing fracture instability in
the post-operative period. The 135° dynamic hip screw
plate system was evaluated in experimentally created fem-
Conservative management is contraindicated. This leads to oral capital physeal fractures in three foals aged five to
malunion, avascular necrosis of the femoral head and sec- eight months. Healing was confirmed on necropsy exami-
ondary osteoarthritis (Figure 32.3), and the resulting, nation three months post-operatively [10]. Use of large
chronic, profound lameness, muscle atrophy and supporting cannulated screws has been reported in five bulls aged
limb complications carry a grave prognosis for life [5]. seven months to two years and weighing 410–690 kg but
Femoral head and neck ostectomy (FHO) has been reported has not been evaluated in foals [11]. The main advantage of
as a salvage procedure for animals younger than 12 months 7.0 or 7.3 mm cannulated screws is that the screws are
of age and weighing less than 100 kg at the time of sur- placed over a prepositioned guide wire which maintains
gery [9]. In the authors’ experience in managing coxofemo- fracture reduction. However, the large cannula through the
ral luxation in mature miniature horses, FHO has been centre of the screw reduces the strength of the fixation and,
successful in restoring pasture soundness and would be in the authors’ experience, has been associated with screw
expected to provide a viable treatment option in ponies and failure when used for equine applications. Large cancel-
horses of small stature. However, in foals anticipated to grow lous and or cortex bone screws placed in lag fashion are the
to normal adult horse size, the likelihood of an acceptable implants most likely to provide reliable fixation.
outcome is poor, and FHO is not recommended [9].
The treatment of choice is prompt surgical repair, with
Surgical Techniques
open reduction to facilitate anatomic reconstruction and
transphyseal fixation. There are many limitations to con- The patient is positioned in lateral recumbency with the
sider when selecting patients for surgical repair. The ideal affected limb uppermost. Exposure of the greater trochanter
(a)
(b)
(c)
Figure 32.3 Capital femoral physeal fracture in a weanling age foal. (a) Ventrodorsal radiograph. Progressive avascular necrosis of
the femoral head (b) in a ventrodorsal radiograph two months later and (c) in a lateromedial radiograph after four months.
is accomplished with a curved skin incision, beginning cra- Prior to creation of the osteotomy, a 4 mm hole is prepo-
nial and dorsal to the greater trochanter, turning distally sitioned extending from the proximal aspect of the greater
just caudal to the greater trochanter and extending along trochanter into the proximal femoral medullary canal. A
the proximal femur beyond the level of the third trochanter. large curved forceps is used to pass an OB or Gigli wire, as
Subcutaneous fascia is incised and the superficial gluteal a saw, around the greater trochanter distal to the attach-
muscle is elevated, following transection of its tendon of ments of the middle and deep gluteal muscles, just proxi-
attachment on the third trochanter, exposing the lateral mal to the femoral neck. The trochanteric osteotomy is
aspect of the proximal femur. Exposure of the femoral neck created in a slightly dorsal to ventral direction producing a
and head is best accomplished by osteotomy of the greater cut deep enough to ensure that all muscular attachments
trochanter. remain with the trochanter. Care is taken to avoid the
Proximal (Capital) Physeal Fractur 683
f emoral neck when creating the osteotomy. The trochanter,

along with the attached gluteal muscles, is retracted dor-
sally to expose the femoral neck and coxofemoral joint.
Arthrotomy of the coxofemoral joint allows the surgeon
to visualize the femoral head, neck, and physeal alignment.
Implant selection is dependent on patient size and in gen-
eral should include the largest diameter screws possible. In
neonates, 4.5 mm screws may be preferred due to size limi-
tations of the proximal femoral epiphysis. In larger foals,
5.5 mm screws are recommended although 6.5 mm cancel-
lous screws with 16 mm threads can be considered. For
standard fixation using cortex screws in lag fashion, at least
one glide hole is predrilled from the lateral metaphyseal
region of the femur to the physeal fracture line, prior to
fracture reduction, to confirm central placement of the
screw in the physis and ensure maximal purchase in the
epiphysis once the screw is placed. As image-guided drill-
ing is not feasible, the surgeon must rely on tactile skill to
direct drilling. Preplacing the glide hole allows the surgeon
to make adjustments if needed prior to drilling the femoral
epiphysis. Fracture reduction is accomplished by manipu-
lating the limb, which can be challenging, especially as the
size of the patient increases and the duration between Figure 32.4 Lateromedial radiograph following capital femoral
physeal fracture repair in a three-month-old filly. Three 5.5 mm
injury and repair is extended. Once reduced, the fracture is cortex screws were placed in lag fashion to reduce and stabilize
compressed and stabilized by preparation of the thread the femoral head. A trochanteric osteotomy was performed to
hole and placement of an appropriate length cortex screw. allow surgical access and was repaired with screws and
It is advisable to complete hole preparation and screw orthopaedic cable to create a lateral tension band.
placement with a finger positioned in the coxofemoral joint
space to ensure that the screw does not penetrate the artic- Results
ular surface. Additional screws are placed adjacent to the The prognosis following femoral capital physeal fracture is
initial screw to create a rotationally stable fixation. A mini- guarded. Surgical repair is challenging for several reasons.
mum of two, and preferably three, cortex screws placed in Achieving and maintaining reduction can be difficult.
lag fashion are recommended. Washers should be applied Instrumentation is limited, and the relatively small and
to the screws to improve bone contact and to prevent the convex shape of the epiphyseal fragment (femoral head)
screw head from penetrating the relatively soft cortical limits screw purchase and increases the risk of inadvertent
bone. Prior to closure, the coxofemoral joint is manipu- articular impingement. These factors, combined with a
lated through its range of motion to ensure that the fixation lack of clear criteria for patient selection and potential for
is not impinging on the articulation. poor outcomes following surgical repair, mean that eutha-
The coxofemoral joint capsule is closed routinely. The nasia is often elected in lieu of reconstruction.
trochanteric osteotomy is repaired by tension band fixa- Conservative therapy has not produced acceptable out-
tion. Following repositioning and using the preplaced comes. In two reports, conservative therapy was attempted
hole for the initial screw to effect anatomic reduction, in a total of nine foals without success [5, 12, 13]. Five sepa-
two 5.5 mm cortex screws, with washers, are placed rate reports document transphyseal fixation in a total of 10
through the greater trochanter into the femoral metaphy- foals [4–6, 12, 13]. Stacked pin fixation was used in five
sis. Large gauge (1.25–1.5 mm) wires or orthopaedic foals, screw fixation in four and a dynamic hip screw plate
cables are used to create the tension band when placed system was used in one foal. Stacked pinning resulted in
between the trochanter and washer on the cortex screw successful fracture healing and long-term soundness in
and distally through a hole placed in the lateral cortex of three foals, aged two to four months and weighing 100–
the femur (Figure 32.4). The overlying soft tissues are 175 kg [13], and was unsuccessful in the other two foals
reconstructed in layers, and a stent bandage is sutured to which required euthanasia [5]. Multiple transphyseal screw
cover the incision. An adherent bandage is applied to fixation was successfully applied in two cases, a 250 kg don-
cover the stent bandage for anaesthetic recovery which key and a 70 kg foal [4, 6]. The foal treated with a dynamic
should be assisted. hip screw plate system was salvaged as pasture sound [5].
Diaphyseal Fractures Clinical Features and Presentation

Severe to non-weight-bearing lameness associated with
Incidence and Causation axial instability when attempting to place the limb are
Diaphyseal fractures are most common in young horses. In characteristic. Displaced fractures are typically accompa-
neonates, they are often the result of a direct blow to the nied by substantial, sometimes massive, swelling of the
thigh by a kick from an adult horse. There is often a small femoral region secondary to soft tissue injury and haemor-
wound in the region of the injury (Figure 32.5). In older rhage. The degree of swelling is often best appreciated by
foals, they are usually associated with free pasture turnout standing behind the patient and comparing widths of the
and caused by a fall onto the affected limb. The oblique to thigh on affected and unaffected sides. Additional findings
spiral configuration suggests that the limb has likely include a relatively shortened femoral segmental length
slipped underneath the body in adduction as the foal falls, when comparing the greater trochanter to stifle landmarks
resulting in a torsion-induced fracture. between limbs. Pain is produced when the area is palpated
and the limb is manipulated. Crepitus may be noted during
attempts at weight-bearing or when the limb is manipu-
lated; however, it can be obscured by soft tissue swelling
and overlying musculature.
(a) Haemorrhage associated with diaphyseal fractures can
be massive. Laceration of the femoral artery by the sharp
fracture fragments as well as medullary haemorrhage from
the fracture put patients at risk for haemorrhagic shock
and death.

Diagnosis is confirmed with radiographs. Standing radio-
graphic examination of the femur can be accomplished, but
obtaining adequate quality images can be challenging.
Images of sufficient quality to evaluate the full extent of the
fracture are best obtained with the patent under general
anaesthesia. A medial to lateral projection is obtained after
(b) (c) positioning the patient in lateral recumbency with the
affected limb down. The support limb is abducted out of the
radiographic field. A craniocaudal oblique may be obtained
with the patient in either dorsal recumbency or lateral
recumbency with the affected limb uppermost. In most
cases, the plate is positioned caudal to the thigh region, and
the radiographic projection is obtained in a slightly cranio-
lateral to caudomedial oblique direction. In the adult horse,
radiographic examination may be attempted in the stand-
ing, sedated patient but complete evaluation of the femur in
the standing horse may not be radiographically possible.
Ultrasound examination may aid in providing a diagnosis in
the adult horse when clinical signs are suggestive and radio-
graphic examination is not possible.
In the adult horse, the energy required to cause a dia-
Figure 32.5 A foal with a right diaphyseal fracture, (a) physeal femoral fracture typically results in substantial
anesthetized and positioned in left lateral recumbency. Clipping comminution (Figure 32.6). In young horses, diaphyseal
of the surgical site revealed a wound, which typically fractures are usually spiral or long oblique in configura-
accompanies a kick injury over the mid-diaphyseal region, (b)
tion with either a large butterfly fragment or smaller com-
caudocranial and (c) lateromedial radiographs of the foal,
demonstrating a displaced transverse mid-diaphyseal fracture minution along the fracture line (Figure 32.7).
consistent with a direct blow. Comminution of the caudal cortex is particularly
rhage. When repair is an option, it is advisable to take

measures to counteract blood loss and, in suitable cases, to
proceed to surgical stabilization immediately after the
diagnosis is confirmed.

Conservative management is not recommended. Support
limb complications are inevitable due to the protracted
period of severe lameness and limb dysfunction.
Additionally, if healing occurs, the resulting malunion is
not likely to produce a functional limb due to the degree of
malalignment and marked reduction in bone length that
results from overriding of the fracture fragments.
Attempting repair of diaphyseal femoral fracture in the
adult horse is contraindicated. Fractures are often exten-
sively comminuted, precluding anatomic reduction. In
addition, currently available implants are not able to pro-
vide adequate strength and stability for healing to occur
even in simple, reconstructible fractures.
In foals of appropriate size with simple, reconstructible
fractures, open reduction and internal fixation is recom-
mended. The goals of internal fixation are to anatomically
reconstruct the bone and provide a bone–implant construct
that is of sufficient strength and stability to enable early
use of the limb and minimize support limb complications.
The most robust implants available should be selected as
Figure 32.6 Lateromedial radiograph of a highly comminuted, implant failure remains a common post-operative compli-
displaced and overriding fracture in an adult horse. This fracture cation. Although there are reports of successful fracture
is not an acceptable candidate for internal fixation due to the healing after application of a single plate, double plate fixa-
highly comminuted configuration and large defects within the tion is recommended [14, 15]. Application of cranial and
caudal cortex. Furthermore, implants suitable for repair in an
adult horse are not available, even for an ideal fracture location lateral plates that span the diaphysis, and if possible, do not
and configuration. cross the distal physis, is recommended (Figure 32.8). If
crossing the physis is necessary to achieve adequate
important to discern. This carries a poor prognosis as any strength and stability of the construct, implant removal
fixation is likely to fail due to the mechanical effects of a may be required.
defect in this location. Displacement and overriding of the Intramedullary, interlocking nail (IIN) fixation, alone or
fracture fragments are often severe due to contraction of in conjunction with a bone plate applied to the cranial sur-
the substantial overlying musculature. However, open face of the femur, has been used to successfully manage
fractures are uncommon because the femur is deeply foals with diaphyseal fractures [16]. Attributes of this fixa-
invested by musculature. tion include ease of use, especially when used as the sole
implant for simple fractures in neonates. IIN constructs
have been shown to have less strength and stiffness com-
pared to double plate fixation in a femoral ostectomy gap
It is not possible to provide stability with emergency coap- model [17]. Nonetheless, the authors have had success in
tation. Inability to immobilize the joints proximal and dis- clinical patients with simple, reconstructible fractures.
tal to the fracture, the additional weight of the splint/ Criteria for case selection are not well defined, but
bandage and the effect of the reciprocal apparatus will patient size relative to fracture characteristics is important.
combine to exacerbate ongoing displacement of fracture The larger the patient, the greater the importance of a sim-
fragments. With immobility of the distal limb, the patient ple configuration, allowing anatomic reconstruction and a
is forced to attempt to use the limb which may intensify near mid-diaphysis location to provide adequate length for
soft tissue injury and exacerbate life-threatening haemor- implant purchase proximal and distal to the fracture. As a
(a) (b) Figure 32.7 (a) Lateromedial

radiograph in a weanling age foal
demonstrating a short oblique,
mid-diaphyseal fracture with minimal
comminution and no evidence of a
caudal cortex defect. In a patient of
appropriate size, this is a suitable
candidate for repair. (b) Lateromedial
radiograph in weanling age foal
demonstrating moderate comminution.
Additional radiographic projections and/
or intra-operative assessment are
necessary to determine surgical
candidacy.
general recommendation, foals with simple mid-diaphyseal

fractures weighing less than 250 kg are reasonable candi-
dates for repair using either double plate or IIN-plate con-
structs. Fractures that are metaphyseal are more complex
or in larger patients are less likely to have a successful
outcome.
Surgical Techniques
A lateral approach is used to expose the femur for open
reduction and internal fixation. The patient should be
secured to the operating table as significant manipulation
may be necessary during fracture reduction. Skin and sub-
cutaneous fascia are incised from the greater trochanter to
the lateral condyle of the distal femur. The fascia lata mus-
cle is incised, allowing identification of the intermuscular
septum separating the biceps femoris and vastus lateralis
muscles. When the two are separated in the region of the
fracture haematoma, digital manipulation effects separa-
tion along the appropriate fascial plane to expose the frac-
ture. If additional exposure is needed distally, the incision
may be extended through the lateral femoropatellar liga-
ment to allow a parapatellar femoropatellar arthrotomy.
Proximally, the incision can be curved cranially to allow
access to the trochanteric fossa if IIN fixation is to be
utilized.
Fracture reduction is made difficult by the extensive and
Figure 32.8 Post-operative lateromedial radiographic of a
mid-diaphyseal fracture repaired with cranial and lateral adherent soft tissues over the caudodistal femur and is
dynamic compression plates. Note lag screw fixation outside of compounded when fragment overriding is severe. Any sig-
the plates crossing the oblique fracture plane used to maintain nificant delay in surgery can further complicate realign-
alignment during plate application. Full and partially threaded
ment. Simple oblique fractures can be ‘walked’ into
6.5 mm cancellous bone screws were employed proximally. The
radiopaque marker of a closed suction drain placed intra- reduction by a combination of traction on the limb and use
operatively is apparent. of large reduction forceps to slide the fragments along the
plane of obliquity. Transverse fractures can be toggled into (a) (b)

reduction by elevating the fracture ends into the incision
and, with the fractured medial cortices in contact, gradu-
ally pressing the tented segments into alignment. In cases
complicated by comminution, the fracture should be first
reconstructed into two main fragments. This can be
achieved through the use of cortex screws placed in lag
fashion. If the screw position is likely to interfere with plate
placement, 3.5 mm screws, with the screw heads counter-
sunk so they are flush with the cortex, may be considered.
After the fracture is reconstructed into two main frag-
ments, final alignment is completed as described above.
However, comminuted fragments may not support the
forces needed to achieve alignment and either re-displace
or fragment further, complicating reconstruction of the
boney column.
After reduction in double plate fixation, the lateral plate
is typically applied first followed by the second plate to the
cranial cortex. For neonates and small foals, two broad
locking compression plates (LCPs) are appropriate unless
the fracture has a complex configuration or involves the
metaphyseal regions. In these instances and in large foals, Figure 32.9 Post-operative lateromedial (a) and caudocranial
more robust implants such as a laterally placed dynamic (b) radiographs of a short, oblique mid-diaphyseal fracture with
an ILN fixation augmented with a single cable wire cerclage.
condylar screw plate (DCS) should be used. Plate fixation Antimicrobial impregnated PMMA beads are visible adjacent to
should be accomplished using 5.5 mm cortex and/or the fracture; skin staples are also present.
5.0 locking screws to achieve the strongest, most stable,
and fatigue-resistant construct possible. When obliquity of (a) (b)
the fracture allows, cable cerclage should be utilized to
augment the repair.
Placement of the plate on the lateral cortex is straightfor-
ward noting that in the distal metaphysis the supracondylar
fossa with the tendons of origin of the superficial digital
flexor and gastrocnemius muscles should be identified and
the plate positioned appropriately. Application of the cra-
nial plate can be challenging, especially in large foals with
substantial overlying musculature. Access for drilling and
placing the screws in a cranial to caudal orientation through
the plate is restricted by the vastus lateralis muscle. Forceful,
leveraged retraction as well as working through stab inci-
sions in the muscle will be necessary. Connecting two drill
guides assists with appropriate orthogonal orientation
when preparing holes for locking screws.
Intramedullary, IIN fixation may be used alone in small
foals with simple, mid-diaphyseal fractures that allow
interlocking of three, 5.5 mm cortical screws proximal and
distal to the fracture [18] (Figure 32.9). If fracture configu-
ration or location preclude bicortical purchase with three
interlocking screws in the proximal and distal segments, or Figure 32.10 Post-operative lateromedial (a) and caudocranial
in large foals, IIN fixation is supplemented with a cranially (b) radiographs of a short oblique, mid-diaphyseal fracture with
applied bone plate [16] (Figure 32.10). a butterfly fragment repaired with an ILN and cranially applied
LCP in a four-month-old Quarter Horse filly weighing 195 kg.
The high risk and catastrophic consequences of infection Additional cerclage wires and cables are present. Antimicrobial-
following open reduction and internal fixation of most impregnated PMMA beads are evident adjacent to the fracture
long bone fracture repairs support the use of antimicrobial and skin stables are present.
impregnated polymethylmethacrylate (PMMA). It can be infection occurred in the majority of cases that failures.
mixed patient-side and applied around the plates and screw The propensity for post-operative seroma formation was
heads, or alternatively beads, which have been pre-made considered a major contributor.
and sterilized can be placed alongside the implants to pro- Success was reported for two foals managed with double
vide high, sustained levels of antimicrobial to the surgical plate fixation using locking technology. Despite superior
site (Chapter 14). Closure should be performed in multiple stability, partial construct failure occurred in both fractures
layers. When distal exposure has been utilized, particular repaired by double LCP application although successful
care is needed to appose the fibrous parapatellar tissues fracture healing occurred despite this [22].
with an interrupted tension-relieving suture pattern. A In a series of 16 diaphyseal fractures in foals weighing
number of surgeons recommend placement of an active less than 250 kg repaired with an IIN or IIN and cranially
drain during closure because soft tissue trauma is severe, applied bone plate, 14 survived to discharge. Nine were
and there is a high risk for seroma or haematoma forma- available for long-term follow-up, with five used as
tion. However, the authors do not routinely use them. A intended, three as broodmares and one for pleasure
stent bandage is sutured over the incision for protection riding [16].
and to provide pressure. An impermeable, iodine-
impregnated adhesive drape is applied to cover the stent
bandage for recovery. Post-operatively, a minimum of Distal Physeal Fractures
8–12 weeks of strict stall rest is recommended determined
by the stability of the bone–implant construct and the Incidence and Causation
patient’s post-operative progress.
Implant removal is generally not recommended, unless The distal femur is not a common site of physeal fracture in
there is evidence of implant infection or it has been neces- foals. Fractures of the distal femoral physis occurred in
sary to span the physis with the implants. Removal can be only 7 of 70 physeal fractures, in horses of 5–18 months of
challenging and requires substantial soft tissue dissection age [3]. However, in a report of femoral fractures in 38
for access. horses less than one year of age, 13 involved the distal phy-
sis [20]. Their mean age was older (2–12: mean 6.7 months)
than those with a diaphyseal fracture (1 day to 11 months:
Results mean 3.25 months) [20]. They result from trauma, with a
Early reports of attempts at femoral fracture repair demon- fall or severe adduction of the limb reported in observed
strated the requirement for optimal stability and strength of fractures [20]. Salter–Harris type II, III and IV fractures
the bone implant construct. Attempts at repair in five neona- have all been reported [3, 20, 23].
tal foals with stacked intramedullary pins (two), Venables
plates (two) and a single broad dynamic compression plate Clinical Features and Presentation
(DCP) (one) all resulted in failure within 10 days of sur-
gery [19]. Since then, more robust and specialized implants Fracture of the distal femoral physis typically results in an
have been used including DCP, LCP, IIN, DCS plating, cobra acute, non-weight-bearing lameness often accompanied by
head plates and distal femoral plates [15, 20–22]. extensive soft tissue swelling of the stifle region. Displaced
Biomechanical testing of an in vitro femoral gap model, SH type II fractures will also exhibit axial instability, which
where there was no contact at the osteotomy site and is variable in type III and IV fractures. In cases of minimally
implants alone were loaded, demonstrated that application or non-displaced fracture, the clinical signs are less severe.
of two DCPs in lateral and cranial positions resulted in supe- Physical examination may reveal evidence of reduced femo-
rior strength and stiffness in bending and torsion compared ral length (displaced SH type II fracture) or an appearance
to IIN and IIN and cranially applied DCP constructs [17]. of upward patellar fixation. Manipulation usually elicits
To date, the most comprehensive study of plate fixation pain and crepitation. Morbidity associated with laceration
detailed the results of 16 diaphyseal fractures in horses less of major vessels and haemorrhage from the medullary cav-
than one year of age. Eight fractures successfully healed ity are of less concern than in diaphyseal fractures.
with double plate fixation, seven patients with two broad
DCPs and one patient with a broad DCP and angled blade
plate [20]. Patients with successful outcomes had a mean
age of two months, compared with a mean age of four Radiographic evaluation defines fracture location and con-
months for the unsuccessful cases, highlighting the signifi- figuration. The most common configuration is a SH type II
cance of age and size on prognosis [20]. Surgical site fracture. In one report, five of seven were classified as SH
Distal Physeal Fracture 689
type II, and one each of type III and IV fractures. The meta-
physeal spike occurred medially in two horses, caudally in
two and cranially in one horse with SH type II fractures. The
lateral femoral condyle was involved in the SH type III and IV
fractures [3]. In another study of 38 horses aged less than one
year of age with femoral fractures, nine were classified as SH
type II fractures, three were type IV and one was a type III
fracture [20]. In this group, most metaphyseal spikes in SH
type II fractures were medial while in type IV fractures the
metaphyseal component was caudal. In type III fractures, the
lateral condyle was most commonly affected [3, 20].

Similar to diaphyseal fractures (“Acute Fracture Management”
section), attempts at emergency coaptation are contraindi-
cated due to the likelihood of increasing displacement and
exacerbating damage to the physis, articular cartilage (SH
type III and IV fractures) and surrounding soft tissues.

Non- or minimally displaced fractures may be candidates
for conservative management when sufficiently comforta-
Figure 32.11 Photograph of a horse managed conservatively
ble to allow acceptable weight-bearing, otherwise support- for a distal femoral physeal fracture demonstrating contraction
ing limb complications are likely. Repeated radiographic in the affected leg and severe angular deformity in the
examination is recommended to ensure that the fracture supporting limb.
does not become displaced. Conservatively managed ani-
mals usually require three to six months of stall confine- sually not provide adequate purchase in the distal frag-
u
ment with analgesia provided by judicious use of ment. This has led to the use of DCP, dynamic hip screw
non-steroidal anti-inflammatories on an as needed basis. plate and other specialized implants (cobra head plates,
Following this, a rehabilitation programme with gradually angle blade plates and condylar plates) (Chapter 8) to aug-
increasing restricted and/or controlled exercise is recom- ment fixation in the epiphyseal segment (Figure 32.12).
mended as determined by fracture healing. Animals are positioned in lateral recumbency with the
If the fracture is displaced, open reduction and internal affected limb uppermost. The femoral diaphysis is exposed
fixation is recommended as conservative management will as previously described (“Surgical Techniques” section),
inevitably result in protracted lameness, malunion or including division of the lateral femoropatellar ligament
non-union, stifle osteoarthritis and flexural contracture in and lateral parapatellar arthrotomy of the femoropatellar
the fractured limb. Consequential support limb complica- joint. Patellar luxation allows access to the femoral con-
tions, including angular deformity and digital hyperexten- dyles. Reduction is made difficult by the extensive and
sion, are almost inevitable (Figure 32.11). In many adherent soft tissues over the caudodistal femur and con-
instances, the size of the patient and distal location of the traction of muscles traversing the caudal aspect of the stifle.
fracture preclude a bone–implant construct of sufficient In SH type II fractures, the resultant cranial angulation at
strength and stability to attempt repair, and the patient the physis and fracture displacement can be very difficult to
should be euthanized. reduce and may require substantial leveraged distraction to
bring the fragments into alignment. Intra-operative imag-
ing is also challenging which makes confident assessment
Surgical Techniques
of articular reduction in type III and IV fractures difficult.
Internal fixation requires the use of specialized implants In type II fractures, double plate fixation is necessary to
that allow enhanced purchase in the relatively short, distal provide adequate strength and stability to encourage
femoral epiphysis. Fixation with standard plates will weight-bearing and allow fracture healing. To achieve the
(b)
(a)
(d)
(c)
Figure 32.12 (a) Lateromedial radiograph of a displaced SH type II distal femoral physeal fracture in a seven-month-old Quarter
Horse colt weighing approximately 115 kg: the metaphyseal spike is caudal. (b) Post-operative lateromedial radiograph demonstrating
repair with a cranially applied LCP and modified condylar plate laterally. Antimicrobial-impregnated PMMA beads are apparent
adjacent to the fracture. Skin staples and radiographic markers in the gauze stent bandage are also visible. (c) Post-operative
caudocranial radiograph. (d) Photograph of a condylar plate (left) and modified condylar plate (right) as used in the repair.
strongest and most stable construct, specialized implants patella. Therefore, the distal end of the plate must be posi-
are advisable. A DCP can be placed laterally, with the large tioned at the proximal aspect of the trochlear groove.
dynamic condylar screw plate distal to the physis. A LCP Fixation into the femoral epiphysis requires distal screws to
with a modified end, such as the distal condylar LCP, is an be angled across the physis towards the condyles of the
alternative. Both plates provide enhanced purchase in the femur. A dynamic hip screw plate with the 135° dynamic
distal femoral epiphysis. The cranial plate cannot be placed hip screw is one alternative for this location. Other options
distally onto the epiphysis due to the trochlear groove and include standard plate fixation using cortex screws to angle
Fractures of the Third Trochante 691
into the condyles. In all cases, the largest possible screw size were treated conservatively and two were treated with
(orthogonal 5.0 mm locking head screws and angled 5.5 mm internal fixation. Of the four in which treatment was
cortex screws) should be used to affix the implants to the pursued, two were euthanized or died and two remained
femur. lame [12].
The high risk and catastrophic consequences of infection It has been the authors’ experience, in a low number of
support the use of antimicrobial impregnated PMMA. cases, that prognosis is affected by the ability to achieve
Closure is routine, with particular care to appose the adequate reduction, a stable bone–implant construct and
fibrous parapatellar tissues with an interrupted tension- rapid return to comfort to preserve the supporting limb.
relieving suture pattern. If considered contributory, an Because of its location adequate protection of the incision
active drain can be placed during closure. A stent bandage is challenging, and when this is combined with the high
is used to protect and apply pressure over the incision. This incidence of seroma formation, there is a substantial risk of
can be protected by an impermeable, iodine-impregnated incisional infection and dehiscence. As a consequence of
adhesive drape for recovery. Post-operatively, a minimum the relatively high complication rate and poor prognosis
of 8–12 weeks of stall confinement is usually required but for long-term soundness following open reduction and
this varies according to fracture configuration and con- internal fixation, particularly in older, heavier foals, many
struct stability. are euthanized following diagnosis.
In contrast to diaphyseal fracture fixation, implant
removal may be considered. Implants that cross the
physis should be removed if there is substantial remain- Fractures of the Third Trochanter
ing growth potential after fracture healing and if it
appears the physis has not fused. It should be noted that Incidence and Causation
physeal trauma from the fracture and fixation may Fractures of the third trochanter are uncommon; however,
result in femoral length disparity with or without its superficial location and function as a tendinous insertion
implant removal due to epiphysiodesis. While this may site make it vulnerable to injury. At one hospital, eight frac-
affect the ability of the patient to achieve elite perfor- tures of the third trochanter were identified over a 12-year
mance, if the disparity is not severe, most horses are period representing 0.05% of orthopaedic referrals [24].
able to adapt to the shortened femoral length by While rarely observed, some have been seen to occur
straightening the angles of the stifle and tarsus to re- after a fall, trauma to the upper hind limb or after exercise.
establish functional limb length. The risk of these com- It appears fractures may have monotonic or fatigue-related
plications must be weighed against the risk of implant aetiologies. Some authors have suggested that third tro-
removal which will entail further major surgical chanter fractures are more common in young horses,
intervention. while others have reported them in horses aged from 3 to
27 (median 9.5) years [24, 25]. As the third trochanter
Results serves at the tendinous insertion site of the superficial glu-
teal muscle and tensor fascia lata muscle (in some horses),
There are no sizable case populations comparing therapeu- it has been suggested that high-speed exercise may also
tic options for the various fracture configurations. result in injury without fracture at the tendinous
Conservative management has resulted in success, defined insertions [24].
as achieving expected levels of performance, in two of
three foals, one each SH type II and IV fractures. The third
foal with a SH type III fracture was able to be used for light
pleasure riding despite the development of slight tarsal val- Monotonic injury to the third trochanter typically results
gus in the support limb [20]. in an acute, moderate to severe lameness. There may be
Open reduction and internal fixation of distal femoral soft tissue swelling of the femoral region, crepitus, or in
physeal fractures appears to carry a poor to grave prog- more protracted cases, gluteal muscle atrophy. As the his-
nosis. Available literature includes only two reports with tory and clinical findings may be suggestive of a pelvic frac-
limited numbers of cases and does not provide details of ture, the clinician should examine both regions in all
fracture configuration or additional information that horses in which a pelvic fracture is suspected.
may have affected the outcomes. In the first, only one of Exercise-related fractures usually present with less dra-
two repaired distal femoral physeal fractures survived to matic clinical signs and are found as part of lameness
discharge [20]. In the other which described seven frac- investigations. They appear most common in racing
tures, three were euthanized prior to any treatment, two Thoroughbreds.
Imaging and Diagnosis Healing is thought to be by fibrous union with the frac-
ture line remaining indefinitely on ultrasound and radio-
Nuclear scintigraphy is helpful in directing further investi-
graphic examinations. Increased radiopharmaceutical
gation in the region of the third trochanter and is often per-
uptake (IRU) may also persist, although this appears to
formed as an initial diagnostic modality when localizing
be inconsistent in the few horses that have had repeated
findings are lacking. Alternatively, it may be performed
examinations, with one horse having more intense IRU
after ultrasound to corroborate significance.
seven months and one horse having reduced, but persis-
Ultrasound or nuclear scintigraphy are often the initial
tent IRU at nine and 12 months post-injury [25].
diagnostic methods performed when a third trochanter or
pelvic fracture is suspected. Both modalities allow the ben-
efit of concurrent evaluation of the femoral and pelvic
regions. A complete diagnostic evaluation of both regions ractures of the Supracondylar
F
is also important to rule out those with concurrent tro- Tuberosity/Gastrocnemius Muscle
chanter and pelvic fractures. Ultrasonic evaluation is Avulsion
straightforward and is recommended [24]: it also allows
examination of the soft tissue for identification of fracture Incidence and Causation
haematoma and tendinous or muscular trauma.
Avulsion fracture of the supracondylar tuberosity has been
Radiographic examination can be challenging as
identified concurrent with gastrocnemius muscle injury.
unconventional views are necessary to image the area.
The injury has been most frequently reported in foals fol-
When third trochanter injury is suspected or confirmed
lowing dystocia or assisted delivery but has also been asso-
by another diagnostic modality, an oblique radiographic
ciated with unassisted parturition [26]. The traction and
projection, described by some authors as a 50° cranial
distraction forces required to deliver a hip-locked foal may
30° lateral to caudomedial oblique and others as a 25°
result in a higher incidence among those foals. The injury
oblique, obtained in the standing sedated patient can be
is thought to result when the tarsus is in flexion and the
useful [24, 25].
stifle is extended [27]. In the adult horse, injury is thought
to occur from forceful extension of the limb or direct
Acute Fracture Management trauma [28]. While gastrocnemius muscle injury most
often occurs at the musculotendinous junction, osseous
In reported cases, the period between fracture and presen-
avulsion of the supracondylar tuberosities can also be
tation varied greatly from the day of injury to four
present.
months [24, 25]. When diagnosed in the acute stages, stall
rest and anti-inflammatories are expected to result in sig-
nificant improvement in lameness within two weeks.
Foals present shortly after birth with soft tissue swelling
proximal to the tarsus, lameness and caudal reciprocal
Non-invasive management is recommended. Rest and apparatus dysfunction. They are often unable to rise and
rehabilitation programmes begin with at least one month have stifle joint distension. Partial tears of the gastrocne-
of strict stall rest and judicious use of systemic anti- mius muscle or tendon result in a hyperflexed (dropped)
inflammatories. Thereafter, a slow return to exercise is hock with extension of the stifle.
recommended, often over a period of three to six months. While clinical signs in the foal are often localizing,
adult horses can present a diagnostic challenge. Affected
horses may demonstrate lameness (AAEP grade 2–3/5)
Results
and gait abnormality, characterized by an inward rotation
Time for return to use has varied between reports. One of the toe and outward rotation of the calcaneus with
group reported seven of eight horses returning to function hyperflexion of the tarsus during the weight-bearing
one to six months after the onset of clinical signs [24]. phase of the stride [28]. Distension of the femorotibial
Others have found a longer (median 12 month) rest and joints is often present. Upper hind limb flexion may exac-
rehabilitation programme was necessary, with only 50% of erbate the lameness. Intra-articular anaesthesia of the
those with follow-up returning to their previous level of distended femorotibial joints does not significantly
use [25]. improve the lameness.
Fractures of the Femoral Condyle 693
Imaging and Diagnosis Results

In most cases, ultrasound confirms disruption of the Of 28 foals with gastrocnemius disruption, only one had
gastrocnemius musculotendinous junction within the radiographic evidence of avulsion fracture of the supracon-
supracondylar fossa. Discontinuity of the osseous mar- dylar fossa. The foal was managed with a sleeve cast for
gin of the supracondylar tuberosity may also be appar- 28 days, and while the authors did not comment on out-
ent. Radiography is used to confirm the presence of an come specific to this foal, 82% were able to undergo training
avulsion fracture. Lateromedial projections are often or start a race following treatment. The presence of concur-
most informative but when suspected should be centred rent disease was significantly associated with a reduced
immediately proximal to the stifle joints with careful likelihood to train or start a race [26]. This is in contrast to
scrutiny of the caudal cortex of the femur. A non- previously published outcomes of six foals with rupture of
weight-bearing flexed lateromedial projection with the the gastrocnemius muscle, of which three were treated for
cassette placed as far proximally as possible can be use- severe muscle tears. Only two survived to discharge and
ful. A caudal 45° medial–craniolateral oblique radio- neither achieved athletic function as an adult [27].
graph skylines the supracondylar tuberosities for Three of four adults treated with stall rest alone for gas-
evaluation of the most common location for avulsion trocnemius muscle injury returned to athletic function and
fragments [29]. Soft tissue swelling is commonly identi- the fourth had significantly improved before it was eutha-
fied radiographically. nized for other reasons [28]. A case report documented a
In cases without localizing clinical signs, nuclear scin- Thoroughbred racehorse with a history of gastrocnemius
tigraphy is often informative and reveals an area of IRU muscle injury and avulsion fracture from the caudal femur
in the caudodistal femur, in the region of the origin of that developed lameness in the affected limb as a two-year
the gastrocnemius muscle. Subsequent radiographs often old in training highlighting the potential for recurring
reveal soft tissue swelling and may demonstrate rough- lameness even after a prolonged period [29].
ening of or avulsions from the supracondylar
tuberosities.
Fractures of the Trochlear Ridges
Acute Fracture Management Fractures of the trochlear ridges are uncommon. They usu-
ally result from impact trauma and may be accompanied
Foals with gastrocnemius muscle injury and femoral avul-
by wounds. Although only small numbers have been docu-
sion fractures should be carefully examined for concurrent
mented, the lateral trochlear ridge appears most commonly
illness. Among 28 foals diagnosed with gastrocnemius dis-
affected. Most fragments are amenable to arthroscopic
ruption, 61% had comorbidities. Eleven percent had acute
removal [30] using techniques described for similarly
blood loss sufficient to necessitate treatment due to disrup-
located osteochondrotic lesions [31]. There is follow-up on
tion of the gastrocnemius vasculature or popliteal
only three cases in the literature in which all returned to
vessels [26].
and sustained athletic function [30].
Fixation of large reducible fragments of the lateral troch-
lear ridge with 3.5 mm screws in lag fashion has been
recorded. The authors emphasize the need to countersink
Reports of significant blood loss following gastrocnemius the heads below the articular surface in order to avoid
disruption highlight the importance of limb stabiliza- impingement damage to the patella [32].
tion [27].The goal of treatment is to immobilize the limb in
a weight-bearing position during healing. External coapta-
tion should be used as needed to allow use of the limb. In Fractures of the Femoral Condyles
foals, a dorsally applied splint or tube/sleeve casts are pref-
erable to full-limb casts that incorporate the foot to allow Genuine fractures of the femoral condyles are uncommon.
axial weight-bearing and minimize development of flex- Impact injuries and jumping falls have been implicated [32].
ural deformity. Adult horses have been managed success- There are anecdotal reports of small fragment removal using
fully with stall rest alone for not less than six weeks, as standard arthroscopy approaches [31] and repair of large
determined by clinical progress, followed by a gradual reducible fractures [32]. A single case report documents
return to exercise [28]. removal of a large caudal medial fragments in an adult [33].
vulsion Fractures of the Cranial

A positive contributions to management with the amount of
Cruciate Ligament cranial cruciate compromise being the primary determi-
nant of lameness, severity and prognosis.
This uncommon injury has been recognized in adult
horses [34] and in foals. Inaccessibility appears to preclude
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697
33
Fractures of the Pelvis

R.C. Pilsworth1 and P.H.L. Ramzan2
1
2
Rossdales Equine Practice, Newmarket, UK
Anatomy and Biomechanics female. The pelvic outlet of the female is also proportionally
larger than that of the male [1].
The pelvis is made up of the paired os coxae which meet on The sacrum completes the bony pelvic girdle, and the dor-
the ventral midline at the pelvic symphysis. Each os coxa sal face of its slightly convex wings articulates with the
comprises the ilium, ischium and pubis that are usually underside of the iliac wings by means of the sacroiliac joints.
described as anatomically distinct, but in reality fuse early The sacral surface of these broad, flat attachments is hyaline
in life. The pelvis articulates with each hindlimb at the cartilage, while the iliac surface is fibrocartilage. The joints
acetabulum (the pelvic side of the coxofemoral joint) and are stabilized by a tight fibrous joint capsule as well as pairs
with the axial skeleton at the paired sacroiliac joints. of strong ventral and dorsal sacroiliac ligaments.
The largest of the pelvic bones is the ilium. Cranially, the The pelvis supports several strong groups of muscles that
ilium is wide and irregularly triangular, with a smooth con- are crucial to locomotion. The large dorsal mass of the mid-
cave gluteal (dorsal) surface and a convex pelvic surface. dle gluteal muscle assists in hip extension and limb abduc-
This iliac wing is continued caudally by the constricted, tion; the cranial muscle group, comprising sartorius, rectus
prismatic iliac shaft which meets the pubis and ischium at femoris, iliopsoas and tensor fasciae latae, produces hip
the acetabular angle. The dorsal border of the caudal iliac flexion and limb protraction; and the caudal muscle group
shaft and acetabular angle is a prominent ridge called the of biceps femoris, semimembranosus and semitendino-
ischiatic spine. The most dorsal (and axial) point of the iliac sus result in hip extension and limb retraction. Muscles of
wing is the tuber sacrale, which sits close to midline adja- the medial thigh (gracilis, pectineus and adductor) that
cent its contralateral counterpart. The lateral angle of the attach to the pelvic symphysis/pubis adduct the limb and
iliac wing is the tuber coxa, which presents as a prominent also flex the hip. Significant mechanical support for these
subcutaneous promontory. muscles is derived from thick fascial coverings and
The posterior part of the ventral pelvis is formed on each septae.
side by the ischium. This component of the os coxae extends Several neurovascular structures have a close association
from the acetabulum caudally to the tuber ischium; the lat- with the bony pelvis. Most important of these in relation to
ter tuberosity serves as a prominent attachment for the cau- fracture outcome are the iliaco-femoral vessels that traverse
dal thigh musculature. The anterior part of the ventral pelvis the underside of the iliac shaft, lying in vascular grooves on
is formed by the smallest of the pelvic bones, the pubis; the the surface of the bone.
pelvic surface of this bone is generally smooth although The equine pelvic girdle is not a rigid structure, and repeti-
irregular eminences may be present along the pubic symph- tive deformations arising from forces of locomotion are the
ysis in the mature horse. The posterior border of the pubis underlying basis for the development of stress injuries.
forms the front margin of each obturator foramen. In the Although the sacroiliac joints are considered low-motion artic-
mature horse, there are differences between the sexes in ulations, they undergo translational movements in response to
some pelvic dimensions; in the female, the iliac shaft is limb loading; at canter, the pelvis rotates anticlockwise or
longer and the posterior pubis narrower than in the male, clockwise when the lead or trailing hindlimb contacts the
and in consequence the obturator foramina are larger in the ground, respectively [2]. The coxofemoral joint, despite being a

698 Fractures of the Pelvis
ball-and-socket articulation, permits little rotation, with the impact injury. This aside, regular examples of tuber coxa
main movements being flexion and extension. fracture as an athletically induced stress injury have also
been encountered [10].
Fractures of the ischium often result from a horse rearing
racture Types, Incidence
F up and falling backwards onto the hindquarters. This can
and Causation result in concurrent fracture of the sacrum or the ischial
fracture can occur in isolation. Fracture of the ischial tuber-
The fracture types experienced in practice will depend osity is also seen less commonly as a ‘spontaneous’ fracture
heavily on the caseload under the practice’s care. In situa- during exercise [10].
tions where the clinic catchment does not include race- Monotonic fractures following direct trauma can occur
horses, the majority of pelvic fractures will be the result of in any part of the pelvis depending on just how the horse
trauma. impacts and onto which surface. These injuries can also be
In practices in which the Thoroughbred (TB) racehorse multiple and can result in an inability to rise if they involve
predominates, the vast majority of fractures will be the result the acetabulum and iliac shaft.
of stress-induced injury from repetitive cyclical loading, In the racehorse, there is a substantial body of evidence
leading to eventual bone failure. Previously published case to suggest that the majority of pelvic fractures are the result
series have reflected these differences. For instance, in a of mismatch between loading and bone adaptation, result-
1980s series of 19 cases of pelvic fracture at the University of ing in chronic weakening and eventual failure as a result of
Minnesota, all were considered to have resulted from the modelling and remodelling processes. These take place
trauma. Eight were known to have a history of a fall whereas in response to increasing exercise loads. Post-mortem stud-
the other 11 were found at pasture with no obvious inciting ies collated from Californian racetracks have shown a high
cause [3]. Around the same time, in a larger series of 100 incidence of pre-fracture pathology in horses that died for
pelvic fractures reported from the University of Pennsylvania unrelated reasons; 28% of 36 horses examined showed evi-
just over half had a history of observed trauma, the majority dence of pre-fracture pathology [11]. In a further study
being falls, but 10 cases (of which 8 were racing TBs) pre- limited to horses killed as a direct result of complete dis-
sented with spontaneous pelvic fracture during racing or placed pelvic fractures, 8/8 had pre-existing periosteal cal-
training [4]. Of 245 fractures diagnosed over a two-year lus at the time of apparently acute fracture [12]. In a clinical
period in a racehorse practice in Newmarket, England, only study of 20 cases of non-fatal pelvic fractures in racehorses
18, in all anatomical locations, were the result of trauma, the in the UK, three of four horses examined ultrasonographi-
remaining 227 comprising athletic injuries during racing or cally also showed evidence of pre-existing fracture cal-
training. In this series, 8% of the total fracture incidence lus [13]. All evidence therefore indicates that the majority
involved the pelvis and all were stress fractures of the of pelvic fractures in the racing TB are stress-induced inju-
ilium [5]. Another Newmarket study reported a total of 148 ries. This has two important implications. Firstly, they have
fractures over a two-year period of which 15% were located predilection sites because they reflect the loading and bio-
in the pelvis [6]. In a further Newmarket-based study of all mechanics of the bone involved. This is helpful in looking
musculoskeletal injuries in TB racehorses in three training for early signs of fracture as efforts can be concentrated on
stables, over three successive seasons, stress fractures of the the sites that are most commonly involved. Secondly,
pelvis comprised 10.8% of all injuries diagnosed [7]. All evi- because these injuries are chronic, it should be possible to
dence therefore suggests that it is a frequent if not common develop surveillance protocols to detect prodromal signs
diagnosis. which, if training remains unaltered, eventually lead to
It is unfortunate that case series have not teased apart complete fracture and to intervene preventively.
athletically induced stress injuries from those resulting
from trauma because fracture configurations are different
and the resultant outcome and prognosis differ greatly. Clinical Features and Presentation
In the non-TB population, causation is almost invariably
the result of trauma either directly to the pelvis via impact The degree of lameness varies from almost imperceptible
with another object or following a fall [8]. For instance, in (for instance in incomplete bilateral iliac wing stress frac-
a series of 29 cases of fractures to the tuber coxae, the fre- ture) to complete non-weight-bearing (as seen in acute dis-
quency of an observed traumatic incident was 100% with placed fracture involving the acetabulum). In horses with
55% of these injuries occurring following a horse running fractures following an accident or fall, then any degree of
into a gateway [9]. The tuber coxa presents a protuberance lameness is possible including inability to rise. A horse that
from the outline of the horse and is therefore prone to has fallen heavily on a hard surface may fracture the entire
Fractures of the Tuber Coxa 699
hemi-pelvis and be unable to rise if lying on the affected clinical signs associated with specific fractures encountered
side. Reflex movements in the hind legs can be temporally as a result of athletic activity as one or more of these inju-
inhibited in these situations and confuse the diagnosis ries is often involved in the complex induced by trauma.
with that of spinal injury [14]. Because the athletically induced stress fractures occur at
Because of the large muscle mass around the pelvis, pal- predilection sites, they commonly present with similar
pation of the bones themselves is limited to the extremities clinical characteristics for each injury.
where the pelvis approaches the skin surface. These are the
tubera sacrale, the tubera coxae, the tubera ischii and to
some extent the greater trochanter of the femur.
The bony prominences should be carefully examined
Fractures of the Tuber Coxae
with the horse standing completely level, both hind feet
In the acute phase, lameness is usually severe (grade 3–5/5)
together on a firm surface. In severely lame horses, this
and is often more noticeable at the walk than the trot. In
may not be possible. The height of each tuber coxa should
one series, the mean lameness score was 3.6/5 (range
be carefully assessed. Although some horses show asym-
2–5/5) even though many of these horses were first exam-
metry of the pelvis in the absence of any clinical signs,
ined between 14 and 60 days after injury [9]. Clinical exam-
marked displacement of the tuber coxa on one or both
ination of the pelvic musculature will often produce
sides gives a fairly reliable indication that a fracture of the
profound guarding and muscle spasm on the affected hind-
ilium is present. Tubera sacrale should also be assessed for
quarter. Scraping and sweating as a result of pain may also
position. Horses vary enormously in the degree of promi-
occur. If the fracture is complete, then displacement almost
nence of the tuber sacrale, and apparent discrepancy in
invariably occurs with the affected tuber coxa pulled
height is not uncommon in the absence of clinical signs.
cranioventrally into the sub-lumbar fossa by the attached
This can be exaggerated by difference in the thickness of
musculature (rectus abdominus, tensor fasciae lata and
the overlying dorsal sacroiliac ligaments. Cases of iliac
internal abdominal oblique). Hindlimb flexion is usually
wing stress fracture will often have a ventral displacement
negative, and rectal examination is unrewarding [9].
of the tuber sacrale on the affected side and marked pain
Affected horses will commonly walk with the hindquarters
on palpation.
tracked off to one side (usually moving towards the affected
The horse can be gently rocked side to side whilst the
side) and often show increased adduction during the
tuber coxa is cupped firmly in the hand; crepitus gives an
swinging phase of the stride [9]. Lameness may reduce rap-
indication of a displaced and/or unstable fracture. Firm
idly and horses will often walk more normally after only
pressure applied over the greater trochanter of the femur
24–48 hours. Haemorrhage can produce a subcutaneous
with rocking motion produced by pulling on the tail can
haematoma in the sub-lumbar fossa. Occasionally, the
give similar information. Rectal examination should be
remaining fracture bed emerges through the skin during
carried out to assess the psoas muscles, the caudal aspect of
convalescence (Figure 33.1).
the iliac shaft, the ventral surface of the lumbosacral joint,
the surface of the pubis and medial aspect of the ischium.
Again, gentle rocking of the horse by an assistant, whilst
the hand is in contact with the rim of the pelvic canal, can
alert the clinician to crepitus from bone movement.
Although the degree of lameness varies with athletically
induced stress fractures, with traumatic fractures it is usu-
ally severe. In one study, 16/19 cases were determined to
have a grade 3–4/5 unilateral hindlimb lameness [3]. In
addition, 11 of these horses had a two-week history of lame-
ness prior to presentation, and lameness would almost
always be more severe in the acute phase. Non-weight-
bearing lameness of the hindlimb in a horse found in the
paddock or stable with no other obvious inciting cause is a
common presentation but causes of distal limb pain must
be excluded before the presumption has foundation. As
traumatic fractures can include any combination of sites, it
Figure 33.1 Tuber coxa fracture and resulting pressure
is not possible to describe characteristic clinical signs for the necrosis of overlying soft tissues leading to exposure of the
group as a whole. Possibly, more useful is to describe the sharp fracture bed.
Fractures of the Iliac Wing
Fractures of the iliac wing are the most common pelvis stress
fracture encountered in the TB racehorse but they appear to
be uncommon in Standardbreds [8]. In a study of 36 TBs
that died on Californian racetracks related to pelvic injury,
10 were iliac wing stress fractures originating on the caudal
border of the ilium, directly over the sacroiliac joint [11]. A
two-year prospective study of fractures in TB racehorses in
the UK included 20 pelvic fractures, of which 85% involved
the iliac wing [6]. Twenty-four of 31 pelvic fractures diag-
nosed scintigraphically at the University of Melbourne
involved the iliac wing including 18 of the iliac wing alone,
and six with fractures at other sites in the pelvis [15].
In the early stages, these horses can be difficult to defini-
tively diagnose. Riders often report the horse moving badly
behind, and the horse will often walk in from exercise
showing reduced protraction of one or both hindlimbs,
similar to exertional rhabdomyolysis (ERM). A useful clini-
cal differential is that horses with ERM will often trot com- Figure 33.2 Haematoma on the caudal thigh (arrows)
pletely normally, whereas horses with pelvic fracture often secondary to an iliac shaft fracture; note the marked ‘dropped’
show a similar or worse grade of lameness at the trot. A appearance to the right side of the pelvis.
narrow, ‘plaiting’ hindlimb action, in which the foot of
each hindlimb wings in to land lateral to the contralateral of the gluteal musculature on the affected side will result in
foot, has been described [13]. Clinical examination often intense muscle spasm and ‘guarding’. Manipulation of the
reveals a marked pain response on palpation of the gluteal distal limb is usually not resented, but abduction of the hip
musculature and tuber sacrale on either one or both sides. will be resented. It is not uncommon for affected horses sub-
In displaced fractures, the tuber sacrale will be ventrally sequently to worsen. This is followed by more marked pelvic
depressed. Muscle wastage occurs rapidly and can often be asymmetry, which (for reasons not understood) is often
appreciated within one or two weeks of injury. Cases of accompanied by reduced pain.
bilateral fracture show stiffness, unwillingness to walk and Horses with constant and severe lameness and marked
guarding of the muscles in response to palpation. If there is pelvic deformity can have complications such as perma-
displacement of the spinal column and sacrum, which can nent upward fixation of the patella, contracture of ‘ham-
occur following displaced fracture of both wings, then the string’ musculature and spastic hyperextension of the
horse may collapse and be unable to rise. tarsus. These complicate care and worsen the prognosis.
When fractures involve the acetabulum, the horse is often
unable to move or bear weight on the limb. If the horse does
Fractures of the Iliac Shaft walk, the caudal phase of the stride is shortened [10]. Firm
palpation over the coxofemoral joint or manipulation of the
These may occur in isolation or as caudal extension of an iliac limb with the palm of the hand on the joint will often elicit
wing fracture [15]. The degree of lameness will depend upon crepitus and pain. Juvenile racing TBs can suffer Salter–Harris
whether the fracture involves the acetabulum, but in all cases type I fractures of the femoral head as the physis is incom-
is severe (between 3 and 5/5). In minimally displaced frac- pletely closed in two year olds. These horses will present with
tures, there can be little sign of asymmetry of the tuber coxae, similar clinical findings; the prognosis is usually hopeless.
but when displacement is marked there is commensurate
asymmetry. Rectal examination often reveals crepitus on the
affected side as the horse is rocked, and sometimes a palpable Fractures of the Ischium
haematoma. Laceration of the internal iliac artery can occur
as a consequence of displacement and result in rapid exsan- Fractures of the ischium are relatively rare. A series of 100 of
guination and collapse. In other situations, haemorrhage pelvic fractures included only five isolated fractures of the
seems to be limited and the horse will develop a large haema- ischium, although in a further 25 cases this occurred in con-
toma in the thigh on the affected side (Figure 33.2). Palpation junction with fractures of the ilium, pubis and acetabulum [4].
Risk Factors Associated with Pelvic Fracture 701
This reinforces the fact that, following falls or accidents, horse is rocked one side to the other. The horse shows a
almost any combination of fracture is possible. Isolated frac- ‘hunched up’ stance, often with the tail raised and walks
tures usually involve the tuberosity alone which can occur by with extremely short hindlimb protraction and marked
rearing up and falling back on the caudal aspect of the quar- lameness. Horses with severe bilateral tibial stress frac-
ters. Fracture of the tuber ischium is also encountered occa- tures can walk in a similar way. When fracture of the pubis
sionally as a stress-induced athletic injury [10]. In the acute is associated with acetabular fractures, then deformity of
stage, these present with swelling over the caudal aspect of the brim of the pelvis is usually palpable per rectum.
the thigh. As this subsides over ensuing days, a depression
forms in the centre of the back of the thigh. With time there is
discrepancy in caudal limb contours with the affected side isk Factors Associated with Pelvic
R
having a ‘stoved in’ appearance when viewed from the side, Fractures
with the tail raised (Figure 33.3). Lameness is usually initially
severe but diminishes over a few days. The gait is often char- Age
acterized by reduced protraction and an unwillingness to
allow full sinkage of the heel as the horse walks over the leg. Several studies have shown an increased incidence in
This presumably mitigates tension on the ‘hamstring’ muscles younger horses, with between 63 and 76% of cases involv-
and pain at the fracture site. There is usually pain on palpation ing horses <4 years of age [3, 4].
of these muscles and over the tuber ischium.
Sex
Most studies have shown a predilection for females with
Pubic Fractures
incidences of 84, 64, and 75% reported [3, 4, 16]. In a study
Isolated pubic fractures are uncommon comprising only 8 of 20 cases of stress fracture, there was a virtually even split
of 100 cases of pelvic fracture; all of which involved the between the sexes [13]. This probably reflects the relative
acetabulum [4]. They normally follow a fall or forced numbers of racehorses in training as in most training sta-
abduction of the hindlimbs. Rectal examination with one bles, colts and geldings outnumber fillies by approximately
hand on the pelvic brim usually reveals crepitus as the three to one, thus inferring that females were still overrep-
resented in the injury group. In a mixed population study,
the incidence in females was greater only in fractures
involving the pubis [8].
Track Surface
Track surface has been shown to play a part in the relative
risk of stress fracture development. One type of all-weather
surface in the UK was particularly linked to the develop-
ment of pelvic fracture even when eliminating the trainer as
a variable [17]. In the United States, the ruling in California
that all racecourses had to convert from dirt to synthetic
tracks, and its later reversal, provided the perfect cross-over
trial. Soon after the introduction of synthetic surfaces, train-
ers reported anecdotally increased numbers of stress frac-
tures in both the tibia and pelvis. This was later borne out by
a multi-centre study in Canada and the United States receiv-
ing referrals from populations of horses that trained on syn-
thetic surfaces and dirt, respectively [18]. The study
reviewed 528 scintigraphic examinations from the Toronto
Equine Hospital between 2003 and 2009 which received
cases from a training centre that changed from dirt to syn-
thetic in 2006. The proportion of horses with hindlimb or
Figure 33.3 Side view demonstrating depression over the left pelvic stress fractures was significantly greater (22.9 and
tuber ischium secondary to fracture (arrows). 38.4%) following the switch to synthetic surfaces.
Other Risk Factors acetabulum. In almost all cases, however, there is merit in
utilizing diagnostic imaging to either confirm or better
A prospective study in Newmarket [6] acted as a source of
define location and severity.
data for a more specific study on the two most common
When initial lameness is severe and there is a clinical
hindlimb stress fractures: those affecting the tibia and pel-
suspicion of proximal limb or pelvic fracture, it is generally
vis [17]. This revealed a number of associations between
inadvisable to transport the injured horse, other than to the
variables in horses’ training environments and pelvic stress
nearest safe stabling. Initial imaging is therefore by neces-
fracture. These included the trainer (controlling for surface)
sity undertaken with mobile equipment and hence ultra-
and the surfaces on which the horse trained (controlling for
sonography has become the most widely employed first
trainer). The major finding however was that a cumulative
diagnostic modality. When ultrasonography does not fur-
distance of slower-speed canter exercise, in the preceding
nish a diagnosis, delayed transfer to a hospital for further
30-day period, presented a significantly increased risk of pel-
imaging (generally scintigraphy or radiography) may be
vic fracture. This association followed a linear progression
warranted if/when the horse is deemed safe to travel.
with increasing distance, reaching a peak at 50 km after
which time the risk reduced. This is an abnormally long dis-
tance for a typical racehorse in the Newmarket environment Ultrasonography
to cover in 30 days. Most horses trained traditionally canter
Ultrasonography developed by Virginia Reef’s group at the
1 km (approximately five furlongs) and 2 km on subsequent
new Bolton Centre [20] quickly became widely adopted
days and then work at high speed for 1–1.5 km on the third
internationally [21–24] and is the most useful initial modal-
day, depending on their race distance. This cycle would then
ity for assessment of pelvic integrity.
repeat and be followed by a rest day. On average, therefore, a
It should be noted that sensitivity for detection of pelvic
traditionally trained Newmarket racehorse would complete
stress fractures using ultrasonography is likely to be no bet-
30 km of slow-speed training exercise in a month.
ter than moderate to good, and therefore failure to detect
A separate study examined risk of fracture during racing
abnormality does not preclude the presence of injury.
rather than training [19]. This compared risk factors
Ultrasonographic techniques include transcutaneous (typi-
between 86 cases, defined as a horse definitively diagnosed
cally with a low-frequency curved array or sector trans-
with a pelvic fracture while still at the racecourse, and
ducer) and transrectal (with a mid-frequency linear array
298 209 controls. Of 122 separate variables examined,
transducer) B-mode imaging, with choice of technique
35 were taken forward for multi-variant analysis. The most
determined by suspected injury location. Transcutaneous
important risk factors included:
ultrasonography is simple, rapid to perform and in thin-
1) That 75% of all previous starts had been in flat racing. coated horses diagnostic quality images can usually be
2) That racing occurred during winter and spring versus acquired using surgical spirit as a coupling agent (it is rarely
summer. necessary to clip prior to scanning); a standoff is usually not
3) The race was over a distance >4.4 km. required but may be employed for assessment of subcutane-
4) The horse was from a training yard where the average ous structures such as the sacral and coxal tuberosities. It is
percentage of horses placed in the first three was ≥36%. most useful for imaging the dorsal (gluteal) face of the iliac
wing, the iliac shaft, the tuber coxae, the tuber ischium and
As a consequence, the British Horseracing Authority
the dorsolateral aspect of the acetabulum. Transrectal ultra-
reduced the distance of National Hunt flat (the most impli-
sonography permits imaging of the pubis, the medial aspect
cated) races with commensurate reduction in injury. The
of the acetabulum, part of the ischium and part of the cau-
finding that a horse originating from a more successful
dal aspect of the ilium. Evaluation of both sides of the pelvis
trainer was at greater risk is at first sight counterintuitive.
is useful to assist interpretation of irregularities and for the
However, in both authors’ experience, trainers with high
detection of bilateral pathology. Colour Doppler sonogra-
success rate also have high injury rates, both presumably
phy has been used to assist identification of stress fractures
consequent of the workload of horses under their care.
in human medicine, by localization of increased vascularity
at the injury site, but has not been adequately assessed in
equine pelvic injuries.
Imaging and Diagnosis Iliac wing: The dorsal face of the iliac wing is readily
imaged transcutaneously. Aside from some roughening of
Clinical presentation can frequently be a strong indicator the bone margins immediately adjacent to the tuber sacrale
of the likely presence of a pelvic fracture, particularly when and tuber coxae, the normal ultrasonographic appearance
the primary injury site is the tuber ischium, tuber coxa or is of a concave and smooth hyperechoic line underlying the
gluteal muscle mass. The entire dorsal face can be imaged the skin surface caudally as the acetabulum is approached.
with systematic axial to abaxial sweeps of the transducer For fractures associated with overt cortical breach or frag-
from the sacral to coxal tuberosities, with particular atten- ment displacement, discontinuity of the bone surface is
tion paid to predilection sites of stress injury (caudal and usually readily detected (Figure 33.6), although the nature
cranial margins, and junction with the iliac shaft). Any of these injuries is such that it is generally not possible to
irregularity in contour should be considered potential evi- image the full extent of any fracture line. Ultrasonography
dence of current or previous stress injury; active injury may can therefore furnish a diagnosis of fracture but allows
take the form of focal immature periosteal callus or loss of only an approximation of severity, presence of comminu-
continuity in the bone surface (‘ski jump’) indicative of dis- tion and risk of catastrophic deterioration.
placed fracture (Figure 33.4). Occasionally, in cases of Tuber coxae: Fractures of the tuber coxae are generally
recent fracture with cortical breach, a hypoechoic area is identified satisfactorily with transcutaneous ultrasonogra-
observed immediately dorsal to the injury, indicative of phy. They are characterized by a sharply delineated dis-
haemorrhage or seroma formation (Figure 33.5a). Healed/ placed fragment/s or an abrupt alteration in the normal
healing injury usually manifests as a smooth-margined con- smooth contour of the tuberosity, with associated acoustic
vexity (Figure 33.5b and c) or less commonly an increased shadowing. Fragment distraction is typically ventral due to
angularity in the usual concave radius of the wing. Acoustic the action of the tensor fascia lata muscle, and assessment
shadowing from overlying gluteal fascial planes or blood of the area below the tuber coxa is therefore important.
vessels may cause artefacts appearing as apparent disconti- Tuber ischium: The dorsal and caudal aspects of the tuber
nuity of the linear echo from the wing. To exclude these, the ischium are readily examined transcutaneously. Comparison
transducer should be rocked slowly in the mediolateral of left and right sides may assist interpretation of irregulari-
plane; acoustic shadowing-induced artefacts will appear to ties given that the tuberosity serves as attachment to the cau-
move in position on the iliac wing, while a genuine cortical dal thigh musculature and in consequence can have a
discontinuity will remain stationary. slightly roughened surface. Ultrasonographic characteristics
Iliac shaft: The iliac shaft is scanned transcutaneously in are similar to fractures involving the tuber coxae, with sharp
longitudinal (sagittal) and transverse planes. It presents a disruption of the normal bone contour and acoustic shad-
less regular bone contour than the iliac wing, being rough- owing noted at the fracture site (Figure 33.7). Care should be
ened on the lateral aspect; imaging is also restricted to the taken to image the entire width of the tuberosity as avulsion
dorsal and dorsolateral aspects of the shaft. It is therefore fractures can often be focal. Transrectal ultrasonography is
more difficult to both accurately define and then attribute not usually needed for diagnosis and is generally reserved
significance to subtle irregularities that potentially repre- for cases in which clinical severity questions the presence of
sent callus formation. In the longitudinal plane, the shaft more complex fractures of the pelvic floor.
appears as a smooth linear echo that descends away from Ventral pelvis and acetabulum: The acetabulum is the
most difficult region of the pelvis to image accurately [24].
Prominence of the adjacent ischiatic spine and acoustic
shadowing from the greater trochanter limit transcutane-
ous visualization to the craniodorsal aspect of the joint
where the rim of the acetabulum and head of femur appear
as smooth surfaces in the normal horse. Effusion of the
coxofemoral joint and irregular articular margins are
abnormal and may be associated with articular fracture.
Although transrectal imaging has a low diagnostic yield for
injuries involving the acetabulum, it should still be
employed when attempting to characterize suspected frac-
tures at this site as it permits assessment of the integrity of
the caudal iliac shaft and ventral pelvis. The pubis can only
be imaged transrectally; the unclosed juvenile pubic sym-
physis has an irregular appearance, and definitive diagno-
sis in cases of suspected injury may require corroboration
by scintigraphic imaging. Rocking the pelvis or passively
moving/flexing the affected limb while the area of concern
Figure 33.4 Transcutaneous ultrasonographic image of an iliac
wing with discontinuity (arrow) of dorsal bone contour associated is scanned transrectally can sometimes aid diagnosis by
with a displaced fracture. visualizing movement at the fracture site. It should be
(a) (b)
(c)
Figure 33.5 Transcutaneous ultrasonographic images of an iliac wings showing (a) focal area of bone disruption and immature
callus with associated fluid accumulation (arrows) typical of active injury, (b) maturing callus typical of healing injury, and (c) mild
residual alteration in dorsal contour typical of fully healed injury.
(a) (b)
Figure 33.6 Longitudinal (a) and transverse (b) transcutaneous ultrasonographic images of an iliac shaft showing disruption of bone
contour indicative of fracture (arrows).
Figure 33.7 Transcutaneous

ultrasonographic images of normal
(left) and fractured (right) tubera ischii.
noted that while ultrasonography may in many cases per- injury site is at its peak. As with other anatomical sites,
mit identification of fractures involving the acetabulum or increased scintigraphic activity persists beyond effective
ventral pelvis, the full extent of injury usually remains healing of any fracture, and repeat scintigraphy is therefore
unknown and indeed it is not uncommon for even serious not considered a useful means of guiding return to athletic
fractures to elude detection entirely. activity.
The half-value layer (the depth of a substance required to
attenuate the intensity of ionizing radiation by 50%) for
Scintigraphy
water (the main constituent of muscle) is 4 cm for gamma
Bone phase gamma scintigraphy has excellent sensitivity rays. This means that surface proximity of the main bony
and specificity for detection of pelvic fractures and is the tuberosities (tubera sacrale, coxae and ischii) and proximal
modality of choice for cases in which ultrasonographic femur causes these sites to have relatively much greater
examination has not been definitive. Although this is not intensity on acquired images than the remainder of the
always possible with a severely lame horse, whenever possi- pelvis [28]. Over most of the dorsal pelvis, attenuation by
ble images should be acquired when the horse is standing the large gluteal muscle mass can sometimes mean that
square on a level surface, in order not to confound interpre- IRU associated with fracture pathology in the iliac wing or
tation when left and right sides are compared. Standard shaft is subtle and can potentially elude detection, particu-
views of the pelvis include dorsal (of the entire pelvis), dor- larly if movement or bladder activity results in sub-optimal
solateral obliques (of the iliac wing and shaft), lateral and images. Conversely, significant unilateral gluteal muscle
caudodorsolateral views of the acetabular region, and a cau- atrophy secondary to injury may result in the appearance
dodorsal view of the tubera ischii, sacrum and ilium [25, 26]. of relatively greater scintigraphic activity in bone on the
Radioactivity of urine pooling in the bladder can diminish atrophied side. A 4 cm loss of muscle mass will effectively
diagnostic quality, and it is important to repeat acquisition double the gamma ray count, and this should be taken into
once urine has been evacuated (usually readily achieved by account when interpreting findings. Fracture pathology at
returning the patient to its stable, but diuretics and/or cath- or near the pelvic symphysis can also be difficult to distin-
eterization are sometimes helpful) [27]. Post-processing guish from bladder activity, and diagnosis may necessitate
masking of residual bladder activity as well as other areas of acquisition of multiple oblique views (Figure 33.8).
‘normal’ high intensity (tubera sacrale and coxae) can assist Abnormal focal IRU is the usual basis for scintigraphic
interpretation of abnormal patterns of activity. The nature of diagnosis of pelvic fracture; however, in displaced fractures
stress fracture pathology is such that increased radiophar- (such those affecting the tuber coxae or tuber ischium)
maceutical uptake (IRU) should precede the onset of clinical left–right asymmetry in pelvic architecture is also indica-
lameness; however, it is sometimes considered that there is tive. Patterns of IRU associated with stress injuries of the
merit in undertaking delayed (>1 week) or repeat scintigra- iliac wing, which are the most common pelvic fracture in
phy in order to image the pelvis when bone turnover at the athletic horses, can be highly variable from small focal
(a) (b)
Figure 33.8 Caudodorsal oblique (a) and right lateral caudodorsal oblique (b) scintigraphic views with focal IRU (arrows) associated
with a pubic fracture.
points of intensity to linear bands or more generalized poor definition (and distortion) of anatomical features on
increased activity (Figure 33.9). Intensity of IRU can range resulting images. The large pelvic muscle mass necessitates
from barely perceptible to marked. Although this is a long exposure times and causes significant soft tissue scatter.
poorly researched area, there does not appear to be a direct Understandably, there is generally a reluctance to perform
relationship between scintigraphic pattern and ultrasono- radiography under general anaesthesia (ventrodorsal pro-
graphic findings or prognosis. jection with the horse in dorsal recumbency) due to the
Sensitivity and specificity of scintigraphy for fractures potential for injury exacerbation during recovery. This has
involving the tubera ischii are excellent, although chronic- led to the development of radiographic techniques that can
ity of some of these injuries at the time of presentation can be undertaken in the standing, sedated patient; the diagnos-
mean that intensity of IRU is diminished relative to those tic value of resulting images is dependent on horse size and
imaged in the acute phase. A caudal scintigraphic view of temperament as well lesion chronicity [24].
the tubera ischii/caudal pelvis can assist diagnosis. When In the standing horse, the tuber coxae can be imaged satis-
interpreting scintigraphic findings related to the tubera factorily using a 45–50° dorsomedial to ventrolateral oblique
coxae, it should be borne in mind that small focal areas of projection, centring approximately 10 cm axial to the affected
IRU (particularly at the ventral margin of the tuberosity) tuber coxa [29]. Lateral 30° dorsal–lateroventral [30] and
can be encountered in normal horses and are not necessar- ventral lateral 30° dorsal oblique [24, 31] projections have
ily bilaterally symmetrical; true tuber coxae fracture results been described for imaging the acetabular region, caudal
in unequivocal IRU as well as physical displacement of the iliac shaft and femoral head and neck. The latter technique
tuberosity when viewed on dorsal images. Injuries involv- involves introducing the X-ray tube underneath the standing
ing the acetabulum are often characterized by a general- horse in an almost vertical position, with the plate posi-
ized IRU in the coxofemoral region; as this is a site with tioned lesion side and resting on the horse’s croup and the
naturally greater scintigraphic activity than adjacent areas leg on the side of interest abducted approximately 30° from
of the pelvis, multiple oblique views (particularly caudola- vertical [24]. Preparation of the patient includes evacuation
teral and caudodorsal obliques) and comparison with the of the rectum.
contralateral side can assist. Standing radiography is most useful for injuries involving
the caudal iliac shaft, acetabulum and pubis that are either sig-
nificantly displaced, comminuted or which have developed
Radiography
abundant callus. Diagnostic yield for fractures with acetabular
Radiography of the pelvis is infrequently employed in prac- involvement is considered by some authors to be superior to
tice due to various factors including the impracticability of that possible with transcutaneous ultrasonography [24].
moving a potentially seriously injured horse to a diagnostic Radiography is most applicable for suspected injuries at this
facility, radiation exposure safety risks to staff and generally site, although ultrasonography remains the initial diagnostic
(a) (b)
(c)
Figure 33.9 Dorsal scintigraphic views of the cranial pelvis in three examples of left-sided iliac wing stress fracture; IRU is indicated
(arrows).
tool of choice. Sensitivity of radiography for non-or minimally reatment Options

T
displaced fractures is poor, and the full extent of articular and Recommendations
involvement cannot be fully assessed [32]. Radiography is not
useful for the detection or assessment of iliac wing fractures. Treatment options and recommendations are determined by
fracture type. Surgical treatment of an iliac shaft fracture has
Computed Tomography been described using a locking compression plate. The horse
suffered infection of the wound and implant, which later
At present computed tomographic (CT) imaging of the had to be removed. The end result in terms of athletic ability
equine pelvis necessitates general anaesthesia and can only is not recorded [33]. Otherwise, surgical treatment is limited
be performed on small or young horses. It is therefore to fractures of the tuber coxae which are either open at the
rarely a viable diagnostic modality and only contributes in time of diagnosis or later become open due to the emergence
cases of suspected acetabular/ventral pelvic fracture that of a sharp spiculated fracture bed (Figure 33.1). These will
have eluded detection by other means and for which a not heal without intervention.
definitive diagnosis is strongly desired. Two cases of pelvic
fracture with acetabular involvement in young ( 1-year
old) horses have been described in which CT was used to Displaced Open Fractures
fully define the fractures and identify articular margin frag- Surgical treatment has been described for contaminated
mentation. Both cases recovered safely from general anaes- open fractures [9]. This was performed in the standing
thesia and regained paddock soundness [32]. horse, under sedation and local analgesia. A fresh surgical
incision was made, to allow removal of the fragments via and a slough. Fractured bone may protrude through the
an uncontaminated approach. Both wounds were then resultant skin deficit. Soon after penetration, serosanguinous
closed with a drain incorporated in the traumatic wound. fluid, from the fracture haematoma, usually drains from the
Broad spectrum antimicrobials were given for five days, skin wound and may froth as the horse moves. Within a
and this was followed by 55 further days of stable rest. short period, the nature of the draining fluid changes to
become more purulent as secondary infection is inevitable.
In cases that develop infected osteitis of the iliac wing or
Delayed Emergence of the Parent Fracture Bed
detached fragments, the area can be foetid. Sequestration
Occasionally, complete displaced fractures of the tubera can also occur. The above sequence of events appears to be
coxae become first degree open fractures. Fractures involv- determined by the nature of the original fracture and is not
ing the entirety of the tuber coxa that extend through the influenced by acute phase management such as cross-tying.
ventral iliac wing are most at risk. The tuber coxa displaces Once the skin is penetrated, the potential for second
cranially and ventrally, adjacent muscle is torn and there is intention healing of the wound is poor as the causative, pro-
almost always substantial adjacent haemorrhage. As the tuberant bone persistently irritates granulation and is a
resultant haematoma resorbs, days to weeks after the initial focus for continued infection. The unpublished treatment
injury, the skin collapses onto the fractured ends of the par- recommendations that follow are based on the approach at
ent iliac wing. In some cases, this is markedly irregular and Newmarket Equine Hospital, UK [34], which involves
may include one or more sharp spikes of bone. These can amputation of the affected bone and removal of any associ-
lacerate the overlying skin and/or result in pressure necrosis ated fragments (Figure 33.10). This is most satisfactorily
(a) (b) (c)
(d) (e) (f)
Figure 33.10 Removal of a protruding osseous ‘spike’ from a tuber coxa fracture. (a) Exposure through a vertical skin incision.
(b) Amputation using an oscillating saw. (c) The removed fragment: the cut surface is uppermost and the sharp abaxial (protruding)
margin is to the left. (d) Evacuated surgery site following removal. (e) Stent bandage over sewn with tension relieving sutures.
(f) Surgical site before staple removal 14 days later.
Case Selection and Managemen 709
performed in the standing sedated horse; use of stocks is from injury. They then trot for two weeks, and at six weeks,
optional. Following aseptic skin preparation, the areas is follow-up ultrasound scan is performed. If healing is progress-
infiltrated with local anaesthetic. Any necrotic or devital- ing satisfactorily, horses canter on alternate days for three
ized skin is excised as the wound is enlarged sufficiently to weeks, and at nine weeks can commence normal training.
allow access to the protuberant bone. This is most usually For displaced iliac wing fractures, lameness is often far
situated on the caudal aspect of the fractured iliac wing. more severe in the acute phase. These horses are stable
Amputation is performed with an oscillating bone saw and rested for four weeks followed by two weeks of walking
requires irrigation to prevent overheating and further bone 15 minutes twice daily and two further weeks of walking
necrosis. The bone should be removed to a level approxi- 30 minutes twice daily. This is followed by one week of jog-
mately 2 cm axial to the remaining skin edges to minimize ging and walking on alternate days before jogging daily for
the potential for ongoing impingement. Most fractures are a further three weeks. An ultrasound scan is performed
abaxial to the iliolumbar artery so major haemorrhage is 12 weeks after injury. If healing is satisfactory, then the
not usually encountered. Any additional sequestra, or bone horse commences cantering on alternate days for three
fragments, should also be removed and any residual, usu- weeks before commencing normal daily exercise. Ischial
ally infected, haematoma evacuated. Lavage with sterile fractures are managed similarly.
polyionic solution containing antimicrobials appears logi- Treatment of fractures involving all other sites (iliac
cal. If possible, the debrided wound edges can be closed and shaft, acetabulum, pubis, ischium or combinations of the
a protective bandage oversewn. In some cases, establishing above) is restricted to long periods of stable confinement
a separate ventral point of drainage for the haematoma and which is judged on an individual case basis.
residual dead space is necessary. This can be some distance
ventrally and may require the insertion of long (Roberts or
gall bladder) forceps which can be palpated through the
skin of the lateral thigh where an incision can be made. The
Case Selection and Management
latter should be generous to minimize risk of premature
Before commencing long periods of inevitably painful con-
closure. This is considered preferable to use drains.
valescence for the horse, careful consideration should be
Administration of antimicrobial drugs is necessary and, in
given to the individual case to ensure that the horse has a
light of the likely multiplicity of organisms, this should be
potentially acceptable future quality of life and an econom-
broad spectrum. Administration should continue until all
ically realistic future. The prognosis is principally deter-
wound healing is complete and/or defects are covered with
mined by avoidance of complications during this period
non-draining stable granulation. In cases in which skin clo-
rather than by any specific treatment. Complications, con-
sure is not possible and second intention wound healing
comitant risks and recommended preventative protocols
has to ensue, protective dressings and establishment of
are discussed below.
drainage are advocated. Horses managed in this manner
have been salvaged for breeding and riding purposes [34].
Pain Control
Displaced fractures of the pelvis are among the most pain-
Iliac Wing Fractures
ful conditions encountered in equine practice, and it is
Many cases of incomplete or minimally displaced iliac critical that this is reduced as much as possible, especially
wing stress fractures are either apparently sound at the in the acute stages. This impacts not only on the well-being
time of diagnosis or rapidly become so. These horses are of the horse but also on the potential likelihood of develop-
not usually treated by being tied up and are left loose in the ing contralateral supporting limb laminitis.
box, but this should be deeply littered to ensure that the Both authors have found that, of the non-steroidal anti-
horse can lie down comfortably and does not slip on the inflammatory drugs, nothing provides greater pain relief
under-floor when trying to rise. There is a small but real than phenylbutazone, and this is the drug of choice.
risk, even in cases where lameness is minimal, of the frac- Administration should begin by intravenous injection at the
ture displacing and fatal haemorrhage ensuing. Although a time of diagnosis and is continued orally. Because of the risk
rare scenario, it is important to explain this to connections of initial excitation, buprenorphine is probably not indicated
at the time of diagnosis so that a joint decision on manage- for additional pain relief during the acute phase, but xyla-
ment can be made. Unfortunately, there is no risk-free zine could be considered. In order to mitigate the develop-
solution, as tying horses up carries risks of its own. ment of gastric ulceration in a horse that is going to be tied
Affected horses usually commence walking exercise as up, fed infrequently and receiving long term non-steroidal
soon as clinically sound at the walk (normally one to two anti-inflammatory drugs, daily prophylactic omeprazole
weeks) and then walk for the remainder of the first month should be considered.
Prevention of Displacement be divided into at least six feeds, and the horse fed one
a liquot at four-hour intervals. In the hospital situation, this
Because of the risk of exsanguination after laceration of
does not present difficulties. If the horse is being treated in
the internal iliac artery by sharp fracture fragments, horses
a stable-yard setting, then inclusion of the night watchman,
with unstable and/or displaced iliac shaft and acetabular
with the use of pre-prepared feeds and clear instructions,
fractures are often treated by cross-tying. Usually, some
can usually be organized.
preparatory work will have to be done to the stable specifi-
Temperature should be monitored twice daily. However, as
cally for this purpose. If the horse is admitted to a hospital,
horses on phenylbutazone medication are unlikely to dem-
there is often a box suitably equipped and reserved for
onstrate the normal pyrexic response to infective challenge,
these cases. The main requirements are that the horse can
and thus early warning signs of a developing pleuropneumo-
be safely tied by two separate stays, which allow it suffi-
nia, it is vital that horses are monitored haematologically on
cient room to use a raised water manger and hay net but
a regular basis. If economics allow, this should be done every
not sufficient to allow it to attempt to lie down. The horse
48 hours, and any rise in inflammatory markers such as
should be tied at the front of the stable looking out so that
serum amyloid A and fibrinogen trigger commencement of
it cannot be startled from behind. A ‘break string’ of two or
broad spectrum antimicrobial treatment and reconsideration
three loops of tough plastic string should be interposed
of risks versus benefits in allowing the horse down.
between the tie ring on the wall and the head restraint to
the head collar so that if the horse does decide to lie down
this string will snap, allowing it to do so rather than leaving Prevention of Laminitis
it hanging from the wall (Figure 7.28). Application of well-
Horses with severe lameness in one hindlimb are at risk of
padded stable bandages to all four legs, up to the knee and
overload laminitis and rotation or sinking of the distal pha-
hock, is advisable to limit the development of lymphedema,
lanx in the contralateral limb (Chapter 14). In many cases,
which almost invariably occurs following immobilization.
this is almost as big a risk as the original injury and has
These bandages should be removed daily, and if staffing
resulted in the death of several high-profile horses treated
levels allow, vigorous rubbing of the skin and leg should be
for severe hindlimb injuries. Although it is theoretically
carried out for a few minutes before re-bandaging.
advisable to fit a frog support on the weightbearing limb as
If the horse is going to be tied up, then realistically it has to
soon as possible, many horses will not allow this limb to be
remain so for at least one month as this is the minimum
raised from the floor in order to do so. The next best com-
period required for the development of some bridging callus
promise is for the horse to be bedded on a deep, loose bed-
as judged by serial ultrasonographic examinations. The time
ding that will pack up underneath the foot and provide
letting the horse down is a compromise between risks of
support. This is also useful so that if the horse does become
developing comorbidities and welfare concerns of keeping a
recumbent it can rise with more ease than a horse on a
horse tied-up for longer and risk of fracture displacement.
thinly bedded rubber-matting stable floor. Once it is possi-
One of the authors has experienced two horses that were
ble to raise the contralateral limb, then the shoe should be
clinically sound at walk and trot after being tied-up for one
removed and a frog support fitted.
month only to be found dead in the box the morning after
As soon as the degree of lameness allows, the horse should
been let-down. Such risks should be explained to connections
be allowed to walk little and often, even if just up and down
and their input should form part of the decision-making
the corridor of the barn or outside its stable. This will encour-
process.
age circulation in all limbs and help mitigate the risk of
laminitis in the supporting hindlimb. Acetylpromazine
administration (25–50 mg orally twice daily or 0.02–0.04 mg/
Prevention of Pleuropneumonia
kg intramuscularly twice daily) can be considered. This
Tying horses up by the head inevitably leads to the develop- relieves some anxiety and allows animals to rest, taking
ment of a degree of pneumonia by compromising drainage some weight on the affected leg. Horses are very variable in
of normal bronchial secretions. It has been shown experi- their response, and the dose should be adjusted in relation to
mentally that horses restrained by a head tie develop path- the degree of sedation produced.
ological changes in the lungs within eight hours [35].
Although the hay net should be kept topped up and within
Prevention of Colic
easy reach, all concentrate feed should be fed from the
floor, with the horse let down from the head tie and held Any horse restricted to the stable is at risk of colic due to
manually, to promote drainage of bronchial secretions. The faecal stasis and impaction of the large colon. There may
total daily amount of food will be small (2–4 kg) but should also be pain during attempts of defaecation because of
Result 711
changes around the pelvic canal. Horses convalescing from summer also demonstrates that bone will ‘de-train’ with
severe pelvic fracture should be fed soaked hay or ‘haylage’ rest, just as effectively as it ‘trains’ (adapts) in response to
(silaged grass hay) rather than dried hay as it has higher exercise. Returning horses with pelvic fractures to exercise
water and lower fibre content than most American or must therefore be done carefully.
Timothy-based dried hays. Addition of 500 ml of mineral Although each case has to be considered on its individual
oil (liquid paraffin) divided between the short feeds is often merits, with regard to the location and severity of injury,
practised, but whether such amounts are contributory has degree of lameness, extent of deformity of the pelvis and
not been established. time the horse has been at rest, some guidelines can be
given. Serial ultrasound examination of the recovering pel-
vis and sequential X-ray examination of other stress frac-
Potential of Problems with Parturition
tures, such as those of the tibia, suggest that bone takes
Fractures involving the iliac shaft and acetabulum often approximately one month to respond in any significant way
curtail further athletic function. Colts and geldings with to injury. It is therefore likely that bone will take approxi-
these injuries therefore will often be subjected to euthana- mately the same period to respond to increasing workloads
sia rather than a prolonged restriction with no useful end. in terms of remodelling and strengthening. For this reason,
This and the purported increased frequency of pelvic frac- horses that have had a prolonged period of layup should
tures in females [3, 4] mean that the main group of patients probably return to exercise with approximately a month at
with severe injuries will be fillies and mares with breeding each gait before stepping up to the next one. In the latter
potential. There are no interventions that can be carried part of each month, the next exercise level can be intro-
out during recovery to ensure the pelvic canal is of suffi- duced in the final week on alternate days to gradually rein-
cient width to allow delivery of a foal. In one author’s expe- troduce the horse to increased loading. For instance, during
rience, even highly proficient and experienced specialists a month of walking, jogging can be introduced in the final
in equine breeding practice have difficulty in firmly prog- week on alternate days before jogging commences daily and
nosticating over the possibility of a successful delivery similarly cantering exercise can be introduced on alternate
through a compromised pelvic canal, and some horses that days in the final month of jogging.
have been classified as inevitably needing a caesarean sec-
tion have delivered normal foals unassisted. In a series of
100 pelvic fractures, 16 were in broodmares and 2 had Results
reports of dystocia following the injury: one of these under-
going caesarean section and the other having an assisted Published rates of survival and return to athletic use follow-
delivery. In the same study, several other mares were ing pelvic fracture should be interpreted with caution as the
admitted to the hospital following their pelvic injury so financial or breeding value has a strong influence on
that a caesarean section could be carried out speedily but decision-making at the time of diagnosis. In general, the
none of these required surgery [4]. Nonetheless, with a risks to survival for the individual horse that has sustained a
valuable broodmare and a potentially valuable foal, it is pelvic fracture (regardless of location or severity) in respect
sensible for the mare to be moved at least near to an equine of potentially catastrophic complications, such as internal
hospital close to the time of parturition. haemorrhage, unremitting pain (necessitating euthanasia)
or inability to rise from recumbency, are encountered in the
initial few weeks following injury. Horses that survive this
Prevention of Injury on Return to Training
period are considered to have a good prognosis for some
All horses with pelvic fractures, including relatively mild form of paddock or athletic activity [15].
non-displaced iliac wing fractures, will have significant If diagnostic imaging has provided accurate localization
time removed from training. Humeral stress fractures, and assessment of the extent of the injury, then more spe-
which can become complete, displaced and catastrophic, cific advice can be given regarding management and prog-
were reported with increased frequency in horses that had nosis. The major determinants of outcome are fracture
been removed from training for a period of approximately location and severity, principally the degree of displace-
60 days and then returned rapidly to normal exercise [16]. ment and comminution. For pelvic stress fractures, reha-
Similar findings have been documented for transverse frac- bilitation times are dependent on the stage of pathology at
tures of the metacarpus, which were more common in which diagnosis was made; injuries detected early through
horses returning to slow-speed exercise following a rest scintigraphic screening require much shorter rest periods
period [36]. The occurrence of stress fractures in skeletally than those identified only when the animal presents with
mature jump racehorses following pasture turnout in the overt fracture and severe lameness.
Iliac Wing rates [15, 22]. Concurrent acetabular and/or iliac wing
involvement has the potential to negatively affect prognosis
Fractures at this site are invariably stress injuries and may
for both survival and athletic future. Additionally (and
therefore be encountered at any point on the pathological
unlike injuries affecting solely the iliac wing), the conse-
spectrum from subclinical to complete and grossly dis-
quences of fracture displacement are potentially catastrophic
placed. Fractures that extend only a short distance into the
with internal haemorrhage from laceration of the internal
bone and are non- or minimally displaced when imaged
iliac artery a recognized complication. These features neces-
ultrasonographically have a good prognosis for return to
sitate a conservative approach to rehabilitation. However,
full athletic use regardless of whether the injury is unilat-
providing the horse survives the immediate post-injury
eral or bilateral. When considering only the published
period, the prognosis for paddock life is good. If no or mini-
studies that specify iliac wing involvement, rates of return
mal displacement of the fracture occurs, residual pelvic
to full athletic soundness and/or racing are high. Reports
asymmetry should be mild and in these cases the prognosis
of injuries in UK TB racehorses documented return to full
for return to athletic use is considered to be good. In a series
training in 6/10 [37] and 15/20 [13] of cases. These were
of four TB racehorses with non-displaced shaft or shaft/
also probably conservative as several cases in each study
wing fractures, three returned to racing [15]. As for iliac
were still undergoing rehabilitation at the time of submis-
wing injuries, a small proportion of cases that return to race
sion. A small racehorse subset of three iliac wing fractures
training may re-injure at future indeterminate time. When
in a North American study all returned to athletic sound-
residual pelvic asymmetry is marked, the prognosis for
ness [22]. The most comprehensive review to date with
return to soundness is guarded to poor [38]. Irrespective of
long-term follow-up involved Australian TB in which 11/12
pelvic asymmetry, the prognosis for breeding is good with no
(92%) cases of unilateral iliac wing fracture returned to rac-
reported increased risk of dystocia.
ing, with a median time to first race (of all categories of
iliac wing fractures) of just under 10 months [15].
Non- or minimally displaced iliac wing fractures gener- Tuber Coxae
ally heal with no (or at worst, subtle) pelvic asymmetry,
Most fractures of the tuber coxae result in permanent flat-
and when imaged ultrasonographically only mild change
tening of the affected site with altered appearance of the par-
in dorsal bone contour at the injury site. Displacement
alumbar fossa. However, following rehabilitation gait
appears to be a feature particular to injuries that traverse
returns to normal, and neither ongoing lameness nor recur-
the entire iliac wing in the sagittal plane. When this occurs
rence of injury are features. The prognosis for return to full
rehabilitation periods are necessarily longer, with an initial
athletic function is excellent with reports of return to previ-
(and sometimes lengthy) period of stall rest to permit stabi-
ous (or intended) performance levels in 4/6 (67%) [4] and
lization of the fracture site. Mild to moderate permanent
27/29 (93%) cases [9]. Fracture configuration has some
pelvic asymmetry usually follows, but the prognosis for
impact on rehabilitation times, with partial fractures gener-
return to racing is still considered to be good [15]. Negative
ally having shorter return to use times (mean three months)
prognostic factors for athletic use are severe unilateral or
than complete fractures (mean 6.5 months) [9]. There is no
complete bilateral displacement.
negative impact on future breeding soundness.
Even though the predilection site for iliac wing stress frac-
tures adjoins the sacroiliac joint [11], once the injury has fully
healed ongoing lameness is highly atypical. Recurrence of Tuber Ischium
injury (ipsi-or contralateral) occurs in a small (<10%) propor-
Although fractures of the tuber ischium usually involve dis-
tion of animals on return to fast work/racing [13]; however,
traction of fracture fragments, associated damage to the
currently there are no guidelines to determine which horses
hamstring musculature and heal through non-bony union,
are at risk of re-injury. Regardless of severity of resultant pel-
the prognosis for return to full athletic soundness is excel-
vic asymmetry, there does not appear to be any increased risk
lent. Permanent flattening of the affected site can be
of dystocia in horses retired to broodmare duties.
expected, but providing sufficient rest is allowed in the
acute phase, ongoing or recurrent lameness is generally not
encountered. In one study, 6/7 (86%) TB racehorses raced
Iliac Shaft
following tuber ischium fracture [15]. This is a more relia-
The full extent of fractures involving the iliac shaft is very ble reflection of the recovery rate than the poor outcomes
difficult to determine accurately antemortem and is likely to (exsanguination in one case) that were documented in four
explaining the lack of sufficient numbers of published cases cases of unstated breed/use [22]. The injuries in the latter
from which to draw meaningful survival and prognosis study appear to have been more complex and extensive
Reference 713
(with acetabular/iliac involvement) than is typical for only 3 (9%) dying of complications [4]. A second report
fractures involving only the tuber ischium. documented 5/7 (71%) horses not euthanized at diagnosis
returning to athletic or paddock soundness with continued
lameness necessitating euthanasia in only one horse after
Ventral Pelvis and Acetabulum
injury [3]. Two young horses with acetabular fractures
Fractures involving the ventral components (pubis and were also reported to be paddock sound at six months [32].
ischium) of the pelvis may be complex and are difficult to It is therefore reasonable to advise that providing the
fully characterize antemortem. Most involve the acetabu- injured horse tolerates cross-tying for the length of time
lum and this can negatively affect outcome, although the necessary for fracture stabilization and that satisfactory
extent of the injury, including degree of displacement, and ultrasonographic and clinical improvement occurs in the
instability are important factors. Non-acetabular fractures initial weeks following injury, then the prognosis for at
of the pubis (including symphysis) or ischium (excluding least paddock soundness is fair. Progress during the initial
the ischial tuberosity) are uncommon. Partial fractures heal weeks in acetabular fracture cases is a strong prognostic
well and carry a good prognosis for athletic soundness, indicator, and determining whether to continue or cease
while complete fractures have a more guarded outlook. rehabilitation can be a fluid process.
As acetabular fractures are diagnostically challenging, Fractures of the ventral pelvis have the potential to
they are overrepresented in published reports of pelvic change the bony dimensions of the birth canal, so internal
fractures from referral facilities [4, 22]. Euthanasia follow- assessment of the pelvic architecture (following healing) is
ing diagnosis due to presumed poor prognosis for return to necessary to advise on individual likelihood of future
function has been commonplace in these caseloads, but breeding problems. As a general rule, however, acetabular
should not necessarily guide future best practice. Of the fractures do not appear to be associated with increased risk
acetabular fracture cases that have survived, a reasonable of dystocia. In one study, only two cases of dystocia were
proportion return to some use. Of 33 cases that were not recorded from 25 broodmares that had previously sus-
euthanized at or after diagnosis, 10 (30%) returned to per- tained pubis/acetabular fractures [4], and in a smaller
formance or racing and 13 (39%) to broodmare duties with series none were recorded in five broodmares [3].
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Vet. Educ. 6: 223–227. 34 Wright, I.M. (2018). Personal communication.
22 Almanza, A. and Whitcomb, M.B. (2003). 35 Raidal, S.L., Love, D.N., and Bailey, G.D. (1995).
Ultrasonographic diagnosis of pelvic fractures in 28 Inflammation and increased numbers of bacteria in the
horses. Proc. Am. Assoc. Equine Pract. 49: 50–54. lower respiratory trace of horses within 6-12 hours of
23 Goodrich, L.R., Werpy, N.M., and Armentrout, A. (2006). confinement with the head elevated. Aus. Vet. J. 72: 45–50.
How to ultrasound the normal pelvis for aiding diagnosis of 36 Ramzan, P.H.L. (2009). Transverse stress fracture of the
pelvic fractures using rectal and transcutaneous ultrasound distal diaphysis of the third metacarpus in six
examination. Proc. Am. Assoc. Equine Pract. 52: 609–612. thoroughbred racehorses. Equine Vet. J. 41: 602–605.
24 Geburek, F., Rötting, A.K., and Stadler, P.M. (2009). 37 Pilsworth, R.C., Shepherd, M., Herinckx, B.M.B., and
Comparison of the diagnostic value of ultrasonography Holmes, M.S. (1994). A review of 10 cases of fracture of
and standing radiography for pelvic-femoral disorders in the wing of the ilium. Equine Vet. J. 26: 94–99.
horses. Vet. Surg. 38: 310–317. 38 Ramzan, P.H.L. (ed.) (2014). The pelvis. In: The
25 Hornoff, W.J., Stover, S.M., Koblik, P.D., and Arthur, R.M. Racehorse: A Veterinary Manual, 168–178. Florida: CRC
(1996). Oblique views of the ilium and the scintigraphic Press: Taylor Francis Group.
715
34
Fractures of the Vertebrae and Sacrum

F. Rossignol
Equine Clinic of Grosbois, Boissy, France
I ntroduction fixation can be used to stabilize the unstable fragments and

thus prevent increased compression due to further displace-
The vertebral formula in the horse is C7 T18 L6 S5 Cy15- ment and to prevent delayed compression by the callus,
21 with the exception of the atlas (C1) and axis (C2). The especially at the ventral border of the canal.
remaining vertebrae are identified using this regional The accuracy of cervical fracture diagnosis, in both foals
numeric classification. Fractures in horses most commonly and adults, has been improved by computed tomography
involve the cervical or thoracolumbar regions [1–4]. Foals (CT) which allows three-dimensional assessment of poten-
are more susceptible than adults, and cervical vertebrae are tial compression of the spinal cord [6]. However, diagnosis
more likely to be affected [4]. The causes of spinal trauma and treatment of thoracolumbar and sacral injuries remain
vary according to the age of the horse. Foals and yearlings a challenge.
often injure the immature cervical vertebrae during hyper-
flexion, hyperextension or lateral bending of the neck
when falling, rearing and falling, collision with immovable
ractures of the Axial Dens
F
objects during play, pulling back during training episodes,
slipping on wet or muddy footing and violently sitting back
with Atlantoaxial Subluxation
on the ground or against solid objects [3–5]. The most com-
Anatomy (Figure 34.1)
mon injuries in young horses (less than six months old)
involve luxations, subluxations and physeal separations of Atlas and axis have highly modified anatomy consistent
the most rostral cervical vertebrae, especially the axial with their functions in movement and support of the head.
dens [3]. Depending on the degree of spinal cord compres- The atlas consists principally of a large vertebral canal with
sion and the neurological deficits, such fractures can be abaxial wings. Cranially deep concave articular surfaces for
stabilized by internal fixation [4]. the occipital condyles border the foramen magnum. The
Adults are more commonly injured in high-speed or race caudal articular surfaces are slightly convex and well sepa-
accidents and fractures can involve both the cervical and rated, except ventrally at the fovea dentis.
thoracolumbar regions [3–6]. Injuries to cervical vertebrae The axis is the largest vertebra characterized by the dens
most frequently involve compression fractures of the verte- (odontoid process) protruding cranially from its body. This
bral body, followed by articular process fractures [4, 6]. High is half-truncated with an excavated and rough dorsal face.
energy impact usually results in catastrophic fracture dis- The axis has small transverse processes, but a large strong
placement, leading to major neurological signs and recum- spinal process runs the whole craniocaudal length of the
bency. For this reason, few attempts have been made to vertebral arch. The atlantoaxial ligaments are well devel-
surgically repair such injuries. In some cases of cervical ver- oped. The dorsal ligament is yellow and elastic, whereas
tebral fracture, spinal compression may be minimal despite the ventral ligament is white and relatively tough. The tec-
obvious bone disruption [3, 4, 7]. In this situation, spontane- torial membrane is large; it is attached from the ventral
ous bone healing can occur, but common complications border of the foramen magnum of the occipital bone to the
include neurologic sequela and recurrent pain due to exu- inner surface of the atlas by a strong lateral expansion. The
berant callus or domino-effect instability [4, 7]. Internal longitudinal ligament of the axial dens is very strong and

716 Fractures of the Vertebrae and Sacrum
Foramen magnum Atlanto-occipital membrane
Base of the occipital bone

Lateral atlanto-occipital ligament
Membrana tectoria
and Occipital condyle
its lateral bundle
Longitudinal ligament of the dens
Atlas wing
and
its lateral bundle
Axis dens
Floor of the vertebral canal Dorsal longitudinal ligament
Transverse process of the axis First intervertebral disc
Figure 34.1 Dorsal view of the atlantoaxial and adjacent joints (after removal of vertebral arches, spinal cord and meninges; the
membrana tectoria was removed on the right side). Source: Adapted from Barone [1]
extends from the excavated dorsal face of the axis to the of the odontoid process (Figure 34.2). Pressure from the
roughened floor of the atlas, cranial to the fovea dentis. poll strap of halters and headcollars is focused on the atlan-
toaxial junction, when a young horse pulls back, and pre-
disposes to fracture [2]. The absence of an intervertebral
disc means that considerable stress is placed on the odon-
Cranial cervical fractures are more common in young toid process and its physis in hyperflexion, hyperextension
horses (<6 months old) and often involve the axial dens [3, and lateral bending during falls and other accidents. The
4, 8–10]. Fractures of the odontoid process (hangman frac- dens remains attached to the atlas by its ligaments, and the
tures) are also commonest in humans. They usually involve axis moves ventrally due to the traction of the nuchal liga-
disruption of the physis of the dens, resulting in separation ment [3, 8–10]. This can lead to spinal cord compression at
Fractures of the Axial Dens with Atlantoaxial Subluxatio 717
Figure 34.2 Fracture of the odontoid process (axial dens) in a foal. Note the moderate ventral displacement of the axis and the
caudal aspect of the atlas due to the traction of the nuchal ligament. Source: Courtesy Margreet Voermans.
the atlantoaxial joint. At this level, however, the vertebral should be fed manually as suckling may cause neck pain.
canal is spacious, which allows the cord to be laterally dis- Diuretics, nonsteroidal anti-inflammatory drugs
placed by the fractured dens and lessening pressure on the (NSAIDs), corticosteroids (dexamethasone 0.2–0.3 mg/kg
spinal cord [3]. iv) and dimethyl sulphoxide (DMSO) infusion (1 g/kg
diluted at 20% in an isotonic solution of sodium chloride
in 5% dextrose) should be administered. Additional pain
Clinical Features and Presentation relief can be provided by butorphanol or morphine, either
Neurologic deficits depend on the degree and force of alone or combined with detomidine. Supplementary
spinal impact at the time of the injury and can range intravenous fluid therapy is recommended for recumbent
from stiff gait to total tetraparesis or even sudden animals.
death [3, 4, 8–10]. In most cases, the foal is able to walk
but may show progressive signs of ataxia, neck stiffness
and tetraplegia. There are marked sensory deficits in the Treatment Options and Recommendations
cervical region, and crepitus may occasionally be elicited If displacement of the axis is moderate and if the foal improves,
by manipulation. Swelling is moderate, and some mala- medical treatment can be continued. Some fractures of the
lignment may be noted on palpation. dens become stable with time when, due to the width of the
vertebral canal at this level, there is no direct effect on the spi-
nal cord and the neurological deficit is slight or negligible.
Despite some residual neck stiffness, ataxia and paresis may
Diagnosis is confirmed by radiography under sedation. The resolve completely. However, clinical signs can recur, usually
lateral view confirms the separation of the cranial physis of caused by callus or soft tissue proliferation [3, 4].
the axis with ventral displacement of the vertebra. The ven- Surgery is indicated if clinical signs deteriorate or if the
trodorsal view can be useful to detect latero-medial devia- foal is valuable and intended for athletic use. Ideally, this
tion of the axis in relation to the atlas [3]. CT can provide should be performed before the foal is unable to stand. The
useful information about displacement of the axis relative to goals are to decompress the fracture site by realigning the
the atlas, possible associated fractures and other traumas. vertebrae and to provide stability with some form of fixa-
tion. Surgical techniques for treating fracture luxations
include Steinman pins, ventral cervical fusion with a
broad dynamic compression plate (DCP) or locking com-
Immediate medical therapy is indicated. This includes pression plate (LCP) and dorsal laminectomy of the caudal
confinement in a comfortable, well-padded stall. Foals atlas [3, 8–10].
Ventral Atlantoaxial Fusion Using an LCP than three days post-operatively, the prognosis is markedly
decreased.
The foal is placed in dorsal recumbency. The approach and
Implants should be removed only in the case of loosen-
exposure are as described in “Plate fixation” section for cau-
ing or bone lysis. After surgery, the range of lateral motion
dal cervical fusion [11, 12]. The major difference is that, at
of the cranial neck will be reduced, as it is only provided by
this level, the oesophagus is in a sagittal position and should
the atlantoaxial joint, but seems to be minimally debilitat-
be carefully retracted to the left. The ventral crest of the axis
ing for most foals [3].
and ventral tubercle of the atlas are exposed. The axial dens
is usually left in place. The ventral spinous process of the
body of the axis is flattened slightly using a curved oste- Other Techniques
otome and bone rongeurs. The vertebrae are carefully rea-
These are anecdotical reports of ventral stabilization of the
ligned and kept in place with bone-holding forceps.
atlantoaxial junction by inserting two 6.5 mm cancellous
An LCP is preferred [4]. This can be a narrow or broad
screws across the articulation after removing cartilage
3.5/4.0 or 4.5/5.0 mm LCP depending on the size of the
from the articular surfaces. However, care must be taken
patient. Two plates, with one placed on each abaxial side of
when drilling the screw holes in the vertebral arches of the
the midline of the vertebra, have also been used [3]. The
atlas to avoid the spinal canal axially and the vertebral
plate should be bent slightly. With the reduction forceps in
arteries and first cervical nerves abaxially. A bone graft was
position, the appropriately sized plate is applied to the ven-
placed in the articulation to promote fusion, and a polyvi-
tral aspect of C1 and C2, and then maintained and pressed
nylidene plate was applied to the ventral aspect of the atlas
onto the bone using the long locking drill guides. One cor-
and axis to provide additional stability [3].
tex screw is inserted into each fragment in loaded fashion.
Various arrangements of Steinmann pins and applica-
The correct length of the screws is determined fluoroscopi-
tion of a Kirschner apparatus in a through-and-through
cally, paying attention not to damage the spinal cord. The
pattern have also been reported. Four pins were placed
remaining holes are filled with locking screws (LHSs)
through the vertebral bodies of the atlas and axis, with one
(Figure 34.3). The muscles, subcutaneous tissue and skin
pin anchoring the dens and securing the pins with plates at
are closed in a continuous fashion. A closed active drain
the skin surface.
can be placed at the level of the plate, exiting and sutured
to the skin near the incision.
Results
A stent bandage is applied and covered with an adhesive
barrier drape to keep the incision clean and dry during The latter techniques preceded the introduction of LCP
recovery. Post-operatively, the foal should be helped to and LHS which are now the implants of choice, although
nurse as soon as possible. If recumbency persists for more at this time there are no published results.
Figure 34.3 Laterolateral radiograph after fixation of atlantoaxial luxation with a human distal femur LCP. Source: Courtesy Anton Fuerst.
Atlantoaxial Subluxatio 719
Atlantoaxial Subluxation that would make sense would be fixation in flexion, but the
approach and room for plate fixation would be extremely
Incidence and Causation limited.
Primary idiopathic atlantoaxial subluxation, without frac-

ture of the dens, is a rare condition seen in young horses up
Dorsal Laminectomy
to three years of age [3, 4, 13–15]. The condition can be con-
genital or the result of a traumatic incident [3, 13]. Combined The horse is usually placed in lateral recumbency, but
stretching or tearing of the ligamentous attachments of the sternal recumbency has also been described. Peri-
dens and the fibrous atlantoaxial joint capsule leads to insta- operative use of NSAIDs and antimicrobials is strongly
bility and spinal cord compression that is exacerbated by recommended.
neck extension and relieved by flexion [3]. This differenti- After aseptic preparation, a 30 cm skin incision is made
ates the condition from the syndrome of the same name in caudally from the occipital protuberance. Once the initial
humans and dogs where compression occurs during and often profuse haemorrhage is under control, the nuchal
flexion. fat is divided, and the funicular portion of the nuchal liga-
ment is incised, bluntly separated along the midline and
then retracted laterally. Finding the separation between the
Clinical Features and Presentation lamellar halves of the nuchal ligament may be difficult but
is important to facilitate the approach. The incision must be
Neurologic signs can be acute but are generally chronic,
sufficiently long because of the depth of the field and the
and may occur months or years after the initial trauma.
inelastic quality of the nuchal ligament. The semispinalis
They vary in severity from mild ataxia to recumbency. The
capitis and rectus capitis dorsalis muscles are divided along
animal may have abnormal head and neck posture and
the midline and folded back from the bone using periosteal
local swelling if the injury is acute. A vertical tilting of the
elevators. The deflected muscles and halves of the nuchal
atlantal wings may be detected on palpation.
ligament are held in place with Inge self-retaining retractors
to expose the dorsal arch of the atlas. The dorsal atlantoax-
Imaging and Diagnosis ial ligament and interspinous ligament are partially and
sharply separated from their attachments to the dorsal arch
Radiographs may reveal malalignment of the atlas and of the atlas with scissors. A high-speed burr is used to
axis. Evidence of subluxation can be confirmed, with the remove an oval shape from the caudal two-thirds of the dor-
head in extension as lengthening of the space between sal arch of the atlas. As soon as the inner cortical layer of
the articular surfaces of the atlas and axis ventrally and bone becomes apparent, reverse-cutting rongeurs can be
reduction of the space between the dorsal arch of the used to remove the dorsal arch while protecting the cord
atlas and the spinous process of the axis [3]. The major (Figure 34.4). This should relieve spinal cord compression
compressive component is the caudal portion of the dor- and maintain the range of motion of the atlantoaxial articu-
sal arch. Definitive diagnosis requires myelography which lation. Part of the dorsal arch (1–1.5 cm) is left in place cra-
should demonstrate compression during extension and nially as well as part of the atlantoaxial membrane. The
relief with flexion. CT, with the head in extension, may dural sac protrudes into the laminectomy defect, but durot-
also be useful to better define the lesion and to detect omy is not necessary. A 5 mm thick autogenous fat graft is
potential rotation, and any concomitant lesions of the harvested from the adjacent nuchal fat and placed in the
atlas. bony defect to prevent laminectomy scar formation. The
surgical wound is closed in four layers, and a stent is placed
Treatment Options and Recommendations over the skin sutures. Neurological signs are slow to
improve.
Prediction of outcome after conservative treatment is
difficult. Subtotal dorsal laminectomy is recommended
if the horse shows neurologic deterioration or if neu-
Results
rologic deficits persist despite conservative treatment [13].
Atlantoaxial subluxations should not be treated by cervi- In a report of four young horses treated by dorsal laminec-
cal fusion, with the atlas and axis in extension, as this tomy, three improved including two who recovered com-
increases compression of the spinal cord. The only fusion pletely; one was lost for long follow-up [13].
Figure 34.4 Anatomic specimen demonstrating

dorsal laminectomy of the atlas. Cranial is to the
left. A high-speed burr is used to remove an oval
shape from the caudal two-thirds of the dorsal
arch of the atlas (white arrows). The dorsal
atlantoaxial ligament (AtAxL) and interspinous
ligament are separated from their attachments
to the dorsal arch of the atlas. SC: spinal cord;
DS: dural sac just dorsal to the defect. The dural
sac and the atlantoaxial membrane have been
removed at the level of the atlantoaxial joint.
omplete Ventral Luxation

C s uccessful, due mainly to subacute or chronic presenta-
of the Axis tion [3]. Acute luxation may sometimes be reduced by pro-
gressive and careful rostral tension of the head and flexion
Incidence and Causation of the atlantoaxial joint. In foals, there is a risk that this
procedure may injure the spinal cord. A recent report
Complete luxation of the atlantoaxial articulation, result- described internal fixation of a complete ventral luxation
ing in displacement of the dens so that it lies ventral to the of the axis in a Quarter Horse yearling [16]. Closed and
atlas, is very rare and indicates that the ligamentous attach- open reductions of the luxation were attempted under gen-
ments of the dens have been completely disrupted. These eral anaesthesia with the aid of a pulley system but were
injuries are traumatic in origin. unsuccessful. The dens was therefore excised, and the atlas
and axis were stabilized with a 4.5 mm T-LCP. Four 5.5 mm
Clinical Features and Presentation cortex lag screws were placed across the atlantoaxial artic-
ulation to provide additional stability. The filly recovered
Immediate clinical signs include extension of the head, neck and did not show any sign of ataxia or reduced mobility of
stiffness, and occasionally an altered head carriage. As with the cranial neck. Subtotal dorsal laminectomy should be
fractures of the dens, neurological signs are usually moder- considered for chronic cases showing neurological
ate or absent, dependant on the severity and intensity of the signs [13].
damage. The author encountered one foal that was tetraple-
gic (Figure 34.5). A recent report described complete luxa-
tion of the dens in a Quarter Horse yearling [16]. The filly Fractures of the Atlas
exhibited a reduced range of motion and resented palpation
of the cranial neck but did not show any sign of ataxia. Fractures of the atlas mainly produce neck pain and stiff-
Others have reported the lesion as an incidental finding [3]. ness, with the degree of ataxia varying according to the
Swelling over the lateral surfaces of the atlas may be appar- type of fracture and degree of spinal cord compression.
ent. Palpation may reveal malalignment with ventral dis- Diagnosis is based on lateral, oblique and dorsoventral
placement of the axis in relation to the atlas and reduced radiographs. The growth plates and their closure times
space between the dorsal spine of the axis and the atlas. should be taken into consideration when interpreting
images in the foal.
Fractures of the ventral arch of the atlas and disrup-
tion of the ligaments are associated with similar clinical
Luxation is readily identified in laterolateral (lateral) radio- signs to ventral luxation of the axial dens. Bony callus
graphs. A dorsoventral view is useful to assess lateral can compress the vertebral canal and later induce ataxia.
displacement. Myelography and, if available, CT scanning or MRI are
useful to document the type of compression. If compres-
sion of the spinal canal is confirmed, it can be managed
similarly to axial dens luxation, by dorsal laminectomy
An attempt can be made under general anaesthesia to of the caudal half to two-thirds of the dorsal arch of the
reposition the dens within the atlas but this is rarely atlas [3]. This may produce long-term improvement in
Fractures of the Axi 721
Figure 34.5 Complete ventral luxation of the axis with severe displacement. Note the associated comminuted fracture of the head of
the third cervical vertebra (white arrow). The foal was tetraplegic and was euthanized.
Figure 34.6 CT three-dimensional reconstruction of a comminuted fracture of the ventral arch of the atlas (arrows). Source: Courtesy
Xavier D’Ablon.
the horse’s neurologic status. It should be noted that, Fractures of the Axis
contrary to the procedure performed for ventral luxation
of the axial dens, most of these compressive lesions Fractures of the axis (other than the dens) can be similarly
result from dorsal proliferation of the bone, which is managed to middle and caudal vertebral fractures, using
often much thicker than on normal specimens [3]. Early ventral plating for internal fixation (see 34.7.7). Due to the
ventral stabilization with a plate is usually prevented by short length of the axis, the strength of the construct can be
comminution of the ventral portion of the fracture improved by combining fixation with ventral fusion to the
(Figure 34.6). third vertebra.
A dorsal approach can also be used as the position of the processes are large and planiform. C6 and C7 are progres-
axis is relatively superficial. The dorsal aspect of the spinous sively shorter with increasing spinous processes particularly
process represents the tension side of the bone and the result- on the latter. This also has an undivided transverse process
ing fixation is very stable [17]. With the patient in sternal and an articular facet on its body for the first rib.
recumbency, a 20 cm straight skin incision is centred over The intervertebral discs are thick, and the dorsal longi-
the fracture site. After exposing the dorsal surfaces of the tudinal ligament is well developed and continuous to the
atlas and axis, the alignment of the vertebrae is corrected longitudinal ligament of the axial dens. In horses, the ven-
and maintained with bone-holding forceps. Large tral longitudinal ligament is replaced by the longus colli
Steinmann pins are inserted into the cranial and caudal muscle.
fragments in a horizontal direction to facilitate reduction. The nuchal ligament (corresponding to the supraspinous
They are grasped with large bone-holding forceps on each ligament in the thoracic area) is highly developed and
side to progressively reduce the fracture. An appropriately divided into cord-like funicular and lamellar parts. The
sized broad LCP is placed on the dorsal aspect of the axis funicular part runs from the external occipital crest to the
and fixed using cortical screws and LHS. One deep layer top of the thoracic spinous processes. Left and right laminae
under the nuchal ligament, the nuchal ligament and the consist of cranial and caudal sections that are differentiated
subcutaneous tissue are closed in layers using a simple con- by their attachments to the cervical spinous processes.
tinuous pattern. The skin is closed with staples. A stent
bandage is applied and covered with an adhesive barrier
drape to protect the incision during recovery. Fracture Types, Incidences and Causation
In adults, compression fractures of the vertebral body, fol-
lowed by articular process fractures, are most frequently
Fractures of Cervical Vertebrae 3 to 7 diagnosed [2, 4]. Causes include hyperflexion, hyperexten-
sion or lateral bending of the neck when falling [2]. In one
study, C3 and C4 were most frequently involved [18].
Equine cervical vertebrae are strong and quite long compared Fracture configurations vary, but a common configuration,
to those of other species with progressively reducing length associated with moderate to mild neurological signs that
from C3 to C7. C3 to C5 have similar shapes. The ventral crest permit surgical treatment, consists of an oblique displaced
is sharp and ends in a tubercle which becomes increasingly fracture of the caudal aspect of the body. This has been
prominent caudally. The spinous process is very short, and reported in C2, C3 and C4 [19]. Due to the strength of the
the transverse foramen is wider from C3 to C5. The articular strong fibrous intervertebral disc, displacement at the
Spinous process
Caudal articular process
Cranial articular process

Caudal incisure
Cranial incisure
Dorsal tubercule of
the transverse process
Transverse foramen
Border of the vertebral fossa
Insertion of the longus colli muscle

Ventral tubercule of Vertral crest
the transverse process
Insertion of the serratus ventral
cervicalls, splenius and
omotransverse muscle
Figure 34.7 Lateral topographic anatomy of the fourth cervical vertebrae.

Fractures of Cervical Vertebrae 3 to 723
argins is minimal but narrowing of the intervertebral

m Clinical Features and Presentation
space can be marked centrally (Figure 34.8). Other frac-
Severe neck pain and stiffness are common. Neurologic defi-
tures follow a transverse plane, across the vertebral body
cits vary depending on the degree of cord injury and compres-
with slight displacement, or involve the base of the cranial
sion and fracture instability. In moderately comminuted
articular process or the dorsal arch (Figure 34.9). The artic-
fractures with little displacement in the area of the cervical
ulations of the cervical vertebrae are strengthened by the
canal, horses can exhibit varying degrees of ataxia, ranging
fibrous intervertebral disc, which means that during falls
from mild to severe, but should be able to stand up spontane-
in immature horses (<2 years old) the articular facets and
ously after the first 24 hours of medical treatment. More com-
physes are the weakest points [4]. Falls in which the neck
minuted fractures often severely traumatize the cord, resulting
is markedly hyperextended can result in a severely dis-
in quadriplegia and sometimes sudden death. If there is no
placed fracture with ventral rotation and displacement of
response to strong pinching of the skin over caudal regions of
the caudal vertebra through the ventral half of the caudal
the body, there is probably catastrophic damage to the spinal
end plate of the cranial vertebra. The ventral portion of the
cord cranial to the desensitized area. Lack of response to deep
epiphysis remains attached to the caudal vertebra by the
pain for more than 24 hours indicates functional transection
strong fibrocartilaginous disc. If trauma is severe, the dor-
of the spinal cord and the horse should be euthanized.
sal lamina and pedicles of the caudal articular process frac-
ture and rise up, effectively deroofing the spinal canal.
Although such fractures can produce severe angulation of Imaging and Diagnosis
the spine, this deroofing reduces the neurologic effects.
A complete neurological exam should be performed and
The dorsal portion of the intervertebral disc that remains
repeated after starting medical treatment. Fracture config-
intact is quite strong and can provide enough support to
uration, mainly for the rostral vertebrae, can be assessed
maintain the stability of the affected joint despite the
radiographically, using lateral and dorsoventral views. CT
deroofing [5, 7, 20] (Figures 34.10 and 7.6). Vertebral body
is extremely helpful to determine the three-dimensional
fractures can also occur after ventral fusion using a kerf-cut
configuration of the fracture and to detect latero-medial
cylinder (KCC), particularly at C5–6 and C6–7 [4, 21].
displacement and compression [6].
Figure 34.8 Oblique displaced fracture of the caudal body of C4 demonstrating narrowing of the mid-intervertebral disc space
(arrow). The horse was moderately ataxic but very stiff and painful in its neck. The fracture was treated by internal fixation using a
ventral LCP.
Figure 34.9 Fracture of the base of the cranial articular process and dorsal arch of C4. The horse was severely ataxic in the acute
stage. This improved after medical treatment, but the neck remained stiff and painful.
Figure 34.10 Long-standing fracture of the vertebral arch of C5 with ventral rotation and displacement of C6 through the ventral
half of the caudal end plate of C5. The ventral portion of the epiphysis remains attached to the caudal vertebra by the strong
fibrocartilaginous disc (large white arrow). Dorsal lamina and pedicles of the caudal articular process are fractured and elevated,
deroofing the spinal canal (white arrow). The horse was only slightly ataxic. Note the domino effect with dorsal luxation of the cranial
aspect of C5 (black arrow) narrowing the spinal canal.
Acute Fracture Management known as the ‘domino effect’, may be encountered in horses
when cervical fracture and luxation is managed conserva-
Horses with minimally displaced fractures, with no or mini-
tively [3, 7]. In such cases, chronic misalignment and insta-
mal neurologic signs, can be managed medically with a NSAID
bility leads to intervertebral spinal compression at sites
(phenylbutazone: 4.4 mg/kg IV s.i.d.), corticosteroids (dexa-
adjacent to the fracture (Figure 34.10). The author suggests
methasone: 0.1 mg/kg IV q12h) and DMSO (1 g/kg q24h) in an
that the domino effect may occur more frequently after
intravenous perfusion of lacted Ringers solution. Corticoids
injury-induced fusion (no surgery) than after surgical
are helpful to reduce oedema but should be used with care and
fusion of the cervical vertebrae [7] and therefore recom-
only for a short period in adult horses as they may induce lami-
mends internal fixation. In cases with frontal fractures of
nitis and, if surgery is elected, may impact bone and soft tissue
the vertebral body, internal fixation can be used to stabilize
healing. The risk of further displacement of the fracture, which
fragments and thus prevent increased compression caused
may occur during intense neck movement when the horse
by further displacement and/or delayed compression due to
stands up after lying down, can be reduced by keeping the
callus, especially at the ventral border of the canal. Some
horse in a sling. The above treatment protocol can be contin-
horses with articular process fractures develop cervical
ued and adapted according to the clinical signs.
osteoarthritis with neck stiffness and limited lateral flexion.
They may also exhibit neurologic deterioration due to insta-
bility and/or formation of callus that impinges on the dor-
solateral aspect of the spinal canal (Figure 34.11). Ventral
Neurologic deterioration is a clear indication for surgical cervical fusion may be used preventively, in the acute stage,
stabilization, but other horses are good candidates for frac- to stabilize articular fractures and improve the prognosis.
ture fixation. These include displaced fractures of the ven- When the fracture has healed and callus is compressing the
tral part of the cervical body; the fracture does not extend to spinal cord, ventral cervical fusion is less useful, particu-
the canal, and ataxia may be due to direct injury to the cord larly if myelography or CT reveals static compression. In
during the fall or to possible mobilization of the disc towards this situation, dorsal laminectomy is preferred [13].
the canal (as described in humans and dogs). In such cases, The vertebral body must have sufficient bone for implant
conservative management is likely to result in exuberant fixation. Severely disrupted vertebrae are difficult to repair
callus formation that, due to marked fragment displace- with screws. The adjacent vertebral bodies can be used to
ment especially at the level of the intervertebral disc, can stabilize the fractured vertebra and is recommended when
bridge the intervertebral space [19]. Mobilization of the the intervertebral disc is damaged. Ventral plating is most
fragment during neck movements and further deterioration commonly used for internal fixation of cervical fractures [3,
of the disc can also lead to chronic pain and instability of 4, 12, 19]. This utilizes the approach used for cervical fusion
adjacent cervical articulations. This common sequela, when using KCC [21, 22].
Figure 34.11 Severe osteoarthritis with proliferation of the articular facets of C6 and C7 (arrow) in a two-year-old filly which had
fractured the articular facet of C7 seven months earlier was moderately ataxic and was managed conservatively. She worsened
progressively and became highly ataxic due to the formation of callus that impinged on the dorsolateral aspect of the spinal canal
producing cord compression. She was euthanized.
(a) (b)
Figure 34.12 (a) Custom-made V-shaped block used to stabilize the neck in a strictly vertical position and hold a radiographic
cassette. (b) Horse positioned for surgery: neck in the block (white arrows), head square and secured. Skin staples (black arrows) mark
the affected vertebra. A mobile X-ray machine (large white arrow) is mounted on an arm at an appropriate fixed angle to ensure
accurate intra-operative imaging.
Plate Fixation
Phenylbutazone treatment initiated at the time of the
accident is continued, and antimicrobials (Penicillin G)
22 000 iu/kg IV and gentamicin 6.6 mg/kg IV are adminis-
tered before induction of anaesthesia. The author prefers
to induce the horse in a sling to prevent trauma to the
neck and possible fracture displacement.
The horse is placed in dorsal recumbency with the head
extended. Custom-made V-shaped blocks stabilize the neck
in a strictly vertical position and also hold and maintain posi-
tioning of radiographic cassettes (Figure 34.12). The involved
vertebra and/or intervertebral space is identified radiographi-
cally, and the surgical site is marked with skin staples.
After routine aseptic preparation and placement of an
impermeable drape, a 30 cm midline ventral skin incision
is made at the level of the fractured vertebra. The trachea is
drawn to the left, and the ventral vertebral surface is
Figure 34.13 Instruments for efficient exposure of the ventral
exposed by blunt dissection. The oesophagus and carotids aspect of the vertebrae. Left to right: curved osteotomes,
are identified and retracted using two strong self-retaining self-retaining Inge retractors (x2) and Beckman–Adson retractor.
Inge retractors (Figure 34.13). The jaws of the retractor are Upper left: bone gouge forceps (rougeurs).
covered by wet abdominal gauze swabs to prevent slipping
and damage to the recurrent nerves and oesophagus, espe- by using a curved osteotome, to allow plate application.
cially over cranial vertebrae. The fracture is reduced by manipulation with bone forceps
After sharply dividing and separating the longus colli and strong digital pressure.
muscle, using strong mayo scissors and a periosteal eleva- In some fractures involving the cranial or caudal aspect of
tor, this is retracted exposing the ventral spine of the the vertebral body and intervertebral disc, reduction and sta-
involved vertebra and the intervertebral disc. The fracture bilization can be combined with fusion to the adjacent verte-
site is debrided, and the haematoma evacuated. The ventral bra. A 14-hole DCP and cancellous screws were used to repair
spine of the body of the vertebra is usually flattened slightly, a displaced horizontal fracture of the axis in a five-year-old
(a) (b)
(c)
Figure 34.14 Lateral radiographs of a horizontal displaced fracture of the caudal body of C2 stabilized with a 14-hole DCP. (a) Pre-operative
image. Note narrowing of the dorsal aspect of the intervertebral disc space (white arrows). (b) Immediate post-operative view: partially
threaded 6.5 mm cancellous screws were placed in lag fashion across the fracture with fully threaded cancellous screws in the other plate
holes in neutral fashion. The most caudal plate hole was too close to the C3/4 articulation for safe screw placement and was therefore left
blank. (c) Five months post-operatively demonstrating good healing and complete C2/C3 fusion (arrows).
French warmblood (Figure 34.14). Cervical fusion was per- ing from the distance between the vertebra and the radio-
formed after drilling out the ventral part of the disc and graphic plate. Alternatively, a radiodense marker or ruler
instilling a bone graft. The fracture healed without complica- can be placed beside the vertebra before drilling to assess
tion, and the horse was subsequently used as a showjumper. the degree of magnification. The drill markers provided
LCPs have advantageous mechanical properties in terms of with the LCP kit are also useful during this procedure. The
stability and strength. They are suitable for the cancellous long-threaded drill guides are well adapted to cervical sur-
bones of vertebrae and are now the implant of choice [23–25]. gery and the associated deep working space. They also
As the dorsal cortex is relatively thin and close to the vertebral ensure that the surgeon drills perpendicular to the vertebra
canal, most screws are only inserted into the ventral cortex and help in positioning the plate close and parallel to the
and cancellous bone of the body. LHS can be combined with ventral surface of the bone (Figure 34.15).
cortical or cancellous screws applied in lag fashion across the Fracture reduction can be very challenging due to lack of
fracture line to compress the fragment. They can either be grip when placing bone forceps and the risk of iatrogenic
placed independently or, more commonly, through the combi damage to the vertebral canal if excessive manipulation is
hole of the LCP and should be inserted before the LHS. attempted. In some situations, the plate itself can be used to
Digital radiographic guidance is used to determine the reduce the fracture. In a displaced fracture of the body of C4,
appropriate drilling depth in relation to the spinal canal. It the stability of the LHS in the plate meant that this could be
is also important to reduce the measured depth of the used as a lever arm to effect reduction. Cortical lag screws
screw by 10% to compensate for the magnification result- can also be used to reduce the fracture before positioning the
(a) (b)
Figure 34.15 Application of a seven-hole broad LCP. The long-threaded drill guides are helpful for positioning the plate in a deep
space. (a) Intra-operative view: large white arrows: LCP drill guides; white arrow: LCP positioned on the ventral surface of the
vertebrae; large black arrows: self-retaining Inge retractors. (b) Intra-operative radiograph. Note the small cage that was placed
ventrally in the intervertebral disc space, after removal of disc material by drilling.
(a) (b)
Figure 34.16 (a) Laterolateral radiograph of a frontal comminuted displaced fracture of the caudal body of C4 (white arrow) in a
jump racehorse. Note the narrowing of the disc space (black arrow). (b) The fracture was repaired by fusion with C5 using a 10-hole
broad LCP. It was reduced by digital pressure, and a 4.5 mm lag screw with a washer was placed across the fracture (black arrow).
Following plate contouring, two further cortical lag screws were placed across the fracture using the combi holes (white arrows). At
seven months post-operatively, the fracture had healed well and fusion was almost complete. The horse returned to previous activity
and won its first race 11 months post-operatively. Source: Courtesy Dean Richardson.
plate. This requires good three-dimensional anatomical fracture of C2. The fragment was located outside the spinal
knowledge and orientation so that previously inserted canal by ultrasonography. The filly was highly ataxic and
screws and plate screws do not interfere (Figure 34.16). stabilized using medical treatment but remained grade 3
When cervical fusion is performed, a cancellous bone ataxic. The subluxation was reduced and the involved verte-
graft, harvested from sternebrae, or calcium phosphate is brae were fused using a combination of a titanium cervical
placed into the intervertebral disc space. We have developed spacer placed into the ventral aspect of the disc space and
a titanium cervical spacer-plate system using 3D printing stabilized with 5.0–3.0 mm cancellous screws and a ventral
technology (3D Medical, www.3D http://medical.fr) which titanium cervical plate fixed with three 6.45–4.0 mm
was used in a two-year-old Lusitanian filly. This horse pre- locking cancellous screws in each vertebra. This implant
sented after field trauma with hyperflexion and marked combines the advantages of a KCC and a LCP, providing
subluxation of the articular facets at C2/C3 and avulsion stability in flexion, extension and rotation (Figure 34.17).
(a) (b)
(c)
Figure 34.17 Ventral cervical fusion to stabilize subluxation and dysjunction of the articular facets of C2 and C3 with avulsion
fracture. The vertebrae were realigned and fused using a combination of a titanium spacer and cervical plate fixed with locking
cancellous screws. (a) Titanium cervical spacer and plate system. (b) Pre-operative lateral radiograph: subluxation of the articular
facets (white arrow) and avulsion fragment (black arrow). (c) Four months post-operative radiograph with good realignment of C2 and
C3 and intervertebral fusion.
The horse improved rapidly after surgery and was almost s pacer-plate system was efficient in promoting vertebral
normal at walk one month post-operatively. fusion as well as preventing intervertebral collapse that is
These implants have also been successfully used by the sometimes observed using the KCC (Figure 34.18).
author in several adult horses and yearlings with cervical At the end of surgery, the surgical site is copiously lav-
stenotic myelopathy with vertebral subluxation. The cervi- aged and an active drain (Redon) is placed under the mus-
cal spacer is applied at the disc space after removal of disc cle. Subcutaneous tissue and skin are routinely closed,
material by drilling with the help of an aiming device and the wound is protected with a stent bandage. Recovery
before the titanium cervical plate is placed ventrally to sta- should be assisted; the author uses a single tail rope
bilize the vertebrae in good alignment. The cervical system.
(a) (b)
(c) (d)
Figure 34.18 Ventral cervical fusion in an 18-month-old trotter colt with C3/C4 cervical stenotic myelopathy and dorsal subluxation
of C4. The horse improved by two neurologic grades. (a) Pre-operative radiograph illustrating dorsal subluxation of C4 (white arrow).
(b) Removal of disc materials using the aiming device. (c) Placement of the spacer through the aiming device. (d) Three-month
post-operative radiograph demonstrating good alignment and fusion with no intervertebral collapse.
Dorsal Laminectomy
A potential intra-operative complication is laceration of
the oesophagus due to slipping from the retractor as the Stabilization by interbody fusion of cervical vertebrae only
external musculature of the oesophagus is similar to that of makes sense if the stenosis is exaggerated by flexion
the longi colli muscle. The risk is greatest at rostral sites (dynamic stenosis). Horses suffering from compressive mye-
where the oesophagus is sagittal and dorsal to the trachea. lopathy due to static stenosis will derive little benefit from
Post-operative complications include surgical site seroma interbody fusion as spinal cord compression is independent
formation and screw pullout. In the author’s experience, of neck position. When callus is already present and com-
the risk of screw pullout is increased when the ends of the presses the spinal cord, decompression may be attempted in
plate are not in contact with the bone. This can lead to certain cases by dorsal laminectomy with the horse in lateral
instability during flexion and to dorsal displacement of the or sternal recumbency [26, 27]. The approach is similar to
screw towards the vertebral canal. that used for laminectomy of the dorsal atlas (“Dorsal lami-
In cervical fractures involving the articular facets or nectomy” section), but the massive musculature surround-
pedicles, fusion may also be performed using a KCC as ing the mid and caudal cervical areas makes the procedure
described for cervical stenotic myelopathy [21]. much more challenging, especially in adults.
(a) (b)
Figure 34.19 Anatomic specimen demonstrating dorsal laminectomy. Cranial is to the left. (a) A peripherical rectangular channel is burred,
outlining the lamina to be removed from each vertebra. Care is taken not to damage the spinal cord when reaching the thin inner cortex.
(b) The free lamina of the cranial and the caudal vertebra are removed avoiding excessive lateral excavation. Following decompression, a fat
graft is placed in the defect, covering the dural sac (the latter has been removed in the photograph). SC: spinal cord.
The horse is positioned in left lateral recumbency with excavation of bone in the abaxial portions of the canal
the neck flexed maximally. Body movement, when the should be avoided as this significantly weakens the bony
neck is pulled into flexion, is counteracted by a sternum support of the articular processes and can result in frac-
brace and neck flexion is maintained by placing a pad- ture of the pedicle. Following decompression, a nuchal
ded strap behind the poll [26]. A dorsal midline approach fat graft is placed in the defect, covering the dural sac.
is used to expose the dorsal lamina. The surgical incision The multifidus muscles are re-apposed over the fat, and
should be very long (40 cm) covering at least four cervi- a suction drain is placed. The surgical wound is closed in
cal vertebrae, to permit retraction of the stiff nuchal three layers.
ligament and strong multifidus muscles overlying the
dorsal lamina of the vertebrae. Large self-retaining
Results
retractors, cushioned with moistened towels, are used to
retract the lamellar ligamentum nuchae and dorsal mus- Plate fixation was considered useful for the treatment of
cles. The tendinous insertions of the multifidus muscles cervical fractures in adult horses in two case reports [19,
and ligamentum nuchae are incised from the spinous 22], and some anecdotal descriptions have mentioned bio-
process using a #12 scalpel blade. A peripherical rectan- mechanical advantages over other techniques, particularly
gular channel is burred, outlining the lamina to be when using LCPs [24, 25].
removed from each vertebra (Figure 34.19). After exci- There are no published results of dorsal laminectomy in
sion of the axial aspect of the joint capsule from the treating stenosis resulting from fractures. In one old
articular facets, a 2 cm portion of the dorsal lamina is study [26], subtotal dorsal laminectomy was used to relieve
removed from the cranially affected vertebra, using a compression due to cervical vertebral malformation in 16
high-speed burr and reverse cutting bone forceps. This is horses. The majority were Thoroughbred or Quarter Horse
a delicate procedure and great care should be taken not males, one to four years old. The caudal cervical vertebrae
to damage the spinal cord as the thin inner cortex is were involved in all but two cases. All horses recovered from
reached. This latter is carefully channelled using a fine surgery without complication or deterioration in neurologi-
diamond burr and regular probing with a curved hemo- cal status. Neurological improvement occurred in 12 cases,
stat. Traction is then applied to the free segment of bone including six that became sound. Three horses subsequently
with bone-holding forceps, while the remaining soft tis- fractured a vertebral articular process and were euthanized.
sue attachments are severed using curved scissors. After A modification to the shape of the laminectomy, avoiding
removing the free lamina of the cranial vertebra, the excessive removal of abaxial portions of the canal, was
procedure is repeated on the caudal vertebra. Excessive adopted to reduce risk.
ractures of Thoracolumbar
F Clinical Features and Presentation
Vertebrae When complete fractures involve the vertebral body or arch in
adult horses, they almost always produce severe neurologic
Anatomy signs that necessitate euthanasia. Fractures of the spinous
Thoracic vertebrae are characterized by long spinous pro- processes are not usually associated with any neurologic
cesses and short bodies with articular facets for ribs. signs [30]. They usually produce local swelling that is painful
Articular and transverse processes are small. Lumbar ver- to palpate. In cases with marked fragment displacement and
tebrae are dominated by large transverse processes and overriding, the dorsal contour or profile may be flattened and
have pronounced but shorter spinous processes. the withers wider than normal (Figure 34.20). In some ani-
mals, fragments may be palpable and, before swelling is
marked, crepitus may be appreciated on manipulation.
Fractures Types, Incidence and Causation Imaging and Diagnosis
Thoracolumbar vertebral injuries are more common in The diagnosis of a thoracolumbar vertebral body fracture
adult horses than in foals [4]. Horses that engage in jump- in an adult horse is complicated by massive surrounding
ing, especially steeple chase races, are most often affected musculature that compromises radiography. The clinician
with life-threatening fractures. Stress fractures of caudal must often rely on physical examination and neuroana-
thoracic and lumbar vertebrae in racehorses may remain tomic localization to make a presumptive diagnosis. In
undetected [27]. Lumbar fractures tend to occur in race- appropriate circumstances, scintigraphy can be useful to
horses, and pre-existing pathology at the L5–L6 junction localize affected vertebrae (Figure 34.21). Transrectal ultra-
can predispose to catastrophic fracture [28]. Fracture of sonography can permit identification of fractures of the
the thoracic spinous processes is often associated with vertebral body of lumbar vertebrae caudal to L4 [31]. Some
horses rearing, falling backwards and striking the with- fractures of the articular facets can be imaged by adopting
ers. They are most common at or near T6 [29]. The most an external approach to the thoracolumbar area [32]. In
common sites of fracture of vertebral bodies include the foals, CT can be used to assess the thoracolumbar spine
first three thoracic vertebrae, around T12 (the area of and myelography can document spinal cord compression.
greatest lateral bending and axial rotation), and the lum- This is needed to determine the extent of decompression if
bar vertebrae. dorsal laminectomy is being considered [3]. Fractures of
(a) (b)
Figure 34.20 Varying degrees of displacement associated with fracture of six cranial thoracic spinous processes. (a) Lateral
radiograph. (b) Resultant flattened dorsal contour of the withers.
Fractures of Thoracolumbar Vertebra 733
(a) (b) (c)
Figure 34.21 Dorsal and oblique lateral scintigraphic studies of a Thoroughbred racehorse revealing increased radiopharmaceutical
uptake (circled) associated with a lumbar laminar stress fracture.
the spinous processes are usually readily identifiable on Surgical Stabilization in Foals
lateral radiographs (Figure 34.20)
This can be performed alone, or combined with a dorsal
laminectomy, with the foal in sternal or lateral recum-
Acute Fracture Management bency [3, 26]. Sternal recumbency allows an approach to
both sides of the spinous process and facilitates radiographic
Acute fracture management will depend on the neurologi- assessment. Powered equipment is used to carefully insert
cal status after the first 24–48 hours. Absence of response the pins. The caudal pins are positioned caudal to the articu-
to strong pinching of the skin over caudal regions of the lar processes and lateral to the vertebral canal. They are
body and/or no response to deep pain for more than angled ventrocaudally 30° off the vertical line and towards
24 hours indicate major and irreversible trauma of the spi- the midline 20° off the vertical line. The pins should barely
nal cord and should lead to euthanasia. exit the ventral portion of the vertebrae. Extreme caution is
Horses that are able to stand should receive NSAIDs necessary to avoid injury to the aorta and vena cava, which
(phenylbutazone: 4.4 mg/kg IV q24h), corticosteroids run close to the ventral surface of the vertebrae. Steinmann
(dexamethasone: 0.1 mg/kg IV q12h) and DMSO (1 g/kg pins are placed in the adjacent vertebral bodies, the verte-
IV q24h) given in lacted Ringers solution. Standing up brae are manipulated into alignment and polyvinylidene or
after lying down can be very painful, with increased risk LCPs [33] are applied to the spinous processes of the injured
of further displacement of the fracture. Managing the and the two adjacent vertebrae. Two plates can be super-
horse in a sling can assist and improve fracture stability posed on one side or one on each side of the spinous pro-
and healing. cesses to improve stability. Polymethyl methacrylate is used
to connect the pins and the plates and produce rigid fixation.
In foals, the plates should be removed after three to four
months to prevent development of lordosis. This procedure
In adults, fractures of the vertebral body and lamina arch has not been described in adults and would probably be
are managed conservatively with prolonged stall rest. extremely difficult to perform due to the strong musculature
Repeated clinical assessments and diagnostic imaging and technical difficulty of intra-operative imaging. Fractures
should be used to monitor progress and to refine prognosis of thoracic and lumbar vertebrae in adults are also often
according to expected use of the horse. Thoracolumbar highly comminuted and associated with major neurological
laminectomy and fracture stabilization in the foal have signs including recumbency.
been described anecdotically but should only be attempted
if the foal shows evidence of deep pain or voluntary move-
Fractures of the Spinous Processes
ment of the hindlimbs [3]. In some circumstances, stabili-
zation with Steinmann pins and polymethyl methacrylate Fractures of the spinous processes usually do not require
bone cement is possible. surgery unless fragments become sequestered or their
position precludes use of a saddle [3, 4]. A special saddle pad thetic fibres and the caudal rectal nerves that originate
may be necessary if the defect is in the withers area. If sur- from these nerve roots [3, 36].
gery is elected, subtotal ostectomy can be performed under
general anaesthesia or in the standing horse [34, 35]. The Clinical Features and Presentation
advantages of performing the procedure standing include
reduced haemorrhage, improved visibility and better access Clinical signs include pain, deformation and swelling over
to both sides of the process(es); all of which facilitate dissec- the croup and tail head (Figure 34.23), tail weakness or
tion and separation of the muscular attachments. Ventral paralysis, decreased anal tone, retention of faeces, bladder
drainage is provided in the presence of infection. distention and urine dribbling [37]. There may be analgesia
of the tail, anus and perineal region and of the surface of
the penis in males. More-extensive injuries, which may
Fractures of the Sacrum also involve the caudal lumbar and cranial sacral regions,
can produce marked hindlimb weakness and ataxia.
In most horses, the sacrum contains five vertebrae that in Imaging and Diagnosis
adults function as a single unit. In foals, the individual verte-
brae are separate and some independent motion is possible [2]. Clinical examination, especially transrectal palpation, neu-
The cranial sacrum is protected by the tuber sacrale of the rologic examinations, external and transrectal ultrasonog-
pelvis, which prevents sacral fracture but may lead to sac- raphy and radiography are useful for localizing the lesion
roiliac subluxation with associated chronic pain and lame- and determining the extent of spinal cord and nerve dam-
ness. The caudal sacrum and tail base region is most age. CT can be used in foals. Scintigraphy may localize
exposed, and in adults stresses from impact injury appear non-displaced fractures.
to be concentrated at the level of S4 and S5.
Sacral fractures may be treated conservatively or surgi-
Fractures of the sacrum usually result from hard impact cally. Conservative treatment, which consists of stall rest,
trauma when horses fall backwards, suddenly sit down or anti-inflammatory drugs and avoidance of tail manipula-
back into a wall. Fractures and luxation of the caudal tion, may allow the formation of a fibro-osseous bridge
sacrum involve the cauda equina and may lead to loss of and possible regeneration of damaged nerves. In horses
function in the sacral and caudal nerve roots leading to the with chronic tail paralysis and faecal soiling, amputation
sciatic, caudal gluteal, pudendal nerve with parasympa- of the tail may be necessary.
II
I III
First sacral IV
spinous process
V
Last sacral
spinous process
Articular process
Dorsal sacral foramen
Caudal incisure
Articular surface
Sacrum apex
Wing
Ventral sacral foramen
Figure 34.22 Lateral diagrammatic anatomy of the adult sacrum. Source: Adapted from Barone [1].
Reference 735
(a)
(b)
Figure 34.23 Five-year-old thoroughbred filly with a complex sacral fracture, sacrococcygeal subluxation and fracture of the first
coccygeal vertebra. (a) External view: note flattening of the caudal part of the sacrum and tail paralysis. (b) Composite lateral
radiograph. Source: Adapted from Barone [1]
Information on the surgical repair of sacral fractures in locking screws into S4, S5 and Cy1. No complications were
large animals is scarce. De-compression by laminectomy, encountered. The technique produced good results, with
open reduction and internal fixation of fractures have been restored tail motility and defaecation, and allowed normal
described in case reports [3, 4, 37–39]. An Arabian stallion calving. There was no narrowing of the pelvic canal, and
with a chronic fracture of S5 and callus formation was the top line of the sacrum was restored.
treated by laminar decompression without internal fixa-
tion. The tail was amputated [38].
In foals, stabilization can be accomplished with long Fractures of the Coccygeal Vertebrae
plates attached to the spinous processes [33]. The plates
must be removed within a few months of repair to prevent On average, horses have 18 coccygeal vertebrae. Fractures
the development of lumbosacral lordosis. generally result from horses falling back onto the tail or
backing into an immovable object [4]. Other causes of tail
Technique and Results injury include entrapment in a door, bite wounds by other
animals and improperly placed tail wraps. Fractures can be
LCP fixation, as reported in three heifers suffering from simple or comminuted, closed or open, depending on the
closed fracture of the sacrum at S5 or S4 and S5 [37], might type of injury. If the tail distal to the injury loses its blood
be adaptable to horses. These were positioned in either supply, amputation is required. Both pain and nerve injury
sternal or right lateral recumbency. A curved paramedian can lead to an inability to move the tail and defecate prop-
incision was made dorsally from S2 to the level of Cy3. The erly [40]. Muscle atrophy over the tail head is consistent
spinous processes and dorsal aspect of S5 and Cy1 were with neurogenic atrophy. Fractures are confirmed
accessed by blunt dissection. Two simultaneous approaches radiographically.
were used to reduce the fracture. In the first, repositioning Most horses are managed conservatively with stall rest
forceps were used to grasp the cranial articular and spinous and administration of anti-inflammatory drugs. Open and
processes of Cy1 and S5, and strongly pull the two frag- necrotic fractures should be debrided [39, 40]. These frac-
ments apart. At the same time, an assistant applied dorsal tures can be relatively slow to heal and may lead to perma-
transrectal pressure to Cy1 and S5. A narrow 4.5/5.0-, 6-, nent neurologic damage as well as conformational changes
8- or 10-hole LCP was then applied by inserting 5.0 mm due to muscle atrophy and callus formation.
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739
35
Fractures of the Ribs

D.G. Levine
A
natomy occur further dorsally, 10–15 cm distal to the costovertebral
articulation [4]. Less frequently encountered are complete
The costae (ribs) are the bones that make up the thoracic fractures of both the dorsal and ventral body (referred to as
wall. There are usually 18 pairs of ribs in the domestic a segmental fracture). These can occur in multiple adjacent
horse, although a nineteenth rib on either side is possible. ribs leaving a ‘flail chest’ in which the integrity of the tho-
The ribs can be divided into three groups determined by racic cage is disrupted and no longer acts as a unit in coor-
their ventral attachment. True ribs (also called sternal ribs dination with breathing. A pathognomonic paradoxical
or the costae verae) articulate with the sternum via their motion is evident in which the flail segment moves inwards
ventral costal cartilage made of hyaline cartilage. False ribs by increased negative intra-thoracic pressure on inspira-
(also called asternal ribs or the costae spuriae) do not artic- tion and then outwards by the increase in positive intra-
ulate with the sternum but instead fuse with the costal car- thoracic pressure on expiration. Most fractures are closed
tilage of adjacent ribs to form the costal arch (arcus externally but can cause trauma to adjacent vessels, the
costarum) [1]. Ribs with no ventral cartilaginous attach- epicardium or the lungs. In foals, displacement is common,
ment are called floating ribs. with moderate displacement seen ultrasonographically in
The dorsal end of the rib is known as the vertebral up to 70% of cases. Of these, all involved medial displace-
extremity or head. It contains two convex facets that articu- ment of the dorsal fragment [3]. Particularly in foals, rib
late with the bodies of the adjacent cranial and caudal tho- dislocation at the costochondral junction is possible and
racic vertebrae with the exception of the first rib that should be considered when there is obvious thoracic cavity
articulates cranially with the body of the seventh cervical asymmetry but no radiographic evidence of a fracture [5].
vertebra. The tubercle, located caudally at the junction of
the neck and body of the rib, articulates with the transverse
processes of the adjacent cranial and caudal vertebrae [1]. Incidence and Causation
Rib curvature differs according to its location with
greater angulation in the dorsal third of the bone. The cos- Rib fractures are common in neonatal foals. They have a
tal groove (sulcus costae), which contains the intercostal reported incidence of 9–20% and account for 37% of life-
vessels and nerves, is found on the caudal edge of the ribs threatening fractures in foals under six months of age [2, 5,
and is most pronounced dorsally [1]. 6]. Pleural and pulmonary lacerations resulting in haemo-
thorax and subsequent pulmonary collapse are the most
common cause of fatality [2]. The majority (69%) of foals
F
racture Types admitted to neonatal intensive care units have suffered rib
injuries [3]. Rib trauma has been associated with abnormal
The most common complete fracture is a simple or mildly foalings (dystocia and assisted vaginal delivery) and with
comminuted oblique transverse fracture of the body. In primiparous mares [5, 7]. Care should be taken when
foals, these are frequently in the ventral third of the rib, manipulating a foal in utero, and attempts should be made
occurring at or near the costochondral junction in 69–84% to correct positioning before assisted/controlled vaginal
of reported cases [2, 3]. In adults, fractures more frequently delivery. Increased pressure on the thoracic cavity during

740 Fractures of the Ribs
parturition particularly with malalignment of the foal can involving ribs T2–T7 in one report and 86% of fractures
traumatize the rib cage. A field study outlining the incidence involving ribs T3–T8 in another [2, 3].
of thoracic trauma in 263 foalings on a single stud farm iden- The true incidence of rib fractures in adults may be
tified a trend towards a higher incidence in fillies but no dif- misconstrued as many with confirmed fractures lack
ference in size between those affected with thoracic cavity either a history of trauma or even pain on palpation of
asymmetry and normal foals [5]. Subsequent studies looking the affected rib; a number may therefore go undiag-
at foals admitted to referral hospitals have shown contradic- nosed [8]. Adults can present with clinical signs of lame-
tory difference in occurrence between fillies and colts [3, 7]. ness, gait alteration or difficulty being saddled or
Rib fractures in adults are uncommon and most likely ridden [4, 10]. Rarely, displaced fractures in adults can
due to trauma such as falls, trailer accidents or kicks. A perforate the pleural cavity causing pneumothorax and
fatigue-related injury has been postulated in Thoroughbred respiratory distress. More commonly, the clinical signs
racehorses presenting with fracture of the first rib (T1), an are vague and do not localize to the thoracic cavity.
injury that was unique to this subset in a retrospective Evaluation for poor performance and difficulty under
analysis of 50 adult rib fractures [8]. tack may lead to investigation of the ribs. In contrast to
foals, rib fractures in adults are more common in the
caudal ribs and specifically T18 which was affected in
Clinical Features and Presentation 10/15 (67%) of cases [4].
Most foal fractures are identified on initial physical exami-

nation. Affected foals are often reported by farm managers Imaging and Diagnosis
to have had difficult foalings. Pain over the rib cage is com-
mon with foals grunting when fractured ribs are pal- Careful physical examination of newborn foals is critical
pated [7, 9]. Respiratory distress is rare. However, rapid to early diagnosis. Often a depression is noted over the
decompensation and sudden death can be seen. Death in fractured rib(s); crepitus is inconsistent. Pain on palpa-
up to 89% of fatal rib fractures occurs within the first week tion is common but not present in all cases. Radiography
of life [2]. A significantly higher incidence occurs in the and ultrasonography can be used to confirm fractures and
left hemithorax; however, right-sided and bilateral frac- identify which ribs are involved. Ultrasonography is more
tures are also seen [3]. Multiple (>3 in 85%) and cranial sensitive in identifying rib fractures in foals with a study
ribs are more frequently affected, with 69% fractures reporting 65% diagnosis rate with ultrasound vs. 19% with
(a) (b)
Figure 35.1 Ultrasonic image of a fractured fifth right rib. (a) Longitudinal view showing displacement and overriding of fracture
ends (arrow). (b) Transverse image at the same level.
Figure 35.2 Delayed phase lateral

scintigraphic views of a fractured right
15th rib. A localizing marker has been
placed over the right kidney.
radiography (Figure 35.1) [3]. Ultrasonography also T

reatment Options
allowed diagnosis of concurrent thoracic trauma when and Recommendations
radiography did not [3, 7].
In adults, nuclear scintigraphy is usually the most use- Conservative Treatment
ful technique to identify rib fractures (Figure 35.2).
Fractures of the first rib can be difficult to image with Foals
standard views because of the overlying scapulohumeral As the true need to repair rib fractures in foals is still debated,
joint. Pulling the limb cranial or caudal for lateral views in many cases conservative management remains the pre-
and taking cranial scintigraphic views can be helpful ferred option. This is certainly true for fractures that are non-
(Figure 35.3). If clinical suspicion localizes to a particu- displaced and those that are not adjacent to important
lar region or scintigraphy reveals increased metabolic cardiovascular structures. Repair is usually limited to frac-
activity, ultrasonographic examination may identify the tures of the third, fourth and fifth ribs and those that are
fracture, or the presence of callus, and allows healing to extensive and causing serious dyspnoea. Increased mortality
be monitored. has been seen with associated comorbidities, including
pneumothorax, haemothorax, haemopericardium and
(a) (b)
Figure 35.3 (a) Cranial and (b) lateral delayed phase scintigraphic images of a left first rib fracture. Note how pulling the limb
forwards allows the fracture to be seen more clearly.
diaphragmatic herniation; in these situations, surgical man-

agement is recommended [11]. Supportive care in conserva-
tive treatment is determined by individual case needs. This
usually includes some form of confinement with or without
the mare, analgesic medication to aid in pain relief and to
ease breathing, assistance to stand and a padded recum-
bency area. Although seemingly counterintuitive, when in
lateral recumbency, the foal should be positioned so that the
affected hemithorax is down to promote maximal aeration
of the unaffected lung. Active conservative management
should be continued until the fracture is stable which can
take several weeks. Repeat ultrasonographic evaluation and
careful palpation can help determine stability.
Figure 35.4 Using towel clamp to elevate a fractured rib in
Adults preparation for repair.
Most rib fractures in adults do not require interference; in
a retrospective series of 50, surgical intervention was per-
formed in only 5 cases [8]. Displaced fractures that may
result from direct trauma are rare, and surgical correction
would only be warranted for a displaced fracture over the
base of the heart. Stall confinement and analgesic medica-
tion only are required for the majority of fractures.
Fracture Fixation
Multiple techniques have been described for repair of rib
fractures in foals. Each has its own pros and cons. The
approach is common to all, and individual techniques will
then be discussed separately.
Figure 35.5 Skin incisions following repair of six rib fractures
Approach through two incisions.
In most cases, all affected ribs do not need to be repaired. The
goal is to stabilize the chest wall sufficiently to ease breathing
and prevent cardiovascular injury by fractured ribs. The foal
is anesthetized and placed in lateral recumbency with the If a pneumothorax is encountered at surgery, either a
rib(s) to be stabilized uppermost. Positive pressure ventila- small diameter chest tube (i.e. modified Stallion Urinary
tion is often used. The rib is approached with a linear incision Catheter, JorVet™, Loveland, CO, USA) or a 3 mm diame-
over the rib starting ventrally at the costochondral junction ter blunt teat cannula (i.e. Teat Udder Cannula, Zikimed,
and extended dorsal to the fracture. In the cranial portion of Lithia Springs, GA, USA) attached to gas suction should be
the thorax, the serratus ventralis muscle is identified and inserted through an intercostal space (avoiding the cau-
incised. Deep to this (and overlying the rib if starting caudally located neurovascular bundle) into the pleural space
dally), the cutaneous trunci muscle is incised down to the within the caudodorsal lung field (Figure 35.6). This
level of the periosteum. At this point, the ventral fracture increases negative intra-thoracic pressure which improves
fragment can be elevated. Towel clamps, Allis tissue forceps ventilation and anaesthetic stability. Following repair, if
or in larger foals small bone reduction forceps can be placed the foal maintains appropriate oxygenation and eupnoea
circumferentially around the ventral fragment near the cos- while breathing spontaneously (which indicates resolution
tochondral junction to effect reduction (Figure 35.4). Often of the pneumothorax), the chest drain can be removed. If
many ribs can be repaired from each incision. The author not, a permanent drain (i.e. Argyle™ Trocar Catheter,
aims to repair two to three ribs through each incision and will Cardinal Health™, Dublin, OH, USA) should be placed
determine incision sites by how many ribs are to be repaired with a one-way sealed flutter valve (Bard-Parker™
(Figure 35.5). The skin incision can easily be manipulated Heimlich Chest Drain, BD, Franklin Lakes, NJ, USA)
over immediately adjacent ribs and separate incisions made attached so that the pneumothorax can dissipate more nat-
through the muscle overlying the additional ribs. urally. Alternatively, serial aspirations can be performed.
with the caudal border of the rib. The needle is then redi-
rected caudally within the intercostal space until bone is no
longer contacted before being advanced slightly. Ideally,
the needle tip will lie deep to the intercostal musculature
but extrapleural within the subcostal space at the level of
the neurovascular bundle. Negative pressure confirms the
absence of vessel or pleural penetration. If blood is aspi-
rated, the needle is redirected slightly cranial in the cranial
thorax and caudad in the caudal thorax to account for vari-
ation in the neurovascular positioning [1]. If air is aspi-
rated suggesting thoracocentesis, draw back slightly to
enter the subcostal space. Once in the desired location, the
predetermined volume of local anaesthetic is injected.
Intercostal perineural anaesthesia in adult horses using a
combination of 0.5% bupivacaine hydrochloride at 1.5 mg/
kg and 0.05% dexmedetomidine hydrochloride at 0.001 mg/
kg has been described to provide analgesia for up to
12 hours [12]. Alpha-2 agonists should be avoided in foals
less than four weeks of age due to potential profound
haemodynamic effects resulting from increased peripheral
vascular resistance leading to a reflex bradycardia and det-
Figure 35.6 Teat cannula inserted and suction applied to
rimental decreased cardiac output [13]. Furthermore,
dorsal caudal pleural space.
many foals requiring surgical fixation have comorbidities
making them poor or at-risk anaesthetic candidates. The
use of locoregional anaesthesia (2% lidocaine) in dogs
Severe pain associated with rib fractures is well recog- undergoing routine castration significantly decreased the
nized in man. This can be extrapolated to equines by the end-tidal isoflurane concentration compared to controls,
marked resentment of palpation, tachycardia and varying thereby decreasing the overall inhalant anaesthetic require-
degrees of dyspnoea, encountered in foals. It has been ment [14]. These results suggest that use of locoregional
argued that as pain is a protective mechanism, the foal may anaesthesia may decrease the anaesthetic requirement in
guard the affected side and thus potentially decrease the these compromised foals. Recently, a commercially availa-
risk of epicardial or lung puncture. In the author’s experi- ble liposomal formulation of bupivacaine (Nocita®) has
ence, these events occur sporadically, typically from a fall been shown in dogs to provide analgesia for up to 72 hours
or struggling during restraint. Surgical stabilization and/or following cranial cruciate ligament surgery [15]. Although
provision of appropriate analgesia are therefore indicated. perineural pharmacokinetics and efficacy have not been
Systemic medication (NSAID’s, opioids, etc.) have been the reported in horses, at the author’s institution Nocita has
mainstay of analgesic therapy; however, there has been a provided prolonged local anaesthesia at thoracic drain,
movement in both human and veterinary medicine towards thoracotomy, fracture and rib resection sites. When anaes-
the application of locoregional perineural techniques. The thesia of multiple intercostal nerves is required, it can be
intercostal nerves, which are the ventral branches of the useful to perform a 1:1 dilution with 0.9% NaCl to increase
thoracic spinal nerves, travel within the costal groove along volume and achieve blockade. Generally, the intercostal
the caudal edge of the rib. At the dorsal extent of the tho- nerve of interest as well as the adjacent cranial and caudal
racic cavity, they lie between the external (inspiratory) and nerves should be anesthetized. In thick-bodied animals,
internal intercostal (expiratory) muscles, but ventrally, the combined use of 20-gauge 3.5″ spinal needle and ultra-
they dive deeper to lie superficial to the parietal pleura [1]. sonographic guidance can increase ease of localization and
These nerves provide motor function to the intercostal ensure accurate delivery of local anaesthetic.
muscles as well as sensory input from the surrounding tis-
sues including rib periosteum. The sensory input is some- Plating
what diffuse, but the majority arises from the intercostal A technique to stabilize rib fractures with reconstruction
space and rib caudal to that with which they are associated. plates and orthopaedic wire used in cerclage fashion has
In order to achieve anaesthesia, the caudal aspect of the rib been reported. A 2.7 mm reconstruction plate is con-
is palpated as far dorsal as possible. A 22–25-gauge needle toured to the fractured rib, 2.7 mm self-tapping cortical
is inserted perpendicular to the skin until contact is made screws are placed such that the cis- and trans-cortices at
two to three sites dorsal and ventral to the fracture plane

are engaged and 18–22-gauge orthopaedic wire is placed
in cerclage fashion encompassing the plate at two sites on
either side of the fracture plane [16]. In some of the cases,
reconstruction plates and cerclage wire were used with-
out screws. Although this technique does not require
drilling towards the thorax, in some of the repairs cortical
screws were also placed in the ribs for added security.
This combination technique of reconstruction plates,
screws and cerclage wire was also used in an adult horse
with a pericardial contusion secondary to a displaced fifth
rib fracture. When figure-of-eight wiring failed to fully
stabilize the fracture, a 5.0 mm six-hole locking–compres-
sion plate with screws produced appropriate
stabilization [10].
Figure 35.7 Nylon zip tie tightened to reduce and stabilize
Nylon Cable (Zip Tie) fracture.
Nylon cable fixation has been described and popularized
due to its low cost and relative procedural ease. Following
exposure and elevation of the ventral fragment, it is
placed to overly the dorsal fragment. The size of the rib
determines if a 4 mm or a 2 mm implant is employed. In
most cranial ribs, a 4 mm tie can be used, while caudally
in young foals, a 2 mm implant is used. For the 4 mm
implants, a 4.5 mm drill bit is used to drill through both
the dorsal and ventral fragments at the same time. Drilling
once with fragments overlying each other reduces the
number of procedures and the risk of thoracic penetra-
tion. Drill holes are placed between 5 and 10 mm from the
fracture ends. In smaller ribs, a 2.5 mm drill bit and 2 mm
implant are used. Once the holes are drilled, the sterilized
nylon cable is placed parallel with the rib through the Figure 35.8 Drill bit placed in the fracture line and drilling
holes. The fracture is reduced manually and held with abaxially to protect thoracic structures.
towel clamps. When adequate reduction is obtained, the
cable tie is tightened and the free edge cut close to limit
protruding sharp edges (Figure 35.7) [17]. The technique fragment overlap increases stability, thereby reducing the risk
can also be performed on multiple ribs through a single of potentially fatal complication [18].
skin incision.
A modification of this technique was made to minimize the Securos Cranial Cruciate Ligament Repair System™
potential complication of reduced but non-overriding frag- and Similar Suturing Techniques
ments displacing and causing pericardial penetration. To Once the ventral fragment is elevated, a 2.5 mm drill bit is
increase stability, the fracture is fixated without reduction. In used to drill a hole from its dorsal end exiting the abaxial
this technique, the drill hole is made in the overriding frag- surface at the cranial border about 1.5 cm ventral to the
ments with the ventral fragment axial to the dorsal fragment. fracture (Figure 35.8). A similar hole is made from the dor-
The cable is then passed through both fragments as drilled sal end to exit the abaxial surface at the caudal border
and tightened cranially while in an overriding position. about 1.5 cm ventral to the fracture. Corresponding drill
Cranial placement of the cable tie is essential to avoid the cau- holes are made in the dorsal fragment starting at its ventral
dally located neurovascular bundle [18]. As above, the diam- edge and exiting the abaxial surface cranially and caudally
eter of drill bit and width of implant are chosen in accordance about 1.5 cm dorsal to the fracture plane. An 80-pound
with overall rib diameter [17]. The reporting authors claimed strand of nylon (Securos Cranial Cruciate Ligament Repair
that perfect reduction of the fracture is not required and that System [SCCLRS], Securos Surgical®, Fiskdale, MA, USA)
Result 745
is passed through these holes in a figure-of-eight pattern so the risk of migration and serious (fatal) complications
that the free ends of the suture are both dorsal to the frac- associated with implant failure, this technique has fallen
ture plane. The SCCLRS clamping technique involves three out of favour. Newer techniques are both safer and easier.
clamps. One placed with each strand going through (the
caudal strand cranially and the cranial strand caudally) as
well as an additional clamp on each strand alone. The Results
SCCLRS clamp is crimpled on each strand, and then once
reduction is complete, the tensioning device is applied to The requirement for surgical repair of rib fractures
the crimped clamps to tighten the nylon strand. The crimp- remains open to debate. Recent unpublished data from the
ing device is then used on the crimp containing both Hagyard Equine Medical Institute compared outcomes of
strands to secure the nylon [19]. 97 foals with fractured ribs: 20/24 (83%) managed conserv-
The author has used this technique and has also atively survived to discharge vs. 57/73 (78%) managed
employed two modifications. In a calf where the ribs are surgically [11]. However, this data does not identify
flatter, the drill hole was difficult to place from the fracture whether death was a result of thoracic trauma secondary
end to the outer surface of the rib. Thus, two full drill holes to rib fracture or another cause. Neonates admitted to
were made in each fragment from the abaxial surface to the intensive care unit often have multi-factorial disease.
axial surface cranially and caudally and the figure of eight Comorbidities aside, in a young rapidly healing foal with
was placed on the axial side of the fracture [20]. This could one or few simple, non-displaced fractures in a non-
be used in small foals with narrow ribs and would have the precarious location, it is likely that healing will proceed
benefit of not drilling towards the thoracic cavity. The other without complications. However, a foal with one or more
modification was to use a large diameter non-absorbable displaced fractures in a precarious location such as over
suture (FiberWire®, ETHIBOND EXCEL®, etc.) which is the heart may develop life-threatening complications. In a
more cost-effective, but does not have the strength and retrospective analysis of 56 foals with rib fractures, 14
tightening ability of the SCCLRS (Figure 35.9). (25%) died as a direct consequence of the fractures of
which 11 suffered epicardial laceration or contusion. This
Pins and Wires suggests that an ‘at-risk’ foal should be surgically stabi-
The use of 2.0 mm diameter Steinmann pins contoured to lized to optimize short-term outcome. Although there is
the rib surface and secured in placed with orthopaedic wire little literature on short-term outcome in adults with rib
used in cerclage fashion has been described [16]. Due to fractures, a similar conclusion may be inferred.
In a retrospective study comparing the long-term out-
come of Thoroughbred foals with rib fractures, 26/35
(a) (b)
(74%) eligible horses raced. These included 9/11 (81.8%)
that underwent surgical repair and 17/24 (70.8%) that
were conservatively managed. The median earnings were
not significantly different between treatment groups [21].
This data indicates a high likelihood of a racing career
despite significant neonatal trauma and suggests that
foals with repaired fractures may have a slightly improved
prospect of racing. Unpublished data out of the Hagyard
Equine Medical Institute found that surgically managed
foals are equally likely to start a race as their maternal
sibling, but earn less [11]. This may echo human medi-
cine which widely describes chronic pain and a decreased
quality of life in patients who sustained multiple rib
fractures.
There is limited information on long-term outcome in
adult horses. In a small retrospective study of adult
horses with rib fractures (most commonly T18) treated
conservatively, 7/8 (88%) in which long-term follow-up
Figure 35.9 (a) Modified technique showing the suture passing
axial to the fractured rib. (b) Original description avoiding was available had returned to their previous level of ath-
structures axial to the fractured rib. letic function [4].
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6 Harrison, L. (1995). Equine fracture cases. Equine Dis. Q. 3: 5. case selection, surgical technique and results. Equine
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56 cases of rib fractures in neonatal foals hospitalized in a 17 Downs, C. and Rodgerson, D. (2011). The use of nylon
referral intensive care unit from 1997-2001. AAEP Proc. cable ties to repair rib fractures in neonatal foals. Can.
47: 395–399. Vet. J. 52: 307–309.
8 Wylie, C.E. and Head, M.J. (2016). Clinical features of 50 18 Williams, T.B., Williams, J.M., and Rodgerson, D.H. (2017).
cases of rib fracture in adult horses. Equine Vet. J. 48 Internal fixation of fractured ribs in neonatal foals with nylon
(Suppl. 50): 25. cable tie using a modified technique. Can. Vet. J. 58: 579–581.
9 Sprayberry, K.A. and Barrett, E.J. (2015). Thoracic trauma 19 Kraus, B.M., Richardson, D.W., Sheridan, G., and
in horses. Vet. Clin. Equine. 31: 199–219. Wilkins, P.A. (2005). Multiple rib fracture in neonatal foal
10 Peters, S.T., Hopkins, A., Stewart, S. et al. (2013). using a nylon strand suture repair technique. Vet. Surg.
Myocardial contusion and rib fracture repair in an adult 34: 399–404.
horse. J. Vet. Emerg. Crit. Care 23: 663–669. 20 Ahern, B.J. and Levine, D.G. (2009). Multiple rib fracture
11 Sandow, C. (2019). Personal Communication. Lexington, repair in a neonatal Holstein calf. Vet. Surg. 38: 787–790.
KY USA: Haygard Equine Medical Institute. 21 Fehin, W.F., Wylie, C.E., Feeney, C. et al. (2017). The
12 Gingold, B.M.C., Hassen, K.M., Milloway, M.C., and future racing performance of neonatal thoroughbreds
Gerard, M. (2018). Caudal intercostal block for abdominal diagnosed with rib fractures treated both surgically and
surgery in horses. Vet. Rec. 183: 164–165. conservatively. Equine Vet. J. 49: 5–29.
747
36
Fractures of the Head

A.E. Fürst
University of Zurich, Zurich, Switzerland
I ntroduction Anatomy
The description and understanding of head fractures is
Fractures of the head, particularly of the mandible, are aided by a good working knowledge of the anatomy of the
common in horses [1]. The main causes are kicks from skull (Figure 36.1). The following outline is designed to
other horses, collision with a solid object or falls during help the reader understand the basic anatomy of the skull,
which the horse’s head hits a hard surface. In a recent but an anatomy textbook should be consulted for more
review of fractures caused by kicks, fractures involving the detailed information [5].
head comprised 12% of all injuries and were the second The bones of the head consist of the skull, the mandible
most common site after splint bone fractures [2]. Fractures and the hyoid bones. The skull is divided into the cerebral
of the incisive bone may also result from inappropriate use cranium or neurocranium, which forms a solid shell
of a mouth gag; weakened bone in old horses, inadequate around the brain, and the visceral cranium or splanch-
sedation or opening the mouth too wide have been cited as nocranium, which forms the basis for the face. In contrast
predisposing factors [3]. to humans, the visceral cranium in the horse is much larger
The paucity of soft tissue makes the head especially sus- than the cerebral cranium and lies rostral to, rather than
ceptible to fractures. Injuries range from minor defects, below, the latter. The bones of the skull are usually flat and
which may only be apparent as small indentations in the have compact external and internal laminae separated by a
bone, to severe, multifragment fractures with secondary cancellous/spongy layer.
involvement of vital structures such as teeth, sinuses, eyes,
nerves or major blood vessels. The extent and type of these Cerebral Cranium
lesions are usually the most important prognostic factors. The cerebral cranium is divided into the roof and base of
Most head fractures occur in the stall or on pasture in the the skull, and consists of the following parts: dorsally situ-
presence of other horses. A common fracture involves the ated frontal, interparietal and parietal bones; laterally
rostral parts of the visceral skull including the alveoli of the located temporal bone that is comprised of petrous and
incisors, when a horse firmly bites an object and suddenly tympanic parts, which contains the inner and middle ear,
withdraws its head while the teeth remain lodged. Many and the squamous part with the zygomatic process; ven-
head fractures are treated surgically and generally the trally situated sphenoid bone and the basilar part of the
prognosis is good: a surprising fact considering that 80% occipital bone; caudally the occipital bone and cranially
are open. In one study, 90% of horses with head fractures the ethmoid bone.
were discharged following successful treatment and 10%
had to be euthanized [2]. Head fractures are sometimes Visceral Cranium
missed or their significance underestimated. They are also The bones of the visceral cranium form the ocular, nasal and
frequently more complex on computed tomography (CT) oral cavities and the paranasal sinuses. These comprise the
than expected from clinical examination or identified on frontal and nasal bones dorsally with lacrymal, zygomatic
two-dimensional radiographs [4]. and incisive bones and maxilla laterally. The incisive bone

748 Fractures of the Head
(a)
(b)
Figure 36.1 Illustration of the bones of the skull: (a) lateral view and (b) ventral view: 1, incisive; 2; nasal; 3, frontal; 4, maxilla; 5,
lacrimal; 6, zygomatic; 7, interparietal; 8, parietal; 9, temporal; 10, petrous and tympanic portions of the temporal; 11, sphenoid; 12,
occipital; 13, palatine; 14, vomer; 15, pterygoid; 16, mandible; 16a, pars incisiva; 16b, interalveolar rim (diastema); 16c, pars molaris;
16d, ramus of mandible; 16e, condylar process; 16f, coronoid process.
consists of the alveolar part, which contains the alveoli of the process and coronoid process. The anatomical terminology
upper incisors, the palatine process, which forms the rostral describing the mandible has not been standardized. In this
part of the hard palate, and the nasal process. Ventrally, the chapter, the tooth-bearing part is referred to as the body or
visceral cranium consists of the palatine, vomer and ptery- corpus and the remaining as the vertical part or ramus. The
goid bones and caudally the ethmoidal bone. two mandibles are fused to form an intermandibular suture
line via a synchondrosis, which ossifies during the second
Mandible year of life [6]. The hyoid bone is located in the intermand-
The mandible consists of the incisive part, the interalveolar ibular space where it is well protected between the two
rim (diastema), molar part, mandibular ramus, condylar mandibular rami.
Introductio 749
Clinical Signs those of the cerebral cranium, cannot be definitively identi-

fied or evaluated. CT has become the diagnostic imaging
The clinical signs of head fractures are manifold and
modality of choice for identification and assessment of skull
depend on location. A fracture should be suspected when
fractures and should be used in all complex cases [1, 4, 9].
there is asymmetry of the skull. In addition to pain on pal-
pation of the affected region, there may be haemorrhage
from the ocular, nasal or oral cavities, regardless of whether Treatment Principles
the neighbouring soft tissues are affected. Occasionally
In the majority of horses, treatment is successful and the
emphysema may be palpated. Horses with head fractures
prognosis is good [1, 10]. This applies not only to open frac-
often have an abnormal demeanour and loss of appetite. A
tures but also to severely displaced fractures. Reasons
foetid odour accompanies open fractures that are several
include a good blood supply despite a paucity of soft tissue
days old. Lateromedial malocclusion of the incisors can be
cover, a relatively small mechanical load to the bones, jag-
manually induced in normal horses because of the side-to-
ged edges of fracture fragments, which allow stable fixation,
side mobility of the temporomandibular joint. However,
the availability of instruments and implants similar to those
both mandibular rami move in the same direction unless a
used in human cranio-maxillo-facial (CMF) surgery and
fracture is present, in which case one side of the mandible
the large cheek teeth, which provide a means of stabiliza-
can be manipulated independently. Often, soft tissue swell-
tion for some fractures. Fractures of the temporomandibu-
ing hinders detection of malalignment, especially when
lar joint or cerebral cranium as well as old, infected and
the fracture is located under the masseter muscles. Horses
extensive fractures have a guarded prognosis. Skull frac-
may object to manipulation and examination of the oral
tures generally heal quickly, and implants do not need to
cavity because of pain. A protruding tongue is a sign of a
remain in place for a long time. Fractures involving the inci-
bilateral fracture. Drooling (ptyalism/sialorrhoea) occurs
sor teeth usually heal in approximately 8 weeks and those of
as a result of inability to properly close the mouth. Fractures
other regions take 12 weeks, after which time implants can
that involve the cerebral cranium usually lead to neurologi-
be removed [11]. As most fractures are open, administra-
cal deficits such as ataxia or vestibular syndrome [7].
tion of antimicrobials is almost always recommended.
Pre-operative Management
Clinical Examination
As for any fracture, pre-operative preparation is essential:
Comprehensive clinical examination including neurological the surgical approach should be carefully planned, and all
evaluation is always required. Of critical interest is whether required equipment must be available. Based on their loca-
the fracture involves soft tissue structures, particularly the tion, skull fractures can be divided into those of the cerebral
brain, but also the eyes or cranial nerves. The clinical exami- cranium, visceral cranium, mandible and hyoid bone. The
nation should be supplemented by endoscopy, ultrasonogra- primary concern with fractures of the cerebral cranium that
phy, radiography and, if available, CT. Depending on must be addressed initially is the risk of cerebral oedema,
whether the central nervous system (CNS) is involved, the which is minimized by the immediate administration of
patient is allocated to one of two groups, which have very corticosteroids, mannitol or a hyperosmolar solution, non
different prognoses and require different treatment priori- steroidal anti-inflammatory drugs (NSAIDs) and intrave-
ties. If the nervous system is not affected, the demeanour, nous fluids. The surgeon must have a wide variety of instru-
general condition and appetite are usually normal and there ments at his/her disposal for the repair of skull fractures.
are no cranial nerve deficits. This is usually the case with Fractures of the rostral mandible or the incisive bone with
trauma to the rostral part of the visceral skull. The risk of or without involvement of the incisors can be repaired in
injury to the CNS increases considerably with trauma and the standing horse using sedation and local anaesthesia
fractures located further caudally, and in these cases the (Figure 36.2). The standing position facilitates observation
immediate application of emergency measures is critical [8]. of symmetry during surgical repair. However, general
Examination of the oral cavity must be carried out with care anaesthesia is preferred because of potential complications
to prevent exacerbation of fractures. A mouth gag is usually associated with patient movement in response to painful
inserted only on the contralateral side to the fracture. A min- stimuli including risks to the surgeon and other personnel.
imum of two radiographic views must be taken in horses General anaesthesia is required for the treatment of compli-
suspected of having a fracture. Additional views including cated fractures, and nasal intubation offers the advantage of
oblique and intraoral radiographs are recommended when a an unobstructed view of the oral cavity. The horse should be
fracture is identified. However, the diagnostic value of skull fitted with good head protection for induction of anaesthesia
radiographs is limited, and many fractures, particularly and whenever possible should be assisted during recovery.
approach. The parotid duct, facial artery and vein, palatine

artery and the infraorbital and mental nerves must be pro-
tected during surgery. Teeth are often involved in fractures
and are a particular problem when alveoli are included.
Fractures of the body of the tooth are rare, whereas the
connective tissue attachment (periodontal ligament) is
often affected. In general, loose teeth associated with frac-
tures should not be extracted. In many instances, teeth
have a stabilizing function and removal may induce insta-
bility and exacerbate osseous damage. However, affected
teeth are often shortened to prevent contact with their
maxillary or mandibular counterparts to reduce stress on
the fracture. If fistulas involving teeth develop at a later
stage, appropriate treatment can be carried out after the
fracture has healed. Many dental disorders resolve spon-
taneously. With normal occlusion, the parts of the maxilla
and mandible that undergo traction (tension) are those
within the oral cavity. For this reason, intraoral implants
provide better stability than those placed on the ventral
Figure 36.2 Local anaesthesia in the head region: 1, aspect of the mandible. A few fractures can be treated
infraorbital nerve block at the maxillary foramen; 2, infraorbital conservatively [13]. Cerclage wire is frequently used in
nerve block at the infraorbital foramen; 3, inferior alveolar nerve
block at the mandibular foramen; 4, inferior alveolar nerve block
repair of skull fractures because it is inexpensive and has
at the mental foramen. a broad range of applications [11, 14]. The use of standard
and locking compression plates (LCPs) and screws is
appropriate in a number of fracture types [15]. Special
The location of the fracture, its complexity and the personal small interlocking implants are available to manage
preferences of the surgeon dictate the position of the patient selected fractures [1]. External fixators can be used to sta-
on the surgery table. Most uncomplicated unilateral frac- bilize fractures of the mandible [10]. The pinless external
tures are repaired in lateral recumbency. Access to both fixator provides quick and minimally invasive fixation of
sides of the mouth is required for bilateral fractures and is some mandibular fractures [16, 17]. Special techniques
most easily accomplished with the horse in dorsal recum- such as a U-frame can also be employed, but use is more
bency, with the poll flexed so that the surgeon can look complicated.
down into the horse’s mouth [12].
Before repair, the mouth is rinsed with water to remove Post-operative Management
ingesta, and a dental pick is used to remove feed material Bandaging head fractures for an extended period of time
from fracture lines. The oral cavity is considered to be a is usually not feasible, and thus protective stent band-
contaminated area, and surgical scrubs are of dubious ages should be used to cover surgical sites. Intraoral
value when intraoral wiring is the only repair used [12]. implants should be cleaned several times daily for the
Repair methods that use internal fixation devices must first few days. After this time, rinsing the mouth with
address all of the precautions and considerations required water from a hose once a day is usually sufficient. Horses
with internal fixation in other areas because the implants should be kept in box stalls in which they can move
are usually left in place. Prophylaxis against tetanus is around, lie down and rise safely without hitting their
indicated in all cases. Peri-operative broad-spectrum anti- heads on protruding objects, particularly when an exter-
microbial drugs and NSAIDs are strongly encouraged nal fixator is used. Sutures should be examined, and
because the surgery is usually carried out in a contami- wounds and fistulas cleaned and rinsed daily. Adequate
nated field. drainage must be ensured to allow open wounds to gran-
ulate from the inside. Open wounds and fistulas often
Surgical Considerations take a long time to heal completely, but they can be eas-
A thorough knowledge of the anatomy of the head is a pre- ily treated by the owner, and an extended period of hos-
requisite for treatment because many vital structures pitalization is rarely necessary. NSAIDs are given for a
including nerves, blood vessels, teeth and salivary ducts short time, and antimicrobial drugs are administered for
may be in close proximity to both the fracture and surgical a longer period, often several weeks, because of wound
Fractures of the Cerebral Skul 751
contamination and infection. The post-operative work- Examination

load of the horse depends on the type of fracture, its
In addition to clinical and radiographic examinations, CT
treatment and the progress of healing. External fixators
is important and often indispensable for comprehensive
and intraoral implants need to be removed after the frac-
assessment of head fractures [8]. Severity is frequently
ture has healed, and this can usually be accomplished
underestimated when CT is not used [4] (Figures 36.4
under sedation. There is often localized infection around
and 36.5). In one study, only about half of all fractures were
the pins of an external fixator, but this resolves quickly
detected by radiography alone [6]. Endoscopic examina-
after removal. In growing horses, most implants are
tion of the upper airways serves to identify neurological
removed, whereas in mature horses, they are removed
deficits involving the larynx and pharynx, injuries to the
only in cases of infection.
hyoid bones or haemorrhage into a guttural pouch.
Cytological analysis of cerebrospinal fluid may provide
Complications additional information in obscure cases or help confirm a
Because head fractures are often missed or underesti- tentative diagnosis. A definitive diagnosis may not be pos-
mated, osteitis/osteomyelitis may develop in the affected sible, especially when imaging modalities are limited, but
region following inadequate conservative treatment. in some circumstances, a presumptive diagnosis can be
Complications may also be encountered after surgical fixa- inferred on the basis of response to treatment. Follow-up
tion, but they can usually be managed successfully. Implant examinations should be carried out at regular intervals to
failures are rare because the mechanical stress is consider- monitor progress [7].
ably lower than in the limbs; broken cerclage wires are sim-
ply replaced, if still needed, or removed. In most open Clinical Signs
fractures, infection of the bone is inevitable, and the devel-
Head fractures which injure the CNS commonly result in
opment of osteitis/osteomyelitis and formation of seques-
changes in behaviour and demeanour such as depres-
tra is therefore common. These require careful removal,
sion, apathy, stupor or coma. Other common signs are
curettage, rinsing with generous amounts of an antiseptic
muscle spasms, opisthotonus, vestibular dysfunction and
solution and prolonged broad-spectrum antimicrobial
specific cranial nerve deficits. The latter are most easily
treatment. Dental fistulas are common following fractures
diagnosed when they involve the eyes. Affected horses
that involve teeth and may require endodontic procedures
may have nystagmus with the fast phase away from the
or in some cases extraction.
lesion, strabismus, bilateral mydriatic unresponsive
pupils, bilateral miosis or anisocoria. All indicate severe
head trauma and a guarded prognosis. Fractures of the
Fractures of the Cerebral Skull base of the skull may be associated with brainstem
lesions and can lead to changes in heart and respiratory
Fractures of the cerebral skull are divided into fractures rates. Other possible signs include haemorrhage into a
of the roof and those of the base. In the horse, fractures guttural pouch or external ear canal and leakage of cere-
of the base of the skull are uncommon. Fractures of the brospinal fluid from the ears and/or nares. The severity
cerebral skull are often associated with intracranial of the clinical signs generally correlates with the severity
haemorrhage and oedema, which lead to neurological of CNS damage, although the absence of identifiable
deficits determined by the areas involved. The parietal neurological signs does not rule out CNS involvement.
bone can be injured after a kick from another horse or Following severe head trauma, affected horses may go
other severe trauma. Depending on the force of the down or die acutely (Figure 36.3).
impact, the bone may sustain a simple fissure fracture or
be compressed into the underlying soft tissues, including
Acute Treatment and Medical Management
the brain. Neurological evaluation and first aid for the
neural injury is critical, and after the horse has been sta- Immediate implementation of systemic medical treatment
bilized, osteosynthesis can be carried out. Although head in a horse with CNS injury is critical especially in a recum-
trauma frequently results in fractures, with the exception bent patient; prolonged periods of recumbency are associ-
of horses that rear over backwards and hit their head on ated with a poor prognosis. After medical stabilization, the
a hard surface during their fall, damage to the CNS is recumbent horse is lifted, preferably with a rescue sling
relatively rare (Figure 36.3). The prognosis is particularly designed for this purpose [18]. However, if the horse is
poor when the basioccipital and/or the basisphenoid unable to support its own weight, it should be allowed to
bones are affected [8]. return to lateral recumbency. Recumbent patients are
(a)
(b) (c)
Figure 36.3 Complex compression fracture of the parietal bone of a mature horse, which resulted in immediate death. (a) Three-
dimensional CT reconstruction. (b) Frontal plane CT demonstrating fracture (black arrow) with fragment impaction into the cerebral
vault. (c) Resulting cerebral damage and haemorrhage.
placed on soft bedding and rolled to the other side every and ongoing hydration must be monitored carefully.
four to six hours to prevent muscle necrosis and damage to Dexamethasone (0.05–0.1 mg/kg, IV, q24h) should be
peripheral nerves. Protective headgear is applied to prevent administered at the start of treatment. Mannitol (1 mg/kg,
soft tissue injuries. Treatment of acute shock is aimed at IV, q6h) may be given to relieve cerebral oedema and
haemostasis and stabilization of respiratory and circula- reduce intracranial pressure but is contraindicated in cases
tory systems. Functions of respiratory, cardiovascular, gas- with intracranial haemorrhage. Clinical improvement typ-
trointestinal and urinary systems including the passing of ically occurs within a few hours. Historically, because of its
faeces and urine are monitored continuously. The primary anti-inflammatory effects, dimethyl sulfoxide (DMSO) has
goal of drug therapy is the prevention and treatment of cer- been used commonly and non-specifically. Although there
ebral oedema and associated increased intracranial pres- are currently no formulations approved for the horse,
sure. If the CNS insult is amenable to treatment, then DMSO has been used as a 20% solution at 1 g/kg, IV, q24h,
clinical improvement can be expected within 12–24 hours. for three days, followed by the same dose every other day
Intravenous fluids prevent a drop in blood pressure, for three further days. As with mannitol, hydration must be
Fractures of the Facial Skul 753
(a) (b)
Figure 36.4 Foal with a fractured petrous portion of the left temporal bone. (a) Head tilt to the left. (b) Frontal plane CT image of the
fracture (arrow).
Surgical Treatment
As soon as the patient is stable enough to undergo general
anaesthesia, surgery becomes an option. However, inter-
vention should be restricted to cases in which genuine ben-
efit can be expected from fracture reduction or intracranial
decompression (Figure 36.6). The parietal and interparietal
bones are surgically accessible, but the base of the skull is
not accessible. Wound assessment, management and skin
closure are described in Sections “Fractures of the Facial
Skull” and “Fractures of the Mandible”. Reduction and
fixation of the parietal bone with rosettes (FlapFix®; see
Section “Rosettes (FlapFix)”) is the recommended tech-
nique. Fragments of the paracondylar process can be
Figure 36.5 Frontal plane CT image of a fractured sphenoid removed [19].
bone (arrows) in a mature horse.
monitored carefully because of the diuretic effect. If neces- Prognosis

sary, intravenous fluids can be administered at the same
The prognosis is generally better than commonly assumed.
time. Because of the risk of haemolysis, DMSO has been
In one study, approximately 62% of horses with fractures of
administered slowly (hours). DMSO has now been replaced
the cerebral skull had recovered at the time of discharge [7].
by the use of osmotically active solutions such as 7.2%
The extent of CNS compromise is the principal determi-
hypertonic saline which like mannitol, require frequent
nant. Horses with fractures of the base of the skull that
administration. To avoid volume depletion, an isotonic
respond poorly to initial treatment and those that have
crystalloid solution at a maintenance rate of 40–60 ml/kg/
been down for more than four hours generally have a
day should be administered concurrently. During this
guarded prognosis.
period, NSAIDs are given at recommended dosages to com-
bat CNS inflammation. Broad-spectrum antimicrobials are
indicated in confirmed or suspected open fractures (sug- Fractures of the Facial Skull
gested by haemorrhage from ears or nares); trimethoprim-
sulphonamide drugs (30 mg/kg, PO, q12h) appear useful Fractures of the facial skull must be examined thoroughly
because sulphonamides reach therapeutic levels in cere- for possible involvement of adjacent structures such as oral
brospinal fluid. If required, diazepam (0.02 mg/kg) may be and nasal cavities, paranasal sinuses, orbits, eyes and
used to treat muscle spasms. adnexa. The cerebrum and other parts of the nervous
(a) (b)
(c)
Figure 36.6 Pony with a kick injury to the forehead. (a) Clinical appearance shortly after the injury. (b) Lateral radiograph showing a
fracture of the parietal bone (black arrow). (c) Surgical approach.
s ystem should also be evaluated. Large impression frac- Surgical exploration of complicated fractures is strongly
tures with multiple fragments of different sizes that are recommended because it allows evaluation of the full extent
pushed inwards by an external force are most common. of damaged tissues. Surgical treatment is indicated in most
Facial fractures are usually open. Fractures of the nasal open fractures; small closed impression fractures with
bones are commonly associated with substantial detach- minimal displacement may be amenable to conservative
ment of soft tissues from the bone (Figure 36.7), whereas treatment. Conservative treatment of open fractures carries a
soft tissue involvement is less common in fractures of the greater risk of wound infection or other complications such as
frontal and maxillary bones. The severity of most facial chronic (sometimes mycotic) sinusitis, sequestrum forma-
fractures is difficult to determine by clinical examination tion, delayed wound healing, deformation, narrowing of the
alone, and two-dimensional radiographic and ultrasono- nasal passages and head shaking. Surgical intervention should
graphic examinations may not give a full evaluation. The be undertaken as soon as the patient is stable and has received
extent of involvement of the facial skull is often underesti- NSAIDs and antimicrobials. Small bone fragments are com-
mated without CT, and surgeons are frequently surprised mon and often compromise exact reconstruction. Although
by the extent of the injury seen on CT images and/or dur- wound healing is generally good in the head region, soft tis-
ing surgery compared to that predicted by two-dimensional sues should be handled gently. A variety of special instru-
radiographs [4, 9]. Special consideration should be given to ments have been developed for repositioning and fixation of
ponies because they have a small frontal sinus, so that the skull fractures in humans, and several of them, including
parietal bone and brain are more easily injured than in extraction instruments and rosettes, are useful in equine sur-
horses. gery. Foals require special consideration because fracture
Figure 36.7 Head trauma involving the (a) (b)

left frontal and nasal bones with exposure
of the nasal cavity in a Quarter Horse.
(a) Appearance at the time of admission.
(b) Close-up view of the injury with
fractures (arrows) readily visible.
Figure 36.8 Fracture of the left frontal (a) (b)

and nasal bones with multiple fragments
in a Warmblood gelding. (a) Surgical
exposure. (b) Fragments were reduced by
traction with bent Steinmann pins
introduced through small drill holes. This
was maintained solely by interdigitation of
the jagged bone fragments – no implants
were used for fixation.
healing is excellent. If fragment reduction is not necessary, are not connected to the periosteum should be removed.
conservative treatment without implants is often indicated. Impression fractures typically have multiple fragments
that are displaced inwards and firmly wedged together;
they are freed and any blood clots are carefully removed.
Surgical Approach
Surgery is usually undertaken in patients under general
Reduction
anaesthesia and rarely standing using sedation and local
anaesthesia. Treatment of soft tissue injuries follows stand- Following fracture assessment and cleansing, reduction can
ard surgical principles. For closed fractures, a curved inci- be effected using one or more techniques determined by indi-
sion is made in the skin starting at the centre and extending vidual configurations and locations. Repositioning hooks are
beyond the length of the fracture. This may incorporate easily made by bending a 90° angle into the end of pieces of
wounds which are excised or debrided and rinsed. The skin 2.0 or 2.6 mm Kirschner wire or Steinmann pins. The hooks
is then retracted, and the fracture assessed. Care must be are introduced into bone fragments through predrilled 3 mm
exercised during preparation of the fracture site to preserve holes (Figure 36.8). Careful, controlled traction is then
periosteal attachments. Small loose bone fragments that applied until fragments are returned to their normal position
Figure 36.9 Illustration of bent pin

reduction and fixation of a collapsed frontal
bone fracture using wire sutures. Source:
With permission of J. A. Auer.
preserve as much contact/interdigitation as possible as this

provides stability to the reduction.
Fixation
Fragment Interdigitation
Fragments with jagged edges that can be wedged into oth-
ers can be left without additional fixation, provided the
fracture appears stable after reduction [20].
Polydioxanone Sutures
Some fractures can be repaired using five metric (No. 2)
polydioxanone sutures. The advantages, when no addi-
tional implants are required, are that the suture material
cuts only minimally into bone, retains its tensile strength
for approximately 56 days and is usually absorbed by
Figure 36.10 Application of a special traction device to reduce 182 days, which eliminates the need for removal [20].
fractures of the frontal and nasal bones and maxilla caused by a
kick.
Orthopaedic (Cerclage) Wire Sutures
Wire is used for fixation when there is no or minimal loss of
(Figure 36.9). Usually, several holes are drilled so that trac- bone. Generally, 1 or 1.2 mm (20 or 18 G) wire sutures are
tion forces are evenly distributed. Periosteal elevators or placed through 2 mm holes predrilled into the bone fragments
Langenbeck retractors can also be used. In human surgery, a (Figure 36.9). Care should be taken to maintain reduction at
threaded traction device is the instrument of choice (Synthes the time of drilling. Sometimes reduction instruments can be
GmbH, Eimattstrasse 3, Oberdorf) (Figure 36.10). It is manu- introduced into the fracture gap to reduce the fragments. Each
factured in two sizes (2.4 and 3.5 mm) and consists of a hori- fragment needs to be fixed to intact bone with one suture.
zontal cross handle, connected to a tap-like rod that is twisted Care should be taken when tightening the sutures because the
into the bone fragment. Depending on the size of the frag- bones of the facial skull are thin and easily cut by the wire.
ment, the instrument is inserted through a 1.8 or 2.4 mm hole
into the bone. Occasionally, it is necessary to trim fragments Rosettes (FlapFix)
to facilitate repositioning and reduction. Bone rongeurs can Stable application of rosettes requires an even surface with
be used to remove the edges but should be used judiciously to no fragment loss but they provide a large area of contact
(a) (b)
Figure 36.11 (a) Illustration of the FlapFix System. (b) Fixation of a fractured maxilla using wire sutures and rosettes.
with bone fragments, which minimizes iatrogenic damage Plates

during reduction. The implants are made of titanium and Plates are used to repair large or highly comminuted frac-
are available in four different diameters (11, 13, 18 and tures and fractures with bone defects. Currently, most sur-
22 mm) with either textured or smooth bottom discs geons favour LCPs because they provide stable fixation.
(Synthes GmbH). The clover-leaf design allows the 3.5 mm LCP reconstruction plates and the 2.4 mm Unilock
implant to adapt to the shape of the bone (Figure 36.11). (Synthes GmbH) system are both useful; locking plates
To reduce the fracture, the top disc is pushed towards the manufactured by other companies can also be used. Short
upper end of the tube until it locks in place. The bottom (8–14 mm) screws are employed, ideally with three in each
disc is then placed under the intact and fractured bone, fragment (Figure 36.12).
and the fragment reduced before the top disc is pushed
down to the bone. The application instrument is used for
Skin Closure
maintaining tension and cutting the tube. First the tube is
placed between the blades of the application instrument, Whenever possible, skin overlying fractures should be
which is the CRIMP side of the instrument. Then, the closed with sutures; sometimes distant relief incisions are
lower disc is pulled up gently so that it is positioned against necessary. However, primary wound closure is not always
the inner surface of the fragments. By pushing the handles possible, particularly in injuries with extensive bone, soft
of the application instrument together, the bone flap is sta- tissue and skin loss or damage. Many of these fractures and
bilized for final tightening. For cutting, the tube must be wounds heal surprisingly well by second intention and
inserted in the CUT side of the application instrument. have a satisfactory functional and cosmetic outcome.
The handles are then pressed together until the implant is Depending on the degree of contamination, a lavage tube
tensioned and the cut is made. may be inserted into an injured sinus to facilitate post-
The application instrument must be closed at the front operative flushing. Drains may also be required if there is
by pushing the ratchet forwards. Then, the implant tube dead space between bone and skin.
is threaded through the tip of the application instru-
ment and the application instrument lowered to the top
Post-operative Care
disc. To apply tension to the implant, the application
instrument is squeezed. While maintaining tension on A head bandage and padded protection are applied before
the clamp, the surgeon crimps and shears the centre recovery from anaesthesia. NSAIDs and antimicrobial
tube of the clamp by squeezing the crimping device trig- drugs are given for three to five days, depending on the
ger. When removal of the discs is required, a Backhaus healing progress, or longer if required. In most cases, pro-
towel clamp is used to grasp the clover-leaf disc between vided that wound healing is normal and persistent draining
its petals. tracts do not develop, implants do not need to be removed.
(a)
(b) (c)
Figure 36.12 (a) Radiographic view of a complex fracture of the facial skull (black arrows). (b) Surgical view of the fractures (blue
arrows). (c) Fixation using multiple LCPs. Some fragments could not be integrated into the repair and were removed.
Fractures of Incisive, Frontal, Nasal Fractures of the frontal, nasal and maxillary bones are
and Maxillary Bones almost always impression fractures with comminution. If
these involve the infraorbital nerve, treatment is necessary
Fractures of the incisive bone are best treated with cerclage to reduce the risk of head shaking as an associated complica-
wires, which can be applied in different ways including a tion. Fractures of the nasal bone often involve the nasal, con-
figure-of-eight configuration or the Obwegeser technique chal or paranasal cavities. It is important to palpate the nasal
(Figure 36.13) as described in Section “Intraoral Wire”. cavities and carry out endoscopy before surgery to identify
Numerous variations of wire placement are possible in the fragments that may protrude into the nasal cavity and/or
upper jaw, and unlike the lower jaw, wire can also be placed conchae. In displaced fractures, reduction and fixation are
across the palate from one side to the other. When incisor necessary to prevent infection. A long incision is often nec-
wire techniques are performed standing, an infraorbital essary to gain access to the multiple fragments (Figure 36.14).
nerve block provides local anaesthesia (Figure 36.2). Fractures of the frontal bone should be similarly managed.
(a) (b)
(c) (d)
Figure 36.13 (a) Fractures of the incisive bone and maxilla after a kick injury. (b, c) Repair using the Obwegeser wiring technique.
(d) Post-operative radiograph.
Orbital Fractures with respect to the globe and its neurovascular supplies.
Some small fractures will heal without fixation after suc-
The orbit consists of the frontal, lacrymal, temporal and
cessful non-invasive reduction, but most will result in
zygomatic bones, which are susceptible to fractures
permanent facial deformity. The outer parts of the orbit
because of their exposed location. They present a special
consist of solid bone and are amenable to fixation with
challenge because, in addition to the bony eye socket, asso-
plates; the deeper parts are thin and do not usually allow
ciated structures such as the globe or neighbouring parts of
repair using implants.
the nervous system may be involved. Thorough examina-
tion is important and should include deep palpation of the
inner surface of the orbit during surgery to identify and Outer Parts of the Orbit
remove fragments that can damage the eye. In common The horse is placed in lateral recumbency with the affected
with other parts of the facial skull, orbital fractures often eye up. The incision is centred over the fracture and extended
have multiple fragments of various sizes, which must be beyond the fracture ends. The frontal, temporal and zygo-
reduced cautiously using traction. Fractures of the frontal matic bones are commonly involved and are typically dis-
bone and its zygomatic process often involve the supraorbital placed inwards. Special attention must be paid to the frontal
nerve. Computer tomographic evaluation helps to evaluate (sometimes called the supraorbital) and the auriculopalpe-
the entire fracture and allows good surgical planning bral nerves which must be identified and isolated to prevent
(Figure 36.15). injury (Figure 36.16). The frontal nerve is part of the oph-
Most orbital fractures require surgical intervention to thalmic division of the trigeminal nerve and is purely sen-
restore correct anatomical relationships, particularly sory for the upper eyelid and the region of the frontal bone.
(a) (b)
(c) (d)
Figure 36.14 Fracture of the nasal bone. (a) Radiographic evaluation. (b) Three-dimensional CT reconstruction demonstrating the
degree of comminution and extent of displacement. (c) Intra-operative view showing fixation with two Unilock 2.4 mm
reconstruction plates and two wire sutures. (d) Lateromedial radiograph three months after surgery. Source: Images courtesy Felix
Theiss, Zürich.
(a) (b) (c)
(d)
Figure 36.15 Horse with a kick injury to the eye. (a) Clinical appearance. (b–d) CT evaluations: (b) dorsal view of the orbit and (c)
dorsal view of the inner part of the orbit. The fractured frontal bone protrudes into the globe (white arrow). (d) The three-dimensional
reconstruction shows this common fracture of the orbital rim (black arrow).
The auriculopalpebral nerve is part of the facial nerve and twisted to fit the shape of the bone (Figures 36.18
innervates the muscles of the upper eyelid. and 36.19). The 2.4 mm Unilock or 3.5 mm LCP reconstruc-
Anatomical reconstruction of the outer part of the orbit is tion plates are suitable because they are easily adapted. If
crucial for proper eye function. After wound debridement, several bones are fractured, a long plate is necessary. Each
the injury is assessed and depressed fragments reduced. fragment should be fixed with a minimum of three screws,
This can be performed with repositioning hooks introduced but not every hole needs to be filled with a screw. Special
into or beneath fragments, but often the combination of pliers are required for bending the plate. Screws with a
Langenbeck hooks, reduction instruments and periosteal maximum length of 8–10 mm should be used to avoid dam-
elevators is necessary (Figure 36.17). Multiple manoeuvres aging the eye. The surgeon should place the finger of one
are often required to bring fragments into alignment. hand between the orbit and the eye to monitor penetration
Some fractures can be stabilized by wire, but displaced, of the dill bit. It is also important to protect the globe and
unstable fractures are best treated with plates, bent and neural structures that run close to the fracture site with a
When fractures result in displacement of the globe into the

maxillary sinus, repositioning may be achieved non-
surgically, but a surgical approach is usually recommended.
2b The skin is incised over the maxillary bone, and a 3–4 cm
flap is created in the bone to allow introduction of at least
3 two fingers beyond/axial to the inner part of the orbit.
2a Digital pressure is then applied to reduce the inner part of
the orbit into normal alignment. The sinus is flushed to
2 remove debris including blood. The bone flap is replaced,
and the skin is closed. Some horses cannot close the eye
completely after this injury and require ongoing eye care.
1
Fractures of the Mandible
The most common head fractures in the horse involve

Figure 36.16 Illustration of nerves close to the orbit: 1, facial the mandible, particularly its rostral parts [10]. Clinical
nerve; 2, auriculopalpebral nerve; 2a, rostral auricular branch; manifestations and treatment options vary depending on
2b, zygomatic branch; 3, supraorbital nerve.
whether the region of the incisors, the interdental space,
the horizontal ramus, the vertical ramus or the temporo-
mandibular joint is affected. Rostral fractures are the
least stable. The cheek teeth and muscles provide some
stability caudally. Mandibular fractures are often open
into the oral cavity because fragments are typically sharp
and have little soft tissue covering. Many fracture sites
are therefore contaminated, and infection is a common
sequel. If dental alveoli are involved, loss of one or more
teeth can result from infection. Although mandibular
fractures can be challenging, a variety of fixation tech-
niques are available and, unlike limb fractures, most
complications can be managed to produce a successful
outcome.
Mandibular fractures have similar aetiologies to other
sites, but rostral fractures also occur when a horse bites
vertical metal bars in the stall with its head in a slightly
twisted horizontal position and then suddenly pulls back
after positioning its head vertically. Because of the rela-
tively large total width of the lower incisors, they become
wedged between the bars, resulting in alveolar fractures
with rostral displacement of the incisors. These fractures
usually cause little pain and, if the displacement is mini-
mal, may be missed and heal without treatment [10].
Figure 36.17 Reduction of an orbital rim fracture with a Treatment is determined by the location and severity of
Langenbeck hook.
the fracture and the age and weight of the patient. Because
most rostral fractures are displaced and unstable, conserva-
periosteal elevator or similar instrument while placing tive treatment is rarely successful and should not be recom-
wires or plates. mended. General anaesthesia with the horse in dorsal
recumbency is suitable for most situations, although less
Inner Part of the Orbit invasive procedures such as intraoral wire fixation of frac-
After fixation of the outer part of the orbit, its inner part and tures involving the incisors are commonly carried out in
the sinus are addressed. Fixation is not needed for fractures the standing, sedated horse. Alveolar nerve blocks provide
of the inner wall of the orbit if the globe is not displaced. suitable regional anaesthesia (Figure 36.2) [14, 21].
(a) (b)
Figure 36.18 Illustrations of (a) a common collapsed fracture configuration of the orbital bones. (b) Repair using a 3.5 mm
reconstruction plate.
(a) (b)
(c)
Figure 36.19 Clinical application of the technique illustrated in Figure 36.18. (a) Intra-operative view of fixation with a 3.5 mm
reconstruction plate. (b) Post-operative oblique radiographic view. (c) Appearance of the horse post-operatively; the eye is normal and
the contour of the plate is clearly visible.
Surgical Planning and Preparation avoided. Antimicrobials and NSAIDs are given for three to
five days or longer if required, particularly in open frac-
As with other head fractures, the full extent of lesions may
tures. Intraoral wires are cleaned twice daily for the first
only become apparent during surgery, and therefore the surgi-
few days and then once daily until removed.
cal team should be prepared for all eventualities. This includes
preparation and patient positioning for intra-surgical imaging,
such as fluoroscopy, orthopaedic techniques and dental proce- Surgical Techniques
dures. The head region involved is generously clipped and
Intraoral Wire
surgically prepared, and the mouth is rinsed thoroughly. If
The majority of rostral fractures are amenable to wire fixa-
manipulations inside the mouth are required, intubation is
tion. Following reduction, wire loops are placed at predeter-
carried out through the nose. The mouth is held open using
mined locations, then tightened first by hand and then using
an appropriate gag that does not put any pressure on the frac-
pliers or needle drivers. This must be carried out in an even
ture site; wedges made from hard rubber or plastic placed
fashion, alternating between multiple loops and while
between uninvolved teeth work well. Equipment that should
monitoring the fracture site to avoid creation of displace-
be available includes instruments for orthopaedic manipula-
ment. After the wires are tightened, the twisted ends are
tion and stabilization, wire fixation, a drill with special bits for
shortened and bent flat so that they do not irritate or injure
dental drilling, surgical plates and screws and arthroscopy
the gingiva. They can also be covered by cyanoacrylate
equipment for intraoral examination [1]. Grinding tools are
(superglue) filled rubber instrument caps for further protec-
often required to lower the occlusal surface of involved incisor
tion. The mouth is closed manually or by applying reduction
teeth to decrease pressure on the fracture site during chewing.
forceps to upper and lower jaws to assess fracture reduction
Dental extractors should also be available. Because the site of
and dental occlusion. If the fracture remains unstable or col-
tension in the mandible and maxilla is in the mouth, implants
lapses during final tightening of the wire, other or additional
should ideally be placed intraorally [1], but with the exception
fixation methods should be used. Wire can also be used to
of tension wires, this is not usually feasible. For practical rea-
repair fractures of the mandibular symphysis or interdental
sons, implants are often therefore applied to the compression
space. In one study, 90% of all rostral fractures that involved
aspect of the bone subjecting then to increased mechanical
incisors could be repaired using wire cerclage [12].
stress and thus risk of failure. In most circumstances, teeth are
left in place because they provide support, improve fixation
Wire Placement
and increase stability. Loose or fractured teeth are usually not
In the horse, 1.2 mm (18 gauge) orthopaedic stainless-steel
be removed until fractures have healed. CT evaluation before
wire is most commonly used [22]. Teeth that are not involved
surgery provides appreciation of the full extent of fractures,
in the fracture serve as anchors [23]. The teeth immediately
allows appropriate planning, directs technique and thus
adjacent to the fracture may not be very stable and therefore
improves fixation considerably.
at least two teeth should be engaged on either side of the
fracture. The wire should always be tight and care must be
Wound Management taken that it is not weakened by repeated bending. Wire
should be cut perpendicular to its long axis; cutting it at an
All associated wounds are carefully cleaned and rinsed. angle creates a sharp end which traumatizes the gingiva. In
This includes trimming wound edges, debridement of young animals, a 2 mm (14-gauge) hypodermic needle can
bones and rinsing with an antiseptic solution to remove be used to penetrate between teeth at the crown-gingiva
debris. Drains are an important consideration because frac- margin to allow passage of the wire. However, small holes
tures are commonly open into the oral cavity and therefore made using a Steinman pin or a small drill bit [12, 14] are
prone to infection. These allow removal of wound secre- usually required for passing wire between adult incisors and
tions as well as therapeutic flushing. Complications are almost always for placing wire between cheek teeth.
common and include infection, sequestrum formation,
implant failure and development of fistulas. In one study, Engagement of the Incisors
these had an incidence of 27% [12] but most respond to For rostral fractures that result in loosening of the incisors,
treatment and have a favourable outcome. the interdental continuous wire-loop splint described by
Obwegeser (1952) is frequently recommended [24]. This
produces uniform tension between all the engaged
Post-operative Care
teeth [11]. Wire placement is illustrated in Figure 36.20;
In the immediate post-surgical period, horses are confined starting on one side of the arcade, one end of the wire is
to a box stall and fed a soft fibre diet; firm feed should be guided back and forth between all incisors to form small
Fractures of the Mandibl 765
(a) (b)
Figure 36.21 Illustrations of fixation of a fracture involving

Figure 36.20 Interdental continuous wire-loop splint as lateral and corner incisors. (a) Insertion of a wire using two
described by Obwegeser. 14-gauge (2 mm) needles. (b) Figure-of-eight wire loop engaging
the canine tooth. Source: With permission of J. A. Auer.
loops. To start, the lingual strand of the wire is pushed

through the first hole in the interdental space to the labial through a protective drill guide, and a hole is prepared
side then pushed back to the lingual side leaving a loop of between the two cheek teeth. Once the wire has been
approximately 1 cm of wire on the labial side before mov- placed to form a loop, it can be twisted together in the
ing onto the next interdental space and repeating. The interdental space to provide tension.
other end of the wire on the labial side of the teeth is then
threaded through the loops, before these are tightened Cable Fixation
sequentially and in a uniform fashion. Finally, the wire is Orthopaedic cables (Synthes GmbH) provide many advan-
anchored caudally (Section “Anchoring the Wire”), and the tages and can be used instead of traditional cerclage wire.
construct is tensioned by twisting both wires at the level of They are much more stable and allow less fracture dis-
the diastema. There are several other ways to place wire placement [1] (Figure 36.23). Multifilament cable (1.0 mm
loops that will stabilize fractures but wires should not be or 1.7 mm) has much higher static and fatigue loading
placed through a fracture line. Simple loops must overlap resistance and because of its flexibility it is able to be ten-
to ensure that teeth are not pulled apart [23], and figure-of- sioned consistently without kinking. The use of a crimp to
eight loops can be used to increase stability (Figure 36.21). secure the cable also avoids slack that is introduced by the
unravelling of a twisted monofilament wire knot.
Anchoring the Wire
Depending on the fracture and the degree of stability Screws and/or Plates
required, wires are anchored around a canine tooth (when Many fractures of the body or the ramus of the mandible
present) or cheek teeth. When using the former, it is neces- can be repaired using screws and plates. In selected cases,
sary to file a notch into the tooth at its base to prevent the interfragmentary screws can also be applied to provide
wire from slipping. Wire can also be passed around a screw compression. Although the oral side is the tension surface,
placed into the mandible, but this increases the risk of plates are applied ventral or ventrolateral to the mandible,
infection, fistulation and loss of tension (Figure 36.22a). where the thick cortex provides a stable fixation
Cheek teeth provide good stability for a tension wire, which (Figure 36.24). The horse is placed in dorsal recumbency,
is usually placed between 06 and 07 (Figure 36.22b). To and the fracture site is prepared and freed from soft tissue
achieve this, the skin is clipped, surgically prepared and a axially and abaxially. Blood vessels (principally the facial
short arthroscopy sleeve with a trocar or obturator is and labial arteries) and parotid salivary ducts are preserved
advanced into the mouth via a stab incision [1, 11]. This and protected using Penrose drains. The fracture is stabi-
technique minimizes the haemorrhage that results when lized using reduction forceps, and the plate is applied.
the tissue is cut with a scalpel. A drill bit is then introduced Unicortical screw implantation provides adequate stability
(a) (b)
Figure 36.22 Illustrations of caudal wire anchors. (a) Using a screw. (b) Drilling a hole between teeth 406 and 407 for insertion of
the wire. Source: With permission of J. A. Auer.
(a) (b)
(c)
Figure 36.23 Fixation of a mandibular fracture using orthopaedic cable. (a) After looping the cable around the teeth, the free end of
the cable is inserted into the open hole in the cable crimp, and the crimp is placed in the desired position in the mouth. (b) The cable
crimp is centred and fully seated in the crimper jaws before crimping the cable, and the handles are squeezed together. (c) Post-
operative appearance with the cable in place.
(a) (b)
Figure 36.24 Illustrations showing the options for plate location for an oblique interdental fracture of the mandible: (a) laterally and
(b) ventrally with a wire placed intraorally to create a tension band. Source: With permission of J. A. Auer.
particularly with LCP constructs. In the vertical ramus, applied along the ventrolateral surface provides optimal
unicortical implantation is the only option; in the horizon- stability [26]. Plates applied to the ventral aspect of the
tal ramus, screws must be short enough to spare the tooth corpus appear less satisfactory unless wire cerclage is
roots. Implant infection occurs commonly when internal used concomitantly.
fixation is carried out in open or infected fractures and
some implant loosening can occur. However, LCP con- U-shaped Splint
structs can maintain adequate stability even in the face of Metal splints can be bent into a U-shape and attached to
infection and partial implant loosening. LCP constructs the labial aspect of the incisors and buccal aspect of the
correspond to the principle of biological osteosynthesis in cheek teeth using wire sutures (Figure 36.25a). The splint
reducing pressure on the bone and periosteum which may is fixed to the incisors and cheek teeth at multiple sites by
prevent additional devascularization of fragments and thus interdental cerclage wires that pass through the bar. The
reduce the risk of sequestrum formation [25]. pre-bent U-shaped splint is most often made of malleable
Depending on the size of the horse, narrow 3.5 mm or brass or aluminium. It is placed on the labial surface of the
4.5 mm LCPs are used. Biomechanical studies have incisors and spans the interdental space and most of the
shown that intraoral wire fixation combined with a plate length of the caudal dental arcade bilaterally. Attachment
Figure 36.25 Intraoral splints. (a) Placement and dental (a) (b)
cerclage fixation of a metal U-splint: note differences in
the cross-sectional shape of the bar rostrally and caudally.
(b) Polymethylmethacrylic splint used to reinforce
interdental wires. Source: With permission of J. A. Auer.
of the splint to the caudal cheek teeth is difficult, time con- and ponies, pins with a diameter of 3–3.5 mm are suffi-
suming and a major limitation to the technique. Holes are cient. Positive-profile threaded pins have good strength
prepared between the incisors and between the cheek teeth and pin–bone interface stability, but Steinmann pins can
(via stab incisions). The intraoral wires are then placed and be used. Use of positive-profile threaded pins may provide
secured around the teeth. Finally, the bar is inserted and superior purchase and prevent or delay pin loosening and
the wires are guided through the bar and tightened by related soft tissue morbidity. If feasible, two pins are used
twisting. An additional intraoral cerclage wire around the on either side of the fracture to provide rotational stabil-
incisors and the cheek teeth can be used to improve stabili- ity [29]. The Kirschner Ehmer apparatus or a modifica-
zation but must be introduced before the U-bar is fixed to tion of this is most commonly used as a type I or type II
the cheek teeth. The U-splint is generally only considered fixator (Chapter 13) [10, 29]. A type I fixator engages the
when plate fixation is not possible or available. two cortices of one branch of the mandible, and a type II
fixator engages both branches; both have been used with
Polymethylmethacrylic Compounds success. For unilateral and bilateral interdental space
Methylmethacrylic implants can be used to reinforce com- fractures, pins are directed through both mandibles to
minuted fractures, particularly those in the interdental permit application of bilateral crossbars (type II fixator)
space that might collapse when transfixing wires are tight- (Figure 36.26a). Transfixation pins should be cut short,
ened (Figure 36.25b). The cement is moulded and fixed to and crossbars should be located close to the face, short-
the jaw at several points using wire loops [27, 28]. The first ened and padded to prevent them from getting caught on
step is to drill 2 mm holes between the teeth and across the objects in the horse’s environment. Crossbars may be
bone in selected locations. The acrylic compound is then bandaged or the horse fitted with a padded recovery hood
mixed and moulded to the area to be reinforced at a thick- to protect the fixator from entrapment and disruption.
ness of 6–8 mm. Implants that are too thick impair chew- Horses with external fixators should be housed in smooth-
ing. In the lower jaw, the mould should have a U-shape so walled stalls and fed from the floor. Mangers, grates and
that the frenulum of the tongue is not restricted; in the gate latches represent hazards.
upper jaw, acrylic can be applied directly over the hard pal- After preparation of the fracture bed and soft tissues,
ate. Cold-curing acrylic is used to prevent thermal tissue stab incisions are made for pin placement. Holes for the
damage. Wires are threaded through the holes in the jaw pins are predrilled, with care taken to cool the drill bit to
and either pushed through the acrylic before it sets or prevent thermal tissue damage. When using Steinman
threaded through predrilled holes after it has set. Once the pins, holes drilled through the bone are 1–2 mm less than
acrylic is hard, the wire loops can be firmly tightened. An the diameter of the pins. When using positive-profile
additional intraoral cerclage wire around the incisors and threaded pins, the size of the drill bit should correspond to
the cheek teeth can be added to improve stabilization. The the core diameter of the pin. The pins are introduced with
technique is inexpensive, minimally invasive and provides a Jacobs chuck. Radiographic guidance is useful in plan-
good stabilization at the tension surface of the fracture site, ning placement, and care must be exercised to avoid dam-
but application is difficult and the splint has limited age to the teeth, the mandibular canal and the parotid
strength. salivary duct. Retraction or drill guides are used to protect
the soft tissues during insertion. The fracture is reduced
External Fixators manually; once pins are in place, they can assist this.
For highly comminuted fractures of the interdental space Crossbars optimize the strength of the fixation and when
and horizontal ramus, particularly those with extensive tightened provide rigid stabilization. Alternatively, a piece
soft tissue damage, use of an external fixator may be the of plastic or rubber hose or cardboard tube can be placed
most appropriate technique. These confer rigid stability over the protruding ends of the transfixation pins and filled
without the need for an appliance to be placed in and/or with methylmethacrylate or similar quick setting acrylic to
across a fracture site that has suffered severe soft tissue maintain the relationships of the transfixation pins.
injury. There is thus reduced risk of infection of the Further rigidity can be produced by connecting the pins
fracture itself, and local wound treatment, which is inside the tube by a twisted wire. When using a tube around
commonly needed with mandibular fractures, is facili- the pins, holes are made in the tube and then the tube is
tated [29]. Disadvantages include potential trauma to slipped over the pins. A 1 cm space is left between the tube
tooth roots, frequent infection of pin tracts resulting in and the skin before it is filled with the acrylic mixture
loosening and the potential for damage because of the while it is still liquid (Figure 36.26b). The last step entails
exposed location of the construct. Pins with a diameter of protecting the ends of the pins. External fixators can be left
approximately 4 mm are used in adults; in young animals in place for 6–10 weeks [30].
Figure 36.26 Illustrations of type II external (a) (b)

fixators to stabilize mandibular fractures. (a) Metal
connecting bars. (b) Transfixation pins connected
by a twisted wire enclosed in plastic or rubber
tubes filled with acrylic.
Pinless Fixator or in lateral or dorsal recumbency. Wires are removed after

The pinless fixator provides quick and minimally invasive six to eight weeks when healing should be complete [14].
fixation of mandibular fractures [16, 17] and is indicated In foals, wire removal is often performed earlier because
when extensive infection precludes immediate use of healing is rapid and there is a risk of abnormal bone or
implants [31]. It uses clamps that function similar to a dental development if the wire is left in place too long.
type I external fixator but do not penetrate the bone. This
technique reduces the risk of dental damage and osteomy-
Symphysis of the Mandible in Young Horses
elitis and allows minimally invasive application and
Compression screws, wire and hemi-cerclage fixations are
repeated use of the clamps. Unfortunately, it is not cur-
all suitable for symphyseal fractures in foals. A skin incision
rently in production.
is made ventral to the symphysis, and the surgical site is
prepared on both sides of the mandible. One or two pins are
Individual Fracture Locations inserted transversely across the symphysis penetrating both
and Configurations mandibles. A cerclage wire is then bent around the pin(s)
protruding from the mandible on one side, and in a figure-
Pars Incisiva of-eight pattern it is looped around the pin(s) on the other
Horses with pars incisiva fractures frequently have only side. The two ends of the wire are twisted together, and
mild clinical signs. Diagnosis is usually possible from clini- once tightened, the ends are bent towards the bone
cal examination. Radiographic and endoscopic examina- (Figure 36.28).
tions may be undertaken to rule out additional injuries.
Dental alveoli are usually involved, but the teeth them- Premaxilla
selves are rarely fractured [12]. The fractures are amenable Most premaxilla fractures are well suited to wire fixation.
to wire fixation (as described in Section “Wire Placement”), Fragments are reduced, and stable fixation is obtained by
with the canine or second premolar used as a caudal anchor multiple cerclage wires applied in different directions. If
(Figure 36.27). In foals, the wire loop should extend across necessary, the wires can also be placed from one side to the
the symphysis to prevent separation, even in unilateral other side of the teeth. The various wires are tightened
fractures. Before surgery, the wound is cleaned and flushed gradually and evenly to prevent displacement. To prevent
with antiseptic solution. The teeth are replaced into their displacement along oblique fracture planes, it may be nec-
normal position, which may require considerable force. essary to feed the wires through drill holes prepared across
Fixation may be performed in the sedated standing patient the branches on either side of the fracture. The upper jaw is
(a) (b)
(c)
Figure 36.27 Fracture of the pars incisiva of the mandible. (a) Clinical appearance. (b) Intra-operative view showing cerclage wires
engaging the canine teeth. (c) Intra-operative view showing overlapping wire cerclages.
(a) (b) Figure 36.28 Fracture of the mandibular symphysis.

(a) Illustration of fixation principles. (b) Ventrodorsal
radiograph of a yearling with interdental wire loops
and figure-of-eight wires around two 4 mm positive-
profile threaded pins.
considerably more stable because it moves less than the addition of an intraoral tension band wire. Another simple,
mandible. Thus, almost all fractures involving the incisive but often neglected, method of reducing stress on the repair
bone and the interdental space of the maxilla are optimally is to prevent incisor occlusion by reducing the height of the
treated with wiring; other techniques are rarely indicated. crowns.
It is important to prevent injury to the palatine artery, In unilateral fractures, intraoral wire fixation alone may
which runs directly under the palatine mucosa. produce sufficient stability, but care must be taken to pre-
vent displacement of fragments during wire tightening. An
Interdental Space additional wire placed ventrally under the skin can add sta-
Fractures of the mandibular interdental space are com- bility. Bilateral and/or very unstable fractures require one or
mon, and although location and type vary, there is a typical occasionally two plates in addition to intraoral wire fixation
rostrodorsal to caudoventral configuration. The angle var- that engages the premolars. Teeth that are involved in the
ies; it can be nearly vertical or nearly horizontal. Fractures fracture are not removed because this reduces fracture sta-
may be unilateral or bilateral, and the fragments are often bility; endodontic treatment of damaged teeth can either be
markedly displaced and highly mobile. Surgery under gen- undertaken at the time of fracture repair or at a later date.
eral anaesthesia optimizes reduction and fixation and dor-
sal recumbency with nasal intubation allow good access to Unstable Bilateral Fractures of the Pars Incisiva
the oral cavity. A variety of fixation techniques are availa- These are common injuries that occur just caudal to the
ble but, in general, the simplest method of repair that roots of the incisors. Fixation with intraoral wiring does
achieves adequate stability should be used. This is espe- not provide adequate stability and can result in fragment
cially true in open or infected fractures that benefit from displacement (Figures 36.29 and 36.30). Additional fixa-
minimizing the amount of implant material. A combination on the ventral side is necessary. This almost invariably
tion of intraoral wire and a wire cerclage that runs along has to be done with wire as application of a plate to the
the ventral aspect of the mandible can be useful in bilateral rostral fragment would involve the roots of the incisors.
rostral fractures, but often plates or external fixators are
also needed. Fractures of the Interdental Space and Pars Molaris
The biomechanical drawback of being unable to apply Unilateral fractures of the interdental space are often
plates to the tension (oral) surface can be ameliorated by minimally displaced as they are supported by the intact
(a) (b)
(c)
Figure 36.29 (a) Illustration of a bilateral unstable fracture of the mandibular pars incisiva. (b) Fixation with intraoral cerclage wire
alone provides insufficient stability. (c) Stability is produced by an additional ventral wire.
(a) (b)
Figure 36.30 (a) Lateral radiograph of bilateral fracture of the pars incisiva of the mandible. (b) Repair using bilateral interdental
wires supplemented by ventral wire anchors to the horizontal rami.
contralateral mandible. Bilateral fractures are inherently angular and axial stability. Damage to tooth roots can be
unstable and, in most cases, displace immediately because prevented by fluoroscopic control of screw insertion and
of contraction of the muscles of mastication. Conservative use of the shortest screw length possible. A 1.2 mm
treatment is indicated for incomplete fractures, usually tension-band wire that includes the second premolar and
when the ventral region of the bone is not involved, but is incisor teeth is applied using the Obwegeser tech-
also possible in other closed fractures that are only mildly nique [33], and finally the upper and lower incisor teeth
displaced [13]. Open and displaced fractures require fixa- are ground down to prevent occlusal contact during masti-
tion using wires, screws and plates [15]. Pre-operative cation. LCP osteosynthesis has provided sufficient
imaging including radiography and CT are necessary to mechanical stability to allow fracture healing even in the
permit fracture planning. Plates are applied ventrally, face of severely unstable, open, comminuted and infected
where the thick cortex is strong, accommodates multiple fractures [15]. Plate fixation has greater stiffness under
screws and provides stable fixation (Figure 36.31). monotonic bending than external fixators, external fixa-
Dynamic compression plates can be used, but LCPs are tors with interdental wires and intraoral splints with inter-
preferred. Locking head screws produce stable fixation dental wires [26].
with monocortical insertion [32] and increase stabil- External fixators are a useful alternative particularly for
ity [15]. Depending on the size of the horse, narrow 3.5 or the treatment of infected fractures. Advantages include
4.5 mm LCPs are used. Dental roots are occasionally dam- ease of application, good tolerance, immediate stability,
aged by the screws: this rarely has negative effects suitability for a contaminated environment and reduced
although cyclical stress during chewing can lead to need for anatomical alignment. Vital anatomical struc-
implant failure. tures such as tooth roots, the mandibular canal, parotid
Surgery is undertaken with the horse under general salivary duct and the facial artery and vein should be
anaesthesia and in dorsal recumbency. A longitudinal avoided. Pins are placed through stab incisions in the skin
incision is made over the affected area of the mandible. and then through the mandible to engage the medial cor-
After debridement and lavage, the fracture is reduced. tex of the contralateral hemi-mandible (type I fixator) [28].
Small, loose fragments are removed while larger frag- In very unstable fractures, the pins should emerge on the
ments are reattached using 3.5 mm cortex screws applied contralateral side, i.e. engage both cortices of the con-
in lag fashion. LCPs are applied to the ventral or lateral tralateral mandible for placement of a bilateral side bar
aspect of the mandible under visual and, when required, (type II fixator) (Figure 36.32).
fluoroscopic control. Intact periosteum is left in place. A Plate or fixator removal can be undertaken approxi-
few combi holes are filled with 4.5 mm cortex screws in a mately 6–10 weeks post-operatively and can often be per-
neutral or loaded position to press the plate onto the bone formed in the standing sedated horse. Interpretation of
before 5.0 mm self-tapping locking head screws are follow-up radiographs is difficult. There is often extensive
inserted in the remaining holes. To provide axial compres- remodelling, and it is almost impossible to determine when
sion, lag screws can be used. The conically threaded heads a fracture is stable enough for implant removal or if seques-
of the locking screws create a plate–screw construct with tration will occur [15].
(a)
(b)
(c)
Figure 36.31 Radiographs illustrating repair of bilateral fractures (black arrows) of the mandibular interdental space. (a) At
presentation. (b) Fixation with two LCPs and intraoral tension wiring. (c) Healing after 10 weeks.
(a) (b) (c)
(d) (e)
Figure 36.32 Comminuted fracture of the mandible. (a) Lateral radiograph showing multiple fracture lines (black arrows). (b)
Three-dimensional CT reconstruction. (c) Insertion of three Steinmann pins through the mandible. (d) Post-operative view with pins
and crossbars in place to create a type II fixator. (e) Dorsoventral radiograph after surgery. Source: Images courtesy Hervé Brunisholz,
Zürich.
Vertical Ramus involved. Fractures may involve the vertical ramus, the
Fractures of the vertical ramus of the mandible are rare. angle of the mandible, the coronoid process or the tempo-
Severe fractures may occur when a horse has its head romandibular joint (Figure 36.33). Fractures that involve
wedged between two solid objects and withdraws force- the temporomandibular joint usually produce severe
fully. Management varies with the specific structures clinical signs. Unilateral fractures with minimal
(a) (b)
(c) (d)
Figure 36.33 (a, c) Illustrations of fractures of the vertical ramus of the mandible. (a) Simple and (c) comminuted fractures. (b)
Oblique radiograph of a simple fracture (arrows) of the vertical ramus in an adult Warmblood. (d) Lateral radiograph of a comminuted
fracture (arrows) of the vertical ramus in an adult Warmblood.
isplacement are managed conservatively by dietary modi-

d v ascular structures are required, and a detailed pre-
fication and NSAIDs. operative anatomic review is recommended. Fracture
Unstable fractures and those with marked displacement reduction is completed with the help of reduction forceps,
require surgery. The horse is placed in lateral recumbency and an LCP is bent to fit the caudal margin of the bone
under general anaesthesia. A skin incision is made over the where the vertical ramus is thickest (Figure 36.34).
caudal and ventral aspect of the mandible, and soft tissues Depending on the size of the horse, narrow 3.5 or 4.5 LCPs
are dissected axially and abaxially. Blood vessels and sali- are used. Plating the ventral and caudal aspects of the verti-
vary ducts are preserved and protected using Penrose cal ramus can be difficult because access for drilling and
drains. Exposure of these fractures is tedious and poten- screw placement is limited by the parotid area and the
tially hazardous. Careful preservation and mobilization of wing of the atlas. This aside, plate application is accom-
the facial nerve, parotid salivary gland and numerous plished using standard techniques.
(a) (b)
(c) (d)
Figure 36.34 Comminuted fracture of the vertical ramus of the mandible in a Warmblood. (a) Pre-operative radiograph. (b) Three-
dimensional CT reconstruction. (c) Intra-operative view of fixation using a 4.5/5.0 mm LCP plate. (d) Post-operative radiograph: note
wire sutures in proximal fragments.
Fractures involving the coronoid process and temporoman-

dibular joint can be challenging as surgical access is difficult. Fractures of the Hyoid Apparatus
Coronoid process fractures may be treated either by conserva-
tive management or excision. The latter is preferable if malun- Fractures of the hyoid apparatus (generally stylohyoid) is a
ion is likely to result in dental abnormalities and chronically rare condition in horses and are mostly reported in associa-
altered mastication (Figure 36.35). Temporomandibular fraction with temporohyoid osteoarthropathy [35]. It has also
tures are difficult to repair. Mandibular condylectomy has been recorded in a horse with a pharyngeal abscess [36],
been suggested as a possible treatment of fractured or luxated and there are anecdotal reports that it has followed laryn-
temporomandibular joints [34]. geal tie-forward procedures.
Reference 777
(a) (b)
Figure 36.35 Fracture (arrow) of the coronoid process: (a) three-dimensional CT reconstruction and (b) typical jaw asymmetry.
R
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779
37
Fractures in Foals
A.J. Ruggles
Introduction maintenance of axial alignment and removing implants to

allow potential growth are important in determining man-
Fractures occur in all breeds of foals and are usually the agement strategies of all physeal fractures.
result of trauma from collisions or kicks or during strenu-
ous activity especially after periods of confinement. Anatomy
Repetitive stress injury is not a component of fractures in
foals. In long bones, the presence of metaphyseal growth The metaphyseal growth plate or physis consists of a disc of
plates creates potential problems of restricted or asymmet- cartilage between the metaphysis and the epiphysis of long
ric growth. This can result both from involvement in frac- bones. The epiphysis and metaphysis have separate vascula-
tures and/or subsequent repair or healing and result in ture. Epiphyseal vessels arise from the perichondrial vascu-
angular or other limb deformities. The limited bone stock lature [3–5], while the metaphysis is supplied by the nutrient
available in foal epiphyses can also present a challenge to artery of the bone. Blood supply to the physeal cartilage
stable reconstruction. Conversely, because of lighter body arises from perichondrial and subchondrial arterial sources.
weights and the tendency for fractures in foals to be closed, Both afferent and efferent vessels are contained in cartilage
there are opportunities for fracture repairs that do not exist canals together with their intervening capillary beds. The
in adults. The inherent ability of juvenile bone to remodel perichondrial ring is a unique structure that encircles the
is also a major contributor to successful management of physis and is composed of dense connective tissue called the
foal fractures. This chapter is restricted to discussion of perichondrium. The perichondrium, which functions like
fractures occurring throughout the first year of life. periosteum, provides both structural support and a source of
undifferentiated cells that can form both osteoblasts and
osteocytes. It receives its blood supply from the perichon-
Physeal Fractures drial vessels. Injury to the perichondrial ring can produce
traumatic exostosis and potentially growth deformity [6].
All types of physeal fractures occur in foals but, as in other Within the physis there are four cellular levels which,
species, Salter–Harris (SH) type II injuries are most com- from epiphysis to metaphysis, are germinal, proliferative,
mon [1, 2]. Since these fractures occur at the end of the hypertrophic and calcifying. The proliferating cartilage is
bones and lead to instability, rigid coaptation or fixation is an area of rapid cellular division which is responsible for
essential to restore axial alignment. If internal fixation is longitudinal growth of the bone and also produces extra-
elected, adequate purchase must be gained in the fracture cellular matrix. Injury to either of the first two cellular lay-
fragments to allow weight-bearing and comfort. In many ers can lead to growth disturbances. The zone of
cases, the physis must be bridged by implants to accom- hypertrophy, where the cells undergo maturation, has little
plish this. Doing so will cause physeal retardation or cessa- matrix, relatively little mineralization and is the weakest
tion of growth, although it is likely in many cases that the area of the physis. It is at this site that fractures through the
injury itself had disrupted potential growth enough to alter growth plate typically occur. The zone of calcification is the
limb length. In most cases, compensatory growth in other site of endochondral ossification and represents the transi-
segments produces adequate limb length. Restoration and tion between cartilage and bone.

780 Fractures in Foals
Salter–Harris Fracture Definitions fractures. It is theorized that the presence of little matrix
and mineralization to this level lead to fracture when load
The Salter–Harris fracture classification system was devel-
is applied. At the physeal level, the joint capsule and liga-
oped by the paediatric orthopaedic surgeons Robert Salter
ments are stronger than the physis itself and the perichon-
and Walter Harris and first published in 1963 [7] in an
drial ring provides substantial support. The support of the
effort to identify specific types or configurations of physeal
periosteum to the metaphysis is weaker than the perichon-
fractures in children [6]. The original classification, which
drium so that fractures though the hypertrophic region of
is generally used in veterinary surgery, had five fracture
the physis often travel towards the metaphysis causing a
types. Other physeal injuries have been added subse-
SH type II fracture. In one study, 62.5% of 67 physeal frac-
quently so that presently nine types of SH fractures are
tures were type II [1].
defined in human orthopaedics [2]. Physeal fractures used
The specialized anatomy of the physis leads to some
in the SH system are caused by compression, bending and
unique considerations. As the principal blood supply is the
or torsional loads. For this reason, pure tension fractures
epiphyseal artery, insult to this will affect the germinal
such as avulsion fractures of the olecranon apophysis
layer of the physis and can lead to post-operative abnor-
might be more appropriately characterized by the fracture
malities. The perichondrial ring provides substantial physi-
classification system developed for the ulna [8] rather
cal and metabolic support, so an effort in surgery to
than as a SH injury.
preserve as much of this as possible and to avoid excessive
Type I: Fracture passes all the way through the growth soft tissue disruption is recommended.
plate, not involving bone (Figure 37.1a). The potential for a physeal fracture to cause growth
Type II: Fracture crosses most of the growth plate and then disturbances in an individual foal is hard to predict.
deviates to exit through the metaphysis: this is the most Questions such as how severely is the physis damaged?
common SH injury in horses (Figure 37.1b). has some of the physis been removed due to the fracture
Type III: Fracture extends some distance along the growth and or procedure? what is the growth potential remain-
plate and then through the epiphysis (Figure 37.1c). ing after injury and/or surgery? what effect will a pro-
Type IV: Fracture plane passes directly through the meta- posed surgical procedure have on growth potential? will
physis, growth plate and epiphysis (Figure 37.2). the procedure cause a growth abnormality and what
Type V: Crushing injury that does not displace the growth effect will compensatory growth from physes in other
plate but damages it by direct compression. bones have on limb length and conformation? are diffi-
cult to answer at the time of injury. In general, it is wise
to believe that growth potential will continue despite the
Pathophysiology of Physeal Fractures
injury and repair. Decisions regarding surgical tech-
The junction of the mineralized and non-mineralized car- niques, post-operative management and removal of fixa-
tilage in the hypertrophic zone represents the ‘weak link’ tion devices should take this into account until proven
in the physis and is the commonest location of physeal otherwise.
(a) (b) (c)
Figure 37.1 Salter–Harris fractures. (a) Type I fracture of a distal radius with marginal comminution in a three-week-old foal. Note
the acquired valgus deformity. (b) Type II fracture of a middle phalanx in a four-week-old foal. (c) Type III fracture of a proximal
phalanx in a seven-week-old foal.
Figure 37.2 Two-month-old Arabian foal with a (a) (b)

SH type IV fracture of the medial condyle of the
femur (arrows). (a) Pre-operative radiograph, (b)
frontal plane CT image and (c, d) five-month
follow-up radiographs after repair with
2 × 5.5 mm cortex screws placed in lag fashion.
Stainless-steel washers were placed to prevent
the screw heads from penetrating the cortex of
the bone and to optimize compression.
(c) (d)
Common Physeal Fracture Locations in management which are unique to foals for different ana-
the Horse tomic sites. Reference to other chapters is also provided in
which information pertinent to specific bones or areas can
Type I fractures: Proximal femur, distal radius and proxi-
be found. In all cases of fracture repair in the foal, the fol-
mal phalanx.
lowing principles should be followed.
Type II fractures: Proximal tibia, distal femur, proximal and
distal radius, distal third metacarpal/metatarsal and ●● Re-establish axial alignment of the limb for growth and
proximal phalanx. weight-bearing.
Type III fractures: Distal radius and distal third metacar- ●● Determine the tension side of the fracture in order to
pal/metatarsal. place implants for optimal strength.
Type IV fractures: Distal radius, distal third metacarpal/ ●● Use implants of the appropriate strength for the type of
metatarsal and proximal phalanx. injury and size of animal.
Type V fractures: These can affect any physis and are ●● Apply implants systems in the correct manner.
uncommonly recognized alone, but can be a component ●● Determine need and/or advantage and apply only con-
of other SH fractures. tributory external coaptation.
●● Understand the potential effects of implants on future
Variations in types, locations and configurations of frac- growth and production of angular deformity.
tures and sizes/ages of patients preclude a comprehensive ●● Determine the optimal, if appropriate, time for removal
description of techniques. However, like all fractures, fol- of implants.
lowing established treatment principles optimizes out- ●● Critically evaluate the outcome. Did you achieve your
comes. The text outlines particular aspects of fracture goals? Is modification required?
Considerations in the Management pletely in compression. Tension forces are produced by

of Orthopaedic Injury in the Foal major muscle and ligament insertions; bones loaded in ten-
sion include the olecranon and the proximal sesamoid
The outcome in cases of foal orthopaedic injury is depend- bones. Bending forces occur in most long bones and are a
ent upon many factors. Some of these can be managed combination of compressive forces on the concave surface
while others, dictated by the nature of the injury, size, use and tension forces on the convex surface. Shear forces are
and disposition of the patient, are beyond surgeons’ con- present in most fractures and cause pieces of bone to move
trol. Foals present specific challenges related to immune parallel to the fracture plane: in simple sagittal fractures of
compromise, risk of gastrointestinal complications, includ- the lateral metacarpal/metatarsal condyles or proximal
ing gastric ulceration and enteritis, and the development of phalanx counteracting, these is a major consideration.
flexural laxity, contracture and angular limb deformities. A Normal insertional forces in the absence of axial continuity
slight miscalculation regarding angular alignment, failure result in torsional forces in most long bone and commi-
to provide enough or using too much external coaptation nuted fractures. The above notwithstanding, it is important
can be the difference between achieving athletic soundness to appreciate that many fractures are subjected to multiple
and failure. Below are points that are considered of most forces. For example, a transverse fracture of the Mc/
importance in determining outcome. Recognition of poten- Mt3 would be subjected to shear, bending and torsional
tial complications is critical to prevention. These include forces.
but are not restricted to haemorrhage, technical errors, In foals, fractures of long bones are usually single event,
excessive surgical time, inadequate fixation, soft tissue i.e. monotonic injuries in which bones are exposed to
management and infection (Chapters 9, 11 and 14). forces that are supraphysiologic in magnitude and/or
direction.
Instability
Fracture Reduction and Load Sharing
Stability and immediate weight-bearing are the foremost
goals. The longer a foal is uncomfortable, the more likely it After repair it is rare that implants by themselves are strong
is to develop angular deformity and/or flexor laxity of the enough to produce stable bone healing conditions. It is
weight-bearing limb or flexural contracture of the injured therefore imperative that proper anatomic reduction with
limb. As in all equine fracture management, stability correct implants and technique are employed to produce
equals comfort and comfort equals success. Surgical plan- load sharing between the implants and the reconstructed
ning and execution should be aimed at restoring the bony bone. Without this, cyclic fatigue of the implants will occur
column with proper alignment and length to allow full and construct failure result. In many repairs, anatomic
weight-bearing with minimal external coaptation. reduction of the fracture fragments is the most challenging
part of the surgery. Pre-operative planning is important
(Chapter 9). Open reduction allows debridement of the frac-
Biomechanical Considerations
ture bed and visual direction and evaluation of reduction. In
While foals’ size and the relatively low energy injuries that a number of articular fractures, arthroscopy can also provide
they frequently suffer offer opportunities for fracture repair visual guidance [9]. Intra-operative radiography and fluoros-
not feasible in adults, their demeanour and comorbidities copy are also commonly necessary supplementary and con-
produce additional challenges. In order to optimize results, firmatory guides. In certain circumstances, minimally
surgeons need to consider several controllable factors invasive techniques using the locking compression plate
including biomechanical forces acting at the fracture site, (LCP) system allow stable fixation and loading conditions
fracture reduction, surgeon’s expertise and equipment. with less than perfect reconstruction of the fracture due to
Bones can be subjected to axial loading (compression), the maintenance of a fixed angle between the screws and
tension, bending, shear and torsion. When applied load plate (Chapter 8).
exceeds mechanical strength, fracture results. Certain Fracture reduction is particularly challenging in the
forces cause characteristic fractures, and individual bones proximal limb. Soft tissue attachments, the size of the ani-
are subjected to characteristic forces. Stable fracture fixa- mal and lack of specialized equipment all contribute to the
tion requires an understanding of the forces present and difficulty of obtaining accurate anatomic alignment.
the ability of implants to counteract them. Perhaps the most important aspect of this is patience on
Axial loading occurs during weight-bearing; the third the surgeon’s part. Inadequate reduction of long bones
metacarpal/tarsal bone (Mc/Mt3) is loaded nearly com- leads to limb deformity, discomfort, implant failure and
Considerations in the Management of Orthopaedic Injury in the Foal 783
poor outcomes. In the author’s practice gravity, tenting of plate (DCP) is used for double plate fixation. Increasingly,
fracture ends, progressive sliding of the fracture ends down LCPs are substituted for DCP plates. In general, the larger
the incline plane of an oblique fracture, large bone reduc- plate is used on the tension surface of the bone with the
tion forceps and Steinmann pins as handles are all utilized narrow plate at 90° to this. Applying a plate to the tension
as individual techniques or in combinations as circum- surface is biomechanically advantageous since the plate–
stances dictate. There is no single or standard technique for bone construct has its greatest stiffness when placed in ten-
any locations; since most fractures in foals are the result of sion compared to compression. Placing a second plate at
monotonic trauma, all cases differ. Nonetheless, some 90° to the plate optimizes resistance to axial compression,
techniques and tips for reduction are included with indi- bending and torsional loads. The principal plate can have
vidual fractures. both compression and neutralization functions, whereas
the second is typically used as a neutralization plate. Sites
Implant Selection and techniques for placement aim to optimize load shar-
ing, diminish compression forces and reduce cyclic fatigue.
Cortex screws placed in lag fashion reduce shear forces and
provide interfragmentary compression. In fractures in
which shear forces predominate counteracting lag screws Prevention of Angular Deformities
should be used whenever possible either alone (Figure 37.2) Angular limb deformities can follow foal fractures in both
or as part of a bone/plate construct. When high torsional, affected and contralateral limbs. In the injured limb, this
bending or compressive forces are present, screws applied can be due to failure to achieve axial alignment and/or
in lag fashion are relatively weak when compared to plate failure to address growth disturbances following physeal
fixation. A number of studies have compared screw types injury and repair. Consideration of potential scenarios
in foal bone. A comparison of 6.5 mm cancellous and should be made at the time of treatment. In the non-
7.3 mm cannulated screws showed similar pullout strength injured limb, varus deformity will occur if comfort, gener-
in foal femoral diaphyses and metaphyses, suggesting that ally determined by stability, is not achieved in the injured
the relatively weak and more expensive 7.3 mm cannulated limb. This typically manifests within a few weeks of an
screw has limited application in foal fracture repair [10]. injury and can often be the limiting factor to ultimate ath-
The pullout strength of 5.5 mm was greater than 4.5 mm letic soundness.
cortex screws in foal Mc/Mt3 diaphyses, while the pullout
strengths of 5.5 mm cortex and 6.5 mm cancellous screws
Analgesia and Medical Management
in metaphyseal bone were similar [11–13]. Additionally,
pre-tapping both screws increased pullout strength versus Compared to adults, foals are substantially more suscepti-
untapped holes. It is therefore recommended that 5.5 mm ble to gastrointestinal issues that may become life threaten-
cortex screws are placed into tapped holes as substitutes for ing including ulceration, enteritis, septicaemia and implant
stripped 4.5 mm screw holes rather the 6.5 mm cancellous infection. Anti-ulcer medication should be given to every
screws. foal that has significant musculoskeletal injury. The author
Bone plates are used for the repair of most long bone recommends routine use of omeprazole and, in some situ-
fractures although fractures involving growth plates may ations, sucralfate. Comfort is primarily obtained by provi-
also be treated with transphyseal bridging techniques. sion of fracture stability and this will limit the requirement
Plates have advantages due to their ability to counteract for non-steroidal anti-inflammatory drugs (NSAIDs). Use
axial compression, bending and torsion. The bending stiff- of the COX-2 inhibitor firocoxib will lessen but not elimi-
ness of a plate is related to the third power of its thickness nate the risk of NSAID-induced ulceration compared to
and directly proportional to its modulus of elasticity. It is flunixin or phenylbutazone although clinical experience
therefore easiest to increase the stiffness of an implant– suggests that it is an inferior analgesic. Prophylactic anti-
bone construct by choosing thicker or multiple plates. microbials are generally considered necessary but use
Double plate fixation is the method of choice for manage- should be relative to the invasiveness of the procedure(s),
ment of most long bone fractures in foals. Anatomic con- operative time and number of implants necessary for
siderations such as soft tissue structures, biomechanical repair. In the author’s hospital, antimicrobial use for a
studies and clinical experience have led to guidelines but major orthopaedic repair in a foal usually consists of five
usually fracture configuration ultimately determines sites days of IV administration. The typical antimicrobial regime
for plate placement. In most cases, a combination of a is potassium penicillin (22 000 iv/kg IV q6h) with an ami-
broad 4.5 mm and a narrow 4.5 mm dynamic compression noglycoside that is either gentamicin (6.6 mg/kg IV q24h)
or amikacin (25 mg/kg IV q24h). If there are no signs of but providing the footing is good most foals quickly
infection either clinically or on laboratory values, IV become adept at rising. In the author’s clinic, stalls have
administration will discontinue. Some surgeons will follow rubber floor mats and straw, rather than sawdust, is
with oral antimicrobials but, in the author’s experience, used for bedding. A clean well-bedded stall with good
these carry an increased risk of gastrointestinal distur- ventilation helps avoid respiratory disease. Foals should
bances frequently manifesting as enteritis. Their use is be allowed to rest, and staff should avoid entering the
therefore limited. Probiotic supplements are given to foals stall excessively: bundling treatments can help unnec-
receiving antimicrobial agents and, for approximately one essary handling. Foals that have concomitant nerve
week after, these cease to reduce the risk of antimicrobial palsy, as encountered with some proximal radial or
induced enteritis. Development of enteritis adds expense humeral fractures, may require assistance when rising
and can lead to secondary implant, physeal or synovial to nurse. In most circumstances, it is recommended
infection. that the mare remains with the foal and that weaning is
avoided for the first four weeks after injury. Medication
through long-term intravenous catheters rather than
External Coaptation
intramuscular injections is recommended. Oral medica-
Protection of surgical sites is of course warranted particu- tions are frequently given but risk eliciting excited
larly due to foals’ tendency to become recumbent to rest. behaviour, and it is recommended that experienced per-
However, excessive external coaptation is a serious risk in sonnel only should handle the injured foal. All bandage
foals. Equine surgeons are conditioned to worry about changes should be outside the stall in a clean environ-
implant failure due to the size and activity of our patients ment and with appropriate sedation.
which creates a tendency to over-protect constructs regard-
less of the effect on the patient (Chapter 13). In the distal
limb, this comes at the cost of weakening soft tissue sup- Fractures of the Distal Phalanx
port often manifesting as flexural laxity which will actu-
ally increase load on bone–implant constructs. In every The most common digital fractures in foals are solar mar-
repair in foals, the goal should be to achieve sufficient sta- gin and non-articular palmar/plantar process fractures of
bility to limit or eliminate the need for or benefit from sig- the distal phalanx. These are most frequently seen in the
nificant external coaptation and to provide a more normal summer months, are associated with hard ground and can
environment for soft tissues. If a cast is employed, time of be predisposed to by poor foot conformation [14].
use should be minimized with changes at two- to three- Anecdotally, they have also been related to the presence of
week intervals depending on the age of the foal. Normal acrylic hoof extensions to treat angular limb deformity.
weight-bearing is the best way to avoid flexor laxity, limb Fractures are usually accompanied by mild to moderate
contracture, angular deformity and to achieve an athletic lameness with increased digital pulse amplitudes and hoof
outcome. surface temperature. Lameness is generally worse with
In contrast to adult horses, laminitis from contralateral articular fractures which are usually sagittal or parasagit-
limb overload (Chapter 14) is rare. However, angular tal. Presenting signs can be similar to a foot abscess or dis-
deformity and fetlock hyperextension of the support limb tal interphalangeal joint infection. Diagnosis is by physical
and flexural deformity of the injured limb are common examination, digital anaesthesia and radiography.
complications of poor weight-bearing due to failure to Fractures of the palmar/plantar processes may be evident
properly manage the fractured limb. Normal weight- in routine projections but are often most readily imaged in
bearing and comfort will not only benefit the musculoskel- dorsal proximal lateral–palmar/plantar distal medial
etal system but also help prevent respiratory and oblique (DPrL-Pa/Pl DiMO) and dorsal proximal medial–
gastrointestinal comorbidities. palmar/plantar distal lateral oblique (DPrM-Pa/Pl DiLO)
projections (Figure 37.3). Occasionally, repeating radiogra-
phy in 7–10 days is necessary to identify non-or minimally
Nursing Care
displaced fractures. In foals with solar margin and non-
Foals usually spend increased amounts of time lying articular palmar/plantar process fractures, no specific ther-
down after orthopaedic injury and repair. Ideally, apy is needed; foals are usually stall confined until sound
repairs will allow relatively normal function and com- and then allowed gradually increasing amounts of exer-
fort. Excessive bandaging should be avoided, but inci- cise. Complete return to soundness and radiographic heal-
sional protection and care is important to prevent ing is expected. Articular wing and parasagittal fractures
infection. The foal should be assisted to rise as needed, are generally treated in a similar manner. Occasionally,
Fractures of the Proximal Sesamoid Bone 785
Figure 37.3 Fracture of the lateral (a) (b)

palmar process of a distal phalanx in a
three-month-old Thoroughbred foal
fitted with a lateral acrylic extension
for management of
metacarpophalangeal varus. (a)
DPr-PaDiO and (b) DPr L-PaDiMO
radiographs.
therapeutic shoeing is needed for articular fractures. firmed radiographically prior to placement of a half-limb
Unlike adults, most distal phalangeal fractures in foals heal cast that encases the hoof (Figure 37.4). If necessary, the
with a bony radiographic union. cast is changed once at 10–21 days depending on the age of
the foal. Some degree of flexor laxity is typical after cast
removal and the use of an extended heel shoe is often nec-
ractures of the Proximal and Middle
F essary (see Figure 13.12). For this reason, prolonged exter-
Phalanges nal coaptation is not recommended.
Other phalangeal fractures occur in foals but are less
A review of physeal fractures of the proximal phalanx common. Internal fixation with screws and plates and/or
found that these were uncommon, but SH types II, III, and pastern arthrodesis are occasionally performed in foals
IV had been reported [15]. SH type I or II fractures of the depending on the configuration. Simple non-displaced
proximal or middle phalanx can produce sufficiently severe fractures of the proximal phalanx can be treated with rest ±
angular deformity that joint luxation is often suspected. external coaptation. Simple displaced fractures are amend-
These injuries are usually closed and do not tend to cause able to screw fixation but are rare. Comminuted fractures
additional associated soft tissue damage. They are usually of the proximal phalanx with a transverse component can
managed by closed reduction and cast coaptation for three be repaired by double plate fixation and cast coaptation,
to six weeks depending on the type of fracture and age of typically for two to three weeks. Distal transverse fractures
the foal. Their stability and limited amount of bone for of the proximal phalanx (Figure 37.5), comminuted frac-
implant purchase lends these fractures to cast immobiliza- tures of the middle and traumatic proximal interphalan-
tion. Placing a single screw in the metaphyseal spike of geal subluxation (Figure 37.6) are best treated with plate
type II fractures will keep the fracture reduced, but exter- and screw fixation with pastern arthrodesis similar to that
nal coaptation is still required to counteract tension forces described in adults (Chapter 18).
present on the opposite side. Single screw fixation is not
recommended as the sole method of repair. If fractures
remain unstable after reduction, a transphyseal bridge of ractures of the Proximal
F
screws and figure-of-eight wire or a bone plate can be used Sesamoid Bones
to counteract the distracting forces biaxially in type I or on
the side opposite the metaphyseal spike in type II fractures. Fractures of the proximal sesamoid bones are common
A case report documented a SH type II fracture of a injuries in foals up to two months of age. Fore and
hindlimb proximal phalanx in a seven-month-old hindlimbs can be affected. Fractures can be uniaxial or
Warmblood filly. This had a plantar metaphyseal ‘spike’ biaxial, affect single or multiple limbs and include a variety
and was repaired using two dorsally positioned three-hole of configurations including different fractures both
4.5 mm narrow LCP under fluoroscopic guidance. Good between and within the same limb (Figures 37.7–37.11). It
healing followed, and implants were removed three months is generally accepted that they result from foals attempting
post-operatively [16]. If non-surgical treatment is elected, to keep up with their dams when galloping. Foals that are
the fracture is reduced under general anaesthesia and con- dysmature, weak or have been subjected to restricted exercise
(a) appear predisposed. Anecdotal evidence suggests that firm

ground conditions can also be contributory. Management
practices thus can limit their incidence.
The proximal sesamoid bones are not fully mineralized
until three months of age. Thus, juvenile fractures may
involve partially or sometimes exclusively the cartilage pre-
cursor. Radiographs will consequently either underesti-
mate or fail to identify fracture damage [17].
Lameness is variable in degree and often, even on well
managed studs, is not recognized in all affected animals.
Other clinical features also vary; even with marked articu-
lar involvement joint distension can be highly variable.
Radiographs in the acute phase frequently underestimate
fracture severity; fractures may be non-discernible and/or
have radiographically silent comminution.
Non- or minimally displaced fractures heal rapidly with
exercise restriction alone (Figure 37.7 and 37.8). Foals usu-
(b)
ally receive stall rest until sound and then are allowed grad-
ual increases in activity. Even when markedly displaced
such juvenile fractures can also heal without interference.
Restricted exercise is considered desirable to minimize dis-
placement. This is logical as juvenile fractures can result in
proximodistally elongated and frequently quite distorted
proximal sesamoid bones; the greater the degree of com-
minution and displacement, the greater the deformity of
the healed bone (Figures 37.9 and 37.10). Affected animals
commonly are sound with little external indication of the
injury except, in some cases, palpable elongation of the
affected proximal sesamoid bone(s). In some animals, heal-
ing may only be fibrous or fibro-osseous. Application of
casts or bandages are counterproductive as these can
induce profound laxity in the suspensory apparatus [17].
In contrast to adults, biaxial fractures of the proximal
(c) sesamoid bones that disarm totally the suspensory appara-
tus in foals can be managed successfully without recourse
to arthrodesis of the metacarpophalangeal joint [18]. The
clinical presentation is similar to that described in adults
and there is, without early provision of (flexed) limb sup-
port, a comparable risk of digital vascular compromise.
Such fractures have been treated successfully by applica-
tion of dorsal splints for periods of four to six weeks during
which second intention healing resulted in adequate
fibrous support. The joint was then allowed gradually to
extend over a three- to four-week period before progres-
sively increasing exercise. Analgesia in the form of phe-
nylbutazone was provided [18] and is likely to be necessary
to reduce the risk of overload complications in the con-
tralateral limb. Marked sesamoid distortion is inevitable,
and athletic function is unlikely (Figures 37.11 and 37.12).
If the fetlock is dropped or the foal is severely lame, fetlock
Figure 37.4 Lateral and dorsoplantar radiographs of a
four-month-old Thoroughbred foal with a displaced proximal SH arthrodesis (including palmar fetlock and/or pastern
type II fracture of a hind proximal phalanx (a) at presentation support) as described for adults in Chapter 20 is recom-
and (b) after closed reduction and cast application which was mended for salvage as breeding or pasture sound animals
maintained for four weeks and (c) 8 weeks after injury.
(a) (b) (c) (d)
Figure 37.5 Transverse, comminuted fracture of a hindlimb proximal phalanx in a four-month-old Thoroughbred foal. (a & b)
Pre-operative radiographs. (c & d) Four-week post-operative radiographs after repair and proximal interphalangeal arthrodesis with
2 × 4.5/5.0 mm LCP using a combination of locking (proximally) and cortex (distally) screws. Note the acrylic-fitted extended heel shoe
to counteract flexor laxity present after two weeks cast coaptation.
(a) (b) (c) (d)
Figure 37.6 (a, b) Pre-operative radiographs of a two-month-old TB with a comminuted middle phalangeal fracture and subluxation
of the proximal interphalangeal joint in a forelimb. (c, d) Seven-month follow-up radiographs following repair and arthrodesis of the
proximal interphalangeal joint with 2 × 4.5 mm DCP and a separate cortex screw in lag fashion to reduce and compress the sagittal
plane fracture. The filly started five races and was then retired for breeding.
(Figure 37.13). Cast coaptation is typically for two weeks hindlimb [19]. Four forelimbs involved bilateral fractures.
post-operatively. Once the cast is removed, a glue on Eleven of 18 foals had fractures of single sesamoid bones of
extended heel shoe is usually needed to counteract deep which 9 were medial. Fifteen foals sustained their fractures
digital flexor tendon laxity as a result of the coaptation. A at up to two months of age, and in the other three the frac-
reduction in metacarpal/metatarsal limb length is possible tures may have occurred at this time. Most had a history of
which may be compensated for by other growth plates in ‘galloping to exhaustion’ which frequently followed period
the limb or possibly require therapeutic shoeing. Implant (days) of box confinement. Lameness was variable, but
removal is not recommended. digital pressure over the affected proximal sesamoid bones
In a report of 18 foals with fractures of the proximal sesa- and fetlock flexion were consistently resented. Six of 12
moid bones, 17 occurred in forelimbs and 1 in a foals that had reached training age were trained and three
(a)
Figure 37.7 Composite DP, LM, DLPMO and DMPLO radiographs of a seven-week-old Thoroughbred foal with biaxial fractures of the proximal
sesamoid bones in left and right forelimbs and left hindlimb: (a) at presentation and (b) (Page 783) following four weeks of restricted exercise
raced; one of these had been treated by fragment removal f ractures. Neither were related to earnings at the end of the
and two conservatively [19]. horse’s three-and four-year-old racing seasons.
Enlarged proximal sesamoid bones consistent with frac- Fractures of the proximal sesamoid bones and bones of
tures occurring as foals were seen in 6 of 753 Standardbred distorted shape can be found in survey radiographs of
trotters in a yearling radiographic survey [20]. A further Thoroughbred yearlings prior to submission to or at sales
four animals had radiographically identifiable apical or as part of screening procedures (Figure 37.14) [21, 22]. A
(b)
Figure 37.7 (Continued) (b) following four weeks of restricted exercise.
substantial portion of these are believed to have originated horses were not lame at presentation [21]. Hindlimb apical
as previously unrecognized foal fractures. In a series of 151 fragments were most common in a series of Thoroughbred
cases, 139 (92%) occurred in hindlimbs, these had equal yearlings submitted for sale in Kentucky [22]. Enthesophyte
left:right distribution and 26 (19%) were bilateral. There formation on the forelimb proximal sesamoids was associ-
were more left than right forelimb fractures. There was no ated with a reduced likelihood of racing and in the
overall medial:lateral difference in incidence, but 9 out of hindlimbs of reduced performance, but there was no sig-
10 single forelimb fractures were medial. The majority of nificant association with sesamoid fractures or elongated
(a)
Figure 37.8 Composite of DP, LM, DLPMO and DMPLO radiographs of a three-week-old Thoroughbred foal with fractures of the
medial proximal sesamoid bones in left and right forelimbs and left hindlimb: (a) at presentation and (b) (page 785) following six
weeks of restricted exercise.
proximal sesamoid bones [23]. Despite these results, mark- potential. It is possible that such animals previously had
edly enlarged proximal sesamoid bones are generally con- been identified and therefore not submitted to the sales
sidered negative prognostic features with respect to racing from which radiographs were obtained [23].
(b)
Figure 37.8 (Continued) (b) following six weeks of restricted exercise.

(a)
(b)
Figure 37.9 DP, LM, DL-PMO and DM-PLO radiographs of a six-week-old Thoroughbred foal with a markedly comminuted fracture of
the apex and abaxial margin of the right forelimb medial proximal sesamoid bone: (a) at presentation and (b) following six weeks of
restricted exercise. The fractures entirely disarmed the insertion of the suspensory ligament resulting in distal displacement of the
remaining bone.
deformity, placement of a transphyseal bridge on both

ractures of the Mid and Distal Third
F sides is recommended (Figure 37.15). Recovery is usually
Metacarpal and Metatarsal Bones in a bandage with a splint that is removed a few days
post-operatively.
Distal physeal fractures are relatively common in foals. Diaphyseal fractures occur more commonly in foals and
Following reduction, which can be by ‘open or closed tech- weanlings than adults. They are usually complete and axi-
niques’, SH type II fractures can be repaired with one or ally unstable, so clinical signs are generally obvious.
two cortex screws placed in lag technique through the Fractures usually have a mid-diaphyseal transverse compo-
metaphyseal spike to maintain reduction [24]. However, nent with some degree of comminution. Instability and
this fixation does not counteract distracting forces. Both displacement are such that fractures may be open as the
SH type I and II fractures therefore usually require pointed end of the proximal fragment tends to pierce the
transphyseal bridging. It is important to understand which skin during attempts at weight-bearing. This type of open
side of the physis is under tension in the fracture and to fracture (type I) does not necessarily preclude surgical
counteract it. In SH type II fractures, this is typically the intervention. First aid should be aimed at realigning the
opposite side to the metaphyseal spike. However, because bony column and preventing the fracture from becoming
a unilateral transphyseal bridge may lead to angular open or the wound worsening. This typically involves
Figure 37.10 Displaced basilar (a)
fracture of the left forelimb medial
proximal sesamoid bone in a
two-week-old Thoroughbred foal:
(a) at presentation, (b) four, (c) eight
and (d) thirteen weeks later
demonstrating progressive healing
resulting in a proximodistally
elongated bone.
(b)
(c)
(d)
bandaging and the application of two splints at 90° to each preferable to lag a large butterfly fragment back to a
other. In distal fractures, the splints may end at the carpus major fracture fragment before completing reduction.
or tarsus; in mid to proximal fractures, the splints should After reduction, plates are contoured to the bone. With
continue further proximally (Chapter 7). Radiography con- the exception of very small foals, two plates placed at 90°
firms and defines the configuration. Particular attention to each other are usually required. The bone is predomi-
should be paid to assess the status of the nutrient foramen nantly loaded in compression with the dorsolateral
as fractures through this can lead to vascular compromise aspect the tension side. Placement of a plate on the dor-
which may inhibit successful repair. Case selection is solateral or dorsal side of the bone is therefore recom-
important. Fractures in which the bony column can be re- mended. Usually, a 4.5 mm broad DCP, LC-DCP or LCP
established and which have good bone stock proximal and is placed dorsally with a 4.5 mm narrow DCP or LC-DCP
distal to the fracture lend themselves best to repair by inter- positioned medially or laterally. Generally, 4.5 mm cor-
nal fixation. tex screws are used, but 5.5 mm cortex screws may be
elected. Lag screws are placed where possible to provide
inter-fragmentary compression. The dorsal plate should
Casts and Transfixation Casts
span the bone from just proximal to the distal metaphy-
Management of diaphyseal fractures by cast or transfixa- seal growth plate to just below the carpometacarpal or
tion cast application can be considered. However, in the tarsometatarsal joint.
author’s opinion, these techniques have limited applica- In fracture configurations in which there is little bone
tion. Transfixation casts (Chapter 13) provide flexibility in stock proximally or distally, a DCS plate may be consid-
managing fractures with little bone stock for plate applica- ered. When positioning plates, screw holes should be
tion and have relatively low initial cost. However, lack of staggered to allow room for the screws in each plate to
stability can lead to complications including fracture col- pass each other. An effort should also be made to prevent
lapse, further displacement to create an open fracture and the plates from ending at the same location on the bone,
fracture through a pin hole. Additionally, if comfort is not particularly if the diaphysis of the bone is not spanned by
quickly established, contralateral limb angular deformity a plate. Intra-operative radiographs at 90° to all implants
can result. are taken to assess fracture repair. Care should be taken to
avoid engagement of the splint bones and injury to the
physis (Figure 37.16). Plate luting with polymethylmeth-
Internal Fixation
acrylate may help to reduce cyclic fatigue and implant
Stable internal fixation with bone plates is the preferred failure (Chapter 8) but should not be performed on LCPs.
method of repair for most diaphyseal fractures of the Closed suction drains are placed at the surgeons’ prefer-
third metacarpal and third metatarsal bones. While ence. A minimally invasive operative (MIO) technique
DCPs have been the workhorse for these fractures, the using LCP plates has been used through small incisions,
advent of LCP-fixed angle constructs improves the although reduction using MIO techniques can be chal-
chance of success and allows the potential for minimally lenging (Chapter 22). Recovery is in a bandage and
invasive osteosynthesis [25]. Precise anatomic align- assisted.
ment and reconstruction of the bony column particu-
larly cortices opposite the plates to allow load sharing
Prognosis
are critical for successful repair. The foal is placed under
general anaesthesia usually in lateral recumbency with Prognosis is largely determined by the nature of the frac-
the affected limb uppermost. Dorsal recumbency can be ture, particularly whether it is open. Successful repair can
used particularly if traction might be useful. For an open be accomplished when stable internal fixation is achieved
approach, an incision is made on the dorsolateral aspect and infection is avoided. In one study, 9 of 11 foals with
of the metacarpus/metatarsus and is gently curved at its diaphyseal fractures were able to be used for their intended
proximal and distal extents. The forelimb lateral or use [26]. In another study, 32 of 42 (72%) horses with axi-
hindlimb long digital extensor tendon is incised longitu- ally unstable fractures were successfully treated with
dinally to provide a good layer for closure after repair. screw/plate fixation [27]. Twenty-four percent of these
After assessing the fracture, any associated debris is fractures were open and 60% of these were treated success-
removed. Reduction is usually achieved by tenting the fully. Incisional infection is the most common complication.
fracture out of the incision. In some circumstances, it is Plate removal of at least the dorsal plate is advised if
Fractures of the Cuboidal Bones of the Carpus and Tarsu 795
(a)
(b)
Figure 37.11 A comminuted biaxial fracture of forelimb proximal sesamoid bones in a three-week-old Thoroughbred foal: (a) at
presentation and (b) after five months. A fibro-osseous union has resulted in markedly distorted proximal sesamoid bones but has
maintained support of the metacarpophalangeal joint.
a thletic use is intended. Both plates can be removed if l igaments, and a biaxial combination of plates and screws is
required, but this should be staged. usually required. Partial (carpometacarpal) carpal arthrode-
sis may be needed if the third carpal bone is needed for bone
purchase. A fixed angle 4.5/5.0 mm T-plate is a useful in this
ractures of the Proximal
F situation.
Metacarpus and Metatarsus
Fractures of the proximal metacarpal bones commonly lead ractures of the Cuboidal Bones
F
to lateromedial instability of the carpus due to loss of collat- of the Carpus and Tarsus
eral ligament support. It is not uncommon to have at least
two metacarpal bones fractured at the same time. Following Cuboidal bone injuries include malformation due to
reduction, support in splints or casts can be considered but delayed mineralization and fractures due to trauma. In the
generally surgical repair is necessary to re-establish stability carpus plastic deformation of the cuboidal bones is com-
and to avoid long-term complications such as rub sores and mon while fractures are rare. This most frequently results
or ligamentous laxity with cast coaptation. Screws alone do from normal loading activity on hypoplastic or dysmature
not counteract the distracting forces of the collateral bones. However, it can also be secondary to overload of
(a) Figure 37.12 (a) Radiographs

demonstrating comminuted displaced
fractures of the medial and apical
fractures of the lateral proximal
sesamoid bones with concurrent
inter-sesamoidean ligament injury
(sesamoid dehiscence) in a 10-week-old
Thoroughbred. (b) Follow-up
radiographs nine months after the injury
following initial treatment with
bandaging and stall rest. The filly
entered training but did not race.
(b)
normal bones and/or their cartilage templates from limb ypoplasia. Fractures are not always immediately appar-
h
overload due to contralateral limb injury or, in a sided ent as there may involve the cartilage template
manner, subsequent to angular deformities originating (Figure 37.17). Affected foals frequently have increased
elsewhere in the leg. tarsal flexural angles (sickle hocks) and valgus deformity.
In the tarsus, fractures of the central and third tarsal The dorsal and dorsolateral portions of the bones sustain
bones are most frequent. Although variably described crush-type injuries that result in wedged or collapsed
deformation of the third tarsal bone had been recognized shapes. Fractures are more common in the third than
for many years, the involvement of dysmaturity and col- central tarsal bones, appear to become more dorsally dis-
lapsing fractures was not reported until 1982 [28]. In this placed and exhibit poorer healing. Healed fractures may
study, five of six foals were premature or twins and suf- be identified in yearling survey radiographs [22]. Their
fered fractures of third (4), central (1) and both central potential to predispose to recurrent injury in horses in
and third (1) tarsal bones. In a subsequent study, 11/22 training is a matter of debate [31, 32].
foals with incomplete ossification were premature or Delayed mineralization should be suspected in prema-
twins. Only 3 of 16 foals with fractures and/or collapse ture or dysmature foals and leads to angular deformities in
performed as intended [29]. A study of 115 Thoroughbred either the sagittal or frontal planes or both. Foals suspected
foals confirmed the connection between gestational age of cuboidal bone hypoplasia should be radiographed to
and degree of ossification of tarsal cuboidal bones and assess the degree of mineralization and be placed on lim-
reinforced its negative impact on racing perfor- ited non-competitive exercise until the risk of cuboidal
mance [30]. Both generally result from cuboidal bone collapse as evidenced by physical appearance and
Fractures of the Cuboidal Bones of the Carpus and Tarsu 797
(a) (b)
(c) (d)
Figure 37.13 Radiographs of the right (a) and left (b) metacarpophalangeal joints in a 30-day-old TB filly with bilateral biaxial
fractures of the proximal sesamoid bones resulting in loss of palmar support. Radiographs four months after surgery of the right (c)
and left (d) joints after arthrodesis using broad LCP plates and transarticular screws with partial engagement of the proximal
sesamoid bones and palmar figure-of-eight wires to support the fetlock.
radiographs has passed. Restricted exercise programmes race and had lower earnings than foals with normal tarsal
are varied according to the degree of hypoplasia and bone mineralization [33].
strength of the foal, but often consists of complete stall rest Osteochondral fragmentation of the cuboidal bones of
or limited hand walking gradually increasing to round pen the carpus/tarsus occasionally occurs and can be removed
and small paddock turnout. No surgical procedures are rec- via arthroscopic techniques as described in older horses
ommended with the exception of transphyseal bridging (Chapters 24 and 29) to eliminate inflammation and avoid
when required for associated angular limb deformities. the development of degenerative joint disease. Palmar frac-
Thoroughbred foals with varying amounts of cuboidal tures of the carpus are more problematic and are not always
hypoplasia of the tarsus were reported to be less likely to amenable to removal.
(a) (b) Figure 37.14 (a) DP and (b) DL-PMO radiographs of

a Thoroughbred yearling demonstrated
proximodistal elongation and a distorted
dorsopalmar shape of the lateral proximal sesamoid
bone. This was found in screening radiographs prior
to sales submission.
(a) (b) (c)
Figure 37.15 Radiographs of a SH type II fracture of the distal metatarsal physis of a three-week-old Saddlebred filly. The
metaphyseal spike is lateral. (a) At presentation. (b, c) Six weeks after surgery. The metaphyseal spike has been repaired with a single
4.5 mm cortex screw and medial distracting forces counteracted with screws and wire with a similar lateral bridge to prevent varus
deformity.
R
adial Fractures a menable to internal fixation [34, 35], but careful first aid
is required to prevent the fracture from becoming open
Proximal and distal SH fractures as well as a wide variety of prior to surgery (Chapters 7 and 25). Of diaphyseal frac-
diaphyseal fractures of the radius occur in foals. Unlike tures, proximal transverse fractures are the most com-
adults, most radial fractures in foals are closed and mon [35]. Placing the foal in dorsal recumbency and
Fractures of the Uln 799
(a) (b) (c)
Figure 37.16 (a) Radiograph of a two-month-old TB filly with a closed transverse mid-diaphyseal fracture of the third metacarpal
bone. (b) Repair with a dorsal 4.5 mm broad LCP and lateral 4.5 mm narrow DCP: 4.5 mm cortex screws are used in the latter with a
mixture of these and locking screws in the LCP. (c) Healed fracture after staged plate removal.
tethering the limb to a hoist or ring in the ceiling can aid cause elbow subluxation and require ulna ostectomy to
reduction; traction is applied when the operating table is correct [36, 37] (Figure 37.18).
dropped and/or the hoist is raised. If the animal is in lateral ●● The cranial plate and any screws connecting cranial and
recumbency, tenting the fracture ends out of the incision is caudal cortices should be removed in animals intended
a viable reduction method. The author prefers dorsal for athletic use (Figure 37.19).
recumbency, a medial approach and traction. Reduction
can be maintained with cortex screws in lag fashion or
reduction forceps while a plate is applied. There are a num-
ber of repair techniques. Detailed description is given in
Fractures of the Ulna
Chapter 25, but there are some important points to empha-
Fractures of the ulna in foals and weanling are reasona-
size in foals:
bly common. Fractures causing loss of triceps support
●● The convex cranial cortex is the tension side of the bone, which are displaced or if lameness is severe require
and in diaphyseal fractures, at least one plate should be repair. Some fractures distal to the articulation can be
placed here. managed non-surgically if patient comfort is acceptable,
●● Failure to properly reduce the caudal cortex will lead to and there is no displaced articular component (see
collapse and cycling of the cranial plate. Chapter 26).
●● While a single cranial plate may be used to repair radial The key component of repair is counteracting the dis-
diaphyseal fractures, no specific guidelines have been tracting forces of the triceps pull on the proximal portion
developed. Because of this, a second plate on the lateral of the fracture. Ulnar fractures are generally easy to
or medial side of the radius is often used especially in reduce by placing the limb in extension and will become
proximal or distal diaphyseal fractures: distracted when the elbow is flexed. Pointed reduction
●● If possible, implants crossing the proximal or distal forceps can be helpful in holding the proximal fracture
growth plates should be avoided. fragment for reduction. Purchase in bone can be aided by
●● In animals less than one year of age, implants should not making a small hole with a 3.2 mm drill bit in the direc-
engage the ulna. Engagement of the ulna with implants tion needed to place the point of the forceps. If an oblique
and/or exuberant callus from the caudal radius may fracture is present, a single cortex screw in lag fashion
(a) (b)
(c)
Figure 37.17 Tarsal cuboidal hypoplasia in a three-week-old Thoroughbred foal. Dorsomedial–plantarolateral oblique and
dorsolateral–plantaromedial oblique radiographs (a) demonstrating initial proximodistal narrowing and rounded margins to the
dorsolateral aspects of the central and third tarsal bones with a discrete slab fracture of the third tarsal bone and fragmentation of
the central tarsal bone in the DL-PMO projection. Improved dorsolateral cuboidal shape and fracture of the central tarsal bone were
apparent as mineralization of the cartilage template proceeded (b) 10 days and (c) four weeks later.
can be placed to maintain reduction while the plate is structs have also been used for different fracture configu-
applied to the caudal surface. In comminuted fractures, rations. In SH type I fractures, wires are used to ‘build a
cerclage wires (1.0–1.25 mm) through predrilled holes cage’ around the apophysis to prevent distraction from
can help to reduce fragments. Typically, a 4.5 mm narrow the triceps muscles (Figure 37.20). If the fracture is com-
DCP is used for this repair. Fixed angle plates can be used minuted and causes mediolateral instability, then a sec-
but care should be taken to ensure bone engagement. ond plate may be placed on the lateral aspect of the ulna.
Figure-of-eight wire and pin/wire and plate/wire con- A complete description of techniques is given in
Figure 37.18 (a) Ten weeks post-operative (a) (b)

radiograph following repair of a complete
transverse radial fracture in a five-day-old
Saddlebred foal with a broad 4.5/5.0 LCP on the
cranial cortex and a narrow 4.5 mm DCP on the
medial surface. Exuberant callus and interosseous
bone (spot welds) from drill holes at the time of
repair have linked radius and ulna causing elbow
subluxation (circle). (b) Intra-operative radiograph
during cranial plate removal with a 5 mm ulnar
ostectomy and breakdown of ‘spot welds’. (c)
Radiograph one day post-operatively
demonstrating rapid resolution of the subluxation.
(d) Radiograph six weeks later confirming normal
proximal radial growth without recurrence of
subluxation.
(c) (d)
(a) (b)
(c) (d)
Figure 37.19 Transverse fracture of the distal radial diaphysis in a 150 kg TB foal. (a) Radiographs at diagnosis. (b) Displacement
evident on hospital arrival. (c) Post-operative radiographs of repair with long cranial and short medial LCPs fixed with combinations of
locking and cortex screws. (d) Healed fracture following staged plate removal.
(a) (b)
Figure 37.20 (a) A two-month-old TB foal with a type I (apophyseal avulsion) fracture of the proximal ulna (arrow). (b) Radiograph
six weeks after repair with a 4.5 mm narrow DCP and 2 × 1.25 mm figure-of-eight wires.
(a) (b)
Figure 37.21 (a) A three-month TB Foal with comminuted displaced articular fracture of the ulna. (b) Post-operative appearance after
repair with nine-hole 4.5 mm narrow DCP, with further tension band wires to reduce and compress the fracture. The figure-of-eight
wires also function to reduce the pullout force on the cortex screws restricted to the distal ulna.
●● Avoiding engagement of the radius in animals less than

Chapter 26. Some important aspects of repair in foals
12 months of age avoids risk of subluxation of the cubital
include the following:
joint due to growth at the proximal radial physis [36, 37]
●● Reconstruction of the anconeal process at the articular (Chapter 26).
margin of the fracture is important. Loss of bone at this ●● Irrespective of the fracture location, plates should be posi-
site will cause a defect on the compressive side of the tioned proximal to the apophyseal physis to prevent a stress
construct and lead to potential cyclic fatigue of the riser effect and fracture or avulsion of the apophysis,
plate. ●● The distal ulna in foals is relatively thin, and screw loos-
●● Placement of the proximal screws in the dense bone of ening can occur at this site. In some cases, the addition
the cranial cortex of the ulna proximal to the articulation of figure-of-eight wires can add stability to the repair
ensures the most stable construct. (Figure 37.21).
●● Some fracture at or below the level of the proximal radial tubercle, although fractures of the scapular neck can also
physis can be managed non-surgically or with multiple occur. Acute fractures are best treated with internal fixa-
figure-of-eight wires to create a tension band. tion using fixed angle plates; techniques are described in
Chapter 28.
H
umeral Fractures C
alcaneal Fractures
A full description of the management and surgical Fractures of the calcaneus can occur in foals. The perma-
approaches of humeral fractures can be found in Chapter 27. nent flexion angle of the tarsus creates a strong plantar ten-
Repair is challenging due to the configurations encountered, sion band similar to the ulna. Fractures therefore are
shape of the bone, difficulty in contouring plates and the generally treated with internal fixation using similar prin-
potential for radial nerve injury either due to the inciting ciples. Screw fixation has been used successfully for a mini-
trauma, fracture displacement or at surgery. A cranial mally displaced fracture [42], but it is important to note
approach is typically chosen with the foal in lateral recum- that this technique is inherently weak in counteracting the
bency and the affected limb uppermost [38]. Care must be plantar tension forces. In complete unstable fractures, sin-
taken to avoid iatrogenic injury to the radial nerve. A caudal gle or double plating is recommended (Figure 37.22). The
approach with an ulnar osteotomy has been used for treat- technique for placement of the plantar plate is similar to
ment of a distal humeral fracture [39]. Reduction is compli- that described for tarsal luxation in Chapter 29. If neces-
cated by access, close location of the radial nerve and sary, a second plate is positioned laterally. Sleeve cast coap-
configuration of the bone. The short, S-shape of the humerus tation is recommended for recovery, and maintaining this
and its proximal location makes traction and tenting of frac- for 12–14 days assists with wound healing.
ture ends difficult. Using Steinmann pins as handles in the
bone ends and “walking “the fracture down the oblique
incline plane with reduction forceps can be very helpful.
Placing independent cortex screws in lag fashion is often dif- Tibial Fractures
ficult, and reduction is usually maintained with reduction
forceps while the plate is applied. Typically, the longest plate In foals, SH type II fractures of the proximal physis and
is placed cranially but purchase in the distal fragment is mid-diaphyseal fractures are most common. Both are usu-
often limited and challenging. Use of an interlocking nail ally amenable to repair. The former are usually caused by
(ILN) or ILN–plate construct offers the most promise. In a an external blow or fall. They characteristically have a lat-
recent study, 12 of 15 (80%) foals weighing up to 375 kg sur- eral metaphyseal spike and are usually closed, but soft tis-
vived to discharge including 11 that survived in the long sue swelling is variable and can be severe. Radiographs
term and were used as intended [40]. Unfortunately, the ILN generally reveal distraction of the medial aspect of the phy-
implant system is not commercially available. Non-surgical sis. Careful examination of the tibial crest should be made
management is sometimes a viable option in foals [41]. as this can also be fractured. SH type II fractures of the
Usually, foals and weanlings managed conservatively begin proximal tibia can be operated in dorsal or lateral recum-
weight-bearing in six to eight weeks post-injury. Nursing is bency (affected limb lowermost). Fracture biomechanics
paramount, and using bedding to bank the stall walls require the medial side of the fracture to be fixed. In dorsal
encourages the foals to lie in partial sternal recumbency recumbency, traction can be applied from the ceiling. In
which helps them to rise. Complications of conservative the author’s experience, reduction is more easily attained
management include flexural deformity of the affected limb, in lateral recumbency using a combination of traction and
which may need splinting and angular deformity, usually toggling. Reduction can be difficult but is necessary both
carpal varus, in the weight-bearing limb. Nonetheless, some for stable fixation and to ensure a straight limb. This can be
animals managed this way have become athletic. aided by using the tension device distally after the plate is
attached to the epiphyseal fragment. A temporary transphy-
seal bridge of screws and wire (usually caudal to the site for
Fractures of the Scapula plate placement) can help maintain reduction. A combina-
tion of transphyseal bridging using screws and wire with
Fractures of the scapula are uncommon in foals and are fixed angle straight or T-plate is recommended (Figure
more likely to occur in yearlings and adults. The most com- 37.23). An additional tension band on the tibial crest is
mon fractures in yearling are those of the supraglenoid often needed to counteract the distraction forces of the
Tibial Fracture 805
Figure 37.22 (a) Radiographs of a (a)

comminuted displaced fracture of the
calcaneus in a three-month-old
Standardbred filly. (b) Nine-month
post-operative radiographs. The fracture
was repaired with two LCPs: one to create
a caudal tension band and the other as a
contoured lateral neutralization plate.
Note that the latter overlaps but is not
fixed to the fourth tarsal bone.
(b)
quadriceps muscle insertion. Careful radiographic control recumbency with the limb lower most, and a medial
is needed to ensure that proximal screws do not enter the approach adjacent to the cranial tibial muscle usually gives
femorotibial joint. Soft tissue coverage on the proximal the best access. Tenting the fracture out of the incision and
medial tibia is minimal, and use of a closed suction drain ‘walking’ the ends down the incline plane of oblique frac-
system is recommended to reduce seroma formation. tures using reduction forceps aid reduction. Axial traction
Diaphyseal fractures tend to be in the mid to distal one- is difficult due to the angle of the hock. If necessary, a
thirds and are generally closed. Those amendable to inter- Steinmann pin placed medial to lateral in the distal frag-
nal fixation are typically long and oblique. Lateral ment can acts as a handle for axial traction. Reduction can
(a) Figure 37.23 (a) Radiographs of a

30-day-old TB filly with a displaced SH
type II fracture of the proximal tibia. (b)
30-day post-operative radiographs after
repair with a medial narrow LCP,
caudomedial screws and wire as a
transphyseal bridge and a tension band
in the tibial tuberosity using screws and
washers to anchor the wire.
(b)
be maintained either with cortex screws in lag fashion or F

emoral Fractures
reduction forceps while the plate is applied. Implant place-
ment depends on the configuration of the fracture, but SH type I fractures of the proximal femur are difficult to treat.
usually double plate fixation with standard or fixed angle Diagnosis is often hampered by the absence of swelling and
plates is elected due to the inherent high torsional loads difficulty in imaging the pelvis in the standing foal. Many
upon the tibia. The cranial lateral aspect of the tibia is fractures therefore go unrecognized in the acute phase.
loaded in tension, and usually the longer plate spans the Displaced fractures of the femoral capital physis require sur-
tibia on this or the cranial surface of the bone. Closed suc- gical repair with cortex screws in lag fashion, which is
tion drainage is usually used with standard closure and described and discussed in Chapter 32. Outcome after repair
minimal bandaging. Use of a full-limb cast is contraindi- is guarded to poor [44]. A case report documented successful
cated. If plate removal is elected or required, it is usually conservative management of a distal SH type III fracture of
staged to reduce the risk of re-fracture after removal. A the lateral condyle in a 10-day-old Standardbred foal [45].
clinical report of nine foals with mid-tibial diaphyseal frac- Fractures of the femoral diaphysis are associated with
tures repaired with double plating yielded good outcomes significant soft tissue swelling and haemorrhage, and
in six, fair outcomes in two and one foal did not sur- reduction of most fractures is easiest when repair is
vive [43]. A description of repair is provided in Chapter 30. attempted within the first few days of the injury. A lateral
Guidelines for Implant Remova 807
approach to the femur with the animal in lateral recum- ●● may cause deformity,
bency is recommended. Tenting of the fracture ends later- ●● have the potential to cause lameness,
ally and cranially aids in reduction and, as in other long ●● presence is not cosmetic
bone fractures, use of Steinmann pins as bone handles ●● prevent resolution of infection.
and walking of the fracture ends with large reduction for-
ceps can also contribute. A complete description of femo-
Risks
ral fracture management and results is given in
Chapter 32. Some important aspects of repair in foals are: A decision on implant removal should be balanced with
the risks vs. benefits of the procedure. The risk of removal
●● Fractures are often accompanied by significant haema-
varies with the location and function of the implant(s), the
toma/seroma formation which complicates soft tissue
original injury and the time from repair to removal.
closure and leads to increased risk of infection. After
Removal of screws generally carries little risk. Soft tissue
open reduction and internal fixation, the use of closed
infection can follow implant removal and occasionally
suction drain systems is recommend.
become serious. A second fracture of a long bone is possible
●● Diaphyseal fractures can be repaired with ILN, ILN/
after plate removal even if this is staged. In general, cos-
plate [46] or double plate [47] fixation based on configu-
metic results after removal of single screws are excellent.
ration and implant availability.
After plate removal, development of a seroma and subse-
●● Specialized implants such as DCS or DHS plate system
quent scar tissue may lead to a less cosmetic result than
are helpful for proximal or distal fractures.
when the implant was in situ. If a foal is to be kept for
●● Careful anatomic reduction of diaphyseal fractures opti-
breeding or pasture activity only, implants are only
mizes the strength of the bone/implant construct,
removed in the presence of infection or if progressive
improves comfort, reduces risk of cyclic fatigue and
deformity is anticipated.
maintains limb length and alignment.
Timing
P
elvic Fractures
Recommendations for removal of screws vary according
Pelvic fractures occur commonly in foals and can have a to fracture location and surgeons’ preference. Removal of
variety of configurations. Diagnosis is aided by ultrasound plates after long bone fracture repair is generally required
and confirmed by radiography. Involvement of the acetabu- if the foal is destined for athletic purposes. An exception
lum is the principal determinant of the foal’s ability to to this is plates used for ulnar fracture repair as unless
become athletic. In a survey of 136 Thoroughbreds with pel- there is engagement of the radius there is no recognized
vic fractures at the author’s clinic, 55 were one year of age morbidity associated with the presence of the implants
or less. Twenty-six (49%) of these involved the acetabulum, per se. That said these plates are commonly removed in
14 (25%) the ilial shaft, 12 (22%) the tuber coxa and three foals destined for public auction due to a perceived nega-
(4%) the pubis. Ten foals with acetabular and 1 foal with an tive impact on purchase value of horses that have
ilial shaft fracture were euthanized after diagnosis. Fifty implants present. Typically, plate removal is 12–16 weeks
percent of surviving (i.e. 30% of total) foals with articular after fracture fixation and at least 30 days after pasture
fractures subsequently raced compared to 71% of foals with turnout. In young foals, plate removal can often occur
non-articular fractures. All foals were treated conserva- earlier; in some circumstances, as quickly as four to six
tively with stall rest followed by pasture activity [48]. While weeks. If two plates are present, removal is usually
there are some fractures of the ilial shaft that may be amend- staged. In the author’s clinic, the plate that is theoreti-
able to surgical fixation [49], the author has no experience cally under most load is removed first after 30 days of
with internal fixation of pelvic fractures in the foal. pasture activity. If removal of the second plate is required,
this is carried out after at least another 30 days of pasture
activity. Occasionally, some secondary, neutralization
Guidelines for Implant Removal plates are left in situ if it is considered that the presence
of the implants would not lead to lameness. Generally,
Indications these have been shorter plates or those placed on the
medial or lateral aspect of long bones with screws which
Removal is generally because implants
do not engage the dorsal and palmar/plantar or cranial
●● are no longer contributory to fracture healing or correc- and caudal cortices. As a general principle, engagement
tion of deformity, of cortices that under load are placed in bending can lead
to lameness either by union of the cortices or potential If a plate is to be removed, this is generally done by
differences between the modulus of elasticity of the bone making a 3–4 cm incision over its proximal or distal end.
and the implants. Screw heads are located with hypodermic needles. An
If implants are to be removed because of infection, then overlying plate of similar dimensions is helpful as a tem-
the surgeon needs to balance effectiveness of leaving an plate. Occasionally, it is necessary to use an osteotome to
infected implant for stability against the effect of persis- remove bone that has grown onto the plate. Following
tent infection on fracture healing, extension to adjacent identification, screws are removed through stab inci-
structures and cosmetic outcome. Prolonged use of the sions. Bone and soft tissue can grow into the screw heads,
infected implant may lead to soft tissue infection and and removal is aided with a hypodermic needle or
potentially spread to adjacent synovial structures or the Kirschner wires. After screw removal, the plate usually
fracture itself. Decisions are based on the circumstances of needs to be loosened using an osteotome and mallet and
the individual case, but implant loosening associated with once mobile a hole can be hooked with a haemostat or
infection is an indication for removal. The use of locking thyroid retractor allowing removal through the initial
screw/plate systems reduces the amount of instability of incision. Sometimes the plate is too deep or bone over-
the construct in the face of infection because the screws growth so excessive that multiple 3–4 cm incisions or one
locked at a fixed angle cannot move relative to the plate. large open approach are necessary for removal. Incisions
for screw removal are often left unsutured but can be
closed if longer than stabs. The incision for plate removal
Techniques is closed in two or three layers. Penrose drains are occa-
For removal of single screws or screws and wire, the head sionally placed to prevent seroma formation if a large
of the screw is located with a hypodermic needle before a dead space or excessive haemorrhage has occurred.
small stab incision is made with a number 15 scalpel blade Placement of drains and absorbable antimicrobial beads
directly onto the screw head. The surgeon must be confi- are recommended after removal of infected implants.
dent that the screw head has been identified before mak- External coaptation for recovery from anaesthesia may
ing the incision. If not, a radiograph should be taken with be necessary depending on the individual circumstance,
the needle in place to confirm the relative positions. but in most cases post-operative bandaging is all that is
Frequently, soft tissue is present in the screw head and this necessary.
can be removed with mosquito haemostatic forceps which
also helps to identify the location and angle of placement
of the implant and thus the screwdriver. The screwdriver
Post-operative Management
should be firmly seated in the screw head prior to com-
and Complications
mencing removal. This is especially important when shal-
low head (such as 3.5 mm) screws are removed as stripping Post-operative management differs with individual cases,
of the screw head socket is possible if the screwdriver is but generally after removal of screws or screws and wires
not seated properly. This risk is increased if soft tissue is no special restrictions aside from wound management are
present in the screw head or if there is bone in or overlap- necessary. After removal of plates, the author generally
ping its margins. If stripping of the head is starting, it is radiographs the affected area after recovery from anaesthe-
important to reassess the seating of the screwdriver before sia to check for injury or re-fracture. After discharge, a
continuing. Removal of screws with stripped heads and period of 10–14 days of stall rest followed by small paddock
broken screws is discussed in Chapter 11. The pros and turnout for four weeks is recommended. If a second plate is
cons of removing broken or stripped screws should be present, the author prefers staged removal. Removal of
considered on a case-by-case basis. During untightening implants standing removes the risk of catastrophic failure
of the screw in the conscious foal, it is important that the during recovery from anaesthesia and is recommended
animal does not move suddenly as this can cause bending when possible.
or breakage of the implant. If multiple screws are to be Infection of the soft tissues can occur after implant
removed, one or more screws are left in place with their removal, so the procedure should as far as possible be per-
heads external to the skin to act as reference points for the formed aseptically and with appropriate post-operative
location of additional screws. Stab incisions may be closed care. Production of white hairs and scar tissue are more
or left unsutured and typically heal cosmetically. Larger likely to occur after larger incisions for plate removal than
incisions usually require skin closure only. stab incisions for screw removal.
Reference 809
R
eferences
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(1986). Physeal fractures in the horse 1. Classification and phalanx in foals. Equine Vet. Educ. 27: 183–187.
incidence. Vet. Surg. 15: 223–229. 16 Van Spijk, J.N., Fürst, A.E., Del Chicca, F. et al. (2015).
2 James, M., Brian, J.M., Choi, D.H., and Moore, M.M. Minimally invasive plate osteosynthesis of a Salter-Harris
(2018). The primary physis. Semin. Musculoskelet. Radiol. type 2 fracture of the proximal phalanx in a filly. Equine
22: 95–103. Vet. Educ. 27: 179–182.
3 Olstad, K., Ytrehus, Ekman, S. et al. (2008). Epiphyseal 17 Wright, I.M. (2020). Fractures of the proximal sesamoid
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4 Olstad, K., Ytrehus, E.S. et al. (2008). Epiphyseal cartilage 18 Honnas, C.M., Snyder, J.R., Meagher, D.M., and Ragle,
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to osteochondrosis. Equine Vet. J. 40: 30–39. apparatus in foals. Cornell Vet. 80: 123–133.
5 Olstad, K., Ytrehus, E.S. et al. (2009). Epiphyseal cartilage 19 Ellis, D.R. (1979). Fractures of the proximal sesamoid
canal blood supply to the metatarsophalangeal joint of bones in thoroughbred foals. Equine Vet. J. 11: 48–52.
foals. Equine Vet. J. 41: 865–871. 20 Grondahl, A.M., Gaustad, G., and Engeland, A. (1994).
6 Rang, M. (ed.) (2008). Injuries of the epiphysis, the Progression and association with lameness and racing
growth plate and the perichondrial ring. In: Children’s performance of radiographic changes in the proximal
Fractures, 2e, 10–26. Philadelphia: JP Lippincott. sesamoid bones of young standardbred trotters. Equine
7 Salter, R.B. and Harris, W.R. (1963). Injuries involving the Vet. J. 26: 152–155.
epiphyseal plate. J. Bone Joint Surg. Am. 45: 587–622. 21 Schnabel, L.V., Bramlage, L.R., Mohammed, H.O. et al.
8 Donecker, J.M., Bramlage, L.R., and Gabel, A.A. (1984). (2007). Racing performance after arthroscopic removal of
Retrospective analysis of 29 fractures of the olecranon apical sesamoid fracture fragments in thoroughbred
process of the equine ulna. J. Am. Vet. Med. Assoc. 185: horses age <2 years: 151 cases (1989–2002). Equine Vet. J.
183–189. 39: 64–68.
9 McIlwraith, C.W., Nixon, A.J., and Wright, I.M. (2015). 22 Kane, A.J., Park, R.D., McIlwraith, C.W. et al. (2003a).
Diagnostic and Surgical Arthroscopy in the Horse, 4e. St Radiographic changes in thoroughbred yearlings. Part 1:
Louis, USA: Elsevier. prevalence at the time of the yearling sales. Equine Vet. J.
10 Johnson, N.L., Galuppo, L.D., Stover, S.M. et al. (2004). 35: 354–365.
in vitro biomechanical comparison of the insertion 23 Kane, A.J., McIlwraith, C.W., Park, R.D. et al. (2003b).
variables and Pullout mechanical properties of AO Radiographic changes in thoroughbred yearlings. Part 2:
6.5-mm standard cancellous and 7.3-mm self-tapping, associations with racing performance. Equine Vet. J. 35:
cannulated bone screws in foal femoral bone. Vet. Surg. 366–374.
33: 681–690. 24 Bregger, M.D.K., Fürst, A.E., Kircher, R.R. et al. (2016).
11 Yovich, J.V., Turner, A.S., and Smith, F.W. (1985). Holding Salter Harris type II metacarpal and metatarsal fracture
power of orthopedic screws in equine third metacarpal in three foals. Vet. Comp. Orthop. Traumatol. 29: 239–245.
and metatarsal bones part II. Adult horse bone. Vet. Surg. 25 Levine, D.G. and Richardson, D.W. (2007). Clinical use of
14: 230–234. the locking compression plate (LCP) in horses: a
12 Yovich, J.V., Turner, A.S., and Smith, F.W. (1985). Holding retrospective study of 31 cases (2004–2006). Equine Vet. J.
power of Orthopedic screws in equine third metacarpal and 39: 401–406.
metatarsal bones part 1. Foal bone. Vet. Surg. 14: 221–229. 26 Bischofberger, A.S., Furst, A., Auer, J. et al. (2009). Surgical
13 Yovich, J.V., Turner, A.S., Smith, F.W. et al. (1986). management of complete diaphyseal third metacarpal and
Holding power of orthopedic screws comparison of metatarsal bone fractures: clinical outcome in 10 mature
self-tapped and pre-tapped screws in foal bone. Vet. Surg. horses and 11 foals. Equine Vet. J. 41: 465–473.
15: 55–59. 27 Beinlich, C.P. and Bramlage, L.R. (2002). Results of plate
14 Faramazi, B., McMicking, H.S. et al. (2015). Incidence of fixation of third metacarpal and metatarsal diaphyseal
palmar process fractures of the distal phalanx and fractures. Proc. Am. Assoc. Equine Pract. 48: 247–248.
association with front hoof conformation in foals. Equine 28 Dewes, H.F. (1982). The onset and consequence of tarsal
Vet. J. 47: 675–679. bone fractures in foals. N.Z. Vet. J. 30: 129–135.
29 Dutton, D.M., Watkins, J.P., Walker, M.A., and Honnas, 39 Ahern, B.J. and Richardson, D.W. (2010). Distal humeral
C.M. (1998). Incomplete ossification of the tarsal bones in Salter Harris (type II) fracture repair by ulnar osteotomy
foals: 22 cases (1988–1996). J. Am. Vet. Med. Assoc. 213: approach in a horse. Vet. Surg. 39: 729–732.
1590–1594. 40 Glass, K.G. and Watkins, J.P. (2018). Humeral fracture
30 Haywood, L., Spike-Pierce, D.L., Barr, B. et al. (2018). intramedullary, interlocking nail and plate fixation in 15
Gestation length and racing performance in 115 horses less than 1 year of age (1999–2013). Proc. Eur. Col.
thoroughbred foals with incomplete tarsal ossification. Vet. Surg.: 27.
Equine Vet. J. 50: 29–33. 41 Carter, B.G., Schenider, R.K., Hardy, J. et al. (1993).
31 Baird, D.H. and Pilsworth, R.C. (2001). Wedge-shaped Assessment and treatment of equine humeral fractures:
conformation of the dorsolateral aspect of the third tarsal retrospective study of 54 cases (1972–1990). Equine Vet. J.
bone in thoroughbred racehorse is associated with 25: 203–207.
development of slab fractures in this site. Equine Vet. J. 42 Bonilla, A.G. and Smith, K.J. (2012). Minimally invasive
33: 617–620. repair of a calcaneus fracture in a Standardbred foal. J.
32 Barker, W.H. and Wright, I.M. (2017). Slab fracture of Am. Vet. Med. Assoc. 241: 1209–1213.
the third tarsal bone: minimally invasive repair using 43 Young, D.R., Richardson, D.M., Nunamker, D.M. et al.
a single 3.5mm cortex screw placed in lag fashion in (1989). Use of dynamic compression plates for treatment
17 thoroughbred racehorses. Equine Vet. J. 49: of tibial diaphyseal fractures in foals: nine cases (1980–
216–220. 1987). J. Am. Vet. Assoc. 194: 1755–1760.
33 Haywood, L., Spike-Pierce, D.L., Barr, B. et al. (2018). 44 Hunt, D.A., Synder, J.R., Morgan, J.P. et al. (1990). Capital
Haywood gestation length and racing performance in 115 physeal fractures in 25 foals. Vet. Surg. 19: 41–49.
thoroughbred foals with incomplete tarsal ossification. 45 Valk, N. and Schumacher, J. (2020). Successful outcome
Equine Vet. J. 50: 29–33. of a Standardbred filly after conservative treatment of a
34 Stewart, S., Richardson, D., Boston, R. et al. (2015). Risk Salter–Harris type III fracture of the distal femoral
factors associated with survival to hospital discharge of condyle. Equine Vet. Educ. 32: 178–181.
54 horses with fractures of the radius. Vet. Surg. 44: 46 Beste, K., Glass, K., and Watkins, J.W. (2018).
1036–1041. Intramedullary, interlocking nail fixation alone or in
35 Sanders-Shamis, M., Bramlage, L.R., and Gable, A.A. combination with a cranial bone plate to repair diaphyseal
(1986). Radius fractures in the horse: a retrospective femur fractures in 16 foals weighing less than 250 kg
study of 47 cases. Equine Vet. J. 18: 432–437. (1993–2016). Vet. Comp. Orthop. Traumatol. 31: A1–A25.
36 Clem, M.F. and DeBowes, R.M. (1988). The effects of 47 Hance, S.R., Schnieder, R.K., and Bramlage, L.R. (1992).
fixation of the ulna to the radius in Young foals. Vet. Surg. Retrospective study of 38 cases of femur fractures in horses
17: 338–345. less than one year of age. Equine Vet. J. 24: 357–363.
37 Stover, S.M. and Rick, M.C. (1985). Ulnar subluxation 48 Peters, S.T., Ruggles, A.J., and Bramlage, L.R. (2014).
following repair of a fractured radius in a foal. Vet. Surg. Short-and long-term outcomes of pelvic fractures in
14: 27–31. 136 thoroughbreds (2000–2010). AAEP Proc. 60: 249.
38 Rakestraw, P.C., Nixon, A.J., Kaderly, R.E. et al. (1991). 49 Ducharme, N.G. and Nixon, A.J. (2020). Fractures of the
Cranial approach to the Humerus for repair of fractures pelvis. In: Equine Fracture Repair, 2e (ed. A.J. Nixon),
in horses and cattle. Vet. Surg. 20: 1–8. 723–733. Wiley Blackwell.
811
Index
Note: Page numbers in italic refer to figures.

Page numbers in bold refer to tables.
a distal phalanx repair 337, anaesthesia, see also local anaesthetics;

abaxial fractures, proximal sesamoid 338–339 recovery from anaesthesia
bones 421–426 navicular bone repair 358, 359 foals 226–228
accessory carpal bone fractures 124, air drills 155, 251 head fractures 749
538–540 air mattresses 219–220, 221 historical aspects 5
emergency support 143 airborne contamination, induction see induction of
ultrasound 76 prevention 242 anaesthesia
acepromazine 131, 210, 297, 710 algometry 324 maintenance 213–215
foals 145, 226 all‐weather surfaces, fracture monitoring 216–218
for laminitis 298 incidence 56 mortality 207
mares with foals 226 allogenic bone grafts 110 pre‐operative planning 209
pre‐medication 211 alloys, instruments 154 risks 249
recovery from anaesthesia 218 Almanza Emergency Compression third metacarpal bone/Mt3
standing fracture repair 252 Boot 138 fractures 459
acetabulum 700, 701 alpha‐2 adrenergic agonists 130, anaesthetists 187
computed tomography 707 131, 208 anal tone, anaesthesia 216
foals 807 epidural 210 analgesia 131–132, 197
prognosis 713 foals 226, 743 diagnostic 334, 419
radiography 706 induction of anaesthesia 211 distal phalanx 334
scintigraphy 706 intra‐operative 214 palmar/plantar subchondral bone
ultrasound 703 post‐operative 213 fractures 450
acetylsalicylic acid 299 recovery from anaesthesia 218 proximal sesamoid bone 419
acrylic see methylmethacrylic standing fracture repair 252 foals 227–228, 783–784
implants ambulances 145, 146, 147 historical aspects 2
acupuncture‐like mode, TENS 315 American Society of laminitis 297
Acutrak screw 165, 526, 537 Anesthesiologists (ASA), odontoid process fracture 717
adaptation of bone 24, 60 classifications 209 pelvic fractures 709
adaptive modelling 42 amikacin 290–291, 293, 294 post‐operative 256
adhesive drapes 196, 242 foals 784 pre‐operative 209–211
adrenaline, local anaesthetics 215 navicular bone surgery 361 rib fractures 743
ageing, on bone healing 108 aminoglycosides, see also anchor points, traction 195
aiming devices, 182–183, see also gentamicin anchoring wires, mandibular
targeting devices foals 783–784 fractures 765

0005313239.INDD 811 01/29/2022 7.55.22 PM

812 Index
anconeal process 557, 563, 565, 803 arterial blood pressure 213–215, atrophic non‐union 104
separation 577, 579 217 auriculopalpebral nerve 759
Anderson sling 222 foals 226, 227 autogenous grafts 110, 432
angled blade plates 176 arthrodesis avascular necrosis, femoral
angular limb deformity 299, carpus 530, 532, 534, 538 head 682
597–598, 783, 784 metacarpophalangeal/MTP joints avulsion fractures 73
anisotropy, toughness 41 436–441, 786–787 carpus 522
ankle weights 320, 321 proximal interphalangeal joint cruciate ligaments 646, 647, 662,
antebrachiocarpal joint 369, 371, 372–376, 377, 787 694
fragments 516, 540 transfixation casts 276 gastrocnemius 692
partial carpal arthrodesis arthroplasty 243 patella 666
sparing 530 arthroscopy 154 radial carpal bone 521
anti‐gravity treadmills 321, 322, carpus 515–519, 522, 524–536 third metacarpal bone/Mt3 489,
519 distal interphalangeal joint 362, 490
antimicrobials, see also 384–385 ulnar apophysis 571, 581, 803
polymethylmethacrylate distal phalanx fractures 346 ultrasound 75, 76, 77
on bone healing 109 epidural analgesia 210 Axe, Wotley 4
distal phalanx fractures 340 intra‐operative 195 axial dens 715–718
foals 783–784 metacarpophalangeal/MTP axial stiffness 37
head fractures 753 joints 402, 403–404, axis (C2) 715
open fractures 133, 199, 469, 579 420–421, 425–426, 429, 464, complete ventral luxation 720
peri‐operative 196–197 465, 468 fractures 721–722, 727
surgical site infections 289–294 patellar fractures 668–669
tuber coxae fractures 709 proximal interphalangeal b
antiplatelet agents 298–299 joint 366–368 back pain 323
antiseptics 200, 289 tarsocrural joint 615–621 bacteria 196–197
intra‐operative wound irrigation arthrotomy biofilm 285
242–243 metacarpophalangeal joints 425 open fractures 199
PVP‐I 242–243 patellar fractures 672–674 surgical site infections 286–287
anxiety 146–147 articular fractures, 45–46, 106, 107, Bair Hugger™ System 227
apical fractures, proximal sesamoid see also individual joints balance pads, proprioceptive 320,
bones 419–421 gas lucency 73–74 321
apophyses 43 palpation 119 bandage casts 136, 137
ulna 43, 557, 558, 559, 564, 571, radiography 73, 74 comminuted fractures of middle
572, 581, 803 aspirin 299 phalanx 378–379, 382
Apsyrtus 2 Assisi loop 316, 317 bandages, 193, see also Robert Jones
aquatic therapy 321–322, 519 assisted recovery from anaesthesia bandages
Arbeitsgemeinschaft für 219 after cast removal 270–271
Osteosynthesefragen (AO) Association for the Study of Internal for casts 260–261
Foundation 4, 153 Fixation (ASIF) 4 foals 784
archaeology 1–2 asternal ribs 739 pelvic fractures 710
area moment of inertia 37, 38, 39 atelectasis 214 standing fracture repair 252,
Arkle 4 atlantoaxial fusion 718 255–256
artefacts atlantoaxial ligaments 715–716 bar shoes
computed tomography 85 atlantoaxial luxation 720 distal phalanx fractures 336
MRI 88, 90 atlantoaxial subluxation 715–720 navicular bone fractures 355
radiography 71–72 primary 719 bars, biting 762
ultrasound 75 atlas, fractures 720–721 basic multicellular units 17
iliac wing 703 atrial fibrillation 216 basilar fractures, proximal sesamoid
arterial blood gases 216 atrioventricular block 216 bones 432–434
0005313239.INDD 812 01/29/2022 7.55.23 PM

Index 813
battery‐powered drills 155 navicular bone 351, 355 ulnar fracture repair 568
standing fracture repair 251 proximal sesamoid bones 416 brood mares, transport 145
BCP (hydroxyapatite and TCP) 111 suspensory apparatus rupture bucked shins 486–488
beads, antimicrobial‐eluting on 435 bupivacaine 215–216
291–294 third metacarpal/Mt3 bone 485 rib fractures 743
beam hardening, computed blood tests, surgical site buprenorphine 210
tomography 85 infections 287 dosages 211
bedding 197, 298 Blundeville, Thomas 2 pelvic fractures 709
banking 804 blurring of images 68 butorphanol 130, 132, 210
foals 784 board splint 141, 144 dosages 211
horses with casts 267 body weight, effective 298, 299 foals 226
bending forces 32–34, 782 bone 11–27 mares with foals 226
bending moment 23, 24, 37 architecture 11–20 butterfly catheters, 252, see also
bending presses 159–160, 170 cellular components 12–13 winged catheters
bending screws, UniLOCK system failure 29 butterfly fragments 32, 33, 35
175 function 20–25 buttress plates 171
biaxial fractures mechanics 35–40
middle phalanx 370, 371, microstructure 15–18 c
381–382 response to load 30–35 C‐arms 194
proximal sesamoid bones stiffness 20, 36, 37 infection prevention 243
123–124, 435–441 ultrastructure 17–19 C‐clamps 182
third metacarpal bone/Mt3 479 bone cement see cables 181
tibial malleoli 617 polymethylmethacrylate mandibular fractures 765, 766
biceps brachii bone clamps 160 metacarpophalangeal joint
tendon 585 bone healing, 97‐111 arthrodesis 437–440
tenotomy 605–607 cellular and humeral influences 101 nylon cable 744
bicipital bursa 585 mechanical influences 103 proximal sesamoid bones,
bicortical external skeletal fixation monitoring 104 transfixation of mid‐body
device 278 phases 98 fractures 430
biofilm 285, 287 bone marrow rib fractures 744
bioglass 111 injection of 109 calcaneus 612
biological osteosynthesis 471 magnetic resonance imaging 87, fractures 127, 621–628
biological techniques in bone healing 88, 89–90 foals 804
109–110 bone morphogenetic proteins (BMP) calcium 19–20
biomarkers 62 109–110 calcium phosphate cement,
bipartite navicular bone 353, 354 bone–pin interface, external antimicrobial‐eluting 293
bisphosphonates 108–109 fixation 272, 276 calcium phosphate ceramic 110
bit depth 68 bone surface lining cells 12, 24 calcium sulphate, as bone
bladder, scintigraphy 705 boots (for compression) 137–138 substitute 110
blood culture medium 287 breakage callus 102
blood pressure see arterial blood instruments 240–241, 478 bisphosphonates 108–109
pressure screws, Mc3/Mt3 fractures 464 bone stiffness 39
blood supply 14, 46, 154 breathing, anaesthesia 216 cervical vertebral fractures 725
bone healing 101–102, 103 bridging neuromuscular electrical
distal phalanx 331 cracks 41, 42 stimulation 316
dynamic compression plates transphyseal 551–552, 792, 804 pre‐fracture pathology 698
on 176 briefings, pre‐operative 194 pre‐mineralized 72
growth plates 779, 780 brittleness 20, 37, 39 radiography 74
metacarpophalangeal joint broad plates 167 third metacarpal bone/Mt3
arthrodesis 440 third metacarpal bone/Mt3 172, 494 condylar fractures 463
0005313239.INDD 813 01/29/2022 7.55.23 PM

814 Index
cambium layer 12 MCPJ 437–438 foals 796, 800

canaliculi 12, 22 PIJ 375 fractures 127, 628–631
cancellous bone 12–13 casts, 136–137, 259–271, see also cerclage wire 181
grafts 110, 430 bandage casts; fibreglass; facial fracture fixation 756
load transmission 23 pin casts; sleeve casts; mandibular fractures 764–767,
remodelling 24 transfixation casts 769, 772
cancellous screws 162, 164 bone changes 25 premaxilla 769, 771
atlantoaxial junction 718 complications 268–269 rib fractures 744
foals 783 foals 269, 784 cerebral cranium 747, 749, 751–753
removal 166 for hooves 298 cerebral oedema 749, 752
cannon bone see third metacarpal mechanical failure 269 Ceretom CT scanner 356, 357, 397,
bone/Mt3 metacarpophalangeal joint 398
cannulated screws 162, 165 arthrodesis 440 cervical vertebrae 715–731
carpus 526 middle phalanx, comminuted C3 to C7 722–731
femoral capital physeal fractures 379, 382 checklists 6, 187–189
fracture 681 navicular bone repair 360 chemical shift artefact, MRI 88, 90
foals 783 PIJ arthrodesis 376 chip fractures see osteochondral chip
removal 166 pre‐operative planning 193 fractures
supraglenoid tubercle proximal sesamoid bones, mid‐ chloroform 4
fracture 605 body fractures 430–432 chondrocytes, bone healing
cannulation removal 270–271 101–103
arterial 217 surgical site infections 286 circumferential transfixation, mid‐
jugular 209 third metacarpal bone/Mt3 body fractures of proximal
foals 226 fractures 462, 794 sesamoid bones 430, 432
cantering tibial malleolar fractures 614 clamp‐rod internal fixators 169
fracture incidence 60, 702 catastrophic bone failure classifications, see also Salter‐Harris
pelvic motion 697 aetiology 41‐43 classification
capital physeal fracture (femur) fatigue life 40 anaesthetic risk 209
679–683 catastrophic injuries, see also external skeletal fixation
capnography 217 mortality devices 277
cardiac arrest 225 fatal injuries (term) 55 fractures 43–46
cardiopulmonary resuscitation 225 patella 668 distal phalanx 331–333
cardiovascular system, pre‐operative post‐operative 283 open fractures 198, 199
examination 208 proximal sesamoid bones 417 proximal phalanx 389–390
carpal canal syndrome 539–540 third metacarpal bone/Mt3 proximal sesamoid bones 417–418
carpus, 124–125, 511–543, see also condylar fractures 458 third metacarpal/Mt3 bone
cuboidal bones training and 59, 60 condylar fractures 446–447
casts 265 cauda equina, fracture involvement ulna 558–561
computed tomography 86 734 non‐union 104
contracture 599 ceftiofur 290 surgical site infections 284, 286
emergency support 143 sodium ceftiofur 133 Clater, F. 3
foals 795–797 cellulose fleece 137 clinical assessment see examination
intravenous regional limb cement see polymethylmethacrylate clipping hair 196, 241–242
perfusion 291 cement lines 29, 30 standing fracture repair 252
ossification 13 crack deflection 41, 42 closed fractures 45
scintigraphy 80 central nervous system, see also closure
stress fracture sites 43 neurologic deficits antebrachial fascia 569
cartilage 13 haemorrhage 131 facial fractures 759
growth plates 779 pain 131 open fractures 201
removal at arthrodesis central tarsal bone 612 patellar fractures 673
0005313239.INDD 814 01/29/2022 7.55.23 PM

Index 815
coccygeal vertebrae 735 relation to proximal phalanx pelvic fractures 707

cold limb syndrome 79 389 PET with 91
cold welding 158 splitting 493 prediction of fractures 62
cold working steel 167 communication proximal phalanx 397–400
colic operating teams 243 quantitative assessment, Mc3
post‐operative 208, 256, 299 on racecourse 118 condylar fractures 448
tied horses 710–711 compact bone 37, 38 sagittal fractures of talus 618
collagen sponges compartmental pressure 217 standing fracture repair 251
distal phalanx fracture treatment complete fractures 45 surgical site infections 288
340, 343 proximal phalanx 390–392, tibia 648
gentamicin‐eluting 294 402–403, 406, 409–410 computer‐assisted surgery, navicular
second and fourth Mc/Mt bone third metacarpal/mt3 bone 449, bone 356, 357
fractures 503 450, 455, 458, 464–465, 479 condylar fractures, see also lateral
collagens 12, 15, 18–19, 21, 22, 29, diaphyseal 491–498 condylar fracture; medial
102 complex fractures condylar fractures
collapsing carpal fractures 124–125 distal phalanx 347–348 femur 693
comminuted 530–534 third metacarpal/mt3 bone 450, third metacarpal/mt3 bone 35,
slab fractures 523 479 123, 249, 250, 445–484
collateral cartilage mineralization complexity of fractures 45 biaxial 479
335 compliance (mechanical) 20 condylar plates, diaphyseal fractures
collateral ligaments complications, see also post‐operative of humerus 690
tarsus 611–612, 615 complications cone beam CT 84
colour displays, scintigraphy 82 casts 268–269 conical extraction screws 166,
combination holes, locking intra‐operative 235–247 240
compression plates 169, navicular bone repair 361–362 constant rate infusions (CRI)
171 strategies for 197–198 analgesia 297
comminuted fractures 35, 97 compression intra‐operative 214
carpus 530–534 cold therapy 314 standing fracture repair 252
femur 684 non‐displaced fractures 106 construct instability, 283–284, see
middle phalanx 371–372, by plates 169 also unstable fractures
377–385 compression boots 137–138 contact, screws in 237
transfixation casts 380, 382–383 compression fractures 35, 73 contact healing 98
non‐union 104 cervical vertebrae 722 contamination, 45, see also infection;
patella 676 MRI 90 surgical site infections
proximal phalanx 118, 120, compression (loading) 31, 32 airborne, prevention 242
122–123, 389, 392, 393, compression plates, 170–171, see also continuous positive airway pressure
397–398, 403–406, 410, 785 dynamic compression (CPAP) 214
transfixation casts 405–406, 410 plates; locking compression continuous ultrasound 318
radius 154, 550 plates contouring plates 159–160, 170
reduction 236, 237 computed tomography 6, 84–87, PIJ arthrodesis 375
third metacarpal/mt3 bone 454, 190 ulnar fracture repair 572–574
485 distal phalanx, lag screw contractures
tibial tuberosity 657 fixation 337–340 avoidance 313
transfixation casts 276, 405–406, intra‐operative 194 carpal 600
410 middle phalanx 191 contrast, images 67–68
ulna 561, 566, 575–577, 578, 581, 582 minimally invasive repair, Mc3/ contrast‐to‐noise ratio 68
common/long digital extensor Mt3, propagating core‐specific exercises 313, 323
tendon 331, 365 fractures 470–471 coronoid process, mandibular
incision for PIJ arthrodesis 374, monitoring bone healing 105 fractures 776, 771
375 navicular bone 356, 358, 359, 360 corrosion, drill bits 241
0005313239.INDD 815 01/29/2022 7.55.23 PM

816 Index
cortex 11 cross‐ties navicular bone fractures 355

blood supply 14 fissure fractures of radius 547 in ulnar fracture repair 566, 567
grafts 110 greater tubercle fractures 588 definition of fractures 6
implants on porosity 25 pelvic fractures 710 deflating air pillows 219–220, 221
cortex screws 161, 162 transport 147, 148 deformation, 20, 21, 23, 35, 38, see
in dynamic compression plates crossbars, mandibular also load–deformation curve
170, 172 fractures 768, 774 dehiscence
foals 783 cruciate ligaments, avulsion tibial fracture repair 650
for interlocking intramedullary fractures 646, 647, 662, patellar fracture repair 675
nails 181 694 dehydration 146, 208
locking head screws with 239 cryotherapy 299, 313–314 delayed emergence of fracture bed,
corticosteroids crystalloids, head fractures 751–753 tuber coxae 708–709
carpus, intra‐articular 515 cubital joint, 557, see also dropped delayed union 98, 104
cervical vertebral fractures 725 elbow posture MRI 91
on fracture incidence 61 comminuted fractures involving radiography 74
cortisol, supporting limb laminitis 582 therapeutic ultrasound for 318
and 295 dysplasia/subluxation 570–571, third metacarpal bone/Mt3
costae spuriae 739 801 fractures 458
costae verae 739 luxation 580 Delta‐Dry™ cast padding 262
cotton wool, Robert Jones bandages cuboidal bones, 12, 124, see also deltoid tuberosity 585, 590
134, 135 carpus; tarsus; slab fractures dens (axial) 715–718
countersinking 157–158, 161 emergency support 143 depth gauges 158, 161
distal phalanx fracture repair 337 foals 796, DePuy Synthes Vet 153, 154, 155
errors 236 ossification 13 deroofing, spinal canal 723
PIJ arthrodesis 376 cuffs, arterial blood pressure 227 desflurane, recovery from
third metacarpal bone/Mt3 461 cultures anaesthesia 218
COX‐2 inhibitors 783 open fractures 199 desmitis, suspensory ligament and
coxofemoral joint 697–698 surgical site infections 286–287 distal sesamoidean
femoral capital physeal fracture cyclic loading 40, 41–42 ligaments 417, 421
679–683 proximal sesamoid bones 417 desmotomy
luxation 269 cyclic shear loading 35 lateral collateral ligament,
cracks 17, 22, 23, 29, 30 cysts, proximal phalanx 470 arthrodesis of MCPJ 439
cyclic loading 41–42 cytokines medial patellar 669, 673
third metacarpal bone/Mt3 448 bone healing 102 detector contrast 67, 68
cranial cruciate ligament, avulsion carpal fragmentation 514–515 detomidine 130, 131, 297
fractures 694 dosages 211
craniomaxillofacial fractures, d epidural 132, 210
UniLOCK system 175 debridement 103 foals 226
cranium, see also facial skull; visceral carpus 516–517 intra‐operative 214
cranium open fractures 199–201 recovery from anaesthesia 218
cerebral 747, 749, 751–753 PIJ osteoarthritis 375 developmental mechanics 101,
radiography 71 second and fourth Mc/Mt bone 103
suture lines 72 fractures 503–505 dexamethasone 717, 725, 752
creep 39, 40 surgical site infections 288–289 dexmedetomidine
critical strain rate 39 decalcified bone matrix 110 intra‐operative 214
cross‐linked dextran gel, deep digital flexor tendon 331 rib fractures 743
antimicrobial‐eluting 294 accessory carpal bone fractures diagnostic analgesia
cross‐pins, tibial fractures 648 involving 76, 124, 540 distal phalanx 333
cross‐sectional imaging, slice comminuted fractures of middle palmar/plantar subchondral bone
thickness 68, 69 phalanx 383 fractures 449
0005313239.INDD 816 01/29/2022 7.55.23 PM

Index 817
proximal sesamoid bone 419 distal phalanx 331–350 double plate fixation 170
diamond concept 111, 457 causes of fractures 333 femur, diaphyseal fractures
diaphyseal fractures 35 clinical features 122, 333–334 685–688
femur 684–688, 806 diagnosis of fractures 334–335 foals 783
humerus 125, 595–600, 804 emergency support 141 humerus, diaphyseal fractures
mid‐diaphyseal, second and fourth foals 331, 332, 333, 334, 336, 348, 689
Mc/Mt bones 506–507 784–785 middle phalanx, comminuted
radius 547–550, 798 fracture types 331, 333 fractures 380383
emergency support 143 management 335–347 proximal interphalangeal
stacked pin fixation 179 results of treatment 348 joint 284–285
third metacarpal bone/Mt3 124, sinking 295, 296–297, 710 radius, diaphyseal
485–500, 792–794 distal physeal fractures fractures 547–550
tibia 127, 641–642, 643, 655–660 femur 688–691 third metacarpal bone/Mt3
emergency support 142 radius 551–553 492–498
foals 806 third metacarpal bone/Mt3 tibia, diaphyseal fractures
ulna 560 485–486, 792 655–661
diazepam 131, 212, 753 tibia 654 drainage
digital planning tools 190 distal sesamoid bone see navicular mandibular fractures 764
digital radiography 68, 69–70, 133 bone open fractures 201
image quality 67 distal sesamoidean ligaments pneumothorax 742–743
dimethyl sulphoxide 717, 723, 752 415–417 surgical site infections 288
direct (primary) bone healing 4, desmitis 417, 421 tuber coxae fractures 709
97–98, 106–107 distilled water, open fracture draping 196, 241–242
dirt tracks, fracture incidence 56, irrigation 201 distal phalanx fracture repair 337
57, 591, 701 disuse atrophy, muscles 313 standing fracture repair 252, 253
displaced fractures 45 DMSO see dimethyl sulphoxide dressings 133
healing 106 dobutamine 218 for casts 260–262
pelvis 707–708, 710 foals 227 drill bits 155–156
ribs 739 domino effect, cervical vertebral breakage 240, 241
third metacarpal bone/Mt3 446, fractures 725 distal phalanx repair 337
449, 458, 459, 480 dorsal cortex, third metacarpal bone, navicular bone repair 358
lateral condyle 454–455, 456, scintigraphy 82, 84 drill guides 156–157, 158
465–469 dorsal fractures, proximal phalanx for aiming device 182
displayed contrast 67, 68 392–393, 406, 407, 410 dynamic compression plate
distal border fragments, navicular dorsal hoof wall width 296 application 171, 172
bone 352–353 dorsal laminectomy external skeletal fixation
distal condyles, Mc3/Mt3 123, atlantoaxial subluxation 719 devices 277
445–484 third to seventh cervical fragment distractors 182
emergency support 141–142 vertebrae 730–731 lag screw fixation 161
distal femoral locking compression dorsal metacarpal disease 486–488 locking head screws 157, 165,
plates (human) 174–175 dorsal plane fractures 173–174
distal femur plate 168 accessory carpal bone 124, for marking 160
distal fractures, second and fourth 538–540 navicular bone 356
Mc/Mt bones 501, 502, dorsal splints 139–140 drills see power drills
509 dorsoproximal articular margin, dropped elbow posture 562, 563,
distal intermediate ridge, tibia, proximal phalanx 595
fractures 618 fragmentation 390 dry‐interface circulating
distal interphalangeal joint, double‐drill guide 156, 161 cryotherapy 314
arthroscopy 362, 384–385 variable angle locking compression duct tape 134, 135
distal limb ESFDs 277 plates 175–176 ductility 37
0005313239.INDD 817 01/29/2022 7.55.23 PM

818 Index
Duraface pin 273, 274 endoscopy, upper airways 195 bone healing 104
dynamic compression plates 167–169 endosteum 12 core‐specific 313, 323
application 171, 172 plates on resorption 25 high‐intensity, fracture risk 59
on blood supply 176 endotracheal intubation, foals high‐speed, fracture risk 59, 60
carpal arthrodesis 530–534 226–227 injury‐specific 322–324
cortex screws in 170, 172 endurance limit 41 proximal sesamoid bones 283
foals 783 endurance riding, fracture incidence rehabilitation 313, 319–324
historical aspects 5 57 stress fractures 711
limited‐contact 176 energy, cracks 41 third metacarpal bone/Mt3 446
middle phalanx, comminuted energy absorbing capacity 20 after ulnar fracture repair 581
fractures 380 Enlightenment 2–4 exertional rhabdomyolysis 700
strain distribution 25 enostosis‐like lesions, scintigraphy exostoses
ulna 565, 568, 570 82, 648 fractures vs 502
dynamic compression units, locking enrofloxacin 290 third metacarpal bone/Mt3
compression plates 169 enteritis, foals 784 fractures 464
dynamic condylar and dynamic hip entheses, ultrasound 76 exsanguination risk, pelvic
screw implant systems enthesophytes, proximal sesamoid fractures 129, 700, 710,
176–177, 178 bones 789–790 712
dynamic condylar screw and epicondylar fossa (Mc3/Mt3) extensor process fractures, distal
dynamic hip screw implant fractures at 452, 453, 464 phalanx 346–347
systems, radius, diaphyseal screws 458, 459, 460, 461, 467, external coaptation 259–282
fractures 176–177 468 foals 784
dynamic mobilization 323 epidemiology 6, 55–65 external fixation
dysplasia, cubital joint 570, 801 epidural analgesia 132, 210 bone changes 25
dystocia see parturition epidural opioids 210 bone healing 107–108
epiphyses 11–12, 779 mandibular fractures 768, 772,
e interlocking intramedullary nails 774
effective body weight 298, 299 and 181 open fractures 201
elastic bands (training) 320, 321 Equine Fracture Repair 4 third metacarpal bone/Mt3
elastic region, load–deformation Equine Injury Database 56 fractures 492
curve 36 Equine Salvage Splint 140–141 transfixation casts 271–276
electric fields, prevention of bone Equisave Motorised Horse external skeletal fixation devices
resorption 25 Ambulance 146 (ESFDs) 276–278
electric stimulation therapy 111, errors, fracture repair 235, 236, external trauma, proximal sesamoid
315–316 237–238 bone fractures 435
electrocardiography 216 ethics 6 extra‐articular fragmentation, patella
elephant foot non‐union 104 euthanasia 677
elongation, proximal sesamoid complications of external extracellular fluid 12–13
bones 418 fixation 275 extracorporeal shockwave therapy
embryology 13 racecourse fractures 119 (ESWT) 111
emergency support 141–144 eventing, fracture incidence 57 extraction bolts 166, 167, 240
radial fractures 547 examination extraction kits, for screws 166–167
suspensory apparatus rupture 436 acute, 119‐122 extraction screws (conical) 166, 240
ulna 563 head fractures 749 eye signs, see also orbital fractures
eminences pelvic fractures 699, 700 head fractures 751
middle phalanx 365, 370–372, pre‐operative 208
373, 376, 380 foals 226 f
proximal phalanx 389 exercise, see also training facial skull, 753–762, see also visceral
tibia, intercondylar 128, 641, 646, bone adaptation 24–25 cranium
647, 661 on bone density 259 failure point 36
0005313239.INDD 818 01/29/2022 7.55.23 PM

Index 819
false negatives first tarsal bone 613 third metacarpal bone/Mt3

radiography 72, 117 fissure fractures 45 485–486, 792–795, 798
scintigraphy 79 radiography 73 thoracolumbar vertebrae 733
false ribs 739 radius 547 tibia 127, 649, 804–806
Farm Vet 4 Fitzwygram, F. 3 transdermal fentanyl patches 132
fascial planes, artefacts 71 flail chest 739 transport 145
fast spin echo sequences, MRI 87 FlapFix see rosettes ulna 799, 799–800, 803–804, 803,
fat grafts, cervical vertebrae 719, flat racing 807
731 fatal injuries 56 fixation to radius 570–571
fat suppression, MRI 87–88 flexion splints 140–141 healing 581
fatal injuries (term) 55 flexural limb deformity 299 vertebral fractures 715, 733
fatigue (mechanical) 23, 283 floating ribs 739 founder distance 296
casts 269 floor plans, operating rooms four‐point bending 34
fatigue fractures, 97, see also stress 195–196 four‐ring circular ESFD 278
fractures fluid accumulation, intra‐osseous 90 fourth carpal bone 511
healing 105–106 fluid therapy sagittal slab fractures 535
proximal phalanx 396 foals 227 fourth metacarpal/Mt bones
ribs 740 head fractures 752–753 501–508, 636
scintigraphy 82 rehydration 146 fourth tarsal bone 613, 636
third metacarpal bone/Mt3 447 flunixin meglumine 132 fracture disease 259
ultrasound 76 fluorodeoxyglucose 91 fracture lines, radiography 70
fatigue life 40, 41 fluoroquinolones 290 fracture repair 590
fatigue limit 40–41 fluoroscopy fragment distractors 181–182
feeding 147 infection prevention 243 fragmentation
pelvic fractures and 710, 711 pre‐operative planning 194 carpus 515, 797
female pelvis 697 foals, 779–810, see also neonatal patella 666, 673, 674
fracture incidence 701 foals radius 513
femoropatellar and femorotibial alpha‐2 adrenergic agonists 226, fragments
joints 128 743 accessory carpal bone fractures
femur 128, 679–695 anaesthesia 226–228 539, 540
foals 806 casts 269, 784 anconeal process 577
diaphyseal fractures 685 distal phalanx 331, 332, 333, 334, butterfly fragments 32, 33, 35
lateral trochlear ridge 127–128 336, 348, 784–785 carpus 512–514, 514, 515–517,
medial condylar fractures 781 femur 806 521–523, 526
fentanyl 132, 197 diaphyseal fractures 685 cuboidal bones 795–797
fetlock joints see gastrocnemius avulsion 692–693 distal phalanx 346
metacarpophalangeal joints humerus 125, 804 humeral greater tubercle fractures
fibreglass 5, 136, 260, 262–263 interlocking intramedullary nails 589
transfixation casts 273, 276 180 interdigitation, facial 756
fibrinogen 287 intravenous regional limb metacarpophalangeal joints
fibrous malunion, navicular bone perfusion 291 420–421, 423–426, 434
fractures 355 mandible 769 navicular bone 352–353, 362
finite‐element modelling 39 nursing 147, 784 patella, removal from joints
firocoxib 783 proximal sesamoid bones 418, 668–673
first aid 117–151 785–790, 792, 793, 795, 796, proximal interphalangeal joint
open fractures 199 797 366–367
radial fractures 547 radius 798–799, 801 proximal sesamoid bones, basilar
suspensory apparatus failure 436 diaphyseal fractures 548 fractures 434
tibial fractures 646–647 ribs 739–746 second and fourth metacarpal/Mt
ulnar fractures 564, 565 sacrum 735 bone fractures 505, 509
0005313239.INDD 819 01/29/2022 7.55.23 PM

820 Index
fragments (cont’d) foals 783–784 growth plates 779

solar margin fractures 347–348 in hydroxyapatite cement 294 blood supply 779, 780
supraglenoid tubercle 605 intra‐osseous perfusion 291 implants affecting 238, 239
third metacarpal bone/Mt3 open fractures 199 radius 545, 570
fractures 467, 468 polymethylmethacrylate with third metacarpal bone/Mt3, distal
tibial malleolar fractures 616 292 445–446
tuber coxae fractures 708 geriatric horses, fracture ulna 570
ulna, proximal 579 incidence 59 guaifenesin 212
fresh gas flow 218 GG Ambulance™ 146 guide pins 165
frog supports 267–268, 298 Gibson, W. 1, 3 guides see drill guides
frontal bone fractures 758 Gigli wire, osteotomy of greater guttural pouch, haemorrhage 73
frontal nerve 759, 761–762 trochanter 682
frontal plane fractures glide holes 161 h
carpus 521, 521, 523–524, distal phalanx fracture treatment haematocrit 208
526–530, 535–536, 537 339 haematoma phase
navicular bone 352 drill bits for 155 bone healing 98, 99, 101, 106
proximal phalanx 393, 406, 410 errors 236 cryotherapy 314
fusion femoral capital physeal fracture rehabilitation 311, 312, 313
metacarpo/metatarsophalangeal 683 haemoglobin dissociation
joint, 436‐441 standing fracture repair 254, 255 curve 217
proximal interphalangeal gloves, perforation 242, 243 haemopoietic stem cells 102
joint 372–373 glycopyrrolate 227 haemorrhage
ventral cervical 718, 725, 727, goniometry 324 central nervous system 131
729, 730 gouges, screw extraction 166 femoral fractures 128, 684
gradient recalled echo, MRI 87 guttural pouches 73
g grafts humeral fractures 596
gabapentin 296 for bone healing 110 iliac shaft fractures 129, 700
gags 764 cervical vertebrae 727 iliac wing fractures 128
gait, see also lameness fat grafts 719, 731 palpation 119, 121
avulsion of gastrocnemius 692 mid‐body fractures of proximal patellar fractures 667
iliac wing fractures 700 sesamoid bones 430 ultrasound 76
strain rate vs 39 second and fourth metacarpal/Mt hair clipping 196, 241–242
tuber coxae fractures 699 bone fractures 503 standing fracture repair 252
tuber ischium fractures 701 graph paper 191 hard callus phase, bone healing 98,
galloping great metatarsal artery pulse, 100, 102
metacarpophalangeal/MTP palmar/plantar subchondral Haversian canals 14, 15, 22
joints 445 bone fractures 449 Haversian systems 29, 30
strain rates 39, 40 greater trochanter 128, 679 hay nets 145
gamma cameras 78–79 osteotomy 682 head, fractures 747–778
gap healing 98, 107 greater tubercle of humerus head and tail rope assistance,
on implants 107 586–588 recovery from anaesthesia
gaps, fractures 45 Greece (ancient) 1, 2 219, 220
gas lucency 73–74 green drill guides 171 headless screws 165
gastrocnemius, avulsion fractures greenstick fractures 45, 486 healing 97–115, 457, 465, 469–470
692–695 grinding tools 764 cryotherapy 314
gauze, Robert Jones bandages 134, ground poles 320, 321 incisors 749
135 growth, radius and ulna 570 indirect 98, 99–100, 107, 311
gender, as risk factor 59 growth cartilage 13 MRI monitoring 91
gentamicin 133 growth factors, bone healing 102, NMES on 316
in calcium phosphate cement 293 109–110 primary 4
0005313239.INDD 820 01/29/2022 7.55.23 PM

Index 821
pulsed electromagnetic field holes, see also glide holes; thread ossification 13
therapy on 316 holes scintigraphy 80
radiographic monitoring 74 combination holes, locking stress fractures 43, 591–592, 592,
rehabilitation 312, 313 compression plates 169, 593
scintigraphic monitoring 82–84 171 hurdle racing, fracture incidence
ulnar fractures, foals 581 distal phalanx fracture treatment 56
ultrasound monitoring 76 337 hyaluronan 519
heart rate dynamic compression plates 167 Hydro‐Pool 222, 223
anaesthesia 216 external fixation 273, 274 hydrocolloid dressing materials
foals 226 navicular bone repair 357–358 261–262
heat production variable angle locking compression hydroxyapatite 19, 29
resin curing 263, 292 plates 175 exogenous 110, 111
tapping 161 Hong Kong, fracture incidence 57 antimicrobial‐eluting cement
heat therapy 313–315 hooks 294
heating, healing 322–323 facial fracture reduction 755 screw coating 284
heel elevation 355 orbital fractures 765 scintigraphy 77
helical fractures see spiral fractures hooves hyoid apparatus 776
hemi‐circumferential transfixation avascular loss 440 hyoid bone 748
430–432 casts 137, 264, 266, 298 hyperbaric oxygen 111
heparin 299 distal phalanx fracture treatment hypercapnia 215
Herbert screw 165, 526 336–337 hypertonic saline 753
hexagonal screwdrivers 158 distal phalanx sinking 295, hypertrophic non‐union 104
99m
Tc‐hexamethylpropylene amine 296–297 hypoplasia
oxime (HMPAO), white immobilization 335 cuboidal bones 795, 800
blood cells 288 podiatry 297–298 third tarsal bone, neonatal foals
high‐density edge gradient, CT preparation for surgery 196, 631–632
85 337–338, 357 hypothermia, prevention 227
high‐inspired oxygen fraction 215 risk factors for fractures 61 hypoxaemia, post‐operative
high palmar four point nerve surgery in 356 224–225
block 215 surgical field preparation 242 hypoxia 14
high plantar six point nerve horizontal fractures, patella 666, hysteresis 39, 40
block 215 667
high‐speed exercise, fracture horseboxes 145 i
risk 59, 60 partitioning 145, 146, 147 ice‐water immersion 314
hindlimb casts 265–266 horseracing see racing IIN‐3/3 construct 181
Hinged Compression Boot™ 138 hospital environment 154 iliac shaft 129, 697, 700
Hippiatrika 2 hot packs 315 prognosis 712
Hippocrates 2 Hounsfield units 84 surgery 707
histology, surgical site Howship’s lacunae 13 ultrasound 703, 704
infections 286 human distal femoral locking iliac wing 128, 130, 697
historical aspects 1–6 compression plates prognosis 712
transfixation casts 271–272 174–175 scintigraphy 707
Hohmann retractor 181 human femoral locking compression stress fractures 699, 700
hoists plates 174 treatment 709
cast application 264, 265 humero‐ulnar subluxation, see ultrasound 702–703, 704
fracture reduction 192 cubital dysplasia ilium 697
positioning of horse 213 humerus 125–126, 585–601 Ilizarov ESFDs 277
radial fractures 549 diaphyseal fractures 125, image quality
recovery from anaesthesia 595–600, 691, 690 radiography 67–68
220, 221 foals 125, 804 scintigraphy 81
0005313239.INDD 821 01/29/2022 7.55.23 PM

822 Index
imaging, 67–96, see also specific impression fractures, facial 754 infection, see also surgical site
modalities incidence of fractures 55–59 infections
false positives 71–72 incisions, see also surgical site on bone healing 102–103, 108
fracture displacement 45 infections head fractures 750
interpretation 68, 72 cervical vertebrae, dorsal removal of implants for 289, 807
intra‐operative 192–192, 194 laminectomy 730–731 second and fourth metacarpal/Mt
pre‐operative planning 194–195 common/long digital extensor bone fractures 503
surgical site infections 287–288 tendon 375 tarsocrural joint 622
IMEX see Duraface pin femur, diaphyseal fractures 685 tied horses 710
imipenem 290 greater tubercle fracture tuber coxae fractures 708
immobilization repair 589 inflammation
hooves 335 humeral fracture 598 bone healing 102–103
on joints 259, 260 metacarpophalangeal joints, casts 268
for pelvic fractures 710 arthrodesis 436 inflammatory phase, bone healing
temporary 133–141 nuchal ligament 719 see haematoma phase
immune system planning 154, 190 inhalational anaesthetic
bisphosphonates on 108 proximal interphalangeal joints agents 213–214
bone healing 101, 102 arthrodesis 374 foals 226
impact trauma, see also kick injuries arthroscopy 368 monitoring concentration 218
patella 666 proximal phalanx fractures 404 innervation of bone 14–15
impaction colic 256 radial fractures 549, 551 instability see construct instability;
implants, 7, 154–155, see also removal of plates 808 unstable fractures
removal of implants; specific rib fractures 742 instruments 154
types standing fracture repair 254 breakage 240–241, 478
antimicrobial‐eluting 197, tibia 651 handling 242
291–294 ulnar fracture repair 566, 567 pre‐operative planning 194
antimicrobials on 109 incisive bone 747–748 standing fracture repair 251
blood supply, preserving 154 fractures 747, 758, 759 insurance, racecourse fractures
bone resorption from 25 incisors 119
complications, plans for 198 mandibular fractures 764 intercondylar eminences, tibia 641,
cultures 287 healing time 749 646, 647
errors 235 incomplete fractures 45 intercostal nerves 743
external fixation 271 healing 106 interdental space, mandibular 771,
failure 283–284 proximal phalanx 390, 391, 397, 771–772
foals 783 398–402, 407, 409–410 interdigitation of fragments,
fracture gaps and 45 third metacarpal bone/Mt3 458, facial 756
gap healing on 107 459–464, 479 interleukin‐1 receptor antagonist
handling 242 longitudinal 488–489 protein (IRAP) 109
historical aspects 4 tibia 661 interleukin‐6, carpal fragmentation
infection 284, 285 indirect bone healing 98, 99–100, 515
imaging 287–288 107, 311 interlocking intramedullary nails
removal 289, 807 induction of anaesthesia 211–213, 180–181
load sharing 782–783 459 diaphyseal fractures of femur 685
radiographic monitoring 74 boxes 251 diaphyseal fracture of
relation to neutral axis 32 foals 226 humerus 598, 600, 804
replacement 289 positioning of horse 211–212, intermediate carpal bone 511, 535
sensors 105 213, 214 intermediate facet
signing out 198 Industrial Revolution 2–4 third carpal bone, slab fractures
synthetic bone substitutes indwelling catheters, for IVRLP involving 523, 529, 530,
110–111 290 531
0005313239.INDD 822 01/29/2022 7.55.23 PM

Index 823
intermittent positive pressure fractures involving see articular supporting limb laminitis 295
ventilation 214, 215 fractures Lameness in Horses (1962) 4
internal fixation 153, 154 gas lucency 73–74 laminar bone 15–16, 22
on bone healing 107 immobilization on 259, 260 laminectomy (dorsal)
equipment 155–160 load transmission 23–24 atlantoaxial subluxation 719
historical aspects 4 screws in 237–238 third to seventh cervical
internal iliac artery, exsanguination jugular cannulation 209 vertebrae 730–731
risk 129, 700, 710, 712 foals 226 laminitis
interphalangeal joints, jump racing foals 784
splinting 139–140 fracture incidence 56 overload laminitis 268, 440, 710
intra‐articular anaesthesia, proximal training 58 prevention 710
interphalangeal joint 366 scapula 126 supporting limb 294–299
intra‐articular corticosteroids, Langenbeck hooks, orbital fractures
k
carpus 515 761
Karcag‐Organdaszentmiklós,
intra‐operative large animal vertical lift 220
Hungary (archaeological
complications 235–247 large fragment sets 155, 156, 157
site) 2
intra‐operative imaging 192, 194 laryngeal masks 227
Kentucky, Thoroughbred racing,
intra‐operative wound irrigation lasers
fracture incidence 56
(IOWI) 242–243 bone strength measurement 21
Kern bone‐holding clamp 160
intra‐osseous fluid accumulation therapy 313, 318–319
ketamine 212, 297
90 lateral and medial abaxial sesamoid
foals 226
intra‐osseous perfusion, nerve block 215
ketoprofen 132
antimicrobials 291 lateral and medial palmar digital
kick injuries 35
intramedullary implants 177–181 nerve block 215
head 747
intramedullary nails see interlocking lateral collateral ligament
radius 35, 546
intramedullary nails desmotomy, arthrodesis of
third metacarpal bone/Mt3 488
intraoral wires 764–768, 769, 772 MCPJ 439
ulna 558
intravenous antimicrobials 197 lateral condylar fracture of Mc3/Mt3
Kirschner apparatus
intravenous regional limb perfusion, 445–484
facial fracture fixation 755
antimicrobials 197, complete 450,452–454, 458,
fracture of dens 718
289–291 464–470, 480
Kirschner Ehmer apparatus,
Iron Age 1–2 complex 450, 479
mandibular fractures 768
irrigation incidence and causation 449, 450
intra‐operative (IOWI) 242–243 l incomplete 449 450, 451, 458,
open fractures 200–201 laceration 459–464, 479
ischium 130 deep digital flexor tendon 124, prediction 62
fractures 698, 700–701 539 propagating 450 454–457,
prognosis 713 oesophagus 730 458–459, 470–479, 480
scintigraphy 80 lacrimation, anaesthesia 216 proximal sesamoid bone fractures
isoflurane 213 lag screw fixation 107, 161–164, with 435
recovery from anaesthesia 218 170 lateral femoral condyle 679
cancellous screws 164 lateral sagittal groove, prediction of
j errors 236 lateral condylar
Japan, Thoroughbred racing, fracture foals 783 fracture 62
incidence 57 lamellar bone 15–16, 22 lateral trochlear ridge,
jaw tone, anaesthesia 216 lameness, 117, see also gait femur 127–128
Jockey Club (North America), data cast removal 270–271 lateral tuberosity, humerus 125
collection 56 magnetic resonance imaging 62 lavage
joints osteoarthritis of PIJ 372 open fractures 199–201
fatigue fractures at 106 scintigraphy 82 surgical site infections 289
0005313239.INDD 823 01/29/2022 7.55.23 PM

824 Index
leg lengthening plates 177 mandibular fractures 767, 772, patella 668
Leg Saver Splint™ 140–141 776 proximal interphalangeal joint
lengthening plates 177 metacarpophalangeal joint 382
lidocaine 215 arthrodesis 436 second and fourth Mc/Mt bone
systemic 297 PIJ arthrodesis 375 fractures 505
Liftex sling 221 radius, diaphyseal fractures 548 tarsus 127
lifting and placing 133 sacral fractures 734 lymphoedema, prevention 710
lifting of horse, 212, see also hoists screw contact 237
lights (operating), infection supraglenoid tubercle 606 m
prevention 243 third metacarpal bone/Mt3 476, Mach lines 71
limb deformities 299 597, 689, 783, 492, 794–796 macrophages, osteal 102
784, 796 tibia 649 maggots 289
limb lengthening ulna 565, 569 magnetic fields, PEMF therapy
casts 267 variable angle (VA‐LCP) 6–7, 316–317
plates 177 175–176 magnetic resonance imaging 6,
transfixation casts 274 ventral atlantoaxial fusion 718 87–91
limited contact dynamic compression locking head screws 162, 165, prediction of fractures 62
plates 176 171–173, 239 standing fracture repair 251
liposomal bupivacaine 743 drill guides for 157, 165, 173–174 surgical site infections 288
load, 20, 21, see also cyclic loading; human femoral locking third metacarpal bone/Mt3 450
overload compression plates 175 malalignment, screws 238
after reduction 236 mandibular fractures 772 malunion 98
bending moment 23 long bones 11–12 diaphyseal fractures of femur 684
bone response 30–35 long digital extensor tendon see navicular bone fractures 355
carpus 512, 514 common/long digital Mamelukes 2
effect of casts 260, 267 extensor tendon mandible 748, 762–777
foals 782 long frontal plane fractures, proximal screws 239
joints, transmission in 23, 24 phalanx 406, 410 mannitol 752
podiatry on 298 long incomplete parasagittal marbofloxacin 290
on proximal phalanx 389 fractures, proximal mares 226, 784
radius 545 phalanx 390, 400–402, 409 transport 145
sharing 782–783 long oblique fractures 31, 33, 35 markers, see also needles as markers
third metacarpal bone/Mt3 446 longitudinal fractures, Mc3/Mt3, distal phalanx fracture
load–deformation curve 36 incomplete 488–489 treatment 336–337,
load drill guides 171 longitudinal ligament of axial 338– 339
local anaesthetics, 209, 215–216, see dens 715–716 navicular bone surgery 357, 358
also peripheral nerve low‐intensity pulsed ultrasonography matrix 15, 17, 101, 102
blocks (LIPUS) 111 decalcified 110
standing fracture repair 252 low palmar four point nerve block matrix vesicles 19
local antimicrobials, open 215 maxilla, fractures 758, 760
fractures 199 low‐pressure irrigation, open maxillary sinus, orbital fractures
locking compression plates (LCP) fractures 201 762
6–7, 168, 169 lumbar spine 732 measurements, see also quantitative
application 171–174 stress fracture site 43 assessment
carpus arthrodesis 530–534 lungs, tied horses 710 radiographic 190
cervical vertebral fixation 726 luting, plates 170 mechanical function of bone 20–25
facial fractures 757 luxation mechanical influences on bone
femur, diaphyseal fractures 686 atlantoaxial 720 healing 103–104
horse positioning 192 coxofemoral 269 mechanical nociceptive threshold
human distal femoral 174–175 cubital joint 580 (MNT) 324
0005313239.INDD 824 01/29/2022 7.55.23 PM

Index 825
mechanostat 24 epidural 132 implants on 25

medetomidine 131, 214 methane, anaesthesia modified Robert Jones bandages
medial condylar fractures monitoring 218 135
femur 781 methylene diphosphonate moment arm 37
third metacarpal bone/Mt3 249, (MDP) 77 monitoring
447–451, 453–459, 470–480 methylmethacrylic implants, anaesthesia 216–218
risks 249, 448, 457, 477 mandibular fractures 768 bone healing 74, 76, 91, 104–105
medial femoral condyle 679, 781 microdamage 17, 22–23, 30, 41–42 casts 268–269
medial tibial eminence 128, carpus 513–514 foals 216, 227
661–662 third metacarpal bone/Mt3 447 for supporting limb laminitis 295
medication history, on fracture Thoroughbred racehorses 43 monocortical screw insertion 239
incidence 61 micromotion monotonic fractures 40–43, 97
Mediaeval period see Middle Ages on bone healing 98 radiography 72
medulla 11, 12 screw loosening 284 monotonic overload 24
blood supply 14 microradiography, fracture Monteggia fractures 561, 580
megapascals 36 prediction 62 morphine 132, 197, 210, 297
mepivacaine 215, 252, 290 microstrain (unit) 37 dosages 211
mesenchymal stem cells 102, 109 midazolam, foals 226 epidural 132
laser therapy on 319 Middle Ages 2 foals 226
metacarpals, see also third middle carpal joint, fragments 516 post‐operative colic 208
metacarpal bone/Mt3 middle phalanx 122, 365–387 recovery from anaesthesia 218
foals 794 computed tomography 191 mortality, see also exsanguination risk
parasagittal grooves, MRI 88 emergency support 141 emergency surgery 208
second and fourth 501–508 foals 785, 787 flat racing 56
transverse fractures 711 fracture types 365–366 peri‐anaesthetic 207
metacarpophalangeal/MTP joints migration, pins 179 foals 226
anatomy 445 Mill Reef 4 recovery from anaesthesia 218
arthrodesis 436–441, 786–787 mineral crystals 19 rib fractures 740, 744
arthroscopy 402, 403–404, scintigraphy 77 motion artefact, CT 85
420–421, 425–426, 429, 464 mineral fraction 20 multi‐planar reformatted images,
destabilizing fractures 435–441 mineralization 15, 19–20, 29, 335, CT 84
fractures 122–123 336 multifidus muscle cross‐sectional
fracture identification 56 minimally invasive percutaneous area, back pain 323
fracture incidence 56–57 plate osteosynthesis multiple transphyseal screw fixation,
fragment removal 423–426, 434 (MIPPO), Mc3/Mt3 femoral capital physeal
palmar/plantar subchondral bone 476–477, 478 fracture 683
fractures 450 minimally invasive repair muscles
proximal phalanx fractures 390 greater tubercle 590 disuse atrophy 313
radiography 71 proximal phalanx 403–404 tone, anaesthesia 216
scintigraphy 80 third metacarpal bone/Mt3 myelomalacia 224
splinting 139–140, 142 diaphyseal fractures 495, 496–497 myocardium, acepromazine on 211
metals, instruments 154 propagating fractures 470 myofascial release 313
metaphyses 11, 779 tibia 650–651 myopathy, post‐operative 217–218,
metatarsal artery cannulation 217 mobile fragments 224
metatarsal bones 613, 795, 799 carpus 515
metatarsophalangeal joints, see proximal sesamoid bones 422 n
metacarpophalangeal/MTP mobilization 153–154 N‐methyl‐D‐aspartate receptor 297
joints dynamic 323 nails, see also interlocking
methadone 132 modelling, 16, 42, see also intramedullary nails
dosages 211 remodelling intra‐osseous 107
0005313239.INDD 825 01/29/2022 7.55.23 PM

826 Index
nasal bone fractures 758, 760 neuropathic pain 296 North America, Thoroughbred
nasal congestion, post‐operative neuropathy, post‐operative 224–225 racing, fracture
225, 226 neutral axis 32 incidence 56
national hunt flat races, fracture neutralization plates 170 nuchal ligament 719, 722
incidence 56 foals 807 nuclear medicine see scintigraphy
navicular bone 12, 351–363 radius, diaphyseal fractures 548 nucleation, mineral 19
complications 361–362 third metacarpal bone/Mt3 nursing 146–148
emergency support 141 fractures 476 foals 147, 784
surgery 354–362 neutrophils nutrient arteries 14
suspected for lameness 122 bone healing 102 third metatarsal bone 485
suspensory ligament 365 surgical site infections 286 nylon cable, rib fractures 744
neck new bone formation
exercises 323 PIJ osteoarthritis 375 o
fractures, clinical features 120 third metacarpal bone/Mt3 oblique fractures 31, 32, 33, 35
necrotic bone 12 fractures 464 plates 170
needles as markers, see also spinal New York, Thoroughbred racing, third metatarsal bone 124
needles fracture incidence 56 Obwegeser technique 759
carpus 520–521, 526, 530, 531, 533 New Zealand, study on fracture odontoid process 715–718
navicular bone repair 357, 358 incidence during oedema
proximal phalanx fractures 399, training 58 cerebral 749, 752
400, 401, 407 Newmarket Compression NMES on 316
proximal sesamoid bone Boot 137–138 treatment modalities 312
fractures 430 Newmarket Flexion Splint oesophagus, laceration 730
removal of implants 807 140–141 offset screw technique, ulnar fracture
third metacarpal bone/Mt3 nociception 131, 296 repair 568–569
fractures 461, 468, 474 mechanical nociceptive threshold olecranon, see also ulna
third metatarsal bone 636 324 fractures 563
third tarsal bone 633 Nocita see liposomal bupivacaine lateral aspect exposure 566
negative studies, see also false noise, images 68 pre‐operative planning 192
negatives non‐articular fragments, proximal olecranon notch, fractures 572–574
imaging 68–69 sesamoid bones 423, 434 olecranon tuberosity 125, 557
Neolithic period 1 non‐displaced fractures 45 omeprazole 709, 783
neonatal foals 226 healing 106 one third tubular plates 168, 177,
hypoplasia of third tarsal bone non‐reduced fractures, healing 179
631–632 107 open fractures, 45, see also wounds
rib fractures 739 non‐self‐drilling transfixation antimicrobials 133, 197, 199, 469
nerve blocks see diagnostic analgesia; pins 273 deltoid tuberosity 589
peripheral nerve blocks non‐steroidal anti‐inflammatory facial 753–755
nerve supply 14–15 drugs 131–132, 210, 296 mandible 762
neurectomy (palmar/plantar on bone healing 108 pelvis 707–709
digital) 335, 336, 362 dosages 726 pre‐operative planning 198–201
neurologic deficits foals 228, 783 radius 546, 554
cauda equina 734 pelvic fractures 709 surgical site infections 285
cervical vertebral fractures 723 non‐union 98, 102, 104 second and fourth metacarpal/Mt
fracture of dens 717 classification 104 bones 503
head fractures 749, 751 MRI 91 stabilization 201
thoracolumbar vertebral fractures therapeutic ultrasound for 318 surgical site infections 285
732 normal forces 36 ulna 579
neuromuscular electrical stimulation normal strain 36–37 operating rooms
(NMES) 315–316 normal stresses 36 infection prevention 243
0005313239.INDD 826 01/29/2022 7.55.24 PM

Index 827
preparation 195–196 external fixation 272, 274, 276 palmar/plantar digital neurectomy
operating tables 212 osteomacs 102 335, 337, 362
operating teams 194 osteonecrosis, external fixation 273 palmar/plantar eminence of middle
communication 243 osteons 14, 29 phalanx 370–372, 373
opioids, 132, 210, see also morphine secondary 17, 22, 29 in comminuted fractures 380
epidural 210 osteopenia 259 reattachment, lag screw
foals 226, 227–228 radiography 72 fixation 376
post‐operative colic 208 third metacarpal bone/Mt3 palmar/plantar fracture removal,
opium 2 fractures 465 middle phalanx 367
oral cavity, pre‐operative preparation transient 42–43 palmar/plantar processes
749 osteophytes, carpus 516 distal phalanx, foals 784
orbital fractures 759–762, 763 osteoporosis 313 proximal phalanx 393–394, 395
ORP see operating teams silicate‐associated 46 palmar/plantar splints 141
orthopaedic wire, 756, see also osteotomy palmar/plantar subchondral bone
cerclage wiring greater trochanter 682 449, 450–451, 457, 458, 459
os coxae 697 ulna 565 results of treatment 479
oscillating saws, cast removal 270 over‐stabilization 98, 103, 107 palmar processes
ossification 13 overbending, plates 170 distal phalanx 331, 332
ostectomy overhead restraints, see also hoists proximal phalanx 123, 407–408,
femur 681 fissure fractures of radius 547 411
fourth metatarsal 505–506 overload, monotonic 24 emergency support 141
thoracolumbar vertebrae 734 overload laminitis 268, 440, 710 pancarpal arthrodesis 530, 532, 538
osteoarthritis 45 overshoot effect (Uberschwinger paraplegia, post‐operative 224
carpus 515 artefact) 71 parasagittal fractures, see also sagittal
cervical vertebral fractures 725 oxygen 215, 217, 225 fractures
proximal interphalangeal hyperbaric 111 distal phalanx 331
joint 366, 372, 374, 375 navicular bone 351–352, 353–362
osteobiologics 109–110 p patella 666, 667, 669, 669,
osteoblasts 12, 16 packing, solar frog clefts 71–72 673–675
bone healing 98, 102 pain 131, 197, 295–297 proximal phalanx 70, 390–392,
scintigraphy 79 bone healing 104 402–403, 409–410
surgical site infections 288 detection 210 emergency support 141
therapeutic ultrasound on 318 foals 227–228 parasagittal grooves, of Mc3/Mt3
osteochondral fragmentation mechanical nociceptive 446, 448
carpus 512–523, 529 threshold 324 MRI 88
cuboidal bones 797 neural inhibition 323 parathyroid hormone, for bone
middle phalanx 366–369 pelvic fractures 709 healing 110
proximal phalanx 390 physiotherapy for, 315–319, see parietal bone, fractures 752, 754
osteochondral necrosis, palmar (POD) also exercise pars incisiva, mandibular
448 rib fractures 743 fractures 769, 771, 772
osteoclasts 13, 16 treatment modalities 312, 313–315 pars molaris, mandibular
bisphosphonates on 108 paleopathology 1 fractures 771–772
bone healing 98 palmar compartments, carpal joints, partial intravenous anaesthesia
osteoconduction 110 osteochondral fragments (PIVA) 214
osteocytes 12, 13, 24 in 521–523 partial slab fractures, carpus 523
osteogenesis 110 palmar intercarpal ligaments, partial volume averaging, CT 85
osteoid 12, 18 avulsion fragments partitioned navicular bone 353,
scintigraphy 78 and 521 354
osteoinduction 110 palmar osteochondral necrosis partitioning of horseboxes 145, 146,
osteolysis 105 (POD) 448 147
0005313239.INDD 827 01/29/2022 7.55.24 PM

828 Index
parturition phenothiazines 131 plantar eminence, see palmar/plantar

pelvic fractures and 711, 713 phenylbutazone 132 eminence of middle
rib fractures in foals 739–740 on fracture incidence 61 phalanx
pascal (unit) 36 pelvic fractures 709 plantar processes, see palmar/plantar
patella 12, 127, 665–678 photon starvation, computed processes
patellar ligaments 128, 665 tomography 85 plantar splints (palmar/plantar
pathologic fractures 46 physeal fractures 43–45, 46, 780, splints) 141
pathophysiology of fractures 29–53 781 plaster moulds 3–4
patient preparation 196 classification 781 plaster of Paris
peak inspiratory flow 225 common sites 781 antimicrobial delivery 293
peak strain magnitude 23 femur casts 262, 264
pelvis 128–130, 697–714 distal 688–691 plastic pipe, splinting 136
foals 806 proximal 679–683 plastic region, load–deformation
risk factors for fractures humerus 594 curve 36
701–702 pathophysiology 780 plate bending presses 159–160, 170
scintigraphy 79–80 radius 550–553 plate screws 164
stress fracture sites 43 tibia 641, 646 platelet‐rich plasma (PRP) 109
transport of horses 144–145, 147, distal 654 platelets, drugs affecting in
148 proximal 648–654 laminitis 298–299
treatment 707–713 physes 13 plates, 167–177, see also double plate
results 711–713 physiotherapy, 315–324, see also fixation; dynamic
penicillin 133 exercise compression plates;
foals 783–784 picture archiving dynamic hip screw plate;
open fractures 199 communication system locking compression plates;
surgical site infections 290 (PACS) files 190 T‐LCP (T‐plate)
Pennsylvania ESFD 277 pin casts, 108, see also transfixation bone healing 106
percutaneous repair of third casts on bone resorption 25
metacarpal bone/Mt3 pinless fixators, mandibular cervical vertebral
diaphyseal fractures 495, fractures 769 fractures 726–730
496–497 pins, 177–180, see also rush pins; contouring 159–160, 170
propagating fractures 470–471 stacked pin fixation; PIJ arthrodesis 375
peri‐anaesthetic mortality 207 Steinmann pins ulnar fracture repair 572
foals 226 cross‐pins, tibial fractures 648 facial fractures 757
perichondrial ring 779, 780 external skeletal fixation foals 783
perineural blocks see peripheral devices 276–278 removal 808
nerve blocks fractures from 276 femur 689
periosteal new bone, Mc3/Mt3 guide pins 165 guides for application 156–157
fractures 464 historical aspects 4 historical aspects 4–5
periosteum 12 humeral fractures 598 humerus
preservation 154 mandibular fractures, external diaphyseal fractures 598
peripheral nerve blocks, 215–216, fixation 768, 772, 774 greater tubercle fracture
252, see also diagnostic migration 179 repair 589
analgesia rib fractures 744 mandibular fractures 765–767,
IVRLP 290 thoracolumbar vertebral fractures 772, 775
rib fractures 743 733 metacarpophalangeal joint
peripheral quantitative CT 356 transfixation casts 271–276 arthrodesis 436
peroneus tertius, rupture 266, 636 loosening 382–383 one third tubular plates 168, 177,
personnel see operating teams pixel size 68 179
phase cancellation artefact, planning see pre‐operative planning/ orbital fractures 761, 763
MRI 88, 90 care radius
0005313239.INDD 828 01/29/2022 7.55.24 PM

Index 829
diaphyseal fractures 547, 550 head fractures 749 pre‐medication 211, 252
foals 798–799 locking compression plates 192 pre‐operative analgesia 209–211
physeal fractures 551 navicular bone surgery 357 pre‐operative planning/care 154,
rib fractures 743–744 radius, diaphyseal fractures 549 187–205
scapula 606–607 standing fracture repair 252 anaesthesia 209
second and fourth metacarpal/Mt ulnar fracture repair 566 examination 208
bone fractures 505 positive end‐expiratory foals 226
third metacarpal bone/Mt3 pressure 214, 215 head fractures 750
fractures 476–477, positive‐profile pins, external fractures of Mc3/Mt3 condyles
492–498, 495–497, 794 fixation 273 459–460
removal 479 positron emission tomography 91 navicular bone 357
tibial fractures 648 post‐antibiotic effects 291 standing fracture repair 251
ulnar fracture repair 565–578 post‐mortem, data 55–56 ulnar fractures 566
pleuropneumonia, prevention 710 post‐operative care pre‐screening testing 62–63
plexiform (laminar) bone 15–16, 22 alpha‐2 adrenergic agonists 213 prediction of fractures 62–63
pliers, for wires 181 comminuted fractures of middle premature screw tightening, Mc3/
pneumothorax 742–743 phalanx 382 Mt3 fractures 464
podiatry 297–298 distal phalanx fractures 340–341 premaxilla fractures 769
pointed drill guide 160 head fractures 750 pressure algometry 324
pointed reduction forceps 160, 172, mandibular fractures 764 priapism 131
430 navicular bone surgery 360–361 Prieur 3
Poisson’s ratio 37 removal of implants in foals primary bone healing 4, 97–98,
polar moment of inertia 37, 38, 39 807 106–107
polydioxanone sutures, facial standing fracture repair probiotics 784
fracture fixation 756 255–256 Procell Cast Liner™ 262
polymerase chain reaction 287 ulnar fractures 580–581 procollagen 18
polymethylmethacrylate acrylic 267 post‐operative colic 208, 256, 299 progenitor cells, bone healing 102
polymethylmethacrylate post‐operative complications projections, radiography 70–71
(PMMA) 111, 170, 361 283–309 PROM exercises 322, 323
antimicrobial‐eluting 292, 687 hypoxaemia 224–225 propagating fractures, Mc3/
implants, mandibular myopathy 217–218, 224 Mt3 446, 450 454–457,
fractures 768 nasal congestion 225, 226 458–459, 470–479, 480
polysulphated glycosaminoglycan neuropathy 224–225 emergency support 142
519 synovial effusions 519 propofol, foals 226
polyurethane resin, casts 263 third metacarpal bone/Mt3 proprioceptive, rehabilitation,
ponies fractures 478 techniques 312, 319–321
facial fractures 754 post‐operative myopathy and/or prostheses 5
navicular bone surgery 362 neuropathy (POMN) proteins, non‐collagenous 18
Pool‐Raft recovery system 222–223, 224 bone healing 102
224 posture 119–120 proton density weighting, MRI
ulnar fractures 580 dropped elbow posture 562, 563, 88
portable CT scanner 337, 356, 357, 595 proximal dorsal fractures, proximal
397, 398 potassium benzyl penicillin 133 phalanx 393
position screws 164 povidone iodine 196, 289 proximal femoral physeal
positioning of horse 190 power drills 155 fracture 681, 683
for anaesthesia 211–212, 213, 214 external fixation 273 proximal fourth metatarsal
cast application 263–264 rib fractures 744 bone 127
cervical vertebral fixation 726 standing fracture repair 251 proximal fractures, second and
dorsal laminectomy of cervical pre‐fracture pathology, racehorses fourth Mc/Mt bones
vertebrae 730 698 502–506, 508
0005313239.INDD 829 01/29/2022 7.55.24 PM

830 Index
proximal interphalangeal joint stress fracture sites 43 radial carpal bone 511–523
365 ultrasound 76, 77, 420, 422, 423 slab fractures 535, 536
arthrodesis 369, 371, 372–377, proximal sesamoid bone lesions radial facet, see third carpal bone
787 following metatarsal artery radial nerve 585–586
articular fractures 366–369 cannulation, 217pubic fracture involvement 545, 551,
double plate fixation 284–285 symphysis, ultrasound 703 599–600
palmar/plantar luxation 382 pubis fractures 701, 713 radio‐ulnar articulation 557–558
proximal phalanx fractures 402 pullout strength see holding strength fractures at 562, 574, 575, 582
subluxation 366 pulse oximetry 216–217 radio‐ulnar ligament 561
proximal phalanx fractures 122–123, pulsed electromagnetic field (PEMF) radiography, 69–74, 132–133, see also
389–413 therapy 316–317 individual bones and
causes 396 pulsed electromagnetic fields 111 fractures
clinical features 396–397 pulsed ultrasound 318 carpal slab fractures 526
emergency support 141 low‐intensity (LIPUS) 111 false negatives 72, 117
foals 785, 786, 787 push–pull devices 159, 171 historical aspects 4, 6
imaging 397–398 PIJ arthrodesis 375 image quality 67–68
incidence 395–396 PVP‐I (antiseptic) 242–243 intra‐operative 243
management 398–408 microradiography, fracture
parasagittal fracture 70, 390–392, q prediction 62
402–403, 409–410 quantitative assessment monitoring bone healing 104
incomplete 390, 391, 397, CT of Mc3 condylar fractures pre‐operative planning 190, 194
398–402, 409 447–448 standing fracture repair 250
results 408–411 scintigraphy 81–82 supporting limb laminitis 295,
standing repair 250, 254, 402 quantitative peripheral CT, navicular 296–297
stress fracture site 43 bone 356 surgical site infections 287–288
proximal radial physeal fractures quantum noise 68 radionuclide imaging see
551 Quarter Horses scintigraphy
proximal sesamoid bone fractures carpal fractures 512, 520, 524 radius 125, 545–555
415–444 fracture incidence in racing 57 comminuted fractures 550
abaxial fractures 421–426 fracture incidence in training 59 diaphyseal fractures 547–550
aiming device 182 emergency support 143
apical fractures 418–421 r foals 798–799, 801
basilar fractures 432–434 R‐gel polymer see cross‐linked diaphyseal fractures 548
causes 417 dextran gel fixation to ulna 570–571
classification 417–418 racecourse fractures 117–119 fragmentation into carpus 513
concurrent with Mc3/Mt3 racecourse post‐mortems 55–56 human femoral locking
fractures 457, 465, 480 racehorses, see also Standardbred compression plates 174
destabilizing fractures 435–441 horses; Thoroughbred open fractures 546, 554
emergency support 142 racehorses; Quarter horses surgical site infections 285
foals 418, 785–790, 791, 792, 793, Arkle 4 ulnar fracture repair and 568
795, 796, 797 carpal fractures 512 rafts, Pool‐Raft system 222–223
forelimb clinical features 123–124 central tarsal bone fractures 628 Raman spectroscopy 22
fractures from external trauma Mill Reef 4 ramps, transport of horses 145,
435 pelvic fractures 698 146
imaging 77 third metacarpal bone/Mt3 Ranatus, Vegetius 2
incidence 417 fractures 486 range of motion
mid‐body fractures 35, 426–432 racing goniometry 324
prediction of 62 ethics 6 rehabilitation 312, 322, 323
sagittal fractures 434 fracture incidence 55–59, 702 ranitidine, foals 228
splinting 140, 142 racing speeds, strain rates 39 reaming
0005313239.INDD 830 01/29/2022 7.55.24 PM

Index 831
interlocking intramedullary nails regions of interest, scintigraphy racecourse fractures 119

180 81–82 recovery from anaesthesia
screw extraction 166–167 rehabilitation 311–329, 710–711 218–219
stacked pin fixation 179 reinsertion of screws, on holding retractors
rebound effect (Uberschwinger strength 241 cervical vertebral fixation 726
artefact) 71 relaxation artefact, ultrasound 75 Hohmann retractor 181
reconstruction plates remodelling 17, 22, 24, 42–43, 98, reversal lines 17
facial fractures 757 100, 102 rhabdomyolysis, exertional 700
orbital fractures 763 after rest periods 60–61 rib fractures 739–746
rib fractures 743–744 bisphosphonates on 109 fixation 742–745
second and fourth Mc/Mt bone implants on 25 scintigraphy 79
fractures 505 radiography 74 ring blocks 252
recovery boxes, standing fracture rehabilitation 98, 312, 313 rising resistance curve 41
repair 251 removal of implants risk factors 59–61
recovery from anaesthesia 218–226, foals 807–808 pelvic fractures 701–702
283, 478 humerus, diaphyseal Robert Jones bandages 134–136,
avulsion fractures from 522 fractures 691 137
casts and 264, 266 infection 289, 807 ROM exercises 322, 323
foals 228 radial fractures, physeal 551, Rome (ancient) 1, 2
patellar fractures 673 553–554 romifidine 130, 131, 211, 214
planning 198 screws 165–167, 464 foals 226
ulnar fractures 558, 580 third metacarpal bone/Mt3 464, mares with foals 226
rectal examination, pelvic 480 recovery from anaesthesia 218
fractures 699, 700 tibia 653 rongeurs, facial fractures 756
recumbency, head fractures 751 diaphyseal 660 ropivacaine 216
reduction forceps timing 104 rosettes 753, 756, 757
in Mc3/Mt3 fractures 467 ulna 581 rostral fractures, mandible
pointed 160, 172, 430 Renaissance 2 762–774
ulnar fracture repair 568 repaired fractures, healing 106–107 rotation angle, distal phalanx 296
reduction of fractures 153, 235–236 reparatory phase of bone healing rotational stability, stacked pin
cervical vertebral fractures 727 cryotherapy 314 fixation 179
devices for 181–182 rehabilitation 311, 312, 313 round ligament 679
facial 755–756 reperfusion injury in arthrodesis of running rails, 256, see also cross‐ties
femur metacarpophalangeal rush pins 107, 179–180
capital physeal 683 joint 440 humeral fracture 600
diaphyseal fractures 687 resistance band training 320, 321
foals 782–783 resistance curve, rising 41 s
radius 799 resolution of images 68 S–N curves 40, 41
humerus, diaphyseal fractures resorption canals 16, 22 sacroiliac joints 697
689, 804 resorption of bone 13, 17 sacrum 697
patella 673–675 adaptive 24–25 fractures, 734‐735
planning 192 prevention 25 sagittal fractures, see also parasagittal
plans for failure 198 third metacarpal bone/Mt3 fractures
rib fractures 742 fractures 463 carpal slab fractures 523–524
tibia 649, 654, 657, 804, 805 respiratory monitoring distal phalanx 341–343, 345
ulna 799–800 anaesthesia 216 middle phalanx 369
Reformation, the 2 foals 227 proximal sesamoid bones
regional analgesia 197 rest periods and fracture risk, 60‐61 434–435
regional limb perfusion, antimicrobials restraint talus 618–619
197, 289–291 fissure fractures of radius 547 third carpal bone 534–535, 537
0005313239.INDD 831 01/29/2022 7.55.24 PM

832 Index
sagittal groove, see also lateral sagittal scintigraphy 82 self‐tapping screws 239
groove and parasagittal screens, on racecourse 117, 118 cortex screws 161
grooves screwdrivers 158 semilunar canal 331
proximal phalanx 396 removal of implants 808 sensory neurons 15
salbutamol 215 screws, 160–167, see also specific sequestra
saline jet treatment, surgical site screw types and uses deltoid tuberosity 590
infections 289 broken 166–167 second and fourth Mc/Mt bone
Salter‐Harris classification 43–45, damage to 240 fractures 503
46, 780 errors 236, 237–238 sequestration, external fixation 273
historical aspects 4 foals 783 serum amyloid A (SAA) 287
Salter‐Harris fractures in plate fixation 169‐177 sesamoid/fetlock fractures,
proximal phalanx 394, 408, 411 large fragment sets 155 Thoroughbred racing,
Type II 780 loosening 283–284 incidence 56
phalanges 785 reinsertion holding strength sesamoidean nerves 416
third metacarpal bone/Mt3 792 241removal 165–167, 479, sesamoids, see navicular bone;
tibia 641, 642, 646, 804 808 patella; proximal sesamoid
ulna 571–572, 581–582 Schanz screws 182 bones
Type IV 781 sizes 162 sevoflurane 213
ulna 558–559 stripping 166, 240, 241 recovery from anaesthesia 218
scapular fractures 126–127, removal of implants 808 shear forces 34–36
603–610 standing fracture repair 254 shear stress and strain 31, 33, 36,
foals 804 too long 239 782
neck and body fractures 607 scutum 365, 415 Shell System sling 221
scintigraphy 80 second and fourth metacarpal/Mt shoes, see also bar shoes; wedged
spine 607 bone fractures 501–510 shoes
stress fractures 43, 604 second carpal bone 511 for distal phalanx fractures 336,
superglenoid tubercle, 606‐607 second tarsal bone 613, 636 340, 343
Schanz screws 182 secondary fractures 283 on fracture incidence 61
scintigraphy 6, 76–84 interlocking intramedullary horses with casts 267, 270
distal phalanx 335 nails 181 laminitis and 298
iliac wing 707 transfixation casts 383 short lateral collateral ligaments,
monitoring bone healing 105 secondary (indirect) bone tarsus 611
pelvic fractures 705–706 healing 98, 99–100, 107, division 615
proximal phalanx 397 311 short medial collateral ligaments
rib fractures 741 secondary osteons 17, 22, 29 611
scapula 80, 81, 605 Securos Cranial Cruciate Ligament short oblique fractures 35
stress fractures 79 Repair System™, rib short tau inversion recovery (STIR),
humerus 591, 592, 593 fractures 744–745 MRI 87–88, 90
monitoring healing 84 sedation 130–131, 210–211 shoulder joint, osteoarthritis 45
stress protection 25 cast removal 270 showjumping, fracture
surgical site infections 288 foals 226 incidence 58
talus, sagittal fractures 618, 619 mares with foals 226 sickle hocks 796
techniques 79–82 recovery from anaesthesia 218 sidebone 335, 335
third metacarpal bone/Mt3 82, standing fracture repair 252 signal‐to‐noise ratio (SNR) 68
451 tied up horses 710 signing out 198
dorsal cortex 82, 84 segmental fractures, ribs 739 silicates, pathologic fractures 46
third trochanter 692 seizures 131 sinking, distal phalanx 295,
tibia 80, 648 self‐adhesive tape 296–297, 710
sclerosis 72 Robert Jones bandages 134 sinus tarsi 612
screening 6, 62–63 splinting 135–136 skin, surgical preparation 196, 337
0005313239.INDD 832 01/29/2022 7.55.24 PM

Index 833
skin staples, standing fracture repair Solleysel, J. de, The Compleat wires 181
252, 253, 254 Horseman 2–3 Standardbred horses
skull, 747–778, see also head, facial Sontec Instruments Inc. 154 carpal fractures 512, 523
skull; visceral cranium sore shins 486–488 distal phalanx fractures 333
computed tomography 85 sores, casts 268–269 fracture incidence 59
haemorrhage 119 spacer‐plate system, cervical proximal phalanx fractures, results
radiography, 73, see also cranium 728–729, 729 of treatment 409
upper airway endoscopy 195 span width, plates 169 proximal sesamoid bone fractures
slab fractures 73 spatial resolution 68 418
carpus 124–125, 512, 523–538 spheno‐occipital suture 72 prognosis 421
third carpal bone 521, 523, 538 spin echo sequences, MRI 87 standing computed
emergency support 143 spinal needles (markers) tomography 85–86
tarsus 127 carpus standing fracture repair 249–257
central tarsal bone 628–631 chip fractures 521, 520 greater tubercle of humerus 589
third tarsal bone 631–635 third carpal bone fractures 526, head fractures 749
sleeve casts 265, 266, 535, 536 527, 528, 535 proximal phalanx 250, 254, 402
sleeves, external fixation 272 proximal sesamoid bone fractures third metacarpal bone/Mt3 250,
slings 428 254, 478
on effective body weight 298, 299 third tarsal bone 633 standing MRI 87, 88
fissure fractures of radius 547 spine see vertebrae standing ostectomy, thoracolumbar
fractures of the greater tubercle of spinous processes, thoracolumbar spinous processes 733–734
the humerus 588 vertebrae 732, 733 standing radiography
historical aspects 3 spiral fractures 31, 33, 35 femoral capital physeal fracture
recovery from anaesthesia third metacarpal bone/Mt3, 450, 680, 681
220–222 454, 456, 470‐479 480 pelvic fractures 706–707
sloping border fractures, navicular splint bones 501–510 Staphylococcus aureus 517
bone 352, 362 splints, 134, 139–141, 142, see also staples (skin), standing fracture
slotted designs, interlocking emergency support repair 252, 253, 254
intramedullary nails 180 dorsal 139–140 star‐drives, stripped 240
small metacarpal/Mt bones, 501–510, mandibular fractures 767–768 star‐lock screwdrivers 158
see also second and fourth radius 143, 547 steel see stainless steel
Mc/Mt bone fractures Robert Jones bandages 135–136, Stefan bone‐holding forceps 160
Smith, F. 3 137 Steinmann pins 177, 179
soap, open fracture irrigation 201 third metacarpal bone/Mt3 794 axis (C2) 722
sodium fluoride, PET 91 tibia 144 dens 718
soft callus phase, bone healing 98, splitting bone fragments 236 external fixation 272–273
99, 103 spontaneous fusion, proximal facial fractures 755
Soft‐Ride boot 298 interphalangeal joint mandible 768, 774
soft tissues 372–373 ribs 745
laxity, casts and 269 spring‐loaded drill guides 156 thoracolumbar vertebrae 733
radiography 73 stability, 97–98, 782, see also tibia 805
solar frog clefts, packing 71–72 construct instability; ulna 579–580
solar margin fractures 331, 333, unstable fractures stem cells
347 stacked combi holes 169 bone healing 102, 109
foals 784–785 stacked pin fixation 179 laser therapy on 319
solar surfaces 298 femoral capital physeal stent bandage, ulnar fracture repair
casts 266–267, 268, 269 fracture 683 569
sole area difference, on fracture humeral fracture 598 step drill, external fixation 273
incidence 61 stainless steel 154–155, 167 sternal ribs 739
sole thickness 296 transfixation pins 274 Steward clog 298
0005313239.INDD 833 01/29/2022 7.55.24 PM

834 Index
stifle joints 127–128 proximal phalanx fractures 396 proximal sesamoid bone
STIR see short tau inversion recovery subject contrast 67, 68 fractures 417
stockinette 137 subluxation risk factors 59
for casts 260–261 atlantoaxial splinting 140
strain 20, 35, 37 dens fracture, 715‐718 ultrasound 76, 77
bone change prevention 25 primary 719 suspensory ligament 415
on bone healing 103 carpal 124–125 avulsion fractures of Mc3/Mt3
peak strain magnitude 23 cubital joint 570, 801 associated 489, 490
stress–strain curve 36–37, 38 patellar 668 desmitis 417
viscoelasticity and 39 proximal interphalangeal insertion 416
strain rate 39, 40 joint 366 sesamoid fractures and 76, 77,
strain rate sensitivity 39 second and fourth Mc/Mt 419, 421–426
strength 36 bone 505 ultrasound 502
rehabilitation, modalities 312 tarsus 127 sustentaculum tali 612, 623, 625,
stress 208, 209 subtotal patellectomy 668–673 626
supporting limb laminitis and sucralfate 783 suture lines, cranium 72
295 superficial incision SSIs 286 sutures, see also wires
stress fractures, 40–43, see also support see immobilization facial fracture fixation 756
fatigue fractures supporting limb deformity 597, rib fractures 744–745
humerus 43, 591–594, 592, 593 689, 784 swarf 461
iliac wing 700 supporting limb laminitis 294–299 sweating, after ulnar fracture
magnetic resonance imaging 87 supportive care 146 repair 580
pelvis 698 supracondylar fossa of femur 687 swelling 73
risk factors 701‐702 avulsion fractures 693 after ulnar fracture repair 580
radiography 72–73 supracondylar tuberosity, diaphyseal fractures of femur 684
scapula 603, 604, 605 femur 693 Mc3/Mt3 fractures 449–450
scintigraphy 79 supraglenoid tubercle, scapula 126, NMES on 316
monitoring healing 84 603–604, 605–607, 608 treatment modalities 312
third metacarpal bone/Mt3 448 supraglottic airway devices 227 Swing lifter 298, 299
dorsal cortical 486–488 suprascapular nerve paresis 586, symphysis of mandible,
tibia 642–643, 644, 645, 646, 661 604 fractures 769, 770
stress (mechanical), 20, 21, 35, 36, see surfaces see track surfaces synovial
also shear stresses surgeons 187 effusions,
bending moment 23 errors 235 post‐operative 519
external fixation 272, 274 surgical field preparation 241–242 Synthes Inc. 153
devices 277 surgical site infections, 284–294, see threaded traction device 756
plateau 41 also wounds synthetic bone substitutes 110–111
reaction (term) 72 diaphyseal fractures of femur synthetic track surfaces, fracture
relaxation 39, 40 688 incidence 591, 701
stress–strain curve 36–37, 38 prevention 241–243
stretching exercises 322 open fractures 198–201 t
stride, see also gait; lameness screw loosening 283–284 T‐handles 158, 166
stripping of screws 166, 240, 241 ulnar fracture repair 581 T‐LCP (T‐plate) 174, 494
removal of implants 807 susceptibility artefact, MRI 88 arthrodesis of carpus 530–534
standing fracture repair 255 suspensory apparatus 415 tibia 649, 650–651
sub‐clinical injury, on training 60 suspensory apparatus failure removal 653
subchondral bone, see also palmar/ 123–124, 435–441 T1 and T2 weighting, MRI 88
plantar subchondral bone foals 786 tactile stimulators 320, 321
adaptation 24 hoof form on incidence 61 tail, injuries 735
0005313239.INDD 834 01/29/2022 7.55.24 PM

Index 835
talus 127, 612 femoral capital physeal fracture ossification 13

fractures 618–621, 622, 623, 624 683 third trochanter 679, 691–692
medial tubercle 621, 623 metacarpophalangeal joint third tubular plates (one third
sagittal 618–619 arthrodesis, 437‐440 tubular plates) 168, 177,
trochlear ridges 619–621, 622 patella 675 179
tapered head run‐out (TRO), tenting, diaphyseal fractures of thoracolumbar vertebrae 732–734
transfixation pins 273, tibia 657 Thoroughbred racehorses
274 Tesla (unit) 87 carpal fractures 512–513, 519,
tapered‐sleeve transcortical pins, tetanus prophylaxis 133 523
external skeletal fixation Theraband see resistance band central tarsal bone, 628‐631
devices 277 training peak strain magnitude 23
tapering, Acutrak screw 165 thermoplastic polymer, casts 137 pelvic fractures 698
tapping 155, 161–163 thermotherapy 313–315 post‐operative colic 208
distal phalanx fracture treatment thiopental 212 proximal phalanx
338, 340 third carpal bone 511 fractures 389–413
heat production 161 fragmentation, 512‐523 proximal sesamoid bone
standing fracture repair 254, 255 sagittal fractures 534–535, 537 fractures 415–444
third metacarpal bone/Mt3 461 slab fractures 523–530 racing fracture incidence, 55‐57
taps 158 third metacarpal bone/ rib fractures 745
targeting devices, interlocking Mt3 536–538 stress fractures 43
intramedullary nails 180 condylar fractures 35, 123, 249, humerus 591–594
tarsal sleeve casts 266 250, 445–484 third carpal bone fractures,
tarsocrural joint 127, 611, 612 biaxial 479 523‐538
fractures 613–622 lateral condylar fracture 448, 457 third metacarpal bone/Mt3
infection 623 displaced 454–455, 455, 465–470 condylar fractures 445‐484
tarsus 127, 611–639 incidence 449, 450 third tarsal bone 612, 631–635
anatomy 611–613 prediction 62 training, fracture
emergency support 144 proximal sesamoid bone fractures incidence 57–58
foals 795–797, 800 with 434–435 Thoroughbred racing, see also
luxation and subluxation 127 medial condylar fractures racecourse fractures
stress fracture site 43 incidence 448 thread cutting screws 161
teams, see also operating teams risks 249, 446, 457, 477 thread forming screws 161
racecourse fracture management third metacarpal bone/Mt3 thread height, cortex screws 161
117–118 536–538 thread holes
teeth diaphyseal fractures 124, drill bits for 155
fracture involvement 750 485–550, 792, 794 errors 236
mandibular fractures 764, 765 emergency support 142 threaded pins, external fixation 273
temporomandibular joint, fractures foals 485–486, 792–795, 798 mandibular fractures 768
involving 776 ossification 13 threaded traction device 756
tensile failure 32 scintigraphy 82, 451 threads see tapping
tension 30–31, 32, 782 dorsal cortex 82, 84 three‐point bending 34
cables 181 strain 37 tibia 127, 641–664
device 159,571 stress fracture sites 43 distal epiphysis 611
supraglenoid tubercle 605–607 proximal fractures 635–636 distal intermediate ridge,
tibial tuberosity 655, 657 standing fracture repair 250, fractures 618
ulna 565, 568, 571, 579–580 254, 478 emergency support 144
wires 181 third tarsal bone 612–613 foals 804–806
tension band foals 796–797, 800 imaging 83
calcaneous 627 fractures 127, 631–635 malleolar fractures 613–618
0005313239.INDD 835 01/29/2022 7.55.24 PM

836 Index
tibia (cont’d) radial fractures 549 triage, 117–151, see also emergency
emergency support 144 tibial fractures 804, 805 care
scintigraphy 80, 648 traffic, operating rooms 243 triangular screw configuration,
stress fracture sites 43 training, see also adaption of bone proximal phalanx
tibial tuberosity 128, 144, 641, 642, and exercise fractures 401
646, 647–648 fracture incidence 57–59, 702 tricalcium phosphate (TCP)
comminuted fractures 657 on peak strain magnitude 23 110–111
fractures 644, 654–655, 656 proximal phalanx fractures 396 triceps brachii 557
tightening of screws 241 rest periods 60–61 atrophy 581
overtightening 163 risk factors 59–60 trimethoprim‐sulphonamide 753
premature 464 stress fractures 711 trimming, hooves 298
tilt tables 223–224 third metacarpal bone/Mt3 446 tripartite navicular bone 353, 354
time‐dependent antimicrobials 290 tranquillizers 131 Tripontium (archaeology) 1
titanium 155 transcutaneous electrical nerve trochlear ridges
toe grabs, on fracture incidence 61 stimulation (TENS) 315 femur, fractures 127–128, 693
toe‐heel angle difference, on fracture transdermal patches, fentanyl 132, talus 612
incidence 61 197 fractures 619–621, 622
toe region, load–deformation transducers, ultrasound 74–75 tropocollagen 18–19
curve 36 transfixation, circumferential true ribs 739
topical antimicrobials, open 430–432 tuber coxae 130, 697, 698
fractures 199 transfixation casts 5, 271–276 fractures 129, 699
topography, fractures 43–45 hybrid with ESFD 278 open fractures 707–709
torque middle phalanx 380, 382–383 prognosis 712
screw placement 241 proximal phalanx 405–406, 410 radiography 706
yield torque, interlocking results 275–276 scintigraphy 706
intramedullary nails 180 third metacarpal bone/Mt3 surgery 707–709
torque‐limiting devices 158–159, fractures 492, 794 ultrasound 703
174 transfixation pins 272–274 tuber ischium 701
torsion 31, 33, 38, 782 mandibular fractures 768, 769 prognosis 712–713
holes on bone resistance 274 transosseous screws 158 scintigraphy 80, 706
torsion wedge non‐union 104 transphyseal bridges 551–554, 792, ultrasound 703, 705
total protein 208 804 tuber sacrale 697, 699, 734
toughness (mechanical) 20, 36, 37, transphyseal screw fixation, femoral turf racing, fracture incidence 56,
41 capital physeal fracture 57
third metacarpal bone/Mt3 446 683 twentieth century, historical
tourniquets 212–213, 289–291 transport of horses 144–146, 147 aspects 4
trabeculae 11–12 radial fractures 547 tying horses, see also cross‐ties
load transmission 24 transrectal ultrasound 702, 703–705 running rails 256
third metacarpal bone/Mt3 446 transverse distraction fracture 33
trabecular bone 37, 38 transverse fractures u
stress fractures 73 distal phalanx 347 U bars, transfixation casts 271
tracheal intubation, foals 226–227 navicular bone 352 U‐shaped splints, mandibular
tracing paper 191 patella 675–677 fractures 767–768
track surfaces proximal phalanx 785 Uberschwinger artefact 71
fracture incidence 56, 57, radius 554 ulna 125, 550, 551, 557–584
591–592, 701 third metacarpal/Mt bone 124, apophyses 43, 557–559, 563, 571,
traction 181 490–491 572, 581, 803
facial fracture reduction 755–756 Trauma Recon drill 155 emergency support 143
humeral fractures 804 treatment records, epidemiological foals 799–804, 803, 807
planning 192, 193, 195 data 61 fixation to radius 569
0005313239.INDD 836 01/29/2022 7.55.24 PM

Index 837
healing 581 vancomycin 290, 293, 294 walking, with casts 268
ulnar carpal bone 511 variable angle locking compression walking casts 271
fragments 521 plates (VA‐LCP) 6–7, walking reduction, radial
ulnar nerve 567, 586 175–176 fractures 549
ultimate load 36 variable pitch screws, Mc3/Mt3 462 washers 342, 345, 553, 673
ultimate strain 20, 21 varus deformity 299, 783 water, see also pool recovery systems
ultra‐high‐molecular‐weight humeral fracture 597 bone content 29, 39
polyethylene (UHMWPE), vascular endothelial growth factor curing fibreglass 263
cables 181 (VEGF), for bone open fracture irrigation 201
ultrasound, diagnostic, 74–76, 133, healing 110 rehydration 146
see also pulsed ultrasound vascular supply see blood supply therapy 321–322, 519
greater tubercle of humerus vasospasm 119 wedged shoes 298
586–590 Vegetius, Publius 2 heel elevation 355
monitoring bone healing ventilation wedges
104–105 foals 227 dorsal splints with 140
patellar fractures 665–678 intermittent positive pressure for mouth 764
pelvis, 128–130, 697‐714 214, 215 wedging, third tarsal bone
proximal sesamoid bones 76, 77, ventilation/perfusion (V/Q) 631–632
419, 423 mismatch 214, 217 weight‐bearing
rib fractures 740–741 ventral atlantoaxial fusion 718 supporting limb laminitis
scapula 605 ventral cervical fusion 718, 725–730 and 294–298
second and fourth Mc/Mt bones ventricular dysrhythmias, surgical site infections 284–294
502 acepromazine on 211 weight (effective body weight) 298,
surgical site infections 287 Verbrugge bone‐holding forceps 160 299
suspensory apparatus failure 76, vertebrae 715–737 weight‐shifting exercises 322, 323
77 cervical 715–731 white blood cells, radiolabelled
third trochanter 692 coccygeal 735 288
ultrasound 313, 318 fractures 119–120 WHO surgical checklist 187–188
ultrastructure, bones 17–19 sacral 734‐735 whole‐body vibration therapy
underwater treadmills 321, 322, thoracolumbar 732‐734 (WBV) 317
519 vertical ramus, mandibular Williams, W. (1893) 3
uniaxial mid‐body fractures, fractures 774–776 window width and level, CT 85
proximal sesamoid bones vibration winged infusion catheters 252,
426–432 on bone healing 111 290
UniLOCK screws 162 prevention of bone resorption 25 wires 107, 181
UniLOCK system 175 whole‐body vibration therapy facial fracture fixation 756, 758
universal drill guide 156, 172 (WBV) 317 greater tubercle fracture repair
unloading, transport of horses 145 visceral cranium, 747–748, see also 589
unsharp masking 71 facial skull mandibular fractures 764–768,
unstable fractures, see also construct viscoelasticity 39, 40 769, 773
instability viscosity 39 metacarpophalangeal joint
healing 107 vitamin E 299 arthrodesis 438–440
upper airways, endoscopy 195 Volkmann’s canals 14 mid‐body fractures of proximal
urinary catheterization, standing volume averaging sesamoid bones 430, 432
fracture repair 252 computed tomography 85 rib fractures 744
MRI 88 ulna 579–580
v foals 800
V‐shaped blocks, cervical vertebral w WNT gene, PEMF on expression
fixation 726 Wagner A‐O forceps see pointed 316
valgus deformity, tarsus 796 reduction forceps work to fracture 36
0005313239.INDD 837 01/29/2022 7.55.24 PM

838 Index
wounds, 133, see also open fractures; foals 226 yellow drill guides 171
surgical site infections intra‐operative 214 yield point 20, 21, 36
intra‐operative irrigation (IOWI) pelvic fractures 709 yield torque, interlocking
242–243 recovery from anaesthesia 218 intramedullary nails 180
mandibular fractures 764 Youatt, W. (1843) 3
woven bone 15, 22 y Young’s modulus 20
Y fractures, Mc3/Mt3 456, 471, 476
x yearlings z
xylazine 130, 131, 210 humerus 125 zip ties, rib fractures 744
dosages 211 proximal sesamoid bone
epidural 132 fractures 422
0005313239.INDD 838 01/29/2022 7.55.24 PM

Fractures in The Horse (VetBooks - Ir)

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Library of Congress Cataloging-­in-­Publication Data

Cover Design: Wiley

Set in 9.5/12.5pt STIXTwoText by Straive, Pondicherry, India

2 Bone Structure and Function 11

­ ositron Emission Tomography

7 Triage and Emergency Care 117

Tarsal Luxation and Subluxation 127

8 Surgical Equipment, Implants and Techniques for Fracture Repair 153

Drill Bits 155

Stacked Pin Fixation 179

9 Pre-­operative Planning and Preparation 187

Debridement and Lavage 199

10 Anaesthesia and Analgesia 207

11 Intra-­operative Complications 235

12 Standing Fracture Repair 249

13 External Coaptation 259

14 Post-­operative Complications 283

­Supporting Limb Laminitis 294

15 Convalescence and Rehabilitation 311

16 Fractures of the Distal Phalanx 331

­ linical Features and Presentation 333

17 Fractures of the Navicular Bone 351

18 Fractures of the Middle Phalanx 365

Incidence and Causation 366

19 Fractures of the Proximal Phalanx 389

20 Fractures of the Proximal Sesamoid Bones 415

Transfixation/Hemi-­circumferential Wire 430

21 Fractures of the Distal Condyles of the Third Metacarpal

­Techniques for Treatment 459

24 Fractures of the Carpus 511

Sagittal Slab Fractures of Other Carpal Bones 535

25 Fractures of the Radius 545

26 Fractures of the Ulna 557

­ ost-­operative Care and Convalescence 580

27 Fractures of the Humerus 585

28 Fractures of the Scapula 603

Supraglenoid Tubercle Fractures 605

29 Fractures of the Tarsus 611

30 Fractures of the Tibia 641

31 Fractures of the Patella 665

32 Fractures of the Femur 679

­ vulsion Fractures of the Cranial Cruciate Ligament 694

33 Fractures of the Pelvis 697

34 Fractures of the Vertebrae and Sacrum 715

Acute Fracture Management 717

35 Fractures of the Ribs 739

I­ ncidence and Causation 739

36 Fractures of the Head 747

Surgical Planning and Preparation 764

37 Fractures in Foals 779

­ alcaneal Fractures 804

Fractures in the Horse, First Edition. Edited by Ian Wright.

Nuclear medicine (scintigraphy) was adopted into equine T

Bone Structure and Function

I­ ntroduction The cells of individual bones express a genetic blueprint

Fractures in the Horse, First Edition. Edited by Ian Wright.

Library of Congress Cataloging-in-Publication Data

ositron Emission Tomography

9 Pre-operative Planning and Preparation 187

11 Intra-operative Complications 235

14 Post-operative Complications 283

Supporting Limb Laminitis 294

linical Features and Presentation 333

Transfixation/Hemi-circumferential Wire 430

Techniques for Treatment 459

ost-operative Care and Convalescence 580

vulsion Fractures of the Cranial Cruciate Ligament 694

I ncidence and Causation 739

alcaneal Fractures 804

I ntroduction The cells of individual bones express a genetic blueprint

mechano-sensitive mechanism. The interconnected net-

Loading Modes to single axis loading in tension, compression, shear, bend-

State of Knowledge genuinely reflect differences in outcome, but it is also the

redictability and Potential

I ntroduction use the technique accurately and to its fullest capacity.

Introduction and Principles damage. The fracture configuration is usually unpredictable.

can progress to complete and sometimes catastrophic Healing of Displaced Fractures

such as with highly comminuted fractures or occasionally Non-steroidal Anti-inflammatory Drugs

formation [84, 85]. Meta-analysis of clinical studies shows

I ntroduction decision-making can follow. Use (maintenance) of a bridle