Equine Fracture Repair 2nd Edition

Equine Fracture Repair
www.ajlobby.com
Equine Fracture Repair
Second Edition
Edited by
Alan J. Nixon, BVSc, MS, Diplomate ACVS

Professor of Orthopedic Surgery
Director of Comparative Orthopaedics Laboratory
Department of Clinical Sciences
College of Veterinary Medicine
Cornell University
Ithaca, NY;
Senior Orthopedic Surgeon
Cornell Ruffian Equine Specialists
Elmont, NY, USA
www.ajlobby.com
This edition first published 2020
© 2020 John Wiley & Sons, Inc.
Edition History
WB Saunders (1e, 1996). All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in
any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by law. Advice on how to obtain
permission to reuse material from this title is available at http://www.wiley.com/go/permissions.
The right of Alan J. Nixon to be identified as the author of this work has been asserted in accordance with law.
Registered Office
John Wiley & Sons, Inc., 111 River Street, Hoboken, NJ 07030, USA
Editorial Office
111 River Street, Hoboken, NJ 07030, USA
For details of our global editorial offices, customer services, and more information about Wiley products visit us at www.wiley.com.
Wiley also publishes its books in a variety of electronic formats and by print‐on‐demand. Some content that appears in standard print versions
of this book may not be available in other formats.
Limit of Liability/Disclaimer of Warranty

The contents of this work are intended to further general scientific research, understanding, and discussion only and are not intended and should
not be relied upon as recommending or promoting scientific method, diagnosis, or treatment by physicians for any particular patient. In view
of ongoing research, equipment modifications, changes in governmental regulations, and the constant flow of information relating to the use of
medicines, equipment, and devices, the reader is urged to review and evaluate the information provided in the package insert or instructions for
each medicine, equipment, or device for, among other things, any changes in the instructions or indication of usage and for added warnings and
precautions. While the publisher and authors have used their best efforts in preparing this work, they make no representations or warranties with
respect to the accuracy or completeness of the contents of this work and specifically disclaim all warranties, including without limitation any
implied warranties of merchantability or fitness for a particular purpose. No warranty may be created or extended by sales representatives, written
sales materials or promotional statements for this work. The fact that an organization, website, or product is referred to in this work as a citation
and/or potential source of further information does not mean that the publisher and authors endorse the information or services the organization,
website, or product may provide or recommendations it may make. This work is sold with the understanding that the publisher is not engaged
in rendering professional services. The advice and strategies contained herein may not be suitable for your situation. You should consult with a
specialist where appropriate. Further, readers should be aware that websites listed in this work may have changed or disappeared between when
this work was written and when it is read. Neither the publisher nor authors shall be liable for any loss of profit or any other commercial damages,
including but not limited to special, incidental, consequential, or other damages.
Library of Congress Cataloging‐in‐Publication Data

Names: Nixon, Alan J., editor.
Title: Equine fracture repair / edited by Alan J. Nixon.
Description: 2nd edition. | Hoboken, NJ : Wiley-Blackwell, 2020. | Includes bibliographical references and index. |
Identifiers: LCCN 2018054082 (print) | LCCN 2018055053 (ebook) | ISBN 9781119108740 (AdobePDF) |
ISBN 9781119108726 (ePub) | ISBN 9780813815862 (hardback)
Subjects: LCSH: Horses–Fractures–Treatment. | Horses–Surgery. | MESH: Horses–surgery |
Fracture Fixation–veterinary
Classification: LCC SF959.F78 (ebook) | LCC SF959.F78 E68 2020 (print) | NLM SF 951 |
DDC 636.1/089705–dc23
LC record available at https://lccn.loc.gov/2018054082
Cover image: Wiley
Cover design: © Liu zishan/Shutterstock
Photos by: Alan J. Nixon
Set in 10/12pt Warnock by SPi Global, Pondicherry, India
10 9 8 7 6 5 4 3 2 1
www.ajlobby.com
To Sally, for her passion for life, love, and encouragement throughout this project,
and
My three children, Bridgette, Nicole, and Ryan, for their patience and understanding while
I toiled and their unwavering love and support throughout these past few years.
www.ajlobby.com
vii
Contents
Contributors xi
Preface to the Second Edition xiv
Preface to the First Edition xv
Acknowledgments xvi
Part I Introduction 1
1 Bone Structure and the Response of Bone to Stress 3

Mark D. Markel
2 Fracture Biomechanics 12
Mark D. Markel
3 Fracture Healing 24
Mark D. Markel
4 General Considerations for Fracture Repair 35

Alan J. Nixon
5 Racetrack Fracture Management and Emergency Care 44

Ian M. Wright
6 First Aid and Transportation of Equine Fracture Patients 83

Larry R. Bramlage
7 Perioperative Considerations 91
Alan J. Nixon
8 Surgical Equipment and Implants for Fracture Repair 107

Joerg A. Auer
9 Principles of Fracture Fixation 127

Alan J. Nixon, Joerg A. Auer , and Jeffrey P. Watkins
10 Application of the Locking Compression Plate (LCP) 156

Dean W. Richardson
11 Bone Grafts and Bone Substitutes 163

Mark D. Markel
www.ajlobby.com
viii Contents
12 Biologic Agents to Enhance Fracture Healing 173

Mark D. Markel and Howard Seeherman
13 Casting and Transfixation Casting Techniques 188

Ashlee E. Watts and Lisa A. Fortier
Part II Specific Fractures 219
14 Fractures of the Distal Phalanx 221

Alan J. Nixon, Norm G. Ducharme, and Alicia L. Bertone
15 Fractures of the Navicular Bone 242

Michael C. Schramme and Roger K.W. Smith
16 Arthrodesis of the Distal Interphalangeal Joint 257

Chad J. Zubrod and Robert K. Schneider
17 Fractures of the Middle Phalanx 264

Jeffrey P. Watkins
18 Arthrodesis of the Proximal Interphalangeal Joint 277

Jeffrey P. Watkins
19 Fractures of the Proximal Phalanx 295

Dean W. Richardson
20 Fractures and Luxations of the Fetlock 320

C. Wayne McIlwraith
21 Fractures of the Proximal Sesamoid Bones 341

Ian M. Wright
22 Fractures of the Condyles of the Third Metacarpal and Metatarsal Bones 378

Ian M. Wright and Alan J. Nixon
23 Arthrodesis of the Metacarpo/Metatarsophalangeal Joint 425

Larry R. Bramlage
24 Fractures of the Third Metacarpal/Metatarsal Diaphysis and Metaphysis 436

Robert K. Schneider and Sarah N. Sampson
25 Third Metacarpal Dorsal Stress Fractures 452

Alan J. Nixon, Sue Stover, and David M. Nunamaker
26 Fractures of the Small Metacarpal and Metatarsal (Splint) Bones 465

Alan J. Nixon and Lisa A. Fortier
27 Fractures of the Carpus 480

C. Wayne McIlwraith
28 Arthrodesis of the Carpus 515

Larry R. Bramlage and Alan J. Ruggles
www.ajlobby.com
Contents ix
29 Fractures of the Radius 527

Joerg A. Auer
30 Fractures of the Ulna 545

Alan J. Nixon
31 Fractures of the Humerus 567

Alan J. Nixon and Jeffrey P. Watkins
32 Luxation of the Shoulder 588

Ashlee E. Watts and Alan J. Nixon
33 Fractures of the Scapula 603

Stephen B. Adams and Alan J. Nixon
34 Fractures and Luxations of the Hock 613

Alan J. Nixon
35 Fractures of the Tibia 648

Jeffrey P. Watkins and Sarah N. Sampson
36 Fractures of the Stifle 664

Alan J. Nixon
37 Fractures of the Femur 688

Alan J. Nixon, Larry R. Bramlage, and Steven R. Hance
38 Luxation and Subluxation of the Coxofemoral Joint 706

Alan J. Nixon and Norm G. Ducharme
39 Fractures of the Pelvis 723

Norm G. Ducharme and Alan J. Nixon
40 Fractures of the Vertebrae 734

Alan J. Nixon
41 Fractures of the Head 770

Anton E. Fuerst and Joerg A. Auer
42 Medical Aspects of Traumatic Brain Injury in Horses 800

Stephen M. Reed
Part III Postoperative Aspects of Fracture Repair 805
43 Systems for Recovery from Anesthesia 807

John B. Madison
44 Postanesthetic Myopathy 814

Manuel Martin‐Flores and Robin D. Gleed
45 Implant Removal 823

Alan J. Ruggles
www.ajlobby.com
x Contents
46 Orthopedic Implant Failure 831

David M. Nunamaker
47 Delayed Union, Nonunion, and Malunion 835

Norm G. Ducharme and Alan J. Nixon
48 Osteomyelitis 851
Laurie R. Goodrich
49 Stress‐induced Laminitis 874

Scott Morrison
50 New Implant Systems 885

Joerg A. Auer
Index 892
www.ajlobby.com
xi
Contributors
Stephen B. Adams, DVM, MS, Diplomate ACVS Cornell University

Professor of Surgery Ithaca, NY;
Department of Veterinary Clinical Sciences Chief Medical Officer
School of Veterinary Medicine Cornell Ruffian Equine Specialists
Purdue University Elmont, NY
Lynn Hall, West Lafayette, IN USA
USA Fractures of the Distal Phalanx; Luxation and
Fractures of the Scapula Subluxation of the Coxofemoral Joint; Fractures of the
Pelvis; Delayed Union, Nonunion, and Malunion
Joerg A. Auer, Dr Med Vet, Dr Med Vet HC,
Diplomate ACVS, ECVS Lisa A. Fortier, DVM, PhD, DACVS
Professor Emeritus, Veterinary Surgery James Law Professor of Surgery
Vetsuisse Faculty Department of Clinical Sciences
University of Zurich College of Veterinary Medicine
Zurich, Switzerland Cornell University
Surgical Equipment and Implants for Fracture Repair; Ithaca, NY
Principles of Fracture Fixation; Fractures of the Radius; USA
Fractures of the Head; New Implant Systems Casting and Transfixation Casting Techniques; Fractures
of the Small Metacarpal and Metatarsal (Splint) Bones
Alicia L. Bertone, DVM, PhD, Diplomate ACVS,
Diplomate ACVSMR Anton E. Fuerst, Dr Med Vet, Diplomate ECVS
Trueman Family Endowed Chair and Professor of Veterinary Surgery
Professor of Surgery Director of Equine Surgery Clinic
Vice Provost for Graduate Studies and Vetsuisse Faculty, University of Zurich
Dean of the Graduate School Zurich, Switzerland
Department of Veterinary Clinical Sciences Fractures of the Head
The Ohio State University
Columbus, OH Robin D. Gleed, BVSc, MRCVS, DVA, DACVA
USA Professor of Anesthesiology
Fractures of the Distal Phalanx Department of Clinical Sciences
College of Veterinary Medicine
Larry R. Bramlage, DVM, MS, Diplomate ACVS Cornell University
Rood and Riddle Equine Hospital Ithaca, NY
Lexington, KY, USA USA
First Aid and Transportation of Equine Fracture Patients; Postanesthetic Myopathy
Arthrodesis of the Metacarpo/Metatarsophalangeal
Joint; Arthrodesis of the Carpus; Fractures of the Femur Laurie R. Goodrich, DVM, MS, PhD
Professor of Surgery
Norm G. Ducharme, DVM, MSc, Diplomate ACVS College of Veterinary Medicine
James Law Professor of Surgery Colorado State University
Department of Clinical Sciences Fort Collins, CO, USA
College of Veterinary Medicine Osteomyelitis
www.ajlobby.com
xii Contributors
Steven R. Hance, LLC, DVM Alan J. Nixon, BVSc, MS, Diplomate ACVS
Equine Sales and Radiographic Consultant Professor of Orthopedic Surgery
Oklahoma City, OK Director of Comparative Orthopaedics Laboratory
USA Department of Clinical Sciences
Fractures of the Femur College of Veterinary Medicine
Cornell University
John B. Madison, VMD, Dip ACVS Ithaca, NY;
Ocala Equine Hospital Senior Orthopedic Surgeon
Ocala, FL Cornell Ruffian Equine Specialists
USA Elmont, NY
Systems for Recovery from Anesthesia USA
General Considerations in Selecting Cases for
Mark D. Markel, DVM, PhD Fracture Repair; Perioperative Considerations;
Dean, Comparative Orthopaedic Research Laboratory Principles of Fracture Fixation; Fractures of the
Department of Medical Sciences Distal Phalanx; Fractures of the Condyles of the
School of Veterinary Medicine Third Metacarpal and Metatarsal Bones; Third
University of Wisconsin‐Madison Metacarpal Dorsal Stress Fractures; Fractures of the
Madison, WI Small Metacarpal and Metatarsal (Splint) Bones;
USA Fractures of the Ulna; Fractures of the Humerus;
Bone Structure and the Response of Bone to Stress; Luxation of the Shoulder; Fractures of the Scapula;
Fracture Biomechanics; Fracture Healing; Bone Grafts Fractures and Luxations of the Hock; Fractures of
and Bone Substitutes; Biologic Agents to Enhance the Stifle; Fractures of the Femur; Luxation and
Fracture Healing Subluxation of the Coxofemoral Joint; Fractures of
the Pelvis; Fractures of the Vertebrae; Delayed Union,
Manuel Martin‐Flores, MV, DACVA Nonunion, and Malunion
Department of Clinical Sciences
College of Veterinary Medicine David M. Nunamaker, VMD, PhD, Diplomate ACVS
Cornell University Professor Emeritus
Ithaca, NY Department of Clinical Studies
USA School of Veterinary Medicine
Postanesthetic Myopathy University of Pennsylvania
New Bolton Center
C. Wayne McIlwraith, BVSc, PhD, Dr Med Vet (HC), Kennett Square, PA, USA
DSc (HC), FRCVS, Diplomate ACVS, Diplomate ACVSMR Third Metacarpal Dorsal Stress Fractures; Orthopedic
University Distinguished Professor Implant Failure
of Orthopaedics
Barbara Cox Anthony Endowed University Chair in Stephen M. Reed, DVM, Dip ACVIM
Orthopaedics Rood and Riddle Equine Hospital
Department of Clinical Sciences Lexington, KY, USA
College of Veterinary Medicine & Medical Aspects of Traumatic Brain Injury in Horses
Biomedical Sciences
Colorado State University Dean W. Richardson, DVM, Diplomate ACVS
Fort Collins, CO Charles W. Raker Professor of Equine Surgery
USA Department of Clinical Studies
Fractures and Luxations of the Fetlock; Fractures School of Veterinary Medicine
of the Carpus University of Pennsylvania
New Bolton Center
Scott Morrison, DVM Kennett Square, PA
Rood and Riddle Equine Hospital USA
Lexington, KY, USA Application of the Locking Compression Plate (LCP);
Stress‐induced Laminitis Fractures of the Proximal Phalanx
www.ajlobby.com
Contributors xiii
Alan J. Ruggles, DVM, Diplomate ACVS Sue Stover, DVM, PhD, Diplomate ACVS
Rood and Riddle Equine Hospital Professor, Department of Anatomy, Physiology &
Lexington, KY, USA Cell Biology
Arthrodesis of the Carpus; Implant Removal University of California
Davis, CA
Sarah N. Sampson, DVM, PhD, Diplomate ACVS, USA
Diplomate ACVSMR Third Metacarpal Dorsal Stress Fractures
Assistant Professor of Equine Sports Medicine and
Imaging Jeffrey P. Watkins, DVM, MS, Diplomate ACVS
Department of Large Animal Clinical Sciences Professor of Surgery
College of Veterinary Medicine & Biomedical Sciences Department of Large Animal Clinical Sciences
Texas A&M University College of Veterinary Medicine & Biomedical Sciences
College Station, TX Texas A&M University
USA College Station, TX
Fractures of the Third Metacarpal/Metatarsal Diaphysis USA
and Metaphysis; Fractures of the Tibia Principles of Fracture Fixation; Fractures of the
Middle Phalanx; Arthrodesis of the Proximal
Robert K. Schneider, DVM, MS, Diplomate ACVS Interphalangeal Joint; Fractures of the Humerus;
McKinlay Peters Equine Hospital Fractures of the Tibia
Newman Lake, WA
USA Ashlee E. Watts, DVM, Diplomate ACVS
Arthrodesis of the Distal Interphalangeal Joint; Fractures Associate Professor of Surgery
of the Third Metacarpal/Metatarsal Diaphysis and Department of Large Animal Clinical Sciences
Metaphysis College of Veterinary Medicine & Biomedical
Sciences
Michael C. Schramme, Dr Med Vet, Cert EO, PhD, HDR, Texas A&M University
Diplomate ECVS, Diplomate ACVS College Station, TX
Professeur de Chirurgie Equine USA
Chef de Clinique Casting and Transfixation Casting Techniques;
VetAgro Sup Shoulder Luxation
Clinéquine, Campus Veterinaire de Lyon
Marcy l’Étoile Ian M. Wright, MA VetMB, DEO, Diplomate ECVS, FRCVS
France Senior Surgeon
Fractures of the Navicular Bone Director of Clinical Sciences
Newmarket Equine Hospital
Howard Seeherman, PhD, VMD Newmarket, UK
Musculoskeletal Therapies Racetrack Fracture Management and Emergency
Wyeth Discovery Research Care; Fractures of the Proximal Sesamoid Bones;
Wyeth Pharmaceuticals Fractures of the Condyles of the Third Metacarpal
Cambridge, MA, USA and Metatarsal Bones
Biologic Agents to Enhance Fracture Healing
Chad J. Zubrod, DVM, MS, Diplomate ACVS
Roger K.W. Smith, MA, VetMB, PhD, DEO, FHEA, ECVDI LA Oakridge Equine Hospital
Assoc., Diplomate ECVS, FRCVS Edmond, OK
European and RCVS Specialist in Equine Surgery USA
(Orthopaedics) Arthrodesis of the Distal Interphalangeal Joint
Professor of Equine Orthopaedics
Department of Clinical Sciences and Services
The Royal Veterinary College
London, UK
Fractures of the Navicular Bone
www.ajlobby.com
xiv
Preface to the Second Edition
It has been many years since the first edition of this text comprehensive updated information on fractures of
was published, and it has long been out of print. During s pecific bones, including new chapters describing repair
this period, changing focus at Elsevier has driven a of fractures of the navicular bone, stifle, pelvis, and skull.
change in publisher to Wiley. While I would like to thank Additionally, novel arthrodesis techniques, including for
Ray Kersey and Saunders/Elsevier for their previous the distal interphalangeal, carpal, and shoulder joints,
interest in this text, it is a pleasure to see Ray now with are added. The final part deals with the postoperative
Wiley, and to deal with the professional commissioning aspects of fracture repair, and provides extensive infor-
and production staff at Wiley Blackwell. mation on anesthesia and anesthetic recovery, implant
Much has happened in the field of equine fracture failure and removal, and complications such as nonun-
repair in this interval. The second edition is almost dou- ion, osteomyelitis, and support limb laminitis. The final
ble the size of the first. Numerous new implant systems, chapter introduces implant systems with real potential to
concepts, approaches to the bones, and enhanced after- make their way into equine fracture repair over the next
care and treatment of complications have improved the few years.
outcome following fracture repair in the horse. Many of The presentation of new techniques in fracture repair
the authors contributing to the first edition have kindly has been enhanced by the excellent artwork of Michael
enhanced and updated their chapters with the wealth of Simmons, who also contributed numerous drawings to
experience gained over another 25 years. Asking senior the first edition. These illustrations provide a valuable
surgeons to update chapters for a textbook was made teaching resource for both trainees and experienced
easier by the profound interest and dedication of these surgeons. I am also pleased to acknowledge the exten-
individuals to seeing a new edition of Equine Fracture sive assistance of the surgery and imaging technicians
Repair become available. My profound gratitude is owed in the preparation of the materials in many chapters of
to these authors for updating previous chapters and this book. In the period between the first and second
providing unpublished case examples and statistics, and editions, digital radiography has been introduced,
additionally to the new authors who have brought their which has meant that many of the examples are now
own unique experiences to the second edition. The represented by pre‐ and postoperative digital radio-
guiding principle for all chapters has been to request a graphs, and three‐dimensional imaging, of exquisite
contribution from those recognized as an outstanding detail. Numerous examples of fractures and their
authority in that area. variations are included to provide a comprehensive
In this edition, we have retained the concept of illustration of fracture types and repair choices. The
introductory chapters in Part I, dealing with fracture patience of the Wiley team as we extensively updated
concepts, surgical systems, emergency splinting, and and expanded this book into its second edition is much
enhancements to fracture healing. Part II then provides appreciated.
www.ajlobby.com
xv
Preface to the First Edition
Equine orthopedic surgery has evolved enormously detailed coverage in these chapters. The results provide a
during the last 20 years. New procedures and implants, current text dedicated specifically to equine orthopedics.
and in many instances a desire to treat serious orthopedic Such considerable published information is now available
injuries, have advanced the state of equine orthopedics in that the general‐purpose textbook, covering all aspects of
many domains. Increasing application of the AO/ASIF equine medicine and surgery, would be enormous. This
implant systems and development or new implants spe- book narrows the scope in an attempt to improve the
cific to the horse have improved the success rate associ- quality and depth of information.
ated with equine fracture repair. Much new information Many chapters are accompanied by medical illustra-
has developed, and the purpose of this book is primarily tions and radiographs to assist in the preparation and
to provide an informative and authoritative text on equine surgical procedures. I am particularly grateful to Ms.
fractures and the current state of the art in fracture repair. Conery Calhoon and Mr. Tom McCracken for the
The authors bring to this book considerable experience, extensive artwork provided in the specific procedures
and their individual efforts have been enormous. As a chapters. Their work enhances our understanding of
result, the book should provide valuable information to these techniques and brings clarity to many complex
equine practitioners and specialists, as well as an in‐depth procedures. Additionally, many photographs have been
coverage of fracture repair for students and veterinarians prepared by the staff in the Biomedical Communications
in surgical training programs. The book provides exten- Lab at Cornell, and their work is most appreciated. The
sive treatment, splinting, casting, surgical and follow‐up revision and typing of manuscripts was expertly per-
details on specific fractures, and, finally, on the complica- formed by Ms. Debbie Lent, whose assistance is greatly
tions and future developments in fracture repair in the appreciated.
horse. In all sections on specific fractures, the book brings My editor at W.B. Saunders, Mr. Raymond Kersey, has
the personal experience of recognized leaders in the field. always been encouraging, and the W.B. Saunders edito-
I am particularly indebted to these people, who took the rial and production staff deserve special mention for
time from already overburdened scheduled to provide keeping the book on schedule.
www.ajlobby.com
xvi
Acknowledgments
A specialized text such as this is considerably enhanced in private practice and university clinics who offered
by case examples from numerous referring veterinarians v aluable assistance and sage advice with many cases.
and consulting surgeons, and I appreciate the permission My thanks to the enormous task of typing and adminis-
to reproduce images throughout the text, and for case trative assistance provided by Amy Ingham, Lyn Park,
follow‐up in specific examples. I particularly appreciate Sue Branch, and Billy Chorley, and the extensive permis-
the numerous cases provided by Drs. David Bogenrief, sions work also undertaken by Billy Chorley. This text
Ryland Edwards, David Murphy, Dean Richardson, would not have been possible without the patience and
Paddy Todhunter, and Ashlee Watts. I would also like to expertise of the Executive Commissioning editor at

thank the Cornell University surgical operating room Wiley Blackwell, Erica Judisch. The Wiley team has been
staff and imaging technicians, at both the Ithaca campus outstanding, including the expert editing of the manu-
and the Cornell Ruffian Equine Specialists practice in script by Sally Osborn, quality assessment by Purvi Patel,
New York City. Additionally, I would like to extend my production and layout by Jerusha Govindakrishnan, and
sincere gratitude to the many surgical interns and resi- cover work and back matter developed under the super-
dents who provided diligent assistance in surgery and vision of Susan Engelken. My thanks to such a skilled and
postoperative care, and to numerous surgical colleagues professional team.
www.ajlobby.com
1
Part I
Introduction
www.ajlobby.com
3
1
Bone Structure and the Response
of Bone to Stress
Mark D. Markel
Comparative Orthopaedic Research Laboratory, Department of Medical Sciences, School of Veterinary Medicine,
University of Wisconsin‐Madison, Madison, WI, USA
Introduction tions, called trabeculae, enclosing the cavities within the

bone that contain either hematopoietic or fatty marrow.
The skeleton serves many essential purposes in the body, Cancellous bone is found in most of the axial skeleton
including the protection of internal organs, the provision and in the ends of the long bones. Bones of the appen-
of rigid kinematic links to allow for locomotion, and the dicular skeleton are generally long and cylindrical, with
storage of calcium and phosphorous, acting as a dynamic relatively narrow mid‐portions. The length of equine
mineral reserve bank.20,26,30 Bone, the principal compo- bones increases the moment arm of each muscle as it
nent of the skeleton, is living connective tissue made acts on the limb, enhancing a horse’s speed and power.
rigid by the orderly deposition of minerals on an organic The expanded ends of long bones diminish the stresses
matrix.1 Bone has many unique structural characteristics that act on the articular surfaces by distributing loads
which allow it to fulfill these functions. It is one of the over a larger cross‐sectional area.
hardest substances in the body, following only dentin An immature long bone is divided into four distinct
and enamel of teeth. Its intricate structural organization, regions (Figure 1.1). The central region of bone is called
combined with its high metabolic activity, allows bone to the diaphysis, with the physis, epiphysis, and metaphysis
respond rapidly to both physical and biochemical at either end. The physis, present in one or both ends of
demands. Additionally, bone is highly vascular with an the bone, separates the epiphysis and metaphysis, and is
excellent capacity for self‐repair. The surfaces of bone responsible for the majority of long bone growth in young
are covered with osteoblasts and osteoclasts, which are animals through a process called endochondral ossifica-
responsible for constant bone turnover through simulta- tion. As an animal matures, the physis ceases growth and
neous bone formation and bone resorption.3 Osteocytes, closes, at which stage the entire expanded end of the bone
the third major cellular component of bone, reside within is represented by the metaphysis, which is composed of
bone tissue and communicate with adjacent osteocytes trabecular (cancellous or spongy) bone surrounded by
and osteoblasts through channels called canaliculi. All cortical and dense subchondral bone. The diaphysis is a
three cell types help bone respond quickly to mechanical hollow tube of cortical bone with a central cavity that con-
and metabolic demands. tains the major arterial and venous blood supply to the
This chapter will describe the structure and function bone and fatty marrow. Most of the hematopoiesis in the
of bone and its response to stress, focusing on the cellu- body occurs in the metaphyseal cancellous bone and in
lar and mechanical characteristics of bone structure. the bones of the axial skeleton, although the fatty marrow
of the diaphysis does contain hematopoietic elements.
Bones of the appendicular skeleton are covered by
Bone Structure periosteum, except in regions covered by articular cartilage
or where ligaments, tendons, or joint capsules attach.1,3
On the microscopic level, two types of bone are found in The periosteum has two layers: an outer, fibrous layer
the mature skeleton. Hard, compact cortical bone occurs permeated by blood vessels and nerves which act in a
in the shafts of the long bones. Cancellous, or trabecular, supportive capacity, and an inner, osteogenic layer which
bone is composed of a network of fine, interlacing parti- provides the osteoprogenitor cells necessary for fracture
Equine Fracture Repair, Second Edition. Edited by Alan J. Nixon.

© 2020 John Wiley & Sons, Inc. Published 2020 by John Wiley & Sons, Inc.
www.ajlobby.com
4 Part I Introduction
Epiphysis
Physis
Metaphysis
Diaphysis
Medullary cavity Figure 1.2 Light microscopic image of a 5 μm undecalcified

section of bone showing osteoblasts (arrows) laying down osteoid
on bone surface (Goldner Stain, magnification ×80).
Periosteum Ultrastructurally, osteoblasts contain abundant endo-

plasmic reticulum, ribosomes, Golgi apparatus, and
mitochondria. These cellular components are responsi-
ble for the osteoblasts’ high metabolic activity and
productivity. Osteoblasts produce the majority of the
organic components of bone, including collagen, proteo-
glycans, and other noncollagenous proteins.
Articular cartilage
Osteocytes
Approximately 10% of the osteoblastic population become
Figure 1.1 Immature equine tibia showing the different regions enclosed in matrix and are then referred to as osteocytes
of a long bone. (Figure 1.3).17 Compared with osteoblasts, osteocytes
have less endoplasmic reticulum and fewer cytoplasmic
organelles. Osteocytes have numerous cytoplasmic pro-
healing and is responsible for appositional growth prior cesses that extend into the surrounding matrix and fill the
to skeletal maturity. During growth, the osteogenic layer canaliculi of bone (Figure 1.3). These processes contact
of the periosteum is thick, highly vascular, and adhered the processes of other osteocytes and osteoblasts to form
to the bone. With maturity, the osteogenic layer thins an intricate transport and communication system within
and becomes only loosely adhered to the bone. the bone. This interconnection of deeply embedded oste-
The microstructure of bone can be divided into three ocytes and surface‐lining osteoblasts regulates the flow of
principal components which are intimately associated mineral ions from the extracellular space surrounding the
with one another to allow for rapid response to the osteoblasts to the osteocytes, from the osteocytes to the
mechanical and homeostatic requirements of the body. extracellular fluid surrounding them, and finally from this
These components include the cells, the organic extracel- fluid to the mineral surrounding the osteocytes. This
lular matrix, and the inorganic portion of bone. organizational structure allows the large surface area of
the osteocyte population to regulate the exchange of
mineral ion between the extracellular fluid and the bone
Cellular Components by means of the canalicular system.
Osteoblasts
Osteoblasts, which develop from fibroblastic osteo- Osteoclasts
progenitor or mesenchymal cells, cover the majority of The cell type responsible for the majority of bone
bone surfaces and are responsible for the formation of resorption is the osteoclast.17 Osteoclasts are large,
the organic matrix, called osteoid (Figure 1.2).3,17,27,39 multinucleated cells on or near bone surfaces that
Osteoblasts deposit osteoid on bone surfaces, enveloping reside within concavities called Howship’s lacunae,
themselves in osteoid seams. which are the active sites of bone resorption (Figure 1.4).
www.ajlobby.com
Figure 1.3 Brightfield (left) and grayscale

composite of Z‐stacked confocal
photomicrographs (right) of osteocytes
surrounding an osteon Haversian canal
(large arrow) in the third metacarpal
bone in a racing Thoroughbred. A dense
syncytial network of vital osteocytes and
their canaliculi are demonstrated
(small arrows) connecting adjacent
lacunae before ultimately reaching the
Haversian canal. Scale bar = 50 μm.
Source: Courtesy Peter Muir, University
of Wisconsin‐Madison.
and concentrating the lysosomal enzymes and hydrogen

ions produced by the osteoclast at the site of resorption.
Osteoclasts produce acid phosphatase and collagenase
to first dissolve mineral and then remove the organic
matrix to a depth of 1–2 μm. Hydroxyapatite crystals and
collagen fibers can be observed in the extracellular space
between the cytoplasmic folds of the ruffled border.
After being degraded, these components are taken up
via endocytosis, transported across the cell, and then
extruded into the extracellular space.
Organic Matrix
Figure 1.4 Light microscopic image of a 5 μm undecalcified Collagen
section of bone showing an osteoclast (arrow) residing within a The organic matrix of bone acts as a supporting structure
Howship’s lacuna where bone is resorbed (Goldner Stain, for the deposition and crystallization of inorganic salts.
magnification ×80). Organic matrix is 21% of the bone by weight, with the
remainder of the bone made up of inorganic material (71%)
Osteoclasts originate from blood monocytes, which and water (8%). Approximately 95% of the organic matrix
circulate in the vascular system before arriving in bone. is collagen, with type I collagen the predominant collagen
The size and number of nuclei in osteoclasts vary, but in bone. Collagen is the most abundant protein in mam-
each nucleus usually is associated with a perinuclear mals, accounting for 20–50% of the dry weight of adult
Golgi apparatus, in which Golgi vesicles exist in various long bones, approximately 70% of the dry weight of skin,
stages of development. Osteoclasts contain little endo- and approximately 90% of the dry weight of tendon.3,17,34
plasmic reticulum and few ribosomes, but they do have Collagen’s unique ultrastructure makes it exceedingly
abundant mitochondria, Golgi apparatus, and Golgi strong in tension. Collagen is composed of three tightly
vesicles. The contact area between osteoclasts and folded polypeptide chains, called alpha chains, each con-
bone consists of two regions, the ruffled border and the sisting of approximately 1000 amino acids. The basic
sealing zone. The ruffled border is composed of finger‐like unit of collagen is tropocollagen, composed of three pro-
membranous folds that extend varying distances into collagen polypeptide alpha chains, each coiled in a left‐
the cytoplasm and are responsible for bone resorption. handed helix, and the alpha chains are then further
The sealing zone is characterized by a dense, homogenous coiled around each other into a right‐handed triple helix
cytoplasmic membrane that lies in close apposition to (Figure 1.5). Tropocollagen molecules, which are approx-
the bone and isolates the ruffled border, preventing leakage imately 1.4 nm in diameter and 300 nm long, polymerize
www.ajlobby.com
proteoglycans and their constituent glycosaminoglycans.

Proteoglycans are high molecular weight molecules, with
acidic glycosaminoglycan side chains that provide flexi-
Alpha chain bility and resilience to the connective tissue matrix.4
Proteoglycans are made up of a central protein core
to which acidic glycosaminoglycan side chains are
covalently attached. The individual glycosaminoglycans
are large anionic molecules of repeating basic and acidic
disaccharides. In bone, proteoglycans do not form the
1.4 nm
large aggregates that predominate in other tissues

Triple helix such as cartilage. Glycosaminoglycans also serve as the
cementing substance between layers of mineralized
collagen fibers in lamellar bone.
Inorganic Component
300 nm The mineral portion of bone consists primarily of cal-
Tropocollagen molecules cium and phosphate, mainly in the form of small crystals
that resemble synthetic hydroxyapatite crystals and have
the composition Ca10(PO4)6(OH)2.3,13 Bone mineral
crystals are extremely small, ~25–75 Å in diameter and
200 Å in length, in contrast to geological apatite crystals
which are much larger.29 Because of their small size, the
microscopic crystals found in bone mineral are more
soluble than geological apatites. They also contain more
Collagen fibril
impurities than pure hydroxyapatite crystals. In addition
Figure 1.5 Molecular features of collagen structure from the alpha to calcium and phosphorous, bone mineral contains car-
chain to the fibril. The flexible amino acid sequence in the alpha bonate, magnesium, fluoride, and citrate in variable
chain allows these chains to wind tightly into a right‐handed triple amounts. This structure of bone (hydroxyapatite in inti-
helix, forming the tropocollagen molecule. This tight triple helical
mate apposition to the organic matrix) is responsible for
arrangement contributes to the high tensile strength of the collagen
fibril. The parallel alignment of the individual tropocollagen its mechanical strength.
molecules, in which each molecule overlaps the other by about
one‐quarter of its length, results in a repeating banded pattern of Osteon
the collagen fibril. Source: Adapted from Nordin and Frankel 1989.30 At the microstructural level, the fundamental unit of bone
Reproduced with permission of John Wiley and Sons.
is the osteon or Haversian system (Figure 1.6). At the center
of each osteon is a small channel, called a Haversian canal,
into larger collagen fibrils. Covalent cross‐links form that contains blood vessels, nerve fibers, and lymphatic‐
between the tropocollagen molecules, adding to the type channels. Surrounding the central canal is a concentric
fibrils’ high tensile strength. Individual fibrils are aligned series of layers, or lamellae, of mineralized bone (Figure 1.6).
in a quarter‐staggered array with fibril lengths of 640 Å. Along the boundaries of each lamella are small spaces
The fibrils are separated by 400 Å gaps called hole zones. known as lacunae, each of which contains individual osteo-
The hole zones are thought to serve as the initial miner- cytes. Canaliculi radiate from these lacunae and connect
alization site within collagen. with adjacent lamellae before ultimately reaching a
Individual alpha chains of type I collagen consist of Haversian canal (Figure 1.3). Cell processes extend from the
repeating tripeptides, composed of the amino acid sequence osteocytes into the canaliculi, allowing nutrients from the
glycine‐x‐y, where x and y can be proline, hydroxyproline, blood vessels in the Haversian canal to reach the osteocyte.
or hydroxylysine.4 Glycine accounts for one‐third of all At the periphery of each osteon is a cement line, a nar-
the constituent amino acids in type I collagen, because it is row area of cement‐like ground substance composed
the only amino acid small enough to fit in the center of the primarily of glycosaminoglycans. The canaliculi of the
collagen triple helix. Type I collagen consists of two identi- osteon do not cross this cement line. Like the canaliculi,
cal alpha chains and one alpha chain of a different amino the collagen fibers in the bone matrix interconnect from
acid composition, [α1(I)]2α2(I). one lamella to another within an osteon, but do not cross
the cement line. This intertwining of collagen fibers
Proteoglycans and Glycosaminoglycans within the osteon increases the bone’s resistance to
The remaining 5% of organic matrix is ground substance. mechanical stress and probably explains why the cement
The predominant constituents of ground substance are line is the weakest portion of the bone’s microstructure.
www.ajlobby.com
Figure 1.6 Microstructural arrangement of a Lacuna

long bone depicted without the marrow Osteocyte
cavity. Secondary osteons are apparent as
the structural units of cortical bone. In the Canaliculi
center of the osteons are the Haversian
canals, which form the main branches of the Circumferential
circulatory network. Each osteon is bounded lamellae
by a cement line and consists of lamellae,
formed by concentric rings of mineral matrix Haversian
Interstitial
surrounding the Haversian canal. Along the canal
lamellae
boundaries of the lamellae are small cavities
known as lacunae, each of which contains a
single bone cell, or osteocyte. Radiating from
the lacunae are tiny canals, or canaliculi, into
which the cytoplasmic processes of the Endosteum
osteocytes extend. Source: Adapted from
Nordin and Frankel 1989.30 Reproduced with
permission of John Wiley and Sons.
Trabeculae
Lamellae
Haversian systems
Haversian Cement line

canals
Periosteum (split)
Blood vessel
Branches of
periosteal
Volkmann’s blood vessels
canals
A typical osteon is 200 μm in diameter, so no portion of progressively diminishing the caliber of each vascular
an osteon is more than 100 μm from the centrally located space. The resulting anastomosing, convoluted areas of
blood supply. In the appendicular skeleton, the osteons bone, occupying what were previously vascular spaces, are
run longitudinally, but they branch frequently and anasto- called primary Haversian systems, or primary osteons.8,9,40
mose extensively with each other. Primary osteons usually turn parallel to the long axis of
Interstitial lamellae span the regions between complete the bone, may contain one to several vascular canals, and
osteons and are continuous with the osteons. As in oste- are always surrounded by woven bone.9,15
ons, no point in the interstitial lamellae is farther than Secondary osteons form during the continuous pro-
100 μm from its blood supply. The interfaces between cess of remodeling that occurs throughout life.6,9,14,33,34
these lamellae contain numerous osteocytes lying within This process is initiated by the osteoclastic resorption of
lacunae, which interconnect with each other through the bone via a structure called a cutting cone, and results in
canalicular system. anastomosing tubular cavities that are oriented longitu-
There are two distinct types of osteons present in dinally (Figure 1.7). Osteoblasts on the inner surface of
lamellar bone, primary and secondary. Primary osteons the cutting cone then deposit successive layers of lamel-
form during appositional bone growth, when the bone is lae with an orderly fiber orientation. The caliber of each
increasing in diameter.9,40 Osteoblasts on the surface of cavity is thereby gradually reduced until only a single
the bone deposit successive lamellae of new bone, small vascular canal remains. The newly formed cylinders
www.ajlobby.com
Lamellar bone, which is composed of osteons, is not

the only type of bone within the body.2,9,40 The other
type, called woven bone, is the first bone to appear in
embryonic development and in the repair of fractures.
Woven bone is gradually replaced by lamellar bone and
serves only as a temporary structure, except in special
locations such as the dental alveolus and osseous laby-
rinths. Woven bone is characterized by coarse fiber
bundles, approximately 30 μm in diameter, running in
a random or interlacing fashion. In contrast, lamellar
bone consists of fine fiber bundles, 2–4 μm in diameter,
that are arranged irregularly in parallel or concentric
curving sheets.
On a macroscopic level, two types of bone are found in
Figure 1.7 Light microscopic image of a 100 μm undecalcified the mature skeleton: hard, compact cortical bone in the
section of a bone‐cutting cone with osteoclasts resorbing bone at shafts of the long bones, and cancellous or trabecular
the apex of the cone (arrows) (Goldner Stain, magnification ×80). bone which is composed of a network of fine, interlacing
partitions, called trabeculae, enclosing the cavities
within bone that contain either hematopoietic or fatty
marrow. Cancellous bone is found in the majority of the
axial skeleton and in the ends of the long bones.
Response of Bone to Stress

Normal daily activity imposes a complex pattern of
forces on the skeletal system that cause small deforma-
tions of the bone.9 The direction and magnitude of these
deformations are dependent on the geometry of the
bone, the direction and magnitude of the loads imposed
on the bone, and the material properties of the bone
tissue. The mechanical response of a bone to stress can
be described by quantitatively assessing the relationships
between various directional loads and their resultant
deformations. These relationships reflect the structural
behavior of the entire bone.
The imposition of forces on a bone also creates a
complex pattern of internal forces and deformations
throughout the bone structure. Local deformations
within the bone are referred to as strains, and the local
force intensities at these sites are the stresses, defined as
a given force per unit area. The relationship between
stress and strain at a particular point in the bone is
Figure 1.8 Backscatter electron microscopic image of a 100 μm governed by the material properties of the local bone
undecalcified section of bone showing secondary osteons within tissue. If the whole bone is loaded with very high forces,
cortical bone. Newly remodeled bone is darker, indicating less the stresses and strains in one region may exceed the
mineralization of the site (backscatter electron microscopy,
magnification ×70). ultimate stresses or strains that the tissue can tolerate,
and a fracture develops.
of bone are called secondary Haversian systems, or
secondary osteons. Secondary osteons consist of con-
centric sheets of lamellar bone. Unlike primary osteons,
Osteonal Remodeling
secondary osteons are always bounded by cement lines, In adult equine long bones, large areas of primary oste-
which are formed where osteoclastic activity ceases and onal bone are often present in the cortex. This primary
osteoblastic bone formation resumes (Figure 1.8). bone is lamellar in nature (although not truly lamellar),
www.ajlobby.com
consisting of layers of woven bone which are separated microcrack development within the bone, with the
by layers of primary osteons. Studies of the r elationship potential to cause catastrophic fracture of the bone.5,18
between the structure and the mechanical properties Several research studies have reported the impact of
of bone have emphasized the comparison between evaluated training regimens on bone modeling and frac-
primary and secondary osteonal (Haversian) bone.
ture. Short bursts of high‐speed gallop during training
Many investigators have suggested that primary oste- reduced the risk of fracture during subsequent racing.32
onal bone is stronger than secondary osteonal Nunamaker and colleagues5 proposed exercise regimens
bone.8,9,12,16 Hert et al.22 showed that fully mineralized for young Thoroughbreds in training, based on experi-
primary bone was as strong or stronger than secondary mental data where short‐distance, high‐speed gallops
osteonal bone. Reilly and Burstein37 demonstrated that rather than longer, slower gallops led to improved bone
bovine primary osteonal bone was significantly stiffer strength and minimized fatigue fracture and the risk of
than secondary bone. Their finding was supported by catastrophic failure.
Carter and Spengler,9 who showed that primary bovine Track surface can also significantly affect the a daptive
bone was more fatigue resistant and was stronger in response of bone. Young et al.,44 in a study evaluating the
tensile tests than secondary bone. Carter et al.8 effects of training regimens and track surfaces on bone
demonstrated that osteonal or Haversian remodeling remodeling, found that the cancellous bone component
of bovine primary osteonal bone reduces the tensile of the equine proximal sesamoid bone of horses trained
strength and fatigue resistance of bone by decreasing on dirt tracks had significantly lower porosity than that
bone density and creating an inherently weaker of untrained horses, enabling the bone to withstand the
structure. higher loads of racing.7,11,28,44 Track surface had a greater
Many investigators have demonstrated that equine effect on the cancellous morphology of the proximal ses-
bone remodels in response to the stresses that are placed amoid bone than a variety of training regimens.33,44
on it. The nature of these stresses is important, especially Young and coworkers45 also demonstrated that equine
given that not all mechanical stimuli result in the same carpal bone remodels in response to the stresses placed
effect. Bone adaptation is induced by dynamic strains on it. This phenomenon, in which bone gains or loses
rather than by static loading.25,41 In addition, the increase cancellous or cortical bone or both in response to the
in cross‐sectional area of bone induced by an osteogenic level of stress sustained, is summarized as Wolff ’s law,
response was found to be highly correlated to the rate of which states that bone is laid down where it is needed
bone deformation. These results suggest that training and resorbed where it is not needed.10,12,24,31,36,38,43 Both
requires a high loading rate to elicit a maximal osteo- theoretical and experimental evidence supports the pre-
genic response. vailing hypothesis that trabeculae within bone align with
The rate at which musculoskeletal tissues adapt varies the maximum and minimum principal stresses placed on
with tissue, age, and exercise regime.41 Age is a potent the bone.7,19,23,36,42,44 Structural anisotropy is expected to
factor in determining the extent of adaptation. The be greatest in regions of primary tension or compression,
immature skeleton is much more responsive than the in contrast to porosity and trabecular width, which cor-
adult skeleton, although this varies among species. relate best with shear stress.21 The osteogenic response
Animals that show limited morphologic change with of bone to remodeling stimuli has been shown to be most
aging, such as rodents, likely exhibit less reduction in the dependent on strain magnitude and strain rate.24,38,44
responsiveness of the skeleton with age, compared to the Significant decreases in porosity have been demon-
more typical aging phenotypes such as the human and strated after controlled, impulsive loading of joints in
the horse. In bone, adaptation can be initiated through rabbits and after exercising of sheep on concrete.35,36 The
brief cyclic‐loading periods given on a number of days nature of the remodeling stimulus in these studies is
per week. This type of exercise, if prolonged or intro- believed to be associated with the high loading rate and
duced too rapidly, may also lead to fatigue damage and the peak magnitude of the applied loads.36
References
1 Arnoczky, S.P. and Wilson, J.W. (1990). The connective 3 Boskey, A.L. (1981). Current concepts of the physiology and
tissues. In: Canine Orthopedics (ed. W.G. Whittick), biochemistry of calcification. Clin. Orthop. 167: 225–257.
21–41. Philadelphia: Lea & Febiger. 4 Boskey, A.L. (1985). Connective tissues of the
2 Ascenzi, A., Bonucci, E., and Bocciarelli, D.S. (1965). An musculoskeletal system. In: Textbook of Small Animal
electron microscope study of osteon calcification. J. Surgery (ed. D.H. Slatter), 1926–1939. Philadelphia:
Ultrastruct. Res. 12: 287–303. WB Saunders.
www.ajlobby.com
5 Boston, R.C. and Nunamaker, D.M. (2000). Gait and 21 Hayes, W.C. and Snyder, B. (1981). Toward a
speed as exercise components of risk factors associated quantitative formulation of Wolff ’s law in trabecular
with onset of fatigue injury of the third metacarpal bone. In: Mechanical Properties of Bone. AMD, vol. 45
bone in 2‐year‐old Thoroughbred racehorses. Am. J. (ed. S.C. Cowin), 43–68. New York: American Society
Vet. Res. 61: 602–608. of Mechanical Engineers.
6 Boyde, A. and Hobdell, M.H. (1969). Scanning electron 22 Hert, J., Kucera, P., Vavra, M., and Volenik, V. (1965).
microscopy of primary membrane bone. Z. Zellforsch. Comparison of the mechanical properties of both
99: 98–108. primary and Haversian bone tissue. Acta Anat. 61:
7 Carter, D.R. and Hayes, W.C. (1977). The compressive 412–423.
behavior of bone as a two‐phase porous structure. 23 Lanyon, L.E. (1974). Experimental support for the
J. Bone Joint Surg. Am. 59: 954–962. trajectory theory of bone structure. J. Bone Joint Surg.
8 Carter, D.R., Hayes, W.C., and Schurman, D.J. (1976). Br. 56: 160–166.
Fatigue life of compact bone II. Effects of 24 Lanyon, L.E. (1982). Mechanical function and
microstructure and density. J. Biomech. 9: 211–218. bone remodeling. In: Bone in Clinical Orthopedics
9 Carter, D.R. and Spengler, D.M. (1978). Mechanical (ed. G. Sumner‐Smith), 273–304. Philadelphia:
properties and composition of cortical bone. Clin. WB Saunders Co.
Orthop. 135: 192–217. 25 Lanyon, L.E. and Rubin, C.T. (1984). Static vs dynamic
10 Chamay, A. and Tschantz, P. (1972). Mechanical loads as an influence on bone remodeling. J. Biomech.
influences in bone remodeling. Experimental research 17 (12): 897–905.
on Wolff ’s law. J. Biomech. 5: 173–180. 26 Markel, M.D. (2006). Bone biology and fracture healing.
11 Cowin, S.C. (1983). The mechanical and stress In: Equine Surgery, 3e (ed. J.A. Auer and J.A. Stick),
adaptive properties of bone. Ann. Biomed. Eng. 991–1000. St. Louis: Saunders Elsevier.
11: 263–295. 27 Marks, S.C. (1983). The origin of osteoclasts:
12 Dempster, W.T. and Coleman, R.F. (1960). Tensile evidence, clinical implications and investigative
strength of bone along and across the grain. J. Appl. challenges of an extra‐skeletal source. J. Oral Pathol. 12:
Physiol. 16: 355. 226–256.
13 Eanes, E.D. and Posner, A.S. (1970). Structure and 28 Martin, R.B. (1982). Porosity and specific surface of
chemistry of bone mineral. In: Biological Calcification bone. CRC Crit. Rev. Biomed. Eng. 10: 179–222.
(ed. H. Schraer), 1–26. Amsterdam: North Holland. 29 Menczel, L.J., Posner, A.S., and Harper, R.A. (1965).
14 Enlow, D.H. (1962). The functional significance of the Age changes in the crystallinity of rat bone apatite.
secondary osteon. Anat. Rec. 142: 230. Isr. J. Med. Sci. 1: 251–252.
15 Enlow, D.H. (1966). An evaluation of the use of bone 30 Nordin, M. and Frankel, V.H. (1989). Biomechanics of
histology in forensic medicine and anthropology. In: bone. In: Basic Biomechanics of the Musculoskeletal
Studies on the Anatomy and Function of Bone and Joints System, 2e (ed. M. Nordin and V.H. Frankel), 3–29.
(ed. F.G. Evans), 93–113. New York: Springer‐Verlag. Philadelphia: Lea & Febiger.
16 Evans, F.J. and Bang, S. (1967). Differences and relations 31 Nunamaker, D.M., Butterweck, D.M., and Provost, M.T.
between the physical properties and the microscopic (1989). Some geometric properties of the third
structure of human femoral, tibial, and fibular cortical metacarpal bone: a comparison between the
bone. Am. J. Anat. 120: 79. Thoroughbred and Standardbred racehorse. J. Biomech.
17 Fetter, A.W. (1985). Structure and function of bone. 22: 129–134.
In: Textbook of Small Animal Orthopaedics (ed. C.D. 32 Parkin, T.D., Clegg, P.D., French, N.P. et al. (2005).
Newton and D.M. Nunamaker), 9–12. Philadelphia: Risk factors for fatal lateral condylar fracture of the
JB Lippincott. third metacarpus/metatarsus in UK racing.
18 Firth, E.C., Goodship, A.E., Delahunt, J. et al. (1999). Equine Vet. J. 37: 192–199.
Osteoinductive response in the dorsal aspect of the 33 Pratt, G.W. (1982). The response of highly stressed
carpus of young Thoroughbreds in training occurs bone in the race horse. In: Proceedings of the American
within months. Equine Vet. J. Suppl. 30: 552–554. Association of Equine Practitioners, vol. 27, 31–37.
19 Fyhrie, D.P. and Carter, D.R. (1986). A unifying Lexington, KY: AAEP.
principle relating stress to trabecular bone morphology. 34 Pritchard, J.J. (1972). General morphology of bone.
J. Orthop. Res. 4: 304–317. In: The Biochemistry and Physiology of Bone, vol. 1
20 Hayes, W.C. and Carter, D.R. (1979). Biomechanics of (ed. G.H. Bourne), 1–20. New York: Academic Press.
bone. In: Skeletal Research: An Experimental Approach 35 Radin, E.L., Martin, R.B., Barr, D.B. et al. (1984). Effects
(ed. D.J. Simmons and A.S. Kunin), 263–300. New of mechanical loading on the tissues of the rabbit knee.
York: Academic Press. J. Orthop. Res. 2: 221–234.
www.ajlobby.com
36 Radin, E.L., Orr, R.B., Kelman, J.L. et al. (1982). Effect 42 Townsend, P.R., Miegel, R.E., Rose, R.M. et al. (1976).
of prolonged walking on concrete on the knees of Structure and function of the human patella: the role of
sheep. J. Biomech. 15: 487–492. cancellous bone. J. Biomed. Mater. Res. Symp. 7:
37 Reilly, D.T. and Burstein, A.H. (1974). The mechanical 605–611.
properties of cortical bone. J. Bone Joint Surg. Am. 56: 43 Woo, S.L.‐Y., Kuei, S.C., Amiel, D. et al. (1981). The
1001–1022. effect of prolonged physical training on the properties
38 Rubin, C.T. and Lanyon, L.E. (1987). Osteoregulatory of long bone: a study of Wolff ’s law. J. Bone Joint Surg.
nature of mechanical stimuli: function as a determinant for Am. 63: 780–787.
adaptive remodeling in bone. J. Orthop. Res. 5: 300–310. 4 Young, D.R., Nunamaker, D.M., and Markel, M.D.
4
39 Simmons, D.J., Kent, G.N., Jilka, R.L. et al. (1982). (1991). Quantitative evaluation of the remodeling
Formation of bone by isolated, cultured osteoblasts in response of the proximal sesamoid bones to training‐
millipore diffusion chambers. Calcif. Tissue Int. 34: related stimuli in Thoroughbreds. Am. J. Vet. Res. 52:
291–294. 1350–1356.
40 Smith, J.W. (1960). Collagen fibre patterns in 5 Young, D.R., Richardson, D.W., Markel, M.D. et al.
4
mammalian bone. J. Anat. 94: 329–344. (1991). Mechanical and morphometric analysis of the
41 Smith, R.K.W. and Goodship, A.E. (2008). The effect of third carpal bone of Thoroughbreds. Am. J. Vet. Res. 52:
early training and the adaption and conditioning of skeletal 402–409.
tissues. Vet. Clin. North Am. Equine Pract. 24: 37–51.
www.ajlobby.com
12
2
Fracture Biomechanics
Mark D. Markel
Introduction called loads.19 Loading a structure such as bone causes

deformation, or a change in dimension such as decreased
Fracture repair in horses remains an arduous process, or increased length. When a load of known direction is
fraught with difficulties. During the repair of adult imposed on the structure, the deformation of that struc
long‐bone fractures, equine surgeons routinely work at ture can be measured and plotted as a load‐deformation
the mechanical limits of fracture fixation devices, and in curve. Essential information regarding the structure’s
regions of the bone that are often poorly covered by mechanical properties can be gathered from this curve.
soft tissues, leading to a wide range of complications. A typical load‐deformation curve for bone is illustrated in
Precarious stability accompanied by a relatively poor Figure 2.1.19 The initial linear portion of the curve, called
fracture healing response in these regions increases the the elastic region, is a measure of the elasticity of a struc
risk of fixation failure or contralateral limb laminitis ture. If the object is loaded only through the elastic region of
before fracture union occurs. In contrast, such fractures the curve, it will return to its original shape when the load is
are not an issue in human orthopedic repairs, in which removed. As loading continues, however, the substance of
patients can be instructed to bear partial weight or to the structure begins to yield. Yield is defined as the point
remain non‐weight bearing after surgery, and in small beyond which the structure will no longer return to its orig
animal orthopedic repairs, in which implants are used inal shape when the load is removed. As the load exceeds
that are routinely far stronger than that required for a the yield point, the structure exhibits plastic behavior,
successful outcome. It is imperative, therefore, that reflected in the second, flatter portion of the curve, the plas
equine surgeons understand the biomechanics of bone tic region. In this region, the structure deforms to a much
and fracture repair, in order to enhance the likelihood greater extent for a given load (the structure is less stiff)
of success. In this chapter, we will define (i) the basic than in the elastic region of the curve. If the load is progres
biomechanical terminology needed to understand frac sively increased, the structure will fail at some point. This
ture mechanics; (ii) the forces causing various fracture load is the ultimate failure point on the curve.4,16,19
configurations; (iii) the biomechanical principles of Three parameters for determining the strength of a
fracture repair; and (iv) the directional loads acting on structure are reflected in the load‐deformation curve:
equine long bones during normal activities. (i) the load that the structure can sustain before failing;
(ii) the deformation that it can sustain before failing; and
(iii) the energy that it can store before failing, known as
Basic Biomechanical Terminology toughness.4,16,19 The strength of the structure in terms of
load and deformation, or ultimate strength, is indicated
on the curve by the ultimate failure point. The toughness
Load‐Deformation Curve of the structure in terms of energy storage is equal to
The most important mechanical properties of bone are the area under the curve. Toughness can be divided
its strength and stiffness. These mechanical characteris into elastic energy (the area under the curve up to the
tics can be assessed best by examining the behavior of the yield point) and plastic energy (the area under the
structure when it is subjected to externally applied forces, curve from the yield point to the ultimate failure point).

www.ajlobby.com
Ultimate failure compressive stress is negative. Commonly used units

point are pounds per square inch (psi) or N m−2 (Pa). For refer
ence, 1 megapascal (MPa) = 106 Pa = 1 N mm−2 ≈ 145 psi.
Plastic region
Shear stress is the intensity of the internal forces parallel
Yield point to a plane that passes through a point in the body,
expressed as force per unit area.
Strain is defined as a localized change in dimension that
Load
n
egio
develops within a structure in response to externally

tic r
Energy applied loads. The two basic types of strain are linear strain,
which causes a change in the length of the specimen, and
Elas
shear strain, which causes a change in the angular relation

ships within the structure. Linear strain is a measure of
localized linear deformation (i.e., longer or shorter) of a
Deformation line oriented in a certain direction divided by its original
length at a point in or on the structure; therefore it is
Figure 2.1 Load‐deformation curve of a viscoelastic structure dimensionless and expressed as a percentage. Shear strain
such as bone. Several important mechanical parameters can be
is measured as the amount of angular deformation (γ) of a
determined from this curve. The ultimate failure point is the load
at which the bone fractures. The stiffness of the structure is shown right angle lying in the plane of interest in the sample. It is
by the slope of the initial elastic region of the curve. The area expressed in radians, and therefore is also dimensionless.
underneath the curve defines the energy the bone stores as it is Stress and strain can be determined in bone specimens
loaded. On fracture, this energy is released into the bone and by machining a standardized specimen (most commonly
surrounding soft tissues.
a cylinder or cube) and loading the specimen to failure.19
The results of this testing can be plotted as a stress–
Toughness is an important concept, because the more strain curve, which is similar in appearance to a load‐
energy a bone absorbs before fracture, the greater the deformation curve. These data may be obtained through
comminution and soft tissue damage that develop at the simple tension, compression, or shear tests. Usually,
moment of fracture.4,16,19 This damage is secondary to stress is plotted along the ordinate and strain is plotted
the rapid release of the stored energy during fracture along the abscissa (Figure 2.2).
propagation. The stiffness of the structure is defined as As in load‐deformation curves, loads in the elastic
the slope of the elastic region of the curve. A steeper region of the stress–strain curve do not cause permanent
slope indicates a stiffer structure. deformation, although, once the yield point is exceeded,
The load‐deformation curve is useful for determining some deformation will remain after removal of the load.
the mechanical properties of whole structures, such as an The strength of the material is defined as the ultimate
entire bone, and is important for understanding fracture
repair and the response of the repair to load.19 This type of
structural testing does not allow characterization of the
local material properties of bone, independent of its Plastic region
geometry. To determine the local properties of a structure, Ultimate stress
testing conditions must be standardized. Such standardi Yield stress
zation is useful for defining the material properties of two Yield point
or more substances. These data are crucial to our under
Stress
ion
standing of fracture repair methods, since we must know

reg
the relative material properties of the fracture fixation

stic
method in comparison to bone. More precise units can be

Ela
used to define these local material properties.

Yield strain Ultimate strain
Strain
Stress and Strain
Figure 2.2 Stress–strain curve of a machined bone sample tested
Stress is the force per unit area that develops on a plane in compression. The slope of the elastic region of the curve is
surface within a structure in response to an externally defined as Young’s modulus in tension and compression and as
shear modulus when the specimen is subjected to pure shear
applied load.4,16,19 Normal stress is the intensity of the forces. As in the load‐deformation curve (see Figure 2.1), if the
internal force perpendicular to a plane that passes specimen is loaded beyond the yield point, permanent
through a point in the body. Tensile stress is positive, and deformation will occur.
www.ajlobby.com
failure stress, and the stiffness of the curve is obtained by Loading Mode
dividing the stress at any point in the elastic portion of
the curve by the strain at that point. When a sample is During normal daily activity, forces and moments are
tested in tension or compression, the stress–strain ratio applied to bone in various directions, producing tension,
(slope) is defined as Young’s modulus; whereas when the compression, bending, shear, torsion, and combined
test is carried out in pure shear forces, the modulus of loading (Figure 2.3).19
elasticity is called the shear modulus.4,16,19 The units of
these moduli are the same as for stress. Stiffer materials Tension
have higher moduli. During tensile loading, equal and opposite traction loads
are applied at the ends of a structure, resulting in tensile
stresses and strains within the structure. Tensile stress
Mechanical Properties of Bone
Mechanical properties differ in the two macroscopic
bone types. Cortical bone is stiffer than cancellous bone,
but fails at a lower ultimate strain. Cancellous bone fails
at approximately 75% strain, whereas cortical bone fails
at approximately 2% strain. Because of its porous struc
ture, cancellous bone also has the ability to store more
energy before failure than does cortical bone. Cortical
bone tends to be a fairly brittle material; it can sustain
only limited strain before fracture. Cancellous bone is a
more ductile material, since it can deform to a much
greater degree before fracture.
Bone has a very limited ability to deform elastically.
Precise testing of cortical bone has shown that the elastic
portion of the curve is not straight but is slightly curved,
indicating that bone is not linearly elastic in its behavior,
but that it yields somewhat during loading in the elastic
region.2 This yielding, when tested in tension, occurs by
debonding of osteons at the cement lines, the weakest
Unloaded Tension Compression Bending
portion in cortical bone.
Bone, as a structure, does not respond similarly to loads
presented in different orientations. For example, bone is
stronger in compression than in tension. This phenome
non of possessing directional properties is called anisot
ropy. A material that exhibits neither structural orientation
nor property dependence on orientation is said to be iso
tropic. Although the relationship between loading pat
terns and the mechanical properties of bone throughout
the skeleton is extremely complex, it can generally be said
that bone strength and stiffness are greatest in the direc
tion in which loads are most commonly imposed.
Biomechanical Behavior
of Bone
The biomechanical response of bone to the forces to
which it is subjected depends on many factors, including Shear Torsion Combined loading
the material properties of the bone tissue, the geometry
Figure 2.3 Various loading modes as they might occur in the
of the bone, the loading mode applied (torsion, tension), equine third metacarpal bone. Source: Adapted from Nordin
the loading rate, and the frequency of loading (single and Frankel 1989.19 Reproduced with permission of John Wiley
cycle versus fatigue).19 and Sons.
www.ajlobby.com
(A) (B) (C) (D) (E)
Figure 2.4 Typical long bone fracture morphology, corresponding to the type of external load applied to the long bone. The fracture pattern
may vary depending on the magnitude of the composite loading mode involved. (A) In compression and bending, the bone initially fails in
tension (small arrows) and the fracture propagates toward the compression surface of the bone, resulting in a large butterfly fragment. (B) In
pure bending, the bone again initially fails in tension (small arrows) and the fracture propagates toward the compressive surface, resulting in
a smaller butterfly fragment than seen with combined bending and compression. (C) In torsion, the bone fails in a spiral pattern, with local
shear and tension as the source of failure. (D) In compression, the bone fails obliquely, due to a combination of shear and compressive forces.
(E) In pure tension, the bone fails transversely. Source: Adapted with permission from Markel 1992.15
can be thought of as many small forces acting away from are rare in the horse, but are the principal cause of Y‐
the plane of interest. Maximal tensile stress occurs on a shaped fractures of the distal humerus and femur.
plane perpendicular to the applied load. When subjected
to tension, the structure lengthens and narrows, with Bending
failure occurring around the osteon by debonding of the In bending, loads are applied to a structure that causes
cement line and pulling out of osteons. Clinically, tensile it to bend about an axis. When a bone is loaded in
fractures occur in a number of locations, including the bending, it is subjected to a combination of tension and
proximal ulna, some proximal sesamoid bone fractures, compression. Tensile stresses act on one side of the
patellar fractures, and some calcaneal fractures (Figure 2.4). neutral axis, and compressive stresses act on the oppo
The fractures are usually transverse in orientation, site side (Figure 2.5). The farther from the neutral axis,
corresponding to the plane of maximal tensile stress. the greater the magnitude of these stresses.
Clinically and experimentally, bending may be caused
Compression by three (three‐point bending) or four forces (four‐point
During compressive loading, equal and opposite compres bending; Figure 2.6). Three‐point bending takes place
sive loads are applied at the ends of a structure, resulting when three forces act on a structure to produce two
in compressive stresses and strains within the structure. equal moments, each being the product of one of the
Compressive stress can be thought of as many small forces two peripheral forces multiplied by the perpendicular
acting toward the plane of interest. Maximal compressive distance from the peripheral force to the middle force. In
stress occurs on a plane perpendicular to the applied a homogenous and symmetrical structure subjected to
load. Under compression, the structure shortens and wid three‐point bending, the structure will fracture through
ens, with failure occurring obliquely through osteons. the site of central load application.
The oblique orientation of the fracture corresponds to the A typical three‐point bending fracture would occur when
plane of maximal shear stress (45° to the orientation of a horse fractures its bone at the top of a cast or by stepping
the compressive load), since bone as a material is strongest in a hole. Since adult bone is weaker in tension, the failure
in compression, followed by shear, and is weakest in begins on the tensile surface of the bone. The fracture trav
tension (Figure 2.4). Clinically, pure compressive fractures els from the tensile surface of the bone to the compressive
www.ajlobby.com
(A) (B)
Neutral axis
Figure 2.6 Two types of bending to which the equine third

metacarpal bone might be subjected: (A) three‐point bending and
(B) four‐point bending. Source: Adapted from Markel 2006.16
Reproduced with permission of Elsevier.
Figure 2.5 Cross‐section of the equine third metacarpal bone

subjected to bending. The distribution of stresses around the
neutral axis (solid line) is shown. Tensile stresses act on the dorsal
surface of the bone and compressive stresses act on the palmar
surface. The stresses are highest on the periosteal surface of the
bone and lower near the neutral axis (arrows). The tensile and
compressive stresses are unequal because the bone is
asymmetrical. Source: Adapted from Nordin and Frankel 1989.19
Reproduced with permission of John Wiley and Sons.
surface transversely, until shear forces acting on a 45° plane

become sufficiently high to result in a butterfly component
on the compressive side of the bone (see Figure 2.4). Neutral axis
Four‐point bending occurs when two force couples or
four forces (two central and two peripheral) act on a
structure to produce two equal moments. A force couple
is formed when two parallel forces of equal magnitude
but opposite direction are applied to a structure (Figure 2.6).
The region between the two central application points is Figure 2.7 Cross‐section of the distal radius loaded in torsion;
subjected to a uniform bending moment, and the bone the distribution of shear stresses around the neutral axis is
shown. The magnitude of the stresses is highest on the
fractures through the weakest point in this central region. periosteal surface of the bone and lowest near the neutral axis
An example of a four‐point bending fracture would be (arrows). Source: Adapted from Nordin and Frankel 1989.19
unusual in a clinical setting, but is commonly used for Reproduced with permission of John Wiley and Sons.
mechanical testing of structures.
the structure (Figure 2.7). When a structure is subjected to
Torsion torsion, shear stresses are distributed over the entire
In torsion, a load is applied to a structure causing it to structure. As in the case of bending, the magnitude of
twist around an axis, resulting in a torque produced within these stresses is proportional to their distance from the
www.ajlobby.com
neutral axis (usually the central axis of rotation). Therefore, trauma energy dependent on the second power of the
for bone, the periosteal surface is subjected to the highest loading rate. This factor explains why horses who are
shear stresses when it is loaded in torsion. Shear stresses training at slower speeds may experience simple frac
are greatest at points parallel and perpendicular to the tures with little comminution, in contrast to horses who
neutral axis of the structure (i.e., the long axis of the bone). suffer fractures during races. At slower speeds, the bone
Maximal tensile and compressive stresses act on a plane at and soft tissues remain relatively intact, and there is little
a 45° angle to the neutral axis. This factor becomes impor or no displacement of the bone fragments. At higher
tant when examining the configuration of fractures that speeds, the bone will absorb more energy before fractur
result from torsional loads. When a bone is loaded in ing. When the bone does fracture, this stored energy is
torsion, the bone first fails in shear with the formation of released, causing more severe comminution and trauma
the initial crack parallel (along the long axis of the cortex) to the surrounding soft tissues.
to the neutral axis. A second crack then propagates along Clinically, fractures can be classified by the amount of
the plane of maximal tensile stress, causing a spiral frac energy released at the time of the fracture: low‐energy,
ture to occur (see Figure 2.4). high‐energy, and very high‐energy. Low‐energy fractures
occur during low speeds, such as when stepping in a
Combined Loading hole or fracturing a limb at the walk or trot. High‐energy
Combined loading is the most common loading pattern fractures can occur when an animal is hit by a car, is
which occurs during daily activity. Loading of bone in an kicked by another horse, sustains a fracture during a
in vivo setting is complex, because bones are subjected to race, or runs into an immovable object. Very high‐energy
multiple indeterminate loads and because their shapes fractures are produced by high‐velocity projectiles, the
are irregular. As will be discussed later, the equine long typical example being gunshot injuries.
bones which have been studied are subjected to varying
strains in different orientations depending on the surface
of the bone (cranial, caudal, medial, lateral) and which Bone Fatigue
portion of the bone is examined (proximal, middle, distal).
Fractures can occur secondary to a single incident, for
example during recovery from anesthesia, or as a result of
Rate Dependency of Bone repeated applications of a load of low magnitude. A frac
ture caused by a few repetitions of high loads or by many
Since bone is viscoelastic, its mechanical behavior varies
repetitions of lower loads is called a fatigue fracture.
with the rate at which it is loaded. Bone is stiffer and sus
The susceptibility of bone to fracture under cyclic
tains higher loads before failure when loads are applied
loads is related to its crystal structure and collagen orien
at higher rates (Figure 2.8). Importantly, bone also stores
tation, reflecting the viscoelastic properties of bone.
higher energy before failure at faster loading rates, with
Cortical bone is vulnerable to both tensile and com
pressive cyclic stresses. Each load cycle releases a small
amount of strain energy, which can be lost through
microcracks along the cement lines. Fatigue load under
certain strain rates can cause progressive accumulation
Fast loading rate
of microdamage in cortical bone. When this process
continues, the bone may eventually fail through crack
propagation. Although bone has rather poor fatigue
Load
resistance in vitro, it is a living tissue and can undergo

repair via remodeling during and after loading. Periosteal
callus and new bone formation near the microcrack can
Slow loading rate arrest crack propagation by reducing the high stresses at
the tip of the crack. For the repair process to be effective,
a relatively low level of stress must be applied and main
tained in the bone. Fatigue loading, for example, is
Deformation involved in the etiology of dorsal cortical fractures of the
third metacarpal bone.
Figure 2.8 Load‐deformation curve demonstrating the rate An important term to understand when discussing
dependency of bone. The load to failure and the energy stored
within the bone are much higher for the bone loaded at the faster
fatigue loading is the stress ratio. The stress ratio is the
rate. Source: Adapted from Nordin and Frankel 1989.19 ratio of the minimum stress to the maximum stress
Reproduced with permission of John Wiley and Sons. under cyclic fatigue loading. Compressive stresses are
www.ajlobby.com
negative, therefore the minimum stress is the maximum associated with condylar fractures of the distal metacar
compressive stress; tensile stresses are positive, therefore pus, is a fatigue‐induced injury associated with coales
the maximum stress is the maximum tensile stress. cence of microcracks leading to condylar fracture.
A stress ratio of −1 is the worst fatigue loading condition.
An example of this loading condition would involve a
fractured tibia with a gap repaired using a single plate. Influence of Bone Geometry
When the horse walks on the limb, the plate is subjected on Biomechanical Behavior
to cycles of compressive and tensile forces; the loading The geometry of a bone influences its mechanical
condition would have a stress ratio close to −1. In a behavior.16,19 In tension and compression, the load to
fatigue test, the endurance limit of a bone is the stress failure and the stiffness of bone are proportional to the
level under which no fracture can develop, regardless of cross‐sectional area of the bone. The larger the area, the
the number of loading cycles applied. stronger and stiffer the bone. In an axial loading test of a
In bone, fatigue fractures are usually sustained during structure with an unknown cross‐sectional area (A) and
continuous physical activity that causes muscle fatigue material elastic modulus (E), the slope of the linear por
and reduces the muscle’s ability to store energy and neu tion of the load‐deformation curve is defined as the axial
tralize the stresses imposed on the bone. The resulting stiffness (AE) of the structure, or the resistance of the
alteration of the stress distribution in the bone causes structure to axial deformation during loading.
abnormally high loads to be imposed, resulting in a In bending, the cross‐sectional area and the distribu
fatigue fracture. Bone may fail on the tensile surface of tion of bone tissue around a neutral axis affect the bone’s
the bone, the compressive surface, or simultaneously on mechanical behavior. The quantity that takes into
both surfaces. When a bone fails on the tensile surface, account these two factors in bending is called the area
the fracture rapidly propagates transversely, resulting in moment of inertia. A larger area moment of inertia
a complete fracture. When the bone undergoes fatigue results in a stronger and stiffer bone. A third factor, the
failure on the compressive surface, the fracture develops length of the bone, also influences the strength and
much more slowly, and the remodeling process may be stiffness of a bone in bending. The longer the bone, the
able to heal the fracture before it becomes complete. greater the magnitude of the bending moment caused by
Scanning electron microscopy (fractal arrays) has the application of a force. Because of their length, the
shown that branching cracks precede development of long bones of the skeleton are subjected to high bending
fractures of the distal limb bones in running athletes, moments and therefore must tolerate high tensile and
including racing greyhounds and Thoroughbreds. These compressive stresses. In a bending test of a specimen
arrays of macroscopic cracks likely arise from nanoscale with unknown elastic modulus (E) and cross‐sectional
damage to the subchondral bone matrix. Thoroughbreds area moment of inertia (I), the slope of the linear portion
have prominent crack arrays in the condylar groove (junc of the load‐deformation curve provides a measure of
tion of sagittal ridge and metacarpal condyle). These bending resistance, and this parameter is defined as the
cracks coalesce, leading to loss of subchondral bone and bending stiffness or flexural modulus of the structure.
its overlying articular cartilage, and the development of The factors that affect bone strength and stiffness in tor
parasagittal linear defects, as described by Briggs and sion are similar to those that operate in bending: the cross‐
Chao3 and Radtke et al.23 These linear defects have marked sectional area and the distribution of bone around the
rounding of the margins of the fracture line in palmar and neutral axis. The quantity that accounts for these two fac
plantar regions of the epiphysis, consistent with this pro tors in torsional loading is the polar moment of inertia. The
gressive mode of fatigue failure. The milder blunting of larger the polar moment of inertia, the stronger and stiffer
the fracture margins in the dorsal regions of the epiphysis the bone. In a torsional test of a specimen with unknown
likely indicates that these arise from postfracture abrasion. shear modulus (G) and polar area moment of inertia (Jo),
Radtke et al.23 demonstrated that comminution of the dor the slope of the linear portion of the torque‐rotation curve
sal cortex of the distal metaphysis of the third metacarpus provides a measure of its torsional resistance or the struc
occurred frequently in animals that had complete dis tural parameter, torsional stiffness. The load that a cylinder
placed condylar fractures, and that this comminution did experiences when loaded under torsion is called torque.
not typically occur in the palmar or plantar cortex. These
data suggest that structural failure of the bone occurred
during cyclic loading in the dorsal‐palmar or dorsal‐plan Stress Risers
tar bending mode, such that the dorsal cortex was loaded Geometric irregularities such as holes, notches, and sharp
in compression and the plantar cortex was loaded in ten corners, as well as sudden changes in material properties,
sion. All these studies indicate that catastrophic break may produce high localized stresses in structural members
down injury in the horse, and in particular injuries under loading. The ratio of the true maximum stress
www.ajlobby.com
caused by these stress risers to the nominal stress calcu with intramedullary rods include rod migration, per
lated at that point by the ordinary formulas of mechanics manent deformation of the rod, fatigue fractures of the
is called the stress concentration factor. The weakening rod, delayed union, and nonunion.
effect of stress risers is particularly prominent under Several material and structural properties of intra
torsional loading. In sheep femora, the total decrease in medullary rods alter their axial, bending, and torsional
bone strength was less than 5% for a defect equal to 10% rigidities (Figure 2.9). These include cross‐sectional
of the bone diameter, 34% for a 20% defect, and 62% for a geometry, rod length, the presence of a longitudinal
50% diameter defect.7,10 For rectangular defects, a 10% slot, and the elastic modulus of the metal.10 The cross‐
by 10% defect (percentage of bone diameter) decreased sectional geometry can have a significant effect on all
ultimate torque by 12%.6 At small length dimensions, rigidities. In general, the overall rigidity of intramedullary
changes in width caused large changes in ultimate torque. rods increases with rod diameter, because the moment of
For example, defects 10% long and 20% wide lost 29% of inertia is approximately proportional to the fourth power
ultimate torque, whereas when the defect was widened of the rod radius. The unsupported length of intramed
to 50%, the bones lost 60% of ultimate torque. With ullary fixation describes the distance between implant–
increasing length of defects, this width effect was elimi bone contact at the proximal and distal segments of
nated. Ultimately, the length of a defect is the predomi bone. This distance will effectively change as the fracture
nant factor in rectangular defects. A defect length 100% heals. During the initial stages of fracture healing using
of the bone diameter is the critical dimension in reduc intramedullary rods, two different unsupported lengths
ing the ultimate torque of bone; beyond this, increases in are important: the unsupported length in bending and
width do not further decrease the ultimate torque. the unsupported length in torsion. For bending loads,
the rod is typically loaded in approximately four‐point
bending, so the interfragmentary motion is proportional
to the square of the unsupported length. Therefore, a
Relative Strengths and
small increase in unsupported length can lead to a larger
Weaknesses of Fixation increase in interfragmentary motion. With torsional
Methods loading, the unsupported length is determined by the
points at which sufficient mechanical interlocking occurs
Numerous techniques are currently available for the between bone and implant to support torsional loads.
treatment of equine fractures. Each method imparts spe For simple rod designs without proximal or distal lock
cific levels of immobilization to a fracture, thus directly ing mechanisms, there may be little resistance to torsion
influencing fracture healing biology.10 When evaluating a and the concept of unsupported length is not applicable.
fracture treatment method, the healing bone and fracture
treatment device should be considered as a mechanical
system, with both the tissue and the device contributing Material and structural
to the system’s biomechanical behavior. The biomechan properties of the rod
ics of the system can thus be altered by changes in frac Proximal fixation
ture properties, in the fracture treatment device, or in the mechanism
mechanical connection between device and tissue.
Additionally, bones are subject to diverse loads that can
be a combination of axial, bending, and torsional loads.
Thus, the axial, bending, and torsional stability of a frac
ture fixation method should be considered.
Implant–bone contact Unsupported length
(reamed / Unreamed)
Intramedullary Rods
Intramedullary rods have several advantages in fracture
treatment, including restoration of bony alignment and Distal locking
recovery of early weight bearing in young, lightweight mechanism
animals.10 These devices are intended to stabilize a frac Bone quality
ture by acting as an internal splint, forming a composite
structure in which both the bone and the rod contribute
to fracture stability. This load‐sharing property of rods is Figure 2.9 Equine humerus repaired with an intramedullary
fundamental to their design and should be recognized device. The important factors in intramedullary fracture fixation
when using them for fracture treatment. Complications are identified. Source: Adapted from Hipp et al. 1992.10
www.ajlobby.com
For locking rods, the unsupported length is typically modulus. It should also be noted that the mechanical
determined by the distance between the innermost properties of bone will affect the behavior of the plate–
proximal and distal locking points. Intramedullary rod bone system. For example, less stiff bone increases the
designs that provide mechanisms for locking the rod load‐sharing contribution of the plate. Loads can be
proximally or distally or both have increased the indica transmitted between plate and bone through the bone
tions for intramedullary rod use. The use of a locking screws and through friction‐type forces between the plate
mechanism on one side of the fracture only can increase surface and the bone. Plate luting has been developed to
the forces transmitted between fracture fragments dur increase the contact and frictional forces between the
ing limb loading. The use of both proximal and distal bone and the plate.21,27 A bone plate is generally a load‐
locking can prevent axial displacement of bone along the sharing device, with some of the load supported by the
rod and can provide additional torsional rigidity. The plate and some load passing between bone fragments.
strength of locking rods depends to a large extent on the Subjected to bending loads, a plated bone can take on a
quality of the surrounding bone. bending open (compressive surface) or bending closed
(tensile surface) configuration. The placement of the
plate relative to the loading direction will determine
Bone Plates the proportion of the load supported by the plate. The
As with intramedullary devices, several basic biome plate–bone composite is far stiffer in the bending
chanical principles are important in fracture fixation closed position than it is in the bending open position.
using bone plates (Figure 2.10).10 These include bone The locking compression plate (LCP) is a relatively
properties, plate material and geometry, screw–bone new design with distinctly different biomechanical prop
interface, number of screws, screw material and tension, erties than standard bone plates.9,25 The LCP is an inter
plate–bone interface, placement of the plate relative to nally positioned external skeletal fixation device (ESFD)
loading, and compression between fragments. The bend combining locking screw technology with conventional
ing stiffness of a bone plate is related to the third power dynamic compression plate (DCP) techniques. The LCP
of the plate thickness and directly proportional to the differs from other DCPs because the screw head has
elastic modulus of the plate. Therefore, plate rigidity threads that allow attachment of the screw to the plate.
can be changed more by plate thickness than by plate This attachment is achieved through the combi hole of
the LCP, where one portion of the hole functions through
traditional DCP technology, whereas the other portion
of the hole is threaded, allowing for fixation of the screw
head to the plate. The LCP can be used in compression,
using traditional compression plate screws in the appro
priate end of the combi hole. In traditional plate applica
tion, cortical screws lag the plate against the bone,
Bone properties creating frictional forces between the bone and the plate,
Plate material
and geometry thereby enhancing fixation rigidity. In contrast, a locking
screw does not compress the bone against the plate.
Plate–bone interface Locking screws provide the ability to create a fixed‐angle
Screw–bone construct, limiting the need for exact plate contouring.
interface In traditional plate fixation, if the cortical screws become
loose and the plate is no longer tightly compressed
Compression against the bone, the screw heads move in the plate and
Number of screws between fragments the construct becomes unstable. With LCP technology,
rigidity is maintained in this circumstance because the
Screw material screws are rigidly locked into the plate. Advantages of
and tension LCP application in the horse include formation of a
Plate placement
relative to loading
stable fixation with less invasive techniques, and a
resulting construct that is inherently more stable in
simple or complex fractures compared to DCP fixation.
LCP application is potentially faster, since locking screws
are self‐tapping, eliminating the need to tap screw holes,
Figure 2.10 Equine radius repaired with a dynamic compression which is a standard technique for typical Association for
plate. The factors that affect the stability of plated fractures are Osteosynthesis (AO) cortical bone screws in equine bone.
identified. Source: Adapted from Hipp et al. 1992.10 Minimal plate contouring is required for LCP application,
www.ajlobby.com
also shortening surgical times. Other advantages of LCP the overall performance of an external skeletal fixation
technology include application of the plate in an extra system. The weakest loading mode for unilateral and
periosteal location, the perpendicular direction of all bilateral fixation systems (applied from the medial or
screws, and the locking screw’s star drive screw head. lateral surface) is in the cranio‐caudal plane. Pin stresses
Disadvantages of LCPs are the inability to angle or lag can be high in less rigid systems, causing permanent pin
locking screws and the significantly increased cost of deformation or fracture of the pin. Even at low loads,
LCPs and locking screws. In a study by Sod et al.,25 LCPs systems of minimal stiffness can cause high stresses as
were compared to limited‐contact dynamic compression pin–bone interfaces, resulting in pressure necrosis that
plate (LC‐DCP) fixation in osteotomized equine third leads to pin‐track infection and loosening. If apposition
metacarpal bones; LCP fixation was significantly stronger of fractured bone ends can be achieved, these stresses
in four‐point bending for all parameters measured, will be reduced to a less damaging level.
with a concomitant increase in mean cycles to failure. Frame stiffness is related to a number of factors and
Under torsional testing, LCP fixation was significantly can be defined as follows for bilateral external skeletal
stronger for all parameters measured, including mean fixation frames:1,3,5,8,12,13,17
yield load, mean composite rigidity, and mean failure
load. The LCP fixation was almost twice as strong or K f 12ME s I / S3
stiff in every parameter measured, compared to 4.5 mm
LC‐DCP fixation. where Kf = axial stiffness; M = pins in each bone segment;
Es = pin modulus; I = pin area moment (proportional to
the fourth power of pin radius); S = distance from the
External Fixation
sidebar to the bone.
External fixation is not widely used in horses, primarily From this equation, we can see that the most impor
due to the high and repetitive loads that the fixator and tant factors affecting frame stiffness are pin diameter
bone must withstand without failure.22 In general, the and the distance of the sidebar to the bone.
following principles apply to external skeletal fixation.11 The most common external skeletal fixation technique
Bone fracture stiffness can be improved with external used in horses is transfixation casts. Threaded or non
skeletal fixation by (i) increasing pin numbers; (ii) threaded pins are applied either in the proximal aspect of
increasing pin diameter; (iii) using pins of enhanced the fractured bone or in the bone above the fracture
material properties (e.g., stainless steel is stiffer than tita bone, subsequently incorporating a cast into the fixation.
nium); and (iv) decreasing sidebar separation from the Positive‐profile pins are the preferred pin profile in order
limb (Figure 2.11). Other parameters have less effect on to limit pin migration. In addition, a 30° divergence of the
pins in the frontal plane has been recommended as a
technique to achieve stronger fixation and lower risk for
Clamp
postoperative fracture.
Nunamaker and coworkers have developed an ESFD
for adult horses with severely comminuted fractures of
the distal limb.14,18,20,22 The ESFD utilizes two or three
Pin group transfixation pins in the intact bone proximal to the frac
ture, with sidebars and a foot base plate. Weight bearing
is transmitted from the bone through the pins to the
Pin group sidebars and to the base plate, unloading the bone below
distance the distal‐most transfixation pin. Early complications of
the device included fractures through the pin tracts.14,22
Pin group In order to minimize these complications, the group
modified the sidebar pin–bone interface by the appli
Pin separation cation of a tapered‐sleeve transcortical pin designed
distance
Fixation to reduce stress at the pin–bone interface.18,20 Large‐
pin diameter tapered sleeves were applied over the trans
fixation pins to closely approximate the bone in order to
Sidebar decrease pin–bone interface stress. This was combined
Bone to sidebar distance with a frame that was stronger and lighter. Nash and
Figure 2.11 Equine tibia repaired with a bilateral external skeletal Nunamaker18 evaluated the stiffness and pin–bone inter
fixator. Some of the important factors affecting fixation stability face stresses for a transcortical tapered‐sleeve pin that
are identified. incorporated a bilateral tapered sleeve over a transcortical
www.ajlobby.com
pin. Three pin diameters were evaluated (6.35, 7.94, and counteracted. Third, intramedullary pins should not be
9.5 mm), each coupled with a 25.4 mm diameter sleeve. placed in areas subjected to high torsional loads without
Significant increases in stiffness and higher loads at yield the pins being locked.
point were verified for all three pin diameters. Current Strain gauges have been applied to the equine tibia,
recommendations are to use the device with two tapered‐ radius, and third metacarpal and third metatarsal bones
sleeve transcortical pins applied through the distal meta to determine the normal stresses and strains to which
carpus for stabilization of commuted distal limb fractures these bones are subjected when a horse walks.24,26 In
or breakdown injuries of the metacarpophalangeal joint.20 addition, the effect of cast application on bone strain has
been determined for the radius and tibia. In the radius,
the principal axis of tensile strain is on the craniolateral
Strain Surfaces of Specific surface of the bone.24 Distally, on the radius, the largest
Equine Long Bones strains are torsional. Application of a cast to the bone
changes the principal axis of tensile strain from the
As has been discussed earlier, all bones in living bodies craniolateral surface to the caudal surface.
are subjected to combined loads that cause widely varying In the tibia, the principal axis of tensile strain is just
stresses and strains within the bone structure. When to the lateral side of cranial in the proximal and diaphy
repairing a fracture, it is imperative that the surgeon be seal regions of the bone.24 Distally, the principal axis of
familiar with these stresses and strains, because the fixa tensile strain is craniolateral; however, the largest
tion device must be able to withstand the loads placed on strains measured are torsional. The application of a cast
it in each direction. For example, plates should be placed to the bone changes the principal axis of tensile strain
on the tensile surface of bone (bending closed position) distally, but it does not reduce the magnitude of the
to achieve maximal stability from the implant. In a sec strains measured.
ond example, bilateral external skeletal fixators should In the third metacarpus and third metatarsus, the
be applied to the bone so that the fixation pins are in the principal axes of tensile strain are dorsomedial and
plane of the highest stresses. Unfortunately, soft tissue dorsolateral, respectively, although the third metacarpus
coverage and overlying musculature dictate the orienta demonstrates highly variable strains with no true tensile
tion of the pins more often than the loads that are being or compressive surface.26
References
1 Behrens, F., Johnson, W.D., Koch, T.W., and Kovacevic, 8 Egkher, E., Martinek, H., and Wielke, B. (1980). How to
N. (1983). Bending stiffness of unilateral and bilateral increase the stability of external fixation units. Arch.
fixator frames. Clin. Orthop. 178: 103–110. Orthop. Trauma Surg. 96: 35–43.
2 Bonefield, W. and Li, C.H. (1967). Anisotropy of 9 Egol, K.A., Kubiak, E.N., Fulderson, E. et al. (2004).
nonelastic flow in bone. J. Appl. Phys. 38: 2450. Biomechanics of locked plates and screws. J. Orthop.
3 Briggs, B.T. and Chao, E.Y.S. (1982). The mechanical Trauma 18: 488–493.
performance of the standard Hoffmann–Vidal 10 Hipp, J.A., Cheal, E.J., and Hayes, W.C. (1992).
external fixation apparatus. J. Bone Joint Surg. 64A: Biomechanics of fractures. In: Skeletal Trauma (ed.
566–573. B.D. Browner, J.B. Jupiter, A.M. Levine and P.G.
4 Chao, E.Y.S. and Aro, H.T. (1991). Biomechanics of Trafton), 95–126. Philadelphia: W.B. Saunders.
fracture fixation. In: Basic Orthopaedic Biomechanics 11 Hipp, J.A., Edgerton, B.C., An, K.N., and Hayes, W.C.
(ed. V.C. Mow and W.C. Hayes), 293–336. New York: (1990). Structural consequences of transcortical holes in
Raven Press. long bones loaded in torsion. J. Biomech. 23: 1261–1268.
5 Chao, E.Y., Kasman, R.A., and An, K.N. (1982). Rigidity 12 Huiskes, R. and Chao, E.Y.S. (1986). Guidelines for
and stress analyses of external fracture fixation devices. external fixation frame rigidity and stresses. J. Orthop.
A theoretical approach. J. Biomech. 15: 971–983. Res. 4: 68–75.
6 DeSouza, M.L., An, K.N., Morrey, B.F., and Chao, 13 Kempson, G.E. and Campbell, D. (1981). The
E.Y.S. (1989). Strength reduction of rectangular comparative stiffness of external fixation frames. Injury
cortical defects in diaphyseal bone. Trans. Orthop. Res. 12: 297–304.
Soc. 25: 113. 14 Kraus, B.M., Richardson, D.W., Nunamaker, D.M., and
7 Edgerton, B.C., An, K.N., and Morrey, B.F. (1990). Ross, M.W. (2004). Management of comminuted
Torsional strength reduction due to cortical defects in fractures of the proximal phalanx in horses: 64 cases
bone. J. Orthop. Res. 8: 851–855. (1983–2001). J. Am. Vet. Med. Assoc. 224: 254–263.
www.ajlobby.com
15 Markel, M.D. (1992). Fracture biology and mechanics. skeletal fixation device that allows immediate full
In: Textbook of Equine Surgery (ed. J.A. Auer), 798–807. weightbearing. Application in the horse. Vet. Surg. 15:
Philadelphia: WB Saunders. 345–355.
16 Markel, M.D. (2006). Bone biology and fracture healing. 23 Radtke, C.L., Danova, N.A., Scollay, M.C. et al. (2003).
In: Equine Surgery, 3e (ed. J.A. Auer and J.A. Stick), Macroscopic changes in the distal ends of the third
991–1000. St. Louis: Saunders Elsevier. metacarpal and metatarsal bones of thoroughbred
17 McCoy, M.T., Chao, E.Y.S., and Kasman, R.A. (1983). racehorses with condylar fractures. Am. J. Vet. Res. 64:
Comparison of mechanical performance in four types 1110–1116.
of external fixators. Clin. Orthop. 180: 23–33. 24 Schneider, R.K., Milne, D.W., Gabel, A.A. et al. (1982).
18 Nash, R.A. and Nunamaker, D.M. (2001). Evaluation of Multidirectional in vivo strain analysis of the equine
a tapered‐sleeve transcortical pin to reduce stress at the radius and tibia during dynamic loading with and
bone‐pin interface in metacarpal bones obtained from without a cast. Am. J. Vet. Res. 43: 1541–1550.
horses. Am. J. Vet. Res. 62: 955–960. 25 Sod, G.A., Mitchell, C.F., Hubert, J.D. et al. (2008).
19 Nordin, M. and Frankel, V.H. (1989). Biomechanics of In vitro biomechanical comparison of locking
bone. In: Basic Biomechanics of the Musculoskeletal compression plate fixation and limited‐contact
System, 2e (ed. M. Nordin and V.H. Frankel), 3–29. dynamic compression plate fixation of osteotomized
Philadelphia: Lea & Febiger. equine third metacarpal bones. Vet. Surg. 37:
20 Nunamaker, D.M. and Nash, R.A. (2008). A tapered‐ 283–288.
sleeve transcortical pin external skeletal fixation device 26 Turner, A.S., Mills, E.J., and Gabel, A.A. (1975). In vivo
for use in horses: development, application and measurement of bone strain in the horse. Am. J. Vet.
experience. Vet. Surg. 37: 725–732. Res. 36: 1573–1579.
21 Nunamaker, D.M., Richardson, D.W., and Butterweck, 27 Young, D.R., Richardson, D.W., Nunamaker, D.M. et al.
D.M. (1991). Mechanical and biological effects of plate (1989). Use of dynamic compression plates for
luting. J. Orthop. Trauma 5: 138–145. treatment of tibial diaphyseal fractures in foals: nine
22 Nunamaker, D.M., Richardson, D.W., Butterweck, cases (1980–1987). J. Am. Vet. Med. Assoc. 194:
D.M., and Provost, M.T. (1986). A new external 1755–1760.
www.ajlobby.com
24
3
Fracture Healing
Mark D. Markel
fracture healing. Systemic factors include age and nutri-

Fracture Healing tional status of the patient, hormone levels, functional
activity, nerve function, and nutrition. Local factors
Knowledge of the biologic principles involved in the cause
include degree of trauma, presence of vascular injury, type
of fractures, management regimens, and healing of frac-
of bone affected, degree of bone loss, degree of immobili-
tures is essential for successful treatment.39 Fracture heal-
zation, presence of infection, degree of contamination,
ing results in the reconstitution of the original structure
and local pathologic conditions.
and material properties of the affected bone, and involves
a number of important processes which can be regarded
as temporary reversions to the embryonic state. The Phases of Fracture Healing
mechanisms controlling the repair processes of fractures
are the most fundamental in biology, involving molecular Fracture healing can be considered as a series of processes
stimuli that (i) prompt cells at the fracture site to alter that occur in sequence but are often overlapping. The
their normal rate of growth; and (ii) recruit cells outside healing process can be divided into at least three distinct
the fractured bone to participate in the healing process. stages: inflammation, reparation, and remodeling.19,20
This chapter includes a description of the various types of Bone reacts to fracture within a few hours by upregulating
fracture healing, and the relationship of these healing types periosteal cell activity. This initial cellular reaction is a
to the biologic and mechanical environments with which very fundamental response of bone to injury and is called
they are associated. In addition, the interplay of collagenous the primary callus response.41
and noncollagenous proteins with fracture healing will be
presented. With the exponential growth of biotechnology Inflammatory Phase
over the past 20 years, orthopedic surgeons may soon find The inflammatory phase is the most critical prerequisite
many cytokines and growth factors available that will aug- for the reparative phase of fracture healing, similar to that
ment fracture healing (see Chapter 12). Therefore, it is in soft tissue wounds, and usually occurs over the first
imperative to understand the role that these cytokines and 2–3 weeks after injury. If serious impairment of the inflam-
growth factors might play in fracture healing. matory phase occurs, tissue healing is compromised.31
Fracture repair follows the principles which govern During the inflammatory phase, the cellular mechanisms
embryonic and fetal development of the skeleton necessary for repair and the processes protecting the
(Figure 3.1).57,59,64 There are four components to a fracture healing tissue from infection are activated. In brief, injury
injury site: the cortex, the periosteum, the bone marrow, is translated to cells by waves of chemical messengers,
and the external soft tissues, all of which contribute to such as kinins, complement factors, histamine, serotonin,
the healing process. Bone has the unique ability of being prostaglandins, and leukotrienes. The coagulation cascade
able to heal completely after a fracture, thereby returning contributes fibrin and fibrinopeptides. Together, these
to its original tissue structure and associated mechanical elements mediate the inflammatory reaction by causing
properties. Skin, muscle, and tendon tissues are unable to vasodilation, migration of leukocytes, and chemotaxis.
fully regenerate after injury, but rather heal with permanent Platelets also contribute growth factors which initiate angi-
scar tissue. Both local and systemic factors influence ogenesis and mesenchymal cell proliferation. On reaching
www.ajlobby.com
the injured tissue, granulocytes ingest and destroy bacte-

ria, but do not contribute to repair. Macrophages, and to a
lesser extent lymphocytes, aid in the destruction of bacte-
External soft tissue response ria, and also stimulate repair by releasing angiogenic
factors and other cell growth factors.31
Periosteal response
Reparative Phase
Cortical response The reparative phase overlaps and follows the inflamma-
tory phase. During the reparative phase, the pattern of
fracture healing is highly susceptible to mechanical fac-
Bone marrow response tors, predominantly the amount of interfragmentary
motion. The reparative phase can take 2–12 months to
be completed. The natural histologic course of fracture
healing (without immobilization) begins with interfrag-
mentary stabilization through periosteal and endosteal
Figure 3.1 The four types of soft tissue response associated with callus formation (Figures 3.1 and 3.2).27 This process
normal fracture healing in an equine third metacarpal bone. restores continuity, and bone union occurs by intramem-
branous and endochondral ossification.
(A) (B)
(C) (D)
Figure 3.2 Light microscopic image of 5 μm undecalcified specimens of a fracture gap (Goldner stain, magnification ×20). (A) Two weeks
after fracture when gap is filled with undifferentiated tissue. (B) Four weeks after fracture with islands of cartilage (c) and woven bone
formation (b). (C) Eight weeks after fracture with bone filling the gap. (D) Twelve weeks after fracture with the cortex almost entirely
reconstituted, although it is still significantly more porous than normal cortical bone.
www.ajlobby.com
Remodeling Phase
The remodeling phase occurs during and following the
reparative phase. Avascular and necrotic areas of bone
are replaced by Haversian remodeling. Malalignment of
fragments may be corrected to a certain extent by remod-
eling of the fracture site and by functional adaptation,
particularly in young animals with remaining bone
growth potential. On loading, convex surfaces carry a
positive charge and attract osteoclasts, whereas concave
surfaces are negatively charged and attract osteoblasts.
Therefore, bone is removed from convex surfaces and
laid down on concave surfaces. This process tends to
realign the bone after malunion. Fracture remodeling
does not correct torsional deformities.
During the inflammatory phase of healing, external
callus tissue consists of primitive mesenchymal cells,
fibroblasts, macrophages, and blood vessels (Figure 3.2).
The origin of periosteal callus cells is still controversial,
although most investigators feel that the cambium layer
of the periosteum plays an important role as a source of
cells with both osteogenic and chondrogenic potential.
The blood vessels of periosteal callus originate from
surrounding extraskeletal tissues (muscles) and from the Figure 3.3 Light microscopic image of a 5 μm undecalcified
medullary cavity.25,53 It is not known whether invading specimen of a fracture gap (Goldner, ×4). Note abundant
periosteal callus without bridging of the fracture gap.
vascular endothelial cells have osteogenic or chondro-
genic potential. Angiogenesis involves migration and
proliferation of endothelial cells, and the process can be and, since this involves the joining of hard tissue, it follows
stimulated by so‐called angiogenic growth factors.7,24 that the whole system must become immobile, at least
A hypoxic tissue gradient seems to be essential for momentarily (see Figure 3.2). At this stage of healing,
the maintenance of angiogenesis in a healing tissue. insufficient fracture immobilization may cause the devel-
Angiogenesis may be controlled by macrophages, which opment of a hypertrophic nonunion by the persistence of
produce angiogenic factors under hypoxic conditions.33 fibrous tissue (Figure 3.3). Transformation of osteogenic
Fracture callus and the medullary cavity show low tissue callus to fibrous tissue between the edges of the external
oxygen tension during external callus formation.3,14,29 callus may also result in hypertrophic nonunion.4,16,44,69
The induction and proliferation of undifferentiated During endochondral ossification, bone matrix replaces
periosteal callus tissue constitute the first critical step the mineralized cartilage matrix. The process involves
in fracture healing by external callus (see Figures 3.1 vascular invasion into mineralized fibrocartilage, and
and 3.2). Formation of such callus will be suppressed by although the basic cellular and biochemical changes of
rigid immobilization and by excessive fracture motion. the process are not completely known, current thoughts
Callus formation depends on several humoral factors. concerning the role of collagenous and noncollagenous
Most importantly, the induction and proliferation periods proteins in this process will be presented later in this
of periosteal callus which occur during the inflammatory chapter. Newly formed bone is structurally immature
and reparative phases have a limited duration. trabecular bone (woven bone), characterized histologi-
During the reparative phase, primitive callus tissue cally by the lack of a lamellar structure.
shows a very rapid chondrogenic transformation. It has During the ossification process of external callus,
not been determined whether cells with chondrogenic the total amount of calcium per unit volume of callus
potential are derived from specific periosteal prechon- increases approximately fourfold; hydroxyproline (an
drogenic cells or represent chondrocytes differentiated indicator of total collagen content) increases twofold;
from primitive mesenchymal cells through signals created and the breaking strength of the callus in tensile tests
in the environment. The size of early external callus increases threefold.4 The radiographic size of external
corresponds to that of cartilaginous callus, as well as to callus is a poor predictor of fracture strength and does not
that of the final bony callus. indicate at a given healing time the number of chemical
The next critical step in obtaining union of a fracture is components within the fracture callus.4,49 The restoration
the establishment of a bony bridge between the fragments of fracture strength and stiffness seems to be related to
www.ajlobby.com
the amount of new bone connecting the fracture frag- types that are vital for fracture healing. Collagen types
ments, and less to the overall amount of uniting callus.10 I, II, III, V, IX, and X are important for bone develop-
ment and fracture healing. Very shortly after fracture,
collagen types III and V are produced in the fracture
Fracture Healing Molecules gap.43,55 Type III collagen, expressed by fibroblasts, is
broadly distributed throughout the mesenchymal
Structural Proteins reparative callus. Type V collagen is found in regions of
Structural proteins may play an important role in fracture fibrous tissue formation associated with blood vessels.
healing (Table 3.1).21 The hematoma and inflammatory The appearance of type V collagen, therefore, signals
stage are responsible for the chemotaxis of specific cell the ingrowth of new blood vessels into the fracture gap.
Table 3.1 The role of structural proteins and enzymes in fracture healing.
Protein or enzyme Comments
Collagen Approximately 11 types of collagen in connective tissue

Types I, II, III, V, IX, and X important for fracture healing
Types III and V predominate initially
Type III expressed by fibroblasts in reparative callus
Type V found in fibrous tissue associated with vessels
Types II and IX predominate as cartilage forms in gap
Type II found in cartilage
Type IX stabilizes type II collagen intersections
Maturing chondrocytes become hypertrophic and produce type X
Type X is hallmark of mineralization of chondroid tissue
Type I is expressed as bone forms
Noncollagenous proteins (17 families involved in mineralization)
Proteoglycans Two main types in fracture callus, heavy (chondroitin 4‐sulfate) forms second to third
week and light (dermatan sulfate) forms early
Dramatically decline after third week
Matrixins = Metalloproteinases May alter proteoglycan and collagen structure to allow for mineralization
(protein‐degrading enzymes)
Collagenase
Gelatinase
Stromelysin (Proteoglycanase)
Alkaline phosphatase Precedes deposition of hydroxyapatite
Probably directly involved in calcification
May hydrolyze phosphate esters to raise local concentration of phosphate ions causing
precipitation of calcium phosphate
May transfer phosphate anions to organic matrix
May inactivate inhibitors of mineralization
Osteopontin (a sialophosphoprotein) Found only in mature osteoblasts
Expressed when mature osteoblasts also produce osteocalcin and alkaline phosphatase
May anchor osteoclasts to bone through integrins; thereby facilitates bone resorption
True role may be to enhance removal of calcified cartilage so that it can be replaced by bone
Osteonectin (a glycoprotein) High affinity for type I collagen and hydroxyapatite
Potent inhibitor of hydroxyapatite crystal formation
Can precipitate calcium and phosphate ions
Expressed in preosteoblasts and early osteoblasts
Good marker of early bone differentiation
Vitamin K–dependent proteins
Osteocalcin (bone γ‐carboxyglutamate May activate bone resorption
protein) Only expressed by osteoblasts
Matrix γ‐carboxyglutamate protein Found in both bone and cartilage
(MGP) Plays a major role in preventing premature calcification of cartilage
Vitamin D–dependent proteins Expressed in mature chondrocytes
(Calbindin D9k) May be involved in transport of calcium to mineralization sites
www.ajlobby.com
As cartilage forms in the fracture gap, collagen types II tributed among mesenchymal cells of all types, including
and IX predominate. Type II collagen is found only in bone. All of the enzymes of this family are inhibited by
areas undergoing chondroid differentiation and is another family of proteins, the TIMPs.38 Matrixins are
deposited where mature cartilage is produced. Type IX thought to play a vital role in the proteoglycan structure
collagen is thought to stabilize type II collagen intersec- modification necessary for the initiation of mineraliza-
tions. As the chondrocytes in the fracture gap mature, tion.15,21 Matrixins have also been correlated with peak
they become hypertrophic and produce type X collagen. alkaline phosphatase activity within the fracture callus,
The synthesis of type X collagen occurs primarily in which suggests the importance of these enzymes in pre-
regions of the fracture callus undergoing vascularization paring the callus for calcification.
and mineralization.26 The appearance of type X collagen Alkaline phosphatase activity directly precedes the
is the hallmark for the onset of mineralization of the deposition of hydroxyapatite in both endochondral bone
chondroid tissue. By the end of the second week of development and experimental fracture healing models
fracture healing, type I collagen begins to be expressed, (see Table 3.1).27,65 It is thought to be directly involved in
indicating that osteoblasts are becoming active in the calcification. It may cause hydrolysis of phosphate esters,
fracture gap. This stage of bone formation is then thereby elevating the local concentration of phosphate
superseded by a remodeling phase, in which osteoclastic ions, which in turn facilitate the deposition of calcium
and osteoblastic activities function to produce a mechan- phosphate. Other roles have been postulated for alkaline
ically competent bony tissue. phosphate, including its action as an agent for the trans-
fer of phosphate anions to the organic matrix and as an
inactivator of the inhibitors of mineralization.
Noncollagenous Proteins The remaining classes of noncollagenous proteins
At least 17 families of noncollagenous proteins are include osteopontin, osteonectin, and the vitamin K– and
involved in the mineralization and bone formation phases vitamin D–dependent proteins (see Table 3.1).27 Bone
of fracture healing (Table 3.1).11,21 These include proteo- phosphoproteins, such as osteonectin and osteopontin,
glycans, osteopontin, osteonectin, vitamin K–dependent serve two roles in mineralization within the callus.
proteins, and vitamin D–dependent proteins (calbindin D9k), Osteonectin, a glycoprotein, has a high affinity for type I
as well as enzymes and their inhibitors: alkaline phos- collagen and hydroxyapatite, and is a potent inhibitor of
phatase, metalloproteinases, and tissue inhibitors of met- hydroxyapatite crystal formation, although it has also
alloproteinases (TIMPs). been shown experimentally to precipitate calcium and
A common feature of endochondral bone formation, phosphate ions in solution.9 Osteonectin is expressed in
whether it occurs in the growth plate or within a fracture preosteoblasts and early osteoblasts and is a good
gap, is the progressive alteration of the content and marker of early bone differentiation.
properties of proteoglycans resident in the extracellular Osteopontin, a sialophosphoprotein found only in
matrix.21,35,71 Two main types of proteoglycans are mature osteoblasts, is expressed when mature osteo-
expressed in the fracture callus: the heavy proteoglycan, blasts also produce osteocalcin and alkaline phos-
chondroitin 4‐sulfate, and the light proteoglycan, derma- phatase.42 Although osteopontin probably plays an active
tan sulfate. Early in fracture healing, dermatan sulfate role in the initiation of calcification, it has also been
is synthesized by proliferating fibroblasts. During the shown to help anchor osteoclasts to bone by acting as a
second week of fracture healing, the production of chon- receptor for cell‐surface integrins, and thereby is a facili-
droitin 4‐sulfate by chondrocytes begins to dominate the tator of bone resorption.52 Osteopontin’s true role may
callus. By the third week, when calcification of the callus be to enhance removal of calcified cartilage so that it can
begins, there is a dramatic decrease in the absolute be replaced by bone. Therefore, osteopontin probably is
amount of proteoglycan as well as the proportion of pro- important in the remodeling phase of fracture healing.
teoglycan aggregates present within the callus. In addi- The vitamin K–dependent proteins, osteocalcin/bone
tion, the ability of the proteoglycan monomers to γ‐carboxyglutamate (Gla) protein (BGP) and matrix Gla
aggregate is reduced.35 These alterations in proteoglycan protein (MGP), were originally thought to be regulators
production and structure may facilitate mineralization of mineralization, but also probably play an active role in
of the fracture callus and are thought to be brought about bone remodeling.27,50 Osteocalcin is only expressed by
by specific protein‐modifying enzymes.71 osteoblasts and may be directly responsible for activat-
Matrixins, also known as metalloendopeptidases or ing bone resorption through osteoclast activation.36
metalloproteinases, are a family of protein‐degrading MGP is found in both bone and cartilage and probably
enzymes, which include collagenase, gelatinase, and helps prevent premature calcification of cartilage.67
proteoglycanase (stromelysin).27,68 These enzymes are The vitamin D–dependent protein, calbindin D9k, is
involved in a wide variety of normal and pathologic expressed by mature chondrocytes and may be involved in
remodeling processes. They are found universally dis- the transport of calcium to mineralization sites.6,27 The
www.ajlobby.com
concentration of cytoplasmic calbindin D9k decreases as enchymal cells originating from the periosteum.34 These
the mature chondrocyte hypertrophies. Calbindin D9k cytokines induce downstream responses from the injury
appears to migrate into matrix vesicles, where it is believed site through a chemotactic effect on other inflammatory
to be involved in the initial onset of mineral deposition.13 cells, enhancing extracellular matrix synthesis, angio-
genesis, and the recruitment of mesenchymal stem cells
(MSCs) to the injury site.34 These cytokines demonstrate
Cytokines, Growth Factors, and peak expression within 24 hours of fracture, are reduced
Other Growth and Differentiation during the process of cartilage formation, and increase
Factors again during bone remodeling.23,34
Cytokines regulate endochondral bone formation.8
Cytokines, growth factors, and prostaglandins are thought For example, TNF‐α is responsible for recruitment of
to play a crucial role in fracture healing (Table 3.2).1,48,64 MSCs, the induction of apoptosis of hypertrophic chon-
drocytes during endochondral ossification, and the pro-
Cytokines motion of osteoclastic activity. Without TNF‐α, delayed
Interleukin‐1 (IL‐1), interleukin‐6 (IL‐6), and tumor resorption of mineralized cartilage occurs, prohibiting
necrosis factor‐α (TNF‐α) play a critical role in initiating new bone formation. Expression of IL‐1, IL‐6, and
the fracture repair process.22,23 They are secreted by TNF‐α are all increased during resorption and bone
macrophages and inflammatory cells, as well as by mes- remodeling.23
Table 3.2 The role of growth factors, cytokines, and prostaglandins in fracture healing.
Element Comments
Competence factors Signal mesenchymal cells in and around the fracture to enter G1 from G0
Platelet‐derived growth factor (PDGF) making them competent to respond to other growth factors
Fibroblast growth factor (FGF)
Progression factors Push cells that are in G1 into the S phase, committing them to replication
Transforming growth factor‐β (TGF‐β)
Mitogenic factors Maintain the dividing cells in a proliferative state
Epidermal growth factor (EGF)
Insulin‐like growth factor‐I (IGF‐I) Vigorously promote synthesis of cartilage matrix and can sustain type II
Insulin‐like growth factor‐II (IGF‐II) collagen in extracellular matrix
Fibroblast growth factor (FGF)
PDGF
TGF‐β
Differentiation factors Act on proliferating pluripotent stem cells causing them to differentiate into
Bone morphogenetic proteins (BMPs) the specialized cells involved in fracture healing
Other members of the
TGF‐β superfamily
Cytokines
Macrophage‐colony stimulating factor (M‐CSF) Important for development of macrophage colonies; macrophages produce IL‐1
Granulocyte macrophage‐colony stimulating factor Promotes neutrophil, eosinophil, and macrophage colonies
(GM‐CSF)
Interleukin‐1 (IL‐1) Important for stromelysin, collagenase, and gelatinase production
Stimulates PGE2
Differentiation facilitator
Suppresses cellular proliferation of chondrocytes
Downregulates expression of type II and IX collagen
Downregulates proteoglycan production
Peaks 14 days after fracture, when metalloproteinases are highest
Interleukin‐6 (IL‐6) Induces production of tissue inhibitors of metalloproteinases
Autocrine regulator of IL‐1
Tumor necrosis factor-α (TNF-α) Induces chondrocyte apoptosis, metalloproteinase production, and promotes
osteoclastic activity
Prostaglandins Released during immediate postfracture period
Biphasic mediators of bone metabolism and homeostasis
Potent stimulators of bone resorption, secondary to macrophage stimulation
and osteoclast differentiation
Cause periosteal callus formation
www.ajlobby.com
Growth Factors osteopontin, osteonectin, and alkaline phosphatase.56

The transforming growth factor‐β superfamily is a broad Its main role during fracture healing is during chondro-
group of growth and differentiation factors that includes genesis and endochondral bone formation (see Table 3.2).8
the bone morphogenetic proteins (BMPs), transforming TGF‐β2 and possibly TGF‐β3 play more important roles
growth factor‐βs (TGF‐βs), growth and differentiation in fracture healing than TGF‐β1, since their expression
factors (GDFs), activins, inhibins, and the Mullerian peaks during chondrogenesis, in contrast to TGF‐β1,
inhibiting substance.64 There are at least 34 members of where expression remains constant throughout fracture
this family that have been identified in the human genome, healing.18
and they originate from high molecular weight precursors Platelet‐derived growth factor (PDGF) is a homo‐ or
that are activated by proteolytic enzymes.60,63 Members of heterodimer consisting of A and B chains. PDGF is
the family typically target serine/threonine kinase mem- synthesized by platelets, monocytes, macrophages, endo
brane receptors.38 This ligand–receptor interaction initi- thelial cells, and osteoblasts, and is mitogenic for cells of
ates an intracellular signaling pathway, ultimately causing mesenchymal origin.62 PDGFs exert their effect through
gene expression in the nucleus. Specific members of this receptors with tyrosine kinase activity. PDGF is released
superfamily include BMP‐5 and ‐6, GDF‐1, ‐5, ‐8, and ‐10, by platelets early in fracture healing, and is chemotactic
and TGF‐β1, ‐β2, and ‐β3, each of which promotes various for inflammatory cells, MSCs, and osteoblasts.2,37,47
stages of intramembranous and endochondral ossification The fibroblastic growth factor (FGF) family consists of
during fracture healing (Table 3.3).18 nine related polypeptides. The acidic and basic FGFs are
BMPs induce a cascade of events driving chondro- the most abundant FGFs in adult tissue and, similar to
genesis and osteogenesis, including chemotaxis, PDGF, exert their effect through tyrosine kinase recep-
mesenchymal and osteoprogenitor cell proliferation and tors.66,70 During fracture healing, FGFs are synthesized
differentiation, angiogenesis, and synthesis of extracel- by monocytes, macrophages, mesenchymal cells, osteo-
lular matrix.45,54 BMPs, including their application blasts, and chondrocytes. They promote both growth
and promotion of fracture healing, will be discussed in and differentiation of fibroblasts, myocytes, osteoblasts,
greater detail in Chapter 12. and chondrocytes. FGFs have high activity during the
TGF‐β has five isoforms.32 Platelets release TGF‐β early stages of fracture healing, and are important for
during the initial inflammatory phase of fracture healing, angiogenesis and mesenchymal cell migration. Acidic
which may help initiate callus formation.12 TGF‐β is also FGF regulates chondrocyte proliferation and is likely
produced by osteoblasts and chondrocytes, and is stored important for chondrocyte maturation, whereas basic
in the bone matrix.37 It acts through types 1 and 2 serine/ FGF (FGF‐2) is expressed by osteoblasts.37,46
threonine kinase receptors activating the Smad‐2 and ‐3 Insulin‐like growth factor‐I (IGF‐I) and IGF‐II are
pathways.28 TGF‐β enhances proliferation of MSCs, principally regulated by growth hormone.37,62 IGF‐I and
preosteoblasts, chondrocytes, and osteoblasts.37 It also IGF‐II are present in the bone matrix, endothelial cells,
induces production of collagenous proteins, proteoglycans, osteoblasts, and chondrocytes. The IGFs exert their action
Table 3.3 Temporal and functional characteristics of members of the TGF‐β superfamily observed during fracture healing in animal
models.
Member of the
TGF‐β superfamily Time of expression Specific responses in vivo and in vitro
GDF‐8 Day 1 Potential function as a negative regulator of skeletal muscle growth

GDF‐10 Days 3–21 Regulatory role in both types of ossification
BMP‐5, ‐6 BMP‐6 may initiate chondrocyte maturation
GDF‐5, ‐1 Day 7 (maximal) to Day 14 (restricted GDF‐5 exclusive involvement in chondrogenesis suggested
expression during chondrogenic phase) Stimulation of mesenchymal aggregation and induction of
GDF‐1 at extremely low levels angiogenesis through chemotaxis of endothelial cells and degradation
of matrix proteins
GDF‐3, ‐6, ‐9 No detectable levels within the fracture GDF‐6 may be expressed only in articular cartilage and with GDF‐5,
callus ‐7 more efficiently induce cartilage and tendon‐like structures in vivo
TGF‐β1 Days 1–21 Potent chemotactic for bone forming cells and macrophages
TGF‐β2 Days 3–14 Proliferation of undifferentiated mesenchymal and osteoprogenitor
TGF‐β3 Days 3–21 cells, chondrocytes
Source: Adapted from Tsiridis et al. 2007,64 with selected data from Cho et al. 2000.18 Reproduced with permission of Elsevier.
www.ajlobby.com
in a cell‐specific manner through IGF‐binding proteins

and IGF receptors.60 IGF‐I promotes bone matrix forma-
tion by differentiated osteoblasts and is more potent than
IGF‐II.17,37 IGF‐II acts at later stages of endochondral
bone formation, stimulating type 1 collagen production,
cartilage matrix synthesis, and cellular proliferation.51
Mechanisms of Fracture Union

Rigid compression plating of an osteotomy was found
more than 40 years ago to inhibit callus formation and
allow bone ends to unite directly by Haversian remode-
ling in contact areas (contact healing) and noncontact
areas (gap healing).58 Subsequently, fracture healing was
divided into two patterns: primary (direct) bone healing
Figure 3.4 Polarized light microscopic image of a 100 μm
and secondary (indirect or spontaneous) fracture heal- undecalcified specimen demonstrating Haversian remodeling of
ing. Indirect fracture healing, which involves healing the fracture, with secondary osteons (yellow arrows) crossing the
with periosteal and endosteal callus, is considered “sec- fracture (blue arrows).
ondary,” because intermediate fibrous tissue or fibrocar-
tilage is formed initially between the fracture fragments limited, confirming the theory of biochemical induction
and only subsequently replaced by new bone.57 of Haversian remodeling.
The ultimate structural goal of fracture healing is The growth of secondary osteons from one fracture
reconstruction of the original cortical bone. Due to the fragment to another does not necessarily require intimate
damage to bone and surrounding soft tissues during contact of fracture fragments. Even after perfect reduction
trauma, the cortical ends at the fracture site become and compression plating, there are incongruencies at the
avascular and necrotic during the initial stages of healing. fracture site which will result in small gaps interspersed
This inevitable vascular compromise does not prevent with contact areas. These gap regions are filled, within weeks
the avascular fracture ends from playing an important after fracture, by direct lamellar or woven new bone.57 The
biomechanical role by serving as the mechanical sup- woven bone formed within the gap acts as a space filler, but
portive elements for any fixation device. Haversian does not “unite” the fracture ends. The boundary between
remodeling has two main functions: (i) the revasculari- the new bone and the original cortex is the weak link of the
zation of necrotic fracture ends; and (ii) the reconstitu- union process at this stage of healing.5 Secondary osteons
tion of the intercortical gap. There are three requirements use the gap tissue as a scaffold to grow from one fragment
for Haversian remodeling across the fracture site: (i) to another. Although this is the crucial step for final union,
exact reduction (axial alignment); (ii) rigid fixation; and the growth of secondary osteons results, paradoxically, in a
(iii) sufficient blood supply (Figure 3.4). In the dog, the transitory and compulsory reduction of cortical bone
growth of secondary osteons begins during the second density. The new bone formed in the gap also shows a
month after fracture. This process occurs somewhat similar “porotic change” as part of the union process.5
later in humans; however, there is always a lag period Fracture union can follow any one of many combina-
before the activation of Haversian remodeling during tions of pathways to the final stage of union. The choice
fracture healing. The factors that initiate the dramatic of which healing mechanism to use should be based on
increase of secondary osteons in healing fractures and many factors, including the treating surgeon’s expertise
influence the direction of their growth are not known. and experience. It would be wrong to assume that a
It has been postulated that the activation of Haversian certain method appears to be easier and thus requires
remodeling is related to tissue damage (avascular necrosis) less technical acumen. Many clinical factors such as the
at the fracture site. Static preloading, studied with animal’s age, prospective use, value, and attitude play
compression plates in intact and osteotomized bones, important roles in the selection of a fixation method.
does not seem to influence the rate of osteonal remod- The biologic system appears to have a high level of
eling.30,40,61 Fracture fragments that are deprived of tolerance and adaptability to even the most adverse
their vascular supply for too long a period of time fail conditions. If the fundamental biomechanical and bio-
to be remodeled for several years. 57 This important logic principles for any fracture fixation modality are
observation clearly shows that the signal for the well understood and carefully applied, the potential for
growth of secondary osteons after fracture is time successful management is maximized.
www.ajlobby.com
References
1 Abe, E., Yamamoto, M., Taguchi, Y. et al. (2000). 15 Brown, C.C., Hembry, R.M., and Reynolds, J.J. (1989).
Essential requirement of BMPs‐2/4 for both osteoblast Immunolocalization of metalloproteinases and their
and osteoclast formation in murine bone marrow inhibitor in the rabbit growth plate. J. Bone Joint Surg.
cultures from adult mice: antagonism by noggin. J. Bone Am. 71: 580–592.
Miner. Res. 15: 663–673. 16 Brown, S.A., Gillet, N.A., and Broaddus, T.W. (1984).
2 Andrew, J.G., Hoyland, J.A., and Freemont, A.J. (1995). Biomechanics of fracture fixation by plastic rods with
Platelet‐derived growth factor expression in normally transverse screws. In: Biomechanics: Current
healing human fractures. Bone 16: 455–460. Interdisciplinary Research (ed. S.M. Perren and E.
3 Aro, H., Eerola, E., and Aho, A.J. (1985). Determination Schneider), 475–480. Boston: Martinus Nijhoff.
of callus quantity in 4‐week‐old fractures of the rat 17 Canalis, E. (1980). Effect of insulin‐like growth factor I
tibia. J. Orthop. Res. 3: 101–108. on DNA and protein synthesis in cultured rat calvaria.
4 Aro, H., Eerola, E., Aho, A.J., and Niinikoski, J. (1984). J. Clin. Invest. 66: 706–719.
Tissue oxygen tension in externally stabilized tibial 18 Cho, T.J., Gerstenfeld, L.C., and Einhorn, T.A. (2000).
fractures in rabbits during normal healing and Differential temporal expression of members of the
infection. J. Surg. Res. 37: 202–207. transforming growth factor beta superfamily during
5 Aro, H., Kelly, P.J., Lewallen, D.G., and Chao, E.Y.S. murine fracture healing. J. Bone Miner. Res. 17:
(1988). Comparison of the effects of dynamization and 513–520.
constant rigid fixation on rate and quality of bone 19 Cruess, R.L. and Dumont, J. (1975). Fracture healing.
osteotomy union in external fixation. Trans. Orthop. Can. J. Surg. 18: 403–413.
Res. Soc. 34: 303. 20 Einhorn, T.A., Hirschman, A., Kaplan, C. et al. (1989).
6 Balmain, N. (1991). Calbindin‐D9K. A vitamin‐D Neutral protein‐degrading enzymes in experimental
dependent, calcium‐binding protein in mineralized fracture callus: a preliminary report. J. Orthop. Res. 7:
tissues. Clin. Orthop. 265: 265–276. 792–805.
7 Banda, M.J., Knighton, D.R., Hunt, T.K., and Werb, Z. 21 Einhorn, T.A. (1992). The biology of fracture healing.
(1982). Isolation of a nonmitogenic angiogenesis factor In: Proceedings of the International Society for Fracture
from wound fluid. Proc. Natl. Acad. Sci. U.S.A. 79: Repair, vol. 3, 1–15. Brussels: ISFR.
7773–7777. 22 Feyen, J.H.M., Elford, P., DiPadova, F.E., and Treschel,
8 Barnes, G.L., Kostenuik, L.C., Gerstenfeld, L.C. et al. U. (1989). Interleukin‐6 is produced by bone and
(1999). Growth factor regulation of fracture repair. J. modulated by parathyroid hormone. J. Bone Miner. Res.
Bone Miner. Res. 14: 1805–1815. 4: 633–638.
9 Bianco, P., Silvestrinig, G., Termine, J.D., and Bonucci, 23 Gerstenfeld, L.C., Cho, T.J., Kon, T. et al. (2003).
E. (1988). Immunohistochemical localization of Impaired fracture healing in the absence of TNF‐alpha
osteonectin in developing human and calf bone using signaling: the role of TNF‐alpha in endochondral
monoclonal antibodies. Calcif. Tissue Int. 43: 155–161. cartilage resorption. J. Bone Miner. Res. 18:
10 Black, J., Perdigon, P., Brown, N., and Pollack, S.R. 1584–1592.
(1984). Stiffness and strength of fracture callus. Relative 24 Glaser, B.M., D’Amore, P.A., Seppa, H. et al. (1980).
rates of mechanical maturation as evaluated by a Adult tissues contain chemoattractants for vascular
uniaxial tensile test. Clin. Orthop. 182: 278–288. endothelial cells. Nature 288: 483–484.
11 Boskey, A.L. (1989). Noncollagenous matrix proteins 25 Göthman, L. (1961). Vascular reactions in experimental
and their role in mineralization. J. Bone Miner. Res. 6: fractures. Microangiographic and radioisotope studies.
111–123. Acta Chir. Scand. 284: 1–34.
12 Bostrom, M.P. (1998). Expression of bone 26 Grant, W.T., Wang, G.‐J., and Balian, G. (1987). Type X
morphogenetic proteins in fracture healing. Clin. collagen synthesis during endochondral ossification in
Orthop. 355S: 116–123. fracture repair. J. Biol. Chem. 262: 9844–9849.
13 Brighton, C.T. and Hunt, R.M. (1986). Histochemical 27 Ham, A.W. (1930). A histological study of the early
localization of calcium in the fracture callus with phases of bone repair. J. Bone Joint Surg. 12: 827–844.
potassium pyroantimonate. Possible role of 28 Heldin, C.H., Miyazono, K., and ten Dijke, P. (1997).
chondrocyte mitochondrial calcium in callus TGF‐beta signaling from cell membrane to nucleus
calcification. J. Bone Joint Surg. Am. 68: 703–715. through SMAD proteins. Nature 390: 465–471.
14 Brighton, C.T. and Krebs, A.G. (1972). Oxygen tension 29 Heppenstall, R.B., Grislis, G., and Hunt, T.K. (1975).
of healing fractures in the rabbit. J. Bone Joint Surg. Am. Tissue gas tensions and oxygen consumption in healing
54: 323–332. bone defects. Clin. Orthop. 106: 357–365.
www.ajlobby.com
30 Holmström, T., Paavolainen, P., Slätis, P. et al. (1986). 44 Müller, J., Schenk, R., and Willenegger, H. (1968).
Effect on compression on fracture healing. Plate Experimentelle Untersuchungen über die Entstehung
fixation studied in rabbits. Acta Orthop. Scand. 57: reaktiver Pseudarthrosen am Hunderadius. Helv. Chir.
368–372. Acta 1: 301–308.
31 Hunt, T.K. (1984). Can repair processes be stimulated 45 Mundy, G.R. (1996). Regulation of bone formation by
by modulators (cell growth factors, angiogenetic bone morphogenetic proteins and other growth factors.
factors, etc.) without adversely affecting normal Clin. Orthop. 324: 24–28.
processes? J. Trauma 24: S39–S49. 46 Nakamura, T., Hara, Y., Tagawa, M. et al. (1998).
32 Kingsley, D.M. (1994). The TGF superfamily: new Recombinant human basic fibroblast growth factor
members, new receptors, and new genetic tests of accelerates fracture healing by enhancing callus
function in different organisms. Genes Dev. 8: remodeling in experimental dog tibial fractures. J. Bone
133–146. Miner. Res. 13: 942–949.
33 Knighton, D.R., Hunt, T.K., Scheuenstuhl, H. et al. 47 Nash, T.J., Howlett, C.R., Martin, C. et al. (1994). Effect
(1983). Oxygen tension regulates the expression of of platelet‐derived growth factor on tibial osteotomies
angiogenesis factor by macrophages. Science 221: in rabbits. Bone 15: 203–208.
1283–1285. 48 Norrdin, R.W., Jee, W.S.S., and High, W.B. (1990). The
34 Kon, T., Cho, T., Aizawa, T. et al. (2001). Expression of role of prostaglandins in bone in vivo. Prostaglandins
osteoprotegerin, receptor activator of NF‐kappaB Leukot. Essent. Fatty Acids 41: 139–149.
ligand (osteoprotegerin ligand) and related 49 Panjabi, M.M., Walter, S.D., Karuda, M. et al. (1985).
proinflammatory cytokines during fracture healing. J. Correlations of radiographic analysis of healing
Bone Miner. Res. 16: 1004–1014. fractures with strength: a statistical analysis of
35 Kopman, C.R., Boskey, A.L., Lane, J.M. et al. (1987). experimental osteotomies. J. Orthop. Res. 3: 212–218.
Biochemical characterization of fracture callus 50 Price, P.A. (1988). Role of vitamin‐K dependent proteins
proteoglycans. J. Orthop. Res. 5: 7–13. in bone metabolism. Annu. Rev. Nutr. 8: 565–583.
36 Lian, J.B. and Marks, S.C. (1990). Osteopetrosis in the 51 Prisell, P.T., Edwall, D., Lindblad, J.B. et al. (1993).
rat: coexistence of reduction of osteocalcin and bone Expression of insulin‐like growth factors during bone
resorption. Endocrinology 126: 955–962. induction in rat. Calcif. Tissue Int. 53: 201–205.
37 Lieberman, J.R., Daluiski, A., and Einhorn, T.A. (2002). 52 Reinholt, F.P., Hultenby, K., Oldberg, A. et al. (1990).
The role of growth factors in the repair of bone. Biology Osteopontin – a possible anchor of osteoblasts to bone.
and clinical application. J. Bone Joint Surg. Am. 84: Proc. Natl. Acad. Sci. U.S.A. 87: 4473–4475.
1032–1044. 53 Rhinelander, R.W. (1972). Circulation of bone. In: The
38 Lin, X., Liang, M., and Feng, X.H. (2000). Smurf2 is a Biochemistry and Physiology of Bone, vol. II (ed. G.H.
ubiquitin E3 ligase mediating proteasome‐dependent Bourne), 1–77. New York: Academic Press.
degradation of Smad2 in transforming growth factor‐ 54 Rockwood, C.A. Jr., Green, D.P., Bucholz, R.W. et al.
beta signaling. J. Biol. Chem. 275: 36818–36822. (1996). Fractures in Adults, 4e. Philadelphia: Lippincott.
39 Markel, M.D., Wikenheiser, M.A., Morin, R.L. et al. 55 Sandberg, M., Aro, H., Multimaki, P. et al. (1989). In
(1991). The determination of bone fracture properties situ localization of collagen production by
by dual energy x‐ray absorptiometry and single photon chondrocytes and osteoblasts in fracture callus. J. Bone
absorptiometry: a comparative study. Calcif. Tissue Int. Joint Surg. Am. 71: 69–77.
48: 392–399. 56 Sandberg, M.M., Hannu, T.A., and Vuorio, E.I. (1993).
40 Matter, P., Brennwald, J., and Perren, S.M. (1974). Gene expression during bone repair. Clin. Orthop. 289:
Biologische Reaktion des Knochens auf 292–312.
Osteosyntheseplatten. Helv. Chir. Acta Suppl. 12: 1–44. 57 Schenk, R.K. (1986). Histophysiology of bone
41 McKibbin, B. (1978). The biology of fracture healing in remodeling and bone repair. In: Perspectives on
long bones. J. Bone Joint Surg. Br. 60: 150–162. Biomaterials (ed. O.C.C. Lin and E.Y.S. Chao), 75.
42 Moore, M.A., Gotoh, Y., Rafidi, K., and Gerstenfeld, Amsterdam: Elsevier Science.
L.C. (1991). Characterization of cDNA for chicken 58 Schenk, R. and Willenegger, H. (1963). Zum
osteopontin: expression during bone development, histologischen Bild der sogenannten Primärheilung der
osteoblast differentiation and tissue distribution. Knochenkompakta nach experimentellen Osteotomien
Biochemistry 30: 2501–2508. am Hund. Experientia 19: 593–595.
43 Mueller‐Glauser, W., Humbel, B., Glatt, M. et al. (1986). 59 Sevitt, S. (1980). Healing of fractures in man. In:
On the role of type IX collagen in the extracellular Scientific Foundation of Orthopedics and Traumatology
matrix of cartilage; type IX is localized. J. Cell Biol. 102: (ed. R. Owen, J. Goodfellow and P. Bullough), 258–273.
1931–1939. Philadelphia: WB Saunders.
www.ajlobby.com
60 Shimasaki, S. and Ling, N. (1991). Identification and experimentally produced callus in rats. J. Bone Joint
molecular characterization of insulin‐like growth factor Surg. Br. 68: 629–634.
binding proteins (IGFBP‐1, ‐2, ‐3, ‐4, ‐5 and ‐6). Prog. 66 Wang, J.S. (1996). Basic fibroblast growth factor for
Growth Factor Res. 3: 243–266. stimulation of bone formation in osteoinductive or
61 Slätis, P., Karaharju, E., Holmström, T. et al. (1978). conductive implants. Acta Orthop. Scand. 269: 1–3.
Structural changes in intact tubular bone after 67 Williams, D.C. and Frolik, C.A. (1991). Physiological
application of rigid plates with or without compression. and pharmacological regulation of biological
J. Bone Joint Surg. Am. 60: 516–522. calcification. Int. Rev. Cytol. 126: 195–292.
62 Solheim, E. (1998). Growth factors in bone. Int. Orthop. 68 Woessner, J.F. (1991). Matrix metalloproteinases and
22: 410–416. their inhibitors in connective tissue remodeling. FASEB
63 Tardif, G., Hum, D., Pelletier, J.P. et al. (2004). J. 5: 2145–2154.
Differential gene expression and regulation of the bone 69 Woo, S.L.Y., Lothringer, K.S., Akeson, W.H. et al. (1984).
morphogenetic protein antagonists follistatin and Less rigid internal fixation plates: historical perspectives
gremlin in normal and osteoarthritic human and new concepts. J. Orthop. Res. 1: 431–449.
chondrocytes and synovial fibroblasts. Arthritis Rheum. 70 Xu, X., Weinstein, M., Li, C. et al. (1999). Fibroblast
50: 2521–2530. growth factor receptors (FGFRs) and their roles in limb
64 Tsiridis, E., Upadhyay, N., and Giannoudis, P. (2007). development. Cell Tissue Res. 296: 33–43.
Molecular aspects of fracture healing: which are the 71 Yokobori, T., Oohira, A., and Nogami, H. (1980).
important molecules? Injury 38S1: S11–S25. Proteoglycans synthesized in calluses at various stages
65 Volpin, G., Rees, J.A., Ali, S.Y., and Bentley, G. (1986). of fracture healing in rats. Biochim. Biophys. Acta 628:
Distribution of alkaline phosphatase activity in 174–181.
www.ajlobby.com
35
4
General Considerations for Fracture Repair
Alan J. Nixon1,2
1
Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY, USA
2
Cornell Ruffian Equine Specialists, Elmont, NY, USA
Introduction system (CNS) must also be evaluated, particularly in the

case of fractures of the facial bones, mandible, or cra-
Fractures occur in horses of all ages and can involve nium. Cranial nerve function can be readily assessed and
almost any bone. Classification schemes for fractures provides considerable information on the likely fracture
allow common groupings so that more precise informa- site. Specific CNS deficits and the associated fractures
tion is available regarding treatment, the likelihood of are discussed in detail in Chapters 40 and 41.
success following repair, and the common complications The clinical examination is important in evaluating the
that may be expected. Treatment of most fractures complexity and location of the fracture. Instability at the
requires assessment of both medical and surgical consid- fracture site indicates a complete fracture with possible
erations, and must be conducted in a systematic and comminution. Perforations of the skin need to be evalu-
thorough manner. In horses, the incidence of trauma to ated to determine whether they are due to external lac-
other organ systems is less than in other species, largely eration or to puncture by bony fracture fragments. An
because of the rarity of automobile‐related injuries in initial prognosis can be developed using two simple crite-
horses. Nevertheless, both a careful review of the history ria: complete or incomplete fracture, and open or closed
of the injury and the postinjury appearance and care of fracture. External skin wounds, while presenting a possi-
the animal are important in establishing the seriousness ble factor in planning the surgical approach, are not as
of the fracture and possible complications. A thorough serious a consequence as wounds due to fracture frag-
physical examination is critical in any fracture patient, ment puncture of the skin. However, massive soft tissue
particularly when the need for general anesthesia is loss or devitalization following some race injuries, trailer-
anticipated. A balance between the need for an expedi- ing accidents, or motor vehicle collisions can expose long
tious and thorough assessment of the fracture, including bones to such an extent that even minor fractures become
new radiographs, and examination of other body sys- more serious, in terms of both cost of repair and likeli-
tems is required for safe management of fracture cases. hood of success. Classification and treatment protocols
Evidence of cardiovascular compromise may develop for open fractures are presented later in this chapter and
in massive trauma cases such as racing accidents, vehicle in Chapter 9.
impacts, trailering accidents, or injuries where arteries Radiography is the single most useful method to evalu-
are severed. Some types of hemorrhage can be less obviate the extent of the fracture and provide an accurate
ous, such as rupture of the abdominal aorta or vena cava prognosis for fracture healing and recovery. Multiple
as a result of racing falls, or rupture of the iliac arteries in views should be obtained to determine the potential for
pelvic fracture cases. Fractures of the distal femur or repair and the likely cost range. The radiographs must be
proximal tibia can also lacerate the femoral or popliteal of diagnostic quality, which may necessitate sedation and
arteries, resulting in massive hematomas. Paddock acci- restraint of foals in lateral recumbency, or general anes-
dents, in which fractures may lacerate the distal limb thesia in adults for fractures suspected to be proximal to
arteries, can allow considerable hemorrhage that goes the stifle or elbow. Under these circumstances, it is fre-
unnoticed when the horse is removed and evaluated out quently better to transport the horse to a facility that can
of the pasture. Possible trauma to the central nervous perform the surgical repair if it is considered feasible. This

www.ajlobby.com
avoids the need for additional anesthesia and the trauma of c) Oblique
recovery without definitive repair. An adequate number of d) Spiral
radiographic projections is essential to gain as much pre- e) Comminuted
operative information as possible. Lateral and craniocau- f ) Multiple
dal views are an absolute minimum. Removal of external g) Impacted
splints or casts for further radiographs should be done h) Avulsion
only when the horse is anesthetized or there is little chance 5) Diaphyseal, metaphyseal, physeal, or epiphyseal (includ-
that weight bearing will exacerbate the fracture or open ing Salter–Harris physeal fractures, types I to VI)
the skin. Radiographs obtained through a cast or splint are 6) Other (pathological fracture; multiple bone
often adequate to make a decision for surgery. Following involvement).
this decision, better‐quality images can be obtained with
Physical and radiographic examinations are adequate to
the horse anesthetized. Ultimately, the decision whether
determine whether a fracture is complete or incomplete
to treat and the use of surgical or nonsurgical means, must
and whether it is stable or unstable. An incomplete frac-
be determined after careful assessment of the fracture, the
ture is defined as one that originates in one cortex or sub-
condition of the limb and the horse, the cost of the repair,
chondral bone plate, but has no apparent fracture line
and the prognosis. Factors that determine the prognosis
perforating the opposite cortex or distant subchondral
include the following:1,5,7,11,37,38,40,41
bone plate. By definition this includes greenstick and fis-
1) Type and location of the fracture sure fractures and some condylar fractures. Complete
2) Open or closed fracture fractures represent full cis‐ and transcortical discontinu-
3) Degree of concomitant soft tissue damage or vascular ity, but may be further subdivided into stable or unstable
injury fractures, since this state affects the repair methods and
4) Age, breed, and weight of the horse prognosis.7,14,31,38 A stable, or nondisplaced, fracture is
5) Cooperative nature of the patient defined as one with residual cortical continuity or inter-
6) Single or multiple fractures digitation of the fracture fragments to the extent that
7) Length of time between injury and repair overriding and rotation are largely p revented. Unstable
8) Effectiveness of first aid measures applied in the field. fractures have little or no remaining cortical continuity to
prevent axial, rotational, and bending motion. Unstable
The type and location of fracture are the primary
fractures not only carry a poorer prognosis for repair due
determinants of the chances of a successful repair. Stable
to their inherent instability, but also need to be repaired
long bone fractures have a better chance of successful
without delay to prevent continued damage to the frac-
repair than complete and unstable fractures.6,7,11,38
ture fragments and soft tissues, and to prevent rounding
Similarly, long bone fractures proximal to the third
or comminution of the fracture ends.5,7,8,38,39,42
metacarpus/metatarsus have a poorer prognosis, partly
Furthermore, unstable fractures of the long bones carry
because of the decreased ability to supplement internal
increased risk of perforating the skin, especially in foals.6,42
fixation with external coaptation.7,15,38 The third
Open fractures carry a significantly poorer prognosis
metacarpus (MC3) and third metatarsus (MT3) are
than closed fractures, at a markedly increased cost to the
fractured relatively frequently, and repair is often
owner.5,7,11,38 An open fracture by definition always has a
attempted. This repair is the model for many plate
communication from the fracture to the skin surface
fixation techniques, and the bones’ simple shape makes
(Figure 4.1). Not all skin lacerations on a fractured limb
plate application relatively straightforward.
are caused by the bone fragments or communicate with
the fracture site. The length of skin opening and degree
of soft tissue loss are used to subdivide open fractures to
Classification of Fracture types I–III (Table 4.1), after a similar scheme in human
orthopedics introduced by Gustilo et al.18
To simplify the approach to treatment and formulation
Type I. Open fractures with a small (<1 cm) skin
of a prognosis, fractures are classified according to the
perforation, usually caused by a momentary spike
following criteria:
action from a sharp fracture end (Figure 4.1). They do
1) Complete or incomplete not result in significant skin loss, exposure of the frac-
2) Stable or unstable (nondisplaced or displaced) tured bones, or appreciable gross contamination.
3) Open or closed Type II. Fractures with a larger skin laceration, but little
4) Configuration significant loss of soft tissues, minimal exposed or lost
a) Greenstick or fissure bone, and minimal gross contamination of the bone or
b) Transverse involved soft tissue.
www.ajlobby.com
(A) Type III. An open fracture with extensive lacerations,

massive skin defects, and gross contamination of the
soft tissues and fractured bones. The variable damage
to the soft tissues led Gustilo to further classify type III
open fractures into types IIIA to IIIC (Table 4.1).17
Type IIIA fractures have large wounds of skin and
deeper soft tissues, exposed and contaminated bone
ends, but sufficient residual viable tissues to be
apposed over the bones at surgery. Type IIIB, on the
other hand, have massive soft tissue loss, which neces-
sitates plastic reconstructive procedures to cover the
fractured bones. Type IIIC also have significant dam-
age to the vascular supply to the limb, which require
vascular repair to salvage the limb. The possibility of
contamination resulting in overt infection increases
(B) according to the Gustilo type assigned.
Fortunately, the incidence of type III open fractures in
horses is quite low. Severe racing injuries or trailering acci-
dents represent the few opportunities for extensive soft tis-
sue loss. Many horses with type III open fractures are
euthanized without repair. The majority of open fractures
in horses are type II with a 2–4 cm skin perforation and
moderate contamination of the deeper soft tissues and frac-
ture ends. The special problems of wound debridement,
Figure 4.1 (A) Open fracture of the metacarpus in a foal, showing lavage, and fracture fixation in open fractures are discussed
a small skin perforation (Gustilo type I) as a result of the internal in Chapter 9. The increased complexity of open fracture
bone spike. (B) Radiographs of the foal show a long oblique surgical repair, the special techniques in fracture stabiliza-
fracture and the medial fragment most likely to have caused the tion (additional implants, plate luting, drains, antibiotic
skin wound. Contamination was minimal and the fracture was impregnated bone cement, or polymers), and the extended
repaired with two 4.5 mm dynamic compression plates and
appropriate lag screws in the long oblique portion. The fracture coverage of broad‐spectrum antibiotics result in at least a
went on to full union. doubling of the cost of repair in the equine. Additionally, the
prognosis is markedly reduced due to the risk of wound
dehiscence, and implant loosening and failure. The strong
likelihood of drainage from the implant sites, even if
the fracture heals, necessitates the added cost and risk of
implant removal.
Table 4.1 Open fracture classification.

Fracture Configuration
Gustilo classification
The configuration of equine fractures is critical in
I Low energy, wound less than 1 cm, usually clean;
the decision to repair.1,5,7,8,11,25,36–39,41,43,44 Incomplete
often results from bone spike penetration
fractures of most long bones in the horse, particularly
II Wound greater than 1 cm with moderate soft tissue
those involving the proximal bones in the limb, are usually
damage but minimal tissue loss
better treated by stall confinement, often with cross‐tying
III Fracture with extensive laceration
or tying to an overhead wire to prevent the horse lying
IIIA Adequate soft tissue cover, despite extensive down for the first three weeks. Many incomplete fractures
laceration or extensive trauma
of the humerus, radius, femur, tibia, or third metacarpus
IIIB Inadequate soft tissue cover, periosteal stripping, or metatarsus have been successfully managed this way
bone exposure, massive contamination
(Figure 4.2).1,3,7,19–21,26–28,32,45 There are inherent risks in
IIIC Massive tissue loss and accompanying arterial injury managing complete nondisplaced fractures by stall
Source: Based on Gustilo et al. 1990.18 Reproduced with permission of rest with cross‐tying, and repeat radiographs can often
Wolters Kluwer Health, Inc. indicate major instability and how close the case came to
www.ajlobby.com
catastrophic breakdown (Figure 4.3). At the very least, the quite satisfactorily with little more than stall rest.
owner needs to be warned of this possibility. Occasionally, a phalangeal or metacarpal incomplete
Additionally, fissure fractures of the phalanges and fracture or a complete but nondisplaced fracture can be
some fractures of the carpal and tarsal bones can heal managed by external coaptation with a cast. Proximal to
the carpus or tarsus, casts may be detrimental when
applied to incomplete, or complete but nondisplaced,
fractures, due to the added torque on the fracture
resulting from the lack of immobilization of the stifle or
elbow.6,15,35 The special case of incomplete fractures
that open into a joint, for example metacarpal condylar
fractures, is better repaired by internal fixation, to
compress the subchondral bone and articular cartilage,
which will optimize reconstruction of the joint surface
and prevent secondary degenerative joint disease.
Complete fractures of the phalanges and long bones in
horses generally displace to some extent. Oblique and
spiral fractures of the humerus, radius, femur, and tibia
can markedly displace and override due to the massive
muscle mass surrounding and attaching to the fractured
bone. In most instances severely overridden bone
ends in adult horses are extremely difficult to reduce
and maintain in apposition while implants are applied.
Nevertheless, some long oblique fractures of the
humerus and femur have healed in a functional malun-
ion with extensive periods of stall rest, due to the sup-
port of the extensive surrounding musculature.10,45
These animals go through significant distress, however,
and this needs to be weighed against the shorter period
of discomfort following internal fixation. Most complete
and displaced fractures in the horse need to be repaired
Figure 4.2 Radiographs of an incomplete fracture of the radius
(arrows) in an adult resulting from a kick to the front of the bone. by internal or external fixation or by external coaptation.
At presentation, the long spiral fractures have inherent stability, The lower body weight of foals makes them better
and the horse was cross‐tied in a stall for six weeks. candidates for internal fixation of all types.7,12,16,38,42

(A) (B) (C) (D) (E)
Figure 4.3 Craniocaudal (A) and lateral (B) radiographs of a complete but nondisplaced fracture of the radius. At presentation there was
pain and swelling on palpation, but no instability. The horse was cross‐tied in a stall for four weeks, and repeat radiographs (C–E) show the
extent of the bridging callus providing progressive fracture healing. The original fracture carries significant risk of destabilization.
www.ajlobby.com
Most transverse, oblique, spiral, or multiple fractures, in fracture reduction, to apply the second plate to the
including Salter–Harris–type physeal injuries, can be fractured bone, or to harvest a bone graft from the
repaired in foals by internal fixation with plates, screws, tuber coxa or sternum.
or intramedullary nails, or, for selected distal limb frac- 6) Adequate recovery room or pool system. A well‐padded
tures, by external fixation. Specific recommendations for recovery room, use of head and tail ropes to assist and
surgery and the choice of implants can be found in the stabilize the horse in recovery, trained personnel for
chapters in Part II. manual assistance in the recovery phase, and many
types of recovery pools all minimize the dangers of
this difficult time in fracture repair.
Fractures in Adults Simple transverse or short oblique fractures give the
best opportunity for effective fracture fixation and
In adults, more careful case selection is required.7,11,25,38,44 healing in adults. Axial weight bearing is absorbed by the
Displaced fractures, especially those with some commi- fracture ends, and the plates and screws provide
nution, of the femur, humerus, tibia, and radius in resistance to torsional and bending forces. Unfortunately,
adult horses can be very difficult to repair. Criteria such fractures are rare in the long bones of adults, in
for
selection of cases for repair include the which most injuries result from substantial impact and
following:1,7,8,11,13–15,37,38,41,43 internal torsional forces that comminute the bone ends.
Transverse, short oblique, or simple multiple fractures
1) Minimal comminution. At least 180° and preferably
are more common in foals. The complex shape of
more of the cortex must be able to carry weight axially
the humerus, femur, and tibia and the tendency for sub-
following internal fixation. Lack of cortical continuity
stantial torque injury in these fractures in adults gener-
opposing the plated surfaces results in cycling and
ally result in long oblique or more complex fracture
eventual failure of the plates and screws.
configurations.
2) Closed fracture. Contamination of major long bone
The third metacarpus and metatarsus in adults are the
fractures in adults generally reduces the chance of a
most frequently repaired axial weight‐bearing long
successful repair substantially. Additionally, costs are
bones in the body.4,7,14,23,30,38,41,43,46 Some comminution
considerably increased, often doubling or tripling the
is common, and with the high energy of this injury the
financial burden.
limited soft tissue cover rarely prevents the fracture
3) Suitable available equipment and implants. A com-
from becoming open. Open comminuted metacarpal
plete stock of broad 4.5 mm dynamic compression
fractures in adults are extremely difficult to get an effec-
plates (DCPs) or limited‐contact dynamic compres-
tive bone union in before implant failure or loosening.
sion plates (LC‐DCPs), dynamic condylar screw
Lower‐energy fractures in adults are good candidates for
(DCS) plates, and 5.5 mm cortical screws, with meth-
surgery if the cortex opposite the anticipated plate site is
ylmethacrylate bone cement for luting of the plate–
intact. In adults, fractures of the metatarsus that enter
bone interface or the screw heads in the plates, is
the nutrient foramen result in compromise to the
essential for adequate long bone fracture repair.
diaphyseal blood supply, and poor fracture healing can
Current case follow‐up on locking compression plates
be anticipated. Additionally, some consideration should
(LCPs) suggests that the LCP must now be considered
be given to avoiding this foramen when applying plate
vital in equine long bone fracture repair.9,24,34 Research
screws to any diaphyseal fracture.
and clinical evaluation of interlocking intramedullary
nails may provide additional implants for effective
equine long bone fracture repair.29,33
4) Calm and sensible horse. Regardless of what implant Fractures in Foals
system is applied to a fracture, a violent recovery will
break plates, screws, the same bone, or another long In foals, most third metacarpal and metatarsal fractures
bone in the body. While postoperative pain control, can be repaired.7,12,42,44 Some short oblique or multiple
well‐designed recovery rooms, and trained personnel fractures with a large butterfly fragment can be ideal
are also imperative, the temperament of the horse candidates for bone plating. In young foals, a single
cannot be overemphasized. broad DCP with additional lag screws to compress the
5) Expeditious surgery. Fracture reduction in adults can butterfly fragment to the larger bone ends can result in
be a time‐consuming and tiring procedure. To mini- primary bone union with minimal callus (Figure 4.4).
mize the delay in the surgery suite, an experienced Nevertheless, severely comminuted fractures can heal in
team of surgeons is an advantage, especially if a sec- a fiberglass cast without any other means of stabilization
ond team with an additional drill can be used to assist (Figure 4.5).
www.ajlobby.com
Physeal fractures represent a special situation, and

(A) (B)
although they often occur in foals and yearlings,
the
epiphyseal portion is generally quite small and
accommodates only a limited number of screws.7,11–13,42
Physeal fractures in young horses have been classified
using the Salter–Harris type I to VI scheme employed
in human pediatrics (Figure 4.6). Most long bone phy-
seal fractures are type II or type IV, although type III
fractures can develop in many bones and are most
common in the proximal epiphysis of the radius or
proximal phalanx (Figure 4.7). Type II and IV fractures
tend to be more destabilizing than type I, III, or VI phy-
seal trauma. As a result, many type II and IV physeal
injuries require surgery, while type III injuries rarely
require internal fixation. For unstable physeal frac-
tures, use of the DCS plate or the cobra head plate
assists in fixation in some locations. However, struc-
tural weakness and splitting of the epiphysis can result
from attempting to place too many screws.2,22 Several
well‐placed 6.5 mm cancellous screws are frequently
adequate for type II and IV fractures (Figure 4.8).
Bridging the physis with the fixation should be avoided
if possible, but in configurations where it is essential,
such as some type I injuries, implant removal is
required within weeks to months after the repair. Injury
to the cartilage layers of the physis is also common,
both during and after fracture and during the repair,
Figure 4.4 (A) Radiograph of a 10‐week‐old foal with a long oblique which often results in premature closure. The conse-
fracture of the third metatarsus with a large butterfly fragment. quences then depend on the age of the foal, the growth
(B) Nine weeks following repair with a single broad 4.5 mm dynamic plate involved, and whether the entire or only part of
compression plate and appropriate lag screws in the butterfly
fragment, the fracture has healed without callus formation.
the physis closes.12,13,42
(A) (B) (C) Figure 4.5 A severely comminuted

fracture of the proximal third metacarpus
in a 16‐week‐old Thoroughbred foal at the
time of injury (A), two weeks following
cast immobilization (B), and seven weeks
following casting (C), showing bony union
by callus formation. Note the osteopenia
of the distal limb and proximal sesamoid
bones associated with prolonged cast
immobilization.
www.ajlobby.com
Type I Type II Type III
Type IV Type V Type VI
Figure 4.6 Salter–Harris physeal injury classification. Type II and IV fractures are the more destabilizing and frequently require internal fixation.
(A) (B)
Figure 4.8 (A) Repair of a Salter–Harris type II physeal fracture of

Figure 4.7 Salter–Harris type III physeal injury of the proximal the distal third metatarsus in a four‐week‐old Percheron foal.
phalanx in a foal. Most type III physeal fractures are inherently (B) Partially threaded 6.5 mm cancellous screws have been placed
stable, and heal with stall confinement. to use the metaphyseal component to stabilize the fracture.
www.ajlobby.com
References
1 Alexander, J. and Rooney, J. (1972). The biomechanics, fractures: a new classification of type III open fractures.
surgery and prognosis of equine fractures 1967–1971. J. Trauma 24: 742–746.
In: Proceedings of the American Association of Equine 18 Gustilo, R.B., Merkow, R.L., and Templeman, D. (1990).
Practitioners, vol. 18, 219–236. Lexington, KY: AAEP. The management of open fractures. J. Bone Joint. Surg.
2 Auer, J. (1988). Application of the dynamic condylar 72 (A): 299–304.
screw (DCS)/dynamic hip screw (DHS) implant system 19 Hance, S., Bramlage, L., Schneider, R., and Embertson,
in the horse. Vet. Comp. Orthop. Traumatol. 1: 18–25. R. (1992). Retrospective study of 38 cases of femur
3 Barr, A. and Denny, H. (1989). Three cases of non‐ fractures in horses less than one year of age. Equine Vet.
displaced radial fracture in horses. Vet. Rec. 125: 35–37. J. 24: 357–363.
4 Bassage, L.H. and Richardson, D.W. (1998). Longitudinal 20 Honnas, C.M. (1992). Surgical treatment of selected
fractures of the condyles of the third metacarpal and musculoskeletal disorders of the forelimb. Humerus.
metatarsal bones in racehorses: 224 cases (1986–1995). J. In: Equine Surgery (ed. J.A. Auer), 1044–1045.
Am. Vet. Med. Assoc. 212: 1757–1764. Philadelphia: WB Saunders.
5 Bowman, K.F. and Fackelman, G.E. (1980). 21 Johnson, P., Allhands, R., Baker, G. et al. (1988).
Management of comminuted fractures in the horse. Incomplete linear tibial fractures in two horses. J. Am.
Compend. Contin. Educ. Vet. 11: 98–102. Vet. Med. Assoc. 192: 522–524.
6 Bramlage, L. (1983). Current concepts of emergency 22 Kirker‐Head, C. and Fackelman, G. (1989). Use of the
first aid treatment and transportation of equine fracture cobra head bone plate for distal long bone fractures in
patients. Compend. Contin. Educ. Vet. 5: 564–573. large animals: a report of four cases. Vet. Surg. 18:
7 Bramlage, L. (1983). Long bone fractures. Vet. Clin. 227–234.
North Am. 5: 285–310. 23 Lescun, T.B., McClure, S.R., Ward, M.P. et al. (2007).
8 Bramlage, L. (1983). The status of internal fixation of Evaluation of transfixation casting for treatment of
long bone fractures in the horse. In: Proceedings of the third metacarpal, third metatarsal, and phalangeal
American Association of Equine Practitioners, vol. 29, fractures in horses: 37 cases (1994–2004). J. Am. Vet.
119–123. Lexington, KY: AAEP. Med. Assoc. 230: 1340–1349.
9 Carpenter, R.S., Galuppo, L.D., Simpson, E.L., and 24 Levine, D.G. and Richardson, D.W. (2007). Clinical use
Dowd, J.P. (2008). Clinical evaluation of the locking of the locking compression plate (LCP) in horses: a
compression plate for fetlock arthrodesis in six retrospective study of 31 cases (2004–2006). Equine
thoroughbred racehorses. Vet. Surg. 37: 263–268. Vet. J. 39: 401–406.
10 Carter, B.G., Schneider, R.K., Hardy, J. et al. (1993). 25 Lundvall, R. (1960). Fractures of the long bones in large
Assessment and treatment of equine humeral fractures: animals. J. Am. Vet. Med. Assoc. 137: 308–312.
retrospective study of 54 cases (1972–1990). Equine 26 Mackey, V., Trout, D., Meagher, D., and Hornof, W.
Vet. J. 25: 203–207. (1987). Stress fractures of the humerus, radius, and
11 Crawford, W. and Fretz, P. (1985). Long bone fractures tibia in horses. Vet. Rad. 28: 26–31.
in large animals: a retrospective study. Vet. Surg. 14: 27 Markel, M. (1990). Fractures of the humerus.
295–302. In: Current Practice of Equine Surgery (ed. N.J. White),
12 Embertson, R.M., Bramlage, L.R., and Gabel, A.A. 652–657. Philadelphia: JB Lippincott.
(1986). Physeal fractures in the horse II. Management 28 Martin, B. and Reef, V. (1987). Conservative
and outcome. Vet. Surg. 15: 230–236. treatment of a minimally displaced fracture of the
13 Embertson, R.M., Bramlage, L.R., Herring, D.S., and radius of a horse. J. Am. Vet. Med. Assoc. 191:
Gabel, A.A. (1986). Physeal fractures in the horse: 847–848.
classification and incidence. Vet. Surg. 15: 223–229. 29 McClure, S.R., Watkins, J.P., and Ashman, R.B. (1998). In
14 Fackelman, G.E. and Nunamaker, D.M. (1982). Manual vivo evaluation of intramedullary interlocking nail fixation
of Internal Fixation in the Horse. New York: of transverse femoral osteotomies in foals. Vet. Surg. 27:
Springer‐Verlag. 29–36.
15 Fessler, J. and Turner, A. (1983). Methods of external 30 Milne, D., Turner, A., and Gabel, A. (1976). Surgical
coaptation. Vet. Clin. North Am. 5: 311–331. approaches to certain long bones of the horse for
16 Gertsen, K.E. and Brinker, W.O. (1969). Fracture repair application of tension band plates. J. Am. Vet. Med.
in ponies using bone plating. J. Am. Vet. Med. Assoc. Assoc. 168: 48–52.
154: 900–905. 31 Muller, M.E., Allgower, M., Schneider, R., and
17 Gustilo, R.B., Mendoza, R.M., and Williams, D.N. (1984). Willenegger, H. (1990). Manual of Internal Fixation, 3e.
Problems in the management of type III (severe) open New York: Springer‐Verlag.
www.ajlobby.com
32 Pilsworth, R. and Webbon, P. (1988). The use of 40 Turner, A. (1982). Long bone fractures in horses part
radionuclide bone scanning in the diagnosis of tibial III. Postoperative management. Compend. Contin. Educ.
stress fractures in the horse: a review of five cases. 4: 254–257.
Equine Vet. J. 6: 60–65. 41 Turner, A., Milne, D., and Gabel, A. (1976). Use of the
33 Radcliffe, R.M., Lopez, M.J., Turner, T.A. et al. (2001). An in dynamic compression plate for treatment of equine
vitro biomechanical comparison of interlocking nail long‐bone fractures. J. Am. Vet. Med. Assoc. 168:
constructs and double plating for fixation of diaphyseal 309–315.
femur fractures in immature horses. Vet. Surg. 30: 179–190. 42 Valdez, H., Morris, D., and Auer, J. (1979). Compression
34 Richardson, D.W. (2008). Less invasive techniques for plating of long bone fractures in foals. Vet. Comp.
equine fracture repair and arthrodesis. Vet. Clin. North Orthop. Traumatol. 1: 10–18.
Am. Equine Pract. 24: 177–189. 43 von Salis, B. (1972). Internal fixation in the horse:
35 Schneider, R.K., Milne, D.W., Gabel, A.A. et al. (1982). recent advances and possible applications in private
Multidirectional in vivo strain analysis of the equine practice. In: Proceedings of the American Association
radius and tibia during dynamic loading with and of Equine Practitioners, vol. 18, 193–218. Lexington,
without a cast. Am. J. Vet. Res. 43: 1541–1550. KY: AAEP.
36 Toth, V.J., Kokeny, G., and Tamas, L. (1987). Ein Beitrag 44 Winstanley, E.W. (1974). Aspects of the compression
zur Osteosyntheses beim Pferd. Mh. Vet.‐Med. 42: 97–99. treatment of fractures. Vet. Rec. 95: 429–433.
37 Turner, A. (1979). Further experiences with the use of 45 Zamos, D.T. and Parks, A.H. (1992). Comparison of
the dynamic compression plate (DCP) in equine surgical and nonsurgical treatment of humeral fractures
longbone fractures. Aust. Vet. Pract. 9: 43–54. in horses: 22 cases (1980–1989). J. Am. Vet. Med. Assoc.
38 Turner, A. (1982). Long bone fractures in horses part I. 201: 114–116.
Initial management. Compend. Contin. Educ. Vet. 3: 46 Zekas, L.J., Bramlage, L.R., Embertson, R.M., and
347–353. Hance, S.R. (1999). Results of treatment of 145
39 Turner, A. (1982). Long bone fractures in horses part II. fractures of the third metacarpal/metatarsal
Intraoperative techniques. Compend. Contin. Educ. 4: condyles in 135 horses (1986–1994). Equine Vet. J.
196–200. 31: 309–313.
www.ajlobby.com
44
5
Racetrack Fracture Management
and Emergency Care
Ian M. Wright
Newmarket Equine Hospital, Newmarket, UK
Introduction Racehorses have a commodity value either for contin

ued racing or for subsequent breeding purposes. Some
Fractures of the appendicular skeleton are an owners will choose to protect this, at least in part by pur
unfortunate but inevitable consequence of racing
chase of insurance. Coverage for most racehorses is
horses. Musculoskeletal injuries (of which fractures available on “All Risk Mortality (ARM)” terms. Many
predominate) are the commonest fatal racetrack inj horses also will have considerable emotional or senti
ury.2,8,9,34,35,49,50,81,82,86,112 In the USA, it has been mental value to owners and other connections that will
reported that between 1 in 600 and 1 in 800 Thoroughbred markedly influence decision‐making in the face of injury.
runners sustains a catastrophic injury.34,35,43,86 In one
calendar year (1991), complete fractures of long bones
accounted for 32% of deaths in racehorses during train Fracture Pathogenesis
ing and racing in California.105 All involved with the rac
ing industry have a moral obligation to limit their Considerable external force is necessary to fracture nor
incidence but, at the limits of athletic endeavor, fractures mal equine bone. Such high‐energy single‐event injuries
can never be eliminated. Fractures that occur during the (monotonic fractures) may occur with falls and thus are
racing and training of Thoroughbreds receive most most common during jump races.2,67,91 Most other rac
attention in the literature and lay press,23,24,49,50,67,91 but ing fractures are fatigue injuries in which the breakdown
fractures occur in all breeds and all types of rac of osseous infrastructure results from cumulative stress/
ing.41,50,76,79,103,110,119,122 The chapter is restricted to man strain imbalance.91 This in turn may have occurred over
agement of fractures of the appendicular skeleton. In a long period of time or, potentially, during the course
racing, fractures of the axial skeleton (particularly the of a race. There is compelling basic science57,92,95,96 and
cervical vertebrae) are almost exclusively associated with epidemiological data70,81–83 that support the protective
jump racing falls. The reader is directed to Chapters 40 effect of stress adaptation (training) in preventing frac
and 41 for consideration of the potential neurological tures. Failure of adaptation and/or fatigue of supporting
implications of these, and also to the specialist texts of soft tissues contribute to fracture pathogenesis by expos
Furr and Reed38 and Mayhew.65 ing bone to forces beyond its ultimate strength. Loads on
On‐call veterinarians at racetracks must use astute the appendicular skeleton due to locomotion have a lin
clinical skills, often with only field/ambulatory diagnos ear relationship with speed.26,78,94 Development of
tic support. This work demands prompt decisive action, microcracks is a “normal” adaptive response to cyclical
frequently conducted in an environment of public scru loading of bone63,85,126 and there is strong circumstantial
tiny. Attending veterinary surgeons have an ethical evidence that microdamage itself is a stimulus for remod
responsibility to provide optimal care for animals which eling.17,61,108 However, progressive microdamage results
are injured during racing. In addition, there are impor in a decline in the stiffness and ultimate strength of
tant public relations, financial, and litigious considera bone.21,37,99 Furthermore, the reduced stiffness of bone
tions. However, patient care is paramount and must not exacerbates the risk of clinical fracture, because greater
be compromised by other considerations. deformation of the bone in response to a given load will

www.ajlobby.com
increase microdamage, and hence a vicious circle is cre On the racecourse, screens should be available of suf
ated.21,62,91 A stress fracture may be considered the ficient number and size to permit evaluation and initial
extension of microscopic fatigue damage to a macro case management out of the public gaze. Screens should
scopic scale.91 However, as already outlined, the repair be of sufficient height to obscure spectators’ sight lines
mechanism of bone (remodeling) paradoxically can con from grandstand views. They should be positioned with
tribute to the development of clinical fracture.61 this in mind, but sufficiently distant from the horse to
The majority of training and racing fractures have an permit complete access to the horse, and strategic ambu
articular component. They are associated with high‐ lance positioning, without adding to the horse’s anxiety.
speed work, occur in the absence of specific trauma, At least one set of screens (48 ft/14.5
m long and
arise in consistent locations, and follow a predictable ≥8 ft/2.5 m high72) should be with the racetrack veteri
course through the bone, thus meeting the criteria for narian or equine ambulance, accompanied by an ade
classification as stress fractures. Additionally, evi quate number of trained personnel.
dence of incomplete fractures at similar locations is Effective, humane management of racetrack fractures
supportive evidence of progressive failure at these requires careful planning and the establishment of pro
sites.91,105,106 However, longitudinal studies are lack tocols suitable for dealing with all equine emergencies at
ing, and clinical and radiological evidence of pre‐exist all possible sites on the racetrack. A team approach is
ing adaptive failure is not consistently found at fracture critical. Dependent on the track, a number of teams,
sites. Additionally, the association between cumula each led by an experienced veterinarian, will be neces
tive exercise and risk of injury is complex and sary. Free movement, knowledge of routes, and access to
nonlinear.9,22,81,113 all parts of the racetrack is paramount. Designation of
Most catastrophic injuries occur when racetrack con spectator‐free emergency routes for horses, ambulances,
ditions are fast.44,45,70 Complete fractures which occur and veterinary and medical attendants is desirable. Radio
during racing and training will readily displace, and communication from team to team and with racetrack
cause extensive soft tissue damage before the horse officials is essential. Exchange of veterinary information
stops or can be pulled up. The spectacle of such injuries frequently is sensitive and should be done discreetly and
frequently draws media and public attention. The pri only to authorized individuals. Each team should be
mary objective at that moment is control: first of the comprehensively equipped for its area of service, and the
horse and then of the unstable limb. Once these are inventory of drugs and splinting materials checked
achieved, logical clinical decision‐making can follow. before racing commences. In addition, equipment for
Use of a bridle or placing a Chifney anti‐rearing bit is catching, restraining, and rolling horses on the track is
highly recommended. Triage is important, particularly necessary. This should include head collars, halters, bri
on the racetrack. For descriptions of the clinical fea dle, lead ropes (3 m), long ropes (10 m), and a twitch.
tures, diagnosis, treatment options, and prognosis asso Suitable techniques and drugs for euthanasia, including
ciated with individual fractures occurring during racing, intravenous catheter sets, also are necessary.
the reader is directed to the appropriate chapters in Part Esthetics and public awareness are important, but con
II of this text. sideration of horse welfare, of which the veterinarians
are guardians, is paramount. Most horses can be
humanely moved from the racetrack for a more consid
Initial Fracture Management ered evaluation. In the majority of circumstances, this
raises the accuracy of the diagnosis, recognition and
Fractures should be a principal differential for all racing‐ assessment of additional clinical issues, and dialog with
or training‐induced lameness. In the acute phase this is connections before a definitive opinion on management
irrespective of the degree of lameness. Horses with is given. Euthanasia of some horses with fractures will be
incomplete fractures, and even some with complete but necessary on the racetrack, but should be reserved for
nondisplaced fractures, can initially exhibit relatively animals in which there is confidence in the inhumanity
mild lameness, particularly while still agitated at the end of movement in the face of a hopeless prognosis.
of a race. Localizing clinical signs commonly then
worsen. Accurate diagnosis requires further investiga
tion, which may involve radiographic examination. Regulatory Considerations
Multiple projections are necessary; however, in the acute
phase some common racing fractures can be radiologi Regulatory aspects of racetrack fracture management
cally silent. Support appropriate to the region of the vary throughout the world and are outside the scope of
limb is then initiated until more definitive diagnostic this chapter. Racetrack veterinarians must be aware of
information is available. prevailing legislative guidelines in cases which justify
www.ajlobby.com
destruction on humane grounds. While discussion with Arrange for a second opinion from another veterinary
owners or their authorized representatives (frequently surgeon.
the trainer) is recommended, there will be instances
It is essential that the attending veterinarian keep a writ
when this is not possible or practical, or when permis
ten record of the injuries, horse identification, and the
sion to euthanize a horse is withheld. Additionally, there
date, time and place. The owner or agent should sign a
may be insurance implications.
euthanasia consent form. Insurance companies frequently
Following assessment, and based on the information
require a post mortem examination, and this must be
given by the racecourse veterinarian, owners or the own
borne in mind when arranging for disposal of the carcass.
ers’ representative may decide to have a horse with a
A supplementary guide to best practice for veterinary
fracture euthanized. This may be based on the poor
surgeons when considering euthanasia on humane grounds
prognosis issued by the veterinarian, or estimates of sub
where horses are insured under an ARM insurance policy
stantial medical costs, or for philosophical concerns
was issued by BEVA in 2008. The guideline is considered to
based on their previous (often unrelated) experience
deal with the emergency situation, for example on the race
with injured horses.
course, where immediate action must be taken by the
Some racehorses may be insured under ARM (Great
attending veterinary surgeon. The decision to advise an
Britain) insurance policies. In order to justify a claim in
owner to destroy a horse on humane grounds must be the
the USA, insurers require compliance with the guide
responsibility of the attending veterinary surgeon, based
lines for recommended euthanasia issued by the
on their assessment of the clinical signs at the time of
American Association of Equine Practitioners (AAEP),
examination, regardless of whether or not the horse is
or the British Equine Veterinary Association (BEVA),
insured. The veterinary surgeon’s primary responsibility
which have generally been adopted by most racing juris
is to ensure the welfare of the horse. The best practice
dictions worldwide. The AAEP also has suggested fur
guide indicates that, if there is a clear‐cut case for imme
ther guidelines through its Insurance Brochure Revisions
diate euthanasia on humane grounds, delay should be
(2008–2009). These modifications have not been
avoided. Ideally, a second opinion should be sought from
accepted by the insurance industry, principally because
a professional colleague, but welfare must take priority and
they do not comply with the wording of ARM insurance
this should not involve any undue delay. Post‐mortem
policies.
findings may be needed to corroborate any decision made.
Under the standard terms of an ARM insurance policy,
If there are suspected but not definite grounds for
humane destruction means:
immediate euthanasia, then it is essential that a second
1) That the horse incurs an injury or is afflicted with an opinion is sought before proceeding. Additionally, insur
excessively painful disease and a veterinary surgeon ance companies should also be informed and given the
appointed by the underwriters shall first have given a option of having their own veterinary surgeon examine
certificate that the suffering of the horse is incurable the horse or at least provide verbal advice. If there are no
and so excessive that immediate destruction is imper grounds for immediate euthanasia in the opinion of the
ative for humane reasons, or attending veterinary surgeon, but the owner insists on
2) That the horse incurs an injury and a veterinary surgeon euthanasia, the attending veterinarian should inform the
appointed by the insured shall first have given a certifi owner that it may invalidate their insurance claim.
cate that the suffering of the horse is incurable and so Findings should be documented and the owner asked to
excessive that immediate destruction is imperative for sign a Request for Euthanasia form, indicating that the
humane reasons without waiting for the appointment of animal has been destroyed at their request. It is recog
a veterinary surgeon by the underwriters. nized that there will be circumstances, for example,
when the estimated cost of treatment may not be an eco
The BEVA guidelines for compliance with a claim nomical proposition when compared to the animal’s
under an ARM insurance policy are as follows: value. The BEVA Guide emphasizes that these are mat
That the insured horse sustains an injury or manifests an ters of negotiation between the insurance company and
illness or disease, that is so severe as to warrant imme owner, and not for the veterinary surgeon to decide.
diate destruction to relieve incurable and excessive
pain, and that no other options of treatment are avail
able to that horse, at that time. Incidence and Risk Factors
If immediate destruction cannot be justified then the
attending veterinary surgeon should provide immedi Numerous epidemiological studies of racetrack injuries
ate first aid and treatment before: 1. Requesting that have identified potential risk factors associated with
the insurance company be contacted or, failing that, 2. fractures. These include gender, age, age at first race,
www.ajlobby.com
frequency of racing, career duration and intensity, A more recent study indicated that the incidence of
individual trainers and training schedules, class, value, catastrophic distal limb fracture at racetracks in the UK
speed, distance, position and numbers in a race, weather was 1 in 1394 starters overall.83 The lowest incidence
and seasons, contact during races, pre‐existing ortho occurred with flat racing on turf (1 in 2657 starters), fol
pedic compromise, lay‐up time, shoes, individual lowed by flat racing on all‐weather surfaces (1 in 1398
surfaces and racetracks, and results of prerace
starters), hurdle races (1 in 1070 starters), steeplechase
inspections.1,2,9,20,24,25,31–33,35,43,46,55,70,75,80–84,89,113,121 An races (1 in 730 starters), and, finally, the highest was in
increased risk of musculoskeletal injury has been National Hunt flat races (1 in 460 starters).
reported on firm/fast turf track conditions,2,9,80,81,117 In New Zealand, steeplechases resulted in 1 death per
while other researchers have found no such association.1 90 starters and hurdle races 1 fatality per 167 starters.11
Some studies have reported no association between Similar results for fatal musculoskeletal injuries were
injury rates and dirt track conditions,86 some indicate reported in Australian studies, with incidences of 1 in
an increased incidence in fast conditions,44,46,70 and 159 and 1 in 173 for hurdle races, and 1 in 70 and 1 in 90
others an increased risk of fractures on softer dirt
for steeplechase races.2,10 The latter study also recorded
surfaces.93,119 a fatality rate of 1 in 2500 starters in flat racing.
In the USA, lower rates of severe musculoskeletal
injuries have been reported on turf compared to dirt
tracks.44,46,50,70,120 In the UK, a similar difference was Clinical Assessment
recorded between turf and “all‐weather” surfaces.117 All
studies report that forelimb injuries account for the The responsibilities of the racecourse veterinarian can
majority of catastrophic injuries in all forms of racing be summarized as (i) relief of pain and anxiety; (ii) estab
and on all surfaces, and this has been quantified at 90% in lishing a diagnosis; (iii) facilitating repair and/or healing;
the USA,86 81% in the UK,117 and 82% in South Africa.60 and (iv) moving the horse to optimal facilities for care
In jump racing, between 42 and 60% of fatalities have and investigation. Systematic evaluation of limb dys
been reported to be associated with falls.10,30,67,88,112 function, abnormal limb position or posture, pain, crepi
Several studies indicate that more horses sustain tus, and local skin trauma should be performed on all
fractures during training than when racing,4,114 although injured horses. A precise diagnosis is often not possible
two Californian studies report similar numbers of cata on the racetrack itself. The most important initial deci
strophic musculoskeletal injuries (predominantly frac sions are to establish whether a fracture is or may be pre
tures) during racing and training.33,49,50 Since the number sent, the bone or bones that may be involved, the
of horses training far exceeds the number running in a classification of the suspected fracture (based on clinical
given period of time, the incidence of catastrophic frac examination), and the presence or absence of additional
ture occurring during training is lower in these studies problems. The value of assessing the whole horse cannot
compared to fractures occurring during racing. Similar be overstated.
results were reported in Japan, with a 20‐fold increase in Visual assessment is important; the animal’s posture
risk of fracture in racing compared to training.111 frequently is revealing. A visual assessment of the limbs
A number of studies document fracture and fatality should include appraisal of angles and alignment, seg
rates during racing. Data from horses racing on New ment lengths, and developing swellings and distensions.
York Racing Association tracks between 1983 and 1985 Careful palpation follows. This should be meticulous,
revealed an overall fracture incidence of 1 per 510 run since localizing clinical signs in the peracute phase often
ners, which was separated to 1 per 470 runners on dirt can be subtle. Palpation commonly can reveal the first
surfaces and 1 fracture per 950 runners on turf.44 The signs of an acute inflammatory response (principally
difference in incidence was statistically significant. There pain and swelling) and can localize, with reasonable con
were no significant differences resulting from track con fidence, the region of injury. Digital pressure over frac
ditions. A report of jump racing in Virginia recorded ture sites frequently will be resented. If necessary,
fatality rates of 1 in 322 for hurdle races and 1 in 164 for cautious manipulation can follow in order to assess the
timber races.104 range of motion and to detect crepitus and signs of pain.
Data collected from all racetracks in the UK between Hemorrhage due to laceration of major vessels is
1987 and 1993 recorded a fatality rate of 1 per 1250 run uncommon with fractures distal to the elbow or stifle
ners in flat racing, 1 in 200 in both National Hunt flat joints, but can be significant proximal to these levels.
and hurdle races, and 1 in 142 starts for steeplechase In such cases, assessment and management of hypov
races.67 The fatality rate varied by a factor of 7 between olemic shock are logical, but, in the absence of tech
individual flat race tracks, 5 for hurdle tracks, and 4 for niques for acute stabilization of proximal limb fractures,
steeplechase courses. generally are futile. Of greater concern in the distal limb
www.ajlobby.com
are vasospasm following repeated stretching and/or foreshortened. Dosage should be determined not only by
direct trauma to vessels, which can lead to vascular com the animal’s size but also its demeanor at the time, the
promise of the distal limb.13 nature of the injury, the efficacy of limb immobilization,
Despite the limitations of evaluating the acutely injured and later transport considerations. Xylazine also can
animal, meticulous clinical examination can localize the safely be repeated, which is an advantage.
site of injury and provide a differential guide to fracture Other α‐2 adrenoceptor agonists, such as detomidine or
type. If immediate destruction of the animal on humane romifidine, offer longer duration of action. These fre
grounds is not necessary, support can be applied to the quently also are combined with opioid analgesics, princi
limb and the horse moved off the racecourse for more pally butorphanol (see the next section). It has been
detailed evaluation. Secondary factors such as age, gen claimed that romifidine may cause less ataxia than deto
der, value, and owner/trainer’s desire then can be given midine,73 but this has not been evident in management of
consideration before further recommendations are made. racetrack fractures, and the lower volume of detomidine
The timing of radiographic examination is important. used is an added advantage. A combination of 5 mg deto
In the presence of an unstable fracture, this should be midine and 10 mg butorphanol has been suggested.39 The
delayed until the limb has been temporarily immobi author recommends syringes prefilled with 8 mg detomi
lized. This will improve comfort and hence improve dine and 10 mg butorphanol for veterinarians following
the quality of radiographic information, as well as limit races. The doses required for control of horses which have
additional soft tissue damage. Digital radiographic sys been injured or pulled up in the course of a race are higher
tems have improved the diagnosis of racetrack fractures, than usually recommended. Immediately after maximal
frequently permitting rapid, accurate diagnosis, and
exercise, up to twice the standard dose of sedatives may be
optimizing acute care, formulation of management necessary to achieve effective clinical sedation.42
plans, and establishing a prognosis. They also permit All α‐2 adrenergic agonists have some analgesic activ
remote consultation. Conventional computed radiogra ity,27 although this is reported to be greatest with xyla
phy (CR) equipment can be installed in a van or trailer. zine. However, they can cause long‐lasting reduction in
The principal disadvantage is lack of flexibility and delay gastrointestinal motility with repeated administration.27
in viewing the image, but there are few disadvantages This can be of concern when combined with other rec
with respect to information obtained and capability of ognized predisposing factors to colic such as reduced
onward transmission. exercise, dietary change, stress, and administration of
phenylbutazone, which all are commonly part of clinical
fracture management.
Sedation Phenothiazine tranquilizers are less desirable, as the α‐
adrenergic blockade they produce may cause sufficiently
Sedation usually is necessary for the application of emer severe hypotension to result in fainting in animals with
gency support after racetrack injuries, and frequently high circulating levels of catecholamines.13,73 Thus,
is needed to control animals for clinical assessment. acepromazine maleate is not generally recommended,
Required speed of onset necessitates intravenous admin although it has good antianxiety activity, and can be com
istration. Alpha‐2 adrenergic agonists are most suitable bined (at 0.02 mg kg−1 intravenously) with other sedative/
and recommended dose rates are given in Table 5.1. analgesic combinations in order to produce more profound
Intravenous xylazine provides good short‐duration (up sedation (and therefore control) of distressed horses. It
to 20–25 minutes) sedation and has good analgesic prop also will prolong the activity of other sedative/analgesic
erties with minimal side effects.13,39,52,73 With agitated combinations. This can be particularly useful while await
horses, the period of sedation obtained frequently is ing decisions on euthanasia of horses with severe racetrack
fractures. Caution must be afforded to its vasodilatory
Table 5.1 Sedatives useful for injured race horses.
and hypotensive properties, and also to its suggested con
traindication in entire males. In emergency situations,
the potential benefits may outweigh the risk of priapism.
Sedative Dose (mg kg−1)
Xylazine 0.2–2.2
Detomidine 0.01–0.02
Analgesia
Romifidine 0.04–0.12
The first and foremost form of analgesia in equine acute
Medetomidine 0.003–0.007 fracture management is correctly applied support and
Sources: Adapted from Cantwell and Robertson 2006;19 Driessen immobilization of the region. Clinical analgesic agents
2008;27 Swor and Watkins 2008.107 are never an adequate substitute for effective splinting.
www.ajlobby.com
Tissue damage and inflammation cause acute pain. Table 5.2 Opioid types and dosages for equine pain control.
Activation of high‐threshold pain receptors (nocicep
tors) sends electrical signals from the periphery to the Opioid Dose Route Interval (h)
spinal cord and brain in multiple parallel neuroanatomic
pathways.74 This is mediated principally by large myeli Morphine 0.1–0.7 mg kg−1 i.v. or i.m. q 4–6
nated A‐δ fibers.19 Acute pain and inflammation lead to Methadone 0.1–0.2 mg kg−1 i.v. or i.m. q 4–6
upregulation of nociceptive pathways within minutes of Butorphanol 0.04–0.4 mg kg −1
i.v. or i.m. q 2–4
the inciting cause. For this reason, analgesics are most
i.m., intramuscularly; i.v., intravenously; q, every.
effective when administered as early as possible in the Sources: Adapted from Kalpravidh et al. 1984a, b;51,52 Bennett and
pain cycle.74,109 The time of onset of pain, as distinct Steffey 2002;6 Mudge and Bramlage 2007;73 Driessen 2008;27 Love
from the anxiety associated with loss of limb support or et al. 2009.59
control, is impossible to determine. That some horses
continue to gallop after suffering a fracture, showing
signs of pain only later, may be akin to the latent pain
syndrome seen in high catecholamine‐charged human Opioids carry an increased risk for ileus, particularly
injuries.109 with repeated administration,27 and with well‐stabilized
Nonsteroidal anti‐inflammatory drugs (NSAIDs) have fractures usually are unnecessary.39 It has been sug
been the foundation of equine pain management. They gested107 that butorphanol should be avoided with fore
exert an anti‐inflammatory effect by inhibiting the limb fractures because it causes the horse to lean forward
cyclooxygenase (COX) enzymes, thus decreasing release and thus increases difficulty in standing. In the author’s
of prostaglandins and thromboxane. They also have experience, if butorphanol is used judiciously, its bene
central activity. NSAIDs reduce platelet adhesion,
fits have outweighed any disadvantages.
which may help in reducing intravascular thrombosis.14 Transdermal fentanyl patches are a useful adjunct to
In most cases, once the horse has been restrained and acute pain management.19,64 Two or three 10 mg patches
the limb appropriately immobilized, little analgesia over placed on a shaved area of skin can confer 48–72 hours of
and above the usual NSAIDs is necessary. Phenylbutazone continuous analgesia commencing within 1 hour of
(2.2–4.4 mg kg−1 intravenously) is the NSAID of choice application. This also can safely be repeated.
for musculoskeletal pain.27 Flunixin meglumine Caudal epidural administration of analgesic agents has
(1.1 mg kg−1 intravenously) or ketaprofen (2.2 mg kg−1 theoretical advantages for some acute, hindlimb inju
intravenously) are alternatives, but in the author’s prac ries,27 although it has received limited use in acute race
tice phenylbutazone has demonstrated greater clinical track practice, principally because of the risks of ataxia
efficacy. and necessity of transporting the majority of patients.
Opioids (e.g., morphine, methadone, and fentanyl) and However, it can be useful for acute pain control with pel
opioid agonist‐antagonists (e.g., butorphanol) act via vic or other hindlimb fractures73 in racetrack stables
specific receptors in the brain and spinal cord. Recently, and/or clinics. Epidural morphine (0.1 mg kg−1) and epi
peripheral receptors also have been recognized.6,100 They dural methadone (0.1 mg kg−1) are claimed not to cause
inhibit c‐fiber transmission and reduce inflammatory excitement or ataxia.19 The latter has a quicker onset of
pain by inhibiting release of substance P.19 Opioids have activity (15 minutes) and lasts 3–7 hours; the former has
well‐documented analgesic properties53,54,90 but a num a duration of action of 6–24 hours, but onset takes
ber of undesirable side effects.6 Most opioids cause a between 45 and 60 minutes. Both are given slowly in
dose‐dependent increase in muscle tone and locomotor 20 ml of saline through an epidural catheter. For further
activity (when given to horses not in pain) that appears information on technique, the reader is directed to
as central excitation.13,19,27,73 When given to horses in Driessen.27 Morphine (0.2 mg kg−1) with xylazine hydro
acute pain, excitatory effects of opioids at clinically rec chloride (0.17 mg kg−1), or morphine (0.2 mg kg−1) plus
ommended doses are uncommon. Nonetheless, opioids detomidine hydrochloride (0.03 mg kg−1), is an alterna
most frequently are given in combination with α‐2 adr tive recommendation.107
energic agonist sedatives.13,19,27,73 Although the latter
diminish the risk of undesirable excitement and opioids
appear to enhance the sedative potency of the α‐2 adren Wounds
ergic agonists, the evidence for synergistic analgesia is
mixed.6 Doses are empiric, but recommendations are On the racetrack itself, little time should be given to
detailed in Table 5.2. The author recommends use of cleansing wounds associated with fractures. These
opioids only in those horses that have an inadequate should be covered and the limb appropriately supported
response to phenylbutazone. for removal of the horse from the track to on‐course
www.ajlobby.com
c linical areas. Here, wounds can be assessed and treated Principles of Temporary
in line with case management. Surgeons vary in their Immobilization
preferred on‐track wound protocol prior to referral of
fractures. The author’s preference is for minimal inter Temporary immobilization of fractures that occur on the
ference, i.e., removal of gross debris only, minimal wound racetrack should be considered in two phases: (i) from the
exploration, no clipping, and no local antiseptic or anti racetrack to clinical areas; and (ii) from the racetrack clini
microbial application. In the distal limb the wound can cal facility to a suitable hospital. If at either stage a fracture
be covered with a nonadherent dressing and appropriate or suspected fracture can be localized, then appropriate
temporary support applied prior to hospital referral. In support should be applied. Distal limb support should be
the proximal limb a sterile gauze pad (stent bandage) can avoided in the presence of proximal limb fractures, as the
be oversewn or glued on to minimize further contamina bandage/splint weight can act as a pendulum, increasing
tion and to protect the tissues in transit. Adequate teta the horse’s pain and ambulatory compromise, and poten
nus prophylaxis should be assured in all cases. In the tially exacerbating fracture displacement. Stable fractures
presence of a wound, broad‐spectrum antimicrobial may not benefit from temporary immobilization per se,
administration is appropriate.14 Suitable currently avail but support still can be useful in neutralizing potential dis
able antimicrobial agents for intravenous use are listed tracting forces, and applying counterpressure. The forces
in Table 5.3. to be neutralized are determined by the individual fracture
Commonly recommended broad‐spectrum antimicro site, its orientation and configuration and by the forces act
bial combinations used for initial (racetrack) administra ing over this area.13,15 Osseous discontinuity means that in
tion to fracture patients include: many cases the fracture becomes, in addition to joints, a
1) Potassium benzyl penicillin (22 000 iu kg−1) with further focus of movement frequently outside the normal
gentamicin sulfate (2.2 mg kg−1 intravenously or parasagittal range of equine limbs. Additionally, the sup
6.6 mg kg−1 intravenously). porting suspensory and reciprocal apparatus, which relies
2) Sodium benzyl penicillin (30 000 iu kg−1 intravenously) on an intact osseous column, often becomes dysfunctional,
with gentamicin as above. which challenges effective temporary immobilization.13,14
3) Potassium or sodium penicillin (as above) with Horses with appendicular fractures frequently exhibit
amikacin (3–4 mg kg−1 intravenously or 10 mg kg−1 “lifting and placing” activity with the fractured limb, accom
intravenously). panied by variable attempts at limb loading. This is highly
4) Sodium ceftiofur (4 mg kg−1 intravenously), or similar destructive to fracture margins, resulting in fragmentation
cephalosporin, with gentamicin or amikacin (as and eburnation that can preclude or compromise the poten
above). tial for reconstruction. Additionally, it can traumatize asso
ciated articular surfaces. Most horses cease this movement
once temporary immobilization has been applied. Loading
may remain reduced or absent, but abolishing the repetitive
Table 5.3 Antimicrobial drugs suitable for administration movement contributes to preservation of osseous and oste
to racetrack fracture patients. ochondral tissues, together with soft tissue and neurovascu
lar elements. Soft tissue preservation and maintenance of
Antimicrobial Dosage, Route, and Frequency vascular integrity are vital to successful repair and healing of
equine fractures.13,14,68 Preservation of skin and avoiding
Amikacin sulfate 10 mg kg−1 i.v. q 24 h
or
open fractures are also critical to case outcome. Equine skin
3–4 mg kg−1 i.v. q 8 h is thin and readily penetrated by the sharp ends of a frac
Ampicillin sodium 10–100 mg kg−1 i.v. q 8 h
tured bone. A correctly applied splint protects the fracture
and provides counterpressure to the limb. Control of the
Cefazolin sodium 11–25 mg kg−1 i.v. q 6–8 h
swelling itself will contribute to analgesia.
Ceftiofur sodium 2–4 mg kg−1 i.v. q 8 h The objectives of acute immobilization can be summa
Cefquinome sulfate 1 mg kg−1 i.v. q 12 h rized as:
Enrofloxacin 5 mg kg−1 i.v. q 24 h
neutralization of distracting forces
6.6 mg kg−1 i.v. q 24 h
●●
Gentamicin sulfate
or ●● relief of pain and anxiety
2.2 mg kg−1 i.v. q 8 h ●● application of counterpressure
Benzyl penicillin sodium −1
20 000–40 000 iu kg i.v. q 6 h ●● protection of soft tissues.
−1
Benzyl penicillin potassium 20 000–40 000 iu kg i.v. q 6 h
If the fracture location has been determined on the track,
i.v., intravenously; q, every. then temporary immobilization should be applied.123,124 If
www.ajlobby.com
the region of the suspected fracture cannot be determined, mal metacarpus or metatarsus requires 3 rolls of cotton
then it is preferable to move the animal carefully to a clini wool, 12–14 rolls of conforming gauze, and approximately
cal facility for further evaluation, rather than to apply inap 4 rolls of elasticized bandage (Figure 5.1). A full limb
propriate support. Whenever possible, the limb should be Robert Jones bandage, extending to the level of the elbow
stabilized by incorporating articulations proximal and dis joint, requires 6–8 rolls of cotton wool, 20–24 rolls of
tal to the fracture. Splinting should neutralize bending and gauze, and 8–10 rolls of elasticized bandage (Figure 5.2).
distracting forces on the fracture. The term “modified Robert Jones bandage” describes
a bandage of similar design but with less bulk. This
Techniques for Temporary
Immobilization
Temporary immobilization of fractures or suspected
fractures can be accomplished by the application of
bandages, splints, casts, or combinations thereof.123 The
advantages and disadvantages of each must be assessed
in the light of individual bony compromise.
Robert Jones Bandages

A Robert Jones bandage relies on the provision of a mass
of conforming material sufficient to resist the movement
across a fracture.15,16 The Robert Jones bandage should
increase the diameter of the leg by a factor of 314,73 and
create a parallel‐sided tube. It consists of multiple layers
of cotton wool, each held in place and compressed by
elastic gauze. Each layer in turn is applied more tightly
than the previous. To be effective the bandage must be
layered, each less than 2 cm thick. Thicker layers result in
shifting and compaction, leading to uneven pressure and
immobilization of joints rather than the fracture site.14 Figure 5.1 A Robert Jones bandage applied from the bearing
Wide (150 mm) conforming gauze such as Kling™ surface to the proximal metacarpus.
(Johnson and Johnson, New Brunswick, NJ, USA), Knit
Firm™ (Millpledge Veterinary, Retford, Notts, UK), or
Conform™ (Kendall Animal Health/Kendall, Dublin, OH,
USA) is suitable to compress cotton wool layers. Cotton
wool rolls torn in half are more readily contoured to
the limb and strips of the same can be used to provide
further filler layers as required, but particularly at the
top and bottom of the bandage. Each circumferential
passage of the cotton wool should overlap the previous to
avoid creasing. The initial layers of gauze are applied with
finger pressure, while at the end there should be suffi
cient cotton wool bulk that the gauze can be pulled as
tight as possible. The bandage is finished by application
of self‐adhesive tape such as Tensoplast (BSN Medical,
Hamburg, Germany), Elastikon™ (Johnson and Johnson,
Skillman, NJ, USA), Elastient™ (Vet‐1, Hampshire, UK),
Flexoplast™ (Robinson Animal Healthcare, Worksop,
UK), or similar materials. Use of zinc oxide (white) tape
on the ends of the adherent tape bandage can help with
security, while application of duct tape aids in fixation to
the foot and offers a degree of protection from soiling.
Immobilization of the distal limb by application of a Figure 5.2 A full forelimb Robert Jones bandage extending to the
Robert Jones bandage from the bearing surface to proxi level of the elbow.
www.ajlobby.com
(A) (B) Figure 5.3 (A) A full forelimb Robert Jones bandage with
lateral and caudal splints applied before incorporation into
the construct. (B) Note the lateral splint extends proximal
to the elbow joint while the caudal splint terminates distal
to the apex of the olecranon. These will be fully secured
into the bandage by further elasticized bandage or duct
tape.
ecessarily will be less effective as a form of immobiliza

n lateral forelimb splint of 84 cm to span from elbow to
tion. However, it can be useful to provide counterpres ground in a 450 kg horse.115
sure and may be a more stable base for the application of To add a splint to a full forelimb Robert Jones bandage,
externally applied rigid splints. the splints should extend from the ground to the elbow
joint (Figure 5.3). Two splints placed at 90° to each other
are necessary.13,14 Wood of similar stock to that used for
Splinted Robert Jones Bandage distal limb splints is readily available, easily cut to appro
A Robert Jones bandage can be reinforced by the exter priate lengths, and cheap. Alternative materials such as
nal application of splinting material to provide additional metal strips (preferably light, such as aluminum) can be
rigidity. Splints should be positioned strategically to utilized in a similar manner if precut pieces are available.
resist movement/distracting forces appropriate to the One‐third circumference of thick‐walled (15 mm/0.5 in.)
fracture or suspected fracture. The greatest flexibility is PVC tubing of 15 cm (6 in.) diameter, cut to length with a
obtained with wooden splints cut to appropriate lengths hand (hack) saw, also can be used (Figure 5.4). Combining
from strips of 20–25 mm × 45–50 mm (1 × 2 in.) cross‐ a caudal PVC pipe with medial and lateral wooden struts
section.18,115 Plastic polyvinylchloride (PVC) pipe of has been recommended.89 Splinted full limb Robert
120–150 mm (4–6 in.) diameter cut into half or third Jones bandages can be reinforced further by application
diameter is an alternative.18,115 Piping should be of of an outer layer of fiberglass casting material. This
5–10 mm wall thickness material or alternatively con should not be thick; two layers generally are adequate, to
structed of multiple layers of thinner material. avoid excessive weight.
Both wood and PVC pipes can be precut to recom When splint material is placed over a Robert Jones
mended lengths, or tailored individually with a hacksaw bandage, the splint edges are of little consequence.
at the time of need. Lengths of 35–40 cm for a dorsal However, when applied over a bandage of less bulk, the
splint to the proximal metacarpus, 70–80 cm for splints edges and ends should be protected by adhesive tape
extending to the level of the elbow, and 140–150 cm for a (Figure 5.5). To be effective, splints must be tightly
lateral splint to scapular level have been recommended.18 applied, either with inelastic tape (duct tape or similar)
For the hindlimb, this author recommends splint lengths or with elasticized tape (Tensoplast, Elastikon, or simi
of 55–60 cm to extend to the proximal aspect of the cal lar), pulled to its elastic limit. Elasticized tape is prefera
caneus. The literature also has other recommended ble, but can be reinforced by a further layer of duct tape.
lengths, including a dorsal splint length of 53 cm to span Alignment of splints is critical to their function and these
from proximal metacarpus to dorsodistal hoof, and a should be secured to the bandage during application to
www.ajlobby.com
(A) (B)
(C) (D)
Figure 5.4 One‐third diameter PVC (plastic) pipe covered by

elasticized bandage, applied from caudal olecranon to the bearing
surface over a modified Robert Jones bandage. Source: Image
from Wright 2017.123
prevent twisting and/or rotation as they are secured.

Poorly applied splints can be a marked encumbrance to
an injured animal and must be avoided.
Bandage Cast Figure 5.5 (A–D) Stages in applying a hindlimb Robert Jones
bandage reinforced by medial and lateral wooden splints
The most complete immobilization and splinting offered extending from the bearing surface to proximal metatarsus.
by a bandage is achieved by the bandage cast. Fiberglass Source: Image from Wright 2017.123
casting tape can be placed over most distal limb band
ages to provide two‐dimensional immobilization. This
hybrid technique requires less bulk than a Robert Jones
bandage (generally doubling the diameter of the limb to with a further roll of fiberglass tape. General use and
produce a parallel‐sided tube), and less casting material. application of cast material are described in detail in
In most circumstances three layers of fiberglass tape are Chapter 13.
adequate. This is applied directly over the modified
Robert Jones bandage.
Casts
The bandage cast has been underutilized as a tech
nique for temporary immobilization, but has many If appropriate limb and joint positions can be obtained,
merits. It can readily be applied, is well tolerated, and in casts offer the best stabilization and counterpressure of
many circumstances is the temporary immobilization all temporary immobilization techniques (Figure 5.7).
technique of choice, particularly when transporting Fiberglass tape is universally recommended as the mate
horses over some distance. When used for short peri rial of choice for all equine casting techniques.3,40,47,77
ods, generally less than 48 hours, complications are The resin is activated by dipping in water and is tem
rare. The majority are applied with the limb in a weight‐ perature dependent. In order to maintain resin activity
bearing position, with fiberglass extending to the for long enough to apply and conform the bandage,
ground (Figure 5.6). Wide 12.5 cm (5 in.) rolls usually and to optimize bonding between layers (avoiding
are most suitable. Once initial curing has occurred, and lamination), the water should be no warmer than tepid
if desirable, the sole of the foot also can be enclosed (21–25 °C). Keeping the cast wet during application and
www.ajlobby.com
circumferential rubbing with tepid water during curing

also will assist in bonding.
Application of stockinette to cover the skin beneath
the cast requires too much limb manipulation to be read
ily applicable in racetrack emergencies. A thin layer of
conforming bandage is preferred. Additional padding
with a 3–5 cm strip of adhesive cast felt/foam is appro
priate at the proximal margin of the cast. An inner, con
forming layer of cast material follows. Water‐activated
resin‐impregnated foam (Custom Support Foam™, 3M
Animal Care Products, St. Paul, MN, USA; Procell Cast
Liner™, W.L. Gore and Associates, Flagstaff, AZ, USA)
has been recommended.15,40 The author prefers the use
of plaster of Paris, which is conforming,36,58 interdigi
tates with the fiberglass, and is of intermediate rigidity.
Fiberglass is applied immediately while the plaster of
Paris is wet. Approximately six layers of fiberglass tape
are adequate for most purposes. Three to five rolls of
cast tape are appropriate for half limb casts, and eight to
ten rolls for full limb casts. The fiberglass should be
applied wet, i.e., without squeezing after removal from
immersion. Finger tension only is necessary. The choice
Figure 5.6 A forelimb bandage cast applied with the limb in a
weight‐bearing position and extending from the distal row of
of fiberglass product is largely a matter of personal pref
carpal bones to the bearing surface. erence. For further details of individual products, see
Chapter 13.
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 distally as the bearing surface before the
limb is raised to enclose the distal wall and sole. The lat
ter technique generally results in less immobilization of
the foot, but for a temporary technique is quite accepta
ble. Horses should stand for 10–15 minutes to allow cast
curing before being moved. Longitudinal reinforced
splinting118 is not usually necessary for temporary sup
port purposes.
Compression Boots
Circumferential distal limb support is offered by com
mercial compression boots. These were initially mar
keted as the Farley Compression Boot (Equine Orthotics,
Indian Harbor Beach, FL, USA and Vet to Vet Marketing,
Bury St Edmunds, Suffolk, UK; Figure 5.8). They are
shaped with a fetlock angle of approximately 135° to sup
port the distal limb in a neutral (weight‐bearing) posi
tion. Two sizes are available. The outer, rigid construct is
of copolymer plastic divided medially and laterally. The
dorsal portion is contiguous with a sole plate to which
the palmar portion is hinged distally. A removable foot
Figure 5.7 A combination cast applied in a weight‐bearing plate is offered to accommodate hooves of differing sizes.
position to the forelimb. The deeper layer is plaster, followed by
fiberglass, and the foot is additionally protected with a layer of When the limb is placed into the dorsal half of the boot,
thermoplastic polymer (Vet‐Lite, Runlite SA, Micheroux, Belgium) the palmar half is raised and secured by sequential tight
to add abrasion resistance and reduce slipping. ening of ski boot clips. The boot is lined by contoured,
www.ajlobby.com
(A) (B)
Figure 5.8 Farley Compression Boot (A) closed and (B) partially open. Note the rigid construct and adjustable ski boot clips.
Figure 5.9 Hinged Compression Boot (A) (B)

showing closed (A) and open for
application (B). This is a lighter and less
substantial splint, but well secured by
nylon Velcro‐fastened straps.
medium‐density polyurethane foam. The palmar com forelimbs, in both length and metacarpophalangeal joint
ponent of the splint extends for less distance proximally angle. However, they do not fit nor are tolerated well on
than its dorsal counterpart, in order to permit carpal hindlimbs; they are too short and excessively angulated.
flexion. The dorsal shell of the splint should sit against the Alternatives include the Hinged Compression Boot™
metacarpal tuberosity of the third metacarpal bone. The (Figure 5.9), produced by Equine Bracing Solutions
original Farley compression boots fit most Thoroughbred (Trumansburg, NY 14886, USA), and the Almanza
www.ajlobby.com
(A) (B)
Figure 5.10 The Almanza emergency compression boot (Red Boot), shown in closed (A) and open (B) positions. This is of intermediate
thickness and secured by Velcro‐fastened straps. The unsecured lining is a disadvantage.
Emergency Compression Boot (Redboot Products, against the metacarpal tuberosity and skin, and then to
Buenos Aires, Argentina; Figure 5.10). These are both fill in minor irregularities. For fitting, the leg can be held
secured by Velcro™ straps. in a flexed position so the distal limb lies on the splint.
A Hinged Compression Boot is also available for Alternatively, an assistant can bring the unweighted limb
hindlimbs. This is longer, with a proximal extension of forward, gripping the limb around the caudal antebra
the plantar component, and is fitted with a rocker bot chium (forearm), to allow the distal limb to hang pas
tom that is claimed to improve ambulation. The hindlimb sively with the third metacarpal bone and phalanges all
brace also is unlined and designed for use with a light leg in line. The splint then can be secured with tape, or fiber
bandage. A major disadvantage to compression boots is glass casting material.13,14,39 It is essential that the splint
their expense, but they are robust and long lasting. is rigidly fixed to the limb and that the whole foot is
enclosed in the procedure. Failure to do so will result
in a loss of stability and the splint then becomes an
Dorsal Splint encumbrance.
The metacarpophalangeal or metatarsophalangeal and With a secure splint, horses can walk with toe‐only
interphalangeal joints can be immobilized in flexion by ground contact; this allows the horse to balance during
use of a dorsal splint, a Monkey Splint (Kruuse UK, transport. A dorsal splint without a cast offers less medi
Sherburn in Elmet, North Yorks, UK), the Kimzey Leg olateral stability, and with toe‐only foot–ground contact
Saver Splint™ (Kimzey Metal Products, Woodland, CA, mediolateral movement is exacerbated. A substantial
USA), or use of a palmar (plantar) board splint. As with wooden wedge placed beneath the heel and included in
all other temporary immobilization procedures, selec the cast can lessen this mediolateral instability. Dorsal
tion of a technique should be based on the nature (or splints are made from 20–25 mm × 45–50 mm (1 × 2 in.)
likely nature) of the injury and thus the distracting forces cross‐section lengths of wood. Strips of metal can be
that are to be resisted. equally useful, including a farrier’s rasp in an emergency.
A rigid dorsal splint is cut to extend from the metacar In the hindlimb it is impossible to adequately align the
pal tuberosity of the third metacarpal bone to the dorsal metatarsophalangeal and interphalangeal joints to the
weight‐bearing surface of the hoof, when the third meta neutral (180°) position. However, the greater degree of
carpal bone and phalanges are in a neutral position, i.e., flexion produced by the board splint is readily achieved,
when their dorsal surfaces are aligned (Figure 5.11). and the flexed distal joints make this the technique of
Sufficient bandaging is used only to cushion the splint choice for the hindlimb.
www.ajlobby.com
(A) (B)
(C) (D) (E)
Figure 5.11 (A) Schematic showing the forces and abnormal vectors generated by a biaxial sesamoid fracture and (B) the neutralizing
effect of a dorsal splint. (C) Application of a wooden splint; note use of bandaging materials to establish dorsal contact. (D) Fitted dorsal
splint and (E) lateromedial radiograph illustrating osseous alignment produced by a dorsal splint. Source: Image parts A and B from Wright
2017.123
www.ajlobby.com
(A) (B)
Figure 5.12 (A) The Monkey Splint and (B) a lateromedial radiograph demonstrating osseous alignment produced by a Monkey Splint.
Source: Image from Wright 2017.123
Monkey Splint Straight‐To‐The‐Toe Brace

The concept behind the Monkey Splint is identical to Although the name suggests that the Straight‐To‐The‐
that for a dorsal splint and heel wedge. It consists of a Toe Brace™ (Equine Bracing Solutions) produces a limb
concave plastic dorsal splint fixed to a flat‐bottom, position akin to a dorsal or Monkey Splint, it is ineffec
strongly wedged foot plate (Figure 5.12). The foot rests tive. The splint flexes the interphalangeal joints, but
on the wedge, with the angle designed to align the meta extends the metacarpophalangeal joint (Figure 5.13) and
carpophalangeal and interphalangeal joints in a neutral thus cannot be recommended.
position. The splint then is secured to the limb by three
broad Velcro straps.
The principal advantage of the Monkey Splint is ease
Leg Saver Splint
of application. It can be applied on the track with little or The Leg Saver Splint produces slightly increased distal
no limb preparation or need for additional materials. For joint flexion. Worldwide it is probably the most popular
fractures which can reasonably be supported with the splint for racetrack injuries. It is robust, light, and very
third metacarpal bone and phalanges in dorsal align easily applied (a major reason for its popularity). The Leg
ment, this splint can allow transport off the track and Saver is made of aluminum with a form foam lining
into a clinical facility. It resists mediolateral rotation of (Figure 5.14). It comprises a foot plate and conjoined
the foot better than a dorsal splint, but has disadvan angled dorsal splint that extends from toe to proximal
tages. The dorsal splint terminates in the proximal dia metacarpus. Here, the dorsal splint is expanded to a shal
physis (distal to the metacarpal tuberosity) of the third low, concave “T” which supports the proximal metacar
metacarpal bone, and therefore the construct is inade pus at the level of the metacarpal tuberosity. Three
quate to resist extension of the fetlock joint. Additionally, Velcro straps secure the splint to the leg and a fourth
the foot plate produces significant limb lengthening, strap fastens over the heel bulbs to the palmar aspect of
there is minimal mediolateral support, and it neither the foot plate.
provides nor permits the application of counterpressure. The standard Leg Saver Splint fits Thoroughbred fore
For these reasons, in the author’s opinion, it is suitable limbs quite well. A hindlimb splint also is produced and
for trackside use only. this incorporates a heel piece. It has been reported that
www.ajlobby.com
Figure 5.13 (A) The Straight‐To‐The‐Toe

(A) (B)
brace and (B) a lateromedial radiograph
with a Straight‐To‐The‐Toe brace fitted
demonstrating the osseous alignment
achieved; note flexion of the proximal and
distal interphalangeal joints and extension
of the metacarpophalangeal joint.
Figure 5.14 (A) The Kimzey Leg Saver Splint and (B) a (A) (B)
lateromedial radiograph with the splint fitted demonstrating
the osseous alignment produced.
the angle of the hindlimb splint is less effective in immo flexed position is appropriate. However, it provides
bilizing the distal hindlimb than use of the forelimb little mediolateral stability. Additionally, some
equivalent.42 A large foot plate version for Warmbloods, Thoroughbreds with relatively large hooves will
a shorter splint suitable for Quarter Horses, and screw‐ not fit into the standard foot plate.73 A modification
on extensions to allow the Leg Saver Splint to extend of this, the “Equine Salvage Splint,” is manufactured
proximal to the carpus also are available. by Ballarat Veterinary Practice (Ballarat, Victoria,
The Leg Saver Splint is suitable for fractures in which Australia). This offers greater foot stability by incorpo
temporary immobilization with the distal joints in a rating a heel block.
www.ajlobby.com
(A) (B) (C)
Figure 5.15 (A) The palmar (plantar) board splint construct and fitting, (B) a lateromedial radiograph demonstrating the osseous
alignment produced by a board splint, and (C) a hindlimb immobilized with a plantar board splint. Source: Image from Wright 2017.123
Palmar (Plantar) Board Splint and approximately 1.5 cm from the foot end of the board.
Corresponding holes then are drilled through the dorsal
The palmar (plantar) board splint produces the greatest hoof wall or between the shoe and dorsal wall. Thick
degree of metacarpophalangeal or metatarsophalangeal wire (9 gauge or similar) is threaded through the holes
and interphalangeal joint flexion (Figure 5.15). As origi and twisted tight, thus securing the foot to the board
nally described,116 it provides excellent emergency sup with one or more mattress sutures. A conforming pres
port for horses with traumatic disruption of the suspensory sure dressing (half Robert Jones thickness) is applied to
apparatus (which occurs almost exclusively in forelimbs). the leg with additional padding over the proximal palmar
However, it is not suitable for long‐term case manage (plantar) metacarpus/metatarsus. The distal limb then is
ment. Pressure sores are inevitable and overload laminitis flexed and secured to the board with adhesive tape.
of the contralateral limb is common.12 Emergency sup The board splint is particularly suited to hindlimb
port of these injuries is critical to the horse’s survival. application, as the reciprocal apparatus precludes the use
Attempts to load the limb result in hyperextension of the of dorsal splinting techniques. It is also possible in the
metacarpophalangeal joint, which stretches the palmar hindlimb to apply a board splint for off‐track support or
vessels and nerves. This can tear or thrombose the vessels, for transport to hospital facilities without drilling holes
resulting in life‐threatening distal limb ischemia. in the board and hoof. If the board extends to the distal
Additionally, when suspensory apparatus breakdown has tarsal level, the relatively weak digital extensor muscles
resulted from biaxial proximal sesamoid bone fracture, are readily disarmed and the horses usually will ambulate
displacement of sharp fragments during hyperextension well, loading the dorsodistal hoof (toe).
of the metacarpophalangeal joint can lacerate the palmar
vessels with similar results (see Chapter 23).
The board should be slightly wider than the horse’s Emergency Care of Specific
hoof. It is wired against the solar surface of the (shod) Fractures
foot (see Figure 5.15), with the distal joints flexed until
the sole is vertical (perpendicular to the ground). The
board should extend to the proximal metacarpus. Boards
Fractures of the Distal Phalanx
can be solid or ply and should be 15–20 mm thick. Ideally, Fractures of the distal phalanx are an uncommon racing
boards should be cut to fit individual horses, but average or training injury and may present in the hours that fol
dimensions are 44.5 × 12.5 cm.116 To apply, two or more low with lameness of increasing severity. The hoof cap
holes are drilled approximately 2.5–3 cm apart centrally sule prevents marked displacement and there is little to
www.ajlobby.com
(A) (B)
Figure 5.16 (A) Lateromedial and (B) dorso‐proximal to plantaro‐distal oblique projections demonstrating a complex fracture of the distal
phalanx sustained during racing.
be achieved by the application of additional temporary palmar (plantar) eminence fractures have been recog
support. Frequently, these do not have the common nized. The latter appear commonest and may be uniaxial
impact‐type configurations of other distal phalangeal or biaxial. Both usually displace, and biaxial fractures
fractures (Figure 5.16); see Chapter 14. generally are accompanied by palmar (plantar) subluxa
tion of the proximal interphalangeal joint. Emergency
support is critical to avoid trauma to the palmar (plantar)
digital neurovascular bundles.
Although the incidence of navicular fractures appears Affected horses are commonly minimally or non‐
low, fractures of the hindlimb navicular bones in horses weight bearing, and instability in the region of the proxi
in training and racing appear to exceed their forelimb mal interphalangeal joint may be clinically apparent.
counterparts. Lameness usually is acute in onset and Soft tissue swelling rapidly develops. The limb should
severe in intensity. Palpable distension of the distal inter receive acute temporary immobilization of the metacar
phalangeal joint may be detected, sometimes accompa pophalangeal or metatarsophalangeal and interphalan
nied by ill‐defined soft tissue swelling in the angle geal joints in a flexed position. A palmar (plantar) board
between the palmar (plantar) surface of the middle pha splint is ideal, but good reduction also can be obtained
lanx and collateral cartilage. Additionally swelling may with a Kimzey Leg Saver Splint. In the absence of these
develop over the deep digital flexor tendon as it emerges and in situations of reduced diagnostic confidence, a
between the heel bulbs, with resentment of digital pres dorsal splint or similar also would be appropriate.
sure on the tendon. Transverse fractures of the navicular
bone are rare but can markedly displace, with distal Fractures of the Proximal Phalanx
interphalangeal joint subluxation (Figure 5.17). In the
acute phase most horses make toe‐only foot–ground Sagittal and parasagittal fractures of the proximal pha
contact, and should be supported in this position for lanx historically were the most common racing and
transport and further evaluation. training fracture in Europe. However, in the last 10 years
their incidence has been superseded by fractures of the
metacarpal condyles. Horses with complete and commi
Fractures of the Middle Phalanx
nuted proximal phalanx fractures usually cannot con
Fractures of the middle phalanx occasionally occur in tinue to gallop. Jockeys are often immediately aware of a
horses in training and racing, but are rare racetrack inju severe injury. Some injuries are audible as a loud crack.
ries.45 Parasagittal, distal condylar, comminuted, and Prompt assistance by the jockey at this time is thought to
www.ajlobby.com
(A) (B)
Figure 5.17 (A) Lateromedial and (B) dorso‐proximal to plantaro‐distal oblique projections of a comminuted, displaced fracture involving
the distal half of the navicular bone sustained during racing.
be a major factor in limiting the severity of comminu halanx are lateromedial, appropriate techniques for
p
tion, degree of displacement, and secondary articular temporary immobilization include a Robert Jones
and soft tissue insult. Horses sometimes will fall and are bandage with medial and lateral splints, a compression
immediately non‐weight bearing. boot, bandage cast, or cast (Figure 5.18). Lateromedial
Proximal phalangeal fractures can occur in either fore‐ stability is enhanced by flat (solar) foot–ground con
or hindlimbs. They are most common in the forelimbs, tact, and whenever possible this should be prioritized.
and while sagittal and parasagittal fractures may occur in A Robert Jones bandage is sufficient for incomplete
the hindlimbs during training and racing, comminuted fractures, while complete fractures may benefit from
fractures of the hindlimb proximal phalanges are rare. the additional lateromedial or circumferential support
Distension of the metacarpophalangeal joint by hemor offered by the other techniques. Incomplete fractures
rhage quickly develops; its severity is roughly proportional that extend from the sagittal groove of the proximal
to the degree of articular damage. Unstable comminuted phalanx into the mid‐diaphysis before coursing later
fractures may exhibit visible shortening of the pastern, ally should be managed as complete fractures, since
and instability is readily palpable. Circumferential pitting propagation (at least from initial radiographs) to the
swelling due to hemorrhage ensues. Fractures that extend lateral cortex is common.
into the proximal interphalangeal joint will usually pro Displacement of fractures of the palmar processes is
duce palpable distension of this joint. diminished by flexion of the metacarpophalangeal
Non‐ or minimally displaced fractures can be equally joint with alignment of the dorsal cortices of the third
lame. However, swelling, including distension of the metacarpal bone, proximal and middle phalanges, and
metacarpophalangeal joint, is less dramatic. In the acute dorsal distal phalanx. A dorsal splint, or Monkey Splint is
phase horses usually exhibit pain on firm digital (thumb) appropriate.
pressure dorsoproximally between the extensor branches Most animals with comminuted fractures of the
of the suspensory ligament. The initial presentation for proximal phalanx will bear little weight on the limb.
fractures of the palmar processes of the proximal pha Circumferential support with a compression boot,
lanx is similar to that of parasagittal fractures. However, bandage cast, or cast is recommended. If there is evi
pain usually is elicited directly over the affected palmar dence of dorsopalmar instability, then flexion of the
process(es). Twisting the proximal phalanx on the third metacarpophalangeal and interphalangeal joints is

metacarpal bone also may be resented. appropriate. This can be achieved by a Kimzey Leg Saver,
Since the principal distracting forces associated with incorporation of a dorsal splint into the bandage cast, or a
sagittal and parasagittal fractures of the proximal complete cast.
www.ajlobby.com
(A) (B) swelling (hemorrhage) in the distal lateral metacarpus

usually accompanies complete fractures of the lateral
condyle (see Figure 5.19). Firm digital (thumb) pressure
at this site is resented. Pain on digital pressure further
proximally in the metacarpal diaphysis is a sign of a prox
imally propagating fracture. Such cases demand careful
radiological scrutiny of the whole metacarpal diaphysis,
particularly if a cortical exit point for the fracture cannot
confidently be determined.
The principal distracting forces are lateromedial
(Figure 5.20). Additionally, complete fractures frequently
rotate due to traction from the lateral collateral and
collateral sesamoidean ligaments when the metacar

pophalangeal joint is flexed. Such fractures are reduced,
both in temporary immobilization and during surgery, by
extension of the metacarpophalangeal joint (Figure 5.21).
It is important therefore that fractures of the metacarpal
condyles are immobilized with the metacarpophalangeal
joint in an extended (weight‐bearing) position. Use of
temporary immobilization techniques that include flex
ion of the metacarpophalangeal joint is contraindicated.
Figure 5.18 Diagrams illustrating the rationale for lateromedial Additionally, such techniques compromise lateromedial
support with sagittal or parasagittal fractures of the proximal
stability by providing toe‐only foot–ground contact
phalanx (A) and lateromedial stability (B) obtained after enclosure
within a Robert Jones bandage. Source: Image from Wright 2017.124 (Figure 5.22).
Incomplete condylar fractures that are restricted to the
epiphysis and metaphysis are likely to require little more
than the circumferential pressure of a Robert Jones
bandage. Complete fractures should be considered
Fractures of the Condyles of the potentially unstable (whether or not this is clinically
evident) and lateromedial distracting forces should be
Third Metacarpal Bone
countered by the application of medial and lateral splints
Fractures of the metacarpal condyles are the most com to a Robert Jones bandage, use of a compression boot,
mon training and racing long bone fracture worldwide, bandage cast, or cast. All should be fitted with the meta
and fractures of the lateral condyle are the single most carpophalangeal joint in an extended position with flat
common site. If complete, these disarm the lateral col foot–ground contact (Figure 5.23).
lateral ligament of the metacarpophalangeal joint, lead All fractures of the medial condyle of the third meta
ing potentially to luxation and creation of an open carpal bone, and any lateral fractures in which there
fracture; these usually are catastrophic and may justify are clinical and/or radiological concerns regarding the
immediate euthanasia. However, most fractures of the potential for proximal propagation of the fracture into
metacarpal condyles do not result in metacarpophalan the metacarpal diaphysis, require medial and lateral
geal luxation, and horses exhibit a wide variation in clini splints and/or circumferential temporary immobili
cal compromise, which is not necessarily proportional to zation to the level of the distal row of carpal bones
the severity of the injury. Some will be unable to con (Figure 5.24).
tinue to gallop, others will complete the race and exhibit Fractures of the metacarpal condyles also may be
lameness on pulling up, while fractures in other horses involved in complex racing injuries. The most common
will be recognized only later during cooling off. Fractures combination is metacarpal condyle fracture in con
of the metacarpal condyles can occur bilaterally, although junction with breakdown of the suspensory apparatus,
lameness and clinical signs may dominate in one limb usually due to biaxial fracture or dehiscence of the
(Figure 5.19). proximal sesamoid bones. The priority in these cir
Clinical evaluation is an important guide to fracture cumstances is preservation of the distal limb vascula
location and configuration. Most fractures of the meta ture and therefore immobilization in flexion is
carpal condyles result in early distension of the metacar necessary. Affected animals usually will make little
pophalangeal joint due to hemorrhage. In the acute effort to load the limb. The support of choice is a dorsal
phase, incomplete fractures may exhibit little else. Pitting splint applied with fiberglass casting material to
www.ajlobby.com
(A) (B) (C)
Figure 5.19 Clinical appearance of right forelimbs with fractures of the metacarpal condyles. (A) Complete nondisplaced fracture of the
lateral condyle; note joint distension and swelling of the distal lateral metacarpus. (B) Spiral propagating fracture of the medial condyle;
note the convex contour to the medial metacarpus. (C) Spiral propagating fracture of the lateral condyle; note the lateral swelling
extending from the metacarpophalangeal joint to the junction of the proximal and middle thirds of the metacarpus.
increase mediolateral stability (see Chapter 23). This is Splints, or board splints all provide appropriate support
aided further by a heel wedge to maximize foot–ground (Figure 5.26).
contact. However, when moving the horse from the
racetrack to an onsite clinical facility, use of a leg saver Luxation of the Metacarpophalangeal
brace is appropriate.
Joint
Luxation or subluxation of the metacarpophalangeal
Fractures of the Forelimb Proximal joint can accompany fractures of the distal metacarpal
condyles and/or palmar process of the proximal phalanx.
Sesamoid Bones Additionally, it can follow disruption of (usually) the
Fractures of proximal sesamoid bones in the forelimb medial collateral ligament and dorsal joint capsule.125
are the most common catastrophic (resulting in death) The luxation often will reduce when the limb is flexed,
injury in training and racing.49 Biaxial mid‐body and this may occur spontaneously. Once reduced, the
fractures of the proximal sesamoid bones disrupt the joint is most stable in an extended (weight‐bearing) posi
suspensory apparatus and thus palmar support of the tion, and horses usually will then load the limb. Open
metacarpophalangeal joint. The consequences to adja luxations are catastrophic and carry a poor prospect for
cent tissues, particularly the palmar neurovascular survival. The large majority justify immediate humane
bundles, necessitate emergency support of the distal destruction. If an animal is of sufficient value to justify
limb in a flexed position to maintain viability perseverance, then the exposed tissues should be
(Figure 5.25; see Chapter 23). Dorsal splints, Leg Saver cleansed before the joint is reduced.
www.ajlobby.com
(A) (B) Jones bandage extending to the proximal metacarpus is

generally adequate.
Transverse or Oblique Fractures

of the Metacarpal Diaphysis
Complete transverse or oblique fractures of the metacar
pal diaphysis are inherently unstable, displace immedi
ately, and invariably are catastrophic in racehorses.
Comminution is common, and due to the paucity of
overlying soft tissue these fractures are frequently
open.5,7,45,66 Unrecognized or inappropriately managed
incomplete fractures of the dorsal cortex are thought to
be a major predisposing fracture.45 The distal limb is
uncontrollable, and when moving at speed afflicted
horses may fall. If possible, the horse should be restrained
(physically and chemically) in a recumbent position until
euthanized. Standing horses are very anxious and some
times panic. Immediate sedation is necessary in order to
gain control long enough for euthanasia to be organized.
Any necessary dialog with connections should be swift
Figure 5.20 (A) Schematic of the distracting forces producing and opinions, including if necessary colleague support,
separation of the lateral condyle after fracture resulting in forthright.
lateromedial instability. (B) The rationale for support of fractures of
the lateral condyle of the third metacarpal/metatarsal bones.
Carpal Subluxation
Optimal temporary support is provided by a bandage Carpal subluxation is an uncommon racing or training
cast or cast that extends from the bearing surface to the injury. Most angular deviations result from displaced or
proximal metacarpus. Once the joint is reduced and collapsing cuboidal bone fractures, which usually are
placed in an extended position, it is usually stable, there comminuted and frequently involve bones in both proxi
fore maintenance with a Robert Jones or splinted Robert mal and distal rows. Radial carpal fracture with additional
(A) (B)
Figure 5.21 Complete fracture of the lateral condyle of the third metacarpal bone with digital extensor tendons and dorsal
metacarpophalangeal joint capsule removed. (A) Joint flexed and (B) joint extended, illustrating fracture reduction with joint extension
and displacement with flexion.
www.ajlobby.com
(A) (B)
Figure 5.22 (A) Diagrammatic representation of the negative

effects of distal joint flexion on complete displaced fractures of
the lateral condyle of the third metacarpal bone. (B) Flexion of the
fetlock rotationally displaces the lateral fracture fragment.
Figure 5.23 Extended limb positioning suitable for application of

third and/or second carpal bone fracture is most com temporary support in a horse with an acute fracture of the lateral
mon, resulting in varus deformity. It is not known condyle of the third metacarpal bone. Source: Image from Wright
2017.124
whether such fractures occur concomitantly or from
sequential overload. Lameness is marked and usually
sufficient to prevent the horse from continuing to run. as Soffban™ (Smith and Nephew) then covers the cast
Angulation generally is visible and accompanied by crep area. A fiberglass and plaster of Paris combination cast is
itus, with an abnormal range of mediolateral motion. then applied from the proximal antebrachium to the dis
Joint distension with hemorrhage is quickly evident, tal metacarpus. The fiberglass terminates 2 cm short of
together with periarticular swelling over the affected the foam and felt at either end of the tube cast, to protect
bones. Mediolateral instability can also result from com the skin from abrasion.
plete disruption of one collateral ligament, without Alternatively, for transport from the racetrack to the
cuboidal bone fracture and collapse, although collateral racecourse clinical facility, a splinted full limb Robert
rupture often involves avulsion fracture at the origin or Jones bandage or bandage cast prevents further collapse,
insertion. Avulsion fracture of the proximal second met and improves limb control and patient comfort. Wooden
acarpal bone is most common. struts should be applied over a modified Robert Jones
Emergency immobilization of choice is a tube (sleeve) bandage that doubles the diameter of the limb. A mini
cast extending from proximal antebrachium to distal mum of two splints placed at 90° to each other are neces
metacarpus, with the limb in a loaded and weight‐bear sary. A lateral splint extending from the level of the elbow
ing position (Figure 5.27). Under sedation, the affected to the ground is necessary in all cases. This may be sup
limb should be placed perpendicular to the ground so plemented by a cranial splint from the level of the elbow to
that the horse “stands square.” Adhesive cast felt can then the distal metacarpus, or a caudal splint from the elbow to
be stuck to the skin at the proximal and distal margins of the ground (see Figure 5.3). In the author’s hands, horses
the cast. A single layer of conforming soft bandage such ambulate better with the cranial rather than caudal splint
www.ajlobby.com
(A) (B)
(A) (B)
Figure 5.24 Diagrammatic representation of support rationale for Figure 5.25 (A) Diagrammatic representations of distracting
spiral propagating fractures of the third metacarpal bone. (A) forces on fractures of forelimb proximal sesamoid bones, showing
Lateromedial bending and torque risk displacing the fracture. (B) hyperextension and sesamoid distraction under weight bearing.
Splinting reduces the bending and some of the torque transferred (B) Influence of a Kimzey Splint to align the bony column and
to the fracture. Source: Image from Wright 2017.124 resist sesamoid separation. Source: Image from Wright 2017.124
(A) (B)
Figure 5.26 (A) LM radiographs of a uniaxial transverse fracture of a forelimb medial proximal sesamoid bone with limb loaded. (B) After
application of a Kimzey Splint showing fracture reduction obtained by joint flexion. Source: Image from Wright 2017.124
www.ajlobby.com
(A) (B)
Figure 5.28 Carpus immobilized with (A) cranial and (B) lateral
splints incorporated into a modified Robert Jones bandage.
Figure 5.27 Carpus immobilized in an extended position with a

tube/sleeve cast applied from proximal antebrachium to distal
metacarpus. Note the cast felt protruding from proximal and distal
ends of the sleeve cast.
(Figure 5.28). An alternative is application of half‐ or

third‐diameter PVC piping caudally from the level of the
elbow to the ground, over a layered cotton wool (Robert
Jones–like) bandage (see Figure 5.4).
Stable Fractures of the Carpus

Fractures of the carpus are a common training and rac
ing injury (see Chapter 27). The vast majority do not
compromise axial limb stability, and bandaging is suffi
cient for transportation. Bandages with splints may be
detrimental to the horse. Counterpressure from an elas
ticized bandage may reduce discomfort.
Fractures of the accessory carpal bone can distract and
separate quite widely. These do not jeopardize axial sta
bility of the limb, but adding a splint to prevent carpal Figure 5.29 Carpus fixed in extension by a cranial/dorsal splint
flexion may minimize trauma to the carpal sheath and its from proximal antebrachium to distal metacarpus incorporated
contents (Figure 5.29). into a modified Robert Jones bandage.
www.ajlobby.com
Fractures of Mid and Proximal cranial and/or caudal splints can then be placed at 90° to
Radius this to provide increased rigidity (Figure 5.31). Although
appearing ungainly, the technique is well tolerated and
Fractures of the diaphysis and proximal metaphysis of horses usually move well.
the radius are uncommon racetrack injuries. When a
fracture occurs in this region, both flexor and extensor
muscles no longer have an intact skeletal strut and they
Fractures of the Olecranon
become abductors of the distal limb about the fracture Fractures of the olecranon tuberosity of the ulna are not
site. Catastrophic medial skin perforation can fol recognized racing injuries, but can arise on the race
low.13,14,39,73 All racing‐ and training‐related fractures in course as a result of traumatic incidents. When com
this region necessitate a guarded to poor prognosis for plete, the triceps apparatus is disarmed, and the horse
survival. Some nondisplaced fractures, which generally cannot fix the limb in extension (see Chapter 30), result
are the result of external trauma rather than race inju ing in a dropped elbow and flexed carpus. This causes
ries, can be managed by cross‐tie or overhead wire marked anxiety. The horse is also unable to use the limb
restraint, but complications associated with contralat as a prop for balance during transport. However, the
eral limb overload can develop. mechanical disability is readily stabilized by splinting
The principal aim in temporary immobilization for the carpus in extension. A splint applied caudally has
fractures of the radial diaphysis is prevention of distal been recommended for this purpose,39,73 but is bulky,
limb abduction. This is achieved by use of a single large less easily applied, and not as well tolerated compared to
splint that extends from the level of the proximal scapula a cranially positioned splint. The cranial splint should
to the ground. The splint should contact the lateral prox extend from the proximal antebrachium to distal meta
imal muscle masses and be incorporated distally into a carpus, and be applied over a relatively light bandage to
modified Robert Jones bandage (Figure 5.30). Additional minimize the pendulum effect and still protect the skin.
(A) (B)
Figure 5.30 Diagrammatic representation of complete diaphyseal fractures of the radius (A) showing the bending forces and resulting
abduction of the distal limb due to lateral antebrachial muscle mass. (B) Lateromedial forces counteracted by a long lateral splint.
www.ajlobby.com
difficult to be confident whether this is a result of disarm

ing the triceps apparatus or damage to the radial nerve.
If the horse is recumbent with the injured limb
uppermost, then a clinical diagnosis can usually be estab
lished without the need to get the horse to its feet. If this
limb is on the underside, then turning the horse may be
necessary in order to establish the reason for recum
bency. This can be achieved by attaching ropes to the
downside fore‐ and hindlimbs and rolling the horse over.
All authors agree that there are no benefits to be gained
from attempting temporary external support to immobi
lize humeral fractures.13,14,39,73 Limb mechanics preclude
effective immobilization and the surrounding muscle
masses protect the fractured bone.
Fractures of the lateral tuberosity of the humerus carry
a better prognosis. Affected animals may be minimally
weight bearing and crepitus may be evident over the lat
eral proximal humerus. There is no brachial shortening,
and within a few minutes the horse usually will tenta
tively load the limb. In contrast to complete diaphyseal
fractures, these often are amenable to removal or repair
with return of function.69 Splint immobilization is
unnecessary and rarely effective.
Most racetrack evaluations of humeral fractures are
clinical only. If adequate radiographic facilities are avail
able, then it is appropriate to obtain verification of the
Figure 5.31 A complete mid‐diaphyseal fracture of the radius
immobilized by lateral and cranial splints incorporated into a fracture. Ultrasonography may confirm osseous discon
modified Robert Jones bandage. Source: Image from Wright 2017.124 tinuity and aid in fracture differentiation.
Fractures of the Humerus Fractures of the Scapula

In racehorses, fractures of the humerus usually are cata Fractures of the scapula can result from stress overload
strophic. A series of 21 complete, unilateral fractures were in flat racehorses or from falls in jump racing. The latter
described in racehorses in California.106 Breeds included most commonly involve the supraglenoid tubercle (see
18 Thoroughbreds, 2 Quarter Horses, and 1 Appaloosa. Chapter 33). After a short initial period of non‐weight
Seventeen of the fractures occurred during training and two bearing, horses with fractures of the supraglenoid tuber
while racing. These typically spiraled from caudoproximal cle will load the limb, although the cranial phase to the
to craniodistal. Ten of thirteen retrieved bones had gross stride is severely reduced due to loss of the biceps brachii
evidence of pre‐existing stress fracture (periosteal callus) at origin. External support is counterproductive, simply
the site of ultimate failure, usually on the caudoproximal increasing limb load. Some, but not all, horses will be
diaphysis of the humerus. In jump racing, fractures of the helped by assistance with limb extension from a rope
humerus generally are monotonic, and associated with col passed around the pastern.
lisions with jumps or impact from the horse falling.117 Fractures of the neck and body of the scapula com
Horses with complete fractures are invariably non‐ monly displace and override. Trauma to axial neurovas
weight bearing. The fracture usually displaces and over cular structures is common and hemorrhagic swelling
rides to result in a flail limb with shortened brachium. The can rapidly develop. Afflicted horses are non‐ or minimally
close proximity of the brachial artery and its major trunks weight bearing, and usually are markedly distressed with
predisposes to marked hemorrhage with sudden swelling. minimal relief from analgesics. Viewed from the front,
This is a poor prognostic sign, and since the majority of the swelling can appear to result in abaxial displacement
horses with complete, displaced fractures that occur on of the scapula from the thoracic wall. The scapulo
the racecourse cannot currently be saved, humane destruc humeral joint may appear ventrally displaced due to
tion is indicated.45 Control of pain is rarely satisfactory. shortening of the scapula length.
Crepitus may be palpable and/or audible. The elbow and If a definitive diagnosis cannot be made on clinical
carpus cannot be fixed, but in the peracute phase it is grounds, then it is appropriate to move the horse from
www.ajlobby.com
the racetrack for confirmation by ultrasonographic or

radiographic examination. In the author’s hands, com
plete displaced fractures of the scapula in adult horses
carry a hopeless prognosis for humane preservation of
life. Even short‐term comfort while connections are con
sulted can be difficult to achieve.
Fractures of the Hindlimb Middle and

Distal Phalanges and Navicular Bone
The reciprocal apparatus makes alignment of the third
metatarsal bone and phalanges impossible. A plantar
(board‐type) splint which produces a greater degree of
distal joint flexion is preferred (see Figure 5.15).
Fractures of the Hindlimb Proximal

Phalanges
Sagittal and parasagittal fractures of the proximal pha
langes in the hindlimbs are less common than forelimb
fractures (described in more detail in Chapter 19).45
They are also more usually simple and/or incomplete.
Horses find it easier to ambulate on two forelimbs and
one hindlimb, and tend to protect hindlimb fractures
better during transport. The principles of temporary Figure 5.32 Hindlimb positioned and supported in an extended
immobilization are similar to those for the forelimb, position suitable for fitting distal limb support in a weight‐bearing
although proprietary boots fit poorly and are less well position. Source: Image from Wright 2017.124
tolerated on the hindlimbs.
Positioning a painful hindlimb forward into a non‐ preference for temporary immobilization of unstable
weighted extended position, with a steadying hand on or propagating fractures is a bandage cast fitted with
the calcaneus, will usually keep the limb fixed while sup reduced bulk (Figure 5.6).
port is fitted (Figure 5.32). A Robert Jones bandage or
bandage cast generally is the technique of choice.
Transverse and Oblique Fractures of the
Diaphysis of the Third Metatarsal Bone
Fractures of the Condyles of the
Third Metatarsal Bone These are rare racing injuries, but can follow traumatic
incidents. The majority of fractures in adult horses are
The severity of fractures of the hindlimb lateral condyle is not amenable to repair and therefore destruction on
less than that for the forelimb, but the propensity toward humane grounds is indicated. When applying temporary
medial, proximally propagating fractures is greater immobilization to those fractures which merit further
(described in detail in Chapter 22). Racetrack evaluation, consideration, the calcaneus can be used as a functional
clinical appearance (Figure 5.33), and management follow extension of the metatarsus.14 A plantar splint can be
similar guidelines to the forelimbs. However, as a general placed from the calcaneus to the ground surface,
principle, bandages in the hindlimb should have less bulk. supplemented by a lateral splint from the level of the base
When splints are employed these should fit in apposition of the calcaneus (adjacent to the calcaneoquartal articula
to the dorsal hoof wall at the bearing surface. Sufficient tion) to the bearing surface (Figure 5.34). These should be
bandaging then is applied to fill in the dead space between placed over a minimal modified Robert Jones bandage to
the limb and splint to maintain the splints in parallel maximize splint contact. If the bandage is too thick, the
alignment to the proximal metatarsus (see Figure 5.5). rigid support offered by the splints will be diminished.
When a propagating (spiral) fracture is present or
suspected, splints should extend to the level of the
Fractures of the Tarsus and Tibia
talocentral‐calcaneoquartal (proximal intertarsal)

joint. Bandages should not be placed further proxi Complete fractures of the tibia are rare training and rac
mad, as these can be strongly resented. The author’s ing injuries. Most are thought to result from pre‐existing
www.ajlobby.com
Figure 5.34 Diagrammatic representation of plantar and lateral

splints suitable for immobilization of diaphyseal fractures of the
third metatarsal bone. Source: Image from Wright 2017.124
Figure 5.33 Distension of the left metatarsophalangeal joint
and swelling of the distal lateral metatarsus associated with an
acute displaced fracture of the lateral condyle of the third reinforcement bars.13 Mild steel rod (12 mm diameter)
metatarsal bone. can be shaped by hand and is strong enough to provide
support.115 The splint extends in a straight line from the
stress fractures (described in Chapter 35).45 Fractures of ground to the tarsocrural joint, where it is bent cranially
the tibia and fractures of the tarsus that jeopardize axial to follow the tibial diaphysis. At the stifle it is bent cau
stability are particularly difficult to immobilize because dally to lie on the surface of biceps femoris up to the level
of the reciprocal apparatus linking tarsal and stifle joint of the coxofemoral joint. The splint is most effective if it
motion. Disruption of the osseous column concentrates is bent back on itself, retracing its course to the bearing
the reciprocal action on the fracture, exacerbating surface.13,14
displacement, fracture overriding, and limb collapse.
In smaller horses, fractures of the tarsus and tibia can
Additionally, the principal muscle masses are situated be immobilized temporarily for transport by a laterally
laterally and these produce distal limb abduction.14,39,73 positioned board splint. This should be approximately
Splinting requires a long lateral splint that should reach 10–15 cm (4–6 in.) wide and 15 mm (0.5 inch) thick, and
the level of the coxofemoral joint. Flexion and extension cut to a length extending from the ground to the level of
of the stifle cannot be prevented, and the normal flexion the coxofemoral joint. The limb is enclosed in bandage
angles of stifle and hock joints prevent the use of cranial material up to the stifle to cushion contact with the
or caudal splints. A single wide lateral splint, cut to follow board, which should lie on the lateral aspect of the biceps
limb angulation, can neutralize rotational forces.13,14,73 femoris. The limb should be held slightly caudal to the
The splint is placed alongside the biceps femoris with contralateral limb during splint application, to extend
the limb as straight as can be tolerated, and the distal the tarsal and stifle joints. The board is then tightly
portion incorporated in the bandage. The bandage bulk secured to the limb with nonelastic tape or tightly pulled
should be minimized to prevent it acting as a pendulum elastic tape.
on the fracture. Both techniques can be strongly resented by horses,
The ideal splint material is lightweight metal such as leading to exaggerated movements, kicking, and poten
aluminum, electrical conduit, or small‐diameter steel tially a fall. All associated personnel should be warned
www.ajlobby.com
experienced personnel is critical, since the horse can

panic and fall away from the affected limb. Fixing the tar
sus as described can result in rupture of the peroneus
tertius. The author has experienced this only in recovery
from general anesthesia and not in horses in which the
cast was applied standing.
Stable Fractures of the Tarsus

Fractures of the tarsus that occur during racing but do not
jeopardize the axial stability of the limb include fractures
of the tibial (usually lateral) malleoli, fractures of the
trochlear ridges of the talus, parasagittal fractures of the
talus, and slab fractures of the central or third tarsal
bones. The latter are seen in all forms of racing, while the
others are most commonly the result of falls and therefore
are most frequent in jump racing. Although fractures of
the lateral malleolus of the tibia frequently disrupt the
majority of the short lateral collateral ligaments, they
rarely extend sufficiently proximad to compromise the
long lateral collateral ligament, and therefore tarsal stabil
ity is retained (Chapter 34). Attempts at immobilization
almost always are counterproductive. Care of the soft tis
sues may be enhanced by a light conforming bandage.
Figure 5.35 Immobilization of the tarsus in a weight‐bearing

position with a tube cast extending from the junction of the
middle and distal thirds of the crus to the junction of the proximal Stifle Fractures
and middle thirds of the metatarsus.
Fractures involving the stifle joints usually arise from
trauma during jump racing. Fractures of the patella and
tibial tuberosity are impact injuries. Fractures of the tib
with respect to personal safety and the inherent risks to ial eminences, most commonly the medial eminence,
the horse. Firm, decisive handling is critical. can result from falls, but often are part of a more com
plex ligamentous injury. There is no adequate immobili
zation for such cases.
Tarsal Luxation and Subluxation
This is a rare racetrack injury. Most occur through the
tarsometatarsal or talocalcaneal‐centroquartal (proxi
Fractures of the Femur
mal intertarsal) joint; the fourth tarsal bone bridges the Fractures of the femur that develop on the racetrack are
centrodistal joint and interdigitation of the tibial malleoli most commonly diaphyseal, complete, and displaced.
and distal intermediate ridge with the talus provides Limb shortening (greater trochanter to patella distance)
osseous support to the remaining joints.71 Collateral and due to overriding of fragments and rotational instability
short intertarsal ligament disruption is inevitable and are common. Marked hemorrhage frequently follows, as
most of these injuries are accompanied by marginal frag the femoral artery and/or major emergent vessels are lac
mentation of tarsal bones. Complete or partial reduction erated by fracture fragments. The animal’s thigh may be
is often spontaneous. The limb is most comfortable and seen to enlarge minute by minute. The prognosis gener
stable when loaded. ally is hopeless, and pain and anxiety are profound and
Ideal support is a tarsal tube cast extending from the often inadequately controlled. Horses with evidence of
distal third of the crus/tibia to the proximal–middle hemorrhage should be moved as little as possible, and as
third junction of the metatarsus and applied with the soon as a definitive diagnosis is reached, the animal
horse standing and limb loaded (Figure 5.35). Sedation is should be euthanized on humane grounds to avoid the
advisable. Most horses tolerate the cast well, although on potential of painful and distressing exsanguination.
their first movement many will lift the limb in a high Fractures which are suspected, but do not have concur
abducted arc with a degree of panic. Firm handling by rent marked hemorrhage, may be moved for further
www.ajlobby.com
evaluation. The femur is surrounded by muscles and dosed to maintain control throughout. Animals should
cannot be stabilized by any temporary immobilization be supervised at all times and prevented from lying
technique.13,14,39,73 down. Ultrasonography can offer quick, reliable confir
mation of a number of displaced fractures, particularly of
Pelvic Fractures the ilial wing. In the acute phase, nondisplaced fractures
may not be evident, and confusing acoustic shadows can
Fractures of the pelvic girdle are common and poten be created by intramuscular vessels.101 Any evidence of
tially life‐threatening racing injuries.98 The vast majority osseous discontinuity is of concern. The principal ques
are stress‐related injuries.87,102 Occasionally, fractures of tion to be answered by ultrasonographic examination is
the pelvis will result from falls or injury in starting gates. the relative safety of transporting the horse. For emer
The ilial wing is one of the commonest sites of stress gency evaluation, good images can be obtained using lib
fracture in skeletally immature Thoroughbred race eral application of alcohol as a coupling medium.101
horses.87 Fractures of the ilial wing usually are complete Hypo‐ to anechoic zones in the muscle pattern consist
and frequently displaced. Trauma to dorsally coursing ent with hemorrhage adjacent to the bone must be
gluteal or caudally positioned iliolumbar arteries will viewed as suspicious.87 Callus can also indicate previous
result in varying amounts of hemorrhage. Affected stress fracture.101
animals frequently are in marked pain, but the amount of The decision to move horses with fractures or poten
hemorrhage rarely is life threatening. There is often tial fractures of the pelvic girdle from the racetrack is one
intense muscle spasm and guarding of the affected hind of the most difficult decisions that face the track veteri
quarter. Asymmetry of osseous landmarks is indicative narian. Often, there is considerable pressure for horses
of fracture displacement. Displaced fractures of the ilial to be moved, and many racetracks do not have facilities
wing may result in displacement of the tuber sacrale or or staffing arrangements suitable for protracted periods
tuber coxa. of onsite nursing care. In these situations, the veterinar
Fractures of the ilial shaft are life threatening. While ian has to act as the advocate for the horse’s welfare.
the degree of pain and lameness is not an accurate Horses with complete fracture of the ilial shaft cannot
guide to the location or severity of pelvic injury, horses safely be transported. Complete fractures of the ilial
with displaced fractures of the ilial shaft usually are wing are less likely to be life threatening, and such horses
extremely distressed. Displacement of the tuber sacrale can be moved for long‐term nursing care.
and tuber coxa on the same side of the pelvis indicates
fracture of the ilial shaft, wing–shaft junction, or a
comminuted fracture of the ilial wing. Displaced frac Transport
tures of the ilial shaft or the junction of the shaft and
wing commonly lacerate iliacofemoral arteries and may The critical points in transporting horses with fractures
lacerate the parent internal iliac artery, or less com are loading and unloading. With appropriate support, it
monly the external iliac artery. This frequently is cata is uncommon for fractures or associated lesions to pro
strophic, resulting in exsanguination. Swelling may gress during movement. The decision on whether to
first be visible in the pubic or perineal areas as hemor transport a horse which is severely lame, and in which a
rhage dissects through fascial planes before the whole fracture is suspected but cannot be confirmed, is often
hindquarter increases in size. At this stage, survival is difficult. However, neither appropriate treatment nor
rare and euthanasia on humane grounds is justified. prognosis is possible without an accurate diagnosis.
Afflicted horses can become uncontrollable, so inter Therefore in most cases, horses should be given support
vention should not be delayed. In one series, 6 of 11 ive care and moved with caution. For the appropriately
horses with racetrack pelvic fractures died from exsan splinted and supported horse, the duration of transport
guination within 1 hour of injury.46 Fractures of the (distance) is of little consequence.13,14,28,97
pubis and ischium are less common racing injuries. Minimizing the distance that the horse walks to the
Crepitus may be appreciated, particularly with frac vehicle is important. Lorries or trailers should be
tures involving the acetabulum.9 maneuvered as close as possible to the injured horse.39
Animals with a potential diagnosis of pelvic fracture The ramp angle should be as low as possible. If normal
must be managed with caution. Identification of fracture trailers and transport are all that are available, custom
location frequently is not possible. Additionally, some loading ramps aid loading and unloading. Well‐designed
fractures may not displace until hours, days, or even hospitals have strategically positioned emergency
weeks later.87 Horses should be moved carefully on low‐ unloading facilities. Most injured horses will load read
loading trailers. Unloading should also be performed ily, even into an unfamiliar vehicle. A manual boost may
cautiously, with appropriate sedation and analgesia be necessary. Some horses will respond well to a lunge
www.ajlobby.com
line fixed to each side of the trailer entrance and crossed incline. This allows animals to walk on and off. Internal
behind the horse, providing a channel into the trailer. partitions should be movable, with padded front and rear
Waving, flapping, and shouting should be avoided. (breast and breeching) bars. The floor and ramps should
Within the trailer the entrance to the stall should be be nonslip and internal surfaces should be washable. A
made as wide as possible to encourage the horse to supporting harness or sling is useful, together with a
enter. Once the horse is loaded, supporting walls and drag mat and appropriate winch for loading recumbent
bars then can be repositioned. animals. Video and audio links from the trailer to the
Close stable partitioning rather than an open box is driver are highly desirable. Additional items should
important, permitting the horse to lean on the walls and include provision for heating, and access to water and
partitions for support, both side to side and front to medical supplies.
back.14,73 The head and neck should be allowed as much
freedom as possible to act as a counterbalance. As accel Equine Ambulances in the USA
eration is usually more controlled than deceleration, it
has been recommended that horses with fractures of the The Kimzey Equine Ambulance (Kimzey Metal Products)
forelimbs should be transported facing rearward and is purpose built and suitable for racetrack work. This
vice versa.13,14,73,97 This is logical, but often not possible includes a hydraulic system which allows the rear of the
due to horsebox design; horses also travel best when in a ambulance to lower to the ground so that loading is
familiar environment and orientation. achieved on an incline of approximately 5°. The horse
Some authors favor the use of a supporting harness travels centrally and loading is facilitated by hydraulically
and believe that horses arrive at the hospital in better movable side walls. These are solid and padded to
condition.39 If a harness is tolerated, it can permit the optimize lateral support to the horse during transit.

horse intermittently to rest and shift position. Most con The horse is unloaded from a single side ramp, which
sist of broad body bands that can be slung ventral to the necessitates the horse turning to the left for exit. A front‐
horse’s thorax and abdomen. However, some animals mounted winch and cable assembly permits use of a
will find them an irritation and resent the additional con drag mat. There is no sling device; the ambulance relies
finement. They should never be used to partially sus on the closely positioned stall walls to provide support.
pend the horse, but simply to allow the horse to sink into The trailer can be pulled by a tractor or other suitable
the harness to relieve limb load. Transportation of towing vehicle.
recumbent horses from racetracks is generally required
for neurological rather than appendicular fractures. The European Equine Ambulances
reader is referred to Chapters 6 and 40, and to special
ized neurology texts.38,39,65 The largest European manufacturer of equine
Having an experienced attendant ride with the horse ambulances (Equisave Horse Ambulances, Stradishall,
provides reassurance while minimizing the horse’s anxi Newmarket, Suffolk, UK) has two models which are in
ety. A hay net can provide an excellent distraction. widespread use on racetracks throughout Europe. These
Soaking hay reduces the risk of choke, and use of two feature a swing‐away towing system that permits rear
nets reduces the bulk obtainable while occupying the load and front unload. In the first design, once the tow
horse for a longer period. ing system is moved, the trailer lowers hydraulically to
Unloading is as critical as loading.39 Minimizing ramp ground level (Figure 5.36). In the second model, long,
incline, providing pain control, and occasional use of wide ramps are provided to minimize slope
sedation are important. Unloading should be slow, with (Figure 5.37). The horse travels centrally. Partitions are
assistance to the injured limb. Horses with proximal moved to the side of the trailer to encourage and facili
forelimb fractures commonly will be reluctant to extend tate loading, and then are moved in close proximity to
the injured limb. They can be assisted by either lifting the horse in order to provide support. The partitions
the leg and placing it forward by hand, or by passing a and therefore the horse stall can be angled if required.
loop of rope around the pastern area and providing Adjustable bars, front and rear, provide further
appropriate timed assistance for extension. restraint and support. Each partition has an access
channel through which a supporting sling can be
passed, and there is a front‐mounted electric winch
Ambulance Trailers and drag mat. Each trailer is equipped with screens
Design features of ambulance trailers have been that can attach to the trailer and thus be erected
described.29,39,45 The trailer should be low loading with and operated by one person. A video camera can
long, shallow front and rear ramps. The best ambulance be mounted in the front of the trailer so the horse
trailers can be lowered hydraulically to eliminate a ramp can be monitored from the towing vehicle. More
www.ajlobby.com
sophisticated ambulances include a motorized horse

ambulance (Figure 5.38) featuring a central, rotating
horse cubicle, which allows all‐around access and low‐
loading facilities.
Nursing and Supportive Care

Horses frequently finish races in a dehydrated state,
which can lead to circulatory compromise when coupled
with sweating from pain and anxiety. Oral rehydration is
often sufficient, and requires little more than attending
personnel regularly offering water. This frequently is
forgotten as people’s attention is focused on fracture
management. The horse’s anxiety with most flail limb
fractures results more from its inability to control the
limb than from pain. Once appropriately splinted, the
horse’s anxiety diminishes and circulatory compromise
improves.
Transportation of horses with racing fractures delays
the initiation of routine methods to enhance cardiovas
cular and metabolic recovery.48 Horses with fractures
therefore may benefit from techniques to compensate
for the absence of an active “cool‐down” period. This
need not be sophisticated. Washing with cold water is an
effective method of cooling horses and reducing stress.56
Avoiding the tendency to rush to surgery also allows
recovery of metabolic stability, and frequently enables
Figure 5.36 Front view of an equine ambulance lowered to better anesthetic management.
ground level with towing system deflected. Extensions on the
front ramp assist in unloading.
(A) (B)
Figure 5.37 (A) Swing‐away towing system with front and rear ramps permits straight loading and unloading. (B) The horse travels
centrally with movable lateral support. Note the screens fastened to the ambulance. Source: Image from Wright 2017.123
www.ajlobby.com
(A)
(B)
Figure 5.38 (A) Rear and (B) side views of a motorized horse ambulance illustrating the central, rotating horse cubicle, all‐around access
and low‐loading facilities.
Communication and Records Officer for entry to a centralized database. Comprehensive

written information is important for ongoing patient
Accurate recording of racetrack incidents is important. management and communication with an equine refer
Primary for the attending veterinarian must be manage ral hospital. Additionally, case records frequently are
ment of the individual horse. In the UK, the British required to answer inquiries from the horse’s connec
Horseracing Authority uses a Racecourse Veterinary tions and insurers. Assimilation and collection of infor
Attendance Form. This triplicate form allows one copy mation also permit retrospective evaluation and
to travel with the horse, one is retained by the attending modification of fracture management strategies that ulti
veterinarian, and one is given to the legislative Veterinary mately may improve outcome and survival.
www.ajlobby.com
References
1 Bailey, C.J., Reid, S.W.J., Hogsdon, D.R. et al. (1997). 14 Bramlage, L.R. (1996). First aid and transportation of
Risk factors associated with musculoskeletal injuries in fracture patients. In: Equine Fracture Repair, 1e (ed.
Australian Thoroughbred horses. Prev. Vet. Med. 32: A.J. Nixon), 36–42. Philadelphia: WB Saunders.
47–55. 15 Bramlage, L.R., Embertson, R.M., and Libbey, C.J.
2 Bailey, C.J., Reid, S.W.J., Hogsdon, D.R. et al. (1998). (1991). Resin impregnated foam as a cast liner on the
Flat, hurdle and steeple racing: risk factors for distal equine limb. In: Proceedings of the American
musculoskeletal injury. Equine Vet. J. 30: 498–503. Association of Equine Practitioners, vol. 37, 481–485.
3 Bartels, K.E., Penwick, R.C., Freeman, L.J. et al. (1985). Lexington, KY: AAEP.
Mechanical testing and evaluation of eight synthetic 16 Brodell, J.D., Axon, D.L., and McCollister, E.C. (1986).
casting materials. Vet. Surg. 14: 310–318. The Robert Jones bandage. J. Bone Joint Surg. 68B:
4 Bathe, A.P. (1994). 245 fractures in Thoroughbred 776–779.
racehorses: results of a 2 year prospective study in 17 Burr, D.B. (1993). Remodelling and the repair of fatigue
Newmarket. In: Proceedings of the American Association of damage. Calcif. Tissue Int. 53: 575–581.
Equine Practitioners, vol. 40, 175–176. Lexington, KY: AAEP. 18 Campbell, N. (1996). Application of a Robert Jones
5 Beinlich, C.P. and Bramlage, L.R. (2002). Results of bandage. In: A Guide to the Management of
plate fixation of third metacarpal and metatarsal Emergencies at Equine Competitions (ed. S.J. Dyson),
diaphyseal fractures. In: Proceedings of the American 21–28. British Equine Veterinary Association.
Association of Equine Practitioners, vol. 48, 247–248. 19 Cantwell, S.L. and Robertson, S.A. (2006). Equine pain
Lexington, KY: AAEP. management. In: Equine Surgery, 3e (ed. J.A. Auer and
6 Bennett, R.C. and Steffey, E.P. (2002). Use of opioids for J.A. Stick), 245–253. St. Louis: WB Saunders.
pain and anaesthetic management in horses. Vet. Clin. 20 Carrier, T.K., Estberg, L., Stover, S.M. et al. (1998).
Equine. 18: 47–60. Association between long periods without high‐speed
7 Bischofberger, A.S., Fürst, A., Auer, J., and Lischer, C. workouts and risk of complete humeral or pelvic
(2009). Surgical management of complete diaphyseal fracture in Thoroughbred racehorses: 54 cases (1991–
third metacarpal and metatarsal fractures: clinical 1994). J. Am. Vet. Med. Assoc. 212: 1582–1587.
outcome in 10 mature horses and 11 foals. 21 Carter, D.R. and Hayes, W.C. (1977). Compact bone
Equine Vet. J. 41: 465–473. fatigue damage – I. Residual strength and stiffness.
8 Boden, L.A., Anderson, G.A., Charles, J.A. et al. (2006). J. Biomech. 10: 325–337.
Risk of fatality and causes of death of Thoroughbred 22 Cohen, N.D., Berry, S.M., Peloso, J.G. et al. (2000).
horses associated with racing in Victoria, Australia Association of high speed exercise with racing injury in
between 1989 and 2004. Equine Vet. J. 38: 312–318. Thoroughbreds. J. Am. Vet. Med. Assoc. 216: 1273–1278.
9 Boden, L.A., Anderson, G.A., Charles, J.A. et al. (2007). 23 Cohen, N.D., Dresser, B.T., Peloso, J.G. et al. (1999).
Risk factors for Thoroughbred racehorse fatality in flat Frequency of musculoskeletal injuries and risk factors
starts in Victoria, Australia (1989–2004). Equine Vet. J. associated with injuries incurred in Quarter Horses
39: 430–437. during races. J. Am. Vet. Med. Assoc. 215: 662–669.
10 Bourke, J.M. (1994). Fatalities on racetracks in Victoria: 24 Cohen, N.D., Mundy, G.D., Peloso, J.G. et al. (1999).
a seven year study. In: Proceedings of the International Results of physical inspection before races and race‐
Conference of Racing Analysts and Veterinarians, vol. related characteristics and their association with
10, 265–268. Dubai: ICRAV. musculoskeletal injuries in Thoroughbreds during
11 Bourke, J.M. (1995). Wastage in Thoroughbreds. In: races. J. Am. Vet. Med. Assoc. 15: 654–661.
Proceedings of the Annual Seminar of the Equine 25 Cohen, N.D., Peloso, J.G., Mundy, G.D. et al. (1997).
Branch of the New Zealand Veterinary Association, Racing related factors and results of pre‐race physical
107–119. Wellington: FCE Publication no. 167, NZVA. inspection and their association with musculoskeletal
12 Bowman, K.F., Leitch, M., Nunamaker, D.M. et al. injuries incurred in Thoroughbreds during races. J. Am.
(1984). Complications during treatment of traumatic Vet. Med. Assoc. 211: 454–463.
disruption of the suspensory apparatus in 26 Davies, H.M.S., McCarthy, R.N., and Jeffcott, L.B.
Thoroughbred horses. J. Am. Vet. Med. Assoc. 184: (1993). Surface strain on the dorsal metacarpus of
706–715. Thoroughbreds at different speeds and gaits. Acta
13 Bramlage, L.R. (1983). Current concepts of emergency Anat. 146: 148–153.
first aid treatment and transportation of equine 27 Driessen, B. (2008). Pain management. In: Equine
fracture patients. Comp. Cont. Educ. 5: 564–573. Emergencies: Treatment and Procedures, 3e (ed. J.A.
www.ajlobby.com
Orsini and T.J. Divers), 647–659. St. Louis: WB 41 Hammer, E.J., Ross, M.W., and Parente, E.J. (1999).
Saunders. Incomplete sagittal fractures of the talus in 11 racehorses.
28 Dyson, S.J. (1996). Assessment of an acutely lame In: Proceedings of the American Association of Equine
horse. In: A Guide to the Management of Emergencies at Practitioners, vol. 45, 162–163. Lexington, KY: AAEP.
Equine Competitions (ed. S.J. Dyson), 7–12. British 42 Hardy, J. (2004). Emergency procedures and first aid.
Equine Veterinary Association. In: Equine Sports Medicine and Surgery (ed. K.W.
29 Ellis, D. (1996). Transporting an injured horse. In: A Hinchcliffe, A.J. Kaneps and R.J. Geor), 1179–1192.
Guide to the Management of Emergencies at Equine Edinburgh: WB Saunders.
Competitions (ed. S.J. Dyson), 122–124. British Equine 43 Hernandez, J., Hawkins, D.L., and Scollay, M.C. (2001).
Veterinary Association. Race‐start characteristics and risk of catastrophic
30 Ely, E.R., Avella, C.S., Price, J.S. et al. (2009). musculoskeletal injury in Thoroughbred racehorses. J.
Descriptive epidemiology of fracture, tendon and Am. Vet. Med. Assoc. 218: 83–86.
suspensory ligament injuries in National Hunt 44 Hill, T., Carmichael, D., Maylin, G., and Krook, L.
racehorses in training. Equine Vet. J. 41: 372–378. (1986). Track condition and racing injuries in
31 Estberg, K., Gardner, I.A., Stover, S.M., and Johnson, Thoroughbred horses. Cornell Vet. 76: 361–379.
B.J. (1998). Intensive exercise schedules and risk of 45 Hill, T. (2003). On‐track catastrophe in the
catastrophic musculoskeletal injury and lay‐up in Thoroughbred racehorse. In: Diagnosis and
California Thoroughbred racehorses. In: Proceedings of Management of Lameness in the Horse (ed. M.W. Ross
the American Association of Equine Practitioners, vol. and S.J. Dyson), 854–861. Philadelphia: Elsevier‐WB
43, 269–270. Lexington, KY: AAEP. Saunders.
32 Estberg, L., Stover, S.M., Gardner, I.A. et al. (1995). 46 Hill, W.T. (2003). Survey of injuries in Thoroughbreds
Cumulative racing‐speed exercise distance cluster as a at the New York Racing Association tracks. Clin. Tech.
risk factor for fatal musculoskeletal injury in Equine Pract. 4: 323–328.
Thoroughbred racehorses in California. Prev. Vet. Med. 47 Houlton, J.E.F. and Brearley, M.J. (1985). A comparison
24: 253–263. of some casting materials. Vet. Rec. 117: 55–58.
33 Estberg, L., Stover, S.M., Gardner, I.A. et al. (1996). 48 Hubbell, J.A.E., Hinchcliffe, K.W., Muir, W.W. et al.
High‐speed exercise history and catastrophic racing (1997). Cardiorespiratory and metabolic effects of
fracture in Thoroughbreds. Am. J. Vet. Res. 57: walking, standing, and standing with a splint during the
1549–1555. recuperative period from maximal exercise in horses.
34 Estberg, L., Stover, S.M., Gardner, I.A. et al. (1996). Am. J. Vet. Res. 58: 1003–1009.
Fatal musculoskeletal injuries incurred during racing 49 Johnson, B.J., Ardans, A., Stover, S.M. et al. (1994).
and training in Thoroughbreds. J. Am. Vet. Med. Assoc. California racehorse postmorten program: a 4‐year
208: 92–96. overview. In: Proceedings of the American Association
35 Estberg, L., Stover, S.M., Gardner, I.A. et al. (1998). of Equine Practitioners, vol. 40, 167–169. Lexington,
Relationship between race start characteristics and risk KY: AAEP.
of catastrophic injury in Thoroughbreds: 78 cases 50 Johnson, B.J., Stover, S.M., Daft, B.M. et al. (1994).
(1992). J. Am. Vet. Med. Assoc. 212: 544–549. Causes of death in racehorses over a 2 year period.
36 Fessler, J.F. and Turner, A.S. (1983). Methods of Equine Vet. J. 26: 327–330.
external coaptation. Vet. Clin. North Am. Large Anim. 51 Kalpravidh, M., Lumb, W.V., Wright, M., and Heath,
Pract. 5: 311–331. R.B. (1984). Analgesic effects of butorphanol in horses:
37 Forward, M.R. and Parker, A.W. (1989). Microdamage dose‐response studies. Am. J. Vet. Res. 45: 211–216.
in response to repetitive torsional loading in the rat 52 Kalpravidh, M., Lumb, W.V., Wright, M., and Heath,
tibia. Calcif. Tissue Int. 45: 47–53. R.B. (1984). Effects of butorphanol, flunixin,
38 Furr, M. and Reed, S. (2008). Equine Neurology. levorphanol, morphine and xyalzine in ponies. Am. J.
Malden, MA: Wiley Blackwell. Vet. Res. 45: 217–223.
39 Fürst, A.E. (2006). Emergency treatment and 53 Kamerling, S.G., DeQuick, D.J., Weckman, T.J., and
transportation of equine fracture patients. In: Equine Tobin, T. (1985). Dose‐related effects of ethylketazocine
Surgery, 3e (ed. J.A. Auer and J.A. Stick), 972–981. St. on nociception, behaviour and autonomic responses in
Louis: WB Saunders. the horse. J. Pharm. Pharmacol. 38: 40–45.
40 Gomez, J. and Stashak, T.S. (2008). Bandaging and 54 Kamerling, S., Weckman, T., Donahoe, J., and Tobin, T.
casting techniques for wound management. In: Equine (1988). Dose related effects of the kappa agonist U‐50,
Wound Management, 2e (ed. T.S. Stashak and C.L. 488H on behaviour, nociception and autonomic
Theoret), 623–658. Malden, MA: Wiley Blackwell. response in the horse. Equine Vet. J. 20: 114–118.
www.ajlobby.com
55 Kane, A.J., Stover, S.M., Gardner, I.A. et al. (1996). 70 Mohammed, H.O., Hill, T., and Lowe, J. (1991). Risk
Horseshoe characteristics as possible risk factors for factors associated with injuries in Thoroughbred
fatal musculoskeletal injury of Thoroughbred horses. Equine Vet. J. 23: 445–448.
racehorses. Am. J. Vet. Res. 57: 1147–1152. 71 Moll, H.D., Slone, D.E., Humburg, J.M., and Jager, J.E.
56 Kohn, C.W., Hinchcliffe, K.W., and McKeever, K.H. (1987). Traumatic tarsal luxation repaired without
(1999). Evaluation of washing with cold water to internal fixation in three horses and three ponies. J.
facilitate heat dissipation in horses exercise in hot, Am. Vet. Med. Assoc. 190: 297–300.
humid conditions. Am. J. Vet. Res. 60: 299–305. 72 Morris, T. (2008). Regulatory aspects of racecourse and
57 Lanyon, L.E. (1987). Functional strain in bone tissue as point to point work. In: Proceedings of the Association
an objective and controlling stimulus for adaptive bone of Racecourse Veterinary Surgeons: Racecourse Casualty
remodelling. J. Biomech. 20: 1083–1093. Management, 16–18. Buckingham: ARVS.
58 Lindsay, W.A. (1990). Casting materials and 73 Mudge, M.C. and Bramlage, L.R. (2007). Field fracture
techniques. In: Current Practice of Equine Surgery management. Vet. Clin. Equine 23: 117–133.
(ed. N.A. White and J.N. Moore), 151–161. 74 Muir, W.W. (2005). Pain therapy in horses. Equine Vet.
Philadelphia: J.B. Lippincott. J. 37: 98–100.
59 Love, E.J., Taylor, P.M., Clark, C. et al. (2009). Analgesic 75 Mundy, G.D. (1997). Review of risk factors associated
effect of butorphanol in ponies following castration. with racing injuries. Proc. Am. Assoc. Equine Pract. 43:
Equine Vet. J. 41: 552–556. 204–210.
60 MacDonald, D.M. and Toms, T.S. (1994). Survey into 76 Murphey, E.D., Schneider, R.K., Adams, S.B. et al.
the incidence of race track injuries in the Transvaal (2000). Long‐term outcome of horses with a slab
Racing District of Southern Africa. In: Proceedings of fracture of the central or third tarsal bone treated
the International Conference of Racing Analysts and conservatively: 25 cases (1976–1993). J. Am. Vet. Med.
Veterinarians, vol. 10, 262–264. Dubai: ICRAV. Assoc. 216: 1949–1954.
61 Martin, B. (1995). Mathematical model for repair of 77 Murray, R.C. and De Bowes, R.M. (1996). Casting
fatigue damage and stress fracture in osteonal bone. techniques. In: Equine Fracture Repair, 1e (ed. A.J.
J. Orthop. Res. 13: 309–316. Nixon), 104–113. Philadelphia: WB Saunders.
62 Martin, R.B. and Burr, D.B. (1989). Structure, Function 78 Nunamaker, D.M. (1986). The bucked shin complex.
and Adaptation of Compact Bone. New York: Raven Proc. Am. Assoc. Equine Pract. 32: 457–460.
Press. 79 Palmer, S.E. (1986). Prevalence of carpal fractures in
63 Martin, R.B., Stover, S.M., Gibson, V.A. et al. (1996). In Thoroughbred and Standardbred racehorses. J. Am.
vitro fatigue behaviour of the equine third metacarpus: Vet. Med. Assoc. 188: 1171–1173.
remodelling and microcrack damage analysis. J. Orthop. 80 Parkin, T.D.H. (2008). Epidemiology of racetrack
Res. 14: 794–801. injuries in racehorses. Vet. Clin. North Am. Equine
64 Maxwell, L.K., Thomasy, S.M., Slovis, N., and Kollias‐ Pract. 24: 119.
Baker, C. (2003). Pharmacokinetics of fentanyl 81 Parkin, T.D.H., Clegg, P.D., French, N.P. et al. (2004).
following intravenous and transdermal administration Horse level risk factors for fatal distal limb fracture in
in horses. Equine Vet. J. 35: 484–490. racing Thoroughbreds in the U.K. Equine Vet. J. 36:
65 Mayhew, I.G. (2008). Large Animal Neurology. 513–519.
Chichester: Wiley Blackwell. 82 Parkin, T.D.H., Clegg, P.D., French, N.P. et al. (2004). Race
66 McClure, S.R., Watkins, J.P., Glickman, N.W. et al. and course level risk factors for fatal distal limb fracture
(1998). Complete fractures of the third metacarpal or in racing Thoroughbreds. Equine Vet. J. 36: 521–526.
metatarsal bone in horses: 25 cases (1980–1996). J. Am. 83 Parkin, T.D.H., Clegg, P.D., French, N.P. et al. (2004).
Vet. Med. Assoc. 213: 847–850. Risk of fatal distal limb fractures among
67 McKee, S.L. (1995). An update on racing fatalities in Thoroughbreds involved in five types of racing in the
the UK. Equine Vet. Educ. 7: 202–204. United Kingdom. Vet. Rec. 154: 493–497.
68 Meagher, D.M. (1980). Management of long bone 84 Parkin, T.D.H., Clegg, P.D., French, N.P. et al. (2005).
fractures in horses and the selection of methods of Risk factors for fatal lateral condylar fractures of the
treatment. In: Proceedings of the American Association third metacarpus/metatarsus in U.K. racing. Equine
of Equine Practitioners, vol. 26, 289–294. Lexington, Vet. J. 37: 192–199.
KY: AAEP. 85 Parsamian, G.P., Norman, T.L., and Kish, V.L. (2000). The
69 Mez, J.C., Dabareiner, R.M., Cole, R.C., and Watkins, mechanics of ultrastructural damage occurrence and its
J.P. (2007). Fractures of the greater tubercle of the influences on the fracture toughness of human bone. In:
humerus in horses: 15 cases (1986–2004). J. Am. Vet. Transactions of the Annual Meeting of the Orthopaedic
Med. Assoc. 230: 1350–1355. Research Society, vol. 46, 744. Rosemont, IL: ORS.
www.ajlobby.com
86 Peloso, J.G., Munday, G.D., and Cohen, N.D. (1994). 102 Shepherd, M.C., Pilsworth, R.C., Hopes, R. et al.
Prevalence of, and factors associated with (1994). Clinical signs, diagnosis, management and
musculoskeletal racing injuries in Thoroughbreds. J. outcome of complete and incomplete fracture to the
Am. Vet. Med. Assoc. 204: 620–626. ilium: a review of 20 cases. In: Proceedings of the
87 Pilsworth, R.C. (2003). Diagnosis and management of American Association of Equine Practitioners, vol. 40,
pelvic fractures in the Thoroughbred racehorse. In: 177–180. Lexington, KY: AAEP.
Lameness in the Horse (ed. M.W. Ross and S.J. Dyson), 103 Spurlock, G.H. and Gabel, A.A. (1983). Apical
484–490. St. Louis: Saunders. fractures of the proximal sesamoid bones in 109
88 Pinchbeck, G.L., Clegg, P.D., Proudman, C.J. et al. Standardbred horses. J. Am. Vet. Med. Assoc. 183:
(2002). Risk factors and sources of variation in horse 76–79.
falls in steeplechase racing in the U.K. Prev. Vet. Med. 104 Stephen, J.O., White, N.A., McCormick, W.H. et al.
55: 179–192. (2003). Risk factors and prevalence of injuries in
89 Pinchbeck, G.L., Clegg, P.D., Proudman, C.J. et al. horses during various types of steeplechase races. J.
(2004). Horse injuries and racing practices in National Am. Vet. Med. Assoc. 223: 1788–1790.
Hunt racehorses in the U.K.: the results of a 105 Stover, S.M., Ardans, A.A., Read, D.H. et al. (1993).
prospective cohort study. Vet. J. 167: 45–52. Patterns of stress fractures associated with complete
90 Pippi, N.L. and Lumb, W.V. (1979). Objective test of bone fractures in racehorses. In: Proceedings of the
analgesic drugs in ponies. Am. J. Vet. Res. 40: 1082–1086. American Association of Equine Practitioners, vol. 39,
91 Riggs, C.M. (2002). Fractures – A preventable hazard 131–132. Lexington, KY: AAEP.
of racing Thoroughbreds. Vet. J. 163: 19–29. 106 Stover, S.M., Johnson, B.J., Daft, B.M. et al. (1992). An
92 Riggs, C.M., Lanyon, L.E., and Boyde, A. (1993). association between complete and incomplete stress
Functional associations between collagen fibre fractures of the humerus in racehorses. Equine Vet. J.
orientation and locomotor strain direction in cortical 24: 260–263.
bone of the equine radius. Anat. Embryol. 187: 107 Swor, T.M. and Watkins, J.P. (2008). Adult orthopaedic
231–238. emergencies. In: Equine Emergencies: Treatment and
93 Rooney, J.R. (1983). Track condition in relationship to Procedures, 3e (ed. J.A. Orsini and T.J. Divers),
fatigue and lameness in Thoroughbred racehorses. 279–308. St. Louis: WB Saunders.
Equine Vet. Data. 4: 134. 108 Taylor, D. (1998). Microcrack growth parameters for
94 Rubin, C.T. and Lanyon, L.E. (1982). Limb mechanics compact bone deducted from stiffness variations. J.
as a function of speed and gait; a study of functional Biomech. 31: 587–592.
strains in the radius and tibia of horse and dog. J. Exp. 109 Taylor, P.M., Pascoe, P.J., and Mama, K.R. (2002).
Biol. 101: 187–211. Diagnosing and treating pain in the horse: where are
95 Rubin, C.T. and Lanyon, L.E. (1984). Regulation of we today? Vet. Clin. North Am. Equine Pract. 18:
bone formation by applied dynamic loads. J. Bone 1–19.
Joint. Surg. Am. 66A: 397–402. 110 Tetens, J., Ross, M.W., and Lloyd, J.W. (1997).
96 Rubin, C.T. and Lanyon, L.E. (1985). Regulation of Comparison of racing performance before and after
bone mass by mechanical strain magnitude. Calcif. treatment of incomplete, mid sagittal fractures of the
Tissue Int. 37: 411–417. proximal phalanx in Standardbreds: 49 cases (1986–
97 Ruggles, A.J. and Dyson, S.J. (2003). Bandaging, 1992). J. Am. Vet. Med. Assoc. 210: 82–86.
splinting and casting. In: Diagnosis and Management 111 Ueda, Y. (1991). Preventing accidents to racehorses:
of Lameness in the Horse (ed. M.W. Ross and S.J. studies and measures taken by the Japan Racing
Dyson), 769–773. St. Louis: WB Saunders. Association. In: Report of the Committee on
98 Rutkowski, J.A. and Richardson, D.W. (1989). A the Prevention of Accidents to Racehorses, 1–16.
retrospective study of 100 pelvic fractures in horses. Tokyo: Japan Racing Association Equine Research
Equine Vet. J. 21: 256–259. Institute.
99 Schaffler, M.B., Radin, E.L., and Burr, D.B. (1989). 112 Vaughan, L.C. and Mason, B.J.E. (1996). A
Mechanical and morphological effects of strain rate Clinicopathological Study of Racing Accidents in
on fatigue of compact bone. Bone 10: 207–214. Horses. London: Horserace Betting Levy Board.
100 Sheehy, J.G., Hellyer, P.W., Sammonds, G.E. et al. (2001). 113 Verheyen, K.L.P., Newton, J.R., and Wood, J.L.N.
Evaluation of opioid receptors in synovial membranes (2003). A case‐control study investigating factors
of horses. Am. J. Vet. Res. 62: 1408–1412. associated with pelvic and tibial stress fractures in
101 Shepherd, M.C. and Pilsworth, R.C. (1994). The use of Thoroughbred racehorses in training. In: Proceedings
ultrasound in the diagnosis of pelvic fractures. Equine of the Society of Veterinary Epidemiology and
Vet. Educ. 6: 223–227. Preventive Medicine, 119–131. SVEPM.
www.ajlobby.com
114 Verheyen, K.L.P. and Wood, J.L.N. (2004). Descriptive 120 Wilson, J.H. and Robinson, R.A. (1996). Risk factors
epidemiology of fractures occurring in British for equine racing injuries. Compend. Contin. Educ.
Thoroughbred racehorses in training. Equine Vet. J. Vet. 18: 682–690.
36: 167–173. 121 Wood, J.L.N., Eastman, J., Lakhani, K.H. et al. (2001).
115 Walmsley, J. (1996). Management of a suspected Modelling a retrospective study of death on racetracks.
fracture. In: A Guide to the Management of In: Proceedings of the Society of Veterinary Epidemiology
Emergencies at Equine Competitions (ed. S.J. Dyson), and Preventive Medicine, 115–126. SVEPM.
13–20. British Equine Veterinary Association. 122 Woodie, J.B., Ruggles, A.J., Bertone, A.L. et al. (1999).
116 Wheat, J.D. and Pascoe, J.R. (1980). A technique for Apical fracture of the proximal sesamoid bone in
management of traumatic rupture of the equine Standardbred horses: 43 cases (1990–1996). J. Am.
suspensory apparatus. J. Am. Vet. Med. Assoc. 176: Vet. Med. Assoc. 214: 1653–1656.
205–210. 123 Wright, I.M. (2017). Racecourse fracture
117 Williams, R.B., Harkins, L.S., Hammond, C.J., and management. Part 2: Techniques for temporary
Wood, J.L. (2001). Racehorse injuries, clinical immobilisation and transport. Equine Vet. Educ. 29:
problems and fatalities recorded in British 440–451.
racetracks from flat racing and National Hunt racing 124 Wright, I.M. (2017). Racecourse fracture
during 1996, 1997 and 1998. Equine Vet. J. 33: management. Part 3: Emergency care of specific
478–486. fractures. Equine Vet. Educ. 29: 500–515.
118 Wilson, D.G. and Vanderby, R. (1995). An evaluation 125 Yovich, J.V., Turner, A.S., Stashak, T.S., and
of fiberglass cast application techniques. Vet. Surg. 24: McIlwraith, C.W. (1987). Luxation of the
118–121. metatarsophalangeal and metatarsophalangeal joints
119 Wilson, J.H., Jensen, R.C., and Robinson, R.A. (1996). in horses. Equine Vet. J. 19: 295–298.
Racing injuries of two year old Thoroughbred and 126 Zioupos, P. and Currey, J.D. (1994). The extent of
Quarter horses. Pferdeleidkunde 12: 582–587. microcracking and the morphology of microcracks in
damaged bone. J. Mater. Sci. 29: 978–986.
www.ajlobby.com
83
6
First Aid and Transportation of Equine
Fracture Patients
Larry R. Bramlage
Rood and Riddle Equine Hospital, Lexington, KY, USA
Introduction thrombosis following continued stretching and direct

trauma to blood vessels often leads to loss of vascu-
After a fracture occurs, horses are not readily ambula- larity to the distal limb. Immobilization is more impor-
tory on three limbs and tend to add to the trauma already tant for the preservation of the vascularity to the distal
present in an injured limb. The objective of first aid limb than for prevention of bleeding at the fracture site,
treatment is to minimize this additional damage. but proper immobilization can accomplish both.
The degree of damage to the limb must be assessed at Although shock seldom results from blood loss, it may
the initial examination. Some limbs are too severely follow the marked anxiety that often accompanies a
damaged for an attempt at repair. Severe loss of soft tissue fracture. Severe anxiety and accompanying volumi-
or loss of bone constitutes a situation where treatment nous perspiration can result in considerable loss of body
may be hopeless. If the limb is in reasonably good condi- fluid and the compromised perfusion often requires
tion for repair, or if there is any doubt about the possibility fluid therapy. Prompt sedation and limb stabilization
of repair, then the soft tissues are in urgent need of protec- will generally reduce anxiety and limit the fluid loss by
tion. Protective splints should be applied immediately; perspiration. Once a splint is applied and the horse is
other procedures, such as radiography, can then be done able to regain control of the limb, the animal generally
with minimal risk of further damage. Radiography is becomes more tractable, even though the limb cannot
actually facilitated by properly applied splints. bear weight. A properly applied splint also provides
Use of a twitch is the initial and primary means of counterpressure over the swollen area. Pressure over
gaining control of the horse. Sedation and analgesia are the fracture site protects the soft tissue by preventing
then used as needed to allow manipulation of the limb. imbibition of blood and edema fluid, which controls the
Emergency first aid measures should be directed at swelling and some of the pain.
minimizing any further damage to the injured limb and The most important tissue to protect, from a repair
maintaining it in a condition that warrants repair. The aspect, is the skin. An intact skin cover greatly reduces
objectives of emergency first aid are as follows: the chances of infection. Equine skin is so thin that it
offers little resistance to sharp bone fragments. If skin
1) Prevent damage to the neural and vascular elements
penetration has occurred, the wound should be covered
of the limb.
with a water‐soluble antibiotic ointment, and a sterile
2) Keep the fractured bone from penetrating the skin and
dressing should be applied immediately to reduce the
becoming an open fracture, or protect the limb from
amount of subsequent contamination. The appropriate
contamination through any existing skin opening.
splint should then be applied over the sterile bandage to
3) Stabilize the limb to relieve the anxiety that accompa-
prevent further damage.
nies an uncontrolled limb in a horse.
Proper splinting helps protect the fractured bone
4) Minimize any further damage to the fractured bone
from self‐abuse. The horse will generally make repeated
ends and surrounding soft tissue.
attempts to place an unstable limb in its normal position.
Hemorrhage due to laceration of a major vessel is The continuous lifting and replacing of the limb grind
infrequent after equine fractures; therefore, hypov- the bone ends against each other, complicating the
olemic shock due to blood loss is uncommon. However, reconstruction. Once the limb is splinted, the horse will

www.ajlobby.com
better protect the limb by resting it instead of continually structures in the horse’s limbs. Systems such as the
trying to place it in a normal stance. The pain associated suspensory apparatus in the front limb and the recipro-
with the fracture is usually severe enough to preclude cal apparatus in the hind limb require an intact skeleton
any serious attempts by the horse to use the limb for to perform properly. Their action is altered if a fracture
weight support. Splint application does not encourage occurs within their sphere of influence.
the horse to walk and thereby cause unnecessary trauma The splinting apparatus must be portable for the horse
to the limb. Instead, it encourages the horse to rest the and neither too heavy nor too clumsy for ambulation.
limb until treatment can be instituted. Loading, unloading, and transportation require the
horse to move on three limbs, and the splint must be
compatible with these maneuvers. Equine fracture
Splinting Techniques patients often resist manipulation that would be toler-
ated if there were no injury. Frequently the owners are
After the initial examination has established that an frantic and of little help if complicated procedures are
unstable fracture exists and requires a splint, the attend- required. Therefore, the splint must be easy to apply
ing veterinarian must decide what type of support is under the worst of circumstances.
necessary. The ideal splint has the following attributes: Previous reports of first aid for fracture patients rec-
ommend general anesthesia for cast application.5,10 This
1) Neutralizes the damaging forces as much as possible.
is a formidable task in the field on an adult patient that is
2) Is not so cumbersome that it prevents the horse moving.
already physiologically disturbed by a fracture. The ideal
3) Can be applied under the most difficult of circumstances.
splint can be applied to the standing adult horse under
4) Does not require general anesthesia and anesthetic
sedation or to a recumbent horse if necessary. A splint
recovery.
must be economical to use, and must be available when
5) Is economical and accessible to the attending veteri-
needed. Techniques discussed in this chapter employ
narian for first aid application in the field or stable.
commonly available material that is generally accessible
The damaging forces to be neutralized are determined on a farm or from a veterinarian’s routine inventory.
by the fracture location and by the dynamic forces acting To immobilize the area of the fracture effectively, the
across the fracture area. When a fracture occurs between fore‐ and hindlimbs must be divided into areas of domi-
the origin and insertion of a muscle, the muscle no longer nant biomechanical force. This discussion deals primarily
has a skeletal frame over which to act, and often engages with the fracture patient; but any cause of a flail limb,
in an action quite different from its intended function. such as a luxation or weight‐bearing tendon laceration
For example, the antebrachial extensor muscles of the within each area described, can be handled equally well
forelimb become abductors of the limb when a fracture with the same splinting techniques. Special consideration
of the radius occurs. With most muscles, some change of fractures on the racetrack are covered in Chapter 5.
in the effect of muscle contraction occurs following a The forelimb has four functional segments (Figure 6.1):
fracture because of the large number of passive‐action (i) distal to the distal portion of the metacarpus; (ii) from
No immobilization
necessary
Caudal splint No immobilization
to lock carpus necessary
in extension
Robert Jones bandage
Robert Jones bandage with extended
with extended lateral splint
lateral splint
Robert Jones bandage Robert Jones bandage
with caudal and with plantar and
lateral splint lateral splint
Dorsal splint Plantar splint
Figure 6.1 The functional divisions of the horse’s limbs for application of external support to stabilize a fracture.
www.ajlobby.com
6 First Aid and Transportation of Fracture Patients 85
the distal radius to the distal metacarpus; (iii) from the

elbow joint to the distal radius; and (iv) from the distal
scapula to the elbow joint. In the hindlimb the functional
divisions include these segments: (i) distal to the distal
portion of the metatarsus; (ii) from the proximal metatar-
sus to the distal metatarsus; (iii) from the stifle joint to the
proximal metatarsus; and (iv) proximal to the stifle joint.
Fractures of the proximal scapula, femur, pelvis, and axial
skeleton cannot be protected by external splinting and do
not usually require stabilization. However, fractures of Board or
these areas do require protection from abuse during PVC splint
transportation, so the suggestions on the movement of
horses with fractures are applicable. Horses with frac-
tures of the axial skeleton resulting in paraplegia or quad-
riplegia are exceptions to the rules for transportation,
because they must be hauled in the recumbent position. Fiberglass cast
material over
the splint
Fractures of the Phalanges
and Distal Metacarpus
The most distal functional division of the forelimb begins
at the coronary band and extends proximally to the distal
quarter of the metacarpus. This division includes all
unstable fractures of proximal and middle phalanges, the
sesamoids, and the distal metacarpus. The area is domi-
nated biomechanically by the angle of the fetlock joint.
Figure 6.2 Cast–splint combination for rigid support of distal
If a fracture occurs in this area, the principal bending
metacarpal and phalangeal fractures. The metacarpal and
focus becomes the fracture site rather than the fetlock phalangeal dorsal surfaces are axially aligned by a rigid splint.
joint, because the dynamic resistance of the suspensory
ligament to extension at the fetlock joint will be larger
than any resistance to bending at the fracture site. alignment during transportation, cast material can be
Therefore, proper splinting must include some means of applied over the limb. To facilitate application, an assis-
counteracting the bending force near the fetlock. The tant should hold the forelimb just proximal to the carpus
distal limb of the horse offers an opportunity to obtain and allow the distal limb to hang during application of
reasonable pressure on the limb with a splint or a cast, the splint and cast. Sedated horses generally tolerate this
because the bones are close to the skin surface. A tradi- maneuver with little objection. Once the splint‐cast is
tional cast with a normal fetlock angle does not neutralize applied, the horse can be allowed to walk on the toe of
the bending force when weight is applied. In addition, the limb with little further trauma.
application of a cast to a flail limb is difficult in the con- It is essential to apply the splint‐cast over minimal
scious, standing animal if an attempt is made to maintain padding. Thick padding is compressed as the bones
a normal fetlock angle. move, which eventually loosens the cast and allows
To facilitate the stabilization of an injury in the most excessive motion of the fracture ends. If no padding is
distal area of the forelimb and to eliminate the bending used and the cast is applied tightly, the swelling may
force of the fetlock joint, the dorsal cortices of the bones increase the pressure within the cast until it begins to
should be aligned by splinting in a straight line strangulate perfusion. Only thin padding is appropriate;
(Figure 6.2). This is done by applying a light layer of sheet it accommodates swelling, but enables the cast to be
cotton or a very light bandage, no more than 0.5 in. thick, applied sufficiently tightly to protect the limb.
over the skin. The bandaged limb and its contained bony An alternative to the splint‐cast for axially stable
column are then taped to a splint placed along the dorsal injuries to the lower limb is the commercially available
surface of the limb, from the carpus to the toe. The splint Kimzey Leg Saver Splint. This is particularly good for
ensures that the dorsal cortices of the bones are aligned suspensory apparatus rupture and sesamoid fractures.
and any bending force is neutralized. To maintain the It is less useful for very unstable fractures, but is quick
www.ajlobby.com
and easy to apply, and can be used in emergency

situations for most injuries to the lower limb.

Transportation may require added stability. Board
Fractures of the Mid Forelimb

For fractures from the mid metacarpus to the distal
radius, the objective of first aid is to utilize the proximal Radius
and distal limb to attach a splint that can immobilize the fracture
fracture. The best immobilization technique for this area
uses a Robert Jones bandage and rigid external splints.
Robert Jones bandages are applied in many layers, each
no more than approximately 1 in. thick. Each thin layer
of padding, such as cotton, is covered with elastic gauze.
If too thick a layer of padding is added with each appli-
cation or if all the padding is applied without layers of
elastic gauze between the individual layers, shifting and Adhesive bandage
compacting of the padding will occur. This renders the and rolled
cotton bandage
splint ineffective or less effective than the multilayered
bandage, and may even cause the splint to become detri-
mental if it shifts and immobilizes the joints and not the
fracture. The total diameter of the finished Robert Jones
bandage should be approximately three times as large as
the diameter of the limb at the fracture site.
The rigid splint material must extend from the elbow to
the ground to prevent shifting during transportation.
A minimum of two splints should be used and should Figure 6.3 Robert Jones bandage with extended lateral splint
preferably be placed caudal and lateral on the limb to for stabilization and prevention of abduction of mid and proximal
ensure that the fracture is supported at 90° angles, and fractures of the radius.
that the splints support each other to prevent their break-
ing or bending during transportation. Any lightweight, tors of the limb distal to the fracture, rather than effectors
relatively strong, rigid material can be used effectively for of extension or flexion. The medial side of the radius has no
splinting. Wood or plastics are ideal, although lightweight muscle cover and when the limb is abducted the unpro-
metal, such as aluminum or flat steel, also works well. tected skin is easily perforated by the sharp internal frac-
Splints are applied over the Robert Jones bandage tured bone ends. Therefore, preventing abduction of the
with nonelastic adhesive tape, which is necessary to limb is essential in fractures of the mid and proximal radius.
prevent shifting of the splint material within the band- This is achieved by applying a Robert Jones bandage, iden-
age. Nonelastic tape does not expand and thereby tical to the bandage used for mid forelimb fractures, but
increases the rigidity of the outer shell of the bandage. with the lateral splint extended up the lateral aspect of the
The tape should be applied as tightly as possible. triceps and chest, and taped securely to the proximal fore-
limb at the level of the axilla (Figure 6.3). This lateral splint
extension lies against the ribs and prevents the fracture act-
Fractures of the Mid ing as a fulcrum with abduction of the distal limb during
and Proximal Radius attempts at weight bearing.
Fractures that extend into the diaphysis or proximal meta-

physis of the radius cannot be adequately stabilized by Fractures Proximal
using a Robert Jones bandage and conventional splints; to the Elbow Joint
inadequate purchase is obtained proximal to the fracture
to prevent abduction. The principal musculature of the Fractures of the humerus, ulna, or neck of the scapula
antebrachium lies on the lateral aspect of the limb.9 When are well protected by muscle coverage and are closely
a fracture occurs in this area, the muscles no longer have an attached to the body on their deep surface. This ana-
intact skeleton over which to act and they become abduc- tomical arrangement minimizes the need for additional
www.ajlobby.com
protection of the actual fracture site in these bones.

However, fractures of the humerus or ulna disrupt the
triceps apparatus, and makes it impossible for the horse
to fix the elbow for weight bearing. This results in an Board or PVC
inability to control the limb, similar to fractures of the splint
radius and third metacarpus. However, the horse is
usually less anxious about the disability because some
extension and flexion are possible. The horse can be
aided in controlling the limb by splinting the carpus in
an extended position. When the triceps apparatus is
disabled, the elbow drops and the carpus flexes, making
the limb useless. If the carpus is kept extended by a splint,
the horse can use the limb for balance and is more
amenable to transport, assessment, and treatment.
The splint and bandage used to stabilize the carpus
need not be as substantial as the Robert Jones bandage
used to support a fracture of the lower limb. A simple Fiberglass cast
material over
padded bandage and a splint placed down the caudal the splint
or cranial aspect of the limb, with the carpus taped to
the splint, are sufficient to maintain the carpus in an
extended and locked position for weight support.
Fractures of the Distal
Hindlimb
Fractures of the hindlimb, from the coronary band to
Figure 6.4 Cast–splint combination for stabilization of distal
the distal metatarsus, can be treated identically to the metatarsal and phalangeal fractures. The splint is applied to the
forelimb, except that the splint is best applied on the plantar surfaces.
plantar surface of the limb (Figure 6.4). The normal
flexion of the fetlock and phalanges by the reciprocal
apparatus makes alignment of the sole surface of the and laterally from the tuber calcis to the ground and are
foot, plantar fetlock, and flexor tendons easier than attached tightly with nonelastic tape.
aligning the dorsal cortices. This type of splint is a little
more difficult to apply on the hindlimb than the fore-
limb, but can be utilized if the limb is supported in exten- Fractures of the Tibia
sion, slightly caudal to the normally positioned limb, and Tarsus
during the splint application. Kimzey Leg Saver Splints
can be used on hindlimbs, but work better if the dorsal Fractures of the tibia and tarsus are particularly difficult
splint is bent to provide more flexion to the fetlock area. to splint adequately because of the reciprocal apparatus
and its effect on joint motion in the tarsus and stifle.1
This action requires an intact skeleton within the recip-
Fractures of the Mid rocal apparatus. If a fracture of the tibia or tarsus occurs,
and Proximal Metatarsus stifle flexion causes overriding at the fracture site and
not hock flexion. As a result, when the stifle is flexed
For fractures of the metatarsus proximal to the distal third, after a fracture, the hock stays in a fixed position and the
the tuber calcis can be used as a functional extension of fracture collapses. Nothing can be done to prevent stifle
the metatarsus. Splints placed plantarly and laterally flexion, but proper splinting can minimize the lower‐
over a Robert Jones bandage furnish adequate support. limb instability and help reduce unnecessary trauma to
The Robert Jones bandage should be less extensive than the limb when the stifle is flexed.
on the mid forelimb. It is difficult to wrap the proximal The muscle location around the circumference of the
tarsal area, and impossible to tape the splints adequately tibia is similar to that of the radius, in that the principal
to the limb if the bandage on the distal metatarsus is musculature is located on the lateral aspect of the limb
too thick. The straight splints are applied plantarly and the medial surface of the bone is covered only by
www.ajlobby.com
skin.9 Therefore, to prevent abduction the splint must be provide rotational stability to the flail limb. Cranial or
extended proximally, similar to the splint for fractures of caudal splints are generally not used on upper hindlimb
the radius. The angulation of the hock and stifle joints fractures and add little to the support.
prevents the use of a cranial or caudal splint, but allows
a single lateral splint to neutralize the bending and
rotational forces if the splint is bent to follow the angula- Fractures of the Femur
tion of the limb. The splint is applied over a Robert Jones
bandage and is taped to the limb with nonelastic tape. It is difficult to effectively stabilize fractures of the femur
The Robert Jones bandage must be thick and tight. The by external means, and generally they do not require
splint is best made of a lightweight metal, such as alu- splinting due to their vast muscle coverage. Adequate
minum, electrical conduit, or even a small‐diameter steel muscle insertions exist distal to a femoral fracture site
concrete reinforcement bar. This bar is bent into a lateral for the horse to control the limb, and although the limb
support, similar to the lateral component of a Schroeder– is almost useless for weight bearing, little can be done
Thomas splint. The metal is bent to follow the angula- with temporary splinting to improve the situation.
tion of the limb across the hock and stifle joints and
extends from the ground to the lateral thigh. The splint is
most effective if it is bent back on itself to mirror the
hindlimb contour back to the ground, creating a double
Moving the Fracture Patient
splint. A viable alternative is a wide (15–20 cm) board
The objective in transporting a horse with a fracture is to
taped on the lateral side of the limb from the ground to
minimize the need to use the fractured limb. If possible,
the ilium (Figure 6.5). The width of the board and the
the transportation vehicle should be brought to the animal
angulation of the limb at the fetlock, tarsus, and stifle
to shorten the distance the injured horse must be walked.
Foals can be carried to the vehicle if they are small and
enough manpower is available. A good method for carry-
ing a foal is for one person to stand on each side of the foal;
the two people then grasp one of each other’s arms under
the caudal abdomen and place the other arm around a
forelimb of the foal into its axilla. This allows the carriers
to move the foal in the upright position with the four limbs
hanging free. Most foals do not object to this method of
Board
handling if they are kept near the mare. If they do object,
tranquilization is usually adequate to calm them.
Superficial
Transportation
Peroneus tertius
tendon digital flexor
tendon Once the patient is properly splinted and supported in
the van or trailer, the duration of the ride is of little
Tibial importance because extra hours in a van do little further
fracture damage to the limb of a properly supported horse. If the
Bandage material horse is improperly supported in the van or trailer, even
(adhesive bandage over a short ride can be severely traumatic.
rolled cotton bandage)
Vans and large “gooseneck” trailers are preferable to
small trailers because they are more stable and allow
transportation of the horse in a facing‐forward or
facing‐backward position. Descriptions of racetrack

ambulances and purpose‐built long‐distance equine
ambulances are available in Chapter 5. Horses with frac-
tures of the forelimbs should be transported facing back-
ward to ensure that their weight is thrown onto the two
sound hindlimbs when the vehicle stops. Acceleration is
Figure 6.5 Robert Jones bandage with wide‐board splint to more controllable and can be gradual. The transition
stabilize a fracture of the tibia. from stopped to moving is easier than the transition
www.ajlobby.com
from moving to stopped. For a horse with a fractured the time the injury is recognized by farm staff. Where
hindlimb, the forward‐facing position is favored for the blood loss or dehydration has developed, appropriate
same reasons. fluid therapy should be instituted upon initial exami-
During transport, the horse should be strictly confined nation, and continued if necessary during transporta-
with chest and rump bars or chains and with partitions tion. Corticosteroid therapy is generally unnecessary
to squeeze it into as limited a stall as possible. This allows because the endogenous corticosteroid level will be
the horse to lean on the supports to maintain its balance. high after the injury.
Hauling is an athletic feat for a horse, because it requires If penetration of the skin has occurred, broad‐spectrum
continual adjustment of foot placement to maintain antibiotic coverage should be started. Gram‐positive and
balance. This is obviously difficult and undesirable for gram‐negative coverage should be included.3 When
a horse with a fracture. A horse that can lean on the there is no injury to the skin, antibiotic therapy is not
supports around its chest and abdomen to maintain its essential if an appropriate splint has protected the limb
balance experiences less of the trauma of repeated limb from further damage.
adjustment. Those inexperienced with horses tend to Nonsteroidal anti‐inflammatory drugs are indicated
remove all partitions and haul fracture patients in an before transportation. They help prevent the soft tissue
open‐box stall. This is the wrong approach, because a inflammation that accompanies a fracture and assist in
horse seldom travels in a recumbent position, and an the control of inflammatory pain. Such drugs are not as
unconfined horse in an open stall inflicts severe trauma immunosuppressant as the corticosteroid preparations
to the injured limb trying to keep its balance. and they have the added benefit of reducing platelet
The ideal situation is to confine the body of the adhesion, thereby helping prevent intravascular throm-
horse but leave the head and neck free. The head of bosis of vital arteries to the distal limb.4
the horse should be loosely cross‐tied or left untied to Analgesia and sedation are best accomplished with
allow use of the head as a counterweight in maintain- xylazine.6,7 When compared with the other drugs availa-
ing balance. Having the head free also helps prevent ble, xylazine has minimal cardiovascular side effects and
the anxiety that some horses experience when confined is the best readily available analgesic for deep skeletal
to a small space. pain.8 The principal disadvantage during transportation
Foals should be hauled in a partitioned area next is the drug’s short half‐life and the occasional necessity
to the dam, with an attendant if possible. Foals will to give repeated injections for long trips. However, no
normally haul recumbent. Bales of hay or straw can be side effects result from repeated dosage. Often when the
useful in reducing a hauling stall to foal size if no atten- horse is loaded and under way, further medication is
dant is available. unnecessary.
A hay net is one of the best tranquilizers for a horse
that has been properly splinted and loaded. The horse
Systemic Medication should not be allowed to engorge before potential
surgery, but small amounts of hay during transporta-
Shock is rarely a factor in the equine fracture patient, tion are not harmful, and the occupational therapy of
except where there is excessive blood loss or pro- trying to pull hay from a hay net helps relieve the anxiety
longed marked perspiration. Internal hemorrhage is a of travel.
major concern with femur and pelvic girdle fracture, When proper measures are taken to splint and trans-
but rare beyond those bones. Occasionally a lower‐ port the equine fracture patient appropriately, the results
limb fracture with arterial laceration will result from a of the operative techniques of fracture repair improve
paddock accident, and blood loss can be extensive by accordingly.2
References
1 Adams, O.R. (2002). Lameness in Horses, 5e, 55. 4 Jones, E.W. (1982). Anti‐inflammatory drugs. In: Equine
Philadelphia, PA: Lippincott Williams & Wilkins. Medicine and Surgery, 3e (ed. J.D. Powers and T.E. Powers),
Bramlage, L.R. (1983). Current concepts of first aid and
2 153. Santa Barbara, CA: American Veterinary Publications.
transportation of the equine fracture patient. Compend. 5 Meagher, D.M. (1980). Management of long bone
Contin. Educ. Pract. Vet. 5: 5564. fractures in horses and the selection of methods of
Burri, C. (1974). Post‐traumatic Osteomyelitis. Bern:
3 treatment. In: Proceedings of the American Association of
Huber. Equine Practitioners, vol. 26:289. Lexington, KY: AAEP.
www.ajlobby.com
6 Muir, W.W. (1982). Tranquilizers, sedatives and muscle 8 Pippi, N.L. and Lumb, W.V. (1979). Objective tests
relaxants. In: Equine Medicine and Surgery, 3e (ed. J.D. of analgesic drugs in ponies. Am. J. Vet. Res. 40:
Powers and T.E. Powers), 250. Santa Barbara, CA: 1082.
American Veterinary Publications. 9 Sisson, S., Grossman, J.D., and Getty, R. (1975).
7 Muir, W.W., Skarda, R.T., and Sheehan, W. (1978). Anatomy of the Domestic Animals, 5e. Philadelphia:
Narcotics agonists, partial agonists and sedatives in WB Saunders.
horses, equine pharmacology. In: Proceedings of the 10 Turner, A.S. (1982). Long bone fractures in horses.
American Association of Equine Practitioners Equine Part III. Postoperative management. Compend. Contin.
Pharmacology Symposium, 173. Lexington, KY: AAEP. Educ. Pract. Vet. 4: S254.
www.ajlobby.com
91
7
Perioperative Considerations
Alan J. Nixon1,2
1
2
Introduction tive locally, especially in combination. Airborne bacteria

cannot be prevented from settling in open surgical sites,
Thorough preparation of the horse, the surgical suite and therefore the status of the blood supply to the fractured
staff, and the surgical plan are essential aspects of equine bone and the extent of concurrent soft tissue trauma at
fracture repair. The immediate need for fracture stabiliza- the fracture site are critical determinants of the potential
tion often leads to hasty preparation. However, the early for infection. Endogenous sources of organisms are
implementation of perioperative measures that can help important in foals, where hematogenous organisms from
avoid problems during surgery and in the postoperative pulmonary, gastrointestinal, or umbilical sources can
period may improve the likelihood of success. Splinting seed devitalized bone and soft tissue at the fracture site.
techniques and transport of the horse to a surgical facility Antibiotics commonly used prophylactically prior to
are covered in Chapters 5 and 6. Immediate preoperative repair of closed long bone fractures include penicillin G
and perioperative preparation is discussed here. potassium or sodium, or a cephalosporin, such as ceftiofur
or cefazolin, and an aminoglycoside, such as gentamicin
sulfate or amikacin. Antibiotics suitable for equine
Antibiotics orthopedic cases and appropriate dose rates are listed in
Table 7.1. Preoperative antibiotics should be given intra-
The selection of antibiotics and the postoperative dura- venously to provide rapid elevations to peak serum levels.
tion of their use are often dictated by the presence or For more simple fracture repair cases involving metal-
absence of skin perforation at the time of fracture. lic implants, prophylactic antibiotics can be limited to
Antibiotics should always be administered preoperatively, only a single antibiotic, such as penicillin G. When chip
using intravenous routes, to achieve high serum concen- fractures are being removed by arthroscopic means,
trations at the time of surgery. Additional doses intraop- antibiotic coverage is generally unnecessary, unless there
eratively may be required during lengthy surgeries. In has been recent administration of intraarticular corti-
closed fractures, antibiotics are given prophylactically to costeroids. Some authors consider that arthrocentesis
suppress proliferation of exogenous organisms deposited within two weeks of intraarticular surgery also warrants
in deeper tissues from skin contaminants that remain perioperative antibiotic therapy.
after sterile preparation, and from airborne fomites The penicillins, including natural forms such as penicillin
present in the surgical theater.28 Complex fracture repairs G and extended‐spectrum penicillins such as ticarcillin,
usually expose damaged bone ends to airborne organisms are bactericidal and act directly on bacterial cell wall
for extended periods, and local wound irrigation with synthesis. They are highly active against many gram‐
antibiotic‐laden polyionic solutions is important to positive organisms, including frequent equine pathogens.
reduce bacterial numbers. Selection of antibiotics for The aqueous salt forms of penicillin G (Na+ or K+) are
local irrigation often utilizes those suitable only for generally administered preoperatively in fracture cases,
nonsystemic use, including polymyxin B, neomycin, particularly where there are open fractures, to achieve
and bacitracin, which tend to have toxicity issues when rapid serum elevations and higher concentrations than
administered parenterally, but are cheap and still effec- are possible when intramuscular forms such as procaine

www.ajlobby.com
Table 7.1 Antibiotics suitable for prophylactic and therapeutic use in equine fracture repair cases.
Antimicrobial Route of
agent administration Dosage Spectrum of activity Additional features
Penicillins
Aqueous i.v. 22–40 000 IU/Kg Gram‐pos. activity, incl. Streptococci, some N+ salt can be given
penicillin G q 6 hr Staph spp., and Pasteurella intraoperatively; K+ salt
carries cardiac risk
Procaine i.m. 22 000 IU/Kg Same Synergistic with
penicillin G q 12 hr aminoglycosides
Ticarcillin i.v., i.m. 50–100 mg kg−1 Same, also antipseudomonal Synergistic with
q 6–8 hr aminoglycosides
Imipenem* i.v. 15–25 mg kg−1 Resistant gram-pos and gram-negative Expensive; meropenem
q 6 hr organisms, and anaerobes similar spectrum and less
expensive. Can be given by
RLP or in PMMA
Cephalosporins
Cefazolin (Ancef ) i.v., i.m. 20 mg kg−1 Strep, Staph (incl. penicillinase producers), First generation
q 8 hr Escherichia coli, Synergistic with
Klebsiella, Proteus mirabilis aminoglycosides
Ceftiofur (Naxcel) i.v., i.m. 2.2 mg kg−1 Gram‐pos.; but expanded gram‐negative Third generation
q 12 hr organisms and anaerobes Foals 4.4 mg kg−1 q 12 hr
Aminoglycosides
Gentamicin i.v., i.m. 6.6 mg kg−1 Gram‐negative aerobes Nephrotoxic; monitor
(Gentocin) q 24 hr creatinine
Amikacin i.v., i.m. 10 mg kg−1 Expanded gram‐negative spectrum Less nephrotoxic than
(Amiglyde‐V) q 24 hr gentamicin; monitor
creatinine. Foals
20–25 mg kg−1 q 24 hr
Sulfonamides
Trimethoprim‐ p.o. 25–30 mg kg−1 Gram‐positive and negative aerobes I.v. formulation available.
sulfamethoxazole q 12 hr Some anaerobes Dose rate total
(Tribressin) sulfonamide+trimethoprim.
Miscellaneous
Metronidazole p.o. 15–25 mg kg−1 Most anaerobes incl. Bacteroides fragilis Less expensive than i.v.
(Flagyl) q 6–8 hr formulation. Cease if anorexia
develops
Enrofloxacin i.v. 5 mg kg−1 q 24 hr Penicillinase producing Staph, gram‐negative Expensive. Pseudomonas dose
(Baytril) p.o. 7.5 mg kg−1 q 24 hr bacteria incl. Pseudomonas, Klebsiella, 7.5–10 mg kg−1
Enterobacter, Salmonella, Proteus Not for use in foals
Ineffective for anaerobes
Vancomycin* i.v. 5–7.5 mg kg−1 Multidrug resistant gram positive aerobes; Dilute and administer slowly.
q 8 hr clostridium spp Expensive. Can be given by
RLP or in PMMA
*Use as last resort; administration in animals controversial.

i.m., intramuscularly; i.v., intravenously; p.o., orally; q, every; RLP, regional limb perfusion; PMMA, polymethylmethacrylate.
penicillin G are used. Additionally, the various forms blood pressure monitored.14 Potassium penicillin G is
of penicillin G are relatively inexpensive. Sequential arrhythmogenic and should not be administered to the
intraoperative doses of sodium penicillin can be given anesthetized horse. An expanded spectrum of activity
intravenously during extended procedures. However, can be obtained using semisynthetic penicillins such as
systemic arterial pressure can be influenced by penicillin ticarcillin, or in exceptional circumstances combinations
G sodium, and the injection should be given slowly and of penicillin derivatives and clavulanic acid (an inhibitor
www.ajlobby.com
of ß‐lactamases). Expense becomes an issue with these for filling drill tracts also provides improved control of
antibiotic forms, and their use is generally confined to bacterial proliferation.
osteomyelitis cases with confirmed organisms and
associated antibiotic susceptibilities. Regardless, for
perioperative prophylaxis and therapeutic use in open Analgesics
fractures, the penicillins are usually combined with an
aminoglycoside and occasionally also metronidazole Effective pain control is critically important, from the time
(for expanded anaerobe coverage). of initial field examination until the late postoperative
The cephalosporins are bactericidal and also act by phase. Initial choices for analgesics are discussed in
inhibiting cell wall synthesis. They have a broader spec- Chapters 5 and 6. One of the most effective calming and
trum of activity than that of penicillins, particularly the analgesic procedures is the use of a firm bandage and an
second‐ and third‐generation cephalosporins. Despite incorporated splint. The addition of a nonsteroidal anti‐
the additional cost, at some institutions cephalosporins inflammatory drug (NSAID) such as phenylbutazone
have replaced penicillin as the drug of choice for pro- (8.8 mg kg−1 body weight intravenously) and a sedative/
phylactic perioperative coverage in equine fracture analgesic such as the α2‐agonist drugs xylazine or detomi-
repair cases. Cephalosporins should be considered in dine usually provides reasonable acute pain control. In
open fracture cases, particularly the third‐generation severely painful preoperative conditions, butorphanol
cephalosporins, which have increased activity against (0.01 mg kg−1 intravenously) may also be used; however,
Pseudomonas spp. and anaerobes. excessive tranquilization should be avoided to prevent the
Aminoglycosides are bactericidal and exert their effect attendant ataxia. Repeated doses of detomidine adminis-
by inhibiting bacterial protein synthesis. The two most tered intramuscularly (0.02 mg kg−1) are often adequate to
commonly used aminoglycosides in fracture cases are calm a horse for extended transit for evaluation at a surgi-
gentamicin and amikacin. Neomycin is frequently com- cal facility. Perineural anesthesia is generally avoided to
bined with other antibiotics in the intraoperative lavage encourage the horse to spare the fractured limb. Even in
solution. Aminoglycosides are most active against gram‐ well‐splinted or cast fractures, ambulation results in some
negative organisms, and some are potent inhibitors of motion at the fracture site, and the resultant rounding of the
Staphylococcus aureus. Most are also nephrotoxic and fracture ends reduces the chances of a successful surgical
ototoxic, and some are neurotoxic. These factors influ- fixation. Mobility in improperly supported fractures can
ence their selection and the duration of their use. even result in the fracture ends lacerating the skin.
Preexisting renal disease is often a contraindication to External coaptation and other support are maintained
aminoglycoside use, and at least dictates careful monitor- while the horse is prepared for surgery. Further adminis-
ing of creatinine levels during the administration of these tration of NSAIDs is generally appropriate eight hours
drugs. Ideally, peak and trough serum levels of gentamicin after the first injection. The horse should recover from
or amikacin should be established to define more appro- anesthesia with high circulating levels of these drugs.
priate dosing schedules. However, testing facilities for Immediate preoperative analgesics should be avoided,
these determinations are not routinely available. The since many induction protocols also include frequently
development of resistance to gentamicin has increased selected analgesic/tranquilizer combinations, such as
the use of amikacin. For open fractures, combinations of xylazine and butorphanol.
amikacin and a crystalline penicillin or cephalosporin are Postoperative pain control must be aggressive.
recommended until results of tissue or fluid cultures Recovery systems to provide safer return to the standing
obtained at surgery are available. Delivery of antibiotics position are critical in fracture repair. These systems are
by regional venous perfusion at the completion of com- described in detail in Chapter 43. Administration of
plex fracture repair surgery has become commonplace. analgesics commences as the horse begins to move
This is easily accomplished if a tourniquet is used to con- following cessation of inhalant anesthetics. Routinely,
trol intraoperative hemorrhage. Administration of one‐ either xylazine or detomidine with or without butorpha-
quarter to one‐third of a systemic dose of amikacin to a nol is administered at low doses in this phase. Repeated
distal limb vein after placing a torniquet prior to surgery administration may be necessary.
or 20 minutes before releasing the tourniquet toward the Pain control in complex arthroscopic procedures can
end of surgery improves local antibiotic levels. Where be provided by intraarticular injection of morphine
previous culture indicates multidrug resistant bacteria, (10–20 mg per joint) following suturing of the arthro-
regional perfusion of vancomycin or imipenem is effec- scopic portals. Morphine has potent analgesic effects by
tive at controlling further exacerbation. Incorporation of direct binding to opiate receptors in the synovial struc-
these antibiotics into polymethylmethacrylate (PMMA) tures, which results in elevated pain thresholds. It also has
bone cement used as separate implants, plate luting, or an effect on the release of nociceptive neurotransmitter
www.ajlobby.com
substances, such as substance P at the neuroterminals.3,30 Perineural anesthesia prior to the horse regaining its
Minimal or negligible circulating serum levels of mor- feet is frequently used to smooth the recovery, and admin-
phine derivatives have been found in animals and people istration early during the surgery assists in minimizing
following intraarticular morphine use.16 This generally inhalant anesthetic levels and the possibility of motion
precludes a central mechanism for pain control and during the procedure. Its use should always be confined to
prevents the secondary gastrointestinal and excitatory the innervation of the distal limb. Comminuted fractures
effects occasionally described with systemic morphine of the phalanges or distal metacarpus or metatarsus may
use in the horse. For more immediate and complete warrant perineural anesthesia with a long‐acting local
intraarticular anesthesia, bupivacaine hydrochloride anesthetic such as bupivacaine. Combinations of 0.5%
(Marcaine, Hospira, Lake Forest, IL, USA) can be admin- bupivacaine (50 ml) and dexmedetomidine (Precedex®,
istered, using 200–350 mg for most joints. In some Hospira; 1 μg ml−1 of bupivacaine) can provide longer‐
horses, combinations of morphine and bupivacaine have term perineural anesthesia, especially when combined
been used to extend the period of analgesia. However, with triamcinolone acetonide (10–20 mg once) at the
additional benefits of the combination have not been injection site (Dr. Jordyn Boesch, personal communica-
readily apparent in horses, a finding that has also been tion). These formulations have not been verified by dose
described in people.17 Bupivacaine has well‐established studies and are listed here as suggestions only until phar-
chondrocyte toxicity concerns;6,7,24 however, instillation macokinetic studies are completed. Sarapin nerve blocks
at the beginning of surgery, followed by arthroscopic may also be helpful in pain management, using equal parts
fluid distension, tends to lavage the joint within minutes sarapin and bupivacaine, and supplemented with dexme-
and minimizes the impact of bupivacaine on the carti- detomidine (1 μg dexmedetomidine per ml bupivacaine).
lage surface. Other local anesthetics including lidocaine Steroids such as triamcinolone can also be added to this
and ropivacaine are also toxic to cartilage after long‐term mixture, as listed previously.
exposure,10,18 but potentially less so than bupivacaine. Ultrasound‐guided perineural anesthesia may be use-
Epidural morphine (0.1–0.2 mg kg−1) has been used ful to ensure accurate delivery of local anesthetic to the
frequently in horses, and has made a significant impact nerve, particularly when blocking proximal to the carpus
in postoperative pain control in equine hindlimb fracture or tarsus in the postoperative period. Direct injection
cases. It is generally given in combination with detomi- into the nerve may provide longer‐term conduction
dine (0.03 mg kg−1), via injection to the sacro‐caudal block. The most common application of bupivacaine
epidural space. Substitution of ketamine (0.5 mg kg−1) in perineural injection in this clinic is following complex
place of morphine in the detomidine/morphine epidural condylar fracture repair or fetlock arthrodesis, where
has given more effective pain relief. An epidural mixture the pain levels are considerable. Preoperative or intraop-
of 3–5 mg detomidine and ketamine (0.5 mg kg−1), mixed erative nerve blocks above the carpus or tarsus are
in saline and containing 0.5% bupivacaine diluted out to avoided to minimize the loss of proprioception to the
provide final bupivacaine concentration in the drug/ limb during the recovery period.
saline mixture of 0.06 vol/vol, can be administered at a Bupivacaine liposomal suspension (Exparel, Pacira
dose of 0.04 ml kg−1 body weight (Dr. Jordyn Boesch, Pharmaceuticals, San Diego, CA, USA; 13.3 mg ml−1)
personal communication). This provides improved provides up to 48 hours of perineural anesthesia after
hindlimb analgesia without motor deficits, compared to ultrasound‐guided perineural injection, which allows
xylazine or detomidine/morphine epidural protocols. potent pain control in the immediate postoperative
Both detomidine and ketamine are absorbed systemi- interval (Dr. Luis Campoy, personal communication).
cally, so sedation and dysphoria may be side effects. The preparation is an aqueous suspension of multive-
For long‐term pain control, a Teflon epidural catheter sicular liposomes containing bupivacaine, which is
(Perifix®, Continuous Epidural Anesthesia Set, Braun slowly released into the perineural environment after
Medical, Bethlehem, PA, USA) should be placed to facili- depot injection. This preparation has not been used in
tate daily reinjection. Analgesia has subjectively been enough cases to make a compelling argument for use in
good, without loss of motor strength to the hindlimbs. horses, particularly given the expense of the formulation.
Quantitative measures of lameness and heart rate after However, a long‐acting local anesthesia that rivals direct
bilateral complex femoropatellar joint arthroscopy were perineural catheter placement for routine delivery of
improved by single epidural administration of morphine bupivacaine seems attractive.
and detomidine.9 However, excessive doses of epidural The need for convalescent pain control generally
morphine in humans and other animal species can result reflects the stability of the fracture repair. Secure fixation
in respiratory depression. Application by epidural injec- results in weight bearing soon after surgery, avoiding the
tion to the cervical region has also been attempted, with complications associated with overloading of the oppo-
variable results. site limb. Most horses with fractures are maintained on
www.ajlobby.com
varying levels of phenylbutazone (2.2–4.4 mg kg−1, orally, sulfate. Perineural administration can provide peripheral
daily). Selective Cox‐2 inhibitor NSAID products for anesthesia for two weeks to six months, depending on
equine application such as firocoxib (Equioxx, Merial, the agent and quantity administered. The use of alcohol
Duluth, GA, USA) provide no better pain control than perineural anesthesia has been the most frequent of the
phenylbutazone, but may be less toxic for long‐term neurolytic compounds used. Transient neurolytic agents
administration. Fracture patients are under stress and may be ineffective in severe fracture‐related lameness,
often on NSAIDs, and a gut protectant such as omepra- and these horses often remain non‐weight‐bearing until
zole (GastrogardTM, Merial) is indicated, either at 25% the fracture is better stabilized. Radiofrequency neural
full bodyweight dose, or at higher levels in acute injury ablation (NeuroTherm, NT1000, St. Jude Medical, St.
or high‐stress periods. Supplementary analgesic therapy Paul, MN, USA) has been used in humans for severe
is often needed during the initial 72 hours after surgery. peripheral neuritis, neuroma, and painful chronic degen-
Repeated intramuscular administration of detomidine erative diseases. Limited application in the horse, using
(0.02 mg kg−1) is beneficial; however, short‐term, more ultrasound‐guided insertion of the RF electrode to the
acute relief can be obtained by intravenous injection of epineural surface, has resulted in functional neurolysis
detomidine at reduced dosage. The addition of butorph- and effective pain control (unpublished data; Dr. Jordyn
anol is also beneficial; however, analgesic doses of this Boesch, Dr. Luis Campoy).
combination result in considerable ataxia, which can be Percutaneous placement of perineural catheters can
detrimental if a horse stumbles. provide a means to deliver long‐acting local anesthetics
Parenteral morphine can be administered (0.05– such as bupivacaine for several days to weeks.31 For frac-
0.15 mg kg−1) intravenously or intramuscularly to control tures distal to the carpus or tarsus, a Touhy needle is
acute musculoskeletal pain, but the effects extend for only placed from lateral to medial at the upper to mid level
eight hours, and the risk of decreased gastrointestinal of the third metacarpus or metatarsus (Figure 7.1) and
motility leading to impaction of the large colon increases a small‐bore epidural catheter (Perifix, 18 g Tuohy nee-
with higher doses and repeat administration. Fentanyl dle) introduced to lie adjacent to the medial and lateral
transdermal patches (Duragesic Fentanyl Transdermal palmar nerves. A constant‐rate (0.14–0.5 ml hr−1) infusion
System, 100 mcg hr−1, 16.8 mg; Ortho‐McNeil‐Janssen disc (Infu‐Disk, MILA International, Erlanger, KY, USA)
Pharmaceuticals, Raritan, NJ, USA) are a transdermally is attached, providing 10 ml of bupivacaine over 72 hours.
active narcotic that provides circulating serum levels of Profound relief for 48 hours was evident in controlled
fentanyl hydrochloride. Application of two 100 μg hr−1 studies on horses with enzymatically induced tendini-
patches to the shaved skin over the medial antebrachium tis,31 and good pain control in clinic cases has been seen
provides a modest mechanism to reduce lameness post- after spiral condylar fracture repair (Figure 7.2).
operatively. Duration of action is only 48 hours, however,
and the patches are expensive.
A mix of narcotics, dissociatives, and α2‐agonists given Anesthesia
by constant‐rate infusion provides variable and at times
dramatic pain relief. Morphine, ketamine hydrochloride, The horse with a fracture can be difficult to safely
detomidine, lidocaine, and acepromazine can be mixed anesthetize. Adequate preoperative splinting or cast-
in two 5 l sterile polyionic fluid bags to make what is ing usually results in a less fractious and safer horse to
termed “pentafusion.”1 Rate of delivery varies from 50 to anesthetize. Some surgical clinics promote the use of
80 ml hr−1. Moderate to severe sedation and reduced gas- recumbent transportation to the repair center, using
trointestinal motility are common side effects. Mineral nondepolarizing muscle blockers.12 This eliminates the
oil must be given to prevent impaction. Pain control con- possibility of the horse exacerbating a fracture, assists in
tinues while the infusion is maintained. Use of ketamine preoperative radiographic procedures, and allows pre-
alone by intramuscular administration (0.5–1.0 mg kg−1 operative surgical preparation, before the horse is placed
three times a day) has also provided good systemic under general anesthesia. The use of a fully equipped
analgesia in recalcitrant fracture and osteomyelitis cases. field ambulance to facilitate transportation of a horse
Side effects include dysphoria, which can be reduced by with a fracture is of considerable help, especially in cases
administration of α2‐agonists. in which muscle blockers are administered, since intuba-
Short‐term neurolytic agents have also been described tion and mechanical ventilation are then required.
and have a place in recalcitrant severe lameness follow- Preanesthetic preparation should include a thorough
ing fracture repair. In this situation, the options often physical examination, evaluation of cardiovascular status,
only include pain relief or breakdown in the overstressed including ancillary tests such as a hematocrit and plasma
foot, with subsequent loss of the horse. Temporary neu- protein determination, and an assessment of all premedi-
rolytic agents include alcohol, phenol, and ammonium cants administered.15 Horses that have been sweating
www.ajlobby.com
(A) (B)
(C) (D) (E) (F)
Figure 7.1 Perineural anesthesia of the lateral and medial palmar nerves using low constant‐rate infusion of bupivacaine. (A) Epidural
catheter and Tuohy needle kit. (B) Infu‐Disk (MILA International) delivering 0.14 ml hr−1 over 72 hours. (C, D) Catheter introduced through a
Tuohy needle inserted between suspensory ligament and accessory ligament of the deep digital flexor tendon. (E) Catheter and delivery
device in place for continuous perineural anesthesia of the palmar nerves. (F) Protection of the limb, catheter line, and Infu‐Disk by
bandaging. Source: Portions courtesy Dr. Ashlee Watts.
excessively because of a painful fracture may also need any consequence as far as large bowel gas distension
replacement fluid and electrolyte therapy. Extensive pain- while under anesthesia is concerned. However, motility
ful fractures and the use of tranquilizers and analgesics is generally decreased preoperatively due to pain and
can also induce hypotension, and preoperative fluid ther- sedation used for restraint in radiography, and, com-
apy is frequently indicated prior to induction. bined with long periods of anesthesia and postoperative
Fasting of fracture patients prior to general anesthesia narcotic use, some postoperative ileus is common.
is rarely possible, given the urgency of the repair. Many Induction agents for general anesthesia are adminis-
horses with major fractures do not eat enough to be of tered through a jugular vein catheter and should result
www.ajlobby.com
(A) (B) (C) (D)
Figure 7.2 Continuous perineural pain control in a horse with persistent postoperative severe lameness associated with a spiral fracture
of MC3. (A) Epidural catheter in place with Infu‐Disk. (B) Day 1 postoperative radiographs showing lag screw repair of long spiral fracture.
(C) Day 10 radiograph showing further fracture propagation (arrows), accounting for the ongoing lameness. (D) Additional lag screw
placed to repair the fracture. Lameness rapidly improved after the additional screw was placed.
The type of induction equipment and techniques vary.

Horses with fractures must be handled carefully to avoid
trauma to the fractured limb, breakage of the supporting
splint or cast, and excitement and possible additional
trauma to the other limbs or the head. The generally pre-
ferred techniques for induction are a padded induction
room with a crowding gate to stabilize and confine the
horse (Figure 7.3), or a combination of head (halter) rope
and tail rope fixed through wall rings to support the
horse against a padded wall (Figure 7.4). Experienced
personnel greatly facilitate rapid and safe induction.
During induction, horses should be stabilized as much as
possible and controlled by head and tail ropes as they
sink to the floor. Proximal and midlimb fractures are
generally not well stabilized by splints and should be
maintained in normal or extended alignment during the
induction procedure. Horses should never be allowed to
Figure 7.3 Induction of anesthesia with the use of a padded
swinging gate to stabilize the horse during induction. Source:
fall suddenly onto the fractured limb. Poor restraint,
Image courtesy Dr David S. Bogenrief. sudden induction, and inadequate splinting can seriously
exacerbate a fracture, occasionally transforming a closed
fracture to an open fracture. A sling is rarely required or
in a rapid, smooth recumbency. Personal preference indicated for a horse in induction, although it is very
and familiarity generally dictate the choice of drug. helpful for moving a horse from the induction area to the
Combinations vary from intravenous xylazine (1.0 mg kg−1 surgical suite.
intravenously) and ketamine (2.0 mg kg−1 intravenously) to Surgical facilities vary in the pharmaceutic protocol
xylazine–diazepam (0.05 mg kg−1 intravenously)–ketamine, used for induction. Most prefer induction of the standing
or xylazine–guaifenesin–barbiturate.5,15 horse using α2‐agonists and dissociative agents, with
www.ajlobby.com
Figure 7.4 Induction of anesthesia

against a padded wall with head and tail
ropes. Note the Kimzey Leg Saver Splint
on a proximal phalangeal fracture.
physical confinement and a well‐protected fractured Cardiac output and peripheral perfusion are superior
limb. As an alternative, neuromuscular blocking agents with isoflurane compared to halothane, and since
can be used to facilitate a smooth induction prior to halothane is no longer manufactured, most practices
intubation and maintenance on gaseous anesthesia. have switched to isoflurane, which has concurrently
Atracurium, a nondepolarizing muscle blocking agent, is become quite affordable. Additionally, isoflurane is not
most frequently used. Recumbency is achieved within arrhythmogenic, which becomes critically important in
40 seconds of injection (0.07–0.20 mg kg−1 intrave- fracture cases in which circulating catecholamine levels
nously), and lasts from 50 to 65 minutes.13 If reversal of are high. Recovery time following cessation of anesthesia
the neuromuscular block is required, it can be safely is reduced; however, this may increase the need for
accomplished with edrophonium (0.5–1.0 mg kg−1 intra- recovery room tranquilization to prevent the horse from
venously).13 Maintenance of general anesthesia with making premature attempts to stand. Halothane manu-
isoflurane is preferred.2 Isoflurane is less soluble than facture and supplies are dwindling, and isoflurane has
halothane; therefore induction, recovery, and adjust- become the standard inhalation anesthetic in most
ments to depth are more rapid than with halothane. facilities.
www.ajlobby.com
Sevoflurane has also been used in equine inhalation at the shoulder and hip, needs deep padding and must
anesthesia, where its principal advantages are good not protrude over the edge of the table and padding.
cardiovascular function and muscle perfusion, coupled The ideal padding for surgery tables is controversial.29,32
with rapid clearance and early ability of the horse to Deep foam appears to be satisfactory, although some
stand soon after completion of inhalation delivery. facilities prefer air mattresses (Snell dorsal pad, Snell
There are anecdotal reports of an increase in unsteadi- Veterinary Systems, Castle Cary, Somerset, UK), dun-
ness after standing, and sevoflurane remains expensive. nage bags, or water beds (Figure 7.5). Closed‐cell foam
Its use for general anesthesia for fractures in foals seems may have advantages over open‐cell foam, including
warranted. less overall compressibility. Studies on pressures in the
The concentration of inhalation anesthetics can be dependent triceps muscle groups indicate that water
reduced by concurrent administration of analgesics, mattresses cause the least elevation in intracompartment
use of peripheral nerve blocks, use of neuromuscular pressure.22,33 The down forelimb should be pulled for-
blocking agents, and opioid administration. Some analge- ward to minimize triceps muscle pressure and pressure
sia and tranquilization may persist for the recovery. on the radial nerve as it courses between the first rib and
However, the prime reason for using these agents is to the humerus.33 The upper forelimb and hindlimb should
reduce isoflurane or sevoflurane requirements, thereby also be elevated to the horizontal plane, to prevent
maintaining the horses in an improved physiologic status. compression of the thorax and medial thigh muscles,
Intraoperative monitoring is critical for optimal respectively. The halter should be removed to prevent
management of orthopedic cases. During lengthy proce- pressure on the facial nerve.
dures, perfusion of the compressed musculature of the In many fracture cases, reduction requires some form
down limbs is vital. Direct blood pressure monitoring of traction to the affected limbs. If this is to be achieved
(>70 mmHg), frequent blood gas analysis, and continuous by axial traction applied to the distal limb, counterstabi-
electrocardiographic assessment are used to ensure that lization of the horse on the table is required. Wide straps
cardiac output, tissue perfusion, and gas exchange are or ropes over pads are passed around the sternum or
being optimized. A pulse oximeter placed on the tongue between the hindlegs, and attached to the opposite
is also a useful gauge of gas exchange and peripheral wall of the surgery or to the side of the surgery table, to
perfusion. Regardless of the padding used and time spent provide countertension when traction is applied during
positioning a horse on the table, the depth of anesthesia fracture reduction. There are advantages to placing a
and the blood pressure are critical in avoiding the horse in dorsal recumbency, where the limb can be sus-
complications associated with myositis.21,23,26,29 pended to the ceiling or to an overhead winch and the
animal’s body weight used to assist in fracture reduction
(Figure 7.6). This also expedites fracture repair where
Positioning of the Horse two separate approaches to the bone are required for
insertion of plates, and facilitates access for a second
The fractured limb needs special care during transport surgical team to assist in application of the second plate.
from induction to surgery. Good surgical practice When the fracture repair is done with the horse in lat-
includes completion of clipping of the hair and at least a eral recumbency, a draped side table inserted under the
preliminary surgical preparation of the site before enter- surgically prepared limb allows manipulation of the limb
ing the surgery suite. Therefore, the existing support and provides counterpressure for drilling and other pro-
from casts, splints, or braces must be removed after cedures (Figure 7.7). The table should adjust in height
induction of anesthesia and the limb is again susceptible independent of the surgery table. The distal limb should
to injury when being moved. An assistant should be be free to allow placement of obstetric chains for axial
assigned to safely support the limb until it can be secured traction.
by a mechanical device, or draped and laid flat on the
surgery table.
Transport from induction to the surgery suite can be Skin Preparation
on the surgery table or via an overhead hoist. Hoists
entering the surgery have been implicated as a source of Positioning of the horse and skin preparation should be
excessive fomite‐laden dust. Careful attention to posi- done with considerable care by a well‐trained team, to
tioning the horse on the surgery table and the use of minimize the time delay in getting the horse to surgery.
thick padding are imperative for the prevention of post- Bedding adhered to the hair needs to be brushed off
operative myopathy and neuropathy. The down surface before induction. The feet must be cleaned of visible
of the body of a horse in lateral recumbency, particularly bedding and manure, and may need more extensive
www.ajlobby.com
Figure 7.5 Various padding systems for

equine surgery tables, including a
combination of open‐ and closed‐cell
foam (top) and air mattresses (bottom;
Snell Veterinary Systems).
scrubbing if they are adjacent to the fracture site. opportunity for clipping of the surgical site prior to
Similarly, hair, scurf, and other debris should be vacu- induction of anesthesia is unusual. Clipping and prelimi-
umed from the exposed surfaces after induction. Skin nary skin preparation the night before surgery have been
preparation aims to remove debris and the vast majority recommended, but may be deleterious.25 Microlacerations
of bacteria. Complete sterilization of the skin is impos- of the epidermis and dermis have an opportunity to
sible, since many bacteria are harbored in hair follicles.19 colonize with skin flora overnight and these organisms
Most long bone fractures present as emergencies, and an are inadequately removed during the aseptic skin
www.ajlobby.com
extensions to the initial incision occur often enough

(A) that a wide margin of safety is mandatory. The use of the
large fracture reduction apparatus often requires extend-
ing the incision to aseptically place temporary Schanz
screws in the adjoining long bone. Unforeseen fissure
fractures may require extension of the incision and
deeper dissection for adequate stabilization. Additionally,
wide margins for the skin preparation and subsequent
draping are essential. All free hair should be vacuumed
off the leg prior to surgical scrubbing. The limb should
be prepared through its entire circumference, and the
sterile area should extend to include half of the long bone
on either side of the fractured bone. If there is any pos-
sibility a bone graft will be required, the tuber coxae or
sternum should be clipped and prepared, along with the
fractured limb.
Although all the feet should be cleaned of debris after
induction, the foot on the fractured limb should be scru-
pulously cleaned and trimmed. This is imperative for
phalangeal fractures, but also quite important if a cast
is applied following internal fixation. Scrubbing of
the clean hoof and sole, and painting with 7% iodine,
minimizes bacterial load. The opposite weight‐bearing
foot should also be trimmed and measured for a heart‐
bar or other support shoe, which is applied in the
recovery stall.
The surgical scrub should cover the entire clipped
area. Choice of germicidal agent and the use of scrubbing
versus painting techniques are controversial. In animals,
the cleansing effect of detergents in germicidal solutions
is critical. The two commonly used agents are povidone–
(B)
iodine scrub and chlorhexidine gluconate scrub. Both
have strong experimental evidence to support their use.20
Povidone–iodine contains 7.5% iodine, of which about
1% is available as free iodine, which kills by penetrating
the microorganism cell wall, oxidizing the contents, and
substituting the cell content with free iodine. It is effec-
tive against most bacteria, fungi, viruses, and some
spores. Chlorhexidine gluconate is a cationic bisbi-
guanide that kills bacterial cells by disrupting the cell
membrane and precipitating the contents. Its activity is
better for gram‐positive bacteria than gram‐negative,
and it has good fungicidal action but poor virucidal
capacity.20 Both of these agents are vigorously applied
with alternating alcohol scrubs. Alcohol kills microor-
Figure 7.6 (A) Horse with fractured tibia being repaired with limb ganisms as it dries, but is also useful in removing some of
suspended by an electric winch attached by sterile obstetric the surface fat on skin. The first two scrubs are applied
chains applied over the padded distal limb. Two plates are being with gauze sponges and the final scrub applied using
simultaneously applied. (B) Winch with 300 lb capacity secured to
ceiling support.
sterile sponges, with the technician wearing sterile
gloves. Some facilities prefer to do at least two scrubs
preparation. Most horses with fracture are clipped after prior to moving the horse to the surgical suite, where the
induction so the benefit of casts or splints can remain final skin preparation is performed. If an adhesive plastic
until the horse is recumbent. An extensive clipped bor- drape is to be applied, all traces of detergent should be
der around the proposed incision site is particularly removed with the last alcohol scrub, and the skin dried
important in fracture cases. Unexpected approaches or and sprayed with adhesive (Adapt 7730 medical adhesive
www.ajlobby.com
Figure 7.7 Fractured limb supported on

an adjustable “fracture table” for
manipulation and fracture stabilization.
A sterile obstetric chain has been placed
on the distal limb for traction (in this case
of a fractured humerus).
spray, Hollister, Libertyville, IL, USA). For most distal (Figure 7.8). For more proximal limb fractures, an imper-
limb fracture cases, the final preparation prior to draping vious stockinette (Surgical Resources, Darlington, MD,
is application of a sterile glove to the foot. USA) is applied to cover the distal limb and extend up to,
but generally not over, the fracture. Waterproof barrier
pads are then placed to quadrant off the three remaining
Surgical Draping sides of a proximal limb fracture, or one sterile barrier
pad is used to totally encircle the proximal limb if the feet
Draping is used to isolate the surgical field and prevent and distal extremity are to remain in the surgical field by
generation of air‐borne organisms from the animal’s hair drawing these draped structures through a fenestration
coat. Personal preference and training generally dictate in the final drape. Use of relatively impervious nonwoven
the methods of draping for major limb surgery. It is safest disposable paper or synthetic draping material is recom-
to initially drape the entire body and unaffected legs of mended for equine fracture repair. Several manufactur-
the horse, thereby preventing inadvertent contact with ers make site specific drape sets, such as those for
these parts during the more complex draping of the frac- arthroscopy and laparotomy (Surgical Resources), and
tured limb. The initial drapes must be carefully applied those with small fenestrations for distal limb surgery.
to avoid generating dust that will settle on the surgically The unilateral arthroscopy drape can be modified to
prepared limb. There is a rationale in applying the pri- make it suitable for most limb surgery by cutting a
mary adhesive plastic drape before applying the body suitably sized opening in the rubber dam and drawing
covering drapes, as any dust generated will be rinsed off the draped distal limb through the fenestration. For cases
the plastic adhesive drape during surgery, rather than in which the remainder of the limb is to be draped out of
being trapped against the skin by the adhesive drape. The the field, a laparotomy drape can be applied with the
foot of the fractured limb should already be covered by a window over the surgical site. Cloth drapes readily
sterile rubber glove. An additional glove can be applied become soaked with blood and lavage fluid, and no
over this if desired. A large sterile adhesive plastic drape longer serve as a barrier to microbes.4,8,11,27
is then applied to cover the entire surgically prepared The use of cloth surgery gowns carries similar short-
area. Iodine‐impregnated adhesive drapes (Ioban2, 3M comings in the preparation of the surgeon. Disposable
Company, St. Paul, MN, USA) adhere strongly and addi- gowns are more impervious to liquids and aerosol bacte-
tional bonding can be achieved by spraying adhesive ria, and are lighter and generally more comfortable. The
(Adapt 7730) on the skin prior to drape application. The orthopedic surgeon should also apply impervious shoe
additional value of the iodine has been questioned. For covers and wear a surgical cap that provides complete
fractures distal to the carpus and tarsus, this drape coverage of scalp and facial hair. Wearing two pairs of
should adhere to the glove on the foot, to complete the gloves allows a quick exchange if an undraped object
impervious seal. A sterile stretch bandage such as vetrap is inadvertently touched during draping, and later is
makes an excellent method to maintain the adhesive an excellent precaution to avoid glove perforation by
drape in place and further isolate the incision site fracture fragments or pins and wire.
www.ajlobby.com
Figure 7.8 Condylar fracture repair with

distal limb isolated by sterile adhesive
plastic drape and vetrap securing the
adhesive drape to a sterile glove on the
foot. The exposed limb can be
manipulated during fracture repair and
the alignment can be visually assessed by
not covering the distal limb by draping.
The careful application of drapes requires a trained

assistant and operating room staff. Often a gloved techni-
cian can hold the prepared limb elevated during the initial
application of the adhesive plastic drape and impervious
stockinette. The remaining drapes can then be applied
with the limb resting on the draped “fracture table.” The
drapes should be firmly fixed to the limb with an adequate
number of towel clamps. Occasionally, skin towels are
sutured or stapled to the skin edge after the incision is
made. Although this practice is common in small animal
and human surgery, it is rarely beneficial in equine ortho-
pedics, where the drapes rapidly become blood‐ and
saline‐soaked rags that flop around on the skin edges.
Preparation
of the Surgical Team
Most equine orthopedic repairs can be better and more
expeditiously accomplished by an experienced surgeon
and at least one and preferably two experienced assis- Figure 7.9 Impervious shoe covers provide additional protection
tants. Familiarity of the assistants with the surgical against contamination of the floor during surgeries where
approach and instruments, particularly the order of their extensive lavage or hemorrhage is expected.
use, minimizes the length of surgery by improving the
efficiency of the team. Nevertheless, the number of other
nonscrubbed individuals and spectators within the oper- shoe covers. The surgical team should also wear impervi-
ating room should be curtailed. All of these individuals, ous shoe covers that extend above the ankle, or up the leg
especially those moving, contribute to air‐borne contam- to immediately beneath the knee if the surgery involves
inants and the likely development of wound infection. substantial lavage or arthroscopic fluid egress (Figure 7.9).
The entire staff within the surgical suite should wear Impervious high shoe covers or booties are particularly
fine woven or unwoven scrub suit apparel, cap, mask, and helpful in keeping the surgeon dry and preventing
www.ajlobby.com
c ontamination of the surgery floor from shoes in arthros- Fracture Reduction Devices
copy and fracture repair cases in which hemorrhage and
lavage are profuse. The surgical team should also wear Reduction devices can be classified as either external
caps and well‐fitting masks that cover all facial and scalp axial traction equipment, or surgical tools or implants
hair. A hood may be necessary for some individuals. In used in fracture distraction and reduction. The applica-
fracture repairs where considerable physical exertion will tion of equipment and the ideal methods vary from
be needed, the surgeon should also wear a sweat band bone to bone. Similarly, the need for traction in fracture
beneath the surgical cap. Nonwoven gowns are often lint reduction is age dependent, with adults often requiring
free and are more impervious to moisture and strike‐ considerably more force than foals.
through by microorganisms, and should always be used The aim in using fracture reduction devices is to pro-
in fracture cases.11,27 However, some brands are more vide sufficient axial tension to bring the fractured bone
comfortable and durable than others. The gown must be ends into a more reasonable proximity. Toggling, bone
a wrap‐around style for each individual in the surgical clamps, cerclage wire, or lag screws can then be used for
team. This provides an additional barrier to skin‐borne final approximation and preliminary stabilization.
debris and organisms, and prevents accidental contami- During closed reduction, axial tension is used to provide
nation of the surgical assistants by the exposed back of better alignment of a fractured bone, which is then stabi-
the surgeon. Most nonwoven gowns are disposable after a lized by external coaptation, with or without transfixa-
single use. Reusable cloth surgical gowns, such as those tion pins.
made of 270‐count cotton and treated on the arms and The most common device for providing axial tension
torso with water‐repellent finishes, often become perme- is a hand‐cranked winch or “come‐along.” This device is
able to liquid after repeated washing and sterilization, used intraoperatively by padding the distal limb, apply-
and are not appropriate for orthopedic cases. The single‐ ing sterile obstetric chains to the padded area, and
use, disposable, nonwoven fabric gown often has addi- attaching them to the cable of a winch, the body of which
tional layers within the sleeves and torso region to add is attached to the wall (Figure 7.10). Suitable restraint of
strength and water resistance. the horse’s torso on the table is provided by tension on
Closed gloving should be standard practice in prepa- preplaced body ropes or straps attached to the opposite
ration for orthopedic surgery. Additionally, double wall. Traction works well on bones other than the
gloving is essential. The outer pair of gloves can be humerus and femur, which require additional toggling
replaced, and a new pair applied on completion of and clamping after axial tension has adequately fatigued
draping. Using a reputable brand of latex rubber glove is the muscles. Occasionally, the addition of a nondepo-
important. The quality of some inexpensive gloves is larizing muscle blocking agent, such as atracurium,
inadequate. Gloves should be thoroughly rinsed prior to provides additional relaxation.13 In general, difficult
starting surgery to remove glove powder, if necessary. fracture reductions with extensive fragment overriding
Although talc powders are now banned for use on gloves, are more often due to the static pull of the reciprocal
the newer absorbable cornstarch‐derived powders also
incite an inflammatory response, and every attempt to
minimize foreign‐body contamination of the wound is
important. The outer pair of gloves should also be
exchanged periodically during the surgery to minimize
the opportunity for accidental wound contamination.
Diligent and frequent inspection during surgery will
detect perforations of the outer gloves by sharp bone
ends and metal implants. Stronger, more perforation‐
resistant gloves made of Dacron or woven Teflon are
available to wear under regular latex gloves for orthopedic
procedures. However, these reduce tactile sensation,
the maintenance of which is so important in difficult
fracture reductions and delicate procedures. Additionally,
where extensive intraoperative image intensifier use is
planned, gloves incorporating radioprotection such as
bismuth oxide latex (Encore® Radiation attenuation
gloves, Ansell Healthcare, Dothan, AL, USA) are
strongly recommended. Wearing a lead apron beneath Figure 7.10 Hand‐operated winch suitable for applying axial
the sterile surgical gown is mandatory. tension to a fractured limb.
www.ajlobby.com
apparatus. The fibroligamentous nature of many of the bone ends into correct anatomical alignment. Hohmann
components of the reciprocal apparatus is more difficult retractors are occasionally necessary to pry overridden
to overcome with traction and fatigue than muscle and ends into position.
tendon units alone. Axial traction on some bones such as In fractures of some bones, such as the radius, tibia,
the femur may make the bone alignment worse and ham- humerus, and femur, the distraction provided by the
per accurate reduction. large fracture distractor (DePuy Synthes; see Figure
Use of an overhead electric winch is very convenient in 8.13 in Chapter 8) is more controlled and can be
clinics equipped with such a system. For fractures of the applied in a line more closely parallel to the long axis
tibia and radius, positioning in dorsal recumbency of the bone. Schanz screws are placed to fix the dis-
allows tension to be placed on the limb, using the tractor to the ends of the fractured bone or the adja-
horse’s own weight to distract the overridden bone ends cent ends of the next long bone. This provides a firm
(see Figure 7.6). This is particularly useful if two surgical anchor for gradual fracture distraction and elimina-
approaches have been made to the bone. Temporary station of fracture overriding. Stabilization is then
bilization with the large reduction forceps (DePuy accomplished routinely. The earlier versions of femo-
Synthes, West Chester, PA, USA) or Kern bone‐holding ral fracture distractors were too small for most equine
forceps can then be used until the first plate is applied, or fracture reductions. Following application of a plate or
separate lag screws or cerclage wires are placed. Some several lag screws, the device can be removed to allow
additional manipulation can be used to further toggle the the plating repair to proceed.
References
1 Abrahamsen, E.J. (2007). Analgesia in equine practice. human chondrocytes following exposure to lidocaine,
In: Proceedings of the Western Veterinary Conference, bupivacaine, and ropivacaine. J. Bone Jt. Surg. Am. 92:
vol. 79, 1–8. Las Vegas, NV: WVC. 609–618.
2 Auer, J.A., Garner, H.E., Amend, J.F. et al. (1978). 11 Ha’eri, G.B. and Wiley, A.M. (1981). Wound
Recovery from anaesthesia in ponies: a comparative contamination through drapes and gowns. Clin.
study of the effects of isoflurane, enflurane, Orthop. Relat. Res. (154): 181–184.
methoxyflurane and halothane. Equine Vet. J. 10: 12 Herthel, D.J., Hamer, E.J., and Martin, F. (1991).
18–23. An equine orthopedic trauma center: a systematic
3 Basbaum, A.I. and Levine, J.D. (1991). Opiate analgesia: approach to long bone fracture management.
how central is a peripheral target? New Eng. J. Med. 325: In: Proceedings of the American Association of
1168–1169. Equine Practitioners, vol. 37, 763–766. Lexington,
4 Beck, W.C. (1981). Aseptic barriers in surgery: their KY: AAEP.
present status. Arch. Surg. 116: 240–244. 13 Hildebrand, S.V., Holland, M., Copland, V.S. et al.
5 Brock, N. and Hildebrand, S.V. (1990). A comparison of (1989). Clinical use of the neuromuscular blocking
xylazine‐diazepam‐ketamine and xylazine‐ guaifenesin‐ agents atracurium and pancuronium for equine
ketamine in equine anesthesia. Vet. Surg. 19: 468–474. anesthesia. J. Am. Vet. Med. Assoc. 195: 212–219.
6 Chu, C.R., Coyle, C.H., Chu, C.T. et al. (2010). In vivo 14 Hubbell, J.A.E., Muir, W.W., Robertson, J.T., and Sams,
effects of single intra‐articular injection of 0.5% R.A. (1987). Cardiovascular effects of intravenous
bupivacaine on articular cartilage. J. Bone Jt. Surg. Am. sodium penicillin, sodium cefazolin, and sodium citrate
92: 599–608. in awake and anesthetized horses. Vet. Surg. 16:
7 Chu, C.R., Izzo, N.J., Papas, N.E., and Fu, F.H. (2006). In 245–250.
vitro exposure to 0.5% bupivacaine is cytotoxic to bovine 15 Hubbell, J.A.E., Robertson, J.T., Muir, W.W., and Gabel,
articular chondrocytes. Arthroscopy 22: 693–699. A.A. (1984). Perianesthetic considerations in the horse.
8 Cole, W.R. and Bernard, H.R. (1967). Wound isolation Compend. Contin. Educ. 6: 401–414.
in the prevention of postoperative wound infection. 16 Joshi, G.P., McCarroll, S.M., Cooney, C.M. et al. (1992).
Surg. Gynecol. Obstet. 133: 1–7. Intra‐articular morphine for pain relief after knee
9 Goodrich, L.R., Nixon, A.J., Fubini, S.L. et al. (2002). arthroscopy. J. Bone Jt. Surg. 74‐B: 749–751.
Epidural morphine and detomidine decreases 17 Joshi, G.P., McCarroll, S.M., O’Brien, T.M., and Lenane,
postoperative hindlimb lameness in horses after P. (1993). Intraarticular analgesia following knee
bilateral stifle arthroscopy. Vet. Surg. 31: 232–239. arthroscopy. Anesth. Analg. 76: 333–336.
10 Grishko, V., Xu, M., Wilson, G., and Pearsall, A.W. 18 Karpie, J.C. and Chu, C.R. (2007). Lidocaine exhibits
(2010). Apoptosis and mitochondrial dysfunction in dose‐ and time‐dependent cytotoxic effects on bovine
www.ajlobby.com
articular chondrocytes in vitro. Am. J. Sports Med. 35: 26 Meagher, D.M. and Mackey, V.S. (1990). Lag screw
1621–1627. fixation of a sagittal fracture of the talus in the horse.
19 Kaul, A.F. and Figgis, J. (1981). Agents and techniques J. Equine Vet. Sci. 10: 108–112.
for disinfection of the skin. Surg. Gynecol. Obstet. 152: 27 Moylan, J.A. and Kennedy, B.V. (1980). The importance
677–685. of gown and drape barriers in the prevention of wound
20 Laufman, H. (1989). Current use of skin and wound infection. Surg. Gynecol. Obstet. 151: 465–470.
cleansers and antiseptics. Am. J. Surg. 157: 359–365. 28 Oishi, C.S., Carrion, W.V., and Hoaglund, F.T. (1993). Use
21 Lindsay, W.A., McDonell, W., and Bignell, W. (1980). of parenteral prophylactic antibiotics in clean orthopaedic
Equine postanesthetic forelimb lameness: surgery. Clin. Orthop. Relat. Res. 296: 249–255.
intracompartmental muscle pressure changes and 29 Richey, M.T., Holland, M.S., McGrath, C.J. et al. (1990).
biochemical patterns. Am. J. Vet. Res. 41: 1919–1924. Equine post‐anesthetic lameness: a retrospective study.
22 Lindsay, W.A., Pascoe, P.J., McDonell, W.N., and Vet. Surg. 19: 392–397.
Burgess, M.L.F. (1985). Effect of protective padding on 30 Stein, C., Comisel, K., Haimerl, E. et al. (1991).
forelimb intracompartmental muscle pressures in Analgesic effect of intraarticular morphine after
anesthetized horses. Am. J. Vet. Res. 46: 688–691. arthroscopic knee surgery. New Eng. J. Med. 325:
23 Lindsay, W.A., Robinson, G.M., Brunson, D.B., and 1123–1125.
Majors, L.J. (1989). Induction of equine postanesthetic 31 Watts, A.E., Nixon, A.J., Reesink, H.L. et al. (2011).
myositis after halothane‐induced hypotension. Am. J. Continuous peripheral neural blockade to alleviate
Vet. Res. 50: 404–410. signs of experimentally induced severe forelimb pain in
24 Lo, I.K., Sciore, P., Chung, M. et al. (2009). Local horses. J. Am. Vet. Med. Assoc. 238: 1032–1039.
anesthetics induce chondrocyte death in bovine 32 White, N.A. (1982). Postanesthetic recumbency
articular cartilage disks in a dose‐ and duration‐ myopathy in horses. Compend. Contin. Educ. 4:
dependent manner. Arthroscopy 25: 707–715. 44–50.
25 Masterson, T.M., Rodeheaver, G.T., Morgan, R.F., and 33 White, N.A. and Suarez, M. (1986). Change in triceps
Edlich, R.F. (1984). Bacteriologic evaluation of electric muscle intracompartmental pressure with
clippers for surgical hair removal. Am. J. Surg. 148: repositioning and padding of the lowermost thoracic
301–302. limb of the horse. Am. J.Vet. Res. 47: 2257–2260.
www.ajlobby.com
107
8
Surgical Equipment and Implants
for Fracture Repair
Joerg A. Auer
Vetsuisse Faculty, University of Zurich, Zurich, Switzerland
Introduction the steel improves the corrosion resistance of the

implants; this is achieved by ensuring that the carbon
Prerequisites for successful fracture repair in horses and sulfur contents are low (<0.03%) and by employing a
include a well‐equipped hospital with room for induction special remelting process. The raw material is initially
of anesthesia and aseptic preparation of the surgical site, tested before being shipped to the instrument and
an aseptic surgery suite, a safe recovery room for horses, implant manufacturing plant, where it is tested again.
dedicated anesthesia personnel, and a number of box The two tests are compared and if disparate results are
stalls to maintain the animals in a clean, safe environment detected, the material is returned. Such rigorous control
during the postoperative period. Additionally, a wide guarantees high‐quality raw material for the products.
variety of surgical equipment is essential. The purpose of Identical measures are applied to pure titanium and the
this chapter is to discuss the instruments and implants various titanium alloys. Presently, a number of titanium
presently used for equine fracture repair. New develop- alloys are being tested to further improve the favorable
ments will be discussed in Chapter 50. results of currently available titanium implants.17
The instruments and the austenitic implants devel-
oped by the AO group and manufactured by DePuy
Materials Synthes form a functional system. The instruments are
used in a logical sequence, each fulfilling a specific task
Most of the instruments and implants are manufactured during the preparation of bone for insertion of implants.
from high‐quality 316L stainless steel. Implants manu- The various instruments are interdependent, and other
factured from titanium and titanium alloys have become manufacturers’ instruments are not readily substituted.
popular, especially in human surgery. The chrome–nickel– The risks of making substitutions extend to possible
molybdenum alloyed austenitic stainless steel used for failure of the fracture repair.
most of the instruments and implants, including the The instruments are manufactured from various
ones produced by the Association for Osteosynthesis corrosion‐resistant steels; the type depends on the func-
(AO) group, complies with International Standard tion of the instruments. All implants are manufactured
Organization (ISO) standards and relevant national from the same steel type.17 However, the hardness or
Deutsche Industrie Normen (DIN), Schweizerische ductility may vary. Very hard steel is used for Kirschner
Normen Vereinigung (SNV), and American Society for wires and Steinmann pins, a moderately hard stainless
Testing of Materials (ASTM) standards.17 In this chapter steel for plates and screws, and soft steel for cerclage
most of the comments pertain to the instruments and wires and reconstruction plates.
implants developed by the AO group and manufactured
by DePuy Synthes (West Chester, PA, USA).
For the DePuy Synthes products, stainless steel is pro- Instruments
duced according to stringent specifications that require
the composition, mechanical properties, and cleanliness The AO instruments and implants are assembled in sets
of the microstructure to meet stricter standards than according to the size of the implant.15 Additional sets
those specified by official guidelines.17 The high purity of include the various instruments needed to reduce a

www.ajlobby.com
fracture, to apply a plate, or to remove stripped or bro-

ken screws. For fracture repair in horses, the large
instrument set and selected small instruments and
implants are predominantly used; mini implants are
rarely used and will not be discussed here.
Power Drill
The use of an air‐driven power drill is strongly encour-
aged for fracture repair in horses. The power drill can be
sterilized easily and allows quick and effective insertion
of implants. Less wobble occurs during drilling, com-
pared with a hand drill.17 This is especially important in
soft foal bone, in which excessive side‐to‐side motion
reduces the bone–screw contact and decreases the
holding power of the screw. Additionally, treatment of
long bone fractures can be expedited by power equip-
ment, which becomes critically important in major
fracture repair in adults.2 For power tapping, oscillation
between forward and reverse drive, to facilitate cleaning
of the bone swath material into the flutes of the tap, can
be accomplished rapidly. Occasionally electric power
Figure 8.1 Battery‐powered autoclavable drill for many fracture
drills are used to save money. These drills are difficult to repair applications, including drilling, tapping, screw insertion,
sterilize and may therefore represent hazards to the osteotomy, and reaming. The Trauma Recon System has
maintenance of aseptic technique. Additionally, switching considerable torque and battery life, and is sufficiently robust for
from forward to reverse drive is not quickly accom- equine osteotomy and plating repair. Source: Courtesy DePuy
plished, delaying the progress of surgery and significantly Synthes Vet, West Chester, PA, USA.
increasing the torque at the bone–drill interface every
time the direction is altered. Large Fragment Set
Several autoclavable battery‐powered drills that
provide forward and reverse triggers and a variety of The Large Fragment set contains all instruments for the
quick‐detachable chucks for drilling, tapping, reaming, insertion of 4.5 and 5.5 mm cortex screws, 6.5 mm
and sawing are available from DePuy Synthes.1 These are cancellous screws, and 4.0 and 5.0 mm locking‐head
an alternative to gas‐powered drills, especially for shorter screws (Figure 8.2). Three separate screw racks exist, one
and less complex procedures, and are particularly useful for 5.5 mm cortex screws (Figure 8.3), one for 4.5 mm
for surgery on standing, sedated animals due to the quiet cortex and 6.5 mm cancellous screws, and one for 4.0 and
motor and flexibility of not requiring a gas line connec- 5.0 mm locking‐head screws. An additional individually
tion. These range from the small battery drive, through assembled plate set contains various selected dynamic
the medium‐sized Trauma Recon System (TRS) modular compression plates (DCPs), limited‐contact dynamic
drive, and up to the Power Drive battery system. Drilling, compression plates (LC‐DCPs), regular and veterinary
tapping, and screw insertion are common to all three locking compression plates (LCPs), and equine LCPs
drills; however, the small battery drive lacks the torque with the stacked combi hole at one end (Figure 8.4). The
for most 5.5 mm screw insertion tasks. Additionally, the various instruments are presented in the subsequent
capacity and range of blades for the small battery drive sections. A 3.5 mm set is also available for insertion of
oscillating saw are inadequate for major equine osteot- 3.5 mm screws and plates.
omy procedures. The TRS modular system (Figure 8.1)
is currently the best choice for most equine applica- Drill Bits
tions, although the small battery drive is suitable for Two sizes of double‐fluted drill bits are used for each size
most drilling and tapping applications and short‐term of screw to be inserted in lag fashion. The larger 3.5, 4.5,
procedures. It is not suitable for major equine plate and 5.5 mm bits are used to prepare the glide hole for the
applications due to limited torque and battery durability. respective sized screws, and the smaller 2.5, 3.2, and
A recently introduced lithium ion battery provides 4.0 mm bits correspond to the core size of the screws and
improved performance and extended battery life that prepare the thread hole. The size of each bit is marked on
make the small battery drive satisfactory for routine the quick coupler. A 4.3 mm drill bit with a centimeter depth
plating procedures. scale is included in the set for the 5.0 mm locking‐head
www.ajlobby.com
8 Surgical Equipment and Implants 109
Figure 8.3 DePuy Synthes Large Fragment Set: 5.5 mm screws.

The set contains up to 10 screws of each of the most frequently
used screw lengths between 30 and 70 mm, as well as smaller
numbers of the shorter screws. Additionally there is one
compartment (on the right side in the figure) where no sizes are
marked, which is intended to be filled by the screws the surgeon
wants to select personally. A set of labels specifically for this
purpose are supplied with the set. Source: Courtesy DePuy
Synthes Vet, West Chester, PA, USA.
assures concentric drilling of the thread hole relative to

the glide hole. The 3.5, 4.5, and 5.5 mm drill guides are
also used as the respective tap guides.
Universal Drill Guide

This type of drill guide is used for plate application and
Figure 8.2 DePuy Synthes Large Fragment Set: Instruments. The contains on one end a 3.5, 4.5, or 5.5 mm drill sleeve and
set contains all the drill bits, taps, drill guides, screwdrivers on the other end a spring‐loaded 2.5, 3.2, or 4.0 mm drill
(hexagonal and star drive), T‐handle, countersink, depth gauge, sleeve. By applying pressure to the spring‐loaded por-
push–pull device, tension device, socket wrench, and torque‐
tion, the hole is drilled in a neutral position (Figure 8.5A),
limiting device that are needed to insert screws (in lag fashion)
into bone as well as through dynamic compression plates, whereas when no pressure is applied and the drill guide
limited‐contact dynamic compression plates, and locking is positioned at the far end of the plate hole, the hole is
compression plates. The instruments are arranged in three trays drilled in a load position across the underlying bone
that fit on top of each other into the main tray with lid. (Figure 8.5B).
Pictographs facilitate correct storage location for each instrument.
Source: Courtesy DePuy Synthes Vet, West Chester, PA, USA.
Special Drill Guides for Plate Application
screws. For the 4.0 mm locking‐head screw, which can be A special 3.2 mm double‐ended drill guide for the
inserted into the same plate holes, the 3.2 mm drill bit is 4.5 mm DCP and LC‐DCP is included in the Large
used to prepare the hole for the core of the screw. Fragment instrument set, and another one with a
4.0 mm diameter hole for the 5.5 mm screws to be
Double Drill Guide inserted into the 4.5 mm DCPs. One end of the guide
The double drill guide is used in conjunction with the has a neutral drill barrel (green), which allows drilling
drill bits and taps for application of lag technique. It of a central hole through the oval plate hole, and the
assists in guiding the drill bit, prevents bending of the other end has an offset barrel (yellow), which results
bit, and protects the surrounding soft tissues from addi- in a 1 mm offset hole to provide compression as the
tional trauma by the instruments. One end of the instru- screws are tightened in the plate.
ment contains the 3.5, 4.5, or 5.5 mm guide, respectively,
and the other end the 2.5, 3.2, or 4.0 mm guide. The Drill Guides for Locking‐head Screws
2.5 mm drill guide fits into the 3.5 mm glide hole, the Four identical drill guides for the 5.0 mm locking‐head
3.2 mm drill guide into the 4.5 mm glide hole, and the screws (see Figure 8.4) are included in the instrument
4.0 mm drill guide into the 5.5 mm glide hole, which set. These drill guides are threaded perpendicularly into
www.ajlobby.com
(C)
(A)
(B)
(D)
Figure 8.4 DePuy Synthes Large Fragment Set: Plates/locking instruments, and screws. The plates desired are arranged in three trays that
fit into the plate set (left container). The plate set contains a selection of narrow (A) and broad (B) 4.5 mm locking compression plates
(LCPs), the 5.5 mm broad LCP (C) with stacked combi hole, and various‐length soft aluminum templates (D), all arranged in front of the
plate set. The locking screw set (right) is only partially filled. The instruments needed for insertion of LCPs are arranged in front of the
screw set, including from left to right the star screw driver, the universal handle for torque limiter, the 4 Nm torque limiter, the power star
drive T25 insert, the 4.3 mm drill, the push–pull device, and three threaded drill guides for 4.3 mm drills. Source: Courtesy DePuy Synthes
Vet, West Chester, PA, USA.
(A) (B)
Figure 8.5 (A) The universal drill guide is shown in the “neutral” position (with the spring compressed) in the center of the combi hole,
and (B) in the “load” position (when the spring is not compressed) on the far side of the combi hole. Source: Courtesy DePuy Synthes Vet,
West Chester, PA, USA.
the plate hole. Care has to be taken to apply the drill ble “click” is appreciated as the drill guide connects with
guide to the plate exactly perpendicular in all planes. It is the threads. It can then be rotated clockwise to appropri-
best to initially turn the drill guide backward when it ately screw into the plate (Figure 8.6). It is prudent to
makes contact with the plate, until an audible and palpa- double‐check the orientation of the drill guide relative to
www.ajlobby.com
Countersink
The countersink is used to prepare a conical indentation
in the cortical surface of the bone, to accept the curved
underside of the screw head. Its 4.5 mm diameter tip fits
into the glide hole. The countersink depression reduces
the load at the screw head–shaft junction. A solitary
contact point which develops when a screw is inserted
obliquely or across a slanted surface, or a contact ring if
the screw is inserted perpendicularly relative to the bone
surface, is transformed into a broad contact area by the
countersink depression. The depression also reduces
screw head protrusion on the bone surface, which is
especially desirable with the 4.5 and 5.5 mm screws.
Depth Gauge
The depth gauge allows exact determination of the
length of the prepared hole, and therefore dictates the
screw length. This device measures the screw length
including the screw head, and contains a conically shaped
nose, which fits into the countersink depression in
bone or the topside of the slot in the plate. It is therefore
important to prepare the bone cortex countersink
Figure 8.6 The 4.3 mm threaded drill guide must be attached depression prior to determining the screw length
perpendicularly to avoid cross‐threading and misdirected drilling. needed. The long thin probe of the depth gauge is
The 5.0 mm locking screw will not thread into the plate
adequately if the hole is misdirected. Source: Courtesy DePuy
inserted into the hole and the opposite bone surface
Synthes Vet, West Chester, PA, USA. engaged by the small hook on the probe end, followed
by direct measurement of screw length from the barrel
of the instrument. Direct measurement, including thick-
the plate before drilling is initiated. It is possible to place ness of the plate, is obtained in an identical way when
the drill guide cross‐threaded into the plate, which locks the depth gauge is also applied through the slot in DCP,
it to the plate at an angle and allows drilling of an inap- LC‐DCP, or LCP, respectively.
propriately oriented hole for the locking‐head screw.
Subsequent screw insertion results in premature binding
of the cross‐threaded screw head in the plate and, as a T‐handle
result, a reduced number of locked threads, reduced The T‐handle is used for manual tapping of the thread
strength of fixation, and poor seating of the screw head hole. For this purpose the tap is inserted into the quick‐
into the LCP. coupling device on the handle. Less commonly, the
The drill guide contains threads at its proximal end as T‐handle is used to drive the small 3.5 mm countersink
well, which allow the attachment of an additional same‐ and the various components of the broken screw/tap kit.
sized drill guide to extend the guide through thick soft
tissues. This double‐length drill guide may be needed in Tap
the event that a locking screw must be inserted through The taps of the different sizes precisely cut screw threads
a stab incision and extensive musculature. The drill guide in the thread hole. When lag technique is applied, threads
must be connected perpendicular to the top surface of are not cut in the overdrilled glide hole, which has the
the plate, which often necessitates use of additional stab same diameter as the tap. The tap is inserted through
incisions to repeatedly span the soft tissues as additional the respective drill guide/tap sleeve to protect the soft
screws are placed. If the screw is inserted at an oblique tissues from additional trauma by the sharp cutting
angle relative to the plate (cross‐threaded), it loses the edges of the tap. The tap has three flutes along the cut-
majority of its holding power within the threaded plate ting portion, to accept bone debris formed during the
hole. Given this, if a perpendicular drill guide cannot be cutting action. In hard equine bone, the tap is advanced
attached, a routine cortex screw should be inserted in two to three half turns followed by a half turn in the
the nonthreaded region of the combi hole. Two 3.2 mm reverse direction, to facilitate transport of the swath
threaded drill guides for the smaller 4.0 mm locking‐ particles into the flutes. This technique assures precise
head screws are included in the set. They are applied in cutting of the threads without binding. The tap cuts
identical fashion. threads along the entire hole length, although it should
www.ajlobby.com
always be recognized that the thread diameter at the tip One power screwdriver attachment for hexagonal drive
of the tap is reduced to make entry and starting of the tap and one for star drive, equipped with a quick‐coupling
in the thread hole more efficient. Large taps such as the device for the power drill, are valuable additions, especially
5.5 mm tap should exit for two to three turns to enlarge for plate fixation, where many screws have to be inserted.
the far cortex to the full 5.5 mm diameter to prevent the
screw tip binding in the cortex and giving the sensation Torque‐Limiting Devices
that the screw is fully tightened, or, worse, stripping out Because the locking‐head screws tighten into the
the hex screwdriver socket in the screw head. This is threaded section of the combi holes within the LCPs and
done only after considering the soft tissues and bone not into the bone, as is the case with the regular screws
adjacent to the cortex that might be impacted by the (cortex, cancellous, etc.), torque‐limiting devices are
emerging tap. The cancellous tap is used for tapping essential (see Figure 8.4). This is especially important
wider thread widths than the core size of the cancellous when titanium implants are used, as is standard protocol
screw. This tap is also manufactured with a quick‐ in human surgery, to prevent cold welding of the screw
coupling device on its end to facilitate attachment to head into the plate threads. In equine surgery, stainless
the T‐handle. The tap contains a centimeter scale in 5 mm steel implants are usually used and cold welding is not
increments on the shaft to indicate the tapping depth, common. Nevertheless, the use of the torque‐limiting
which can be compared with the measured hole length. attachment for either the compact air drive or the TRS
battery drive is strongly encouraged. This device allows
Screwdrivers full insertion of the locking‐head screw. A torque‐
The 3.5, 4.5, and 5.5 mm cortex screws and the 6.5 mm limiting screwdriver is also available, but screw insertion
cancellous screws contain a hexagonal hole in the head is slow because the threads of the locking‐head screws
to accept the screwdriver. Positive locking of the screw- are finer and have a lower pitch, so screw insertion takes
driver in the screw ensures firm implant placement with- many more revolutions. Use of power screw insertion
out the risk of screw head damage and metal debris significantly reduces surgery time.
remaining in surrounding soft tissues. The small hex‐
head screwdriver is designed for the 3.5 and 4.0 mm Tension Device
screws, while the large hex‐head driver is designed for The tension device (Figure 8.8) is connected to the bone
the 4.5, 5.5, and 6.5 mm screws. For 3.5 mm screws the at the end of a plate with a short unicortical screw. A hook
weakest mechanical component is the hexagonal socket engages the plate and as the tensioning screw in the
in the screw head, and complete insertion of the screw-
driver into the screw head before turning is vital. This is
particularly relevant during screw removal, when soft
tissue or even bone can grow into the screw head, mak-
ing meticulous cleaning of the head important to prevent
stripping of the hex socket. The locking‐head screws
contain the star‐lock drive (Figure 8.7), which requires a
different screwdriver. The star‐lock screwdriver sits
firmly into the locking screw head and obviates the need
for a screw holding device to collect the screw from the
rack or retain the screw on the screwdriver when angled
downward. The force transfer from the screwdriver to
the screw head occurs at a much more favorable angle
and larger surface area, and prevents stripping of the
screw head–screwdriver connection.
Figure 8.8 Articulated tension device for additional axial fracture

Figure 8.7 5.0 mm locking-head screw with self‐tapping tip. compression. Source: Courtesy DePuy Synthes Vet, West Chester,
Source: Courtesy DePuy Synthes Vet, West Chester, PA, USA. PA, USA.
www.ajlobby.com
instrument is turned, it pulls the plate in the direction of the Screw Sets
device. Through this action, compression may be applied to
a fracture plane or across a joint. Plate screws should The equine surgeon specializing in fracture treatment
only be inserted in the bone remote to the tension device, must have access to a wide variety of implants and screws
prior to applying tension. After compression is accom- (see Figures 8.3 and 8.4). This is especially important if long
plished, screws are inserted on both sides of the fracture bone fractures are double plated. To avoid catastrophic
line and the tension device can subsequently be removed. results, at least eight screws of the same size and the most
frequently used lengths should be available during surgery.
After every surgery the rack should be refilled and replace-
Push–pull Device
ments for the used screws ordered. Because the variety of
This instrument (Figure 8.9A) is used to hold LCPs on the
available screw types has increased, it is no longer possible
bone to obviate the need for forceps application. This
to include all types and sizes of the screws potentially
reduces clutter in the surgical field. A second function
needed in one set. Additionally, the screw set needs to have
includes pressing the plate onto the bone surface, as these
dimensions that allow it to fit into an average‐sized auto-
plates were initially designed to be applied with a 2 mm
clave, so several screw sets are generally needed.
separation between the underlying bone and the plate.
This design suits minimally invasive application for frac-
ture repair in humans, but in equine fracture repair there Cannulated Screw Set
is often the need to angle regular cortex screws in various
planes, and better plate contouring and fit are desirable. Cannulated screws are infrequently applied in horses despite
The drill bit forming the tip of the push–pull device is the useful concept of drilling and inserting a screw under
powered into the bone at a slight angle through the desired guide pin control. The strength of the cannulated screw in
hole (Figure 8.9B). The collet is then threaded downward bending can lead to failure, and many surgeons prefer the
until it makes contact with the plate. By continuing with 5.5 mm cortex screw or the 6.5 mm cancellous screw.
turning, the plate is pressed onto the bone surface.
Additional Instruments
Fracture Reduction Set
Additional instruments included in the basic set are a The fracture reduction set contains the various instru-
2 mm drill bit and its pointed drill guide, large pointed ments needed for fracture reduction, including a periosteal
reduction forceps, a Jacobs chuck, and a double drill elevator, two large pointed reduction forceps, large bone
guide for cancellous screws. holding forceps, two Hohmann retractors, a chisel handle
(A) (B)
Figure 8.9 (A) The push–pull device for pressing and stabilizing the locking compression plate against the cortex of the bone. (B) The
push–pull device is applied toward the end of the plate using a power drill to insert the self‐drilling, self‐tapping pin, and the collet is
tightened to force the plate against the bone. The push–pull device can be removed after application of several adjacent screws. Source:
Courtesy DePuy Synthes Vet, West Chester, PA, USA.
www.ajlobby.com
Figure 8.10 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 centering 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 is used for all
these attachments. Additional instruments not shown include the
extraction pliers for gripping round‐shaft broken screws, and the
gouge to expose the stump of shallow‐seated broken screws.
Source: Modified from photographs courtesy DePuy Synthes Vet,
with three exchangeable chisel blades of different widths, are included in the set. Additional 3.5 mm standard and
and a mallet. Most equine surgeons already own several of broad plates may be added at the discretion of the
these instruments, hence this set is rarely sold in its entirety. surgeon.
Plate Set Broken Screw Extraction Set

The plate set contains a selection of broad and narrow A special set has been developed for the retrieval of
4.5 mm DCPs, LC‐DCPs, and regular and veterinary screws with stripped heads, and broken screws, drills, or
LCPs that each surgeon can assemble to his/her liking taps (Figure 8.10). If part of the broken screw can be
(see Figure 8.4). Special plates are rarely included, but grasped with a special pair of pliers, it is retracted manu-
can be added as desired. Two plates of every size should ally by routine backing out with counterclockwise action
be in the set and every plate used should be immediately (Figure 8.11). If the screw has sheared off flush with the
replaced by a new one. cortical surface, a gouge can be used to expose adequate
Soft aluminum templates are supplied in various lengths, portions of the broken shaft to allow the pliers to grasp
and facilitate contouring of the plates. The templates are the shaft and back out the broken end. Where the broken
pressed onto the bone at the anticipated plate location. shaft is deeply embedded in the bone, a hollow reamer
With the help of a plate bending press and occasionally (akin to a core saw) with centering pin (Figure 8.12) is
bending irons, the plate is contoured to fit the shape of used to remove the bone cortex circumferentially
the template and therefore the bone. around the screw or tap fragment until it can be secured
by the inside surface of an extraction bolt that contains
threads in the opposite direction to the screw threads
3.5 mm Set (see Figure 8.11). The extraction bolt, generally held in a
In selected cases 3.5 mm cortex screws are applied in the T‐handle, is threaded over the end of the screw shaft and,
horse. This set contains similar, but smaller, instruments once the resistance of the cone‐shaped bolt threads over
compared to the basic set. The functions of the instru- the screw shaft is higher than the resistance of the broken
ments are identical to the 4.5 mm set. The glide hole is screw in the bone, the screw loosens and is backed out by
prepared with the 3.5 mm bit, whereas a 2.5 mm bit is continuous turning in the same counterclockwise direc-
used for the thread hole. A number of third tubular plates tion. Hollow reaming cutters and extraction bolts are
www.ajlobby.com
Figure 8.11 (A) Stripped screw heads are (A) (B)

extracted with the conical extraction screw; (B)
shallow broken screws can be exposed with the
gouge and (C) removed with pliers; (D) the
assembled hollow reamer exposes deep‐seated
broken screws for extraction bolt (E) entry for
removal by anticlockwise rotation. Source:
Modified from photographs courtesy DePuy
Synthes Vet, West Chester, PA, USA.
(C) (D) (E)
made for all screw sizes including 1.5, 2.0, 2.7, 3.5, 4.0, 4.5, broken screw shaft after hollow reaming, a hollow
5.5, 6.5, and 7.0 mm screws. Similarly, the extraction bolts gouge to expose shallow screws, and a useful etched
that match these screw sizes are part of the kit. metal instruction set to guide the surgeon.
For stripped hexagonal screw heads, a special conical
extraction screw with reverse‐threaded conical tip is
used. This extraction screw has cutting threads Cerclage Set
machined onto the outside of the conical tip, which The cerclage set includes rolls of cerclage wire of various
tighten in the screw head as the cone is driven into the sizes, in addition to several precut wire pieces with a wire
stripped hex socket (see Figure 8.11). The conical loop on one end. Also wire cutters, pliers, wire tighten-
extraction screw is held in a T‐handle and tightened ers, and special wire applicators are included in the set.
into the screw head by a counterclockwise action, even-
tually binding in the stripped head and backing the
screw out of the bone. The conical extraction screw is
available in three sizes, one for 1.5 and 2.0 mm screws,
Fragment Distractor Set
another for 2.7 and 3.5 mm cortex screws, and one for The universal large fragment distractor allows fracture
large screws (4.5, 5.5, and 6.5 mm, since all have the alignment and reduction without stretching the joints
same hex head). The kit also has a plier‐type forcep distal and proximal to the fracture. The set (Figure 8.13)
with curved jaws for gripping broken screw shafts, contains 3.5 and 5.0 mm drill bits and drill guides, for
a dental pick for cleaning out the bone from around a thread hole and gliding hole respectively, three different
www.ajlobby.com
(A) Figure 8.12 Broken screw extraction.

Assembly of the hollow reamer with (A)
centering pin, followed by (B) reamer
barrel, allowing (C) cutting of bone over
the broken screw shaft by rotation of the
assembled unit. Source: Modified from
photographs courtesy DePuy Synthes Vet,
(B)
(C)
(C)
(A) (D)
1 (E)
3
4
2
(B)
(F) (G)
(H)
Figure 8.13 The large fracture distractor set. (A) Assembled distractor with 48 cm threaded rod. The threaded carriage (1) with double joint
provides a fixed point of attachment using various lengths of 5.0 mm Schanz screws. The sliding carriage (2) can be used to distract a fracture
by turning the locking knurled nut (3), or compress the fracture by turning the other knurled nut (4), to move the Schanz screw in the distal
fracture fragment. (B) A shorter (33 cm) threaded rod is suitable for shorter bones. (C) Various lengths (150, 175, and 200 mm) of 5.0 mm
Schanz threaded screws are available to fix the distractor to the fracture ends. (D) Drill insert sleeves accept the 3.5 and 5.0 mm drills (E), and
the 3.5 mm sleeve has a trocar to form a path through soft tissues. (F) Long (105 mm) holding sleeves with wing screws are available for
additional stand‐off in bulky soft tissue regions. The scale is marked in centimeters. (G) The universal chuck with T‐handle for inserting Schanz
screws, and (H) the pin wrench for turning the knurled nuts are shown inset (not to scale). Source: Images courtesy Dr. Alan J. Nixon.
www.ajlobby.com
length 5.0 mm Schanz screws for introduction into the Cortex Screws
drill holes in the bone ends either side of the fracture, a
universal chuck with a T‐handle for insertion of the Cortex screws are fully threaded screws with a rela-
screws, a pin wrench for tightening the spindle carriages tively short thread height of 0.5 mm in 3.5 mm screws,
containing the Schanz screws, and the 48 cm fragment 0.7 mm in 4.5 mm screws, and 0.75 mm in 5.5 mm
distractor threaded spindle itself. Compression or dis- screws. Screw lengths available from DePuy Synthes
traction can be achieved, depending on which knurled for 3.5 mm screws vary from 10–50 mm in 2 mm incre-
nut on either side of the sliding carriage is tightened. ments, and 50–70 mm in 5 mm increments. Similarly,
4.5 mm cortex screw lengths range from 14–72 mm in
2 mm increments and 80–100 mm in 5 mm incre-
Dynamic Condylar Screw/Dynamic ments. For 5.5 mm cortex screws, lengths range from
Hip Screw Implant Set 24–60 mm in 2 mm increments, followed by 64, 70, 80,
A special instrument set is available to the human and 90, and 100 mm. Cortex screws do not contain any
large animal market, which contains the dynamic con- regions of a bare shaft, and are the most widely used
dylar screw (DCS) and dynamic hip screw (DHS) screw type in equine fracture treatment.
implant systems and the instruments needed to apply
them. This set is discussed in further detail later in this
chapter.
Self‐tapping Screws
The term self‐tapping screw refers to implants that can
Oscillating Bone Saw be inserted into a predrilled thread hole directly, without
first tapping the thread. There are two categories of
An oscillating power saw is mandatory for the equine
self‐tapping screws: thread‐cutting and thread‐forming
orthopedic surgeon specializing in fracture repair.
types. In hard cortical bone, thread‐cutting screws are
A variety of saw blades may be used with this device,
usually used because they perform better than thread‐
depending on the task being carried out. The newer
forming (squeezing) screws. Thread‐cutting screws
types of power equipment allow the connection of
cause much less damage to the bones’ microstructure
either an oscillating saw head or a reciprocal saw head,
and require less insertion torque and axial force. The
the latter of which is preferred if a saw cut has to be made
AO/ASIF self‐tapping bone screws for diaphyseal appli-
along the caudal aspect of a bone, which is frequently
cation are thread‐cutting screws. An experimental study
covered by tendons and ligament, effectively preventing
comparing the insertion torque and pullout force of the
the use of the standard oscillating saw.
self‐tapping screw to the standard 4.5 mm cortex screw
inserted after tapping showed no significant increase in
General Comments insertion torque and no significant decrease in pullout
force for the self‐tapping screw.3 The loss in pullout force
Proper care and maintenance of instruments and power was much smaller than with other self‐tapping screws.
equipment is of paramount importance for efficient and The only manufacturing differences between the DePuy
appropriate use, and to prolong their functional life. The Synthes 4.5 mm self‐tapping cortex screw and the stand-
sets and instruments should be kept complete and in good ard 4.5 mm cortex screw are three short, large‐volume
working order. Dull drill bits and taps should be exchanged cutting flutes at the tip of the screw over a length of
as soon as the problem is identified. Maintenance of power approximately 5 mm, and a slightly tapered core diameter
equipment should be done after every use according to the at the tip. Studies in human cadaveric femora showed that
manufacturer’s recommendations. introduction of the self‐tapping screw raised the surface
temperature to approximately 40 °C.3 In conventional
screw use the tap raised the temperature to approximately
Screws 30 °C and the screw inserted into a tapped hole to 33 °C. If
a non‐self‐tapping screw was inserted in an untapped
Several types of screws were developed by DePuy hole, the temperature reached approximately 50 °C. Also,
Synthes and the AO group. The same screws may be the heat generated by the self‐tapping screw, or by a tap, in
used in various applications, depending on the fracture relation to speed of insertion is not relevant.
location and type. The various sizes and types of screws An experimental study evaluating self‐tapping screws
used in the horse are summarized in Table 8.1. The manufactured by different companies, using an identical
following screws will be described in further detail:
experimental design in hard adult equine bone, revealed
cortex screws, self‐tapping screws, cancellous screws, significant differences between products.19 However,
and locking‐head screws. using the power‐tapping technique, the screws could
www.ajlobby.com
Table 8.1 Overview of the bone screws used in equine surgery. All the pertinent data for most of the important screws are summarized.
Characteristic 3.5 mm cortex 4.5 mm cortex 5.5 mm cortex 6.5 mm cancellous 3.5 mm locking 4.0 mm locking 5.0 mm locking
Screw diameter 3.5 4.5 5.5 6.5 3.5 4 5

Gliding hole 3.5 4.5 5.5 4.5 None None None
diameter
Thread hole 2.5 3.2 4 3.2 2.8 3.2 4.3
diameter
Tap diameter 3.5 4.5 5.5 6.5 None None None
Screw shape
Thread type Cortical Cortical Cortical Cancellous Cortical Cortical Cortical

narrow narrow narrow
Pitch 1.25 1.75 2 1.75 0.8 1 1
Screw head 6 8 8 8 5 6.6 6.6
diameter
Special head – – – – Conical Conical Conical
design threaded threaded threaded
Thread length Fully Fully threaded Fully threaded 16 mm/32 mm/ Fully threaded Fully threaded Fully threaded
threaded Fully threaded
Shaft diameter – – – 4.5 – – –
Core diameter 2.4 3.1 4 3 2.9 3.4 4.4
Self‐tapping Yes Yes Yes No Yes Yes Yes
Self‐drilling No No No No Available Available Available
easily be introduced into equine bone. In the clinical holding power. However, cancellous screws are not used
situation an identical technique is applied. in equine bone as frequently as they once were, because
of the advent of newer screws such as the 5.5 mm cortex
screw and the locking-head screw system.
Cancellous Screws
Cancellous screws have a wider thread height (1.45 mm)
compared to cortex screws and a different pitch (angle Cannulated Screws
of the threads relative to the long axis of the screw). The cannulated screw has a virtually identical geometry
These 6.5 mm diameter screws are available as partially to the cancellous screw. However, it contains a central
threaded screws with either 16 or 32 mm of thread canal to allow insertion over a guide pin (Figure 8.14).
length, or as fully threaded screws. Available 6.5 mm Fracture reduction followed by guide pin insertion can be
screw lengths vary from 20–100 mm in 5 mm increments helpful to maintain fracture alignment during subsequent
for fully threaded screws, and 30–100 mm for 16 mm cannulated screw insertion. However, all associated
partially threaded screws. The 32 mm partially threaded instruments, including drill, tap, and screwdriver, require
cancellous screw is available in 45–100 mm lengths. a cannulated design to accommodate the guide pin. These
Because of its geometry, this type of screw is preferen- specific tasks require a dedicated instrument set.
tially applied in soft cancellous bone, to allow maximum Cannulated screws are weaker in bending than cortex
www.ajlobby.com
(A) Locking-Head Screws

The head of the locking screw is manufactured with a
fine conical thread (see Figure 8.7) that is captured in the
threaded part of the combi hole in the LCP through more
than 200° of circumference, which according to finite
element analysis is sufficient to provide angular as well
(B) as axial stability for the screw in the plate.7 The core
diameter of the screw has been increased, compared to
cortex screws, and the thread width and thread pitch
have been reduced, essentially resulting in a “threaded
bolt” that provides significantly greater breaking resistance
than regular cortex screws.8 The locking-head screw tips
are either equipped with a self‐tapping portion (see
Figure 8.7) or, as occasionally used in human surgery, a
self‐drilling, self‐tapping tip. The latter type of screw is
only used as a unicortical screw, because protrusion of
the sharp self‐cutting tip into the surrounding soft tis-
sues would result in significant damage and potential
loss of function.
The 5.0 mm locking-head screw is preferred in equine
fracture management. It is possible to use the smaller
4.0 mm locking-head screw in the same plate; however,
these screws are weaker than the 5.0 mm screws and are
rarely added to the fixation. Additionally, a smaller LCP
is available that accommodates 3.5 mm locking-head
screws, but these are rarely used in equine applications.
Headless Screws
Headless screws were initially introduced into the
human market to avoid protrusion of the screw head
above the bone surface, which is particularly indicated
in and near joint surfaces. The Herbert screw (Zimmer
Orthopedics, Warsaw, IN, USA) is an example of a self‐
contained compression screw. This screw is fully
threaded over its entire length, including the portion
representing the head. The head is the widest portion
of the uniformly tapered screw and can be completely
Figure 8.14 Cannulated screws. (A) Fully threaded and partially buried in the bone. Recently a cannulated, tapered,
threaded 7.3 mm cannulated screws. (B) Characteristics of the
7.3 mm cannulated screw.
variable‐pitch, self‐compressing screw has been devel-
oped (Acutrak® Equine Screw, Acumed Veterinary,
Hillsboro, OR, USA). This screw is 45 mm long and has
screws and failure by screw breakage has limited the a diameter of 6.5 mm at its base, which tapers to a
application of cannulated screws to fractures that require diameter of 5.0 mm at its apex. Because of its tapered
firm reduction and stabilization during subsequent drill- shape, no glide hole is needed. The screw is manufac-
ing and screw insertion. Additionally, fractures in regions tured out of titanium. Biomedical studies comparing
with limited direct exposure can be reduced and stabi- Acutrak to 4.5 mm AO cortex screws inserted in lag
lized under radiographic control, followed by facilitated fashion revealed that both screws had similar biome-
guide pin drill and subsequent screw insertion. These chanical shear properties.9 The self‐compressing
screws have been applied in supraglenoid tubercle frac- action of the Acutrak screw provided only 70% of the
tures of the scapula, fractures around the stifle, and proxi- compression force achieved with the 4.5 mm AO cor-
mal femoral physeal separation, but are rarely used in tex screw.9 The pushout strength was higher with the
equine surgery outside of these few applications. Acutrak screw.10
www.ajlobby.com
Table 8.2 Overview of the plates most frequently used in equine surgery. All the pertinent data are summarized. The lengthening plates are not included. For additional information, review the DePuy Synthes
catalog.
One third
LC‐DCP 3.5 LC‐DCP 4.5 DCP 3.5 LCP 3.5 tubular
Characteristic LC‐DCP 3.5 broad LC‐DCP 4.5 broad veterinary DCP 4.5 broad DCS plate DHS plate LCP 3.5 broad LCP 4.5 LCP 4.5 broad LCP 5.5 plate
Plate type Standard Standard Standard Standard Special Special Special Special Special Special Special Special Special Special
Plate
cross‐section
Width (mm) 11 13.5 13.5 17 12 16 16 19 11 13.5 13.5 17.5 17.5 9

Thickness 3.3 4.2 4.2 5.2 3.6 4.8 5.4 5.8 3.4 4.2 4.2 5.2 6 1
(mm)
Length (mm) 25 (2 holes) 90 (7 holes) 34 (2 holes) to 106 (6 holes) to 86 (7 holes) 103 (6 holes) 114 (6 holes) 46 (2 holes) to 33 (2 holes) 94 (7 holes) 44 (2 holes) 116 (6 holes) to 188 (10 holes) 28 (2 holes)
to 259 to 285 394 (22 holes) 394 (22 holes) to 266 to 359 to 370 270 (16 holes) to 293 to 289 to 440 440 (24 holes) to 332 (18 holes) to 148
(20 holes) (22 holes) (22 holes) (22 holes) (22 holes) (22 holes) (22 holes) (24 holes) (12 holes)
Plate angle Straight Straight Straight Straight Straight Straight 95° 135° (140°, Straight Straight Straight Straight Straight Straight
145°, 150°)
Angled _ _ _ _ _ _ Barrel 25 mm Barrel 25 and _ _ _ _ _ _
portion long 38 mm long
Screw size 3.5, 4.0 3.5, 4.0 4.5, 5.5, /6.5/ 4.5, 5.5, /6.5/ 3.5, 4.0 4.5, 5.5, /6.5/ 4.5, 5.5, /6.5/ 4.5, 5.5, /6.5/ 3.5, 4.0 3.5, 4.0 4.5, 5.5, 4.5, 5.5, /6.5/ 4.5, 5.5, /6.5/ 3.5, 3.5 LS
(mm) 3.5 LS 3.5 LS /6.5/ 5.0 LS 5.0 LS 4.0, 5.0 LS
Hole Straight Staggered Straight Staggered Straight Staggered Staggered Staggered Straight Straight Straight Straight Staggered Straight
arrangement
Hole spacing 13 13 18 18 12 (16 16 (25. central) 16 16 13 (9.4 13 (9.4 18 (12.8 18 (12.8 central) 18 (12.8 central) 12
central) central) central) central) (16 central)
Hole design DCU DCU DCU DCU DCP DCP 2 round rest DCP Combi Combi holes, Combi holes, Combi holes, Combi holes, one Oval,
DCP holes, one tip one tip one tip beveled tip beveled one round
one tip beveled one beveled one one tip round tip round with w/collar
beveled tip round tip round with stacked stacked combi
one tip with stacked with stacked combi hole hole
round combi hole combi hole
with
stacked
combi
hole
Plate No No No No Yes Yes No No Yes Yes Yes Yes Yes Yes
mid‐section
DCP, dynamic compression plate; DCS, dynamic condylar screw; DCU, dynamic compression unit; DHS, dynamic hip screw; LC‐DCP, limited‐contact dynamic compression plate; LCP, locking compression plate.
0004257035.INDD 120 www.ajlobby.com 9/14/2019 4:15:56 PM

Plates Two screws on either side of the fracture can be com-

pressed using the plate holes alone, providing a maxi-
Various plates are being utilized in the treatment of equine mum of 4 mm of compression. Prior to tightening the
fractures. The distinction has to be made between the second screw, the first screw on the same side of the
types and the function of the plates, because a particular fracture plane has to be loosened to achieve the addi-
plate of the same type may be applied to fulfill various tional 1 mm compression. Following second screw tight-
functions. Up until recently, the DCP and LC-DCP were ening, the loosened screw is retightened. Additional
the standard plates used for equine fracture repair; how- compression requires the external tension device.
ever, the LCP has now largely replaced the DCP as the
standard veterinary plate, at least in the USA. Indeed, sup- Limited‐contact Dynamic Compression
plies of the DCP are declining, but both DCP and LC‐DCP Plate
are still considered useful for equine fracture repair. Most In humans and small animals, application of DCPs has
equine surgeons stock DCP or LC‐DCP and LCP. resulted in avascularity beneath the plate, which occa-
sionally culminated in pathologic fracture following
implant removal. The LC‐DCP contains undercuts on the
Standard Plates
surface that contacts the bone, which reduces the contact
The standard plates include the 3.5 mm broad, the area between bone and plate, and thereby improves main-
4.5 mm narrow, and the 4.5 mm broad DCPs and LC‐ tenance of bone vascularity. Studies in sheep have shown
DCPs. The specifications for the different plates are that the LC‐DCP design disturbs vascularity under the
summarized in Table 8.2. plate to a lesser extent. Because of the relationship
between the cortex thickness and the plate sizes used in
Dynamic Compression Plate horses, no detrimental changes under the plate have been
The DCP is considered the basic plate in equine fracture reported. Furthermore, the technique of plate luting (see
treatment and is slowly becoming obsolete with increased Chapter 9), which is commonly used in DCP or LC‐DCP
use of the LC‐DCP or LCP systems. The 4.5 mm plate application in horses, assures a 100% contact area
comes in two widths: the narrow with holes arranged in between the plate–PMMA–bone construct. A disadvan-
a straight line, and the broad with holes offset to the left tage of the LC‐DCP in equine fracture repair has been
and right of the midline. The 3.5 mm broad plate, devel- soft tissue closure over the implants, which is compli-
oped mainly for small animals, is manufactured from the cated by the slightly wider plate stock in the LC‐DCP, par-
same plate stock as the 4.5 mm narrow plate. However, ticularly when double plating. The top side of the LC‐DCP
due to the stiffness and hole configuration of the plate, is machined with oval holes of the dynamic compression
this basic plate is stronger than the narrow 4.5 mm DCP unit (DCU) design. The DCU design contains an incline
and therefore may also be applied in foals.2 The 4.5 mm on either end of each hole, allowing compression to be
narrow DCP is manufactured in lengths from 2 to 16 applied on either side and therefore in either direction.
holes in 1 hole increments, and 16 to 24 hole in 2 hole There is no designated middle of the plate, and the holes
increments. The 4.5 mm broad DCP is available from 6 are arranged evenly along the entire length of the plate, in
to 10 hole lengths in 1 hole increments, and 10 to 26 a staggered line for the broad plate and in a straight line
hole plates in 2 hole increments. The popular 11 and 13 for the narrow plate. When a screw is applied and tight-
hole broad 4.5 mm DCPs have been discontinued. The ened in load position through the thread hole previously
holes in a DCP are designed to achieve dynamic com- drilled using the LC‐DCP double drill guide, the screw
pression with tightening of the screws. The holes are head glides downward along the incline in the plate hole
machined according to the sliding spherical principle, toward the center of the hole. Therefore a fracture may be
with an incline or slope pointing downward toward the located anywhere along the plate and still be compressed
central solid portion of the plate. When a screw is by dynamic compression using adjacent screw holes. This
inserted in the load position (using the drill guide with is particularly valuable in multisegmental fractures.
the 1 mm offset), the screw head contacts the plate at Additionally, the DCU design and undercut of the plate
the top of the incline. When tightened, the screw head allow greater screw angulation within the plate, both lon-
moves down the slope until it comes to rest at the bot- gitudinally and laterally.
tom of the incline, just about in the center of the oval
screw hole. Throughout this procedure, as the screw is Special Plates
introduced into the bone, the screw “moves” toward the
fracture line and the bone follows, resulting in axial Locking Compression Plate
compression of the fracture site. The center of the plate The 4.5 and 3.5 mm broad and narrow LCPs are manu-
should be located over the fracture site and this offset factured out of the same plate stock as the corresponding
drilling can be carried out on either side of the fracture. DCPs. In the broad plates the holes are staggered
www.ajlobby.com
(A) (B)
(C)
Figure 8.15 Locking compression plate (LCP). (A) The combi hole slot has a threaded portion for locking screws, and a dynamic
compression unit (DCU) portion for self‐compressing cortex screws. (B) LCP with a locking-head screw in place in the locking portion of
the combi hole and a standard 4.5 mm cortex screw inserted in the DCU slot. The locking portion of the combi slot is closer to the center
of the plate (arrow). (C) The 5.5 mm LCP has a broad configuration and stacked combi hole at one end, through which either a locking‐
head or a cortex screw can be inserted. The opposite end is beveled and pointed for easier insertion through the soft tissues in minimally
invasive procedures. Note that the DCU portion in each combi hole is arranged away from the center of the plate, whereas the threaded
portion is located in each combi hole toward the center of the plate. Source: Courtesy DePuy Synthes Vet, West Chester, PA, USA.
alternately to the sides, whereas in the narrow plates they In an experimental biomechanical study using synthetic
are arranged in a straight line (Figure 8.15). The specifi- bone models, the DCP, LC‐DCP, LCP, and the clamp‐rod
cations of the various plates are summarized in Table 8.2. internal fixator (CRIF) were compared in torsion and
The LCP is equipped with so called combi holes, which bending (the CRIF is not used in horses because of its
consist of a threaded portion on one side of the hole for bulky size and inferior holding properties).6 The study
locking-head screws and a DCU part for standard screws revealed that the LCP was significantly stiffer than the
(Figure 8.15A). The plate holes are oriented with the other three implants. This was attributed mainly to the
threaded locking portion positioned toward the center locking head technology preventing any movement of
of the plate and the DCU portion toward the ends of the screw heads within the plate holes.
the plate (Figure 8.15B). One end of the veterinary LCP
contains a tapered and pointed end for submuscular, Third Tubular Plates
minimally invasive plate insertion, whereas the other end The one‐third tubular or semitubular plates are very thin
has a rounded, slightly tapered shape that contains a and are not designed to withstand the forces exerted on
stacked combi hole (Figure 8.15C), through which either most fracture repair applications in equine patients. The
a locking-head screw or a cortex screw can be inserted. 3.5 mm third tubular plate is occasionally used in the horse,
Limited angling away from a joint is possible with cortex however, for fixation of proximal fractures of the second or
screws. The 5.5 mm LCP was developed exclusively for fourth metacarpal/metatarsal bones.3 These plates are
use in horses and is manufactured out of the dynamic ideal because they are thin and, together with 3.5 mm
condylar screw (DCS) plate stock. The plate has a width of screws, provide adequate fixation of these fractures.
17.5 mm, and a thickness of 6 mm. The arrangement of the Application of such plates is also indicated in open frac-
holes along the plate is identical to the broad 4.5 mm tures of the splint bones.
LCP. Plate length varies from 3 to 16 holes for the narrow
4.5 mm LCP, and 6 to 18 holes for the broad 4.5 mm LCP. Modified Cobra Head Plate
The 5.5 mm LCP is only available in broad configuration, The cobra head plate was designed for humans and made
with 10-18 hole lengths and 1-hole increments. of similar plate stock to the DCS plate. However, the
www.ajlobby.com
has to be applied with the help of the tension device.

This implant is available as a 10‐hole (5 holes on either
side) or an 8‐hole (4 holes on either sides) plate. The
center portion without holes can measure from 50 to
120 mm, at 10 mm increments, in the 10‐hole plate,
and 30 to 60 mm, again at 10 mm intervals, in the 8‐
hole plate. These plates have occasionally been applied
in pancarpal arthrodesis, and other extremely commi-
nuted or nonunion fracture indications, but are now
rarely used due to the availability of heavier plate stock
in standard plates, and the introduction of the locking
compression plate.
Figure 8.16 Cobra head plates with the standard surface milling Dynamic Condylar Screw–Dynamic Hip
for dynamic compression plate action (top) and reverse milling
of the underside of the plate (bottom) for application to
Screw Systems
many equine metaphyseal fractures. Source: Images courtesy The DCS and DHS implant systems are a replacement
Dr. Alan J. Nixon. for the angled blade plate (ABP). These plates consist
of a long lag screw with a 12.5 mm thread width, a
25 mm thread length, and an 8 mm shaft diameter
(Figure 8.17). The shaft is flattened on two opposing
cobra head plate is preshaped and has an enlarged head sides to prevent rotation when introduced into the
at one end, giving rise to the name (Figure 8.16). The barrel of the plate, which contains the same cross‐
standard configuration, designed for use in proximal sectional geometry. The lag screw is inserted at the
femoral fracture repair in humans, is less applicable to predetermined angle: 95° for the DCS plate and 135°
the horse. However, if the plate is reversed and the (standard) for the DHS plate. Application of these
dynamic compression holes machined on the “under- systems is much easier than for the ABP.
side” of the plate, it fits perfectly to the distal end of the Aside from the 5.5 mm LCP, the DHS and DCS plates
femur and radius of the horse. The long stem of the plate are the strongest plates available in the AO system. The
has regular DCP‐like holes, and application uses routine DCS and DHS plates are very versatile, are rapidly
DCP principles. The thick cross‐section of the plate implanted, and are a real asset in large animal surgery,
resists bending but makes contouring more difficult. especially when treating long bone fractures toward the
The expanded end of the plate contains six round holes end of the bone in the adult equine patient.1 The DCS
that provide latitude for divergent screw insertion angles system is very useful in metaphyseal fractures of the
to allow maximum purchase in short expanded bone third metacarpus or third metatarsus, the proximal and
ends. The plate is designed for application in metaphy- distal radius, and even the femur. The DHS may be
seal and epiphyseal fractures, and is an excellent choice applied in selected femoral fractures.11 Combined with
for stabilization of proximal and distal radius and distal 5.5 mm screws and occasionally plate luting, these plates
femur fractures, and proximal third metacarpus and produce an extremely strong fixation.
metatarsus fractures with adjacent articular fractures.
Additionally, the standard configuration cobra head Additional Miscellaneous Plates
plate can be applied to fractures of the proximal femur, Additional plates are available such as the round hole
where it allows multiple diverging screws to be inserted plates; however, these plates have largely been replaced
into the femoral metaphysis, femoral neck, and femoral by more functional implants. The only round hole plate
head. These applications are also suited to DCS and DHS used in equine fracture repair is the 4.5 mm broad
stabilization, but the cobra head plate has more versatility lengthening plate for spanning severely comminuted
in screw angle, and the DCP technique for compression fracture regions, and even then it is generally used more
plating with the cobra head plate is generally more familiar frequently in small animal fracture repair.
to the surgeon. Thorough knowledge of the basic principles of internal
fixation, as well as application of the instruments and
Lengthening Plates the numerous implants, is a prerequisite for successful
Lengthening plates are manufactured from the same fracture repair.2,17 It is suggested that anyone interested
plate stock as the broad 4.5 mm DCP. However, the in treating long bone fractures attend a continuing
plate holes are round and the mid portion of the plate education course on internal fixation and have a current
is devoid of screw holes. If compression is required, it catalog illustrating all the implants available.
www.ajlobby.com
Figure 8.17 DePuy Synthes dynamic hip

screw/dynamic condylar screw (DHS/DCS)
set. The set consists of three trays that fit
into one big tray. All the instruments
needed are included and their place in the
trays marked for easy recognition. An
example of the large 12.5 mm threaded
lag screw for the DCS is shown below the
trays. Source: Courtesy DePuy Synthes Vet,
Cerclage Wire
Cerclage wires are used infrequently in the horse
compared to other species. However, they are still

applied in a few situations. Cerclage wire was success-
fully applied for the treatment of proximal sesamoid
fractures.13 One frequent application of cerclage wire
is temporary physeal growth retardation surgery.
Additionally, there have been reports of the use of
cerclage wires in the treatment of nondisplaced ulnar
Figure 8.18 The Fastight cerclage wire tightener and twisting
fractures in foals. Cerclage wire is also used in arthro- plier 391.23 (DePuy Synthes West Chester, PA, USA) allows
desis of the metacarpophalangeal joint, following tensioning of the cerclage wire before twisting. Source: Image
breakdown injuries due to comminuted fractures of the courtesy Dr. Alan J. Nixon.
proximal sesamoid bones (see Chapter 23).4 In such a
case a double cerclage wire tension band is applied
across the palmar/plantar aspect of the metacarpo‐ or Cables
metatarsophalangeal joint, in addition to application
of a dorsal plate. Cables are manufactured from multiple 316L stainless
Cerclage wire for use in horses is usually confined to steel wires that are braided. Cables available from DePuy
the heavier‐gauge material. Wires range in size from 0.8 Synthes have a much higher static and fatigue loading
to 1.2 mm. Various tensioning pliers and devices are resistance compared to cerclage wire. The static strength
available to apply, tighten, and assist in twisting wires. of the 1.0 mm stainless steel cable is 1200N, and that of
The large Fastight™ developed by DePuy Synthes is 1.7 mm diameter cable 2770N, both of which compare
particularly useful for equine application because of its favorably to standard cerclage wire with a breaking
robust construction and ability to tension wires prior to strength of approximately 250N. Additionally cables
commencing the twist (Figure 8.18). have much higher fatigue strengths and only about 10%
www.ajlobby.com
of the elongation characteristics of cerclage wire.5 External Fixateur

Tightening of the cable construct is performed with a
special tensioning device, and tension is maintained The external fixateur consists of Steinmann pins or Schanz
through the application of a crimp clamp. Presently, cables screws (Steinmann pins with one end threaded), inserted
have been infrequently applied in equine orthopedic proximally and distally to the fracture, and connected to
surgery, but the favorable mechanical characteristics external rods, which may be applied in various configura-
suggest they are well suited for many applications. tions. This fixator has not been successfully applied to
long bone fractures in the horse. However, a modification
of an external fixateur, the pinless external fixator, has
Intramedullary Implants been successfully applied to mandible fractures.
Pins Pinless External Fixator

Steinmann Pins The pinless external fixator is available for selected frac-
Steinmann pins are not frequently used in fracture treat- tures in large animals.2 This device consists of three sizes
ment in the horse, mainly due to the lack of stability pro- and configurations of titanium clamps, which are applied
vided. Large‐diameter Steinmann pins have been used in over a bone without completely penetrating the cortex.
the past as transfixation pins in conjunction with a walking The clamps are fastened through a connecting rod and
bar, transfixation cast, or other external coaptation. Use of clamps to an external fixator tube or carbon fiber rod.
smooth Steinmann pins for transfixation casts has now This device is not rigid enough to support weight bearing
largely been replaced by positive‐profile threaded pins of a large animal with a fractured limb, but is effective in
(IMEX Veterinary, Longview, TX, USA).14 One of the stabilizing mandible fractures in cattle and horses, and
few intramedullary applications of Steinmann pins is in fractures of the tail in the horse.12 In vivo studies show that
humerus fractures in the foal. Multiple pins of 4.5 or 5 mm the clamping force is maintained over several weeks, while
diameter are introduced parallel to each other from the inducing only minor bony changes where the clamps
proximal end of the bone, filling the entire medullary contact the bone. Animals tolerate the device well. The
cross‐section at its isthmus at the distal third of the bone. advantage of this type of external fixator for mandibular
Other applications for smaller pins include olecranon frac- fractures is the minimal damage to bone and tooth roots.
tures and slipped femoral capital physeal fractures in foals.
Rush Pins External Skeletal Fixation Device

The Rush pin method of fracture treatment was popular An external skeletal fixation device has been developed
before bone plating was introduced. Usually, two curved for horses with severely comminuted proximal phalan-
pins were introduced, one from each side of the bone. geal fractures and suspensory apparatus breakdown
If the technique was performed correctly, good rota- injuries.18 This fixation device transfers weight directly
tional stability was achieved, with a minimum of implants from the foot, which is solidly fixed to a foot plate, to the
and surgical trauma. proximal portion of the third metacarpus or metatarsus,
bypassing the fracture region. Two 6 mm diameter pins
Interlocking Intramedullary Nails are introduced proximal to the fracture. The pinholes are
The use of interlocking intramedullary nails started with prepared by the progressive use of continuously increas-
the Huckstep nail four decades ago. Several horses were ing drill diameters up to 5.5 mm. Large‐diameter, tapered
treated with varied success, but the Huckstep nail did sleeves are applied over the transfixation pins (biaxially
not become widely applied in equine fracture repair. loaded in tension and shear) and are incorporated in a
A similar system was developed at Texas A&M University strong but lightweight frame. The pins, once introduced
and has shown good clinical results on a relatively small into the bone, are connected using acrylic to vertical bars
population of horses.14 General application of this device attached to a specially designed shoe, which is applied to
is described in Chapter 9, and application in fractures of the foot by means of routine hoof nails. The new design
the humerus and femur in the respective chapters. minimizes transcortical pin bending under weight
bearing, while also enhancing overall fixation stiffness.
These features minimize complications at the bone–pin
External Fixation interface. In vitro tests, applying cyclic loading, show
that significant increases in stiffness, reduced bending,
External fixation using pins and clamps is a common and increases in load to failure of bone could be achieved
procedure in human and small animal surgery, but it is with the new sleeved‐pin design. Since bone failure
not popular in the horse. occurs at a finite strain level, it appeared that the larger
www.ajlobby.com
loads to failure were indicative of lower strains in the cortical pin by means of nuts applied to the threaded
bone at the working stress level. portion on either side of the bone. The tapered sleeves are
A new type of transfixation pinning is presently being subsequently incorporated into a fiberglass cast. The con-
adapted from the external skeletal fixation device just struction has been mechanically tested on cadaveric limbs
described, using the same tapered sleeve mounted on the of horses with multifragment fractures of the proximal
transcortical pin. The sleeves are solidly fixed to the trans- phalanx with good results, and awaits clinical application.16
References
1 Auer, J.A. (1988). Application of the dynamic condylar condylar bone fragment compression and screw pushout
screw (DCS)–dynamic hip screw (DHS) implant system strength between headless tapered variable pitch and AO
in the horse. Vet. Comp. Orthop. Traumatol. 1: 18–25. cortical bone screws. Vet. Surg. 31: 201–210.
2 Auer, J.A. (2018). Principles of fracture treatment. 11 Hunt, D.A., Snyder, J.R., Morgan, J.P., and Pascoe, J.R.
In: Equine Surgery, 5e (Ed J.A. Auer, J.A. Stick, J, (1990). Femoral capital physeal fractures in 25 foals.
Kümmerle, J., T. Prange), 1277–1314. St. Louis, MO. Vet. Surg. 19: 41–49.
Saunders Elsevier. 12 Lischer, C.J., Fluri, E., Kaser‐Hotz, B. et al. (1997).
3 Baumgart, F.W., Cordey, J., Morikawa, K. et al. (1993). Pinless external fixation of mandible fractures in cattle.
AO/ASIF self‐tapping screws (STS). Injury 24: Vet. Surg. 26: 14–19.
S1–S17. 13 Martin, B.B., Nunamaker, D.M., Evans, L.H. et al.
4 Bramlage, L.R. (1982). Arthrodesis of the fetlock joint. (1991). Tension band repair of mid body and large
In: Equine Medicine and Surgery, 3e (ed. R.A. base sesamoid fractures in 15 horses. Vet. Surg.
Mansmann and G.S. McAllister), 1064–1066. Santa 20: 9–14.
Barbara: American Veterinary Publications. 14 Nixon, A.J., Auer, J.A., and Watkins, J.P. (2019).
5 Disegi, J.A. and Zardiackas, L.D. (2003). Metallurgical Principles of fracture fixation. In: Equine Fracture
and mechanical evaluation of 316L stainless steel Repair, 2e (ed. A.J. Nixon), 127–155. Ames Iowa:
orthopaedic cable. In: Stainless Steels for Medical and Wiley‐Blackwell.
Surgical Applications, ASTM STP 1438 (ed. G.L. 15 Nunamaker, D.M. (2000). General principles and
Winters and M.J. Nutt). West Conshohocken, PA: biomechanics. In: AO Principles of Equine
American Society of Testing Materials. Osteosynthesis (ed. G.E. Fackelman, J.A. Auer and D.M.
6 Florin, M., Arzdorf, M., Linke, B. et al. (2005). Nunamaker), 11–24. Thieme.
Assessment of stiffness and strength of four different 16 Nunamaker, D.M. and Nash, R.A. (2008). A tapered‐
implants available for equine fracture treatment: a sleeve transcortical pin external skeletal fixation
study on a 20 degree oblique long bone fracture model device for use in horses: development, application,
using a bone substitute. Vet. Surg. 34: 231–238. and experience. Vet. Surg. 37: 725–732.
7 Frigg, R. (2001). Locking compression plate (LCP): an 17 Richards, R.G. (2007). Implants and materials in
osteosynthesis plate based on the Dynamic fracture fixation. In: AO Principles of Fracture
Compression Plate and the Point Contact Fixator Management; Vol 1 – Principles, 2e (ed. T.P. Ruedi, R.E.
(PC‐Fix). Injury 32: SB 63–SB 66. Buckley and C.G. Moran), 33–47. Thieme.
8 Frigg, R., Appenzeller, A., Christensen, R. et al. (2001). 18 Richardson, D.W., Nunamaker, D.M., and Sigafoos,
The development of the distal femur Less Invasive R.D. (1987). Use of an external skeletal fixation device
Stabilization System (LISS). Injury 32: SC24–SC31. and bone graft for arthrodesis of the
9 Galuppo, L.D., Stover, S.M., Jensen, D.G. et al. (2001). metacarpophalangeal joint in horses. J. Am. Vet. Med.
A biomechanical comparison of headless tapered Assoc. 191: 316–321.
variable pitch and AO cortical bone screws for fixation 19 Schnewlin M. Anwendung der AO/ASIF selftap
of simulated lateral condylar fractures in equine third schrauben im MTIII des Pferdes: eine studie an
metacarpal bones. Vet. Surg. 30: 332–340. kadaverknochen (A study of AO/ASIF self-tapping
10 Galuppo, L.D., Stover, S.M., and Jensen, D.G. (2002). screws in MTIII of horses: A study in cadaver limbs).
A biomechanical comparison of equine third metacarpal Doctoral dissertation, University of Zurich. 1998.
www.ajlobby.com
127
9
Principles of Fracture Fixation
Alan J. Nixon1,2, Joerg A. Auer 3, and Jeffrey P. Watkins4
1
2
3
4
Department of Large Animal Clinical Sciences, College of Veterinary Medicine & Biomedical Sciences, Texas A&M
University, College Station, TX, USA
Introduction Management of Soft Tissue Injury

Fracture management in horses follows many of the same Many fractures in horses involve considerable impact
basic techniques used for fracture repair in humans and energy, which is transformed to both comminuted
small animals. Techniques and equipment used in osseous fragmentation and extensive soft tissue injury.
humans, particularly those developed by the Association The additive effect of motion on an unstable limb can
for Osteosynthesis (AO; DePuy Synthes, West Chester, compound the soft tissue trauma of the initial fracture,
PA, USA), are used in equine fracture reconstructions, reducing the prognosis for repair and increasing the cost.
sometimes with modification and sometimes with- The possibility of disruption to the skin by the fracture
out.16,42 Specific recent improvements are described in ends depends on the energy of the fracture, the ana-
this chapter, including the 5.5 mm cortical screw, the tomic location of the break, particularly the amount of
limited‐contact dynamic compression plate (LC‐DCP), surrounding musculature, and the care of the limb in the
the locking compression plate (LCP), the dynamic con- postfracture phase. The classification of open fractures is
dylar screw (DCS) plate and dynamic hip screw (DHS) described in Chapter 4. Injury can involve small skin
plate, the equine intramedullary interlocking nail (IIN), wounds and increase to extensive skin wounds, muscle
and the equine external fixator. These implants and loss, and finally damage to the vasculature and peripheral
devices expand on prototypes developed to fill a need for nerves. Casting and splinting techniques are designed
immediate weight bearing of large animals, using implants to prevent exacerbation of soft tissue injury following a
able to withstand extraordinary stress, and yet capable of fracture and are described in Chapters 5 and 6.
being applied expeditiously. Given the new implants
entering use in equine fracture repair, the principles of
fracture compression and rigid stabilization remain.
Closed Fractures
Further, the care of adjacent soft tissues is critically Intact skin generally prevents skin‐borne organisms
important in the optimization of fracture healing. The from invading the fracture site. However, intact skin
increased application of the LCP has done more to pre- that has been extensively bruised or stretched or covers
serve the soft tissues than most previous plating systems, extremely swollen structures becomes pervious to bacte-
and minimally invasive approaches to plate insertion are rial invasion. Vascular compromise can often result from
possible due to the reduced need for precise plate con- the stretching of vessels, such as with fetlock breakdown
touring and bone to plate surface contact. Detailed infor- injuries, in which compromise of the digit is rapid unless
mation on LCP application is provided in Chapter 10. hyperextension of the fetlock is corrected.

www.ajlobby.com
to assist in fracture reduction are important factors in

minimizing the soft tissue damage.
Plate luting for improved plate–bone contact is a spe-
cial compromise between more secure fixation and dis-
turbed vascular supply. Use of bone cement as an
interpositional material to improve plate–bone congruity
has been shown to reduce screw loosening and implant
failure by increasing the number of cycles to failure for
plate application in horses.47 Several studies in small
ruminants demonstrate that cortical density is main-
tained beneath luted plates, although several other studies
showed reduced vascularity and increased bone loss
beneath the plates.47,53,56 Regardless, carefully applied bone
cement enhances frictional contact between implants and
Figure 9.1 High‐energy fracture of the radius in a weanling bone, and, provided that the bone cement is not allowed
showing massive muscle bruising and stripping of the periosteal
sleeve for 10 cm.
to penetrate the fracture line, improves the chance of bone
union before implant failure. More detailed information
on plate luting is available later in this chapter.
The repair principles for closed fractures include: Intraoperative care of exposed muscle, fascia, and
neurovascular structures should include careful padded
1) Immediate preoperative stabilization to reduce
retraction of tissues, use of soft Penrose drains to
swelling, to support the fracture, to prevent bone ends
retract vessels and nerves, and frequent moistening
penetrating the skin or entrapping nerves and lacerat-
of tissues with saline or lactated Ringer’s solution.
ing vessels, and to alleviate stretching of vessels that
Addition of antibiotics to the saline or lactated Ringer’s
may promote vascular spasm or thrombosis.
solution is also recommended. Air‐borne organisms
2) Carefully planned surgical approaches to minimize
settle on exposed tissues in most surgical suites, despite
the additional soft tissue damage. This becomes vital in
precautions, and local lavage reduces bacterial num-
high‐energy fractures in which muscles are frequently
bers. Neomycin (4 mg ml−1) and potassium penicillin
macerated and the periosteum is stripped from the
(5 × 103 IU ml−1) are commonly added to the lavage.
bone (Figure 9.1).
Application through a spray bottle efficiently wets the
3) Stabilization techniques that minimally interrupt the
surfaces and minimizes solution waste.
soft tissue attachments and blood supply to the bones.
In many complex and comminuted fractures, such as
Open Fractures
unstable fractures of the proximal phalanx, avoiding
surgical dissection and internal fixation by the use of High‐energy fractures frequently result in comminuted
external fixators has been recommended. In other configurations that have an increased tendency to pene-
circumstances, comminuted long bone fractures such as trate the skin. Limited muscle coverage of the third met-
those of the third metacarpus in foals may be better man- acarpus and metatarsus, and the medial aspects of the
aged by casts with transfixation pins. For fractures of the tibia and radius, makes fractures of these bones more
femur, tibia, and humerus, interlocking nails have been prone to become open. Open fractures are classified into
developed that can be inserted without extensive expo- three types, as described in Chapter 4.
sure of the entire bone. Similarly, LCP application requires Repair of all open fractures commences with appropri-
less plate–bone contact, and thereby less plate contouring ate first aid and initiation of broad‐spectrum antimicro-
and soft tissue removal for an exact plate–bone fit. Where bial therapy. The skin wound is cleaned of hair and debris
plating or screw insertion is required, the preservation of and packed with antimicrobial gels. Small skin punctures
soft tissue attachments is critical in the maintenance of may represent external wounds rather than penetrations
blood supply. Muscle attachments should be minimally from the fracture ends. Gentle probing after the initial
disturbed, and plates should be applied to the surface of cleansing may define a shallow subcutaneous wound
the bone after the periosteum has been dissected laterally rather than a path to the fracture. It should be assumed
only enough to allow full plate contact. Complete strip- that deep wounds are made by fracture ends until proven
ping of the periosteum should be avoided. Reduction of otherwise at surgery.
equine fractures can often be difficult and some associ- Most equine open fractures are type 1 (skin laceration
ated trauma to adjacent structures is inevitable. The <1 cm) or type II (large skin laceration but little actual tis-
surgeon’s experience and the methods or devices used sue loss). If repair is being considered, most horses will
www.ajlobby.com
already have been commenced on a course of penicillin for exact plate–bone contact and makes luting obsolete.
or a cephalosporin, and gentamicin or amikacin. For standard luting, the plates are loosened sequentially
Supplementation with metronidazole for increased and polymethylmethacrylate (PMMA) applied beneath
anaerobe coverage may also be warranted. Following each prior to retightening. Some benefit is derived if only
induction of anesthesia, all hair is clipped for a wide mar- the heads of the screws are luted in the dynamic compres-
gin, the wound edges and proposed incision site are sion plate (DCP) slots.71 Adding antibiotics to the PMMA
shaved, and the skin is sterilely scrubbed. After the initial used for plate luting in the repair of open fractures is
skin preparation, the skin opening and deeper wounds always indicated. All excess methacrylate is removed
are draped and further explored using a separate set of before it polymerizes, and all fracture gaps must be care-
instruments. All debris is removed by tissue debridement fully cleaned of residual bone cement.
and rigorous pulsatile lavage of lactated Ringer’s solution Drain placement is indicated in many open fractures
containing antimicrobials. Completely detached small following plate repair. Hematoma and seroma formation
fragments of bone can be discarded. When the wound is are very dangerous developments in open fractures.
clean, it is packed with sterile gel or an antimicrobial gel, Heparinized, fenestrated drains are placed in any dead
and the skin is partly apposed with several sutures. spaces remaining at the time of soft tissue closure. Drains
The horse and limb are then positioned for the are exteriorized remote to the skin incision and must be
approach to the bone for fracture stabilization. The opti- firmly attached to suction devices. If a cast is to be applied
mal approach avoids the previous skin laceration, but following plating of a fracture, a drain is rarely indicated
depends more on the fracture configuration and the or productive, and often necessitates an early cast change.
tension band surface of the bone. The skin is aseptically Antibiotics are continued in the postoperative period for
prepared once again and then draped. New sterile instru- several weeks. Regional limb perfusion of antibiotics for
ments are used and the surgical team should rescrub and the initial five to seven days after surgery provides higher
apply new gowns and gloves. Preservation of the vascu- tissue levels of antibiotics compared to simple intravenous
lar supply to the fractured ends of open fractures is criti- injection, and is always indicated for open fractures distal
cal. Fracture fixation by rigid internal fixation is still to the elbow or stifle. Topical cleansing of residual open
preferred in most open fractures; however, extensive wounds is done daily if a cast has not been applied, and if a
skin loss or devitalization results in a tenuous vascular suction device is used, culture of the drainage to monitor
supply to the fracture, which increases the need for lim- the condition of the interior of the wound is helpful.
ited surgical interference and possibly the application of Additionally, culture of clots from the interior of the drain,
an external fixator, transfixation cast, LCP, or IIN. following its removal, allows confirmation of the suitability
During open fracture plating, any devitalized soft tissue of antibiotics. Radiographs are of little value in the detec-
remaining is gently debrided back to bleeding tissue, tion of osteomyelitis until three weeks postoperatively. The
and the bone and soft tissues are thoroughly lavaged with status of the limb swelling, drainage, and level of pain are
solutions containing antimicrobials. Tissue samples or better indicators of progress.
culture swabs are taken for identification of organisms
and testing of antibiotic sensitivity. Reconstruction of the
fracture must be fastidious to maximize cortical conti- Application of Screws (Auer)
nuity and the chance of a persisting stabilization. Lag
screw insertion is used to reconstruct comminuted frac- Cortex screws may be applied as lag screws, as position
tures as two‐piece units. The sites for plate application screws, or as plate screws.
must be selected early and all lag screws inserted to avoid
complicating the plate contact. A plate should always be
positioned over any residual cortical gaps, so that the
Lag Screw Technique
opposite side of the bone is left with full cortical contact. The lag screw technique is the most frequent application
Large butterfly fragments should be secured with lag of cortical bone screws in fracture repair.42 It uses cortex
screws and one of the plates should be applied over the screws applied in a lag screw manner rather than using
fragment. Cancellous bone graft is always indicated in actual lag screws. The near cortex is overdrilled through
plate repair of open fractures. Harvested graft material is the large end of the double drill guide, with a drill bit the
placed in the medullary cavity after debriding the fracture same size as the outside thread diameter of the screw
hematoma and foreign debris. Cortical defects are filled (Figure 9.2A). During subsequent screw insertion the
with bone graft, and plates are applied over them. After threads do not engage the bone surrounding the hole, but
plating is completed, bone cement luting of each plate, glide through, giving rise to the name glide hole for this
other than LCPs, is indicated for added stability. The portion. The smaller portion of the double drill guide is
locked screw head design in the LCP obviates the need inserted into the glide hole to facilitate concentric drilling
www.ajlobby.com
(A) (B)
(C) (D)
(E) (F)
Figure 9.2 Lag screw technique demonstrated on a lateral condylar fracture of the third metacarpal bone. The distal screw is already
inserted. (A) the glide hole is drilled with the large drill bit and the double drill guide; (B) the insert portion of the double drill guide is
inserted into the glide hole and the concentric thread hole cut with the small drill bit; (C) the countersink depression is prepared on the
surface of the near cortex; (D) the length of the screw needed is determined with the depth gauge; (E) the threads are cut in the far cortex
with the tap through the double drill guide; and (F) a screw of the predetermined length is inserted and tightened with the hexagonal‐
tipped screwdriver.
www.ajlobby.com
of the thread hole, the dimension of which matches the Lag Screw Application
core diameter of the screw. This hole is drilled across the
far cortex (Figure 9.2B). The drill bit and drill guide are From a functional point of view, a lag screw contains a
subsequently removed. In most cases, a countersink portion without threads. Therefore, it is a partially
depression is created to facilitate optimal seating of the threaded screw. Most lag screws are cancellous screws,
screw head and provide an enlarged contact area between but a partially threaded cortex screw, referred to as a
the head and the bone (Figure 9.2C). This results in shaft screw, has been available in the past. To use lag
decreased force per square millimeter of contact area. screws, a hole of only one size, the thread hole, is drilled
The cortex should be prepared carefully, especially if it is across the entire bone. In soft bone, the cancellous screw
thin. Excessive countersinking can result in the screw is then simply inserted, cutting its own threads as it pen-
head actually pulling completely through the cortex. The etrates. In more dense bone, particularly adult cortical
countersink should be used in a 360° motion. The depth bone, threads are cut along the total length of the hole
gauge is subsequently used to determine the entire length with the cancellous tap and the lag screw is inserted. The
of the screw needed (Figure 9.2D). The depth gauge has a threads in the near cortex are not filled by the partially
small hook at the distal end, which can be engaged on the threaded screw, because the screw threads are located
outer surface of the far cortex. The tapered barrel of the toward the screw tip and engage the far cortex or on the
depth gauge is snugged gently down onto the near cortex far side of the fracture plane, allowing solid interfrag-
and the shaft of the depth gauge tightened to allow direct mentary compression (Figure 9.3A). If the threads are
reading of the exact screw length needed. In equine bone, partially located in the near cortex as well as in the far
the measured length is generally used, or occasionally cortex, no compression can be achieved (Figure 9.3B).
2 mm is subtracted to avoid irritation of soft tissues by the Only the partially threaded 4.5, 7.0, and 7.3 mm cannu-
exiting screw tip. Where maximum screw purchase is lated screws and the partially threaded 4.0 and 6.5 mm
necessary and the soft tissues are limited and not tightly cancellous screws can be used as lag screws. All other
adherent to the far cortex, 2 mm can be added to the screws have to be applied using lag technique if
measured length to ensure that the tapered tip of the compression is to be achieved.
screw is outside the bone, resulting in good contact of the
entire threads and the cortex. Using the tap sleeve to pro-
(A)
tect the soft tissues and help guide the tip into the screw
hole, the tap is inserted into the glide hole and the threads
are cut in the thread hole (Figure 9.2E). The tap is con-
tinuously advanced until resistance increases, indicating
that the tap has encountered dense cortical bone, in
which case the tap is advanced two to three half turns fol-
lowed by one half turn in the opposite direction. This
action clears the threads of bone debris, which will subse-
quently accumulate in the three flutes cut into the tap.
Through this action, clean cutting of the threads is
assured. Once the hole has been tapped, the tap is with-
drawn, the hole flushed, and the screw of predetermined (B)
length inserted. The hexagonal‐tipped screwdriver is
inserted into the screw head and the screw tightened
(Figure 9.2F). Solid force should be used; however, over-
tightening should be avoided, because it may break off the
screw head, especially with 3.5 and 4.0 mm screws and
occasionally with the 4.5 mm screw. The 5.5 mm screw is
very difficult to break, and stripping of the hex socket in
the screw head is more likely.
The lag technique is identical for all sizes of screw;
only the sizes of the drill bits and instruments vary. In
equine surgery, when many screws are inserted, it is Figure 9.3 Lag screw application using a partially threaded
advisable to use power equipment for tapping and insert- cancellous lag screw. (A) A cancellous screw of correct thread
ing screws. This technique can be performed with the air length is inserted into the tapped thread hole. Note that all the
threads are located beyond the fracture plane, allowing the
drill and some battery‐powered drills equipped with a fracture line to be compressed. (B) Selection of a cancellous screw
reverse trigger. Power tapping should be practiced exten- with too long a thread length; threads are located on both sides of
sively prior to applying it during surgery. the fracture plane, preventing interfragmentary compression.
www.ajlobby.com
Position Screw Technique hexagonal‐tipped screwdriver. A special set has been

assembled for the cannulated screws containing various
Position screw technique is applied to cortex screws if a sizes of screws and the instruments needed for their
fragment has to be maintained at a certain distance, insertion (described in Chapter 8). Mechanical charac-
especially where compression would pull the fragment teristics of the 7.3 mm cannulated screw are similar to
into the medullary cavity. Therefore lag technique is the 6.5 mm cancellous screw,25 although the cannulated
avoided. With position screw technique, only a thread screws are known to be weaker in shear.
hole is drilled. The entire hole is tapped, and because the
threads engage the near cortex as well as the far cortex,
no interfragmentary compression is achieved when the Locking-Head Screws
screw is tightened. It should be noted that in position
Locking screws are only applied through LCPs. The
screw technique no countersinking can be performed,
technique is described later in this chapter and their
except for the 3.5 mm screw, because the centering tip of
application is covered in Chapter 10.
the countersink is too wide to fit into the thread hole.
An alternate technique would involve the use of a
washer under the screw head to distribute the forces Screw Sizes
applied to the bone. Position screw technique may be
desirable in certain situations, for example if a small The various sizes of screws employed in equine surgery,
fragment is kept in place and subsequently protected by with all the pertinent data, such as screw type, screw
a neutralization plate. diameter, gliding hole diameter, thread hole diameter,
relevant tap diameter, and the screw shape, are summa-
rized in Table 8.1 in Chapter 8. Generally, the outside
Plate Screw Technique thread diameter of the various types of screws is respon-
sible for the name of the screw. For example, the 5.5 mm
Insertion of a plate screw in most instances requires the cortex screw has an outside thread diameter of 5.5 mm.
same technique as that described for the position screw. Screws are classified as large, small, and mini. Large
The plate screw, as the name suggests, is used only screws include the 4.5 and 5.5 mm cortex screws, the
through plates and a thread hole is drilled across the 4.5, 7.0, and 7.3 mm cannulated screws, the 6.5 mm
entire bone. Since the hole or slot in the plate is larger cancellous screw, and the 4.0 and 5.0 mm locking-head
than the thread diameter, the threads do not catch in the screws. The small screws include the 4.0 cancellous
plate, and by tightening the screw the plate is pressed screw, the 3.5 mm cortex screw, and the 3.5 mm locking-
onto the bone. This is true for all plates except the LCPs head screw. The smaller screws available for small
(see Section 9.7). animals and humans are not described here. For
information on these and other implants, the reader is
referred to the Association for Osteosynthesis (AO)
Cannulated Screw Technique manuals and DePuy Synthes catalogs.42
The 5.5 mm cortex screw has been shown in equine
Cannulated screws are inserted over a guide pin. The
adult bone to have greater strength than the 4.5 mm
fracture is reduced and the location for screw insertion
cortex screw.77 In foal bone it is comparable to the
selected. A guide wire may be placed adjacent to the
6.5 mm cancellous screw.78 Therefore the 5.5 mm
desired location and its position and angle evaluated
screw has become very popular in equine fracture
with the help of an image intensifier or intraoperative
repair. It is mainly used in critical locations where
radiographs. Once the guide wire is correctly placed, a
potential increased strain and movement may occur
2 mm hole is drilled parallel to the guide wire in the cor-
during healing.
rect location. The hole is advanced to the desired depth.
Subsequently, the 2 mm drill bit is exchanged for a guide
pin. The direct measuring device is placed over the guide
pin. A cannulated screw approximately 5 mm shorter
Screw Removal
than the measured length is selected. Care is taken to Cortex screws, locking-head screws, and fully threaded
also select the correct thread length, to ensure lag effect cancellous screws are easily removed because they are
during tightening. The cannulated drill bit is placed over fully threaded. However, after a fracture has healed, a par-
the guide pin and the hole prepared to the desired depth, tially threaded screw may be impossible to remove from
which is verified using an image intensifier or intraop- the hard equine bone. During fracture healing, the precut
erative radiographs. The thread hole is subsequently threads in the near cortex fill with solid bone, which sur-
tapped over the guide pin using the cannulated tap. The rounds the shaft of the screw. Removal of the screw would
selected screw is then inserted with the cannulated require that the threads cut their own way backing out
www.ajlobby.com
through the bone, for which most screw threads are not placed in lag fashion, the plate is contoured and subse-
designed. This can result in screw breakage, usually at the quently attached to the bone by means of screws. The
head–shaft junction. Therefore, the surgeon has to be very first screw hole is drilled in a neutral position (green
careful in using cancellous screws in hard equine bone, DCP drill guide or the universal drill guide) through one
especially in cases where implant removal might be neces- of the plate holes toward the end of the plate. The screw
sary at a later stage. For the cannulated screws this prob- is inserted, but not completely tightened. This allows dis-
lem has been corrected by manufacturing a self‐cutting placement of the plate to a loaded position, if so desired.
device in the proximal‐most threads, which allows The same effect can be achieved by drilling the initial
removal of the screws. However, it is questionable whether hole with the use of the load (yellow) DCP guide and
these devices will be sufficient to cut threads in the hard maintaining the plate in the same position. When addi-
equine bone. To date, no experimental evaluation of these tional axial compression is needed, the hole for the
screws has been performed in the horse. second screw is drilled on the other side of the fracture
line, again toward the end of the plate, using the load
drill guide (Figure 9.4). Care is taken to ensure correct
Cerclage Wire Application plate position prior to drilling of the second hole. By ini-
tially applying a screw toward each end of the plate,
Cerclage wires are used frequently for fracture stabiliza- the surgeon can be sure that the entire plate is correctly
tion in humans and small animals, where they are applied positioned along the bone surface, especially when long
around oblique long bone fractures. This type of fixation plates are used. If the initial screws are inserted near the
has not been popular in the horse because of its lack of center of the plate, only a minor abaxial malalignment of
stability and the ease of breakdown of fixation under the the plate may result in the plate ends being displaced off
extreme loads placed on the equine limb. However, cer- the bone and into the soft tissues. The drilled hole is then
clage wires are still applied in a few situations. Several measured for screw length and tapped for the screw,
studies describe cerclage wire application for repair of which is subsequently inserted. Fracture line compres-
proximal sesamoid fractures.32 Perhaps the most frequent sion is achieved through alternately tightening the two
application of cerclage wire is physeal growth retardation screws. One additional screw may be applied in load
surgery. Additionally, there have been reports on the use position on either side of the fracture line. Should an
of cerclage wires in the treatment of apophyseal and additional screw be placed under load, the screw initially
nondisplaced ulnar fractures in foals.33,40,52 A distinct inserted on that half of the bone has to be slightly loos-
advantage to the use of wires is the elimination of the pos- ened to allow motion of the plate relative to the bone as
sibility of a plate repair bridging the ulna and radius with the additional axial compression is applied. The remain-
screws. Cerclage wire is also used in arthrodesis of the ing screws are then inserted in neutral position through-
metacarpophalangeal joint following breakdown inju- out the plate. Any screw placed through the plate
ries due to comminuted fractures of the proximal sesa- across a fracture line is introduced using lag technique, if
moid bones.5 In such a case a cerclage wire tension band possible. Obviously, for this technique the double drill
is inserted through the palmar/plantar aspect of the met- guide or the universal drill guide has to be used and not
acarpophalangeal joint, in addition to the application of the DCP drill guide.
the dorsal plate. Cerclage wires also occasionally still have The screws in a DCP can be applied in neutral, in
a use in temporary stabilization of fracture fragments load, or in buttress position. Under loading conditions,
while plates and other implants are applied to the bone. the arrow on the yellow drill guide must point toward
the fracture line. This results in 1 mm of compression.
If the arrow points away from the fracture line, the
screw is placed in buttress position and does not pro-
Dynamic Compression Plates vide fracture axial compression. During double plating,
only two screws are placed in load position in the sec-
The pertinent specification data on the most frequently ond plate, which is usually arranged at 90° relative to
used plates in equine fracture repair is collated in Table the first. Plates have to be contoured to fit the surface of
8.2 in Chapter 8. the bone. For large plates, the bending press is preferred
over bending irons. If the plate is perfectly contoured to
the bone surface, only the near cortex will be under
Dynamic Compression Plating compression, whereas the far cortex will be spread
apart. Therefore, the plate is minimally overbent at the
Plate Application fracture site, which provides a slight space under the
After a fracture is reduced and stabilized by reduction plate near the fracture line and places the far cortex
forceps or independent 3.5 or 4.5 mm cortex screws under compression as well.
www.ajlobby.com
Plate Luting following implant removal.56 These complications have

Stability of the fixation is derived from friction between not been evident in the horse.
the plate and the bone. There is a direct proportional
relationship between the amount of plate contact and the Screw Positioning and Direction
stability of the fixation. A technique developed to obtain Whenever possible, plate screws should be inserted
100% plate–bone contact, through interfacing bone perpendicular to the plate or the long axis of the bone.
cement between the plate and the bone, has been termed This is of particular importance if two plates are
plate luting.45,47 This is done after all screws in the plate applied at 90° angles relative to each other.2,3,6 Applying
are inserted. The screws of one plate are subsequently the screws in this way reduces the possibility that
loosened, the plate is lifted off the bone, and PMMA in a screws from each plate will connect or touch within the
doughy consistency placed between the bone and the bone. Every hole in the plate should be filled with a
plate. All the screws are immediately retightened using screw. Should a hole be located over a fracture line
power equipment. Penetration of bone cement into the after all other screws have been tightened, lag tech-
fracture line must be prevented, because it prevents bony nique is applied and the screw directed in such a way
union in that region. Once the screws are tightened, the that it engages the opposite cortex next to the fracture
excess soft cement is removed. The procedure is repeated line. Application of 4.5 mm screws through the 4.5 mm
with the second plate. To assure effective local tissue plate allows 20° of angulation in either longitudinal
concentrations of antibiotics, the selected drug may be direction and 7° in the lateral direction. If 5.5 mm
incorporated into the PMMA (see Chapter 48). The screws are used through a 4.5 mm DCP hole, angulation
hardening process of the PMMA is an exothermic reac- of only 10° in each longitudinal direction is possible and
tion, requiring cooling of the bone and metal with sterile 3–4° to either side.
saline solution. The soft cement also enters the oval hole
of the DCP or LC‐DCP and provides additional support Plate and Double Plate Positioning
to the screw head, making the fixation extremely rigid. Ideally, plates applied for fixation of a long bone fracture
Plate luting increases the area of plate–bone contact and should extend over the entire length of the bone. Shorter
the congruency of plate fit to the bone.62 A study on plates must be staggered to ensure plate coverage over
unstable equine limb specimens revealed that plate the total length of the bone.6 The distal‐most end of the
luting results in increased stress protection for repaired proximal fragment in an oblique bone fracture should be
third metacarpal and metatarsal bones.69 A subsequent wedged between a plate and the opposing distal frag-
study in which only the plate holes were filled with ment. Therefore, the configuration of a fracture may also
PMMA demonstrated a similar increase in stress protec- dictate the location of the plate to be applied, not just the
tion.71 It is therefore most likely that the main effect of tension side of the bone.2 Additionally, implants should
plate luting is achieved through addition of stability to be applied to avoid severely bruised skin or discrete
the screw heads by filling the plate hole around them. skin defects, and, whenever possible, plates should not
The concept of plate luting is not applicable in humans be applied to areas where the bone is covered only by
and small animals because of the danger of bone avascular- skin. Plate application is easier in such regions, but the
ity under the plate, possibly inducing a pathologic fracture risk of developing a surgical site infection is much higher.
Figure 9.4 Repair of a simple oblique third metacarpal fracture with two cortex screws applied in lag technique and a broad limited‐
contact dynamic compression plate (LC‐DCP). (A) The fracture is reduced and temporarily maintained in reduction with the large pointed
reduction forceps. Two 3.5 mm cortex screws are then applied across the fracture plane using lag technique. After drilling the 3.5 mm glide
hole across the fracture line, the 2.5 mm insert portion of the double drill guide is inserted into the glide hole and the 2.5 mm thread hole
drilled through the opposite cortex. (B) The remaining steps of the lag technique are completed and the two 3.5 mm screws inserted. It is
important to preplan the screw location to avoid later interference with the plate. The large pointed reduction forceps can now be
removed. (C) The 12‐hole broad LC‐DCP is contoured to the shape of the bone surface, and applied and maintained temporarily with two
large pointed reduction forceps. The plate is slightly overbent at the fracture site, sufficient to allow an aluminum template to be inserted
between the plate and the bone, to facilitate compression of the far cortex following screw tightening. (D) The yellow load drill guide is
placed into the second most distal plate hole for drilling of the first thread hole. The arrow on the top of the drill guide should point
toward the fracture line. (E) The hole is tapped and the screw is inserted but not tightened, allowing the screw head to protrude above the
plate. On the opposite end of the plate a second screw hole is prepared using identical technique. The screw is inserted and subsequently
both screws are completely tightened, which places the two fracture fragments under compression. The two large pointed reduction
forceps are now removed. (F) The remaining screw holes with exception of the one crossing the fracture line are prepared using the green
neutral drill guide and the screws inserted and firmly tightened. (G) The last screw is applied using lag screw technique across the fracture
line. (H) After the final screw is inserted and tightened, all other screws are checked for tightness.
www.ajlobby.com
(A) (B)
Stabilized
fracture
Fracture
reduction
forceps
2.5 mm drill bit

3.5 mm cortical
screws placed
in lag position
(C) (D)
Reduction forceps
Broad
4.5 mm
dynamic
compression
plate
Lag screws
Aluminum
template
spacer
Yellow “load”
dynamic
compression
plate
drill guide
www.ajlobby.com
(E) (F)
Second screw
placed
in loaded position
Loaded
screws
Partially
tightened
first screw
Green
“neutral”
dynamic
compression
plate
drill guide
(G) (H)
All screws
tightened
4.5 mm
drill for
insertion of
lag-screw
through
the plate
Figure 9.4 (Continued)
www.ajlobby.com
Neutralization Plating fractures at the ends of long bones. It has also been
applied for carpometacarpal and tarsometatarsal frac-
A neutralization plate is applied after reconstruction of ture/luxation and arthrodesis stabilization.44 Application
a multifragment fracture with cortex screws inserted in requires only DCP instrumentation, without additional
lag fashion. Through this technique, compression is specialized tools. Intraoperative radiographic monitor-
developed between the various fracture fragments. ing is required in most cases, given the proximity to
However, such a configuration is not able to withstand articulations during most applications.
significant axial loading forces. To allow stress continu-
ity, a plate is applied over the entire length of the bone.
This plate is applied without axial compression, neutral-
izing the various diverging shear, bending, and rota- Limited‐contact Dynamic
tional torque forces; it effectively bridges the long axis of Compression Plate
the entire bone. It is important to plan the entire fixa-
tion to prevent interference of the independent lag The basic application of the LC‐DCP as well as the self‐
screws applied in various planes across the bone frag- compressing function is identical to the DCP. Minor
ments with the eventual plate screws. differences include the dynamic compression unit
(DCU) plate hole design, which provides the capability
Buttress Plating of compression from either end of each plate hole and
therefore axial compression of a fracture anywhere
If a cortical defect persists after the fracture has been along the plate. Additionally, there is no center to the
reduced, a weak area is created in that region. It is imper- plate. The recessed underside of the plate also allows
ative that the defect is bridged by a plate to prevent col- increased axial deviation of the cortex screws in the
lapse of the fracture into the defect. In such a case, no bone. This provides up to 40° of angulation along the
compression is applied because compression would axial plane of the plate when using 4.5 mm screws.
result in an altered bone axis and possibly alter the axis Because there is the same amount of plate material at
of associated joints. Therefore, the screws are placed any given location, there are no stress concentrators
through the plate in buttress position, with the screw located at the plate holes, and the plate bends more
head down in the extreme end of the plate hole closest to evenly in the bending press than a DCP.
the fracture and unable to provide compression. Such an A comparison between the broad 4.5 mm DCP and the
application prevents collapse of the bone and maintains broad 4.5 mm LC‐DCP showed that the broad LC‐DCP
the axis while healing occurs. The cortical defect should provided increased stability in static overload testing;
be filled with a cancellous bone graft or a bone substi- however, it was significantly less stable in cyclic fatigue
tute. Any screw placed through the plate in the region of testing.58 A special 5.5 mm LC‐DCP was developed for
the defect should engage the opposite cortex. All the equine fracture repair. An in vitro comparison between
other principles of fixation have to be maintained. the 5.5 and the 4.5 mm LC‐DCP revealed that the 5.5 mm
LC‐DCP fixation was superior to the 4.5 mm LC‐DCP
fixation in resisting the static overload forces of palmaro-
Cobra‐Head Plating dorsal four‐point bending.59 There was no significant
The cobra‐head plate is a modified DCP with an difference between the 5.5 mm LC‐DCP fixation and
expanded end designed to improve fixation of long 4.5 mm LC‐DCP fixation in resisting static overload
bone extremities.27 The plate has improved application forces under torsion. However, the 5.5 mm LC‐DCP pro-
if it is custom ordered with the underside milled for vided significantly less stability (80% of that of the 4.5 mm
screw insertion, rather than standard milling (see LC‐DCP) in cyclic fatigue testing.59 Additionally, the
Chapter 8). The curvature of the reverse‐milled plate 5.5 mm LC‐DCP was not pursued to market due to the
fits the contour of the distal femur and proximal radius development of the LCP. In general, the LC‐DCP pro-
more accurately, reducing the need for extensive plate vides an advantage in screw angulation and bidirectional
contouring. The round holes of the expanded end fracture compression that makes it a versatile plate for
accept 4.5, 5.5, or 6.5 mm screws. After fracture reduc- equine fracture repair.
tion and preliminary screw insertion, additional screws The double‐ended LC‐DCP drill guide provides neutral
are placed in the expanded plate end. Compression can and load configuration, but must be positioned in the
be applied in the DCP holes of the plate shaft, which all DCU slot with the arrow oriented toward the relevant
compress toward the expanded end. The cobra‐head fracture line, to provide appropriate directional com-
plate is designed for metaphyseal fractures and other pression. The handle of the drill guide has an undercut
www.ajlobby.com
surface to alert the surgeon to the LC‐DCP guide rather when two LCPs are applied, because the locking-head
than the DCP drill guide. screws must be inserted perpendicular to the plate. The
fact that the screw position differs if a locking-head
screw or a cortex screw is used through a combi hole
Locking Compression Plate represents an additional difficulty in the planning of the
surgery. This fact is further compounded if a combination
The LCP was developed to incorporate the axial loading of a DCS, with mainly DCP holes, and an LCP is used,
capabilities of the DCP and LC‐DCP, the decreased because the lengths of the DCP hole and the combi hole
plate–bone contact of the LC‐DCP, and the rigidity and are different. Once locking-head screws are applied, the
stiffness of the Less Invasive Stabilization System (LISS), plate is solidly fixed in its position, and cannot be further
where locking-head screws were first used.19,20 The goals compressed to the bone.
were met by designing a “combi hole” where either a The LCP drill guide is carefully twisted into the threaded
standard screw or a locking screw could be inserted. It is part of the combi hole. To facilitate perpendicular inser-
not necessary to only apply locking-head screws. A study tion and solid engagement of the threads in the plate hole,
comparing the application of two LCPs at right angles the drill guide is placed into the combi hole and then
relative to each other, with identical constructs using twisted backward until a click generated when the drill
DCPs, LC‐DCPs, and clamp‐rod internal fixators guide slips from the upper thread onto the one located just
(CRIFs) in four‐point bending, showed that implanting below is heard. Then the drill guide is twisted clockwise to
two locking-head screws on either side of an oblique engage the threads of the combi hole. When solidly seated,
saw cut across an artificial bone composite (Canevasit™, its position relative to the plate is evaluated once again,
Erhard Hippe, Spremberg, Germany) provided signifi- assuring its perpendicular orientation. All the LCP drill
cantly increased stiffness to the construct.17 Substituting guides provided in the set can be fixed to the plate to speed
cortex screws for locking-head screws in several holes in up the procedure, followed by drilling all the holes
the LCP significantly reduces cost without jeopardizing (Figure 9.5C). The drill guides are removed and the screw
the stability and stiffness of the construct. Without appli- lengths are determined using the depth gauge. The 4 N
cation of the push–pull device or standard cortex screws, torque‐limiting device is attached to the power drill, fol-
both of which compress the plate onto the surface of the lowed by insertion of the power attachment for the star
bone, a gap of 2 mm or more will be present between the drive. By pressing the screwdriver into the star drive inden-
plate and the bone after application of the LCP. Therefore tation of the LCP screw in the rack, the screw is selected,
an early basic decision in LCP application hinges on secured by friction, and withdrawn from the rack, and then
whether there is a necessity to apply the LCP close to the advanced into the predrilled hole using the power‐tapping
bone. For most open repairs in horses, the stability of technique. The screw is fully inserted until the torque‐lim-
fixation in the LCP construct is enhanced by additional iting device releases, indicating that the 4 N maximum
bone–plate friction. This supplements the rigidity pro- insertion force has been reached. This precautionary step
vided by the locking-head screws. was initially introduced in human surgery to prevent cold
The LCP is positioned with the plate holder and the welding between the titanium plate and screws. Most
push–pull device inserted at a slight angle through the equine LCP application uses stainless steel implants, which
DCU portion of the combi hole (Figure 9.5A). By turning minimizes the danger of cold welding. Nevertheless, the
the collet in a clockwise direction, the plate can be use of the torque‐limiting device is recommended, at least
pressed onto the bone surface. At the same time, it in soft bone. Adult equine bone is quite hard, and for long
temporarily fixes the plate to the bone and maintains screws the 4 N threshold may be reached prematurely,
fracture alignment. A second push–pull device can also before complete tightening of the screw head threads in
be applied through the stacked combi hole on the other the plate. It is therefore prudent to provide final tightening
end of the plate if desired. The strategic cortex screws are with the hand screwdriver (Figure 9.5D). Once all locking-
then inserted and tightened to facilitate solid bone–plate head screws are implanted, any empty plate hole should be
contact (Figure 9.5B). A second plate can be positioned filled by applying a cortex screw through the DCU portion
and similarly fixed to the bone with several cortex screws. of the combi hole at the angle necessary to avoid contact
After removal of the push–pull device and the plate with a screw in the other plate.
holder, the locations for the locking-head screws are The finely machined threads in the locking screw head
selected to avoid contact with the cortex screws and any and plate form a tightly bonded unit, which prevents the
other interfragmentary screws. The planning of screw screw head from moving within the plate and thereby
insertion is a vital part of LCP application. Planning provides significant stiffness to the construct. Locking-
screw position and angles becomes even more important head screws inserted into the plate feel very solid,
www.ajlobby.com
(A) (B)
(C) (D)
Figure 9.5 Application of a locking compression plate to an oblique third metarcarpal fracture. (A) After reducing and temporarily stabilizing the
fracture with two 3.5 mm cortex screws, the plate is applied to the desired bone surface with the plate holder and temporarily fixed in place with the
push–pull device. By turning the collet on the push–pull device in a clockwise direction (arrow), the plate is pressed onto the bone surface. (B) To
facilitate good plate–bone contact along the entire plate, cortex screws are inserted and tightened using plate screw technique in the self‐
compressing portion of each combi hole at both ends and in the center of the plate. (C) The holes where locking-head screws are to be inserted are
selected and the drill guide twisted into the threaded portion of the combi hole. Because the plate is solidly fixed to the bone, and no further
compression of the fracture or plate to the bone is required, all four drill guides provided in the set are applied, followed by drilling all four holes. (D) The
locking-head screws are inserted with the power drive with the torque‐limiting device interconnected between the drill and the power screwdriver. The
screws are subsequently hand tightened, followed by insertion of the remaining cortex or locking-head screws through the empty plate holes.
www.ajlobby.com
because the threads in the screw head engage the corre- of the DHS plate for proximal femur fixation. It is still
sponding threads in the plate. This does not mean that used on occasion for plating repair of distal femoral
the screw is solidly inserted into the bone beneath the fractures.
plate. This is a new experience for the surgeon and must The most important step in the application of the DCS
always be kept in mind. When inserting locking screws and DHS plate systems is the correct placement of the
through significant soft tissue overlying an LCP, it may 2.5 mm guide pin (Figure 9.6A).1 Drill guides for the dif-
be difficult to twist the drill guide perpendicularly into ferent angles of the DCS and DHS plates ensure exact
the threaded portion of the combi hole. Separate stab placement of the guide pin, which is verified with an
incisions through the overlying muscle bellies may be image intensifier or intraoperative radiography. Once
required to provide access to the combi hole at a right correct placement of the guide pin is confirmed, the sub-
angle. The drill guides can be lengthened by threading sequent steps are carried out swiftly, because all instru-
several guides end to end to facilitate engagement in the ments contain a central canal to accept the guide pin.
plate and subsequent correct drilling of the hole. The triple reamer is placed over the guide pin, to allow
The LCP has quickly established itself as the preferred drilling of the thread hole for the large lag screw, drilling
plate for many equine fracture fixation applications, of the 12.5 mm hole for the plate barrel, and beveling of
despite the additional cost of both plates and screws.10,24,31 the cone shaped plate–barrel interface (Figure 9.6B). The
A recent study comparing 4.5 mm LCPs with 4.5 mm LC‐ threads for the DCS lag screw are prepared using a suit-
DCPs confirmed the superior strength and stiffness of ably sized tap (Figure 9.6C) and the screw of appropriate
the LCP.60 Recently a 5.5 mm LCP designed specifically length is introduced, followed by the plate (Figure 9.6D).
for equine fracture repair has been developed, replacing Once the shaft of the screw and the barrel are aligned,
the 5.5 mm LC‐DCP (see Chapter 8).61 the barrel slides easily over the shaft and the plate posi-
tion can be adjusted before impacting it onto the bone
(Figure 9.6E). The barrel has the same inside configura-
Dynamic Condylar Screw tion as the screw shaft cross‐section (8 mm and flattened
and Dynamic Hip Screw at two opposite sides). This prevents screw rotation
Application within the barrel after the plate is attached to the bone,
making loosening impossible. The DCS plate has a barrel
The DCS plate has established itself as a very useful length of 25 mm, whereas the DHS is supplied in ver-
implant in the treatment of equine long bone fractures,2 sions with a barrel length of 25 and 38 mm.23 After their
more so than the DHS system.1,4 The primary applica- implantation, the lag screw and the plate are joined with
tion of the DCS plate is in metaphyseal fractures, where a connecting screw, uniting the two separate compo-
only a few screws can be secured in the smaller fragment. nents (Figure 9.6F). Tightening of the set screw creates
The DCS plate has replaced the angled blade plate for interfragmentary compression, provided that the lag
application in long bone fractures with a short metaphy- screw threads have passed beyond the fracture line.
seal fracture fragment.18 The DHS plate has been applied Remaining screw holes in the DCS and DHS plates are
in femoral capital physeal fracture repair,23 but alterna- filled by 4.5 or 5.5 mm screws placed under load or in a
tive fixation methods such as cannulated 7.3 mm screws neutral position. The two holes adjacent to the lag screw
or diverging 5.5 mm cortex screws have reduced the use can only be placed in a neutral position.
Figure 9.6 Application of the dynamic condylar screw (DCS) plate to the distal radius. (A) The distal radius fracture is reduced and temporarily
fixed with two 3.5 mm cortical screws, applied in lag fashion across the fracture plane. Subsequently, a 14‐hole limited‐contact dynamic
compression plate is applied to the cranial bone surface (tension side) with two cortical screws providing axial compression. The guide pin (b) is
applied through the special drill guide (a). The measuring device (c) applied over the guide pin allows the determination of the pin length
inserted in the bone in this instance (70 mm). (B) The DCS triple reamer is assembled and set for the drilling depth desired (65 mm), which is
5 mm less than the pin length in the bone and assures maintenance of the pin during DCS screw insertion. The triple reamer is placed over the
guide pin (a) and the shaft hole for the DCS screw (b), the barrel hole for the plate (c), and the barrel–plate junction (d) are prepared. (C) The
DCS centering sleeve (c) is placed over the tap (b), which is subsequently placed over the guide pin (a). After inserting the centering sleeve into
the barrel hole, the tap is advanced to the desired depth (65 mm). (D) The DCS coupling screw (d) is placed through the T‐handle and the DCS
plate (e) of selected length (12‐hole) and connected to the DCS screw (b) of desired length (60 mm). The centering sleeve (c) is applied over the
coupling screw. After placing the assembly over the guide pin (a), the screw is inserted to a depth of 65 mm, which is marked on the centering
sleeve as 5 mm. (E) After tightening the screw and adjusting the horizontal bar of the T‐handle (c) parallel to the long axis of the bone, the DCS
plate (b) is seated over the shaft of the DCS screw with the help of the DCS impactor (a) and a mallet (not shown). Orientation of the
instruments and implants is important, because the DCS screw (left insert) and the plate barrel (right insert) contain complementary parallel
contours, which have to be aligned to allow sliding of the barrel over the screw shaft. (F) The DCS compression screw is inserted through the
plate barrel and tightened into the back end of the DCS screw. This unites the three components (DCS screw, DCS plate, and connecting screw)
to one. Insertion of the remaining cortical screws and final tightening of all screws completes the procedure.
www.ajlobby.com
(A) (B) (C)
d c
c c
b b b
a a
(D) (E) (F)
c
b
b a
a
www.ajlobby.com
Intramedullary Fixation weight bearing, undoubtedly contributes to the success

(Watkins) of IM single‐pin fixation in small animal practice.
Unfortunately, equine fracture fixation can only rarely be
Intramedullary fixation has been used sparingly in large accomplished using closed techniques. Furthermore, a
animal orthopedics. Few reports advocate this method of single IM pin is not likely to provide the stability neces-
fixation for repair of diaphyseal fractures, but success has sary for substantial postoperative weight bearing. The
been reported in femur fractures in foals and calves and severity of complications related to the lack of weight
humeral fractures in foals.6,63,64 Other reports advocate bearing on the fractured limb dictates that the fixation
intramedullary (IM) fixation techniques for repair of provide adequate strength and stability at the fracture
physeal fractures of the proximal tibia, femoral capital site for an early return to unprotected weight bearing;
physeal fractures, and fractures of the olecranon.40,52,70,75 otherwise complete restoration of function is unlikely.
Application of multiple parallel pins across capital
femoral physeal fractures has been advocated and has
Intramedullary Pins resulted in some success.70 Steinmann pins have also
Steinmann Pins been used in the treatment of olecranon fractures in the
Veterinarians are most familiar with traditional IM fixa- very young foal, in combination with a tension band such
tion, which uses a single smooth Steinmann pin with a as cerclage wire.52
diameter of approximately 60% of the diameter of the In most equine fractures, the goals of strength and sta-
medullary canal.13 Intramedullary pinning alone, as well bility at the fracture site are best achieved by accurate
as in conjunction with cerclage wires or an external fixa- anatomic reconstruction of the fractured bone and stabi-
tor, is commonly utilized for management of long bone lization with one, or preferably two, DCPs or LCPs.
fractures in small animal veterinary practice. A number When this is not possible and the fractured bone is either
of general guidelines have been formulated to improve the humerus or femur, or occasionally the proximal
success rates, including recommendations on fracture aspect of the tibia, IM fixation should be considered as a
location, configuration, and implant selection. In gen- potential alternative. However, traditional IM fixation
eral, mid‐diaphyseal fractures which are stable in com- with a single Steinmann pin, as previously discussed, is
pression and rotation are best suited for IM fixation inadequate in most cases. Several methods are recom-
alone. Transverse or short oblique fractures with sub- mended to increase the strength and stability of the
stantial interdigitation between fracture fragments are fixation over that provided by a single IM pin, and
ideal candidates. Long oblique fractures require the use include stacked pin fixation, or preferably an IIN.
of supplemental fixation in the form of cerclage wires to
prevent telescoping and to provide rotational stability Stacked Pin Fixation
during weight bearing. Significant comminution, particu- Stacked pin fixation fills the medullary canal with multiple
larly when there is less than 50% contact between the IM pins. When the entire medullary space throughout
proximal and the distal cortices at the fracture site, pre- the narrowest portion of the diaphysis (the isthmus) is
cludes adequate fixation with traditional IM techniques. filled, frictional forces between the implants and medullary
Intramedullary fixation with a single pin relies on load cortical bone are increased. In vitro studies performed on
sharing between the implant and the intact cortical bone transverse fractures in dog femurs showed that stacked
of the major proximal and distal fracture fragments. The pin fixation provided up to three times more rotational
implant serves primarily to maintain alignment at the stability than a single IM pin.12,72 As with single IM pin
fracture site, with contact between fracture fragments fixation, axial and rotational stability depends predomi-
providing axial and rotational stability. Resistance to nantly on the location and configuration of the fracture.
bending forces is provided by contact of the pin with Although stacked pin fixation increases resistance to tor-
the medullary canal. Because absolute stability is not sional forces, significant rotational instability remains.
achieved, indirect bone healing with periosteal callus is Transverse and short oblique fractures in the mid diaphy-
responsible for fracture union. sis are best suited to stacked pin fixation. Mid‐shaft
In many cases in which a single IM pin is utilized, the fractures develop maximal contact between the implants
fracture is reduced and stabilized using closed‐fracture and the medullary cortex of the bony cylinder on either
techniques. This approach results in minimal additional side of the fracture. When the medullary canal is filled by
trauma to the soft tissue envelope, which reduces the implants, translation, telescoping, and overriding of the
potential for infection and promotes early revasculariza- fracture fragments are prevented. Although rotational
tion and fracture healing. Closed fixation, combined with stability relies heavily on fracture interdigitation, friction
the ability of most small animal patients to ambulate between the medullary cortical bone and stacked IM
effectively while protecting the fractured limb from full pins will resist rotational forces significantly better than
www.ajlobby.com
Figure 9.7 (A) Comminuted femur fracture (A) (B)

in a miniature foal. (B) Treatment of the
fracture by the use of stacked‐pin fixation
in conjunction with multiple cerclage
wires.
a single IM pin. In fractures with significant obliquity, the

addition of a cerclage device substantially improves
stability. Unfortunately, cerclage wiring in large animals is
frequently inadequate to provide stability.
Stacked pin fixation has been used successfully in the
management of short oblique and transverse fractures of
the mid‐humeral diaphysis in foals.6 Other applications
have included femoral fractures in calves and foals
(Figure 9.7).64 As many 1/4 in. Steinmann pins as possi-
ble are inserted into the diaphysis. Usually four or five
pins can be placed in a foal’s humerus or femur. The
space between the 1/4 in. pins is then filled with pins of
smaller diameter such as 5/32 in. Steinmann pins, to
ensure maximal contact of the IM pins and the cortical
bone of the diaphyseal medulla.
Placement of the multiple IM pins is accomplished in
normograde fashion. Exposure of the fracture is generally
necessary to allow realignment and temporary stabiliza-
tion of the fracture fragments with a bone clamp or a
similar device. In addition, adequate exposure of the prox-
imal long bone is needed to allow pin placement. Driving
several IM pins the length of the diaphysis can be difficult
even with power equipment. Preferably, the medullary
canal can be reamed prior to pin placement (see the dis-
Figure 9.8 Humeral fracture in a foal stabilized by multiple
cussion of IIN fixation later in this chapter). Medullary intramedullary pins. Overriding of fracture fragments has resulted
reaming simplifies pin placement and increases the degree in pin migration.
of contact between the IM pins and the medullary cortical
bone. Following reaming of the medullary canal, the
fracture is aligned and stabilized with a bone clamp, and instability associated with IM pinning, implant migration
pin placement commences as previously described. is a major concern. Motion at the fracture site during
Complications associated with stacked pin fixation use of the repaired limb often initiates pin migration
include those associated with any form of open reduction (Figure 9.8). Pin migration tends to be retrograde, particu-
and internal fixation. In addition, because of the inherent larly if axial collapse is occurring at the fracture site. As the
www.ajlobby.com
pins migrate, stability is compromised, which allows more overlying soft tissues, results in a biologic and mechani-
motion at the fracture site and perpetuates the cycle of cal environment which supports fracture healing while
further implant migration and instability. Eventual success also allowing early mobilization of the fractured limb.
or failure is a race between the increasing ability of the Additionally, many of the complications associated with
healing fracture to sustain the forces of weight bearing and open reduction and fracture fixation by plating methods
the decreasing ability of the fixation to provide stability at are avoided.
the fracture site. An additional concern is the tendency for Intramedullary nailing in humans currently utilizes a
migrating pins to penetrate the skin. Environmental con- slightly flexible nail passed normograde down the pre-
taminants can follow pin tracts, gaining access to the med- reamed medulla. Interlocking nails have recently been
ullary cavity, and osteomyelitis can result. Instability, introduced which eliminate the need for medullary
when complicated by infection, seriously compromises reaming prior to fracture fixation.8,14 Once the nail is in
the healing capacity of the affected bone. The time to frac- the medulla, interlocking is accomplished in the proxi-
ture union is substantially prolonged, and in some cases mal fragment using a targeting jig attached to the nail,
an infected nonunion may result. which positions the cortical drill hole to coincide with a
prefabricated hole in the nail through which a screw of
Rush Pins appropriate size is placed. The slight flexibility of the
The Rush pin method of fracture treatment was popular nail, while allowing it to fit the contour of the medullary
before bone plating was introduced. Fracture fixation cavity, also requires the use of image intensification and
using these devices is an art. The slightly prebent pins are sophisticated targeting devices to interlock the nail in
introduced obliquely into the distal fragment and the distal fragment.
advanced toward the opposite cortex. The tip of the pin, Interlocking the IM device to the major proximal and
which is flattened on one side, slides off the opposite cor- distal bone cylinders provides a static form of fracture
tex and is redirected toward the near cortex. The length fixation that resists compressive and rotational forces
of the pin has to be predetermined to allow the tip to and provides bending stability. Fixation positioned in
engage in the near cortex proximal to the fracture, pro- the medullary cavity near the center of the bone, close
viding four‐point contact. Usually, two pins are intro- to the neutral axis of the diaphysis, imparts a significant
duced, one from each side of the bone. If the technique is mechanical advantage over plate fixation, particularly
performed correctly, good rotational stability is achieved, when the bony cylinder cannot be reconstructed.
with a minimum of implants and surgical trauma. The In vitro tests, using a comminuted subtrochanteric
Rush pin fixation technique is not applicable in commi- femoral fracture model, showed that in combined bend-
nuted or open fractures. With the better stabilization ing and compression, interlocking nails supported the
and early mobility afforded by the numerous plating and highest loads to failure.68 In that study, interlocking
interlocking nail techniques in horses, the use of Rush nails supported 300–400% of body weight, whereas
pins is only of historical interest. plate systems failed at loads equivalent to 100–200%
of body weight. Intramedullary interlocking nail con-
structs rely less on the reconstructed fracture to resist
Intramedullary Interlocking
the forces of weight bearing. This reduces the necessity
Nail Fixation for anatomic reduction and rigid fixation of all fracture
Transfixation of the major proximal and distal bone fragments that are specifically recommended for most
fragments to an IM rod was first described by Kuntscher, forms of plate fixation.50
who termed it “centromedullary pegging” and named the
device a “detensor nail.”29 Modifications by Klemm and Equine Application
Schellmann28 were later incorporated, and the device Interlocking nail systems for use in large animal fracture
was renamed the intramedullary interlocking nail. In fixation are not yet commercially available.22,35,37,38,51 The
human orthopedics, interlocked nailing is currently the implants used in human orthopedics are for the most
preferred method of fixation for a variety of complex part slotted, tubular designs, which compromise the
fractures of the femur, and is becoming more frequently strength of the fixation and mitigate against their use in
used in humerus and tibial fractures.7,8,11,14 equine fracture repair. A recent equine investigation of an
interlocking nail designed for use in the human tibia
Interlocking Nail Technique found that the yield torque for the IIN constructs was less
In most human fractures, IIN fixation is accomplished than that associated with strains measured in vivo in the
using closed surgical techniques.14 Closed interlocking tibia of a horse at the walk.39 The slotted design of human
nail fixation provides excellent stability at the fracture nails substantially reduces the stiffness of the implant and
site and, because of the minimal operative trauma to the results in a drop in the torsional moment of inertia to
www.ajlobby.com
approximately 1/50th of the value of a nonslotted nail of in. in diameter. The holes for interlocking accept 5.5 mm
equal dimension and wall thickness.66 Furthermore, the cortical bone screws (DePuy Synthes) and are positioned
slot must be oriented toward the tension surface of the throughout the length of the nail to allow the use of many
bone to achieve maximal bending stiffness. If the slot is transcortical bone screws for interlocking the major
oriented in another direction, buckling of the nail is likely fracture fragments. Targeting of the screw holes is
to occur secondary to bending forces. accomplished by the use of a jig, which accepts drill
A study of an intramedullary AO nail for third meta- guides as well as other instrumentation necessary for
carpal and metatarsal fractures has been published.21 hole preparation (Figure 9.10). The rigid nature of the
Introduction of the nail into the bone was achieved nail allows use of an attached rigid targeting device for
through an osteotomy of the attachment of the extensor locating screw holes, obviating the need for specialized
carpi radialis tendon and an arthrotomy of the carpo- targeting systems using image intensification.
metacarpal joint. After introduction of the nail into the
medullary cavity of the third metacarpus, the osteot- Technique in the Horse
omy fragment was reattached to the metacarpus using Techniques for fracture fixation using the interlocking
lag screws, in conjunction with an arthrodesis of the car- nail system are similar to those for stacked pin fixation.
pometacarpal joint using screws and cerclage wire. Initially, the fracture is exposed and debrided. The
Extensive reaming was necessary to introduce the nail. medullary canals of the bony cylinders proximal and
Once in place, the nail was very functional; however, the distal to the fracture are reamed. In most instances, the
mode of introduction proved to be impractical. distal cylinder is reamed retrograde, commencing from
An equine interlocking nail (Prototype manufac- the fracture and advancing distally. Rigid medullary
tured by IMEX Veterinary, Longview, TX, USA) for use reamers of increasing size are used to reach a final diame-
in the humerus and femur of foals and calves has been ter of 13 mm. The proximal bony cylinder is subsequently
developed (Figure 9.9).35,51,73,74 The IM implant is con- reamed, usually in normograde fashion, beginning
structed from implant grade 316L stainless steel rod ½ from the proximal end of the bone and progressing to
the fracture site. Once both cylinders are reamed, the
fracture is reduced and temporarily stabilized with a
bone clamp. A nail of appropriate length is selected and,
with the targeting jig attached, the nail is passed into the
Figure 9.10 Cross‐section of foal humerus demonstrating the

Figure 9.9 A large animal intramedullary interlocking nail system procedure for drill hole preparation with the targeting jig and drill
showing targeting jig, various length nails, and drill guides. guide.
www.ajlobby.com
benefits of interlocking nail fixation are apparent. 4

As with all forms of fixation, the location and configu-
ration of the fracture significantly affect the surgeon’s
ability to achieve stability and subsequent healing of the
fractured bone. For ideal fixation of fractures in foals,
three interlocking screws should be positioned on either
side of the fracture, and the distance between the two
screws inserted nearest the fracture should be as short as
possible. Fractures located near the epiphysis are less
readily stabilized using interlocking nail fixation, and the
epiphyseal segment is at an increased risk for secondary
fracture through the interlocking screw holes. In these
instances, some form of supplemental fixation is neces-
sary to decrease the potential for catastrophic failure of
the fixation. Long oblique fractures, particularly those in
which the plane of the fracture interferes with screw
placement adjacent to the fracture line, appear to be at
increased risk for implant failure. Although three inter-
locking screws can be positioned in the proximal and
distal fracture segments, if the length between the two
screws on either side of the fracture is great, cyclic bend-
ing forces put the implant at risk for fatigue failure. In
these instances, the implant is best positioned to allow
one or two additional interlocking screws to be placed
Figure 9.11 Caudal to cranial radiograph, demonstrating in lag fashion across the fracture plane. If this is not
intramedullary interlocking nail in 4/4 fixation of humeral osteotomy.
feasible, then some form of cerclage must be relied on to
neutralize the bending forces. Unfortunately, standard
reamed medullary canal. Screw holes are drilled with cerclage wire fixation is unreliable for this purpose.
guidance from the targeting jig and the screws inter- Alternative devices such as stainless‐steel cables are
locked (Figure 9.11). When possible, at least three 5.5 mm currently being evaluated to identify an implant for this
cortical bone screws are interlocked on both sides of purpose. Supplementing the interlocked nail with a DCP
the fracture. This fixation is described as an IIN‐3/3 or LCP applied using a unicortical technique to the
construct, a designation that delineates the number of cranial aspect of the humerus has enhanced the stability
interlocking screws proximal and distal to the fracture. of repair in oblique fracture configurations and improved
If possible, fractures with significant obliquity are success in clinical cases.76
afforded additional stability by placing one or two inter-
locking screws across the fracture in lag fashion. If this is
not feasible, then some form of cerclage wire fixation is External Skeletal Fixation
recommended. In addition, washers (DePuy Synthes) are
recommended to prevent the conical head of the inter- In principle, external skeletal fixation (ESF) offers an
locking screws penetrating the cortical bone. This fixa- attractive method for fracture management, particularly
tion device has been evaluated by in vitro and in vivo in those fractures accompanied by substantial soft
controlled studies.35,73,74 An in vitro study, using a foal tissue trauma. The ability to stabilize a fracture without
humerus fracture model, showed that IIN fixation pro- surgically invading the overlying soft tissue envelope,
vides significantly more rotational stability than stacked stripping the bone of remaining soft tissue attachments,
pin fixation.74 In addition, in vivo studies have shown and implanting large quantities of foreign material into
there are no detrimental effects of medullary reaming the wound is a distinct advantages when considering the
alone or in conjunction with IIN fixation on the growth biology of fracture healing.49 However, the mechanical
and development of the normal foal humerus.73 More limitations of most devices used for ESF, particularly in
recent studies document that healing of transverse large animal practice, markedly limit their application.
humeral and femoral osteotomies will occur within four Fracture healing relies on the fixation method to provide
to six months after IIN fixation.35 adequate stability to create and maintain a mechanical
Although the number of clinical cases in which IIN environment suitable for new bone formation. In addition,
fixation has been used is limited, the deficiencies and the fixation must provide adequate strength to protect
www.ajlobby.com
the fracture from the forces of weight bearing through- The strength and stiffness of a fixation after applica-
out the healing period. One of the major limitations of tion of external skeletal fixators are determined by a
ESF in equine patients is the inability of conventional variety of mechanical factors. As with all treatment
ESF techniques to neutralize the forces associated with modalities, the configuration of the fracture significantly
full weight bearing.48 Mechanical failure of the devices is influences the ultimate mechanical properties of the sur-
highly probable, with the clamps used to connect the gical construct. This is especially true with ESF, where
transfixation pins to the sidebars at greatest risk. there is usually no attempt to reconstruct and internally
ESF devices with adequate strength to support weight stabilize the fractured bone. The ESF frame must be able
bearing in large animals are still at risk for implant loos- to neutralize all forces acting on the fracture until the
ening, just as they are for ESF applications in all animal healing bone can begin to accept some of the load. In the
species. Implant loosening is primarily the result of bone equine patient, these forces are great and are likely to
resorption at the interface of the transfixation pin and promote premature loosening of the transfixation pins,
the cortical bone. Although a number of factors contrib- with resultant instability. The race between the gradually
ute to loosening at the bone–pin interface, the strain increasing load‐carrying capacity of the healing bone
environment at this interface is probably the most and failure of the fixation modality is particularly
important factor.49 If pin stress secondary to the forces of important in equine ESF. The more initial strength and
weight bearing results in substantial pin deflection and stiffness the ESF device has, the longer the expected
therefore significant strain at the interface, then bone duration of fracture fixation. Strength and stiffness of the
resorption is initiated. Bone resorption leads to increased assembled ESF device depend on the frame configuration
pin motion, and a vicious cycle of resorption and motion and the distance separating the bone from the sidebars,
is perpetuated (Figure 9.12). This complication is par- as well as the size, number, location, and arrangement of
ticularly common in equine ESF because of the extremely the transfixation pins.49
large loads placed on the transfixation pins during full
weight‐bearing activity.
Mechanical Characteristics
and Classification of Devices
External skeletal fixators are classified according to
the configuration of the assembled frame.15 Unilateral
frames are classified as type I fixators (Figure 9.13) and
can be either uniplanar (type Ia) or biplanar (type Ib).
Also known as half‐pin splints, these fixators utilize con-
necting bars on only one side of the bone. Type I frames
provide the least resistance to compressive forces and are
the least rigid in bending and torsion. Type II frames are
bilateral and constructed using transfixation pins passed
perpendicular to the long axis of the bone (Figure 9.14).
The transfixation pins are affixed to connecting rods on
both sides of the bone, and are also termed full‐pin
splints. In practice, the pins are parallel and coplanar in
arrangement. These frames are significantly more rigid
than type I frames in compression and in bending, when
the bending forces are parallel to the pins. However,
when the bending forces are perpendicular to the pins,
a type Ib frame provides more stability than a type II
frame. Type III frames are constructed by combining a
type I frame at 90° to a type II frame (Figure 9.15). The
type III frame offers the most strength and stiffness of
all traditional ESF devices in use today. Recently, there
has been growing interest in circular and semicircular
Figure 9.12 Radiograph showing substantial bone resorption at external frame configurations. They are currently used
the site of a transfixation pin utilized for transfixation cast
stabilization of a distal limb injury. In this case a single in human orthopedics for a number of reconstructive
transfixation pin was utilized, which may have contributed to the procedures and have been introduced into clinical
degree of resorption. orthopedics in small animal practice. However, their use
www.ajlobby.com
Figure 9.13 External skeletal fixators. (A)

(A) (B) Type Ia external skeletal fixator consisting
of a single connecting bar in a uniplanar
configuration. (B) Type Ib external skeletal
fixator utilizing two frames, each using a
single connecting bar but positioned in a
biplanar configuration.
Figure 9.14 Type II external skeletal fixator configuration using Figure 9.15 Type III configuration of an external skeletal fixator in
transfixation pins and two connecting bars in a coplanar which type I and type II frames are combined to achieve maximal
configuration. frame strength and stiffness.
www.ajlobby.com
in large animal fracture management has been limited, The importance of pin design on maintenance of the
although transfixation casting offers some of the advan- bone–pin interface has become increasingly apparent.
tages of circular ESF techniques. Threaded pins have substantially more holding power
Pin stiffness is another important factor in determining than smooth pins, particularly after the pins have been
the rigidity of the ESF device. The relationship is in place for a period of time. However, pins that have
geometric, with stiffness of the pin proportional to the had threads cut into them (negative thread profile) are
fourth power of the pin radius. Therefore, the use of pins substantially weakened, and failure typically occurs at
of larger diameter can substantially decrease pin deflec- the junction of the shaft and the threaded portion. Pins
tion when loaded, and thereby increase frame stiffness in which the thread diameter is greater than the shaft
within certain limits. These limits are determined by the (positive thread profile) provide the increased holding
corresponding decrease in bone strength that results power of threaded pins while maintaining pin stiffness
from the larger holes created by pin placement. Although and resistance to fatigue failure.
data for equine bones are somewhat conflicting, it The technique of pin insertion also contributes to
appears that hole diameters up to 20% of the bone diam- premature pin loosening. This is particularly important
eter do not significantly decrease the strength of the when using ESF or transfixation casts in the horse,
bone in torsional failure, beyond that decrease produced because of the density and thickness of equine cortical
by the stress‐concentrating effect of the defect.36 bone. Pin placement should result in minimal trauma
However, as hole size is increased beyond this level, and thermal injury to the cortical bone surrounding the
there is a linear decrease in torsional strength. This will pin hole. Predrilling the pin holes to a diameter nearly
increase the potential for secondary failure through the equal to that of the fixation pin is required.30 Sharp drill
pin hole. Further, bending strength is proportionally bits that are lubricated by constant saline application
decreased as the size of the cortical defect increases.36 during drilling should be used. If threaded pins are
In vitro tests in the equine metacarpus confirm that large‐ utilized, they should be self‐tapping or, better yet, an
diameter pins result in a stiffer frame and less strain on the appropriate‐sized tap should be used to cut threads into
surface of the metacarpus.34 However, the incidence of the cortical bone. Self‐drilling and self‐tapping positive‐
catastrophic failure of the transfixed bone through the profile pins result in increased thermal necrosis and
pin hole is increased as the size of the pin increases.57,67 better designs are still required before they can be safely
The distance spanned by the transfixation pin between utilized in equine cortical bone.9,41 The pin should be
the cortical bone interface and the sidebar is termed the carefully inserted using every precaution to minimize
working length. Pin stiffness and therefore pin deflection trauma and thermal injury. Improper pin hole prepara-
during loading are inversely proportional to the third tion and pin placement invariably result in bone necrosis
power of the working length. Therefore, stiffer frames and formation of a ring sequestrum surrounding the pin
can be assembled by minimizing the working length. hole (Figure 9.16). Not only is fixation compromised
In addition, as the working length decreases in type II when this occurs, but the increased size of the cortical
frames, the resistance to perpendicular bending forces defect may predispose to secondary fracture through the
correspondingly increases. Stiffer constructs, attained by pin hole.
maximizing pin size and minimizing working length, will Two of the various ESF configurations designed for
result in less pin stress. Decreasing pin stress preserves humans and small animals were used in an experimental
the bone–pin interface and decreases the potential for in vivo study in foals, in which healing of transverse and
cyclic fatigue failure of the pins. oblique tibial osteotomies was evaluated.65 A full‐pin
splint (type II), consisting of four or more Steinmann
pins inserted across the bone and soft tissues in a frontal
plane, and attached through clamps to one vertical bar
Pin Insertion on each side of the bone, was compared to a three‐
Mechanical properties of traditional ESF frames are also dimensional tent configuration (type III), which con-
affected by the number and arrangement of the transfixa- sisted of a full splint, whose vertical bars were connected
tion pins. In general, increasing the number of pins to a to a third bar oriented at 90° axial rotation either crani-
maximum of four on either side of the fracture increases ally or caudally. The third vertical bar was also connected
the stiffness and strength of the surgical construct and to the bone with Schanz screws, collectively representing
decreases the cyclic stress applied to each fixation pin. a three‐dimensional tent fixation. The study showed that
Pins should be positioned to minimize the distance the animals treated with the three‐dimensional tent con-
between pins adjacent to the fracture, as well as to maxi- figuration did not bear weight on the limb, developed
mize the distance between pins within the same major additional problems, and had to be euthanized early.
fragment. Conversely, full‐splint external fixation resulted in
www.ajlobby.com
Preloading of the pins also delays eventual loosening of

the Steinmann pins. Radially preloaded Schanz screws
(through a conical pin geometry) have also been com-
pared to axially preloaded Steinmann pins, and the radi-
ally preloaded conical pin was found be superior to axial
preload in every aspect.
To ensure the greatest stability, the vertical bars
should be positioned as close as possible to the skin. This
reduces the working length of the pin and increases
stability. A minimal distance of about 1 cm should ini-
tially be established between the skin and the clamps
connected to the vertical bars, to allow soft tissue swelling
to occur without the tissues making contact with the
Steinmann pin–clamp interface. If pressure necrosis
does occur, the vertical bars can be moved further away
from the skin by simply loosening the clamps while the
limb is supported in a non‐weight‐bearing position.
Fracture healing with external fixation occurs at a slower
pace than healing after internal fixation, and is associated
with callus formation, which indicates motion at the frac-
ture site. A mechanical study that compared in vitro mod-
els of external fixator configurations for the horse, testing
to 5000 Nm in compression and four‐point bending,
revealed that a three‐dimensional configuration contain-
ing four radial preload 5 mm Schanz screws, together with
six Steinmann pins of 5 mm diameter, withstood the load
with only minimal movement at the 1 cm osteotomy gap.
Figure 9.16 Ring sequestrum at the transfixation pin site

secondary to faulty pin insertion technique.
Equine External Skeletal
c omplete healing in 67% of the animals. The investiga- Fixation Device
tors concluded that a type II splint was a viable alterna-
tive for fracture fixation in foals weighing less than A type II frame utilizing full‐pin splintage has been
150 kg. Half‐pin splints (type I) applied in the horse were developed by Nunamaker et al.48 The equine external
only marginally successful. skeletal fixator originally used large, partially threaded
fixation pins which were self‐tapping and had a core
Surgical Technique diameter of 8.6 mm in the threaded portion and 9.6 mm
in the nonthreaded portion. The sidebars were fashioned
The ESF repair is started by drilling a 4.5 mm diameter from a composite polyurethane reinforced with steel
hole perpendicular to the long axis of the bone, 2 cm rods. Designed for injuries of the distal limb, the sidebars
away from and on either side of the fracture line. connect the transfixation pins placed proximal to the
A Steinmann pin is inserted in each hole. The fracture is fracture to a foot plate. The foot plate is rounded to
reduced and the vertical bars are attached to the medial reduce ground contact and angled 15–25° from the
and lateral end of each of the Steinmann pins. Additional ground surface. The foot plate is bolted to a bar shoe,
Steinmann pins or Schanz screws are placed further which is individually fashioned for each horse. A tapered
away and may be introduced at different angles. A special sleeve has been added over smooth 7.94 mm pins with
guide, allowing exact drilling and aiming toward finely threaded ends in recent years to add to the
the opposite clamp on the vertical bar, facilitates pre- mechanical integrity by improving bone–pin strain tran-
cise construction of the full splint frame. Biomechanical sition (Figure 9.17).46 The sleeves are compressed against
studies have shown that axially preloading the pins the bone cortices by nuts tightened onto the machined
against each other within one fragment, combined threads on the pin ends.
with compression of the fracture using temporary Mechanically, the original and new versions of this
com
pression clamps, achieves the greatest stability. fixator are extremely strong. The overall construct
www.ajlobby.com
to the use of the equine external skeletal fixator included

secondary fracture through the pin holes in four patients.
Two of these fractures occurred through the proximal
pin hole with the device in place, and the remaining two
occurred following removal of the frame. One of the lat-
ter was associated with the development of a ring seques-
trum due to faulty pin design (self‐threading vs.
self‐tapping). Modifications to the foot plate decreased
the incidence of fracture during treatment, and removal
of the frame with the horse standing has reduced frac-
ture following device removal.
Surgical Technique
Application of the original frame commenced with a
stab incision in the skin over the mid‐portion of the
third metacarpus or metatarsus and a 5.5 mm hole was
drilled across the bone, perpendicular to the long axis
of the bone and in the frontal plane. Additional holes
are drilled parallel to the first, 6–7 cm proximally and
distally. The holes are enlarged with a hand chuck and
Figure 9.17 Equine external skeletal fixator, version III. Source: 8.73 mm diameter drill. Using manual insertion, self‐
Designed by Nunamaker and coworkers.46 threading pins with a core diameter of 8.6 mm and an
outside thread diameter of 9.6 mm are introduced into
the holes. The pins are centered within the third meta-
has stiffness and strength characteristics that allow carpus or metatarsus. Occasionally, limited internal
immediate full weight bearing by adult horses. fixation of the fracture with several lag screws is used to
Mechanical testing of the original fixator indicated that unite major bone fragments and provide some inter-
the bones within the lower limb were shielded from fragmentary compression. This type of surgery also
strain with loads equivalent to 1758.4 kg, at which time allows introduction of a cancellous bone graft and
plastic deformation of the device occurred. At this load, removal of articular cartilage, where indicated. The
stress in the most proximal pin was over 350 MPa. In vivo foot plate is screwed onto the horseshoe, and the verti-
strain measurements in a single clinical case resulted in cal connecting bars are aligned next to the transfixation
calculated maximal stress in the same pin to be less than pins. The pins are cut to extend 1 cm beyond the verti-
92 MPa. This pin is subjected to the greatest stress dur- cal bar. Soft insulation tubing is subsequently placed
ing weight bearing, and from these studies there is clearly over each vertical bar extending up from the foot plate,
a large margin of safety between in vivo loads imposed and tied off around the bar at the level of the coronary
when a horse is walking, and loads necessary to cause band. A steel wire grid, providing additional reinforcing
mechanical failure of the device. support, is introduced inside the entire length of the
The equine external skeletal fixator allows complete soft tubing, parallel to the vertical bar. The cross pins
immobilization of unstable comminuted fractures, pro- are then carefully pushed through the axial wall of the
vides ready access to local wounds or soft tissues, and tubing and allowed to protrude into its lumen. The tub-
provides a mechanism to deal with severely traumatized ing should extend well proximal to the most proximal
soft tissues without further tissue disruption through pin, e.g., to the carpal area for a problem involving the
surgical intervention. In the initial description of the proximal phalanx. A distance of about 2.5 cm should be
device, reasonably good success was reported for a num- allowed between the inside of the tubing and the skin.
ber of severe orthopedic injuries in adult horses.48,54 When the vertical bars are appropriately lined up and
These injuries included highly comminuted fractures of contacting the horizontal transfixation pins, a two‐
the distal metacarpus and proximal and middle phalan- component acrylic is prepared and poured into the
ges, as well as traumatic disruption of the suspensory tubes. The acrylic sets in 5 minutes, and during that
apparatus. Some of these injuries were open. In most period of time adjustments in alignment can be made
cases the patients were stable in their frames for eight or and reduction of the fracture achieved. The acrylic is
more weeks. For the 15 horses treated, healing of the poured into one tube and allowed to set before more
original injury was achieved in 7.48 Complications related acrylic is poured into the second tube. After the acrylic
www.ajlobby.com
has hardened, the proximal portion of the tubing can

be shortened to the appropriate length using a hacksaw.
The entire device is incorporated into a bandage, and
recovery from anesthesia is assisted to allow the horse
to rise without undue trauma. Owing to the frame’s
considerable weight and the animal’s resistance to it,
such trauma is not uncommon, and may lead to
catastrophic failure of the bone containing the large
transfixation pins.
A modified version of the equine skeletal fixator has
been developed (see Figure 9.17).43,46 The tapered‐
sleeve transcortical pin device uses 7.94 mm diameter
smooth pins with machine threads cut into either end
to allow a nut to be applied. Tightening of the nut inside
the tapered sleeve on either side of the limb tensions
the pin and provides a broader area for transition of
force from bone to pin. As a result, pin loosening is far
less likely. Application in seven horses with severely
comminuted fractures distal to the third metacarpus,
including six with comminuted proximal phalanx frac-
tures (Figure 9.18), resulted in survival of five of the
seven horses.46 The tapered‐sleeve concept and reduced
pin size compared to the initial ESF resulted in a device Figure 9.18 External skeletal fixator (III) with tapered conical
that supports approximately 10 times the horse’s sleeves applied to case with comminuted phalangeal fracture.
weight, which significantly improves upon the previous
version, which supported 3 times the body weight.46 70% (14 of 20 horses) when applied to comminuted
Further case evaluation is required to determine the proximal and middle phalanx fractures in one study,26
value of the equine skeletal fixator compared to trans- and 82% (9 of 11 horses) in a more recent study using a
fixation casts, which have resulted in survival rates of combination plaster/fiberglass transfixation cast.55
References
1 Auer, J. (1988). Application of the dynamic condylar 8 Brumback, R.J. and Virkus, W.W. (2000).
screw (DCS)/dynamic hip screw (DHS) implant system Intramedullary nailing of the femur: reamed versus
in the horse. Vet. Comp. Orthop. Traumatol. 1: 18–25. nonreamed. J. Am. Acad Orthop. Surg. 8: 83–90.
2 Auer, J.A. (2018). Principles in fracture treatment. In: 9 Bubeck, K.A., Garcia‐Lopez, J.M., Jenei, T.M., and
Equine Surgery, 5e (ed. J.A. Auer, J.A. Stick, J. Kümmerle, Maranda, L.S. (2010). In vitro comparison of two
and T. Prange), 1277–1314. St. Louis: Elsevier. centrally threaded, positive‐profile transfixation pin
3 Auer, J.A. and Watkins, J.P. (1987). Treatment of radial designs for use in third metacarpal bones in horses.
fractures in adult horses: an analysis of 15 clinical cases. Am. J. Vet. Res. 71: 976–981.
Equine Vet. J. 19: 103–110. 10 Carpenter, R.S., Galuppo, L.D., Simpson, E.L., and
4 Auer, J.A. and Watkins, J.P. (1996). Instrumentation and Dowd, J.P. (2008). Clinical evaluation of the locking
techniques in equine fracture fixation. Vet. Clin. North compression plate for fetlock arthrodesis in six
Am. Equine Pract. 12: 283–302. thoroughbred racehorses. Vet. Surg. 37: 263–268.
5 Bramlage, L.R. (1982). Arthrodesis of the fetlock joint. 11 Chalidis, B.E., Petsatodis, G.E., Sachinis, N.C. et al.
In: Equine Medicine and Surgery, 3e (ed. R.A. Mansman (2009). Reamed interlocking intramedullary nailing for
and G.S. McAlister), 1064–1066. Santa Barbara: the treatment of tibial diaphyseal fractures and aseptic
American Veterinary Publications. nonunions. Can we expect an optimum result?
6 Bramlage, L. (1983). Long bone fractures. Vet. Clin. Strategies Trauma Limb Reconstr. 4: 89–94.
North Am. 5: 285–310. 12 Dallman, M.J., Martin, R.A., Self, B.P., and Grant, J.W.
7 Brumback, R.J. (1996). The rationales of interlocking (1990). Rotational strength of double‐pinning
nailing of the femur, tibia, and humerus. Clin. Orthop. techniques in repair of transverse fractures in femurs of
Relat. Res. 324: 292–320. dogs. Am. J. Vet. Res. 51: 123–127.
www.ajlobby.com
13 DeYoung, D.J. and Probst, C.W. (1985). Methods of 26 Joyce, J., Baxter, G.M., Sarrafian, T.L. et al. (2006).
internal fracture fixation. In: Textbook of Small Animal Use of transfixation pin casts to treat adult horses
Surgery, 1e (ed. D.H. Slatter), 1949–1972. Philadelphia: with comminuted phalangeal fractures: 20 cases
WB Saunders. (1993–2003). J. Am. Vet. Med. Assoc. 229: 725–730.
14 Duan, X., Li, T., Mohammed, A.Q., and Xiang, Z. 27 Kirker‐Head, C. and Fackelman, G. (1989). Use of the
(2011). Reamed intramedullary nailing versus cobra head bone plate for distal long bone fractures in
unreamed intramedullary nailing for shaft fracture of large animals: a report of four cases. Vet. Surg. 18:
femur: a systematic literature review. Arch. Orthop. 227–234.
Trauma Surg. 131: 1445–1452. 28 Klemm, K. and Schellmann, W.D. (1972). Dynamic and
15 Egger, E.L. and Greenwood, K.M. (1985). External static locking of the intramedullary nail. Monatsschr
skeletal fixation. In: Textbook of Small Animal Surgery, Unfallheilkd Versicher Versorg Verkehrsmed 75: 568–575.
1e (ed. D.H. Slatter), 1972–1988. Philadelphia: WB 29 Kuntscher, G. (1968). Intramedullary nailing of
Saunders. comminuted fractures. Langenbecks Arch. Chir. 322:
16 Fackelman, G.E., Auer, J.A. and Nunamaker, D.M. 1063–1069.
(2002). AO Principles in Equine Osteosynthesis. New 30 Lescun, T.B., Frank, E.A., Zacharias, J.R. et al. (2011).
York: Thieme. Effect of sequential hole enlargement on cortical bone
17 Florin, M., Arzdorf, M., Linke, B., and Auer, J.A. temperature during drilling of 6.2‐mm‐diameter
(2005). Assessment of stiffness and strength of 4 transcortical holes in the third metacarpal bones of
different implants available for equine fracture horse cadavers. Am. J. Vet. Res. 72: 1687–1694.
treatment: a study on a 20 degrees oblique long‐bone 31 Levine, D.G. and Richardson, D.W. (2007). Clinical use
fracture model using a bone substitute. Vet. Surg. 34: of the locking compression plate (LCP) in horses: a
231–238. retrospective study of 31 cases (2004–2006). Equine
18 Frauenfelder, H.C. (1979). Proximal radius fracture in a Vet. J. 39: 401–406.
horse: angle blade plate repair. Vet. Surg. 10: 96–100. 32 Martin, B.B., Nunamaker, D.M., Evans, L.H. et al.
19 Frigg, R. (2001). Locking Compression Plate (LCP). An (1991). Circumferential wiring of mid‐body and large
osteosynthesis plate based on the Dynamic basilar fractures of the proximal sesamoid bone in 15
Compression Plate and the Point Contact Fixator horses. Vet. Surg. 20: 9–14.
(PC‐Fix). Injury 32 (Suppl 2): 63–66. 33 Martin, F., Richardson, D.W., Nunamaker, D.M. et al.
20 Frigg, R., Appenzeller, A., Christensen, R. et al. (2001). (1995). Use of tension band wires in horses with
The development of the distal femur Less Invasive fractures of the ulna: 22 cases (1980–1992). J. Am. Vet.
Stabilization System (LISS). Injury 32 (Suppl 3): Med. Assoc. 207: 1085–1089.
SC24–SC31. 34 McClure, S.R., Watkins, J.P., and Ashman, R.B. (1994). In
21 Frolich D. Versuche zur intramedullären osteosynthese vitro comparison of the effect of parallel and divergent
des metacarpus beim pferd. Thesis, University of transfixation pins on breaking strength of equine third
Zurich 1973. metacarpal bones. Am. J. Vet. Res. 55: 1327–1330.
22 Galuppo, L.D., Stover, S.M., Aldridge, A. et al. (2002). 35 McClure, S.R., Watkins, J.P., and Ashman, R.B. (1998).
An in vitro biomechanical investigation of an MP35N In vivo evaluation of intramedullary interlocking nail
intramedullary interlocking nail system for repair of fixation of transverse femoral osteotomies in foals.
third metacarpal fractures in adult horses. Vet. Surg. 31: Vet. Surg. 27: 29–36.
211–225. 36 McClure, S.R., Watkins, J.P., Bronson, D.G., and
23 Hunt, D.A., Snyder, J.R., Morgan, J.P., and Pascoe, J.R. Ashman, R.B. (1994). In vitro comparison of the
(1990). Femoral capital physeal fractures in 25 foals. standard short limb cast and three configurations of
Vet. Surg. 19: 41–49. short limb transfixation casts in equine forelimbs.
24 Jackson, M., Kummer, M., Auer, J. et al. (2011). Am. J. Vet. Res. 55: 1331–1334.
Treatment of type 2 and 4 olecranon fractures with 37 McDuffee, L.A., Stover, S.M., Bach, J.M., and Taylor,
locking compression plate osteosynthesis in horses: a K.T. (2000). An in vitro biomechanical investigation of
prospective study (2002–2008). Vet. Comp. Orthop. an equine interlocking nail. Vet. Surg. 29: 38–47.
Traumatol. 24: 57–61. 38 McDuffee, L.A., Stover, S.M., and Taylor, K.T. (2000). In
25 Johnson, N.L., Galuppo, L.D., Stover, S.M., and Taylor, vitro cyclic biomechanical properties of an interlocking
K.T. (2004). An in vitro biomechanical comparison of equine tibial nail. Vet. Surg. 29: 163–172.
the insertion variables and pullout mechanical 39 McDuffee, L.A., Stover, S.M., Taylor, K.T., and Les,
properties of AO 6.5‐mm standard cancellous and C.M. (1994). An in vitro biomechanical investigation of
7.3‐mm self‐tapping, cannulated bone screws in foal an interlocking nail for fixation of diaphyseal tibial
femoral bone. Vet. Surg. 33: 681–690. fractures in adult horses. Vet. Surg. 23: 219–230.
www.ajlobby.com
40 Monin, T. (1978). Repair of physeal fractures of the bone graft for arthrodesis of the metacarpophalangeal
tuber olecranon in the horse, using a tension band joint in horses. J. Am. Vet. Med. Assoc. 191: 316–321.
method. J. Am. Vet. Med. Assoc. 172: 287–290. 55 Rossignol, F., Vitte, A., and Boening, J. (2014). Use of a
41 Morisset, S., McClure, S.R., Hillberry, B.M., and Fisher, modified transfixation pin cast for treatment of
K.E. (2000). In vitro comparison of the use of two comminuted phalangeal fractures in horses. Vet. Surg.
large‐animal, centrally threaded, positive‐profile 43: 66–72.
transfixation pin designs in the equine third metacarpal 56 Roush, J.K. and Wilson, J.W. (1990). Effects of plate
bone. Am. J. Vet. Res. 61: 1298–1303. luting on cortical vascularity and development of
42 Muller, M.E., Allgower, M., Schneider, R., and cortical porosity in canine femurs. Vet. Surg. 19:
Willenegger, H. (1990). Manual of Internal Fixation, 3e. 208–214.
New York: Springer‐Verlag. 57 Seltzer, K.L., Stover, S.M., Taylor, K.T., and Willits, N.H.
43 Nash, R.A., Nunamaker, D.M., and Boston, R. (2001). (1996). The effect of hole diameter on the torsional
Evaluation of a tapered‐sleeve transcortical pin to mechanical properties of the equine third metacarpal
reduce stress at the bone–pin interface in metacarpal bone. Vet. Surg. 25: 371–375.
bones obtained from horses. Am. J. Vet. Res. 62: 58 Sod, G.A., Hubert, J.D., Martin, G.S., and Gill, M.S.
955–960. (2005). An in vitro biomechanical comparison of a
44 Nixon, A.J. (1996). Fractures and luxations of the hock. limited contact dynamic compression plate fixation
In: Equine Fracture Repair, 1e (ed. A.J. Nixon), with a dynamic compression plate fixation of
259–272. Philadelphia: WB Saunders. osteomized equine third metacarpal bones. Vet. Surg.
45 Nunamaker, D., Bowman, K., Richardson, D., and 34: 579–586.
Herring, M. (1986). Plate luting:a preliminary report of 59 Sod, G.A., Mitchell, C.F., Hubert, J.D. et al. (2008).
its use in horses. Vet. Surg. 15: 289–293. An in vitro biomechanical comparison of a 5.5 mm
46 Nunamaker, D.M. and Nash, R.A. (2008). A tapered‐ limited‐contact dynamic compression plate fixation
sleeve transcortical pin external skeletal fixation device with a 4.5 mm limited‐contact dynamic compression
for use in horses: development, application, and plate fixation of osteotomized equine third metacarpal
experience. Vet. Surg. 37: 725–732. bones. Vet. Surg. 37: 289–293.
47 Nunamaker, D.M., Richardson, D.W., and Butterweck, 60 Sod, G.A., Mitchell, C.F., Hubert, J.D. et al. (2008). In
D.M. (1991). Mechanical and biological effects of plate vitro biomechanical comparison of locking
luting. J. Orthop. Trauma 5: 138–145. compression plate fixation and limited‐contact
48 Nunamaker, D., Richardson, D., Butterweck, D. et al. dynamic compression plate fixation of osteotomized
(1986). A new external skeletal fixation device that equine third metacarpal bones. Vet. Surg. 37: 283–288.
allows immediate full weightbearing application in the 61 Sod, G.A., Riggs, L.M., Mitchell, C.F. et al. (2010). An in
horse. Vet. Surg. 15: 345–355. vitro biomechanical comparison of a 5.5 mm locking
49 Palmer, R.H., Hulse, D.A., Hyman, W.A., and Palmer, compression plate fixation with a 4.5 mm locking
D.R. (1992). Principles of bone healing and compression plate fixation of osteotomized equine
biomechanics of external skeletal fixation. Vet. Clin. third metacarpal bones. Vet. Surg. 39: 581–587.
North Am. Small Anim. Pract. 22: 45–68. 62 Staller, G.S., Richardson, D.W., Nunamaker, D.M., and
50 Perren, S. (1987). Biomechanics of intramedullary Provost, M. (1995). Contact area and static pressure
nailing. In: The Science and Practice of Intramedullary profile at the plate–bone interface in the nonluted and
Nailing (ed. B.D. Browner and C.C. Edwards), 67–75. luted bone plate. Vet. Surg. 24: 299–307.
Philadelphia: Lea & Febiger. 63 Stick, J.A. and Derksen, F.J. (1980). Intramedullary
51 Radcliffe, R.M., Lopez, M.J., Turner, T.A. et al. (2001). pinning of a fractured femur in a foal. J. Am. Vet. Med.
An in vitro biomechanical comparison of interlocking Assoc. 176: 627–629.
nail constructs and double plating for fixation of 64 St‐Jean, G., DeBowes, R.M., Hull, B.L., and Constable,
diaphyseal femur fractures in immature horses. P.D. (1992). Intramedullary pinning of femoral
Vet. Surg. 30: 179–190. diaphyseal fractures in neonatal calves: 12 cases
52 Richardson, D. (1990). Ulnar fractures. In: Current (1980–1990). J. Am. Vet. Med. Assoc. 200: 1372–1376.
Practice of Equine Surgery (ed. N.A. White and J.N. 65 Sullins, K.E. and McIlwraith, C.W. (1987). Evaluation of
Moore), 641–646. Philadelphia: J.B. Lippincott Company. 2 types of external skeletal fixation for repair of
53 Richardson, D. and Nunamaker, D. (1991). Evaluation experimental tibial fractures in foals. Vet. Surg. 16:
of plate luting, using an in vivo ovine osteotomy model. 255–264.
Am. J. Vet. Res. 52: 1468–1473. 66 Tarr, R.R. and Wiss, D.A. (1986). The mechanics and
54 Richardson, D.W., Nunamaker, D.M., and Sigafoos, R.D. biology of intramedullary fracture fixation. Clin.
(1987). Use of an external skeletal fixation device and Orthop. Relat. Res.10–17.
www.ajlobby.com
67 Taylor, D.S., Stover, S.M., and Willits, N. (1993). The 73 Watkins, J.P. and Ashman, R.B. (1990). Intramedullary
effect of differing pin size on the mechanical interlocking nail fixation in foals: effects on normal growth
performance of transfixation in the equine third and development of the humerus. Vet. Surg. 19: 80.
metacarpal bone. In: Proceedings of the Veterinary 74 Watkins, J.P. and Ashman, R.B. (1991). Intramedullary
Orthopedic Society, vol. 20, 2. Parker, CO: VOS. interlocking nail fixation in transverse humeral
68 Tencer, A.F., Johnson, K.D., Johnston, D.W., and Gill, K. fractures: an in‐vitro comparison with stacked pin
(1984). A biomechanical comparison of various fixation. In: Proceedings of the Veterinary Orthopedic
methods of stabilization of subtrochanteric fractures of Society, vol. 18, 54. Parker, CO: VOS.
the femur. J. Orthop. Res. 2: 297–305. 75 Watkins, J.P., Auer, J.A., and Taylor, T.S. (1985).
69 Turner, A.S., Cordey, J.R., Nunamaker, D.M. et al. Crosspin fixation of fractures of the proximal tibia in
(1990). In vitro strain patterns of unstable fractures due three foals. Vet. Surg. 14: 153–159.
to bone cement around the screw heads. Vet. Comp. 76 Watkins, J.P. and Glass, K. (2016). Intramedullary,
Orthop. Traumatol. 3: 84–89. interlocking nail and plate fixation of humeral
70 Turner, A.S., Milne, D.W., Hohn, R.B., and Rouse, G.P. fractures in fifteen horses less than one year of age
(1979). Surgical repair of fractured capital femoral (1999–2013). In: Proceedings of the American College
epiphysis in three foals. J. Am. Vet. Med. Assoc. 175: of Veterinary Surgeons Surgical Summit, 9.
1198–1202. Germantown, MD: ACVS.
71 Turner, A., Smith, F., Nunamaker, D. et al. (1991). 77 Yovich, J.V., Turner, A.S., and Smith, F.W. (1985).
Improved plate fixation of unstable fractures due to Holding power of orthopedic screws in equine third
bone cement around the screw heads. Vet. Surg. 20: metacarpal and metatarsal bones Part 2. Adult horse
349–350. bone. Vet. Surg. 14: 230–234.
72 Vasseur, P.B., Paul, H.A., and Crumley, L. (1984). 78 Yovich, J.V., Turner, A.S., and Smith, F.W. (1985).
Evaluation of fixation devices for prevention of rotation Holding power of orthopedic screws in equine third
in transverse fractures of the canine femoral shaft: an in metacarpal and metatarsal bones Part 1. Foal bone.
vitro study. Am. J. Vet. Res. 45: 1504–1507. Vet. Surg. 14: 221–229.
www.ajlobby.com
156
10
Application of the Locking Compression
Plate (LCP)
Dean W. Richardson
Department of Clinical Studies, School of Veterinary Medicine, University of Pennsylvania, New Bolton Center,
Kennett Square, PA, USA
Overview with an LCP. Therefore, extraperiosteal plate placement

and minimally invasive techniques are far more feasible
The locking compression plate (LCP) is a major advance with LCPs than with traditional plates.11,16 Locking
ment in internal fixation. The mechanical support afforded plates have been used in nearly all possible anatomic
by traditional plates depends upon the frictional forces locations in the horse and have proven their clinical
between the plate and the bone. These frictional forces value.1,2,4,5,9–11,14–16
are generated by compression of the plate to the bone by It is important to emphasize that in larger patients,
the plate screws. If the screws in standard plates loosen hybrid application of the plate (use of both locked and
at all, the vector forces drawing the plate and bone unlocked screws) will usually be most desirable, because
together are lost and the stability of the fixation is jeop perfect anatomic reconstruction allows weight sharing
ardized. Compression of the plate–bone interface can be of the device and the patient’s bone. Appropriate use of
increased by using larger‐diameter screws tightened interfragmentary lag screws, both independent as well as
with more torsional force, but this is inherently limited through the plate, is almost always necessary to achieve
by the strength of both implant and bone. For maximal sufficient anatomic reconstruction that weight sharing is
stability a traditional plate needs to be accurately con established. Given the extreme forces equine patients
toured to distribute the plate–bone frictional forces can apply to implants, it should always be a goal to recon
over its length. Such accurate contouring is technically struct cortical surfaces to share loads when possible.
demanding in some bones with complex surface geom Even in the comparatively small human species, weight
etry and this increases surgical time. The stability of a bearing of inadequately reconstructed bones will com
traditional plate can also be augmented by roughening monly result in implant failure.8,13
the underside of the plate, i.e., increasing friction by
changing the surface characteristics of the plate, or by
use of interpositional material in the form of plate lut Plate Design
ing. All such efforts to increase stability in traditional
plating (increasing plate‐to‐bone compressive force, The DePuy Synthes (DePuy Synthes, West Chester, PA,
area, and friction) have been challenged because of USA) locking plate is the only one being used widely in
concerns about the biologic consequences on the bone. humans and horses. It is technically a “hybrid” plate,
So‐called biologic plating that lessens contact between because the holes in the plate are designed to accommo
the plate and bone is proposed to preserve the vascularity date either a locking‐head screw or a traditional cortical
of the bone.17 The LCP provides increased stability without screw. Each “combi hole” in the plate has two parts. One
the need to move away from the ideal concept of biologic has a tapered shape and threaded interior that accom
plating because the locking plate is a different fixation modates the thread on the screw head (Figure 10.1). The
concept. The screws are frictionally “locked” into the other part of the combi hole is similar to the dynamic
plate to create a stable, fixed‐angle construct that pro compression unit of traditional plates: it accommodates
vides significant stability, even if the plate–bone inter the hemispherical head of the traditional screw and
face is poor or absent. Plate–bone friction is irrelevant allows eccentric placement of the screw to create

www.ajlobby.com
10 Application of the Locking Compression Plate 157
Figure 10.1 A 10‐hole 4.5 mm broad

locking compression plate with the
stacked combi hole shown at the left end.
The other end of the plate is tapered. The
lower right shows the standard combi
hole with the threaded portion for the
locking‐head screw and the sloped DCU
edge of the portion of the hole intended
for cortical screw insertion.
ovement of the plate relative to the bone. If eccentric

m (A)
screw placement is used, compression of a fracture plane
can be achieved, as described in Chapters 8 and 9. In
horses, 4.5 narrow and broad LCPs and the 5.5 broad
LCP are the most commonly used sizes. Both will accom
modate 4.5 and 5.5 mm cortical screws and 4.0 and
5.0 mm locking‐head screws. The current design has one
end of the plate tapered to facilitate minimally invasive
plate placement and the other end is rounded, with a
“stacked” combi hole close to its end (Figure 10.1). The
stacked hole will accommodate either a locking or tradi
tional screw. A significant advantage of this design is that
the locked plate can be placed closer to the end of a bone,
a big benefit in a fracture in the metaphyseal or epiphy
seal regions of a bone, or when used in an arthrodesis (B)
close to a joint margin (Figure 10.2). Other features of
the plate are similar to a limited‐contact dynamic com
pression plate (LC‐DCP; see Chapter 8).
The 5.5 mm LCP is, predictably, a much stronger
implant than the 4.5 mm LCP,19 although at present the
4.5 mm plate has been more extensively utilized in equine
applications. The 5.5 mm LCP will most likely find its
predominant application in unstable long bone fractures
of adult horses. However, the 5.5 mm plate is more diffi
cult to contour and is possibly less than optimally
designed for the horse.20 The 5.5 broad LCP would prob
ably be an even better plate for adult long bones if larger‐
diameter locking‐head screws were available.
Figure 10.2 Two examples of fracture fixation demonstrating

Screw Design the value of the stacked combi hole near the plate end. In the
pastern arthrodesis (A), the locked screw in the middle phalanx
can be properly engaged without risk of the plate impinging on
The screws used in the LCP provide greater bending the extensor process of the distal phalanx. In the partial carpal
strength because the core diameter of a 5.0 mm locking‐ arthrodesis (B), having the stacked combi hole screw close to the
head screw is 4.3 mm and the core diameter of a 5.5 mm end of the plate allows a second plate screw to be placed in the
cortical screw is 4.0 mm (Figure 10.3). This makes it 16% carpal bone without affecting the adjacent middle carpal joint.
stronger in bending. The threads are finer than cortical
screws, but the decrease in pullout strength is insignifi Locking‐head screws are self‐tapping and that elimi
cant because the fixed angle of the screw–plate construct nates one step of screw insertion, a major time saver in
makes direct pullout under load (and mechanical failure) equine long bone fracture repair. Because the threads are
unlikely. shallow, they are usually inserted without difficulty even
www.ajlobby.com
Surgical Technique
The basic mechanical principles of the LCP differ from
those of traditional plating, and the clinical application
of the LCP requires care in technique and the sequence
of screw insertion. The plate’s combi holes are designed
to allow insertion of either locking or standard cortical
screws. If cortical screws are used in a hybrid plating
(using both locked and unlocked screws), they must be
inserted and fully tightened before the locking screws
are inserted. A cortical screw placed through an LCP
combi hole functions to compress the plate against the
bone, and a second cortical screw placed in the load
position will compress the fracture. If there is a locked
screw already in the plate, the cortical screw cannot
move the plate toward the bone to add to bone–plate
friction forces, or move the bone to compress the
fracture if the locked screw is on the same side of the
fracture gap. The optimal distribution of locked and
unlocked screws in a plate is not entirely proven, but it
is likely that locked screws should be placed near the
fracture and at the ends of the plate.18 Placing locked
screws on either side of an unlocked screw probably
helps minimize screw loosening. If possible, there
should be at least three bicortical locked screws on
either side of a fracture line,6 but significant improve
ments in mechanical function are seen with only a
single locked screw.7
Figure 10.3 The 5.0 mm locking‐head screw (left) has a self‐drilling, In equine long bone fracture repair, double plating
self‐tapping tip and a tapered threaded head, which locks into the
threaded part of the plate hole (lower left). The screw head (left) has through a single incision is common. In traditional
the star‐drive recess. The 5.5 mm cortex screw has coarser threads plating, the difficulties of inserting screws in the ends
(upper right) and a hex‐head recess. The hemispherical contour on of the less well‐exposed plate can be overcome by vig
the underside of the screw head slides into the dynamic orous retraction, usually with Hohmann retractors and
compression unit component of the locking compression plate toggling the drill bit and guide into position in the
combi hole (lower right).
plate hole. Attempting to insert locked screws with this
limited exposure is difficult to impossible with an LCP,
because application of the locked screw requires the
in dense equine cortical bone. If necessary, the screws drilling to be done perpendicular to the plate by using
can be inserted using a power‐tapping technique, similar a 5 cm long drill guide screwed into the plate hole. The
to that used during tapping prior to the insertion of need for the drilling to be precisely perpendicular to
standard cortical screws. the plate often means it is necessary to make stab inci
The heads of locking screws have a star‐drive recess sions through skin and/or muscle to insert the drill
design (ISO 10664/T25/“Torx 25”) that is significantly guide and lock it into the plate (Figure 10.4). In heavily
superior to the hex‐head design still used in cortical muscled regions of the upper limb, it may be necessary
screws (see Figure 10.3). The star‐drive head is much less to screw two locking drill guides together end to end in
likely to strip during insertion or removal, which has order to secure the guide to the plate and avoid soft
been a persistent problem with the 5.5 mm cortical tissue trauma. The drill guide must be screwed into
screw. It also is easier to blindly insert the screwdriver place carefully to avoid cross‐threading, which ulti
into the star recess than with a hex head, which again mately leads to cross‐threading of the threads on the
provides advantages during both screw insertion and screw head and inadequate screw seating. The locking
plate removal. Friction between the star drive and lock head is slightly tapered, so if it is not accurately and
ing screw head allow the screw to be withdrawn from the fully seated in the threaded plate hole, the head will not
rack and retained on the screwdriver during insertion engage properly and the fixed‐angle properties of the
without the need for a retaining clasp. device are not as secure.12
www.ajlobby.com
Figure 10.4 The drill guides must be precisely threaded

perpendicularly into the plate, which may necessitate placing the
guides through separate stab incisions (arrow), especially when
double plating.
Locking plates provide stability without relying on Figure 10.5 Locking plates are an enormous advantage if
plate‐to‐bone contact, and therefore are especially useful minimally invasive plate fixation is elected. A plate passing device
for minimally invasive fracture repair. The LCP is gener (top) can be used to make a subcutaneous tunnel (bottom) and
ally placed in an extraperiosteal position, which provides the drill guides and screws are placed through stab incisions.
Intraoperative imaging is essential.
benefits for fracture healing by improving the balance of
mechanics and biology. Application of plates through
minimally invasive approaches requires a tunneling are tightened to the plate (Figure 10.6). Although the
device. A simple minimally invasive method is to sharpen mechanical function of the LCP does not depend on
a “plate‐shaped” piece of steel attached to a handle and accurate contouring and bone–plate contact, there are
use it to make a tunnel in an extraperiosteal position into still mechanical advantages to accurate contouring and
which the LCP is passed (Figure 10.5). Stab incisions are the use of a hybrid technique with a mix of standard cor
made over the screw holes and correct positioning of tex screws and locked screws. It is useful to conceptual
implants and drills is checked with intraoperative fluor ize the LCP as a subcutaneously placed type 1 external
oscopy or digital radiography. fixator. The farther the plate (equivalent to the sidebar) is
With traditional plating techniques, an essential step is from the surface of the bone, the greater is the bending
contouring the plate to the surface of the bone in order to moment on the locked screws (equivalent to the ex‐fix
maximize the frictional forces generated by screw tight pin), increasing the chance of screw failure and instability.3
ening. Furthermore, tightening cortical screws through a The other major advantage of moving the plate closer to
poorly contoured plate moves the bone to the plate. This the bone is to avoid interference with overlying soft tis
typically results in worsening of the fracture reduction. sues. This is particularly important in the equine distal
One of the major advantages of an LCP for repair of a limb, where soft tissue coverage is at a premium. The
comminuted fracture (especially in smaller horses/foals) three means of keeping the LCP as close as possible to
is that approximate reduction and acceptable alignment the bone are (i) good contouring; (ii) use of one or more
can be maintained with a minimally invasive LCP fixa cortical screws to lag the plate to the bone; and (iii) use of
tion, because the fragments do not move as the screws a push–pull device that temporarily pulls the plate to the
www.ajlobby.com
Figure 10.7 It is always mechanically advantageous to position

the plate close to the bone. The surgeon can accomplish this
using a cortical plate screw, or a threaded push–pull device as
shown here. The push–pull device is power drilled and threaded
into the bone through a combi hole, the power drive removed,
and the locking collar advanced down onto the plate to draw the
locking compression plate and bone into proximity.
important. It is particularly difficult to plan the plate

positioning and select the type of screw for each combi
Figure 10.6 A severely comminuted metatarsal fracture repaired
with two locking plates applied using minimally invasive hole when one plate is on a relatively straight bone
technique and screws inserted through stab incisions. In such a surface and the other is significantly contoured. Intra
severe fracture, rough reduction and alignment are maintained operative imaging is almost essential for double plating
with the locking compression plate because screws do not pull in such circumstances.
the fragments to the plate.
A key element in LCP application is that a locking
screw tightens only into the plate. There is no relevant
bone (Figure 10.7). It is vital that contouring of the LCP tactile feedback relating to screw thread to bone contact
minimizes deformation at the threaded portion of the pressure and resistance, because the forces of the locking
combi hole, where the locked screw is intended to be screw as it threads into the bone are masked by the force
inserted. Acute bending focused on the threaded portion required to thread the screw head into the threaded
of a combi hole can prevent the screw head and plate combi hole. Given this, it is impossible to “feel” whether
thread from becoming perfectly aligned, which results in or not a screw is even in the bone. However, when the
premature locking, screw head protrusion, and some threaded screw head fully seats into the plate, there is a
compromise of strength. precipitous increase in resistance to further rotation.
Double plating is common in equine long bone fracture The screw‐to‐plate frictional resistance does not reflect
repair, and avoiding screw interference is often a major adequate bone purchase and, worse still, if the screw has
part of the surgical plan, dictating intraoperative choice inadvertently become cross‐threaded during insertion,
of screw type and direction. With traditional plating resistance to rotation may not reflect adequate engage
techniques, it is relatively easy to avoid screw interfer ment of the screw head into the threaded plate hole.
ence by staggering the plates by one‐half of a hole and Although failure by prolapse and extrusion of the screw
angling the screws where necessary. With the LCP, there head into the nonlocked portion of the combi hole has
is no option to angle the locking screws, so planning anecdotally occurred (as has inadvertent insertion of a
of plate placement and screw selection is even more locked screw in the unthreaded portion), these really
www.ajlobby.com
should be extremely rare errors. Either results in com sharing of the metal and the bone still increase the risk
plete loss of the locked principle and will lead to screw of failure. Both mechanical and biologic failures still
loosening. The manufacturer recommends limiting occur, especially in challenging fracture cases in adult
insertional torque to 4 Nm because of concern that the horses. The LCP does allow more stable minimally
screw will permanently “cold weld” to the plate with invasive plate fixation, more secure fixation at the bone
more force applied. This is more of a concern with the ends, and subjectively more stable/comfortable early
titanium implants. Because we use the stronger stain fracture repairs and arthrodesis. It has been shown to
less‐steel implants, it has been common practice in improve outcome in fetlock arthrodesis,4 ulnar frac
equine surgery to tighten the screws maximally by hand, tures,9,10 supraglenoid fractures of the scapula,1 and
probably to at least 7–8 Nm of torque. To the author’s pastern fractures and arthrodesis.11 Additional plan
knowledge, there have not been any complications ning and accurate LCP placement are vital to avoid
associated with screw overtightening when using stain screw misdirection,15 and use of two LCPs in a mini
less‐steel plates. Because the head of a locking screw is mally invasive double plated long bone repair requires
slightly tapered, its strength is markedly compromised if image intensification to ensure accurate staggering
it is not fully inserted and tightened. of the plate holes. The increased expense of the LCP
Locking plate technology is a step forward in inter plates and screws compared to regular DCP implants
nal fixation, but LCP use does not guarantee success. has decreased, especially in proportion to the overall
The underlying surgical principles remain the same cost of managing a fracture case. In this author’s opin
even though the plates are clearly superior for most uses. ion, locking plate technology has already completely
Inadequate reduction and failure to achieve weight supplanted traditional plates.
References
1 Ahern, B.J., Bayliss, I.P.M., Zedler, S.T. et al. (2017). 9 Jackson, M., Kummer, M., Auer, J. et al. (2011).
Supraglenoid tubercle fracture repair with transverse Treatment of type 2 and 4 olecranon fractures with
locking compression plates in 4 horses. Vet. Surg. 46: locking compression plate osteosythesis in horses: a
507–514. prospective study (2002–2008). Vet. Comp. Orthop.
2 Ahern, B.J. and Richardson, D.W. (2010). Distal humeral Traumatol. 24: 57–61.
Salter Harris (Type II) fracture repair by an ulnar 10 Jacobs, C.C., Levine, D.G., and Richardson, D.W.
osteotomy approach in a horse. Vet. Surg. 39: 729–732. (2017). Use of locking compression plates in ulnar
3 Ahmad, M., Nanda, R., Bajwa, A.S. et al. (2007). fractures of 18 horses. Vet. Surg. 46: 242–248.
Biomechanical testing of the locking compression plate: 11 James, F.M. and Richardson, D.W. (2006). Minimally
when does the distance between bone and implant invasive plate fixation of lower limb injury in horses:
significantly reduce construct stability? Injury 38: 358. 32 cases (1999–2003). Equine Vet. J. 38: 246–251.
4 Carpenter, R.S., Galuppo, L.D., Simpson, E.L., and 12 Kaab, M.J., Frenk, A., Schmeling, A. et al. (2004).
Dowd, J.P. (2008). Clinical evaluation of the locking Locked internal fixator: sensitivity of screw/plate
compression plate for fetlock arthrodesis in six stability to the correct insertion angle of the screw.
Thoroughbred racehorses. Vet. Surg. 37: 263–268. J. Orthop. Trauma 18: 483.
5 Carpenter, R.S., Goodrich, L.R., Baxter, G.M. et al. 13 Kanchanomai, C., Muanjan, P., and Phiphobmongkol,
(2008). Locking compression plates for pancarpal V. (2010). Stiffness and endurance of a locking
arthrodesis in a Thoroughbred filly. Vet. Surg. 37: compression plate fixed on fractured femur. J. Appl.
508–514. Biomech. 26: 10.
6 Freeman, A.L., Tornetta, P. 3rd, Schmidt, A. et al. (2010). 14 Keller, S.A., Furst, A.E., Kircher, P. et al. (2015). Locking
How much do locked screws add to the fixation of compression plate fixation of equine tarsal
“hybrid” plate constructs in osteoporotic bone? subluxations. Vet. Surg. 44: 949–956.
J. Orthop. Trauma 24: 163. 15 Kuemmerle, J.M., Kuhn, K., Bryner, M., and Furst, A.E.
7 Gardner, M.J., Evans, J.M., and Dunbar, R.P. (2009). (2013). Equine ulnar fracture repair with locking
Failure of fracture plate fixation. J. Am. Acad. Orthop. compression plates can be associated with inadvertent
Surg. 17: 647. penetration of the lateral cortex of the radius. Vet. Surg.
8 Glassner, P.J. and Tejwani, N.C. (2011). Failure of 42: 790–794.
proximal femoral locking compression plate: a case 16 Levine, D.G. and Richardson, D.W. (2007). Clinical use
series. J. Orthop. Trauma 25: 76. of the locking compression plate (LCP) in horses: a
www.ajlobby.com
retrospective study of 31 cases (2004–2006). Equine. 19 Sod, G.A., Riggs, L.M., Mitchell, C.F. et al. (2010). An in
Vet. J. 39: 401–406. vitro biomechanical comparison of a 5.5 mm locking
17 Perren, S.M. (2002). Evolution of the internal fixation of compression plate fixation with a 4.5 mm locking
long bone fractures. The scientific basis of biological compression plate fixation of osteotomized equine
internal fixation: choosing a new balance between third metacarpal bones. Vet. Surg. 39: 581–587.
stability and biology. J. Bone Joint Surg. Br. 84: 1093. 20 Sod, G.A., Riggs, L.M., Mitchell, C.F. et al. (2010).
8 Plecko, M., Lagerpusch, N., Pegel, B. et al. (2012). The
1 In vitro biomechanical comparison of a modified
influence of different osteosynthesis configurations 5.5 mm locking compression plate fixation with
with locking compression plates (LCP) on stability and a 5.5 mm locking compression plate fixation of
fracture healing after an oblique 45° angle osteotomy. osteotomized equine third metacarpal bones. Vet.
Injury 43: 1041–1051. Surg. 39: 833–838.
www.ajlobby.com
163
11
Bone Grafts and Bone Substitutes
Mark D. Markel
Introduction 0.1–1.0 mm of the bone surface survive if handled

properly by keeping the bone graft wrapped in a blood‐
Bone grafts have been used for augmentation of bone soaked sponge prior to transplantation.20 Cancellous
repair for over a century.8,69 They have been principally bone has a large surface area and more cells survive per
applied to enhance fracture repair, for treatment of seg unit volume of graft than in cortical bone grafts. Therefore,
mental bone loss secondary to tumor or trauma, for autogenous cancellous bone has a greater potential to
treatment of osteomyelitis, and for revision of total joint form new bone than autogenous cortical bone.
arthroplasty. Autogenous bone has repeatedly been The second mechanism by which bone graft causes
shown to be superior to all other types of bone grafts bone formation is osteoinduction. Osteoinduction is the
or bone substitutes, but because of limited supply and process of recruitment of mesenchymal precursor cells
difficulty in reconstructing large segmental bone to differentiate into preosteoblasts or chondroblasts,
defects, allogeneic bone and bone substitutes have been resulting in cartilage and bone production.20,68 As dis
developed for application in many of these circum cussed in Chapter 12, bone morphogenetic proteins
stances.33,65,73 In horses, abundant sources of autogenous (BMPs) and some other members of the TGF‐β (trans
bone are found in the ilium and sternum, and to a lesser forming growth factor‐β) superfamily are responsible for
extent in the proximal tibia; therefore, sources of bone the recruitment and differentiation of these mesenchy
augmentation beyond autogenous graft have been mal precursor cells.33,68
explored to only a limited degree. This chapter describes The third mechanism by which bone graft augments
the biologic events, typical applications, and outcomes bone healing is osteoconduction.18 Osteoconduction
related to the use of autografts in bone, and presents occurs through provision of a matrix for the ingrowth of
application of other sources of osteoinduction or osteo recipient site capillaries, perivascular tissue, and osteo
conduction, such as allografts and bone substitutes. progenitor cells necessary for bone formation.33,68 The
graft functions as a scaffold and mechanically supporting
structure during bone replacement.
The ultimate goal of bone grafting, whether with
Bone Graft Biology autogenous bone or a bone substitute, is for the grafted
site to assume a load‐bearing capacity and support the
Bone grafts, whether they are autogenous, allogeneic, forces developed during daily activities. As in fracture
xenogeneic, or synthetic, serve one of three major healing, bone graft incorporation typically proceeds in
functions – they either provide cells for osteogenesis, defined phases over a prolonged period of time.32
bone production through osteoinduction, and/or they Initially, there is the inflammatory phase which begins
act as mechanical support, which is called osteoconduc within hours of grafting. During this phase, inflamma
tion.3,6,33,35 Autogenous bone can result in primary osteo- tory cells and fibroblasts are recruited into the grafted
genesis within the recipient bed via synthesis of new site via chemical messengers such as kinins, complement
bone by the cells of the graft or by the cells of the host. factors, histamine, serotonin, prostaglandins, and leu
Though the majority of graft cells die, some cells within kotrienes. Mesenchymal cells begin proliferating by

www.ajlobby.com
Table 11.1 Autograft/allograft characteristics.
Structural
Bone graft strength Osteogenesis Osteoinduction Osteoconduction
Autograft
Cancellous No 3 3 3
Cortical 3 2 2 2
Allograft
Cancellous
Frozen No No 1 2
Freeze‐dried No No 1 2
Cortical
Frozen 3 No No 1
Freeze‐dried 1 No No 1
Score: No (none) to 3 (excellent).

Source: Adapted from Giannoudis et al. 2005.28 Reproduced with permission of Elsevier.
Day 3, with recognizable chondrocytes present by Day 5 lous bone has the greatest osteogenic capacity of any of
and osteoblasts within the graft bed by Day 10.33 The the bone grafts, and is therefore a potent osteoinductive
osteoinduction of pluripotent stem cells by members of agent (Table 11.1). Because its use is widespread, cancel
the TGF‐β superfamily, including the BMPs, occurs in lous bone harvesting and grafting in the horse will be
the first few weeks after bone grafting. In contrast, osteo described in detail.
conduction requires months in cancellous grafts, and it
may take years to completely replace a cortical graft. As Surgical Technique
in fracture healing, bone remodeling occurs through a To limit total surgery time, it is recommended that a sec
process of bone resorption followed by bone formation. ond surgical team be used to harvest the graft. The graft
Bone remodeling ultimately enhances the mechanical should be collected so that it will be immediately availa
properties of the grafted bone, so that it can act as an ble for application to the host bed. This ensures maxi
efficient supporting structure for the skeleton. Bone mum cellular survival and osteogenic capabilities.3,70 If
grafts often proceed through a period of mechanical
there is a lag from the time of harvesting to the time of
weakness due to bone resorption prior to bone reforma
graft application, the graft should be stored in blood‐
tion. The final outcome of a bone graft is dependent on
soaked sponges, since exposure to air or saline‐soaked
the type of bone grafted. Cancellous bone grafts are
sponges may cause increased cell death.3 In addition, the
completely resorbed and replaced by new bone within a graft should not be directly treated with antibiotic solu
few months of grafting. Cortical bone grafts may never tions, since antimicrobial agents may also decrease cel
be completely resorbed, and the site can remain a com lular survival.36 When the recipient region is ready for
posite of dead bone of the original graft and viable new graft application, the bone graft should be lightly packed
host bone. This admixture of dead and live bone is typi into the host bed. If packed too vigorously, excessive
cally weaker, with poorer resistance to fatigue loading pressure in the site may decrease cell survival and revas
and subsequent microcracking, compared to normal cularization. For bone grafts to be effective, it is impera
cortical bone. tive that the fracture bed and graft are stable in order to
allow for bone ingrowth.
Types of Bone Graft

Harvest Sites
Three principal sites are used for bone graft harvesting
Cancellous Bone in the horse: the sternum, the tuber coxae, and the proxi
Cancellous bone is the most common form of bone graft mal tibia (Figure 11.1). All three are readily accessible,
used in the horse, for two important reasons. First, abun although the tuber coxae has the greatest potential vol
dant cancellous bone is available in the horse and there is ume of available graft, followed by the sternebrae, and
little morbidity associated with harvest. Second, cancel then the proximal tibia.
www.ajlobby.com
(B)
(C)
(A)
Figure 11.2 Sagittal section of the sternum demonstrating the

location and quantity of cancellous bone. CR, cranial aspect; VN,
ventral aspect.
Figure 11.1 Illustration depicting three common sites of

autogenous cancellous bone graft collection in the horse: (A) the
sternum, (B) the tuber coxae, and (C) the proximal tibia.
Sternebrae
The sternum has several advantages as a source of can
cellous bone for grafting.55 First, the site is easily accessed,
particularly when the horse is in dorsal recumbency.
Second, the sternum is dependent and hidden, so if
infection or incisional dehiscence occurs, drainage is
easily achieved and a scar is not visible. Third, the site
can provide a large volume of high‐quality bone graft.
The one major disadvantage of the site is that if a horse
is in lateral recumbency for the repair of a proximal
forelimb fracture, the two surgical teams may impede
each other during the harvesting of the graft. Figure 11.3 Ilium sectioned in a broad obliquely horizontal plane
For the approach, a straight median incision is made demonstrating the location and quantity of cancellous bone. CR,
over the sternum, beginning approximately 20 cm cranial cranial aspect; TC, tuber coxae; TS, tuber sacrale; VN, ventral aspect.
to the xiphoid, and extending 5–10 cm caudally. The pec
toral muscles on both sides of the hyaline cartilage of the
sternum are elevated with a periosteal elevator for c omplication that has been reported with the use of the
1–2 cm abaxial to the midline of the sternum. Large ron sternum as a donor site is dehiscence of the incision,
geurs are used to remove a 2 cm long section of hyaline although the wound will heal secondarily without
cartilage until cancellous bone is seen. If cancellous bone difficulty.
is not evident after removing a depth of 1–2 cm of hya
line cartilage, the procedure is repeated 1–2 cm cranial Tuber Coxae
or caudal to this site. A large curette is used to remove A straight to slightly curved skin incision is made over
as much cancellous bone as needed. If necessary, the the tuber coxae, through the subcutaneous tissue and fat
incision is lengthened and as many as six sternebrae can pad, and down to the bone.63,70 A 1–2 cm cortical bone
be accessed for cancellous bone harvesting (Figure 11.2). plug is removed, and set aside, from the tuber coxae,
If smaller volumes of cancellous bone are required, a sin to gain access to the cancellous bone within the tuber
gle sternebra can be exposed through a 3 cm incision, a coxae (Figure 11.3). Cancellous bone is harvested with
self‐retaining retractor inserted, and a rongeur used to a curette, carefully avoiding the thin inner cortex of the
remove muscle and cartilage to open an individual stern ilium so that it is not fractured. The cortical plug is
ebra. Care should be taken not to incorporate hyaline replaced after cancellous bone harvesting, and the fat
cartilage into the bone graft. The muscle, subcutaneous pad and subcutaneous tissues are closed routinely. The
tissues, and skin are apposed routinely. The only skin should be apposed with tension sutures, and a
www.ajlobby.com
stent applied over the site to protect the incision from Vascularized Bone
excessive trauma in recovery or after surgery. The only
significant complication that can occur secondary to Although attempted in numerous laboratories, free
using this site for cancellous bone harvest is traumatic transfer of bone, skin, or muscle flaps has been univer
dehiscence of the wound after surgery. The wound can sally unsuccessful in the horse. Invariably, the venous
be difficult to manage, since drainage from this location side, or more rarely the arterial side, of the graft throm
is not easily achieved. boses, resulting in venous congestion and death of the
graft. With further advances in managing the equine
fibrinolytic and hemostatic pathways, we may someday
Proximal Tibia be able to overcome these difficulties. The advantages
A straight incision is made over the medial aspect of the of vascularized bone graft are simple. Cancellous bone
proximal tibia through the skin, subcutaneous tissue, grafts are rapidly remodeled after surgery, but cannot
and periosteum.5 The marrow cavity is accessed with a bear significant loads during this time. In contrast,
4.5 or 5.5 mm drill bit, and bone marrow is removed with although cortical bone grafts can bear significant loads
a curette. The deep tissues and skin are closed routinely, after surgery, they gradually weaken as they
and a stent bandage is applied over the incision. The only remodel.12,13,25,32,74 Vascularized bone grafts provide
significant complication that has been reported with this load‐bearing capacity without concomitant secondary
technique is fracture of the tibia secondary to stress con porosity and weakening.34 Experimental and clinical
centration of the drill hole or holes. This complication studies have shown that immediate vascularization
can be minimized by limiting cortical holes to less than of cortical autografts improves osteocyte survival and
5.5 mm. enhances bony incorporation.1,4,21,22,34,53,59,60,62,66,71,72
The remainder of the chapter discusses other sources These grafts heal at their ends with little resorption of
of osteoinductive and osteoconductive materials. The the grafted bone. In humans, good clinical results have
majority of these materials are not used in equine sur been reported in cases in which the fibula was trans
gery at this time, but a few have significant potential for planted with its vascular pedicle into segmental cortical
application to the horse in the future. defects.62,66,72 Healing is rapid and the bone graft hyper
trophies secondary to load transfer through the graft.
Vascularized bone grafts have been used to reconsti
Cortical Bone tute segmental bone loss in clinical situations such as
Cortical bone grafts heal much more slowly than cancel osseous gaps greater than 6 cm, deficient soft tissue, and
lous bone grafts, but follow the same sequential pro chronic infection. By providing immediate vascularity,
cesses.25,33 This delay is related to slowed revascularization the slow process of repair by osteonal remodeling is cir
in cortical grafts secondary to the limited porosity of cumvented, improving the chances of clinical success.
cortical bone. For cortical bone to be remodeled, it first
has to be invaded by osteoclasts, which resorb regions
of bone, allowing vascular invasion. Therefore, the
Allografts
incorporation of cortical grafts is starkly different to Allograft bone is the most commonly chosen bone substi
cancellous grafts, because incorporation is initiated by tute and in human orthopedics is regarded as the surgeon’s
osteoclasts rather than osteoblasts. Cortical resorption next best option to autograft bone.16,28,48 Over the past
begins approximately two weeks after surgery, and can decade, the use of allografts in humans has increased 15‐
take months to years to be completed, depending on the fold and accounts for approximately one‐third of bone
size of the graft. Because osteoclasts can resorb bone at grafts performed in the United States. Allograft bone can
a relatively high rate, 50 μm day−1, and osteoblasts can be used as cancellous bone chips, as cortical bone, and as
only form bone at 1 μm day−1, cortical bone becomes osteochondral grafts (Table 11.1).28,58 Cancellous bone
significantly more porous and structurally weaker as it allografts function poorly in comparison to cancellous
remodels.13,14,33 It is predisposed to fracture if it is not autografts. Fresh cancellous allografts invoke a vigorous
adequately protected during this period. Even under immune response in the first two weeks after surgery,
ideal circumstances, more than 40% of the original which delays and eventually destroys the osteoinductive
necrotic bone remains in cortical bone grafts at ability of the graft.23,33 Osteoconduction is also delayed,
one year.33 The graft probably always retains some mix because blood vessels in the fresh allografts are rapidly
ture of original necrotic bone and new bone, although occluded by inflammatory cells. Cancellous bone allo
over time the graft is remodeled via cutting cones and grafts that have been preserved, either by freezing or
longitudinally directed osteons in response to the freeze‐drying, appear to incorporate much better than
stresses to which the graft is subjected. fresh allografts. Preserved allografts revascularize and
www.ajlobby.com
Table 11.2 Osteoconductive scaffolds.
Type Graft Osteogenesis Osteoinduction Osteoconduction Advantages
Bone Autograft 2 2 3 “Gold standard” Available in many

Allograft No 1 3 forms
Biomaterials DBM No 2 1 Supplies BMPs, bone graft extender
Collagen No No 2 Good as delivery system
Ceramics TCP, hydroxyapatite No No 1 Biocompatible
Calcium phosphate No No 1 Possibly some initial structural
cement (CPC) support
Composite β‐TCP/BMA composite 2 2 3 Ample supply
grafts BMP/synthetic composite – 3 – Potentially limitless supply
Score: No (none) to 3 (excellent).

BMA, bone marrow aspirate; BMP, bone morphogenetic protein; DBM, demineralized bone matrix; TCP, tricalcium phosphate.
remodel more slowly than autografts, but allografts do Bone Graft Substitutes
provide osteoinduction and osteoconduction in the
graft bed.33 Optimally, a bone graft substitute should be osteocon
Allografts have also been implanted as cortical bone, ductive, osteoinductive, bioresorbable, biocompatible,
either as strips of bone or as large bone grafts. When easy to use, and cost‐effective.28 There are a significant
transplanted in this fashion, the graft undergoes similar number of bone graft substitutes that are currently com
early phases of the inflammatory process, in a manner mercially available for human orthopedic use. Few of
similar to that described for autografts. As the allograft these are used in veterinary orthopedics, although many
revascularizes, however, the host becomes sensitized have the potential to augment bone healing. Table 11.2
to graft‐derived cellular antigens. The initial inflamma highlights a variety of bone graft substitute materials and
tory response subsides, and a specific immunologically their ability to serve in an osteoconductive, osteoinductive,
directed lymphoplasmacytic infiltration occurs.27 The or osteogenic capacity.
graft vessels ultimately become occluded and necrosis
of the graft ensues. Because fresh cortical allografts
perform so poorly, preservation of the graft is preferred.
Demineralized Bone Graft
The method of preparation is typically designed to Demineralized bone grafts are widely used in human
minimize host immune response, and therefore viable orthopedics.28,30 The typical form of these grafts is
cells are not present to provide osteogenesis in these demineralized bone matrix (DBM), which is produced
grafts. The more aggressive the allograft processing, through decalcification of cortical bone. DBM retains
the less intense the immunologic response from the the trabecular collagenous structure of the original tissue
host.23,28,64 Frozen allografts induce stronger immune and can serve as an osteoconductive scaffold, despite the
responses than freeze‐dried allografts.52 Allografts typ loss of structural strength once contributed by the min
ically are processed through two primary means: freez eral.47 DBM is used in three clinical forms in human sur
ing and demineralization. Freeze‐dried (lyophilized) gical application. Fine powders provide the largest
allografts are usually washed twice in antibiotics, fro surface area and are preferred for small defects.31,50,61 For
zen at −70 °C, and dried down to 5% water. Fresh‐frozen cystic lesions, small chips of DBM can provide a porous,
allografts are more osteoinductive and stronger than spongy surface to fill defects of this type.30 Segmental
these freeze‐dried grafts. One advantage of freeze‐ defects have been treated with large corticocancellous
dried bone is its indefinite shelf‐life. The shelf‐life of blocks or strips, because they can be easily carved to fit
fresh‐frozen bone stored at −20 °C is one year, and can the dimensions of the defect.
be extended to five years if stored at −70 °C.28 In sum Demineralized bone grafts are potent osteoinductive
mary, although freezing or freeze‐drying of cortical stimulants.30 They have been shown to induce endo
allografts succeeds in reducing the initial inflammatory chondral bone formation in heterotopic and ortho
stage of incorporation, resorption and diminished bone topic sites. Precursor cells are attracted to the graft
formation remain prominent concerns during allograft and are stimulated to become chondroblasts. These
incorporation. cells produce cartilaginous matrix that becomes
www.ajlobby.com
c alcified before being replaced by bone through endo disadvantages of these materials in surgery include low
chondral bone formation. DBM does not act as an or unpredictable resorption, difficulty in handling (for
osteoconductive agent, even in membranous bone, example coral‐derived HA), and occasional inflamma
but rather as an osteoinductive agent, first producing tory foreign body reaction.7,11,19 Many of the newer,
cartilage, which is then replaced by bone via endo modified materials have overcome these complications.
chondral ossification.
Generally, demineralized bone grafts stimulate healing
within three to six months of implantation. Long‐term Ceramics
complications with these grafts are rare as long as the Ceramics are synthetic scaffolds that are made from
grafts are used appropriately. In weight‐bearing, seg calcium phosphate, and have been used in human ortho
mental defects, prolonged fixation is required to protect pedics and dentistry since the 1980s.39,67 TCP ceramic
the grafts, since they do not have load‐carrying capabili has a stoichiometry that is similar to amorphous bone
ties when implanted.30 The advantages of this technique precursors, whereas HA has a stoichiometry similar to
are that a harvesting procedure is not required, there bone mineral. Bone ceramics possess no osteogenic or
is a theoretically unlimited supply of graft that can be osteoinductive properties, and demonstrate minimal
prepared, the osteoinductive process is rapid, and no late immediate structural support. When attached to healthy
graft resorption has been reported when the graft has bone, osteoid is laid directly onto the surface of the
been used in craniofacial surgery. ceramic in the absence of a soft tissue interface. The
osteoid subsequently mineralizes and the resulting new
Collagen bone undergoes remodeling. Both TCP ceramic and
HA are highly biocompatible. They differ in their bio
Extracellular bone matrix is approximately 95% collagen. logic response at the host site, with porous TCP ceramic
Collagen contributes to the bone formation process, being removed from the implant site as bone grows into
including mineral deposition, vascular ingrowth, and the scaffold, while HA is a more permanent resident in
growth factor binding.19 Despite these benefits, collagen the implant site.
has potential immunogenicity and provides minimal The surface layers of TCP ceramic enhance bonding of
structural support. To date, collagen’s primary use has adjacent host bone and stimulate osteoclastic resorption
been as a delivery system for other osteoconductive, and osteoblastic new bone formation within the resorbed
osteoinductive, or osteogenic factors.26 As a sole bioma implant.49 TCP ceramic has been studied experimentally
terial, collagen functions poorly as a graft material, but in the horse for grafting of segmental defects in the
if it is coupled with BMPs, osteoprogenitor precursors, equine third metacarpal bone. TCP ceramic cylinders,
or hydroxyapatite (HA), graft incorporation can be 11 mm in diameter, were implanted into the metaphysis
significantly enhanced. Collagen is typically used as
of the third metacarpal bone.2,56 Within six to nine months,
a composite with other bone substitutes such as gels, substitution and partial degradation of the implant
granules, biphasic ceramics of HA and tricalcium
occurred. The implant was vacuolized in cancellous
phosphate (TCP), or bone marrow.17,51,75 regions and replaced by cortical bone in cortical regions.
In articular defects, fibrocartilage covered the implants
along the articular surfaces.56
Synthetic Bone Substitutes There are several injectable calcium phosphate cements
that are ceramic composites used as void fillers. For
Many advances have been made with synthetic bone example, α‐TCP can be mixed with calcium carbonate
substitutes over the past decade. Until very recently, syn and monocalcium phosphate monohydrate and prepared
thetic bone substitutes were the third choice behind as a moldable paste that can be injected into the fracture
autografts and allografts in human orthopedic surgery.28 site or bone defect, which then hardens at body tem
At best, synthetic bone substitutes possess only two of perature without generating significant additional heat.
the desirable characteristics of an ideal bone graft: oste The initial compressive strength of this product is similar
oinduction and osteoconduction. Optimally, synthetic to that of cancellous bone and undergoes long‐term
bone substitutes should be biocompatible, show mini remodeling. Many of these injectable products have a
mum inflammatory reaction, undergo remodeling, and wide range of porosities, mechanical properties, and
support new bone formation. Synthetic bone substitutes resorption profiles. Some are extremely hard, requiring
should also have similar strength to the cortical/cancel many years to resorb, whereas others are designed to frag
lous bone that is being replaced. Synthetic materials ment and resorb relatively rapidly after implantation.46,57
that demonstrate some of these material properties are Ultraporous β‐TCP is a highly porous void filler that is
composed of calcium, silicon, or aluminum. Some of the composed of 90% interconnected void space with a broad
www.ajlobby.com
range of pore sizes (1–1000 μm). The porosity of the properties. A strong bond can form between bioactive
material allows phagocytic resorption and infiltration by glass and bone through HA crystals similar to that of
bone‐forming cells. β‐TCP is available in a porous or bone.37 Bioactive glasses have significantly greater
solid form as either granules or blocks. Larger pore sizes mechanical strength when compared to calcium phos
encourage vascularization and bone ingrowth. Like all phate preparations such as ceramic HA. Bioactive glass
ceramic scaffolds, β‐TCP does not provide intrinsic oste blocks can be difficult to drill and shape. They have been
ogenic or osteoinductive properties.10,42,45 used as successful bone graft expanders.44,54
Porous HA functions well as an osteoconductive mate Bioactive ceramics, a new variation of bioactive glass,
rial experimentally.11,38,41 Formation of osteons is pre are stronger than bioactive glasses with improved
ceded by ingrowth of blood vessels into the gaps within mechanical properties. However, they are relatively brit
the HA. Experimentally, HA has been used in the horse tle and prone to fracture with cyclic loading. In order to
for repair of intraarticular subchondral defects.29 At improve the fracture toughness of bioactive glasses and
six months, the deeper areas of the implant were replaced bioactive ceramics, incorporation of stainless‐steel fibers
by bone, but the more superficial areas near the articular has been investigated to increase bending strength.
surface did not fill with bone. HA is more brittle and Increased bending strength and toughness have also
undergoes slower resorption than TCP ceramic, with the been induced by incorporation of ceramic particles (zir
potential to become a mechanical stress riser with subse conia) into apatite‐wollastonite (AW) glass ceramic.15
quent failure if not adequately protected with metallic
implants. HA is often modified and combined with other
materials to improve functionality and faster resorption. Glass Ionomers
These materials include TCP ceramic as well as autoge Glass ionomer cements were first used in the dental field.
nous cancellous bone. Ionomeric cement consists of calcium/aluminum/fluo
Coralline HA is a natural material derived from sea rosilicate/powder mixed with polycarboxylic acid to pro
coral. Certain species of sea coral produce a structure duce a porous cement paste. The paste typically hardens
made of calcium phosphate (coralline) which is similar to in 5 minutes and at 24 hours has mechanical properties
human cancellous bone. Coralline substitutes may be comparable to cortical bone. It is both biocompatible
natural or manufactured. The natural form is harvested and osteoinductive, in a manner comparable to bioactive
directly from the oceans, whereas the manufactured glasses. Its porous structure aids in osteoconduction and
form (coralline HA) is converted from natural coralline. subsequent bone formation. It is nonresorbable and
The material has high compressive strength, but is brittle therefore not replaced by bone, and is considered as a
with low tensile strength. In human orthopedic surgery, potential replacement for polymethyl‐methacrylate
coralline HA has been used as filler material, in the man (PMMA), but without the exothermic reaction that
agement of fractures of the tibial plateau, and results occurs with PMMA. Glass ionomers may also be impreg
have been comparable to those obtained with autoge nated with antibiotics and high molecular weight pro
nous bone graft. Coralline HA has also been used as a teins for slow release.9,43
carrier for some growth factors and BMP.24,40
Biologic/Synthetic Composite Grafts
Bioactive Glasses
One of the most promising surgical options for enhanc
Bioactive glasses are hard, nonporous materials consisting ing fracture healing and the treatment of bone defects is
of calcium, phosphorous, and silicate (silicon dioxide). By the use of composite grafts that contain osteogenic cells
varying the properties of sodium oxide, calcium oxide, and osteoinductive growth factors along with a synthetic
and silicon dioxide, a material can be produced that osteoconductive matrix. The discussion of these sub
ranges from soluble to nonresorbable. Bioactive glasses stances as they relate to bone grafting is presented in
can possess both osteoinductive and osteoconductive Chapter 12.
References
1 Adelaar, R.S., Soucacos, P.N., and Urbaniak, J.R. (1974). 3 Bassett, C.A.L. (1972). Clinical implications of cell
Autologous cortical bone grafts with microsurgical function in bone grafting. Clin. Orthop. 87: 446–456.
anastomosis of periosteal vessels. Surg. Forum 25: 487–489. 4 Berggren, A., Weiland, A.J., and Dorfman, H. (1982).
2 Auer, J.A. and Schenk, R. (1989). The application of Free vascularized bone grafts: factors affecting their
tricalcium phosphate cylinders in articular and cortical survival and ability to heal to recipient bone defects.
defects in the horse. Vet. Surg. 18: 73. Plast. Reconstr. Surg. 69: 19–29.
www.ajlobby.com
5 Boero, M.J., Schneider, J.E., Mosier, J.E. et al. (1989). pedicles: an experimental study in dogs. J. Bone Joint
Evaluation of the tibia as the source of autogenous Surg. Am. 59: 809–815.
cancellous bone in the horse. Vet. Surg. 18: 322–327. 23 Ehrler, D.M. and Vaccaro, A.R. (2000). The use of
6 Bonfiglio, M. and Jeter, W.S. (1972). Immunological allograft bone in lumbar spine surgery. Clin. Orthop.
responses to bone. Clin. Orthop. 87: 19–27. 371: 38–45.
7 Bostman, O. and Pihlajamaki, H. (2000). Clinical 24 Elsinger, E.C. and Leal, L. (1996). Coralline
biocompatibility of biodegradable orthopaedic implants hydroxyapatite bone graft substitutes. J. Foot Ankle
for internal fixation: a review. Biomaterials 21: Surg. 35: 396–399.
2615–2621. 25 Enneking, W.F., Burchardt, H., Phyl, J.J. et al. (1975).
8 Boyce, T., Edwards, J., and Scarborough, N. (1999). Physical and biological aspects of repair in dog
Allograft bone: the influence of processing on safety cortical‐bone transplants. J. Bone Joint Surg. Am. 57:
and performance. Orthop. Clin. North Am. 30: 237–252.
571–581. 26 Fleming, J.E. Jr., Cornell, C.N., and Muschler, G.F.
9 Brook, I.M. and Hatton, P.V. (1998). Glass‐ionomers: (2000). Bone cells and matrices in orthopedic tissue
bioactive implant materials. Biomaterials 19: 565–571. engineering. Orthop. Clin. North Am. 31: 357–374.
10 Bruder, S.P., Kraus, K.H., Goldberg, V.M., and Kadiyala, 27 Friedlaender, G.E., Strong, D.M., Tomford, W., and
S. (1998). The effect of implants loaded with autologous Mankin, H.J. (1999). Long‐term follow‐up of patients
mesenchymal stem cells on the healing of canine with osteochondral allografts. A correlation between
segmental bone defects. J. Bone Joint Surg. Am. 80: immunologic responses and clinical outcome. Orthop.
985–996. Clin. North Am. 30: 583–588.
11 Bucholz, R.W., Carlton, A., and Holmes, R. (1989). 28 Giannoudis, P.V., Dinopoulos, H., and Tsiridis, E.
Interporous hydroxyapatite as a bone graft substitute in (2005). Bone substitutes: an update. Injury 36S:
tibial plateau fractures. Clin. Orthop. 240: 53–62. S20–S27.
12 Burchardt, H., Busbee, G.A. II, and Enneking, W.F. 29 Gillis, J.P., Auer, J.A., and Holmes, R.E. (1987). The use
(1975). Repair of experimental autologous grafts of of a porous bioimplant in the treatment of subchondral
cortical bone. J. Bone Joint Surg. Am. 57: 814–819. bone cysts in the horse. Vet. Surg. 16: 90.
13 Burchardt, H., Jones, H., Glowczewskie, F. et al. (1978). 30 Glowacki, J. (1992). Tissue response to bone‐derived
Freeze‐dried allogeneic segmental cortical‐bone grafts implants. In: Bone Grafts and Bone Substitutes (ed.
in dogs. J. Bone Joint Surg. Am. 60: 1082–1090. M.B. Habal and A.H. Reddi), 84–92. Philadelphia: W.B.
14 Burwell, R.G. and Gowland, G. (1961). Studies in the Saunders.
transplantation of bone: I. Assessment of antigenicity. 31 Glowacki, J., Altobelli, D., and Mulliken, J.B. (1981).
Serological studies. J. Bone Joint Surg. Br. 43: 814–819. The fate of mineralized and demineralized osseous
15 Cao, W. and Hench, L.L. (1996). Bioactive materials. implants in cranial defects. Calcif. Tissue Int. 33:
Ceram. Int. 22: 493–507. 71–76.
16 Carter, G. (1999). Harvesting and implanting allograft 32 Goldberg, V.M., Shaffer, J.W., Stevenson, S. et al. (1991).
bone. AORN J. 70: 660–670. Biology of vascularized bone grafts. In: Bone and
17 Chapman, M.W., Bucholz, R., and Cornell, C. (1997). Cartilage Allografts: Biology and Clinical Applications
Treatment of acute fractures with a collagen‐calcium (ed. G.E. Friedlaender and V.M. Goldberg), 13–26. Park
phosphate graft material: a randomized clinical trial. J. Ridge, IL: American Academy of Orthopaedic
Bone Joint Surg. Am. 79: 495–502. Surgeons.
18 Constantino, P.D. and Freidman, C.D. (1994). Synthetic 33 Goldberg, V.M. and Stevenson, S. (1989). Bone
bone graft substitutes. Otolaryngol. Clin. North Am. 27: transplantation. In: Surgery of the Musculoskeletal
1037–1073. System, 2e (ed. C.M. Evarts), 54–81. New York:
19 Cornell, C.N. (1999). Osteoconductive materials and Churchill Livingstone.
their role as substitutes for autogenous bone grafts. 34 Goldberg, V.M., Stevenson, S., and Shaffer, J.W. (1991).
Ortho. Clin. North Am. 30: 591–598. Biology of autografts and allografts. In: Bone and
20 Cypher, T.J. and Grossman, J.P. (1996). Biological Cartilage Allografts: Biology and Clinical Applications
principles of bone graft healing. J. Foot Ankle Surg. 35: (ed. G.E. Friedlaender and V.M. Goldberg), 3–12. Park
413–417. Ridge, IL: American Academy of Orthopaedic
21 Davis, P.K., Mazur, J.M., and Coleman, G.N. (1982). A Surgeons.
torsional strength comparison of vascularized and 35 Gray, J.C. and Elves, M.W. (1979). Early osteogenesis
nonvascularized bone grafts. J. Biomech. 15: 875–880. in compact bone isografts: a quantitative study
22 Doi, K., Tominaga, S., and Shibata, T. (1977). Bone of contributions of the different graft cells. Calcif.
grafts with microvascular anastomoses of vascular Tissue Int. 29: 225–237.
www.ajlobby.com
36 Gray, J.C. and Elves, M.W. (1981). Osteogenesis in bone 51 Muschler, G.F., Hyodo, A., Manning, T. et al. (1994).
grafts after short term storage and topical antibiotic Evaluation of human bone morphogenetic protein 2 in
treatment. J. Bone Joint Surg. Br. 63: 441–445. a canine spinal fusion model. Clin. Orthop. 308:
37 Gross, V. and Brandes, J. (1981). The ultrastructure of 229–240.
the interface between a glass ceramic and bone. 52 Muscolo, D.L., Caletti, E., Schajowicz, F. et al. Tissue‐
J. Biomed. Mater. Res. 15: 291–305. typing in human massive allografts of frozen bone.
38 Hollinger, J.O. and Battistone, G.C. (1986). J. Bone Joint Surg. Am. 69: 583–595.
Biodegradable bone repair materials. Synthetic 53 Ostrup, L.T. and Fredrickson, J.M. (1975).
polymers and ceramics. Clin. Orthop. 207: 290–305. Reconstruction of mandibular defects after radiation,
39 Hollinger, J.O. and Brekke, J. (1996). Role of bone using a free, living bone graft transferred by
substitutes. Clin. Orthop. 324: 55–65. microvascular anastomosis: an experimental study.
40 Holmes, R.E. (1979). Bone regeneration within a Plast. Reconstr. Surg. 55: 563–572.
coralline hydroxyapatite implant. Plast. Reconstr. Surg. 54 Peltola, M., Suonpaa, J., Aitasalo, K. et al. (2000).
63: 626–633. Experimental follow‐up model for clinical frontal sinus
41 Holmes, R.E., Bucholz, R.W., and Mooney, V. (1987). obliteration with bioactive glass. Acta Otolaryngol.
Porous hydroxyapatite as a bone graft substitute in Suppl. 543: 167–169.
diaphyseal defects: a histometric study. J. Orthop. Res. 55 Richardson, G.L., Pool, R.R., Pascoe, J.R., and Wheat,
5: 114–121. J.D. (1986). Autogenous cancellous bone grafts from
42 Johnson, K.D., Frierson, K.E., Keller, T.S. et al. (1996). the sternum in horses. Comparison with other donor
Porous ceramics as bone graft substitutes in long bone sites and results of use in orthopedic surgery. Vet. Surg.
defects: a biomechanical, histological, and radiographic 15: 9–15.
analysis. J. Orthop. Res. 14: 351–369. 56 Rose, P.L., Auer, J.A., Hulse, D. et al. (1988). Effect of
43 Jonck, L.M. and Grobbelaar, C.J. (1989). The biological beta‐tricalcium phosphate cylinders in surgically
compatibility of glass ionomer cement in joint created subchondral bone defects in male horses. Am. J.
replacement. Clin. Mater. 4: 85–107. Vet. Res. 49: 417–424.
44 Kinnunen, I., Aitasalo, K., Pollonen, M., and Varpula, 57 Sanchez‐Sotelo, J., Munuera, L., and Madero, R. (2000).
M. (2000). Reconstruction of orbital floor fractures Treatment of fractures of the distal radius with
using bioactive glass. J. Craniomaxillofac. Surg. 28: remodellable bone cement: a prospective, randomized
229–234. study using Norian SRS. J. Bone Joint Surg. Br. 82:
45 Kon, E., Muraglia, A., Corsi, A. et al. (2000). 856–863.
Autologous bone marrow stromal cells loaded onto 58 Sandhu, H.S., Grewal, H.S., and Parvataneni, H. (1999).
porous hydroxyapatite ceramic accelerate bone repair Bone grafting for spinal fusion. Orthop. Clin. North
in critical‐size defects of sheep long bones. J. Biomed. Am. 30: 685–698.
Mater. Res. 49: 328–337. 59 Schwarzenback, O., Regazzoni, P., and Aebi, M. (1989).
46 Kopylov, P., Runnqvist, K., Jonsson, K., and Aspenberg, Segmental vascularized and nonvascularized bone
P. (1999). Norian SRS versus external fixation in allografts. In: Bone Transplantation (ed. M. Aebi and
redisplaced distal radial fractures. A randomized study P. Regazzoni), 78–81. Berlin: Springer‐Verlag.
in 40 patients. Acta Orthop. Scand. 70: 1–5. 60 Shaffer, J.W., Field, G.A., Goldberg, V.M. et al. (1985).
47 Ludwig, S.C. and Boden, S.D. (1999). Osteoinductive Fate of vascularized and nonvascularized autografts.
bone graft substitutes for spinal fusion: a basic Clin. Orthop. 197: 32–43.
science summary. Orthop. Clin. North Am. 30 (4): 61 Sonis, S.T., Kaban, L.B., and Glowacki, J. (1983).
635–645. Clinical trial of demineralized bone powder in the
48 Mankin, H.J., Doppelt, S.H., Sullivan, T.R. et al. (1982). treatment of periodontal defects. J. Oral Med. 38:
Osteoarticular and intercalary allograft transplantation 117–121.
in the management of malignant tumors of bone. 62 Sowa, D.T. and Weiland, A.J. (1987). Clinical
Cancer 50: 613–630. applications of vascularized bone autografts. Orthop.
49 McAndrew, M.P., Gorman, P.W., and Lange, T.A. Clin. North Am. 18: 257–273.
(1988). Tricalcium phosphate as a bone graft substitute 63 Stashak, T.S. and Adams, O.R. (1975). Collection of
in trauma: preliminary report. J. Orthop. Trauma 2 (4): bone grafts from the tuber coxae of the horse. J. Am.
333–339. Vet. Med. Assoc. 167: 397–400.
50 Mulliken, J.B., Glowacki, J., Kaban, L.B. et al. (1974). 64 Strong, D.M., Friedlaender, G.E., Tomford, W.W. et al.
Use of demineralized allogenic bone implants for the (1996). Immunologic responses in human recipients of
correction of maxillocraniofacial deformities. Ann. osseous and osteochondral allografts. Clin. Orthop.
Surg. 1981: 366–372. 326: 107–114.
www.ajlobby.com
65 Summers, B.N. and Eisenstein, S.M. (1989). Donor site 71 Weiland, A.J. (1989). Fate of vascularized bone grafts.
pain from the ilium: a complication of lumbar spine In: Bone Transplantation (ed. M. Aebi and P.
fusion. J. Bone Joint Surg. Br. 71‐B: 677–680. Regazzoni), 29–50. Berlin: Springer‐Verlag.
66 Taylor, G.I. (1977). Microvascular free bone transfer: a 72 Weiland, A.J. and Daniel, R.K. (1979). Microvascular
clinical technique. Orthop. Clin. North Am. 8: 425–447. anastomoses for bone grafts in the treatment of massive
67 Truumees, E. and Herkowitz, H.N. (1999). Alternatives defects in bone. J. Bone Joint Surg. Am. 61: 98–104.
to autologous bone harvest in spine surgery. Univ. Pa. 73 Younger, E.M. and Chapman, M.W. (1989). Morbidity at
Orthop. J. 12: 77–88. bone graft donor sites. J. Orthop. Trauma 3: 192–195.
68 Urist, M.R. (1965). Bone: formation by autoinduction. 74 Zdelick, T.A., Shaffer, J.W., and Field, G.A. (1988). The
Science 150: 893–899. healing of vascularized segmental tibial osteotomies:
69 Van Heest, A. and Swiontowski, M. (1999). Bone‐graft the effect of retained endosteal circulation. Clin.
substitutes. Lancet 353 (Suppl 1): 28–29. Orthop. 236: 296–302.
70 von Rechenberg, G. and Auer, J.A. (2006). Bone grafts 75 Zerwekh, J.E., Kourosh, S., Scheinberg, R. et al. (1992).
and bone replacements. In: Equine Surgery, 3e (ed. J.A. Fibrillar collagen‐biphasic calcium phosphate
Auer and J.A. Stick), 1030–1036. St. Louis: Saunders composite as a bone graft substitute for spinal fusion.
Elsevier. J. Orthop. Res. 10: 562–572.
www.ajlobby.com
173
12
Biologic Agents to Enhance Fracture Healing
Mark D. Markel1 and Howard Seeherman2
1
2
Musculoskeletal Therapies, Wyeth Discovery Research, Wyeth Pharmaceuticals, Cambridge, MA, USA
Introduction cancellous bone grafting. Ideally, at least some of these

treatment strategies would be available to treat slow or
As highlighted in Chapter 3, fracture healing is a c omplex delayed union by transcutaneous application to the
process that involves the interaction of cells, molecular fracture in the standing horse. This chapter will discuss
mediators, vascularity, and stability.15,46 The local inflam biologic‐based strategies currently being developed for
matory process is initiated immediately after the frac acceleration of fracture healing, focusing on growth
ture, leading to cellular chemotaxis and activation of factors, gene therapy, and cell‐based strategies.
intracellular signaling molecules, cytokines, adhesion
molecules, and other autocoids.34,39,44,45
Every fracture in the horse presents unique challenges Bone Morphogenetic Proteins
for repair that require careful consideration regarding
how best to stabilize the fracture and enhance the likeli Many of the cell types within the fracture callus, includ
hood of bony union. Equine fractures are frequently ing osteoprogenitor cells, mesenchymal cells, osteoblasts,
comminuted and, despite improved fixation devices, the and chondrocytes, produce bone morphogenetic pro
repair in adults is often tenuous, necessitating rapid pro teins (BMPs). BMPs have consistently been shown to be
gression toward union to minimize the probability of one of the most successful accelerators of fracture healing
fixation failure or laminitis of the contralateral limb. available today.109 BMPs induce a cascade of events driv
New fixation methods have been developed to enhance ing chondrogenesis and osteogenesis, including chemot
fracture repair in horses, as outlined in other chapters. axis, mesenchymal and osteoprogenitor cell proliferation
However, complications such as delayed union or non and differentiation, osteogenesis, and s ynthesis of extra
union can still occur. Resulting instability with its associ cellular matrix (Table 12.1).4,109 The various BMP regula
ated lameness can lead to implant failure or contralateral tory effects depend on their local concentration, including
limb complications, such as laminitis in adult horses or interactions with other circulating factors, and on the tar
angular limb deformities and/or flexural deformities in geted cell and its stage of differentiation.49
young animals. As highlighted in Chapter 11, autoge Members of the BMP family are divided into four or
nous cancellous bone grafting is the most common tech more separate subgroups based on their primary
nique used to accelerate fracture healing, and remains amino acid sequence. Group 1 consists of BMP‐2 and
the gold standard for promoting union by stimulating BMP‐4; group 2 includes BMP‐5, BMP‐6, and BMP‐7;
osteoprogenitor cells at the fracture site. Despite the group 3 consists of growth and differentiation factor
availability of large volumes of bone graft in the horse, (GDF)‐5 (similar to BMP‐14), GDF‐6 (or BMP‐13),
there remains significant interest in developing other and GDF‐7 (or BMP‐12); and group 4 includes BMP‐3
treatment strategies that do not require surgical harvest (or osteogenin) and GDF‐10 (or BMP‐3B). BMP‐1 is
or that enhance fracture healing better than autogenous not a member of the transforming growth factor‐β

www.ajlobby.com
Table 12.1 Temporal and functional characteristics of members of the transforming growth factor‐β superfamily observed during fracture
healing in animal models.
Member of the
TGF‐β superfamily Time of expression Specific responses in vivo and in vitro
BMP‐2 Days 1–211,33(the earliest gene to be Recruitment of MSCs

induced and second elevation during Chondrogenesis
osteogenesis) May initiate the fracture healing cascade and regulate the
expression of other BMPs
BMP‐2, ‐6, ‐9 may be the most potent to induce osteoblast
lineage‐specific differentiation of MSCs.34
BMP‐3, ‐8 Days 14–211(restricted expression during Temporal data suggest a role in the regulation of osteogenesis
osteogenesis)
BMP‐4 Transient increased expression in the Involvement in the formation of callus at a very early stage in
surrounding soft tissues 6 h to day 532 the healing process
Days 14–211 In vitro: BMP‐3 and ‐4 stimulate the migration of human
Throughout fracture healing33 blood monocytes4
GDF‐10 (BMP‐3B) Days 3–211 Regulatory role in both types of ossification
BMP‐5, ‐6 BMP‐6 may initiate chondrocyte maturation1
BMP‐7 Days 14–211 Regulatory role in both types of ossification
From the early stages of fracture healing32 In vitro: stimulation of relatively mature osteoblasts34
GDF‐1 Days 7 (maximal) to 141 (restricted GDF‐5 may have an exclusive involvement in chondrogenesis
GDF‐5 expression during chondrogenic phase) Stimulation of mesenchymal aggregation and induction of
GDF‐1 at extremely low levels angiogenesis through chemotaxis of endothelial cells and
degradation of matrix proteins
GDF‐6 (BMP‐13) No detectable levels within the fracture GDF‐6 may be expressed only in articular cartilage 1 and with
GDF‐9 callus1 GDF‐5, ‐7 more efficiently induce cartilage and tendon‐like
structures in vivo46
BMP, bone morphogenetic protein; GDF, growth and differentiation factor; MSC, mesenchymal stem cells; TGF, transforming growth factor.
(TGF‐β) superfamily, but it may modulate BMP

Osteogenic Hierarchy of BMPs
actions by the proteolysis of BMP antagonists/binding
proteins.32,33,109 Most BMPs
BMPs bind to two different serine/threonine kinase BMP-2, -6, -9 BMP-2, -4, -7, -9 (except BMP-3)
receptors, termed type 1 and type 2 receptors. Both types
are required for signal transduction, with BMP binding
to high‐affinity type 1 receptors, which then recruit
lower‐affinity type 2 receptors.41 This initiates the Smad
intracellular signaling cascade, which ultimately regu
lates the transcription of target genes, resulting in pro Pluripotent MSC Osteoprogenitor Osteoblast Osteocyte
tein translation.50,75,108 (C3H10) (C2C12) (TE-85)
BMPs are pleiotropic morphogens which play a
critical role in regulating growth, differentiation, and Figure 12.1 Illustration of osteogenic activity of human bone
apoptosis of osteoblasts, chondroblasts, and other cell morphogenetic proteins (BMPs). BMP‐2, ‐6, and ‐9 may be the
types.96,115 It has been shown both in vitro and in vivo most potent agents for induction of lineage‐specific
differentiation of mesenchymal progenitor cells. Most BMPs can
that BMP heterodimers such as BMP‐4/‐7 and
promote terminal differentiation of committed osteoblasts and
BMP‐2/‐7 have enhanced osteoinductive activities reg their precursors. Source: Adapted from Cheng et al. 2003.22
ulating both differentiation and proliferation of mesen Reproduced with permission of Wolters Kluwer Health, Inc.
chymal cells to osteoblasts.1,61 BMPs are structurally
and functionally related. However, each type has a the most potent in inducing osteoblast differentiation
unique role and a distinct temporal expression pattern of mesenchymal progenitor cells; however, most BMPs
during the fracture repair process (Table 12.1).15,23,109 (except BMP‐3 and ‐13) promoted terminal differentia
Cheng et al. comprehensively analyzed the osteogenic tion of committed osteoblastic precursors and osteo
activity of 14 types of BMPs.22 BMP‐2, ‐6, and ‐9 were blasts (Figure 12.1). BMPs also stimulate the synthesis
www.ajlobby.com
and secretion of other bone and angiogenic growth (A) (B)

factors, such as insulin‐like growth factor (IGF) and
vascular‐endothelial growth factor (VEGF).30,111 Tsuji
et al. demonstrated the importance of BMP‐2 in the
initiation of fracture repair.110 Knockout mice lacking
the ability to produce BMP‐2 had spontaneous frac
tures that did not heal over time. The earliest steps of
fracture healing appeared to be blocked in these mice,
despite the presence of the other BMPs and their ability
to induce bone formation.
Numerous studies have investigated the effects of
BMPs on bone healing. Welch et al. studied the effects
of recombinant human bone morphogenetic protein‐2
(rhBMP‐2) in an absorbable collagen sponge on bone
healing in the tibia of mature goats.116 Bilateral closed
tibial osteotomies were reduced and stabilized with
external fixation; at six weeks, rhBMP‐2–enhanced oste (C) (D)
otomies had superior radiographic healing scores com
pared to buffer groups and controls. The investigators also
demonstrated that fractures treated with rhBMP‐2 had
significantly stronger callus when the collagen sponge was
wrapped around the fracture compared to laying it on
the fracture. Increased callus volume, and increased
strength and stiffness, were found in the rhBMP‐2 groups
compared to the controls.
Edwards et al. evaluated percutaneous injection of
rhBMP‐2 in a calcium phosphate cement (CPC) in an
adult bilateral tibial ostectomy (1 mm gap) model in
dogs.36 The tibiae were repaired with unilateral exter
nal skeletal fixators and the ostectomy was injected
four hours post‐surgery with rhBMP‐2/CPC, an equal
volume of CPC alone, or a sham injection. Dogs were
evaluated radiographically and weight bearing assessed Figure 12.2 Microradiographic (A and C) and histologic (B and D:
at four and eight weeks after surgery, and then they Goldner’s Trichrome) appearance of a tibial osteotomy treated
with rhBMP‐2/α‐BSM (A and B) administered four hours after
were euthanized at eight weeks. The rhBMP‐2 treated
surgery, compared to the contralateral surgical control (C and D)
tibiae had significantly greater callus volume with eight weeks after surgery.
improved weight‐bearing capabilities at both time
intervals, compared to sham‐operated controls and
CPC controls (Figure 12.2). At the completion of the
study, rhBMP‐2–treated tibiae were stronger and bone and to no treatment controls. Radiographs were
stiffer than CPC control and sham‐operated controls. taken at 1, 2, 4, 6, 8, 10, and 12 weeks after surgery, with
The study concluded that a single percutaneous injec animals euthanized at 12 weeks. Both cancellous bone
tion of rhBMP‐2 delivered in rapidly resorbable CPC grafts and BMP groups resulted in better radiographic
four hours after fracture accelerated the healing of a union scores than untreated controls 12 weeks after sur
canine tibial ostectomy. gery, for both MT2 and MT4 defects (Figure 12.3).
Perrier et al. evaluated rhBMP‐2 acceleration of splint Maximum torque at failure for the 5 mm MT2 defects
bone healing in an osteotomy/ostectomy model in was greater for the BMP group compared to autogenous
horses.90 Ostectomies (5 mm gap) were created in the cancellous bone and control groups. Increased bone for
second metatarsal bone (MT2) and osteotomies per mation and more mature bone at the ostectomy site were
formed (1 mm gap) in the fourth metatarsal bone (MT4) evident in histologic samples from the BMP and autoge
bilaterally in nine adult horses. A resorbable putty con nous cancellous bone graft groups, compared to con
taining rhBMP‐2 was implanted in the 5 mm MT2 trols. The study concluded that administration of BMP‐2/
defects, while BMP‐2 was combined with an injectable CPC and autogenous cancellous bone a ccelerated heal
CPC for the 1 mm MT4 defects. Treatments with ing at 12 weeks in 5 mm surgically induced ostectomies of
rhBMP‐2/CPC were compared to autogenous cancellous the splint bone of horses. The propensity of BMP/CPC
www.ajlobby.com
Figure 12.3 Histologic analysis of the

(A) (B) second metatarsal bone (MT2) at
12 weeks. (A) Untreated control group and
(B) recombinant human bone
morphogenetic protein‐2 (rhBMP‐2)/
calcium phosphate group.
and autogenous cancellous bone to accelerate 1 mm techniques to deliver genes coding for the BMPs. Studies
osteotomy defects was less clear at 12 weeks. by Ishihara et al. indicated accelerated bone healing by
Other studies have examined the effect of rhBMP‐7 adenoviral‐mediated human BMP‐2 or ‐6 gene delivery
(osteogenic protein, OP‐1) on fracture healing in a closed into equine osteotomy and ostectomy models in the
tibial fracture in adult goats.31 Healing of closed frac metatarsal bone of horses.60 Four gene therapy groups
tures in this model was accelerated by a single local were evaluated, including adenoviral BMP‐2, adenoviral
administration of rhOP‐1. Use of a carrier material did BMP‐6, and adenoviral‐LacZ (marker gene) delivered at
not seem to be crucial in this application. 14 days after osteotomy or ostectomy. A fourth group
Currently, rhBMP‐2 and OP‐1 have been approved for remained as a no‐treatment control. Horses were eutha
use in humans for acceleration of fracture healing and nized eight weeks after surgery and splint bones evalu
vertebral fusion. In a prospective, randomized, con ated by radiography, quantitative computed tomography
trolled, single blind study, the safety and efficacy of (CT), torsional properties, gene expression, and serum
rhBMP‐2 to accelerate healing of open tibial shaft frac antiadenoviral antibody titers. Radiographic and quanti
tures were evaluated.48 Patients (n = 450) were randomly tative CT indicated earlier and more profound mineral
allocated into three groups: a control group receiving ized callus for both osteotomy and ostectomy sites in the
standard of care including intramedullary nail fixation BMP‐treated groups. Maximum torque and torsional
and routine soft tissue management; a treatment group stiffness were greatest for the ad‐BMP‐2 group followed
repaired with the standard care fixation and implants by the ad‐BMP‐6 group, with both being greater than ad‐
containing 0.75 mg ml−1 of rhBMP‐2; and a second treated LacZ or untreated osteotomies. Studies of gene expres
group receiving standard care with an implant containing sion within the mineralized callus at eight weeks
1.50 mg ml−1 of rhBMP‐2. The higher rhBMP‐2 dose indicated upregulation of genes related to osteogenesis
group had significantly reduced frequency of secondary in ad‐BMP‐2 and ad‐BMP‐6 groups, including TGFβ‐1,
interventions (from 46% to 26%), accelerated healing, and Cathepsin, and Gelsolin‐like capping proteins. No evi
reduced infection rates compared to the control group. dence of adenovirus biodistribution to distant organs
Similarly, a prospective randomized study examining the was detected, although increased serum antiadenoviral
effect of OP‐1 (rhBMP‐7) on the healing of open tibial vector antibodies were detected. This study demon
shaft fractures amenable to intramedullary nailing was strated greater relative potency of ad‐BMP‐2 over ad‐
reported.73 The investigation showed that the technique BMP‐6 in accelerating osteotomy healing, although both
was straightforward, was not associated with increased genes were effective at increasing bone at both osteot
adverse events, decreased the number of procedures omy and ostectomy sites, compared to controls.
required for resolution of delayed union or nonunion, These studies and others reveal the ability of BMPs to
and appeared to correlate with improved function.74 accelerate normal and delayed union fracture healing.
In addition to the delivery of BMPs as recombinant rhBMP‐2, while expensive, will likely be available to vet
proteins, investigators have more recently developed erinarians in the coming years for treatment of canine
www.ajlobby.com
and equine fractures. It is unlikely that equine BMP‐2 with delayed healing, as well as in rats with normal frac
will be produced in sufficient quantities in protein form ture healing. Others have shown that exogenous rhbFGF
to be useful clinically, but viral delivery may allow a less enlarged the cartilaginous callus, but failed to induce
expensive method of equine‐specific BMP‐2 delivery for faster healing in a closed rat fracture model.83 Radomsky
treating problematic equine fractures. et al. reported better mechanical properties and increased
callus size, periosteal reaction, vascularity, and cellularity
in rhbFGF‐treated fibular osteotomies in baboons.92
Other Growth Factors Other investigators have reported that rhFGF accelerated
and Signaling Molecules fracture healing, whereas some studies have demon
strated no significant effect on the rate of healing.13,21,63
A wide range of growth factors and other cytokines are
expressed during fracture healing (described in detail in
Chapter 3).46 Many of these molecules have been investi Platelet‐derived Growth Factor (PDGF)
gated experimentally to examine their ability to enhance Hollinger et al. reported the importance of platelet‐
fracture healing and fracture union rates. derived growth factor (PDGF) for repair in osseous tis
sues.56 PDGF is a potent chemoattractant and mitogen
Transforming Growth Factor‐β (TGF‐β) for mesenchymal cells, including osteogenic cells, and an
angiogenic promoter in a wide range of animal models,
Lind et al. evaluated exogenous TGF‐β infusion in a including maxillofacial, spine, and appendicular skeletal
rat tibial osteotomy model, using continuous doses of repair sites. Clinical success and safety have been dem
1–10 μg day−1 for six weeks; both increased maximal onstrated with recombinant human platelet‐derived
bending strength and callus formation.72 Critchlow et al. growth factor (rhPDGF) in the repair of periodontal
reported that TGF‐β2 did not stimulate fracture healing defects, leading to its Food and Drug Administration
under stable or unstable mechanical conditions during the (FDA) approval for this application.
initial healing phases of a rabbit tibial osteotomy model.29
Park et al. evaluated the relationship between axial motion
and TGF‐β1 application during repair in a rabbit tibial Vascular Endothelial Growth
fracture model;86 TGF‐β1 inhibited the normal develop Factor (VEGF)
ment of peripheral callus when axial interfragmentary Exogenous administration of VEGF has been reported to
motion was present. Nielson et al. reported increased cal enhance blood vessel formation, ossification, and callus
lus formation and strength following the administration of maturation in a mouse femur fracture model.106 VEGF
TGF‐β in a rat tibial osteotomy fracture model.84 also promotes bony bridging in a rabbit segmental defect
model of the radius. Li et al. evaluated the effect of cell‐
Insulin‐Like Growth Factor‐I (IGF‐I) based VEGF gene therapy on healing of a segmental tibial
bone defect in New Zealand white rabbits.70 Implantation
Schmidmaier et al. evaluated the application of IGF‐I and of fibroblasts expressing the VEGF gene were compared
TGF‐β1 in a rat tibial fracture model.99 These studies to control groups treated by naive fibroblasts, and a group
showed that IGF‐I had a greater stimulatory effect on frac treated with saline alone. Histologic evaluation of the tib
ture healing than TGF‐β1. Both growth factors applied iae at 12 weeks showed new bone bridging the defect in
together on a coated intramedullary pin resulted in higher the VEGF gene therapy repairs, compared to fibrous tis
maximal load and torsional stiffness than either used alone. sue bridging the gap in both non‐VEGF exposed control
Fracture callus remodeling rate was also increased in the groups. VEGF‐treated defects had significantly greater
experimental groups. The same investigators conducted a bone volume, density, bone surface/bone volume, trabec
long‐term study in the identical rat tibial fracture model, ular number, and trabecular thickness, compared to con
taken out to 84 days, and reported significantly improved trol tibia. Radiographic assessment indicated that 89% of
healing when IGF‐I and TGF‐β1 were combined in the fractures treated with VEGF healed, whereas only four of
early phases of fracture healing up to 42 days.100 seven in the naive fibroblast, and four of seven in the saline
groups, healed by 12 weeks after surgery.
Basic Fibroblast Growth Factor (bFGF
or FGF‐2) Parathyroid Hormone (PTH)
The effect of local application of recombinant human Parathyroid hormone (PTH) has been shown to increase
basic fibroblast growth factor (bFGF) has been examined bone mineral density and prevent fractures, and has been
by Kawaguchi et al.63 Bony union was enhanced in rats approved as an anabolic treatment for osteoporosis.6
www.ajlobby.com
PTH is a naturally occurring 84 amino acid peptide, and dependent on the gene transfer technique used. Both
is a major systemic regulator of the concentration of cal short‐term and long‐term protein production are possi
cium, phosphate, and vitamin D metabolites in the blood, ble. Fortunately, bone healing application typically
and the cellular activity within bone. Andreassen et al. requires only short‐term production, although theoreti
showed in adult rats that intermittent administration of cally with massive segmental defects longer duration of
200 μg kg−1 of PTH increased the ultimate load and exter administration may be required.9
nal callus volume of fractures after 40 days of healing.3 Vectors are used to enhance the transfer of cDNA into
Continued increases in mechanical strength and bone target cells. This process is termed “transfection” when a
density were observed well after the cessation of PTH nonviral vector is used and “transduction” when a viral
treatment. Studies by Nakajima et al. showed that doses vector is used.38,81 When a viral vector is used, the cDNA
of 5 and 30 μg kg−1 of PTH significantly increased bone either integrates into the host genome, resulting in long‐
mineral content, bone mineral density, and total osseous term expression, or remains outside the genome as a cir
tissue volume in rat fractures.82 Additionally, Seebach cular plasmid called an episome. When the cDNA
et al. showed that PTH increased the ultimate load by remains as a plasmid, a relatively shorter period of
greater than 50% and was associated with an increased expression occurs, avoiding the dangers of insertional
amount of new mineralized bone.101 Finally, Kakar et al. oncogenesis. When this technique is used, portions of
reported that PTH preferentially enhanced chondrocyte the viral vector genome are deleted to minimize or elimi
recruitment and the rate of chondrocyte maturation in nate virus replication; nevertheless, there are safety con
the fracture callus of mice.62 cerns with the use of viral vectors. Viruses have the
Overall, these studies support the concept that PTH potential to undergo recombination with other viruses
treatment increases bone mineral density and reduces present in the host cell, resulting in replication compe
fracture risk by increasing coupled remodeling. tence and virulence. Alternatively, certain viruses (e.g.,
Intermittent PTH treatment can decrease osteoclast‐ adenovirus) are immunogenic and may induce an inflam
mediated bone resorption, and enhance osteoblast‐ matory response that limits the duration of gene expres
mediated new bone formation, increasing the amount sion and can pose a danger to the host.24,76,93 Nonviral
of deposited bone. Systemic PTH can cause an early vectors are appealing because they are relatively safe;
proliferative response of osteoprogenitor and chondro however, they typically have poor transfection efficiency
progenitor cells, although PTH preferentially enhances and a shorter period of gene expression.
chondrogenesis over osteogenesis. There are two fundamental gene therapy strategies,
referred to as in vivo and ex vivo transduction. In vivo
gene transfer occurs within the host, with direct admin
Gene Therapy Applications istration of the vector systemically or locally at a specific
for Fracture Healing anatomic site. Alternatively, for ex vivo applications host
cells are harvested from a specific location, expanded in
The established use of rhBMP‐2 and rhBMP‐7 in human culture, transduced ex vivo in tissue culture, and then
orthopedics has introduced the concept of biologic ther reimplanted to the desired location.
apy to enhance fracture healing.19,98 Unfortunately, high
doses of BMP are required to achieve the desired effects,
which are concomitantly associated with high costs. This
In Vivo Gene Therapy
concern and the desire to deliver protein over a prolonged With in vivo gene therapy, the viral vector is directly
period of time have led to the investigation of alternative administered to the host.19 Vectors can be delivered
delivery mechanisms to promote fracture repair. Regional either systemically or, as is the case in fracture repair,
gene therapy has the ability to offer a new approach to locally. The most common method currently under
enhance fracture healing. Genetic sequences encoding investigation for fracture repair is the injection of viral
species‐specific growth factors can be transferred to cells vectors containing BMP cDNA.14,40,59 The primary
at the fracture site, resulting in the production of osteo advantage of this technique is that it is a one‐step proce
genic peptides in a sustained and physiologic manner. dure that can be carried out in a minimally invasive
Numerous animal studies have demonstrated the poten manner with less expense than ex vivo therapy. The
tial for these techniques to succeed. disadvantages are lower transduction efficiency, lack of
In the context of bone repair, gene therapy functions as control over the target cell population, the risks associ
a protein delivery system. A complementary deoxyribo ated with viral inoculation such as the initiation of a sig
nucleic acid sequence (cDNA) encoding for a therapeu nificant immune response, and the potential for genetic
tic protein is transferred to the desired target cells, recombination resulting in virulence. As highlighted in
resulting in production of the protein at the fracture site. the BMP section earlier, Ishihara et al. investigated the
The duration of protein induction is significantly injection of adenoviruses containing the cDNA for
www.ajlobby.com
BMP‐2 and BMP‐6 in the horse, and showed improved BMP‐4 and PTH produced greater bone healing than
fracture healing with either expressed protein, although either agent alone.
BMP‐2 was more effective.60 When these BMP‐expressing These gene‐activated matrices have low transfection
adenoviruses are injected to a fracture site, gene efficiency compared to viral delivery systems. Strategies
expression in the bone and surrounding soft tissues
have been developed to enhance this transfection effi
develops for up to six weeks. Many other studies have ciency. Huang et al. described a method of condensing
demonstrated the efficacy of this therapeutic approach DNA plasmids in order to facilitate cell uptake.59 In a
in other animal models, including rabbits and rats.5,8,9,37 critical‐sized rat cranial defect model, condensed DNA
Animal studies have demonstrated the significant generated greater amounts of bone ingrowth, osteoid
impact of vector dose on the healing of bone defects deposition, and mineralization compared to noncon
using direct percutaneous in vivo gene delivery. Work by densed DNA gene‐activated matrices.
Betz et al. indicated that 2.7 × 109 plaque‐forming units
(PFUs) of adenoviral vector carrying human BMP‐2
cDNA successfully healed critical‐size mid‐femoral
Ex Vivo Gene Therapy
defects in rats, compared to a medium 2.7 × 108 or low Ex vivo gene therapy is more complicated than in vivo
2.7 × 107 PFU dose where healing was not profoundly gene therapy, and requires harvesting of host cells, expan
improved.11 This study highlighted the importance of sion of these cells in tissue culture for a period of time,
appropriate viral vector dose to achieve fracture healing. transduction of the cells to express the gene of interest,
The timing of the administration of in vivo gene ther and then reimplantation at the fracture site, where the
apy appears to affect efficacy. Betz et al. injected ad‐ cells produce the desired protein.19 An advantage of ex
BMP‐2 into critical‐size femoral defects in rats at 0, 1, 5, vivo therapy is that specific cells can be targeted and selec
and 10 days after surgery and reported that delayed tively transduced, which is in contrast to in vivo strategies,
administration at 5 or 10 days resulted in more frequent where all cells in the fracture region are exposed to the
bone union than earlier administration of the viral vec vector. In addition, in vitro transduction of cells is more
tor.10 Delayed delivery most likely coincided with the efficient than in vivo transduction, and the patient typi
arrival of osteoprogenitor cells at the fracture site.102 cally does not incur the risk of direct viral inoculation. The
Many of these original in vivo experiments were per disadvantage of ex vivo therapy is that the technique is
formed with first‐generation adenoviral vectors that are typically a two‐stage process where autologous cells are
both easy to produce and are efficient transducing harvested on one day and implanted on another. An alter
agents.5,8,9,37 Unfortunately, these vectors evoke a strong native to this strategy is the development of allogeneic cell
immune response to the adenoviral proteins, which limits lines that are then held in cell banks and the transduced
the duration of gene expression and may be hazardous to cells transplanted to the affected site, although this intro
the host.24,76,93,117 Researchers are working to develop less duces the potential for immunologic reactions and/or
immunogenic vectors such as adeno‐associated virus, rejection phenomenon against the cell wall antigens.
which is a replication‐deficient virus that has no associa There are four critical components to ex vivo gene
tion with immunogenicity or human disease.69 “Gutless” therapy strategies: cell type, cDNA sequence, vector, and
or helper‐dependent adenoviruses have also been des delivery system. The ideal cell source should be easily
cribed by deleting the viral‐encoding genes.2,68 harvested without significant patient morbidity. The
There are nonviral methods described for in vivo gene cells must be expandable in culture, efficiently trans
therapy. Due to the complications associated with viral duceable, and able to express the desired protein at suf
vectors, there has been significant interest in the devel ficient levels to enhance fracture healing. Typical cell
opment of plasmid‐based delivery systems. cDNA plas sources include bone marrow aspirates, skin fibroblasts,
mids can be delivered via scaffolds, where the scaffold muscle‐derived cells, and adipose‐derived cells.35,54,55,66,
71,88,89,91,95
serves as a local bioreactor, releasing plasmids that then With ex vivo fracture gene therapy, some
transfect the local cell population. The scaffold is placed researchers have hypothesized that the ideal cell source
in the area where the cDNA is needed, providing sus should have the potential to express an osteoblast
tained release from the plasmids as the scaffold degrades, phenotype, which can then contribute to bone healing
and also offering a surface for cellular attachment. A through both paracrine and autocrine mechanisms.43,98
wide variety of scaffolds have been investigated, includ The cells can express BMPs that stimulate host cells
ing collagen, demineralized bone matrix, hydroxyapatite, (paracrine), but also respond to BMP themselves
and polylactic glycolic acid.14,20,59,85 An example of this (autocrine) by undergoing osteogenic differentiation and
technique was demonstrated by Fang et al., who contributing to bone repair directly. Although this auto
implanted a collagen sponge loaded with plasmids crine function theoretically is important, it remains to be
encoding for BMP‐4, PTH, or a combination of both in a demonstrated whether the autocrine contribution to
5 mm rat femur osteotomy model.40 The combination of bone formation is clinically relevant.
www.ajlobby.com
The next and most intensely investigated component Naked DNA and liposomes are two additional nonviral
of ex vivo gene therapy is the selection of the cDNA options for ex vivo strategies that have received increased
sequence. The most common sequence currently used is attention by researchers.19 These nonviral approaches
one of the BMPs, especially BMP‐2. This is particularly are appealing because they pose less of a safety risk; how
relevant in equine orthopedics, where it is unlikely that ever, they have poor transfection efficiencies.
sufficient quantities of equine‐specific BMP‐2 protein In conclusion, gene therapy likely will be an important
will be produced by commercial manufacturers. The mechanism to enhance fracture healing in the clinical
ability to deliver an equine‐specific protein to the frac setting in the coming decades. There are advantages and
ture site via ex vivo gene delivery is highly appealing. In disadvantages of both viral and nonviral vector delivery
addition, a wide range of growth factors identified in ear systems. Many show promise with regard to clinical
lier parts of this chapter can be investigated with regard application, although it is too early to determine which
to their ability, either alone or in combination, to enhance techniques or technologies ultimately will be available to
bone repair. Several studies have shown that a combina the equine surgeon in the coming years.
tion of growth factors may be more effective than a
single gene.40,64,88,89,118 BMP‐2 and BMP‐7 appear to be
more effective when delivered in combination than when Cellular Strategies
delivered as single genes.64,118
Once the appropriate cDNA sequences have been Many studies have focused on developing cellular strate
selected, there are many vectors available to transfect gies to enhance fracture repair.87 Orthopedic tissue engi
the cell source. The duration of protein expression, the neering strategies seek to increase the number or relative
safety profile, and the efficiency of transduction or performance of bone‐forming cells at the injury site.
transfection are all important parameters to consider Patterson et al. described the global term “connective tis
when selecting a vector. As highlighted previously, sue progenitors” to define the heterogeneous population
adenovirus has been used most frequently; however, of stem and progenitor cells that are found in native tis
it can induce a strong immune response that limits sue and are capable of differentiating into one or more
the duration of gene expression and poses safety con connective tissue phenotypes.78,87 Stem and progenitor
cerns.24,76,93,117 Adeno‐ associated virus has been cells are present in all adult tissues and are important for
modified to be less immunogenic in order to address tissue maintenance and the response to injury or disease.
some of these concerns.69 Lentivirus has also emerged Stem cells give rise to progenitor cells and are distin
as an attractive alternative, because it integrates into guished from them by the ability of stem cells to self‐
host DNA and therefore provides long‐term gene renew through a process of asymmetric cell division.
expression with minimal immunogenicity.58,107 Using Progenitor cells, in contrast, have finite limits on their
two vectors can allow for both short‐term and long‐ capacity for self‐renewal and usually give rise to one or
term delivery of protein. Virk et al. evaluated short‐term more differentiated phenotypes.78,79 In fracture applica
adenoviral vector‐ and prolonged lentiviral vector‐ tion, the targeted sources for progenitor cells include
mediated BMP‐2 expression on the quality of bone bone, cartilage, fat, and fibrous tissue. The number of
repair in a rat femoral defect model.113 In all animals, 5 connective tissue progenitor cells in these tissues is most
million rat bone marrow cells (RBMCs) were transduced often estimated by use of the term colony‐forming unit
with either a lentiviral vector, an adenoviral vector, or (CFU) assays. In these assays, cells give rise to a colony of
combinations of lentiviral and adenoviral vectors. This proliferating progenitor cells in vitro under selected con
study demonstrated that in vitro RBMCs transduced ditions designed to promote activation and proliferation
with adenoviral vectors produced more than three times of one or more fractions of the connective tissue pro
greater BMP‐2 when compared to RBMCs transduced genitor population. It is important to understand that
with lentiviral vectors. Lentiviral vector‐mediated deliv connective tissue progenitor–derived cells are not a pure
ery did not lead to significantly better healing rates com or uniform population, and likely are derived from more
pared to adenoviral vector‐mediated delivery, or the than one pool of stem cells and progenitor cells that exist
combination of lentiviral vector and adenoviral delivery. in native tissues. Culture‐expanded cell populations sig
In this rat femoral defect model, prolonged delivery of nificantly differ from the heterogeneous population of
BMP‐2 was not required to achieve a successful out connective tissue progenitor cells that are present in native
come. In a different study, however, investigators dem tissue. Under culture conditions, this heterogeneous
onstrated that sustained production of BMP induced by population quickly becomes more homogenous, and in
lentiviral transduction in a rat femoral 8 mm defect vitro expansion therefore provides a strong selective
model restored biomechanical characteristics of bone pressure favoring cells that divide most rapidly and that
more effectively than did adenoviral transduction.58 have the greatest capacity for continued proliferation.
www.ajlobby.com
The following section highlights strategies for the appli Some clinical studies have suggested that transplanta
cation of autogenous connective tissue progenitor cells tion of connective tissue progenitor cells in aspirated
for enhancement of fracture healing. bone marrow can enhance bone healing.17,27,28,42,52
Additionally, concentration of bone marrow cells by
centrifugation appears to further increase osteogenesis.
Autogenous Progenitor Cell
The aspiration technique is important with regard to
Application bone marrow aspirates. Muschler et al. demonstrated
As described by Patterson et al., there are five major that limiting the volume of aspirate to less than 2 ml
types of cell‐based tissue engineering strategies: per site reduced dilution with peripheral blood and
increased the concentration of marrow‐derived connec
1) Local targeting of connective tissue progenitor cells tive tissue progenitor cells.77 The efficacy of bone mar
where new tissue is needed. row graft can be enhanced with certain porous and
2) Homing of connective tissue progenitor cells into plasma materials that selectively concentrate marrow‐
areas where they may not currently reside. derived connective tissue progenitor cells from bone
3) Physically transplanting autogenous connective tissue marrow, a process known as selective retention.80
progenitor cells to augment the local population. During this process, marrow‐derived connective tissue
4) Transplanting culture‐expanded or gene-modified progenitor cells are enriched by removing red blood
connective tissue progenitor cells. cells, serum, and most other cells in marrow and con
5) Transplanting fully formed tissue.87 taminating peripheral blood. The use of a centrifuge
to concentrate low‐density cells from bone marrow has
Targeting of Connective Tissue
also been described.25,26,53
Progenitor Cells Platelets initiate hemostasis and release mediators that
Local targeting strategies promote desired tissue forma modulate inflammatory responses and many of the cel
tion by stimulating the activation, migration, proliferation, lular functions involved in fracture healing and bone
and differentiation of local progenitor cells. By definition, repair.112 The alpha granules of platelets contain multiple
this strategy relies on sufficient local populations of con growth factors, including PDGF, TGF‐β, IGF‐I, fibroblast
nective tissue progenitor cells. Tissue scaffolds provide a growth factor (FGF), and VEGF, each of which is known
surface on which cells and connective tissue progenitor to play an important role in bone repair. After centrifuga
cells can attach, proliferate, migrate, and differentiate. tion of blood, a clear yellow fluid layer of plasma is visible
Examples of targeting include implantation of acellular overlying the red blood cell pack. A thin layer lies between
tissue scaffolds such as allograft bone, locally derived the two called the buffy coat, which contains most of the
growth factors such as BMPs, biophysical stimulation white blood cells and platelets. The platelet concentrate
such as mechanical loading and electromagnetic or ultra fraction above the buffy coat, known as platelet‐rich
sound stimulation, and systemic pharmacologic strategies plasma (PRP), can be harvested and the platelets used
such as the administration of PTH for osteoporosis. therapeutically. Platelets are not osteoinductive because
they are not a rich source of morphogenetic proteins, but
Homing of Connective Tissue they are believed to promote osteoblast proliferation and
Progenitor Cells differentiation through the release of other factors.105
Homing typically refers to the recruitment of cells from There are numerous commercial examples of PRP tech
the systemic circulation. Several studies have suggested nology, including Autologous Growth Factors (AGF,
that osteogenic progenitor cells may travel through the Interpore Cross International, Irvine, CA, USA) and the
systemic circulation, although the extent to which circu Symphony Platelet Concentrate System (Johnson and
lating osteogenic cells contribute to normal fracture Johnson/DePuy, Warsaw, IN, USA).112 Because these
repair is unclear.6 Kumagai et al. showed in a mouse para materials are developed from a patient’s own blood, clear
biosis model that approximately 6–12% of cells present at ance for marketing in humans was achieved without the
the fracture site two weeks after injury were derived from need for randomized controlled trials evaluating their effi
circulating cells.67 These data suggest that stem cell hom cacy. Although PRP has been used in recent years in
ing may be a normal biologic process which could become humans to improve bone defect healing in maxillofacial
the target of new therapies in the future. reconstructions, there are no published reports to assess
the efficacy of stand‐alone PRP use in critical‐size long
Transplantation of Autogenous bone defects or nonunions. Volgas et al. presented prelimi
Connective Tissue Progenitor Cells nary data from a prospective randomized controlled trial
Autogenous cancellous bone grafting is the most comparing iliac crest bone grafting with the use of AGFs
prevalent and effective example of cell transplantation. combined with cancellous allograft for nonunions and
www.ajlobby.com
delayed unions.114 These show that 15% of patients with Transplantation of Genetically Modified
iliac crest bone graft required reoperation for persistent Cells and Their Progeny
nonunion, whereas 19% of patients with AGF/allograft As highlighted in the gene therapy application section of
required reoperation. The study did not have sufficient this chapter, the intrinsic potential and performance of
power to conclude that the success rates were equivalent, connective tissue progenitor cells can be genetically
but it did suggest that a combination of products with syn modified by either transiently or permanently altering
ergistic properties may be useful in a nonunion setting. In the expression of one or more genes. This is described in
a different study, a 2.5 cm critical‐sized defect in the tibial further detail in the ex vivo gene therapy section.
diaphysis of adult sheep was used to evaluate autogenous
PRP in a collagen carrier compared to collagen alone as
control.97 Platelets in the PRP were enriched approximately Summary
3.5‐fold compared to normal blood. Bone volume, mineral
density, mechanical rigidity, and histology of the newly Fracture fixation and biologic treatments available to
formed bone in the defect did not differ significantly enhance fracture healing are becoming complementary
between the PRP‐treated and the control group, and no treatment modalities. Within the next 20 years, there
effect of PRP on bone formation was observed. likely will be numerous strategies that can be employed
to enhance and accelerate normal fracture healing, in
Transplantation of Culture‐expanded Cells addition to treating delayed unions and nonunions.
Cells that have been culture expanded from muscle, fat, Specific strategies will likely be developed that can be
and bone marrow have been investigated for the regenera targeted to difficult fractures such as open fractures,
tion of bone, cartilage, muscle, and tendon tissue.12,16,18,47,94 fractures with poor vascularity, and fractures that are
In vitro expansion can generate a large number of progeni healing slowly and require percutaneous and/or systemic
tor cells; however, the process adds substantial costs and is treatments in order to speed up healing. Many of the
associated with risks such as potential contamination with strategies highlighted in this chapter probably will be
bacteria or viruses and/or depletion of the proliferative employed in the coming years, although it is uncertain
capacity of the cells.51,103,104 The strategy is applied clini without further research and clinical studies which will
cally in the area of cartilage repair.7,57,65 work most effectively in the clinical setting.
References
1 Abe, E., Yamamoto, M., Taguchi, Y. et al. (2000). parathyroid hormone treatment. J. Bone Joint Surg.
Essential requirement of BMPs‐2/4 for both osteoblast Am. 90: 120–127.
and osteoclast formation in murine bone marrow 7 Bentley, G., Biant, L.C., Carrington, R.W. et al. (2003).
cultures from adult mice: antagonism by noggin. J. Bone A prospective, randomized comparison of autologous
Miner. Res. 15 (4): 663–673. chondrocyte implantation versus mosaicplasty for
2 Abe, N., Lee, Y.P., Sato, M. et al. (2002). Enhancement of osteochondral defects in the knee. J. Bone Joint Surg. Br.
bone repair with a helper‐dependent adenoviral transfer 85: 223–230.
of bone morphogenetic protein‐2. Biochem. Biophys. 8 Bertone, A.L., Pettman, D.D., Bouxsein, M.L. et al.
Res. Commun. 297: 523–527. (2004). Adenoviral‐mediated transfer of human BMP‐6
3 Andreassen, T.T., Ejersted, C., and Oxlund, H. (1999). gene accelerates healing in a rabbit ulnar osteotomy
Intermittent parathyroid hormone (1–34) treatment model. J. Orthop. Res. 22: 1261–1270.
increases callus formation and mechanical strength of 9 Betz, O.B., Betz, V.M., Nazarian, A. et al. (2006). Direct
healing rat fractures. J. Bone Miner. Res. 14: 960–968. percutaneous gene delivery to enhance healing of
4 Aspenberg, P., Jeppsson, C., and Economides, A.N. segmental bone defects. J. Bone Joint Surg. Am. 88:
(2001). The bone morphogenetic protein antagonist 355–365.
Noggin inhibits membranous ossification. J. Bone Miner. 10 Betz, O.B., Betz, V.M., Nazarian, A. et al. (2007).
Res. 3: 497–500. Delayed administration of adenoviral BMP‐2 vector
5 Baltzer, A.W., Lattermann, C., Whalen, J.D. et al. (2000). improves the formation of bone in osseous defects.
Genetics enhancement of fracture repair: healing of an Gene Ther. 14: 1039–1044.
experimental segmental defect by adenoviral transfer of 11 Betz, V.M., Betz, O.B., Glatt, V. et al. (2007). Healing of
the BMP‐2 gene. Gene Ther. 7: 734–739. segmental bone defects by direct percutaneous gene
6 Barnes, G.L., Kakar, S., Vora, S. et al. (2008). Stimulation delivery: effect of vector dose. Hum. Gene Ther. 18:
of fracture‐healing with systemic intermittent 907–915.
www.ajlobby.com
12 Bittira, B., Kuang, J.Q., Al‐Khaldi, A. et al. (2002). In 27 Connolly, J.F., Guse, R., Tiedeman, J., and Dehne, R.
vitro preprogramming of marrow stromal cells for (1989). Autologous marrow injection for delayed
myocardial regeneration. Ann. Thorac. Surg. 74: unions of the tibia: a preliminary report. J. Orthop.
1154–1160. Trauma 3: 276–282.
13 Bland, Y.S., Critchlow, M.A., and Ashhurst, D.E. (1995). 28 Connolly, J.F., Guse, R., Tiedeman, J., and Dehne, R.
Exogenous fibroblast growth factors‐1 and ‐2 do not (1991). Autologous marrow injection as a substitute for
accelerate fracture healing in the rabbit. Acta Orthop. operative grafting of tibial nonunions. Clin. Orthop.
Scand. 66 (6): 543–548. Relat. Res. 266: 259–270.
14 Bonadio, J., Smiley, E., Patil, P., and Goldstein, S. (1999). 29 Critchlow, M.A., Bland, Y.S., and Ashhurst, D.E. (1995).
Localized, direct plasmid gene delivery in vivo: The effect of exogenous transforming growth factor‐
prolonged therapy results in reproducible tissue beta 2 on healing fractures in the rabbit. Bone 16:
regeneration. Nat. Med. 5: 753–759. 521–527.
15 Bostrom, M.P. (1998). Expression of bone 30 Deckers, M.M., van Bezooijen, R.L., van der Horst, G.
morphogenetic proteins in fracture healing. Clin. et al. (2002). Bone morphogenetic proteins stimulate
Orthop. 355S: 116–123. angiogenesis through osteoblast‐derived vascular
16 Bruder, S.P. and Fox, B.S. (1999). Tissue engineering of endothelial growth factor A. Endocrinology 143:
bone. Cell based strategies. Clin. Orthop. Relat. Res. 14: 1545–1553.
1115–1122. 31 den Boer, F.C., Bramer, J., Blokhuis, T.J. et al. (2002).
17 Burwell, R.G. (1964). Studies in the transplantation of Effect of recombinant human osteogenic protein‐1 on
bone. VII. The fresh composite homograft‐autograft of the healing of a freshly closed diaphyseal fracture. Bone
cancellous bone. An analysis of factors leading to 31: 158–164.
osteogenesis in marrow transplants and marrow‐ 32 Devlin, R.D., Du, Z., Pereira, R.C. et al. (2003). Skeletal
containing bone grafts. J. Bone Joint Surg. Br. 46: 110–140. over expression of noggin results in osteopenia and
18 Caplan, A.I. and Bruder, S.P. (2001). Mesenchymal stem reduced bone formation. Endocrinology 144:
cells: building blocks for molecular medicine in the 21st 1972–1978.
century. Trends Mol. Med. 7: 259–264. 33 Dixon, M.E., Armstrong, P., Stevens, D.B., and
19 Carofino, B.C. and Lieberman, J.R. (2008). Gene Bamshad, M. (2001). Identical mutations in NOG
therapy applications for fracture‐healing. J. Bone Joint can cause either tarsal/carpal coalition syndrome
Surg. Am. 90: 99–110. or proximal symphalangism. Genet. Med. 3 (5):
20 Chen, B., Lin, H., Wang, J. et al. (2007). Homogeneous 349–353.
osteogenesis and bone regeneration by demineralized 34 Dong, Y. and Canalis, E. (1995). Insulin‐like growth
bone matrix loading with collagen‐targeting bone factor (IGF) I and retinoic acid induce the synthesis of
morphogenetic protein‐2. Biomaterials 28: 1027–1035. IGF‐binding protein 5 in rat osteoblastic cells.
21 Chen, W.J., Jingushi, S., Aoyama, I. et al. (2004). Effects Endocrinology 136: 2000–2006.
of FGF‐2 on metaphyseal fracture repair in rabbit 35 Dragoo, J.L., Choi, J.Y., Lieberman, J.R. et al. (2003).
tibiae. J. Bone Miner. Metab. 22 (4): 303–309. Bone induction by BMP‐2 transduced stem cells
22 Cheng, H., Jiang, W., Phillips, F.M. et al. (2003). derived from human fat. J. Orthop. Res. 21: 622–629.
Osteogenic activity of the fourteen types of human 36 Edwards, R.B. III, Seeherman, H.J., Bogdanske, J.J. et al.
bone morphogenetic proteins (BMPs). J. Bone Joint (2004). Percutaneous injection of recombinant human
Surg. Am. 85 (8): 1544–1552. bone morphogenetic protein‐2 in a calcium phosphate
23 Cho, T.J., Gerstenfeld, L.C., and Einhorn, T.A. (2002). paste accelerates healing of a canine tibial osteotomy.
Differential temporal expression of members of the J. Bone Joint Surg. Am. 86: 1425–1438.
transforming growth factor beta superfamily during 37 Egermann, M., Baltzer, A.W., Adamaszek, S. et al.
murine fracture healing. J. Bone Miner. Res. 17: 513–520. (2006). Direct adenoviral transfer of bone
24 Christ, M., Lusky, M., Stoeckel, F. et al. (1997). Gene morphogenetic protein‐2 cDNA enhances fracture
therapy with recombinant adenovirus vectors: healing in osteoporotic sheep. Hum. Gene Ther. 17:
evaluation of the host immune response. Immunol. 507–517.
Lett. 57: 19–25. 38 Evans, C.H., Ghivizzani, S.C., Herndon, J.H., and
25 Connolly, J.F. (1995). Injectable bone marrow Robbins, P.D. (2005). Gene therapy for the treatment of
preparations to stimulate osteogenic repair. Clin. musculoskeletal diseases. J. Am. Acad. Orthop. Surg. 13:
Orthop. Relat. Res. 313: 8–18. 230–242.
26 Connolly, J.F. (1998). Clinical use of marrow 39 Fakhry, A., Ratisoontorn, C., Vedhachalam, C. et al.
osteoprogenitor cells to stimulate osteogenesis. Clin. (2005). Effects of FGF‐2/‐9 in calvarial bone cell
Orthop. Relat. Res. 355 (Suppl): S257–S266. cultures: differentiation stage‐dependent mitogenic
www.ajlobby.com
effect, inverse regulation of BMP‐2 and noggin, 53 Hernigou, P., Poignard, A., Beaujean, F., and Rouard, H.
and enhancement of osteogenic potential. Bone 36: (2005). Percutaneous autologous bone‐marrow grafting
254–266. for nonunions. Influence of the number and concentration
40 Fang, J., Zhu, Y.Y., Smiley, E. et al. (1996). Stimulation of progenitor cells. J. Bone Joint Surg. Am. 87: 1430–1437.
of new bone formation by direct transfer of osteogenic 54 Hirata, K., Mizuno, A., and Yamaguchi, A. (2007).
plasmid genes. Proc. Natl. Acad. Sci. U.S.A. 93: Transplantation of skin fibroblasts expressing BMP‐2
5753–5758. contributes to the healing of critical‐sized bone defects.
41 Fujii, M., Takeda, K., Imamura, T. et al. (1999). Roles of J. Bone Miner. Metab. 25: 6–11.
bone morphogenetic protein type I receptors and Smad 55 Hirata, K., Tsukazaki, T., Kadowaki, A. et al. (2003).
proteins in osteoblast and chondroblast differentiation. Transplantation of skin fibroblasts expressing BMP‐2
Mol. Biol. Cell 10: 3801–3813. promotes bone repair more effectively than those
42 Gang, N.K., Gaur, S., and Sharma, S. (1993). expressing Runx2. Bone 32: 502–512.
Percutaneous autogenous bone marrow grafting in 20 56 Hollinger, J.O., Hart, C.E., Hirsch, S.N. et al. (2008).
cases of ununited fracture. Acta Orthop. Scand. 64: Recombinant human platelet‐derived growth factor:
671–672. biology and clinical applications. J. Bone Joint Surg. Am.
43 Gazit, D., Turgeman, G., Kelley, P. et al. (1999). 90 (Suppl 1): 48–54.
Engineered pluripotent mesenchymal cells integrate 57 Horas, U., Pelinkovic, D., Herr, G. et al. (2003).
and differentiate in regenerating bone: a novel cell‐ Autologous chondrocyte implantation and
mediated gene therapy. J. Gene Med. 1: 121–133. osteochondral cylinder transplantation in cartilage
44 Gazzerro, E., Pereira, R.C., Jorgetti, V. et al. (2005). repair of the knee joint. A prospective, comparative
Skeletal overexpression of gremlin impairs bone trial. J. Bone Joint Surg. Am. 85: 185–192.
formation and causes osteopenia. Endocrinology 146: 58 Hsu, W.K., Sugiyama, O., Park, S.H. et al. (2007).
655–665. Lentiviral‐mediated BMP‐2 gene transfer enhances
45 Giannoudis, P.V. and Pountos, I. (2005). Tissue healing of segmental femoral defects in rats. Bone 40:
regeneration. The past, the present and the future. 931–938.
Injury 36 (Suppl 4): S2–S5. 59 Huang, Y.C., Simmons, C., Kaigler, D. et al. (2005).
46 Giannoudis, P.V., Psarakis, S., and Kontakis, G. (2007). Bone regeneration in a rat cranial defect with delivery
Can we accelerate fracture healing? A critical analysis of PEI‐condensed plasmid DNA encoding for bone
of the literature. Injury 38: 81–89. morphogenetic protein‐4 (BMP‐4). Gene Ther. 12:
47 Glimm, H. and Eaves, C.J. (1999). Direct evidence for 418–426.
multiple self‐renewal divisions of human in vivo 60 Ishihara, A., Shields, K.M., Litsky, A.S. et al. (2008).
repopulating hematopoiete cells in short‐term culture. Osteogenic gene regulation and relative acceleration of
Blood 94: 2161–2168. healing by adenoviral‐mediated transfer of human
48 Govender, S., Csimma, C., Genant, H.K. et al. (2002). BMP‐2 or ‐6 in equine osteotomy and ostectomy
BMP‐2 evaluation in surgery for tibial trauma (BESTT) models. J. Orthop. Res. 26: 764–771.
study group. Recombinant human bone morphogenetic 61 Israel, D.I., Nove, J., Kerns, K.M. et al. (1996).
protein‐2 for treatment of open tibial fractures: a Heterodimeric bone morphogenetic proteins show
prospective, controlled, randomized study of four enhanced activity in vitro and in vivo. Growth Factors
hundred and fifty patients. J. Bone Joint Surg. Am. 84‐A: 13: 291–300.
2123–2134. 62 Kakar, S., Einhorn, T.A., Vora, S. et al. (2007). Enhanced
49 Groeneveld, E.H.J. and Burger, E.H. (2000). Bone chondrogenesis and Wnt‐signaling in parathyroid
morphogenetic proteins in human bone regeneration. hormone treated fractures. J. Bone Miner. Res. 22:
Eur. J. Endocrinol. 142: 9–21. 1903–1912.
50 Hata, A., Lagna, G., Massagué, J., and Hemmati‐ 63 Kawaguchi, H., Nakamura, K., Tabata, Y. et al. (2001).
Brivanlou, A. (1998). Smad6 inhibits BMP/Smad1 Acceleration of fracture healing in nonhuman primates
signalling by specifically competing with the Smad4 by fibroblast growth factor‐2. J. Clin. Endocrinol.
tumor suppressor. Genes Dev. 12 (2): 186–197. Metab. 86: 875–880.
51 Hayflick, L. and Moorhead, P.S. (1961). The serial 64 Kawai, M., Bessho, K., Maruyama, H. et al. (2006).
cultivation of human diploid cell strains. Exp. Cell Res. Simultaneous gene transfer of bone morphogenetic
25: 585–621. protein (BMP)‐2 and BMP‐7 by in vivo electroporation
52 Healy, J.H., Zimmerman, P.A., McDonnell, J.M., and induces rapid bone formation and BMP‐4 expression.
Lane, J.M. (1990). Percutaneous bone marrow grafting BMC Musculoskelet. Disord. 7: 62.
of delayed union and nonunion in cancer patients. Clin. 65 Knutsen, G., Engebretsen, L., Ludvigsen, T.C. et al.
Orthop. Relat. Res. 256: 280–285. (2004). Autologous chondrocyte implantation
www.ajlobby.com
compared with microfracture in the knee. A 77 Muschler, G.F., Boehm, C., and Easley, K. (1997).
randomized trial. J. Bone Joint Surg. Am. 86: 455–464. Aspiration to obtain osteoblast progenitor cells from
66 Krebsbach, P.H., Gu, K., Franceschi, R.T., and human bone marrow: the influence of aspiration
Rutherford, R.B. (2000). Gene therapy‐directed volume. J. Bone Joint Surg. Am. 79: 1699–1709.
osteogenesis: BMP‐7‐transduced human fibroblasts 78 Muschler, G.F. and Midura, R.J. (2002). Connective
from bone in vivo. Hum. Gene Ther. 11: 1201–1210. tissue progenitors: practical concepts for clinical
67 Kumagai, K., Vasanji, A., Drazba, J.A. et al. (2008). applications. Clin. Orthop. Relat. Res. 395: 66–80.
Circulating cells with osteogenic potential are 79 Muschler, G.F., Midura, R.J., and Makamoto, C. (2003).
physiologically mobilized into the fracture healing site Practical modeling concepts for connective tissue stem
in the parabiotic mice model. J. Orthop. Res. 26: cell and progenitor compartment kinetics. J. Biomed.
165–175. Biotechnol. 3: 170–193.
69 Li, J.Z., Hankins, G.R., Kao, C. et al. (2003). 80 Muschler, G.F., Nitto, H., Matsukura, Y. et al. (2003).
Osteogenesis in rats induced by a novel recombinant Spine fusion using cell matrix composites enriched in
helper‐dependent bone morphogenetic protein‐9 bone marrow‐derived cells. Clin. Orthop. Relat. Res.
(BMP‐9) adenovirus. J. Gene Med. 5: 748–756. 407: 102–118.
68 Li, J.Z., Li, H., Hankins, G.R. et al. (2006). Different 81 Musgrave, D.S., Fu, F.H., and Huard, J. (2002). Gene
osteogenic potentials of recombinant human BMP‐6 therapy and tissue engineering in orthopaedic surgery.
adeno‐associated virus and adenovirus in two rat J. Am. Acad. Orthop. Surg. 10: 6–15.
strains. Tissue Eng. 12: 209–219. 82 Nakajima, A., Shimoji, N., Shiomi, K. et al. (2002).
70 Li, R., Stewart, D.J., von Schroeder, H.P. et al. (2009). Mechanisms for the enhancement of fractures healing
Effect of cell‐based VEGF gene therapy on healing of a in rats treated with intermittent low‐dose human
segmental bone defect. J. Orthop. Res. 27: 8–14. parathyroid hormone (1‐34). J. Bone Miner. Res. 87:
71 Lieberman, J.R., Daluiski, A., Stevenson, S. et al. (1999). 731–741.
The effect of regional gene therapy with bone 83 Nakajima, F., Ogasawara, A., Goto, K. et al. (2001).
morphogenetic protein‐2‐producing bone‐marrow Spatial and temporal gene expression in chondrogenesis
cells on the repair of segmental femoral defects in rats. during fracture healing and the effects of basic
J. Bone Joint Surg. Am. 81: 905–917. fibroblast growth factor. J. Orthop. Res. 19: 935–944.
72 Lind, M., Schumacker, B., Soballe, K. et al. (1993). 84 Nielsen, H.M., Andreassen, T.T., Ledet, T., and Oxlund,
Transforming growth factor‐beta enhances fracture H. (1994). Local injection of TGF‐beta increases the
healing in rabbit tibiae. Acta Orthop. Scand. 64: strength of tibial fractures in the rat. Acta Orthop.
553–556. Scand. 65: 37–41.
73 McKee MD and the Canadian Orthopaedic Trauma 85 Ono, I., Yamashita, T., Jin, H.Y. et al. (2004).
Society. The effect of human recombinant bone Combination of porous hydroxyapatite and cationic
morphogenetic protein (rhBMP‐7) on the healing of liposomes as a vector for BMP‐2 gene therapy.
open tibial shaft fractures: results of a multi‐center, Biomaterials 25: 4709–4718.
prospective, randomized clinical trial. Orthopaedic 86 Park, S.H., O’Connor, K.M., and McKellop, H. (2003).
Trauma Association 2002; Annual Meeting, Toronto, Interaction between active motion and exogenous
Ontario, Canada, 12 October:Paper 45. transforming growth factor Beta during tibial fracture
74 McKee MD, Schemitsch EH, Waddell JP. The effect of repair. J. Orthop. Trauma 17: 2–10.
human recombinant bone morphogenetic protein 87 Patterson, T.E., Kumagai, K., Griffith, L., and Muschler,
(rhBMP‐7) on the healing of open tibial shaft fractures: G.F. (2008). Cellular strategies for enhancement of
results of a multi‐center, prospective, randomized fracture repair. J. Bone Joint Surg. Am. 90: 111–119.
clinical trial. Proceedings of the Annual Meeting of the 88 Peng, H., Usas, A., Hannallah, D. et al. (2005). Noggin
American Academy of Orthopedic Surgeons (5–9 improves bone healing elicited by muscle stem cells
February 2003) 2003; New Orleans, LA. expressing inducible BMP4. Mol. Ther. 12: 2369–2246.
75 Merino, R., Rodriguez‐Leon, J., Macias, D. et al. (1999). 89 Peng, H., Wright, V., Usas, A. et al. (2002). Synergistic
The BMP antagonist Gremlin regulates outgrowth, enhancement of bone formation and healing by stem
chondrogenesis and programmed cell death in the cell‐expressed VEGF and bone morphogenetic
developing limb. Development 126: 5515–5522. protein‐4. J. Clin. Invest. 110: 751–759.
76 Molinier‐Frenkel, V., Gahery‐Segard, H., Mehtali, M. 90 Perrier, M., Lu, Y., Nemke, B. et al. (2008). Acceleration
et al. (2000). Immune response to recombinant of second and fourth metatarsal fracture healing with
adenovirus in humans: capsid components from viral recombinant human bone morphogenetic protein‐2/
input are targets for vector‐specific cytotoxic T calcium phosphate cement in horses. Vet. Surg. 37:
lymphocytes. J. Virol. 74: 7678–7682. 648–655.
www.ajlobby.com
91 Peterson, B., Zhang, J., Iglesias, R. et al. (2005). stem cells is enhanced by telomerase expression. Nat.
Healing of critically sized femoral defects, using Biotechnol. 20: 587–591.
genetically modified mesenchymal stem cells from 104 Simonsen, J.L., Rosada, C., Serakinci, N. et al. (2002).
human adipose tissue. Tissue Eng. 11: 120–129. Telomerase expression extends the proliferative life‐
92 Radomsky, M.L., Aufdemorte, T.B., Swain, L.D. et al. span and maintains the osteogenic potential of human
(1999). Novel formulation of fibroblast growth bone marrow stromal cells. Nat. Biotechnol. 20:
factor‐2 in a hyaluronan gel accelerates fracture 592–596.
healing in nonhuman primates. J. Orthop. Res. 17: 105 Slater, M., Patava, J., Kingham, K., and Mason, R.S.
607–614. (1995). Involvement of platelets in stimulating
93 Raper, S.E., Chirmule, N., Lee, F.S. et al. (2003). Fatal osteogenic activity. J. Orthop. Res. 13: 655–663.
systemic inflammatory response syndrome in a 106 Street, J., Bao, M., deGuzman, L. et al. (2002).
ornithine transcarbamylase deficient patient following Vascular endothelial growth factor stimulates bone
adenoviral gene transfer. Mol. Genet. Metab. 80: repair by promoting angiogenesis and bone turnover.
148–158. Proc. Natl. Acad. Sci. U.S.A. 99: 9656–9661.
94 Ringe, J., Kaps, C., Burmester, G.R., and Sittinger, M. 107 Sugiyama, O., An, D.S., Kung, S.P. et al. (2005).
(2002). Stem cells for regenerative medicine: advances Lentivirus‐mediated gene transfer induces long‐term
in the engineering of tissues and organs. transgene expression of BMP‐2 in vitro and new bone
Naturwissenschaften 89: 338–351. formation in vivo. Mol. Ther. 11: 390–398.
95 Rutherford, R.B., Moalli, M., Franceschi, R.T. et al. 108 ten Dijke, P., Fu, J., Schaap, P., and Roelen, B.A. (2003).
(2002). Bone morphogenetic protein‐transduced Signal transduction of bone morphogenetic proteins
human fibroblasts convert to osteoblasts and form in osteoblast differentiation. J. Bone Joint Surg. Am. 85
bone in vivo. Tissue Eng. 8: 441–452. (Suppl 3): 34–38.
96 Sakou, T. (1998). Bone morphogenetic proteins: 109 Tsiridis, E., Upadhyay, N., and Giannoudis, P. (2007).
from basic studies to clinical approaches. Bone 22: Molecular aspects of fracture healing: which are the
591–603. important molecules? Injury 38: 11–25.
97 Sarkar, M.R., Augat, P., Shefelbine, S.J. et al. (2006). 110 Tsuji, K., Bandyopadhyay, A., Harfe, B.D. et al. (2006).
Bone formation in a long bone defect model using a BMP2 activity, although dispensable for bone
platelet‐rich plasma‐loaded collagen scaffold. formation, is required for the initiation of fracture
Biomaterials 27: 1817–1823. healing. Nat. Genet. 38: 1424–1429.
98 Scaduto, A.A. and Lieberman, J.R. (1999). Gene 111 Valdimarsdottir, G., Goumans, M.J., Rosendahl, A.
therapy for osteoinduction. Orthop. Clin. North Am. et al. (2002). Stimulation of Id1 expression by bone
30: 625–633. morphogenetic protein is sufficient and necessary for
99 Schmidmaier, G., Wildemann, B., Gäbelein, T. et al. bone morphogenetic protein‐induced activation of
(2003). Synergistic effect of IGF‐I and TGF‐beta1 on endothelial cells. Circulation 06: 2263–2270.
fracture healing in rats: single versus combined 112 Veillette, C.J.H. and McKee, M.D. (2007). Growth
application of IGF‐I and TGF‐beta1. Acta Orthop. factors – BMPs, DBMs, and buffy coat products: are
Scand. 74: 604–610. there any proven differences amongst them? Injury 38:
100 Schmidmaier, G., Wildemann, B., Ostapowicz, D. et al. 38–48.
(2004). Long‐term effects of local growth factor (IGF‐I 113 Virk, M.S., Conduah, A., Park, S.H. et al. (2008).
and TGF‐beta 1) treatment on fracture healing. A Influence of short‐term adenoviral vector and
safety study for using growth factors. J. Orthop. Res. prolonged lentiviral vector mediated bone
22: 514–519. morphogenetic protein‐2 expression on the quality of
101 Seebach, C., Skripitz, R., Andreassen, T.T., and bone repair in a rat femoral defect model. Bone 42:
Aspenberg, P. (2004). Intermittent parathyroid 921–931.
hormone (1–34) enhances mechanical strength and 114 Volgas D, Emblom B, Stannard JP, et al. A randomized
density of new bone after distraction osteogenesis in controlled prospective trial of autologous bone graft
rats. J. Orthop. Res. 22: 472–478. versus iliac crest bone graft for nonunions and delayed
102 Seeherman, H., Li, R., Bouxsein, M. et al. (2006). unions. Proceedings of the 20th Annual Meeting of
rhBMP‐2/calcium phosphate matrix accelerates the Orthopedic Trauma Association, 10 October
osteotomy‐site healing in a nonhuman primate model 2004. 2004.
at multiple treatment times and concentrations. 115 Wang, E.A., Israel, D.I., Kelly, S., and Luxenberg, D.P.
J. Bone Joint Surg. Am. 88: 144–160. (1993). Bone morphogenetic protein‐2 causes
103 Shi, S., Gronthos, S., Chen, S. et al. (2002). Bone commitment and differentiation in C3G10T1/2 and
formation by human postnatal bone marrow stromal 3T3 cells. Growth Factors 9: 57–71.
www.ajlobby.com
116 Welch, R.D., Jones, A.L., and Bucholz, R.W. (1998). with recombinant adenoviruses. J. Virol. 69:
Effect of recombinant human bone morphogenetic 2004–2015.
protein‐2 on fracture healing in a goat tibial fracture 18 Zhu, W., Rawlins, B.A., Boachie‐Adjei, O. et al. (2004).
1
model. J. Bone Miner. Res. 13: 1483–1490. Combined bone morphogenetic protein‐2 and ‐7 gene
17 Yang, Y., Li, Q., Ertl, H.C., and Wilson, J.M. (1995).
1 transfer enhances osteoblastic differentiation and
Cellular and humoral immune responses to viral spine fusion in a rodent model. J. Bone Miner. Res. 19:
antigens create barriers to lung‐directed gene therapy 2021–2032.
www.ajlobby.com
188
13
Casting and Transfixation Casting Techniques
Ashlee E. Watts1 and Lisa A. Fortier 2
1
2
Cast Indications still utilized in fracture repair when transitioning from a

standard cast to a bandage, or when cast sores are too
Casts are utilized in equine veterinary care for the pri- severe to be kept under a standard cast and some rigidity
mary treatment of fractures,5,38 joint luxations,6,45,71 is still desired.
wounds and tendon lacerations,5 for stress protection There are three main lengths of casts, all of which
following internal fixation,51 and to protect against cata- incorporate the foot: foot cast, half limb cast, and full
strophic fixation failure during recovery from anesthe- limb cast. An exception to this foot rule is the tube cast
sia.51 When used in conjunction with internal fixation, a or sleeve cast. Tube casts are generally reserved for the
cast reduces strain on a plate, allowing it to undergo treatment of angular limb deformities and incomplete
more cycles prior to failure, and this increase in plate ossification of carpal and tarsal bones in foals, and are
fatigue life may facilitate bony union and avoid fixation useful in fracture repair only for procedures such as par-
failure.51 In contrast, proximal limb fractures of the tial or pancarpal arthrodesis, carpal or tarsal luxations,
radius and tibia are not afforded this cyclic protection. A and other severe carpal injuries.
full limb cast changes the tensile surface of the radius Foot casts are utilized in two lengths. In the shorter
and tibia,58 thus potentially increasing cyclic stresses on type, a foot cast includes but does not extend signifi-
a plate(s) placed cranially and/or laterally. Therefore, the cantly beyond the coronary band. Indications include
majority of cast coaptation in equine fracture repair is hoof wall lacerations and support for fractures of the dis-
for distal limb fractures, since casts are only useful for tal phalanx following internal fixation (type III), or those
distal radial or tibial fractures.8,58 Casts can also be used not amenable to internal fixation (types I, II, or III). A
for stabilization of cervical fractures.57 longer adaptation of the foot cast extends beyond the
coronary band, ending either proximal to the coronary
band or just distal to the fetlock joint, but not mid‐pas-
Cast Types tern.13 These casts have many names: foot cast, phalan-
geal cast, pastern cast, short cast, distal cast, or slipper
There are three main types of casts utilized in horses for cast. Foot casts are not used in fracture repair directly;
fracture repair: standard casts, which consist of only thin rather, they are used most often for stabilization of soft
layers of cast padding under casting tape that closely tissue wounds during healing.7,26,30 Foot casts are also
matches the limb conformation; transfixation pin casts, used to maintain comfort following hoof wall resection
which consist of the same cast set‐up as the standard cast in the treatment of laminitis.
with the addition of transcortical pins incorporated Half limb casts extend to the proximal metacarpus
within the cast; and bandage casts, which have a signifi- (tarsus), terminating just distal to the carpometacarpal
cant amount of cotton padding under casting tape that or tarsometatarsal joint, allowing flexion and extension
reduces the close apposition of the cast to the limb, mak- of the carpus (tarsus), and full limb casts extend to the
ing the bandage cast not appropriate for rigid limb fixa- elbow joint or tibial crest. Both are used in the treatment
tion. Despite the lack of rigid fixation, bandage casts are of soft tissue injuries and in fracture repair.

www.ajlobby.com
Cast Principles to be wicked from the surface of the limb and through
the casting tape.9
Historically, plaster of Paris (POP) was used as a casting Waterproof cast padding made of a porous form of
material in equine fracture repair; however, current polytetrafluoroethylene (Gore Procel Cast Liner, W. L.
casts are made exclusively out of resin‐impregnated Gore, Flagstaff, AZ, USA) is available in 2, 3, and 4 in.
fiberglass tapes (Table 13.1). POP cast material had sev- widths (Figure 13.1), and may be used in place of 3M
eral advantages, including low cost and superior con- Custom Support Foam. This material allows a cast to be
formability, but POP also had many deficiencies, completely submerged or soaked in water without
including slow setting times, permeability to water, low absorption of water or continued moisture retention
strength, and radio‐opacity when compared to resin‐ against the skin. It can be particularly useful for foot
impregnated fiberglass tapes.6,24 Rolls of fiberglass cast- casts when hoof wall resections have been performed
ing tapes are available in 4 yard lengths (3.66 m) and and/or the clinician wishes to soak a casted foot
varying widths, generally ranging from 2 to 5 in. These (Figure 13.1). It may also be useful when a wound is
materials are water activated through submersion in expected to be especially exudative or when the cast
warm water, which initiates an irreversible transforma- may become wet. The cast padding is applied directly to
tion of the resin to a rigid material within the fiberglass the limb and used in the complete absence of stocki-
fibers. Casting tape that feels firm, is difficult to unroll, nette, orthopedic felt, or other cast padding materials if
or is beyond its expiration date should not be used. it is being used for a water‐resistant cast. Otherwise,
Details such as optimal water temperature (generally additional materials including stockinette or orthopedic
that of tepid bath water or 20–25 °C), duration of immer- felt can be used concurrently. Gore Procel is not water
sion, number of times to squeeze the material while activated and does not transform into a single unit or
under water, and whether excess water should be layer. Rather, it can be removed by unrolling at any point
squeezed from the tape are specific to each manufac- during application, although the padding has light adhe-
turer and are available on the package insert. As a rule, sive on one side to prevent unintentional unraveling or
increasing the temperature of the water and increasing shifting of the padding prior to fiberglass casting tape
the number of squeezes while the roll is immersed and application. Because it does not stretch or expand, two
after the roll is removed from water will decrease the layers should be used (one layer is a single pass down the
setting time, as will an increase in the ambient tempera- limb with 50% overlap with each turn). Although the
ture. A higher water temperature will also increase the material does not stretch or expand, and it is nearly
exothermic reaction during cast curing.25 impossible to avoid wrinkles and folds, there does not
Following the introduction of resin‐impregnated fiber- seem to be an increased risk of developing cast sores or
glass casting tapes, there was an increase in the severity other cast complications. 3M and BSN (BSN Medical,
and number of cast sores in horses.9 This was due to the Charlotte, NC, USA) also have waterproof cast padding
abrasiveness of the open weave in fiberglass tapes and products, Scotchcast Wet or Dry Cast Padding and
the rigidity of the fiberglass, which reduced conformabil- Delta‐Dry Water Resistant Cast Padding, respectively.
ity to the limb. Use of an equine‐specific, water‐activated Scotchcast is made of polypropylene, nonwoven fibers
polyurethane resin‐impregnated open cell foam as cast that are treated with a proprietary technology to make
padding (3M Custom Support Foam, 3M Company, St. them hydrophobic (Table 13.1).
Paul, MN, USA) decreased the incidence and severity of The ultimate strength of a cast is a product of the
cast sores with fiberglass casts. Cast foam was available material’s compressive strength (cast material is weakest
in 3 in. × 3 yard rolls but is no longer available due to the in compression) and tensile strength, the strength of the
limited shelf life. Similar alternative products have not resin, and the amount of adhesion between and within
yet been described. The original custom support foam layers, or the degree of lamination. Therefore, when each
conformed to the limb extremely well, compressing over layer bonds together into a single unit, achieving maxi-
bony prominences and expanding into depressions on mal lamination, the construct strength should not be
the limb surface under the cast material. It also bonded changed by the width of the casting tape. However, when
well to itself, as well as to the overlying casting tape, cre- casts do not cure ideally, as is common in clinical appli-
ating a single unit. This served to minimize movement cation due to differences in resin distribution that occur
within the cast and allow a more closely fitted cast. The during casting tape storage, as well as differences in ten-
creation of a single unit also minimized the risk of sion applied to the tape and operator efficiency during
cutting underlying structures with the oscillating saw application, they may fail to bond each layer into a single
during cast removal, as the innermost layer was more unit, thus decreasing construct strength. Therefore, the
mobile and less likely to be cut with the saw. Finally, widest tape that can be conformed to the limb should be
the foam was porous and allowed exudates and moisture utilized to maximize cast strength.69
www.ajlobby.com
Table 13.1 Examples of available and commonly used casting tapes and liners/padding.
Name Material Notes
Fiberglass casting tapes

Vetcast™ Plus Veterinary Fiberglass tape Strong
Casting Tape Polyurethane resin Conformable
(3M) Room temperature water, 21–24 °C (70–75 °F)
5 in. × 4 yard
White only
Scotchcast™ Plus Casting Knitted fiberglass fabric Lubricating agent
Tape Polyurethane resin and lubricating agent in the resin provides a slippery feel
(3M) Room temperature water, 21–24 °C (70–75 °F) when exposed to water
Squeeze three times while immersed
1 in. × 2 yard
2–5 in. × 4 yard
Available in colors
Delta‐lite® Plus Knitted fiberglass tape with extensible yarns Good conformability
(BSN Medical) Polyurethane resin (tack‐free properties) Outstanding molding
Water temperature 20–25 °C (70–77 °F) Smooth surface and decreased
Squeeze 1–3 times while immersed abrasiveness
Lightly squeeze post dipping Improved (high) lamination
1 in. × 2 yard
2, 3, 4, 5 in. × 4 yard
Zim‐Flex™ Cast Tape Fiberglass tape Strong
(Zimmer Inc.) Polyurethane resin Conformable
Room‐temperature water, 21–24 °C (70–75 °F) Lubricating agent can be added during
Available in colors application
2, 3, 4, 5 in. × 4 yard
Delta‐Cast® Elite and Knitted elasticized polyester fibers Increased conformability
Delta‐Cast Conformable Resin Three‐dimensional stretch
(BSN Medical) 2, 3, 4, 5 in. × 4 yard Approximately 50% of ultimate strength
Available in colors of other commonly used casting tapes70
Flashcast Elite® Polyester substrate with extensible yarns Increased conformabilitya
(BSN Medical) 2, 3 in. × 4 yard
Techform™ I and II Polyester fiberglass fabric Excellent conformability
(Ossur) “High‐action” resin Superior smoothnessa
1.5, 2, 3, 4 in. × 4 yard
Available in colors
Altocast™ Knitted fiberglass Multidirectional stretch
(Altochem) 2, 3, 4, 5, 6 in. × 4 yard Excellent conformabilitya
Available in colors
CaraGlas Ultra™ Polybithane™ brand TacControl™ resin Excellent conformabilitya
(DeRoyal) 2, 3, 4, 5 in. × 4 yard
Available in colors
Cast padding
Custom Support Foam™ Open cell foam impregnated with a polyurethane resin Conformable
(3M) (discontinued by Ideal water temperature 18–24 °C or 65–75 °F for Not water resistant
manufacturer) 2–3 min working time
Squeeze once post dipping and apply
Delta‐Dry® Water‐Resistant Open knit structure Conformable
Cast Padding Not water activated during application Water resistant
(BSN Medical) 2, 3, 4 in. × 2.6 yard
Scotchcast Wet or Dry Polypropylene/polyethylene knit and nonwoven fiber Water resistant
Cast Padding Proprietary treatment for hydrophobicity
(3M) Not water activated during application
2, 3, 4, 6 in. by 4 yard
Gore Procel® Polytetrafluoroethylene Waterproof
(W. L. Gore) Not water activated during application Not conformable
Adhesive backing on one side
Specialist Cast Padding Polyblend, rayon and cotton blend, micropleated Conformable
(BSN Medical) Not water resistant
a
Newer‐generation, conformable tapes may have reduced ultimate strength compared to older tapes.70
www.ajlobby.com
(A) (B)
Figure 13.1 (A) Waterproof cast padding made of a porous form of polytetrafluoroethylene (Gore Procel) is available in 2, 3, and 4 in.
widths. This material allows a cast to be completely submerged or soaked in water without absorption of water or continued moisture
retention against the skin. It is nonconformable and not water activated. Slippage during application is prevented by light adhesive on
one side of the liner. It is useful when the cast may become wet or wounds are especially exudative. In (B), a dorsal and palmar window in
the foot cast, along with the impermeable cast liner, allowed treatment and soaking of a hoof wall resection during treatment for support
limb laminitis. The horse was markedly more comfortable on the laminitic limb immediately following foot cast application, and was
discharged from the hospital with a glue‐on shoe six weeks later.
Casting tape should be applied by spiraling up and joint distal to the fracture.20 However, this may not be
down the limb. Each layer should overlap the previous possible or necessary for all fractures. When full limb
layer by at least 50% to maximize bonding (lamination) casts are used for distal radial or tibial fractures, the body
between layers. Because widths of tape utilized may vary and muscle mass adjacent and proximal to the elbow or
depending on availability and surgeon preference, it is stifle precludes their incorporation and immobilization.
important to apply sufficient layers of casting tape and Even when immobilization is easily performed, immobi-
not a set number of rolls. Generally, 5–6 layers of casting lization of the joint proximal to a fracture may not always
tape with 50% overlap are sufficient to prevent cast fail- be required. For example, in selected distal metacarpal
ure for a half limb cast.6 To increase cast strength in a fractures, a half limb cast can be sufficient, leaving the
particularly large or active patient, or for a full limb cast, carpus free to flex and extend.
the cast should be made thicker through the addition of Casts, regardless of length, should end as close to
extra layers (this will decrease the porosity of the cast). the proximal joint as possible, and should never end
Additionally, increasing the distance of the cast from the in the mid‐diaphysis. This allows the increased width
neutral axis of rotation, by making the cast thicker, will of the metaphysis to distribute stress that transfers from
increase cast strength.70 Although not usually necessary, the cast to a larger area of underlying bone.8 It also allows
splint augmentation may be used and is most effective flexion and extension at the adjacent joint to mitigate
when placed along the compression side of a fiberglass these bending forces.
cast and farthest from the neutral axis.69,70 Because the
compressive side of a cast will change with weight bear-
ing, splint augmentation should be placed on both the Routine Casting
dorsal (cranial) side and the palmar/plantar (caudal) side
of the cast.20,69 Splints should be made of water‐activated
fiberglass casting tape folded back and forth on itself
Casting Method
(accordion folded) and secured within the cast immedi- Prior to cast application, the clinician should check that
ately prior to the final layer of encircling casting tape. all supplies are available and collected, as cast curing
This will maximize the splint distance from the neutral occurs quickly (Table 13.2; Figure 13.2).
axis of rotation and maximize augmentation of cast The shoe should be removed and the foot trimmed and
strength. cleaned. The contralateral limb should be shod with a
Theoretically, when used for fracture repair, a cast support shoe of choice and full pads added as necessary
should immobilize at least the joint proximal and the to increase limb length, closely matching the height of the
www.ajlobby.com
Table 13.2 Equipment that should be prepared and gathered important during shoe removal if the horse develops sup-
prior to cast application. port limb laminitis. The affected limb should be clean
and dry and surgical sites or wounds covered with a thin,
Application Function Equipment nonadherent dressing. Historically, a drying agent such
as boric acid was applied to the limb. Due to the porosity
Preparation Shoe Shoe pulloffs
of current casting materials, this is no longer necessary.
of foot and removal (Optionally) Nail puller, clinch
limb cutter The cast limb should be stably positioned in partial to
full extension depending on the site to be protected. If
Trim, clean, Hoof knife
and dry foot Hoof nippers distraction is indicated, traction can be applied to the
Rasp limb by placing wires through the hoof wall, much like a
Povidone‐iodine scrub and water horseshoe nail superficial to the sensitive laminae. Wire
Scrubbing brush placement along the hoof quarters, toward the heel, will
Towel
allow some fetlock extension, while placement at the toe
Dress Nonadherent dressing will maximize alignment of the bony column. The wires
wounds Stretch gauze
can be secured to the wall, a brace on the operating table,
Limb Attach wire 1.2–2.2 mm wire or tensed by an assistant. These hoof wires can also
traction and to hoof Power drill and bit
be secured to a metal brace on the solar surface of the
positioning Wire cutters
Pliers foot and incorporated into the cast to prevent flexion
of the distal limb within the rigid cast during walking.
Assistant Radiographic control
Gloves The appropriate degree of extension is determined by
the purpose of the cast and surgeon preference. For
Cast Cast lining 2–4 in. stockinette rolled onto
application limb in two well‐secured layers long‐term cast support and avoidance of rub sores, most
(one inward and one outward) surgeons prefer to place the distal limb in a near neutral
Towel clamps to mildly extended position, with an aligned bony column.
Cast Orthopedic felt (1/4 in.) in This is especially true in the hindlimbs, where an extended
padding 1–2 in. wide strips for position, achieved by an assistant pressing on the patella,
circumferential application helps maintain a functional walking position through the
Porous adhesive tape
action of the reciprocal apparatus (Figures 13.3 and 13.4).
Resin‐impregnated foam (or
water‐resistant padding/liner) For short‐term cast support or for bandage casts, a fully
Bucket with warm water extended, weight‐bearing posture can be utilized. If the
Gloves limb has been cast in a weight‐bearing posture, many
Wires for Two Gigli (obstetric) wires 40 cm horses are more comfortable and develop fewer and less
cast longer than proposed cast length frequent cast sores if the solar surface is slightly rounded,
removal within plastic tubing allowing foot breakover to occur more easily. Finally, ade-
Plastic tubing (cut to length of
quate heel elevation with additional cast rolls applied to
proposed cast length)
Porous adhesive tape the heel becomes increasingly important to avoid dorsal
rub sores when the distal joints are not fully extended.
Cast Rolls of resin‐impregnated
material fiberglass casting tape
Bucket with warm water Half Limb/Routine Application
Gloves Cast application is typically performed under general
Cast Polymethyl methacrylate resin anesthesia, often at the conclusion of surgery for a pri-
protection Disposable container to mix mary problem.20 When the primary problem does not
Discarded foil wrapper from require general anesthesia or for a routine cast change,
casting tape
Tongue depressor cast application can be done in the standing patient.
Gloves Foot casts26,55 and forelimb half limb casts can be
Elastic adhesive tape applied with the limb held up by an assistant.55 When a
weight‐bearing posture is desired, the horse is then
allowed to stand quietly on the cast limb, allowing the
cast limb (Figure 13.3). The contralateral shoe and solar cast to cure with a cast conformation that matches that
impression material should maximize support to the cau- of the normal hoof–pastern axis.26,55 One publication
dal half of the foot, reducing load on the hoof wall.66 has described half limb cast application to the hindlimbs
Additionally, the shoe should be applied as atraumatically of standing horses for medial condylar fractures.38 This
to the hoof capsule as possible (i.e., glue‐on or wood is made especially difficult by the reciprocal apparatus
screw attachments rather than nail‐on), which becomes causing flexion of the fetlock when the limb is held off
www.ajlobby.com
(B) (C) (D)

(A)
(G)
(E) (F)
Figure 13.2 Supplies for cast application. (A) Stockinette, divided to equal halves with an inward and outward roll; (B) orthopedic cast felt;
(c) cast padding, Gore Procel; (D) obstetric wires for cast removal; (E) cast padding, 3M Custom Support Foam (discontinued by
manufacturer); (F) casting tapes; (G) polymethyl methacrylate powder, liquid, and mixing cup.
(A) (B) (C)
Figure 13.3 Contralateral limb support shoe. The shoe should be applied as atraumatically to the hoof capsule as possible (i.e., glue‐on or
wood screw attachments rather than nail‐on). (A) Two‐part impression material is placed in the frog sulci and sole palmar to the frog apex
to enhance support to the palmar half of the foot, improving patient comfort and reducing load on the hoof wall. (B) Additional full pads
are added as necessary to allow the contralateral limb length to match that of the cast limb when fixed in a partially extended, aligned
bony column position. (C) Equal limb length enhances patient comfort and encourages even weight bearing.
the ground. To overcome this flexion, the hindlimb application.38 Due to stepwise application, there is some
can be drawn forward in an extended non‐weight‐ risk that the cast over the foot region will not laminate
bearing position, and cast material applied with the appropriately to the remainder of the cast. Additionally, a
hindlimb extended and maintained low to the ground. major risk during standing cast application, especially for
Alternatively, the limb can be elevated into slight flex- half or full limb casts, is the possibility of patient move-
ion and the cast material applied to enclose the foot, ment before complete curing of the cast. Movement can
which is then placed on the ground to obtain a normal result in stretched, wrinkled, and misfitted casts and
weight‐bearing posture, followed by completion of cast increased risk of cast complications.
www.ajlobby.com
Figure 13.4 Limb positioning for a half

(A) (B)
limb cast. (A) Generally, limbs are
positioned with an aligned bony column
to a slightly extended posture. This
increases patient comfort on the limb,
encourages even weight bearing, and
minimizes the chance for cast rub sores. If
a cast is to be used for short‐term support,
a more weight‐bearing/extended posture
may be utilized. The cast in (B) was
applied with a mild degree of fetlock
flexion due to inadequate extension of
the limb during cast application. During
hindlimb cast application, an assistant
should press on the patella throughout
application to maintain proximal limb
extension while manipulation at the toe is
used to position the distal joints. This
flexed posture would not be acceptable
for long‐term cast support and the
development of cast sores would be likely.
A double layer of stockinette made of synthetic fibers the risk for cast rub sores. If the limb is to be manipu-
(polyester) is rolled over the foot, extending at least 4 cm lated, it should be done carefully with the flat part of the
beyond the proximal extent of the cast. Stockinette is hand and not the fingertips. Additionally, gloves should
available in 1, 2, 3, 4, and 6 in. widths of 25 yards per box. be worn by all persons handling the water‐curable cast-
The purpose of the stockinette is to create a uniform, ing materials.
nonshifting, comfortable padding that will allow cast One to two layers of synthetic cast padding or water
material adherence, while protecting the hair and skin impermeable cast padding such as Gore Procel or 3M
from adhering to the casting tape. This is facilitated by Synthetic Cast Padding should be applied. Gore Procel
prerolling, in two equal portions, a length of stockinette and 3M cast padding are simply applied dry. Cast pad-
at least 8 cm longer than twice the length of the antici- ding should be laid on the limb with just enough tension
pated cast. One portion is rolled inward and the other to avoid wrinkles and folds. If Gigli or fetotomy wires
rolled outward (Figure 13.5). The outwardly rolled spool are the method of choice for cast removal, they should
is unrolled onto the limb from the foot, the stockinette is be added after the cast padding to avoid focal skin pres-
then twisted at the foot 360°, securing the distal end, and sure. Wires should be placed at the medial and lateral
the second spool is rolled onto the limb. Both ends aspect of the limb to facilitate cast removal by two cuts
should be temporarily held proximally during cast appli- to form dorsal and palmar/plantar halves of the cast.
cation by towel clamps, tape, or an assistant prior to Wires should be cut 40 cm longer than the expected
inclusion in the proximal end of the cast. The stockinette length of the cast, allowing 20 cm of free wire at both the
should be tight enough circumferentially so that it does proximal and distal ends. Spraying the wires with lubri-
not wrinkle or bulge (see Figure 13.5). cant, such as WD‐40 (WD‐40 Company, San Diego, CA,
Strips of orthopedic felt 1–2 in. wide are placed with- USA), and placing them in flexible tubing (e.g., intrave-
out overlap over the stockinette in areas of increased nous dripset tubing), prior to application of the cast, will
pressure and risk for rub sores.60 This always includes an facilitate their use during cast removal. The tubing
encircling ring of felt at the proximal aspect of the cast. should extend just beyond the ends of the cast, leaving
Some surgeons also place an encircling ring of felt at approximately 20 cm of free wire to be coiled and
the level of the coronary band. If cast rub sores are pre- secured to the cured cast with porous tape. Handles will
sent during a cast change, they can be protected with a later be attached to these free ends to allow the fetotomy
doughnut‐shaped piece of felt placed around the sore, wire to cut the cast in half.
minimizing pressure directly on the wound. Prior to starting fiberglass casting tape application, the
When working with water‐curable fiberglass materials, clinician should double‐check limb positioning, ensur-
it is imperative that the surgeon and assistant(s) do not ing appropriate extension of the foot and neutral valgus/
place focal pressure on casting materials, as permanent varus bending, and an assistant should maintain this
pressure points within the cast could result, increasing position by manipulating the toe and supporting the
www.ajlobby.com
(A) (B) (C) (D)
(E) (F) (G) (H)
(I) (J) (K) (L)
Figure 13.5 Half limb cast application (hindlimb). (A) Stockinette application is facilitated by prerolling the stockinette in opposite
directions. (B) The outwardly rolled half is unrolled onto the limb. (C–E) Stockinette is secured to the distal end of the limb by turning the
inwardly rolled section 360° prior to unrolling onto the limb. (F) The proximal ends of stockinette should extend at least 4 cm proximal to
the proposed end of the cast. (G) An encircling ring of orthopedic felt is placed at the proposed proximal end of the cast, without overlap,
and is secured with porous tape. (H) Cast padding is applied by spiraling down the limb with a 50% overlap. Obstetric wires are placed
over the cast padding, medially and laterally, to facilitate cast removal. Note the assistant’s hand, pulling up on the toe to maintain distal
limb extension and an aligned bony column. An assistant is also pressing on the patella to maintain the proximal joints in extension. (I)
Five to six layers of water‐activated fiberglass tape are applied by spiraling up and down the limb with a 50% overlap. (J, K) The proximal
free ends of stockinette are cut to allow wires to be placed through the stockinette, which is then folded down over the cast and held with
the final layer of casting tape for secure incorporation within the cast. (L) The free ends of the obstetric wires are coiled and secured to the
cast with porous tape.
www.ajlobby.com
underside of the limb. The casting material is then the casting tape can be used for manipulation and secur-
removed from its foil package, immersed in tepid water, ing of the polymer, although it will be incorporated into
and applied evenly over the limb. Only one roll should be the cast. Elastic tape should be placed over the acrylic
opened at a time, as room humidity can initiate tape cur- once hardened to increase traction (Figure 13.6).
ing. Application can begin either over the foot or at the Once the cast has cured, elastic tape should be placed
proximal end, at the level of the orthopedic felt. At least at the proximal aspect of the limb, spanning from the
1 cm of orthopedic felt should be left uncovered by cast- skin of the exposed limb to the cast itself, to seal the cast
ing tape proximally to prevent skin abrasions from hard- from environmental contamination. This tape should be
ened cast material during limb flexion (see Figure 13.5). changed daily for routine cast monitoring. Applying a
The first layer of casting tape should be applied with only semipermanent ring of elastic tape 1 cm proximal to the
a minimal amount of tension, essentially just enough cast serves as a point of attachment for the elastic tape
tension to avoid wrinkles and folds. Smaller tapes (i.e., that is changed daily, thereby minimizing skin irritation.
3–4 in.) are more easily conformed to the limb for the At the completion of cast application, an additional
initial layers. Each subsequent layer should be applied 10–15 minutes of curing time should be allowed before
with more tension than the previous, ending the final roll recovery of the anesthetized horse or allowing the stand-
with firm, even tension on the casting tape during appli- ing horse to move. In the case of general anesthesia, the
cation. With each new roll, application should begin at horse should be placed in the recovery stall with the cast
the same level as the previous roll was ended. All rolls, limb uppermost.
except at the foot, should be applied in the same direc-
tion around the limb. Each layer should be applied Full Limb Cast Application
quickly and carefully, and overlapped by 50% to ensure The principles for a full limb cast are the same as for a
even pressure and maximal bonding between casting half limb cast, although there are several major differ-
tape layers. Care should be taken to ensure that the cast- ences to be considered.
ing tape is smooth and without wrinkles, especially the Approximately 10–12 rolls of 4 or 5 in. tape are needed
first one to two layers. The foot, excluding the toe where for the forelimb and 12–14 rolls for the hindlimb. It is
the assistant is maintaining limb positioning, should be important to apply an appropriate number of layers
included and covered with each successive layer up and rather than the appropriate number of rolls, as previ-
down the limb. During the final layers, the cast will be ously discussed. The approximate number of rolls is
adequately cured for the assistant to release the toe and given here only for planning and gathering of supplies.
allow complete foot enclosure without limb movement. The full limb cast should terminate proximally, just distal
Smoothing and rubbing of the applied cast material to the cubital joint or just distal to the stifle at the level of
between layers and after completion while curing will the tibial crest. Occasionally, in young foals or ponies
help maximize bonding lamination between layers. with minimal muscle mass, the cast can extend to just
If the limb is cast in a neutral or partially extended proximal to the elbow or stifle (Figure 13.7). Increased
position, a foot wedge, or one flattened roll of 4 in. cast- scrutiny for developing cast sores at the proximal extent
ing tape, can be secured with a second roll of casting tape of the cast should be maintained if an extra‐long cast
to build up the heel and create a flat solar surface for is used.
weight bearing. The size of the wedge is determined by A full limb cast requires additional orthopedic felt. In
the extent of lower limb flexion that needs to be over- the forelimb, the accessory carpal bone can be protected
come to provide adequate heel contact (Figure 13.6). with a ring or doughnut of felt. Some surgeons also place
Inadequate heel support can cause rub sores along the a felt doughnut over the medial and lateral prominences
dorsoproximal metacarpus/tarsus. During the final roll of the distal radius. In the hindlimb, the calcanean tuber-
of casting tape, the two layers of stockinette extending osity and medial and lateral malleoli can be protected
from the proximal aspect of the cast can be folded down with rings of felt. A full limb cast will require additional
onto the cast and covered by casting tape, thereby pre- fiberglass casting tape layers in the areas most likely to
venting slippage. Alternatively, the stockinette can be develop bends or cracks, including immediately distal to
folded over the proximal end of the cast and held in place and over the carpus/tarsus (cast material is weakest in
by elastic tape. compression). If fetotomy wires are placed beneath the
Hoof acrylic (polymethyl methacrylate, PMMA) cast for later cast removal, they need to be secured at the
should be placed on the solar surface of the cast to carpus/tarsus as well as the proximal and distal ends,
protect against excessive wear, especially at the toe
keeping them positioned medial and lateral during cast-
(Figure 13.6). The mixed methacrylate should set to a ing tape application. This will ensure that the two halves
putty‐like consistency before being spread onto the sole of the cast are approximately equal in size, facilitating
with a tongue depressor. A discarded foil wrapper from cast removal. In the hindlimb, two separate wires can be
www.ajlobby.com
(A) (B) (C)
(D) (E) (F)
Figure 13.6 Heel elevation. (A, B) When the limb is cast in a partially extended position (aligned bony column), one roll of 4 in. casting
tape can be secured with a second roll of tape to build up the heel and create a flat solar surface for weight bearing. (C) Acrylic is mixed in
a disposable cup until it achieves a putty‐like consistency, (D) spread on a casting tape foil wrapper, and (E) applied to the solar surface
and toe to improve wear and water resistance. (F) Elastic tape should be placed over the acrylic once hardened to increase traction.
www.ajlobby.com
(A) (B) (C)
(D) (E)
Figure 13.7 (A) Lateral to medial (LM) and (B) cranial to caudal (CC) radiographs of a severely comminuted mid to distal tibial fracture in a
14‐year‐old pony mare. Due to the pony’s small size and decreased musculature, the cast could be placed proximal to the stifle joint. The
pony was discharged two weeks postoperatively and was transitioned to a similarly long bandage cast four weeks postoperatively. (C) LM
and (D) CC radiographs three months postoperatively: the implants remained stably positioned and there is radiographic evidence of
fracture healing. (E) Pony at one week postop, showing cast over the stifle joint. Cast bandaging was discontinued eight weeks after
surgery and the pony did well in the long term.
www.ajlobby.com
placed on both the medial and lateral aspects of the limb, lameness. Cast sores are rare unless the cast ends mid‐
one for the proximal half and one for the distal half. pastern.13 The cast is left in place for approximately three
During removal, if the two cuts do not join, a cast cutter weeks to allow healing of lacerations and is removed
may be used to connect them. The use of two wires per standing. Fetotomy wires may also be placed for foot cast
side requires more attention during casting tape applica- removal, although such a short cast can easily be removed
tion, but allows for straighter cuts and decreases the without wires.
chance of wire breakage during sawing for cast removal.
Distal limb positioning for a full limb cast is similar to Bandage Cast Application
positioning for a half limb cast. However, it is critical that Bandage casts (Figures 13.9 and 13.10) can be applied as
the carpus/tarsus is positioned in an extended, weight‐ either half limb or full limb devices. The biggest advan-
bearing conformation in a full limb cast. This is espe- tages of the bandage cast are:
cially difficult to maintain in the hindlimb. An assistant
should press on the patella to keep the limb in a locked ●● comfort with reasonable stability
position (extended) throughout cast application. With ●● ability to bivalve the cast and address wounds with
the proximal joints locked in extension, the distal limb reapplication of the same cast shell over a fresh
should be positioned by manipulating the toe. Most bandage
horses will be more comfortable in a full hindlimb cast ●● reduced incidence and severity of cast rub sores.
when the distal limb is partially extended, with an aligned If the cast shell is to be bivalved for reapplication, the
bony column. Sedation and assistance to rise during initial bandage must be easily reproducible for the cast
recovery are important for horses with full limb casts, shell to be accurately reapplied without gaps or overrid-
especially hindlimb casts. The first time the horse is ing between the two halves. Because of the bandage
walked and during anesthetic recovery, an assistant thickness, it is easier to detect when the bandage mate-
should be available to place a rope around the distal end rial has compressed or shifted within the cast, necessitat-
of the cast to help advance the limb if needed. ing replacement.
Although pound (roll) cotton may be used, sheet cot-
Tube Cast Application tons are easier to apply initially and reproducibly, and are
A tube cast supports the carpus or tarsus from flexion less likely to continue to compress and/or shift following
and lateral bending and extends from just distal to the cast application. A typical bandage cast will have a two‐
elbow or stifle to the level of the fetlock joint, allowing sheet combination of folded sheet cotton secured with
flexion and extension of the fetlock and distal joints brown gauze, followed by a second two‐sheet combina-
while the carpus/tarsus is fixed in extension. Despite tion. The second set of sheet cottons is firmly secured
similarities to the full limb cast, most horses are more with both brown gauze and flexible cohesive wrap (3M’s
comfortable in a tube cast due to the continued normal VetrapTM), including the bulbs of the heel. The tight
use of the distal joints. Application of orthopedic felt gauze should not extend beyond the cotton padding. The
beneath the distal extremity of the cast, immediately completed bandage should be approximately 1 in. thick,
proximal to the fetlock, protects the skin in the same nearly noncompressible, and even down its length. If
manner as the proximal felt strip in all casts. Encircling wires are elected for cast removal, they should be
elastic tape is required at the distal and proximal ends to included at this stage. Fiberglass casting tape application
seal the cast from environmental contamination. While a follows as for a standard cast, with the foot and distal
support shoe can be placed on the contralateral limb, limb in a weight‐bearing position to avoid rub sores over
additional pads to increase the limb length of the con- the palmar/plantar fetlock. Due to the bandage thick-
tralateral limb are not required. Otherwise, the tube cast ness, significant tension can be applied during all layers
is applied in the same fashion as for a full limb cast. of casting tape application. The cast often completely
encloses the hoof, depending on the region and need for
Foot Cast Application stabilization.
Similar to other casting techniques, a double layer of A bandage cast can be left in place for up to three weeks,
stockinette is placed followed by 1 in. wide orthopedic provided bandage compression and cast loosening are
felt strips at the proposed proximal end of the cast not detected. For bandage changes and reapplication of
around the pastern and optionally at the coronary band. the cast shell, the cast should be bivalved in the frontal
Some authors utilize a cast padding (Gore Procel)13,30 plane to form dorsal and palmar/plantar shells. The two
and others place casting tape directly over the stocki- halves can be completely separated by a cut across the
nette.26 Usually, three rolls of 3 in. casting tape are suffi- solar surface of the foot, connecting the medial and lateral
cient (approximately four layers; Figure 13.8). Most cuts. Reapplication is easier, more accurate, and more
horses tend to walk comfortably with little obvious secure when the solar surface of the cast in the foot is not
www.ajlobby.com
(A) (B) (C)
(D) (E) (F)
Figure 13.8 Forelimb foot cast application in the standing horse. (A) Stockinette and cast felt are applied. Cast padding is not required for
a foot cast, although some clinicians prefer its use. (B) Casting tape is applied while the limb is suspended by an assistant. (C) Once the
foot is enclosed, final casting tape layers are applied with the limb in a weight‐bearing position. (D) Once the cast has cured, acrylic is
applied to the solar surface. (E) The proximal free stockinette is incorporated into the cast as for a standard cast. (F) The proximal end of
the cast should be sealed against environmental contamination with the use of elastic tape, as for a standard cast. Tape marked with an
“X” is a semipermanent ring for adherence of the tape that is changed daily.
cut all the way through and acts as a hinge. The bandage A foot block consists of a 1 in. wide × 2 in. tall × 6 in. long
can then be changed and the cast shell reapplied and wooden block attached to a large flat piece of plywood
secured with porous, nonelastic tape from proximal to for stabilization. The contralateral foot is placed on a
distal (Figure 13.10). When the cast has been bivalved and block of similar cumulative height. The limb to be cast is
reapplied, it should be changed at least weekly. then placed flat on the foot block, leaving as much toe
To assist in the application of bandage casts to the as possible extending forward of the sole contacting
hindlimbs of standing horses, a foot block can be utilized. the block (Figure 13.11). This allows maintenance of a
www.ajlobby.com
(A) (B) (C) (D)
Figure 13.9 Bandage cast application for severe wounds. Photographs of the left forelimb of a 7‐year‐old Thoroughbred gelding
presented for severe lacerations (A) with avulsion of the lateral collateral ligament of the left forelimb metacarpophalangeal joint and
open metacarpophalangeal and proximal interphalangeal joints. Rigid limb fixation was required to stabilize the metacarpophalangeal
joint; however, due to marked soft tissue swelling and need to address wounds, a bandage cast was applied and later bivalved for
frequent bandage changes. Twelve days after presentation, a marked reduction in soft tissue swelling dictated the need for a new cast
shell. (B) Two days later, there was exudate coming through the cast at the palmar fetlock, necessitating immediate removal. (C) The cast
was bivalved and partial thickness cast sores were present over the sesamoid bones. The same cast shell was used for an additional two
weeks with frequent cast changes (every two to three days). (D) One month after presentation, the wounds and cast sores healed without
incident. The horse was discharged from the hospital for an additional month of bandage changes with cast shell reapplication. The horse
subsequently returned to athletic use.
weight‐bearing position during cast application, includ- Cast Complications

ing nearly circumferential inclusion of the hoof margins
with fiberglass tape. Extra layers of casting tape are uti- Rub sores are the most common cast complication.6,27,29
lized to wrap across and under the toe region, where They range from mild, partial‐thickness skin ulcerations
extra force will be applied when the horse flexes the hock of no long‐term consequence, to life‐threatening, full‐
and stifle. Once the cast has cured, the limb can be thickness wounds involving vital structures such as bone,
extended forward off the foot block for complete enclo- joints, tendon sheaths, or tendons. They are often the
sure of the foot and acrylic application. The clinician result of inadequate heel elevation or increased motion
should use caution when applying fixation to the within the cast resulting from poor cast fit (overly loose
hindlimb of a standing horse, as some horses can be star- cast), compression of padding, and/or decreased limb
tled by the sudden inability to flex the hindlimb. swelling. Static pressure from poor limb positioning
within the cast, or poor techniques during casting (overly
tight cast or focal pressure points from manipulations of
the cast prior to complete curing), may also result in cast
Cast Variations sores. Cast sores predominantly occur over the dorso-
Window casts have been used to allow access to part of proximal aspect of the metacarpus/tarsus, the palmar/
the limb while maintaining a cast for rigid support.5 After plantar aspect over the sesamoid bones, and along the
cast application, a cast cutter is used to cut out a section heel bulbs. Ideally, cast sores would be treated as open
of the cast, creating the window which is then filled with wounds without cast reapplication. Often, this is not
bandage material that can be changed at the clinician’s possible and a cast must be reapplied. In this case, sores
discretion. This is not commonly practiced due to exces- should be cleaned, examined for involvement of critical
sive edema and soft tissue swelling that often cause pro- structures, debrided if necessary, swabbed for microbial
lapse of the soft tissues into the window, but can be used identification and sensitivity testing, and bandaged with
to stage removal of loose pins in a pin cast combination. an antibiotic ointment. Rings of orthopedic felt can also
www.ajlobby.com
(A) (B) (C)
(D) (E) (F)
Figure 13.10 Bandage cast application. When the limb requires more frequent treatment and there is a decreased need for rigid support,
a bandage cast can be used with reapplication of the cast shell at each bandage change. (A) The bandage cast shell is removed with cuts
made medially and laterally in the frontal plane with preplaced wires. The solar surface of the cast is scored, but not cut through its entire
width. (B) A well‐compressed uniform double‐layer sheet cotton bandage is applied, followed by (C) application of the hinged bivalved
cast, which is (D) firmly closed around the bandage, allowing a near perfect fit of the cast shell after a bandage change. (E) Nonelastic tape
should be used for cast shell reapplication. (F) This horse was being treated for a severely comminuted P1 fracture. Shortly after she was
taken out of a pin cast, she was transitioned from a standard half limb cast to a half limb bandage cast to allow frequent wound treatment.
Despite decreased rigidity of the fixation, the bandage cast was adequate for comfortable weight bearing on the limb.
be used around the cast sore to reduce continued pres- transition to a cast bandage that will better protect the
sure under the new cast. Depending on the severity of rub sores.
the wounds, involved structures, and other clinical Joint immobilization in all species causes detrimental
parameters, the horse may require antimicrobial admin- effects on the articular cartilage, supporting ligaments
istration and/or regional limb perfusion, especially if a and soft tissues, and bone.2 In the horse, clinically rele-
cast must be reapplied. Every effort should be made to vant periods of immobilization (30 days) have minimal
www.ajlobby.com
(A) (B) (C)
(D) (E) (F)
(G) (H) (I)
Figure 13.11 Standing hindlimb bandage cast application using a foot block. The limb was being transitioned from a standard cast to a
bandage cast, after fetlock arthrodesis. (A, B) The limb is placed flat on the foot block, leaving as much toe as possible extending forward
of the sole contacting the block. The contralateral foot is placed on a block of similar cumulative height. Bandage materials are applied,
carefully including the solar surface of the heel. (C, D) Casting tape is applied with extra layers of tape across and under the toe region,
where extra force will be applied when the horse flexes the hock and stifle. (E, F) The foot remains on the block until the cast has
sufficiently cured. (G, H) Once the cast has cured, the limb can be extended forward, off the foot block, for complete enclosure of the foot
with casting tape and acrylic application. (I) The finished bandage cast with the limb in a weight‐bearing position.
www.ajlobby.com
effect on the articular cartilage of weight‐bearing areas, (A) (B)

probably due to continued weight bearing during cast
immobilization. However, because the proximal sesa-
moid bones do not continue to undergo weight‐bearing
forces during cast immobilization, their cartilage appears
to be significantly affected, with lowered proteoglycan
content.53 Elevated synovial fluid total protein after
seven weeks of cast immobilization of the fetlock has
also been documented, indicating either synovial inflam-
mation or a decreased ability to produce normal synovial
fluid in the immobilized joint.64
Disuse osteopenia appears to be significant following
cast immobilization in horses, especially with transfixa-
tion pin casts.12,17,27,28,35 Osteopenia was seen after six
weeks of experimental cast immobilization in ponies17
and mild osteopenia was seen after eight weeks of exper- (C) (D)
imental cast immobilization in horses.12 In another
study, significant mineral loss and bone volume loss after
seven weeks of cast immobilization were most pro-
nounced in non‐weight‐bearing areas of bone, and were
improved, but not reversed, after eight weeks of enforced
treadmill exercise.65 In the same horses there was lame-
ness, increased fetlock joint circumference, and reduced
fetlock joint range of motion following cast removal. The
lameness improved overall, but range of motion and
joint circumference did not improve in the eight weeks
of enforced treadmill exercise following cast removal.64
Osteopenia secondary to cast immobilization is likely
a result of both increased bone resorption and slowed
Figure 13.12 Radiographic images of the right hind pastern in a
bone production.15 In just one week of cast immobiliza- 16‐year‐old Morgan mare. The mare was presented for chronic (six
tion in horses, a decrease of 50–60% in serum alkaline months) luxation of the pastern joint and non‐weight‐bearing
phosphatase (ALP) occurs, suggesting reduced bone lameness. (A) Preoperative lateral to medial (LM) radiograph: there
production.15 To minimize increased bone resorption, was luxation of the proximal interphalangeal joint, periosteal new
there is experimental evidence that the administration of bone on the distal and proximal aspects of the first and second
phalanges, and severe osteopenia of the proximal sesamoid
1 mg kg−1 bwt tiludronate intravenously on days 0–28 of bones, characterized by a granular or punctuate appearance to
immobilization can prevent long‐term (56 days) cast the bone. (B) After luxation reduction and pastern arthrodesis
immobilization–induced osteopenia.15 This may allow with two 5‐hole narrow dynamic compression plates (DCPs), the
for shorter rehabilitation times and safer return to exer- mare was maintained in a half limb cast for 5½ weeks. (C) Uniaxial,
cise by maintaining bone density. The hallmark radio- mid‐body fracture of the lateral proximal sesamoid bone occurred
while a well‐fitted half limb bandage cast was in place, six weeks
graphic sign of osteopenia is a punctate or granular postoperatively. A bandage cast was maintained for an additional
appearance to the bone. This is usually first recognized eight weeks. (D) Dorsolateral to palmaromedial radiograph,
in the proximal sesamoid bones, as they undergo com- 3½ months postoperatively: there is minimal additional
plete loss of weight‐bearing loads when the fetlock can- displacement of the fractured lateral sesamoid bone and
not be extended.39,53 radiographic evidence of fracture healing.
Biaxial hindlimb proximal sesamoid bone fracture
following cast removal has been reported due to disuse
osteopenia following cast immobilization39 and trans-
fixation pin cast immobilization.28,36 In our hospital, of the presenting problem, six months of traumatic pas-
uniaxial hindlimb proximal sesamoid bone mid‐body tern luxation causing non‐weight‐bearing lameness. In
fracture occurred while a well‐fitted half limb bandage patients where severe sesamoid osteopenia is detected
cast was in place, six weeks postoperatively for pastern following cast removal, confinement with gradual and
arthrodesis in a 16‐year‐old Morgan mare (Figure 13.12). controlled return to exercise is imperative.39
This horse had severe bone mineral loss evident on pre- Local tendon and ligament laxity is a complication
operative radiographs due to the chronicity and severity largely limited to foals following cast immobilization.29
www.ajlobby.com
(A) (B) Cast Care and Monitoring

Stall confinement is absolutely required during cast
immobilization. Due to the importance of cast and
patient monitoring during fracture treatment, many cli-
nicians require that the horse remain hospitalized for the
duration of casting. Systemic health and signs of cast
complications should be assessed at least twice daily,
keeping in mind that cast rub sores are the most com-
mon complication. This includes a thorough physical
examination, cast examination, cast palpation, and
observation of the horse at a walk in a straight line for at
least 5–7 steps. The horse should always be turned away
from the casted limb, to prevent pivoting on the injured
limb. The tape at the top of the cast should be changed
daily, allowing a more thorough examination of the prox-
imal region of the limb and cast.
Signs of possible cast complications include:
●● increased rectal temperature
●● increased heart rate
Figure 13.13 A 7‐week‐old foal after three weeks of rigid cast ●● swelling of the limb proximal to the cast
fixation for a pastern arthrodesis. (A) Following cast removal, there
●● visible sores or exudate at the proximal aspect of
is moderate metacarpophalangeal and phalangeal laxity of the
left forelimb. (B) A glue‐on shoe with a heel extension (^ ^ ^) was the cast
applied to increase palmar support and reduce distal limb ●● increased lameness or increased periods spent
hyperextension. Together with heavy bandaging rather than recumbent
casting and controlled exercise, the laxity resolved and the shoe ●● increased focal heat detected manually or utilizing
was removed two weeks later.
a thermographic camera37
●● moisture or exudate coming through the cast
●● odor from the cast
This may lead to further injury of the limb, especially the ●● cracks or bends in the cast
lax soft tissue structures themselves, the dorsal aspect ●● wearing through the sole of the cast.
of cuboidal bones of the carpus and tarsus, and the
proximal sesamoid bones. If laxity is present, it should If any of these signs are detected, the clinician should
be addressed with heel extensions to increase palmar/ consider removing the cast immediately, as seemingly
plantar support, bandages and splints as necessary, and mild signs of cast complications can progress to life‐
confinement with controlled exercise (Figure 13.13).60 threatening complications quickly.6,60 Even with the best
Finally, long bone fractures during cast coaptation monitoring, cast sores also may cause no to minimal
have occurred, but are relatively rare due to application appreciable clinical signs, only to be discovered during a
of a cast up to the proximal metaphyseal region of long routine cast change.
bones, avoiding termination of the cast in the diaphyseal The horse’s systemic status should be carefully moni-
region.60 tored, including appetite, manure production, weight,
Full limb casts can cause cast sores in the same loca- and skin health. The other limbs, especially the con-
tions as half limb casts, and additionally will commonly tralateral limb, should be carefully monitored for signs of
incite cast sores at the proximal aspect of the cast, and support limb laminitis,66 including increased digital
the accessory carpal bone in the forelimb or calcanean pulses, increased heat within the hoof capsule, decreased
tuberosity in the hindlimb. Full hindlimb casts can also willingness to turn in the stall, increased time spent in
result in disruption of the reciprocal apparatus (rupture recumbency, and increased weight bearing on the cast
or avulsion of the peroneus tertius) due to maintenance limb (for a more complete discussion of stress‐induced
of the hock in a fixed position while the stifle is allowed laminitis, see Chapter 49).
to flex and extend. This usually has minimal long‐term The fracture patient requires special stall care. Many
consequences, and will resolve with an additional two to fracture patients will lay down with increased frequency
three months of stall rest.6,60 In addition, coxofemoral and duration. The clinician should encourage this
luxation has been reported in two foals wearing hindlimb through deep, comfortable, clean bedding, banked extra
tube casts.63 deep along the back wall of the stall, and a quiet barn
www.ajlobby.com
with reduced light at night. Many horses will be more Disadvantages of wire include breakage of the wire dur-
comfortable with their feed and water elevated, espe- ing sawing, and entrapment of the wire within acrylic
cially when wearing forelimb casts. covering the foot, making it impossible to use. When an
oscillating cast saw is used, the clinician should cut the
cast with multiple short cuts, made from shallow to deep,
Cast Removal with each subsequent cut overlapping the previous cut
Cast removal timing is dictated by several factors includ- by 30–50%, moving in a proximal to distal direction,
ing type of fracture, type of fracture fixation, age of the rather than a single longitudinal cut down the cast. This
patient, degree of lameness, and degree of radiographi- allows a distinct feeling of “give” to alert the clinician that
cally visible healing. In general, foals require more fre- the cast has been penetrated to full thickness. Experience
quent cast changes due to continued growth which is required for safe use of an oscillating cast saw, and
changes the fit of the cast. They also require earlier cast practice should be sought on a cadaver limb prior to use
removal due to increased rate of bone healing and the in a live patient. Lacerations are easily made in the under-
need to avoid cast‐induced limb laxity (see Figure 13.13). lying skin, despite the fine oscillations of the blade, and
This can be accomplished by transitioning to a bandage can be devastating. Cast spreaders are then used to sepa-
and splint much sooner than would be done in an adult rate the bivalved halves and scissors may be used to cut
with the same fracture. In foals and adult horses alike, underlying cast padding and stockinette for full removal
cast changes often occur ahead of schedule due to an of the cast (Table 13.3; Figure 13.14). Rebound limb
index of suspicion for the presence of cast complications edema is not commonly seen due to routine use of a
such as cast sores. Without signs of cast complications, bandage after cast removal.60
casts should be changed at least every 4–6 weeks in adult
horses and every 2–3 weeks in foals.
Cast changes are often done under general anesthesia Transfixation Casting
to protect the healing fracture. Cast removal without
reapplication is frequently done in the standing horse. When the fracture is comprised of multiple and com-
Most standing horses should be sedated during cast minuted fragments, internal fixation with external
removal, especially if an oscillating cast saw is to be uti- coaptation may be insufficient to protect the fracture
lized rather than preplaced Gigli/fetotomy wires repair from failure.20 Transfixation casting (pin cast) is
(Figure 13.14). Both methods allow full‐thickness cuts to a form of external skeletal fixation that has been used
bivalve the cast in the frontal plane. The advantage of the in large animals since the 1950s.31,52 It involves trans-
wire is reduced risk of cutting underlying structures, cortical pins placed proximal to the fracture and a cast
particularly over joints and over the coronary band, which surrounds the pins and incorporates the foot.41,48
the most commonly injured structures,6 and decreased This configuration allows the axial weight‐bearing
noise and vibration, which may bother some horses. forces to be transferred from the bone proximal to the
Figure 13.14 Materials required for cast

(B) (C) removal: (A) oscillating saw; (B, C) cast
(A) spreaders; (D) handles for obstetric wire;
(E) heavy bandage scissors.
(D) (E)
www.ajlobby.com
Table 13.3 Equipment that should be prepared and gathered cast use when compared to casts alone, is a reduction
prior to cast removal. in fracture fragment displacement during weight bear-
ing, achieved by distracting and stabilizing the frac-
Application Function Equipment ture.43,44,48,49 Other advantages include avoidance of
soft tissue disruption over the fracture, thereby reduc-
Cast cutting Cutting Gigli wire handles for wire
ing bacterial contamination and further disruption of
fiberglass Cast saw
material the blood supply, and return to immediate comfortable
weight bearing.35,41,49
Cast removal Cutting Cast spreaders
cast liner Heavy bandage scissors
and
padding Pin Cast Indications
Management Wound Povidone‐iodine scrub The pin cast technique is most appropriate for severely
of the limb and limb Scrub brush or gauze sponges comminuted fractures that otherwise cannot be recon-
post cast cleaning Saline, water, or alcohol
removal Sterile swab for culture structed (Figure 13.15). The most common indication
Towel for a pin cast combination is a severely comminuted
Gloves proximal phalangeal fracture that lacks an intact strut of
Bandaging Nonadherent dressing bone.28,33,35,56 Except in the fracture confined to the
Stretch gauze mid‐diaphyseal region of the metacarpus/tarsus, many
Cotton (pound, roll, or sheet) fractures potentially treated by pin cast combination
Nonstretch gauze (brown gauze) also have articular involvement. This often renders the
Flexible cohesive wrap (Vetrap)
Elastic tape pin cast technique useful only as a salvage procedure
due to the lack of reconstruction of the involved articu-
lar surface(s). Selective placement of lag screws followed
fracture, through the pin(s) to the cast, which then by pin cast application can assist in both aims (see
transfers weight‐bearing forces to the ground, thereby Figure 13.15).
minimizing forces at the fracture site.10,22,43 It is tech- Pin casts may also be useful as a salvage technique for
nically simple, requires minimal instrumentation,48,54 a failing or infected fracture repair (Figure 13.16),35 frac-
has been used in horses weighing up to 660 kg,35 and tures with overlying severe soft tissue damage or loss,35,44
can be used either alone or as an adjunct to internal and open fractures with or without bone loss.35 Although
fixation.28,35 The principal advantage gained with pin the pin cast can be utilized transiently to allow soft tissue
(A) (B) (C) (D)
Figure 13.15 (A) Lateral to medial radiograph and (B) computed tomographic (CT) reconstruction viewed from proximal of a comminuted
middle phalangeal fracture. (C) A transfixation pin cast with a “U” bar connected to the distal pin was placed. By adding the “U” bar, the
construct is considered a “walking cast.” A single screw has been placed in the distal aspect of the middle phalanx to compress a
parasagittal fracture component. (D) Eight weeks later, there was a marked increase in lameness and breakage of the distal transfixation
pin. This was likely due to the increased working length created by the use of a “U” bar. By increasing the working length, pin deflection is
increased and pin stiffness is decreased (pin deflection is proportional to working length to the third power). This concentrates more
stress within the pin and bone–pin interface, which increases the potential for cyclic failure of the pins. Also, incorporation of a “U” bar in a
fiberglass pin cast does not significantly increase stability. Therefore, with current cast materials, a “U” bar is not recommended in pin casts.
The reader should also note that the proximal pin was placed within the diaphyseal region of the cannon bone. Current recommendations
dictate pin placement within or closer to the distal metaphyseal region.
www.ajlobby.com
(A) (B) (C) (D) (E)
Figure 13.16 (A) Lateral to medial and (B) cranial to caudal radiographs of a comminuted, mid to distal tibial fracture in a pony. (C, D) The
fracture was initially treated with internal fixation. (E) Secondary to fixation failure, a pin cast was applied. Distal pins(s) were utilized
despite incorporation of the entire distal limb and foot within the cast. This is necessary to maintain bending strength, construct stiffness,
and minimize fracture movement with fractures proximal to the level of the fetlock.
healing prior to internal fixation,41 it does not allow con- used in the pin cast combination, which also increases the
tinued access to the soft tissues. Only the Nunamaker construct stiffness.44,50 This method is favored by some,
external skeletal fixation device achieves similar benefits but has recently been questioned,35 as including more than
to the pin cast while allowing continued access to the soft two pins increases the chance of diaphyseal pin placement,
tissues overlying the fracture.33 and subsequently may increase the risk of catastrophic
pin hole fracture.28,35 Additionally, although increasing
the number of pins (6.35 mm) from three to six in the
Pin Cast Principles distal radius was found to increase construct stiffness,
Due to the preponderance of pin‐related complications, it also decreased bone strength.23
many different techniques have been studied to optimize Several factors affect stability at the BPI and the
pin stability and to decrease loads at the bone–pin inter- stresses within the pin, including pin diameter and pin
face (BPI). Pins diverging by 30° in a frontal plane are sig- length. Unlike with bone screws, pin size is described
nificantly stronger, with a higher torque at failure than by the shaft diameter and not the outside diameter of the
when pins are placed in a parallel orientation.42 This is threads, although when ordering it is useful to know
likely due to more evenly distributed forces that are not both pin and thread diameter, as well as thread length
aligned along cement lines. Although smaller degrees of and whether they are positive‐profile threads. This
pin divergence (<30°) were not tested, the authors sug- emphasizes the importance of the shaft diameter, and
gested that it may be similarly effective. An additional ben- not that of the threads, in selecting the appropriate pin
efit of pin divergence in the frontal plane might include size for pin cast application. Various pin diameters have
increased stability at the fracture site due to more symmet- been used in pin cast combinations, including pins mar-
ric loading of the fracture during bending.42 In a different keted for large animal use, such as the 1/4 in. (6.3 mm)
study by the same authors, no difference was determined and 3/16 in. (4.8 mm) pins, and pins marketed for small
with the use of parallel pins (only axial loading was tested), animal use, including 5/32 in. (4.0 mm), 9/64 in.
divergent pins, or a “U” bar; although the authors still rec- (3.5 mm), 1/8 in. (3.0 mm), 7/64 in. (2.8 mm), and 3/32
ommended the use of divergent pins.43 The same group in. (2.4 mm) (Table 13.4). Other pin sizes have been
also hypothesized that the weakest point in the pin cast tested experimentally in the equine metacarpus and
was the interface of the cast material and the pins, and that radius, including a 3/8 in. (9.5 mm) pin and a 5/16 in.
a method of attachment that would distribute the load to a (8 mm) pin. These large pins have not been used clini-
greater surface area than the pins alone would be benefi- cally due to a significant decrease in bone torsional
cial. Although they found no differences between four dif- breaking strength when the pin size is greater than 20%
ferent methods of pin attachment to the cast material, they of the dorsopalmar‐plantar diameter of the bone.23,59
concluded that there still may be benefit from plugs of Pin size selection is affected by pin stiffness which, as
PMMA placed over the pin ends prior to the final roll of described in more detail in Chapter 2 and Chapter 9, is
casting tape.44 Another method described to distribute the related to the pin shaft diameter in a nonlinear fashion
load over a greater area is to increase the number of pins (pin stiffness is proportional to the pin diameter to the
www.ajlobby.com
Table 13.4 IMEX external skeletal fixation centrally threaded, positive‐profile pins, marketed for large animal and small animal use.
Shaft diameter Drill bit size Thread diameter Thread length Overall length
Large animal pins

1/4 in. (6.3 mm) 6.2 mm 5/16 in. (8 mm) 2 1/2 in. (64 mm) 8 in. (200 mm)
3/16 in. (4.8 mm) 4.7 mm 1/4 in. (6.3 mm) 2 1/2 in. (64 mm) 8 in. (200 mm)
TRO 1/4–5/16 in. (6.3–8 mm) 6.2 mm 5/16 in. (8 mm) 2 1/2 in. (64 mm) 8 in. (200 mm)
Small animal pins
1.0 mm 0.045 in. (1.2 mm) 0.055 in. 12 mm 75 mm
1.1 mm 0.045 in. (1.2 mm) 0.055 in. 12 mm 75 mm
1.5 mm 0.062 in. (1.6 mm) 0.072 in. 12 mm 75 mm
2.0 mm 2.0 mm 2.5 mm 15 mm 95 mm
3/32 in. (2.4 mm) 2.3 mm 1/8 in. (3.2 mm) 3/4 and 1 in. (19 and 25 mm) 4 and 6 in. (100 and 150 mm)
7/64 in. (2.8 mm) 2.7 mm 9/64 in. (3.5 mm) 1 and 1 3/8 in. (25 and 35 mm) 4 1/2 and 6 1/2 in. (115 and
165 mm)
3.0 mm 3.0 mm 3.5 mm 28 mm 120 mm
1/8 in. (3.2 mm) 3.1 mm 5/32 in. (4.0 mm) 1 1/4 and 1 3/4 in. (30 and 45 mm) 5 and 7 in. (125 and 175 mm)
9/64 in. (3.5 mm) 3.5 mm 4.3 mm 1 3/8 and 2 in. (35 and 55 mm) 5 1/2 and 7 1/2 in. (140 and
190 mm)
5/32 in. (4.0 mm) 3.9 mm 3/16 in. (4.8 mm) 1 1/2 and 2 1/4 in. (38 and 57 mm) 6 and 8 in. (150 and 200 mm)
TRO, threaded runout. Shaft and thread diameter and length are listed, as well as the recommended drill bit size to optimize radial preload (large
animal pins) or to allow pin insertion without tapping (small animal pins). N.B. Drill sequence for drilling progressively increasing pin hole
diameters and appropriate tap for the large animal pins are not included. The 1/4 in. and the TRO 1/4 in. pins use the same drill size and tap.
fourth power). Larger pins are stiffer, undergo less pin occurs when the bone and/or the pins are loaded.18,23
deflection, and consequently concentrate less stress at the This translates to a decrease in bone breaking strength
BPI. Additionally, larger pins have greater surface area when a larger pin size is selected, secondary to both the
contact with bone, causing further reduction of stress at stress concentration effect and the decrease in bone sur-
the BPI and less tissue strain. This translates to less bone face area at the drill hole. Therefore, although a smaller
resorption and more osteogenic activity at the BPI when a pin size will compromise pin stiffness and undergo more
larger pin is used.49,59,61 The benefits of increasing pin size pin deflection, concentrating more stress at the BPI, a
without increasing bone hole size are utilized in the new smaller pin also requires a smaller cortical defect and,
large animal IMEX Duraface® (IMEX Veterinary, subsequently, will reduce the incidence of catastrophic
Longview, TX, USA) tapered thread runout (TRO) pins, failure.43,61
where the non‐trocar end of the pin has 8 mm profile In addition to pin size, the distance from the bone sur-
threads that transition to the same pin shaft diameter face to the sidebars, the “working length,” determines the
(8 mm/5/16 in., TRO) to attenuate any potential stress amount of pin deflection (pin deflection is proportional
riser effect at the thread junction with the shaft, which also to working length to the third power).49 By reducing the
increases fatigue life, increases bending strength, increases working length, pin deflection will be reduced and the
ultimate strength, and decreases bone resorption at the stability of the construct can be maintained with a
BPI through reduced pin deflection.21 The trocar cutting smaller pin. A short working length is readily achieved in
end of the TRO pin has a reduced shaft diameter of 6.3 mm a pin cast combination due to the close apposition of the
(1/4 in.), expanding to positive‐profile 8 mm threads for cast to the limb. In contrast, a “U” bar, or the sidebars on
standard insertion technique using drills and tap. an external fixator, inherently has a longer working
However, bigger pin sizes are not necessarily better length than a pin cast and should not be used in combi-
and there are a few important limits dictating maximum nation with a pin cast to create a walking cast (see
pin size. Cortical defects between 10% and 20% of the Figure 13.15). The short working length achieved in a pin
bone dorsopalmar/plantar diameter create a stress riser cast allows the use of relatively small pins, 6.3 mm in the
in bone. Defects greater than 20% of the bone dorso- average adult cannon bone.
palmar/plantar diameter decrease the torsional strength In summary, the surgeon should aim to use the s mallest
of bone in a linear fashion. This decreased strength pin size possible that is able to withstand weight‐bearing
www.ajlobby.com
loads, placed in the area of the bone with the greatest smaller disparity between pin diameter and outside
diameter that is farthest from the proximal end of the thread diameter, and the decreased density of smaller
cast. This translates to two 6.3 mm (1/4 in.) pins in the and/or younger large animal bone.
distal metaphysis of the cannon bone in an average Various coating materials have been tested for their
500 kg horse, or two 4.8 mm (3/16 in.) pins in a horse or ability to minimize bone resorption and increase the
foal weighing less than 160 kg.35 force of extraction by improving osteointegration.3,72
Currently, threaded pins (positive profile) are used Solution‐precipitated calcium phosphate coating
almost exclusively for pin cast application in large ani- improved the osteointegration at the BPI 40 days after
mals. A threaded pin has an increased interval to pin pin placement, with decreased occurrence of pin tract
loosening of 40 days versus 30 days for smooth pins.35 exudate and osteolysis in a calf fracture model.3 A biomi-
Additionally, threaded pins have increased pullout metic hydroxyapatite coating has been tested in vitro and
strength,1 decreased medial to lateral migration,4,14 and has insertion characteristics similar to uncoated pins in
cause less osteolysis in the surrounding bone.1 Positive‐ equine bone.72
profile threads (i.e., ¼ in. pin with a 6.3 mm shaft diame- Traditional forms of external skeletal fixation require
ter and 8.0 mm outside thread diameter) also minimize fixation of the limb distal to the fracture with additional
the stress riser within the pin at the threaded to non- transcortical pins and connecting bars. In the equine
threaded junction when compared to threads cut into transfixation cast system, this is not routinely done for
the pins of a negative‐profile threaded pin.50 A further fractures distal to the fetlock, as distal fixation is pro-
reduction in the stress riser at the threaded to non- vided by enclosing the foot within the cast.43 When frac-
threaded junction is achieved on one end of the TRO pin tures are located proximal to the fetlock, distal pins(s)
recently introduced by IMEX. should be utilized despite incorporation of the entire dis-
Pin insertion techniques have also been intensively tal limb and foot within the cast.35 This maintains bend-
studied. New designs have introduced the self‐tapping ing strength and minimizes fracture movement (see
positive‐profile transfixation pin, which has similar pull- Figures 13.15 and 13.16). A distal 4.8 mm (3/16 in.) pin
out strength to a non‐self‐tapping pin, but has not over- placed through the middle phalanx for stabilization of a
come excessive heat generation during application.11 proximal phalangeal fracture has also been applied by
Therefore, non‐self‐drilling and non‐self‐tapping posi- the authors (Figure 13.17). Application in additional
tive‐profile pins (IMEX) should be used for equine appli- cases will be required to establish the merit of distal pin
cations, as they cause less micro‐ and macroscopic use in comminuted proximal phalangeal fractures.
damage to bone while maintaining pullout strength.46 In Historically, “U” bars were incorporated into the pin
a retrospective study, power insertion of pins rather than cast to maximize stability and the pin cast was subse-
hand turning was found to significantly reduce the inci- quently called a walking cast.48 Although casting mate-
dence of pin‐related complications.35 Therefore, separate rial remains the weakest link in determining the stiffness
power drilling, tapping, and pin insertion at low speeds of the pin cast combination, current fiberglass casting
(<300 rpm) and high torque, with a sharp drill bit and tap material does not require the use of a walking bar.44
and liberal lubrication to speed swath removal, is recom- Additionally, a walking bar limits pin positioning and pin
mended to reduce wobble, reduce heat generation during divergence, and increases the working length, which
drilling, and minimize pin‐related complications.14,35,46,62 increases pin deflection, as discussed earlier. Each of
Sequential drilling of progressively increasing pin hole these limitations could result in increased pin‐related
diameters decreases heat generation in the bone sur- complications and a walking bar is not presently recom-
rounding the pin hole,34 and may decrease drill bit and mended (see Figure 13.15).
tap wobble, which can contribute to stripping of the cis
cortex. Additionally, the final drill hole size should be
0.1 mm smaller than the pin core diameter to maintain
Pin Cast Application
ideal radial preload to maximize pin stability and mini- Pin cast application is generally done with the horse
mize damage to the surrounding bone.47 Therefore, the under general anesthesia in lateral recumbency, most
authors recommend a drilling sequence of at least 4.5 mm often with the affected limb uppermost. Soft tissue inju-
followed by 6.2 mm drill bits prior to tapping and inser- ries that need to be addressed during anesthesia or the
tion of a standard positive‐profile threaded 6.3 mm application of internal fixation may dictate a different
(1/4 in.) pin. In smaller patients, when 3.5 or 4.0 mm pins recumbency. The foot and contralateral shoe should be
from the small animal set are to be used, specific taps prepared as for a standard cast. The limb should be posi-
are not available. Although taps can be custom made for tioned and stabilized as described for standard cast appli-
this set, it is possible to power insert these pins without cation, with wires through the hoof capsule to provide
tapping in young horses. This is possible due to the axial traction. Positioning should allow for pin placement,
www.ajlobby.com
(A) (B) (C) (D)
Figure 13.17 (A) Lateral to medial (LM) radiographs of a severely comminuted proximal phalangeal fracture. A 4.8 mm (3/16 in.) pin was
placed in P2, distal to the fracture, and two 6.3 mm (1/4 in.) pins were placed in the metacarpus. Current recommendations dictate pin
placement within the distal metaphyseal region of the metacarpus, avoiding pin placement in the mid‐diaphysis, as was done in this case.
Although not currently routine in fractures distal to the fetlock, the distal‐most pin may have increased construct stiffness, thereby
minimizing fracture collapse. (B) Dorsal to palmar (DP) radiograph of the same fracture, four weeks after pin cast placement. There is
periosteal reaction and bony lysis present at the proximal‐most pin. This pin was removed due to increasing lameness and pin loosening
one week later (five weeks postoperatively) and the final two pins were removed four weeks after that. (C) DP and (D) LM radiographs
5½ months after fracture: there is continued fracture healing and minimal fracture collapse.
radiographic control, and additional limb traction during ing with incremental size increases until a hole 0.1 mm
fracture reduction. The limb should be clipped, prepped, smaller than the pin core diameter is reached) and pre-
and draped as for any surgical procedure with orthopedic tapped holes. Additional pins distal to the fracture may
implants. A tourniquet is not necessary, unless regional be used for fractures proximal to the fetlock and may
limb perfusion is being performed. increase construct stiffness. The drill bits should be well
Internal fixation, where indicated, should be com- lubricated with saline during drilling, and should be
pleted prior to transfixation pin placement. Pins should removed often to clear accumulated swath material from
be placed through vertical stab incisions in healthy soft the drill bit threads. Drill bits and taps should be sharp
tissues and should minimize soft tissue disruption. Stabs and drilling, tapping, and pin insertion should be done
should be large enough to avoid excessive skin stretching with power equipment at low speeds (300 rpm). The pins
during pin insertion, which may lead to friction or pres- should be trimmed with large bolt cutters or a hacksaw
sure necrosis. Care should be taken to ensure that the pin so that they protrude 3–5 cm from the skin (Figure 13.18).
is placed in the center of the medullary cavity, to avoid Once the pins are placed, the fracture is reduced and
generating a defect and stress riser on the endosteal sur- alignment confirmed with radiographic control. Without
face of a cortex. To confine pins in the distal metaphysis internal fixation, limb position and limb traction should
of the metacarpus/tarsus, pins are placed in close prox- be carefully maintained throughout cast application.
imity to each other (2–3 cm apart), with the distal pin at Significant limb traction is necessary during cast appli-
the level of the physeal scar. This is contrary to the exter- cation to maintain fracture reduction, which results in an
nal skeletal fixation principle of placing pins with a maxi- upright conformation (aligned bony column). Traction
mum distance between them to increase the bending wires placed more palmar/plantar in the hoof capsule
strength of the construct.44 can be used, and an assistant can apply force to extend
Two positive‐profile threaded pins with a shaft diam- the coffin joint, both of which help extend the distal
eter of <20% of dorsopalmar/plantar bone diameter joints and minimize this extreme straightness through
(6.3 mm in the average adult metacarpus/tarsus) should the toe. During fiberglass tape application, an assistant
be placed using low‐speed (<300 rpm), high‐torque should use a scalpel blade to create 2–3 cm longitudinal
power insertion in the distal metaphysis, in up to 30° of slits in the casting tape to correspond with pins, allowing
divergence in the frontal plane, through predrilled (drill- the tape to slide over the pins and sit smoothly around
www.ajlobby.com
(A) (B) (C)
(D) (E) (F)
Figure 13.18 Pin cast application as for a phalangeal fracture. (A, B) After pin placement, the pins should be trimmed with large bolt
cutters or a hacksaw so that they protrude 3–5 cm from the skin. The stockinette is applied, pushing the cut pins out through the layers.
(C, D) Cast materials are applied as for a standard cast, except for incorporation of pins. The cast foam or padding is pushed over the cut
pins to provide a padded inner layer. (E) During casting tape application, an assistant makes longitudinal cuts in the tape, allowing it to sit
smoothly over and around the protruding pins. It is critical that the number of layers of casting tape adjacent and distal to the pins is the
same or more than that for the remainder of the cast. Obstetric wires can be placed in close proximity to each pin to later assist in cast
removal. (F) At the completion of cast application, the pins may be trimmed again if necessary, covered with acrylic, and a final roll of
casting tape applied.
www.ajlobby.com
the protruding pins (Figure 13.18). The extensible yarns Pin Cast Removal
of fiberglass in the Delta‐lite (BSN Medical) casting tape
may obviate the need for an assistant cutting the tape, as The duration of pin cast application depends on many
this material easily slides over the pins. Applying fiber- factors, but is largely dictated by the extent of fracture
glass around, rather than over, the pins does not provide healing and pin loosening. There is usually at least one
adequate pin support and should be avoided. At the cast change under general anesthesia during pin casting,
completion of casting tape application, the pins are followed by a standard cast for a minimum of one
trimmed again if they protrude from the cast surface. month.28,35 In small animals, dynamization by inten-
PMMA can be placed over the exposed pin ends prior to tional loosening of the connecting bars with sequential
the final roll of casting tape or over the final roll of tape increases in weight bearing through the limb allows
for protection, and potentially to provide a broader pin gradual removal of the external fixator. Dynamization is
to cast interface. PMMA should be placed on the sole not possible in the pin cast combination, although the
and toe of the foot to protect from wear. pins can be removed sequentially at separate cast changes
Additional radiographs should be obtained prior to or through a window in the cast, allowing a slower tran-
moving the horse to recovery to recheck fracture reduc- sition to full weight bearing through the fracture and
tion. Recovery from general anesthesia should be decreased stiffness of the construct.68 For horses, most
assisted, if possible, especially for hindlimb fractures and pin casts do not provide the profound stability seen in
following pin removal if done under anesthesia. external fixation in small animals, and the need for
dynamization is reduced and often provided by sequen-
tial pin loosening.
Pin Cast Postoperative Care The development of pin‐related complications, most
Systemic broad‐spectrum antibiotics with or without often pin loosening, is the most common reason for pin
local antibiotic therapy through regional limb perfusion cast removal.28,35,41,67 Pin loosening is usually preceded
is often indicated, depending on the presence of skin by radiographically visible bony lysis surrounding the
damage or perforation at the fracture site. The duration pin(s),35 and the main clinical sign of pin loosening is a
of parenteral and/or local antimicrobial therapy is dic- decrease in patient comfort. If loosening of one pin (usu-
tated by the health of the soft tissues, the presence of an ally the proximal‐most pin) dictates early pin removal, it
open fracture, and the health of the pin tracts. If pin tract may be removed alone, leaving a single pin to transmit
infection is suspected, bacterial culture with sensitivity weight‐bearing forces.33 This usually improves patient
profiles should be utilized when possible. In the case of comfort, prolonging the transition to a standard limb
minimal soft tissue injury, parenteral antimicrobials cast by 1–2 weeks. Another option, which may be elected
should be continued for a minimum of three days, fol- if 1–2 additional weeks of pin cast time is insufficient, is
lowed by enteral antimicrobials. The duration of oral to remove the loose pin(s) and place a third and/or fourth
antimicrobial therapy varies among surgeons; we prefer pin through newly drilled holes.41 The benefits of new
to maintain horses on oral antimicrobials for the dura- pins should be weighed against the likelihood of diaphy-
tion of pin cast placement, or at least four weeks. Others seal pin placement and its subsequent risk of catastrophic
administer antimicrobials perioperatively28 or for pin hole fracture.
13 days.35 Many horses are surprisingly comfortable on Recommended pin cast durations vary from 40 to
their pin cast limb and may require little if any analgesics 55 days,28,35 57 days,67 4–6 weeks,33 or >40 days to mini-
for much of their treatment duration.28,67 Clearly, the mize fracture collapse and <80 days to minimize disuse
ability to monitor the horse’s use of the limb and appreci- osteopenia.28 In the absence of pin loosening, the horse
ate minor changes in comfort is vital in detecting com- should be transitioned to a standard half limb cast at
plications, specifically pin loosening. around 6–8 weeks. Frequently, there is inadequate radio-
graphic evidence of fracture healing at the time of pin
cast removal; however, this does not preclude pin
Pin Cast Monitoring removal, as the formation of stabilizing fibrocallus is
Monitoring and care should be the same as for a stand- usually adequate to stabilize the fracture. Foals require a
ard cast. Radiographically apparent bony lysis surround- shorter duration of pin casting (~30 days) and more fre-
ing the pin hole should be noted, as it generally precedes quent cast changes, dictated by their rate of growth.35
pin loosening by approximately nine days.35 Stall con- Removal of the pin cast and application of a standard
finement without hand‐walking exercise should be con- cast are often done under general anesthesia to facilitate
tinued for 2–4 weeks after standard cast removal, when standard cast application. However, they may be per-
there is little chance of catastrophic fracture through formed with the horse sedated for forelimb fractures. The
the pin holes, although pin holes will often remain pin tracts should be lavaged, curetted if ring sequestra
radiographically visible for several months.41 exist, and topical antibiotic ointment applied. If infection
www.ajlobby.com
is suspected, bacterial culture and sensitivity testing of comfortable. Many horses with articular fractures will
the pin tracts should be obtained, and local and systemic remain lame at a walk until natural ankylosis or arthrode-
antimicrobial therapy should be continued to minimize sis of affected joints.
the chance of progression to osteomyelitis. A standard
cast should be applied, maintaining an aligned bony col-
umn. If general anesthesia is utilized, the recovery should Pin Cast Complications
be assisted. Because the stability of fracture healing dur- Other than lack of anatomic reconstruction of articular
ing pin cast removal is primarily due to fibrocallus, fur- surfaces, the primary complications of the pin cast
ther collapse of the fracture is a possibility following pin combination are pin related. The most common pin‐
cast removal. The collapse, stretching of the soft tissues, related complication in horses, dogs, and humans is
and increased weight bearing invariably lead to increased premature pin loosening. In horses, pin loosening is the
lameness following the transition to a standard cast. This most common reason for increasing lameness necessi-
increased lameness may require additional analgesia and tating pin removal.28,35,44 Other pin‐related complica-
will generally resolve within a few days. The standard cast tions include osteolysis,35 pin tract infection and
can be removed when there is radiographic evidence of osteomyelitis,28 and ring sequestration of bone sur-
fracture healing, including complete, bridging callus, and rounding the transfixation pin (Figure 13.19).33,35
good patient comfort, or at least four weeks after pin Additionally, fracture of the bone through a transcorti-
removal. Radiographic evidence of bone filling the pin cal pin hole28,33,35 and bending or breakage of the pins32
holes is not required prior to standard cast removal and are relatively frequent complications. In one study,
takes several months. Hand‐walking exercise can be increasing body weight was the most important factor
allowed once the horse is no longer wearing a cast and is in predicting risk for pin‐related complications. After
(A) (B) (C) (D)
Figure 13.19 (A, C) Lateromedial and (B) dorsolateral to palmaromedial oblique and (D) dorsopalmar radiographs of the metacarpus
during treatment of a severely comminuted P2 fracture with a pin cast. (A, B) Radiographs the day of pin removal, six weeks after pin
placement, demonstrate ring sequestration around the proximal and distal pin holes, as well as a large sequestrum of bone between the
two pin tracts. Ring sequestration is likely due to excessive heat generation during drilling, tapping, and pin placement. There is also a
marked amount of periosteal bone production, which is likely due to pin tract infection. (C) Lateromedial and (D) dorsopalmar
radiographs five weeks later: there is resolution of the ring sequestra with improved but continued evidence of bone sequestration
between the pin tracts. The tracts were no longer draining, the horse was continued on parenteral antibiotics, and the sequestra resolved
without additional treatment.
www.ajlobby.com
adjusting for weight and age, diaphyseal pin placement weeks) transfixation is utilized,48 and chronic lameness
significantly increased the rate of premature pin loos- associated with osteoarthritis of the proximal interphalan-
ening when compared to metaphyseal pin placement.35 geal joint and metacarpo(tarso)‐phalangeal joint.33,35
Similarly, when adjusted for body weight, longer pin Interestingly, support limb laminitis appears to be a much
cast duration increased the incidence of bony lysis sur- less common complication of fracture treatment with a pin
rounding the pin.35 Finally, the most proximal pin cast when compared to severe fractures treated with inter-
accepts the greatest transfer of axial and bending forces nal fixation alone.28 This is likely due to the increased com-
from the limb, and subsequently suffers the highest fort level of fracture patients when the weight‐bearing
complication rate, including exclusive occurrence of forces are transmitted around the fracture, rather than
pin hole fractures in one report,35 and majority occur- through it. Cast sores are also a less common complication
rence of pin hole fractures in another report.28 of a well‐applied pin cast, because the limb is suspended
Pin hole fracture is the most devastating pin‐related within the cast.
complication. Most pin hole fractures occur within the
first 36 days28 to 56 days of treatment,33 while the pin cast
is in place, but have occurred up to one week after pin
Pin Cast Prognosis
removal.28,33 The importance of avoiding mid‐diaphyseal Despite the severe nature of fractures treated with pin
pins to prevent pin hole fracture was initially noted by cast techniques, results compare favorably with internal
Nemeth and Back in 1991.48 More recently, retrospective fixation alone, and outcomes documented in the litera-
studies confirm the increased incidence of pin hole fracture range from poor to good,16,19,28,33,40,48 and continue
ture with diaphyseal pin placement.28,35 This may be due to improve with updated techniques.67 A recent report
to the greater cross‐sectional area of the metaphysis, documented a 92% success rate (11 survivors/12 horses)
which decreases the stress concentration effect of the pin when pin casts were utilized in the treatment of severely
hole.35,44 Additionally, metaphyseal insertion results in a comminuted proximal phalangeal fractures, a clear
greater end insertional torque than that of a pin placed improvement on initial reports.35 When metacarpal/tar-
within the diaphysis of the cannon bone. This may trans- sal and middle phalangeal fractures were included, there
late to later pin loosening of pins placed in the metaphy- was a 77% success rate (27 survivors/35 horses).35 The
seal region.36 prognosis remains lower for fractures of the radius or
Complications specific to pin casts that are not directly tibia treated with the pin cast combination,48,67 and it is
related to the pins or the BPI include increased severity and rarely appropriate to expect a return to athletic function
incidence of disuse osteopenia distal to the transfixation when using a pin cast for stabilization of fractures that
pins,28,35 especially when prolonged (greater than eight involve a joint.
References
1 Aaron, D.M., Toombs, J.P., and Hollingsworth, S.C. 6 Booth, T.M., Dart, A.J., and Watkins, J.P. (2003). Equine
(1986). Primary treatment of severe fractures by external limb casts: materials and methods. Compend. Contin.
skeletal fixation: threaded pins compared with smooth. Educ. Pract. Vet. 25: 708–714.
J. Am. Anim. Hosp. Assoc. 22: 659–670. 7 Booth, T.M. and Knottenbelt, D.C. (1999). Distal limb
2 Akeson, W.H., Amiel, D., Abel, M.F. et al. (1987). Effects casts in equine wound management. Equine Vet. Educ.
of immobilization on joints. Clin. Orthop. Relat. Res. 11: 273–280.
219: 28–37. 8 Bramlage, L.R. (1983). Long bone fractures. Vet. Clin.
3 Anderson, D.E., St‐Jean, G., Richardson, D.C. et al. North Am. Equine Pract. 5: 285–310.
(1997). Improved osseointeraction of calcium 9 Bramlage, L.R. (1991). Resin impregnated foam as a
phosphate‐coated external fixation pins. studies in cast liner on the distal equine limb. In: Proceedings of
calves. Acta Orthop. Scand. 68: 571–576. the American Association of Equine Practitioners, vol.
4 Anderson, M.A., Mann, F.A., Wagner‐Mann, C. et al. 37, 481–485. Lexington, KY: AAEP.
(1993). A comparison of nonthreaded, enhanced 10 Brommer, H., Back, W., Schamhardt, H.C. et al. (1996).
threaded, and Ellis fixation pins used in type I external In vitro determination of equine third metacarpal bone
fixators in dogs. Vet. Surg. 22: 482–489. unloading, using a full limb cast and a walking cast.
5 Booth, T.M., Dart, A.J., and Watkins, J.P. (2003). Equine Am. J. Vet. Res. 57: 1386–1389.
limb casts: classification and indications. Compend. 11 Bubeck, K., Garcia‐Lopez, J., Jenei, T., and Maranda, L.
Contin. Educ. Pract. Vet. 25: 701–707. (2010). In vitro comparison of two centrally threaded,
www.ajlobby.com
positive profile transfixation pin designs for use in the 27 Janicek, J.C., McClure, S.R., Lescun, T.B. et al. (2013).
equine third metacarpal bones in horses. Am. J. Vet. Risk factors associated with cast complications in
Res. 71: 976–981. horses: 398 cases (1997–2006). J. Am. Vet. Med. Assoc.
12 Buckingham, S.H. and Jeffcott, L.B. (1991). Osteopenic 242: 93–98.
effects of forelimb immobilisation in horses. Vet. Rec. 28 Joyce, J., Baxter, G.M., Sarrafian, T.L. et al. (2006). Use
128: 370–373. of transfixation pin casts to treat adult horses with
13 Celeste, C.J. and Theoret, T. (2006). Managing heel comminuted phalangeal fractures: 20 cases (1993–
bulb lacerations. Compend. Contin. Educ. Vet.‐Equine 2003). J. Am. Vet. Med. Assoc. 229: 725–730.
Edition 1: 136–140. 29 Kelly, N.J., Watrous, B.J., and Wagner, P.C. (1987).
14 Clary, E.M. and Roe, S.C. (1995). Enhancing external Comparison of splinting and casting on the degree of
skeletal fixation pin performance—consideration of the laxity induced in thoracic limbs in young horses.
pin‐bone interface. Vet. Comp. Orthop. Traumatol. 8: Equine Prac. 9 (10): 10–16.
6–13. 30 Ketzner, K.M., Stewart, A.A., Byron, C.R. et al. (2009).
15 Delguste, C., Amory, H., Doucet, M. et al. (2007). Wounds of the pastern and foot region managed with
Pharmacological effects of tiludronate in horses after phalangeal casts: 50 cases in 49 horses (1995–2006).
long‐term immobilization. Bone 41: 414–421. Aust. Vet. J. 87: 363–368.
16 Dubs, B. and Nemeth, F. (1975). Treatment and 31 Kirk, H. (1952). Modern methods of fracture repair in
prognosis of fractures of the first phalanx in the horse. large animals. Vet. Rec. 64: 319–329.
Schweiz. Arch. Tierheilkd. 117: 299–309. 32 Klopfenstein Bregger, M.D., Fürst, A.E., Kircher, P.R.
17 Eagle, M.T., Koch, D.B., Whalen, J.P. et al. (1982). et al. (2016). Salter‐Harris type II metacarpal and
Mineral metabolism and immobilization osteopenia in metatarsal fracture in three foals. Treatment by
ponies treated with 25‐hydroxycholecalciferol. Cornell minimally‐invasive lag screw osteosynthesis combined
Vet. 72: 372–393. with external coaptation. Vet. Comp. Orthop.
18 Edgerton, B.C., An, K.N., and Morrey, B.F. (1990). Traumatol. 18 (29): 239–245.
Torsional strength reduction due to cortical defects in 33 Kraus, B.M., Richardson, D.W., Nunamaker, D.M., and
bone. J. Orthop. Res. 8: 851–855. Ross, M.W. (2004). Management of comminuted
19 Ellis, D.R., Simpson, D.J., Greenwood, R.E.S. et al. fractures of the proximal phalanx in horses: 64 cases
(1987). Observations and management of fractures of (1983–2001). J. Am. Vet. Med. Assoc. 224: 254–263.
the proximal phalanx in young thoroughbreds. Equine 34 Lescun, T.B., Barno, E.A., Zacharias, J.R., and Moore,
Vet. J. 19: 43–49. G.E. (2007). Effect of sequential hole enlargement on
20 Fessler, J.F. and Turner, A.S. (1983). Methods of cortical bone temperature during creation of a 6.2 mm
external coaptation. Vet. Clin. North Am. Equine Pract. transcortical hole in the equine third metacarpal bone
5: 311–331. diaphysis. In: Proceedings of the Veterinary Orthopedic
21 Griffin, H., Toombs, J.P., Bronson, D.G. et al. (2011). Society, vol. 34. Parker, CO: VOS.
Mechanical evaluation of a tapered thread‐run‐out 35 Lescun, T.B., McClure, S.R., Ward, M.P. et al. (2007).
half‐pin designed for external skeletal fixation in small Evaluation of transfixation casting for treatment of
animals. Vet. Comp. Orthop. Traumatol. 24: 257–261. third metacarpal, third metatarsal, and phalangeal
22 Hopper, S.A., Schneider, R.K., Ratzlaff, M.H. et al. fractures in horses: 37 cases (1994–2004). J. Am. Vet.
(1998). Effect of different full‐limb casts on in vitro Med. Assoc. 230: 1340–1349.
bone strain in the distal portion of the equine forelimb. 36 Lescun, T.B. and Oliver, L. (2008). The influence of
Am. J. Vet. Res. 59: 197–200. transcortical pin location on pin end‐insertional torque
23 Hopper, S.A., Schneider, R.K., Ratzlaff, M.H. et al. in the equine third metacarpal bone. In: Proceedings of
(1998). Effect of pin hole size and number on in vitro the American College of Veterinary Surgeons Veterinary
bone strength in the equine radius loaded in torsion. Symposium, vol. 18. Germantown, MD: ACVS.
Am. J. Vet. Res. 59: 201–204. 37 Levet, T., Martens, A., Devisscher, L. et al. (2009).
24 Houlton, J.E. and Brearley, M.J. (1985). A comparison Distal limb cast sores in horses: risk factors and early
of some casting materials. Vet. Rec. 117: 55–58. detection using thermography. Equine Vet. J. 41: 18–23.
25 Hutchinson, M.J. and Hutchinson, M.R. (2008). Factors 38 Lloyd, D., Johanson, C., and Phillips, T.J. (2008).
contributing to the temperature beneath plaster or Treatment of medial condylar fractures of the third
fiberglass cast material. J. Orthop. Surg. Res. 3: 10. metatarsus in three horses with fibreglass casts under
26 Janicek, J.C., Dabareiner, R.M., Honnas, C.M., and standing neuroleptanalgesia. Vet. Rec. 162: 586–589.
Crabill, M.A. (2005). Heel bulb lacerations in horses: 39 Malone, E.D., Anderson, B.H., and Turner, T.A. (1997).
101 cases (1988–1994). J. Am. Vet. Med. Assoc. 226: Proximal sesamoid bone fracture following cast
418–423. removal in 2 horses. Equine Vet. Educ. 9: 185–188.
www.ajlobby.com
40 Markel, M.D., Richardson, D.W., and Nunamaker, D.M. 54 Richardson, D.W., Nunamaker, D.M., and Sigafoos,
(1985). Comminuted first phalanx fractures in 30 R.D. (1987). Use of an external skeletal fixation
horses: surgical versus nonsurgical treatments. Vet. device and bone graft for arthrodesis of the
Surg. 14: 135–140. metacarpophalangeal joint in horses. J. Am. Vet.
41 McClure, S.R., Honnas, C.M., and Watkins, J.P. (1995). Med. Assoc. 191: 316–321.
Managing equine fractures with external skeletal 55 Riggs, C.M. (1997). Indications for and application of
fixation. Comp. Cont. Educ. Pract. Vet. 17: 1054–1063. limb casts in the mature horse. Equine Vet. Educ. 9:
42 McClure, S.R., Watkins, J.P., and Ashman, R.B. (1994). 190–197.
In vitro comparison of the effect of parallel and 56 Rossignol, F., Vitte, A., and Boening, J. (2014). Use of a
divergent transfixation pins on breaking strength of modified transfixation pin cast for treatment of
equine third metacarpal bones. Am. J. Vet. Res. 55: comminuted phalangeal fractures in horses. Vet. Surg.
1327–1330. 43: 66–72.
43 McClure, S.R., Watkins, J.P., Bronson, D.G., and 57 Schneider, J.E. (1981). Immobilizing cervical vetebral
Ashman, R.B. (1994). In vitro comparison of the fractures. In: Proceedings of the American Association of
standard short limb cast and three configurations of Equine Practitioners, vol. 27, 253–256. Lexington, KY:
short limb transfixation cast in equine forelimb. Am. J. AAEP.
Vet. Res. 55: 1331–1334. 58 Schneider, R.K., Milne, D.W., Gabel, A.A. et al. (1982).
44 McClure, S.R., Watkins, J.P., and Hogan, H.A. (1996). In Multidirectional in vivo strain analysis of the equine
vitro evaluation of four methods of attaching radius and tibia during dynamic loading with and
transfixation pins into a fiberglass cast for use in without a cast. Am. J. Vet. Res. 43: 1541–1550.
horses. Am. J. Vet. Res. 57: 1098–1101. 59 Seltzer, K.L., Stover, S.M., Taylor, K.T., and Willits, N.H.
45 Moll, H.D., Slone, D.E., Humburg, J.M., and Jagar, J.E. (1996). The effect of hole diameter on the torsional
(1987). Traumatic tarsal luxation repaired without mechanical properties of the equine third metacarpal
internal fixation in three horses and three ponies. J. bone. Vet. Surg. 25 (5): 371–375.
Am. Vet. Med. Assoc. 190: 297–300. 60 Smith, R.W. (1993). Bandages and casts. Equine Vet.
46 Morisset, S., McClure, S.R., Hillberry, B.M., and Fisher, Educ. 5: 108–112.
K.E. (2000). In vitro comparison of the use of two 61 Taylor, D.S., Stover, S.M., and Willits, N. (1993). The
large‐animal, centrally threaded, positive‐profile effect of differing pin size on the mechanical
transfixation pin designs in the equine third metacarpal performance of transfixation in the equine third
bone. Am. J. Vet. Res. 61: 1298–1303. metacarpal bone. Proc. Vet. Orthop. Soc 6: 2.
47 Muller, M.E., Allgower, M., Schneider, R., and 62 Toews, A.R., Bailey, J.V., Townsend, H.G. et al.
Willenegger, H. (1990). Manual of Internal Fixation, 3e. (1999). Effect of feed rate and drill speed on temperatures
Berlin: Springer Verlag. in equine cortical bone. Am. J. Vet. Res. 60: 942–944.
48 Németh, F. and Back, W. (1991). The use of the walking 63 Trotter, G.W., Auer, J.A., Arden, W., and Parks, A.
cast to repair fractures in horses and ponies. Equine (1986). Coxofemoral luxation in two foals
Vet. J. 23: 32–36. wearing hindlimb casts. J. Am. Vet. Med. Assoc.
49 Nunamaker, D.M., Richardson, D.W., Butterweck, D.M. 189: 560–561.
et al. (1986). A new external skeletal fixation device that 64 Van Harreveld, P.D., Lillich, J.D., Kawcak, C.E. et al.
allows immediate full weightbearing application in the (2002). Clinical evaluation of the effects of
horse. Vet. Surg. 15: 345–355. immobilization followed by remobilization and exercise
50 Palmer, R.F., Hulse, D.A., Hyman, W.A. et al. (1992). on the metacarpophalangeal joint in horses. Am. J. Vet.
Principles of bone healing and biomechanics of Res. 63: 282–288.
external skeletal fixation. Vet. Clin. North Am. Small 65 Van Harreveld, P.D., Lillich, J.D., Kawcak, C.E. et al. (2002).
Anim. Pract. 22: 45–68. Effects of immobilization followed by remobilization on
51 Parente, E.J. and Nunamaker, D.M. (1995). Stress mineral density, histomorphometric features, and
protection afforded by a cast on plate fixation of the formation of the bones of the metacarpophalangeal joint
distal forelimb in the horse in vitro. Vet. Surg. 24: in horses. Am. J. Vet. Res. 63: 276–281.
49–54. 66 Virgin, J.E., Goodrich, L.R., Baxter, G.M., and Rao, S.
52 Reicher, E.C. (1956). Treatment of fractures of the long (2011). Incidence of support limb laminitis in horses
bones in large animals. J. Am. Vet. Med. Assoc. 129: treated with half limb, full limb or transfixation pin
8–15. casts: a retrospective study of 113 horses (2000–2009).
53 Richardson, D.W. and Clark, C.C. (1993). Effects of Equine Vet. J. Suppl. 40: 7–11.
short‐term cast immobilization on equine articular 67 Watkins, J.P. (2003). Transfixation casting. In:
cartilage. Am. J. Vet. Res. 54: 449–453. Proceedings of the American College of Veterinary
www.ajlobby.com
Surgenos Annual Veterinary Symposium, vol. 13, 71 Yovich, J.V., Turner, A.S., Stashak, T.S., and McIlwraith,
479–500. Germantown, MD: ACVS. C.W. (1987). Luxation of the metacarpophalangeal and
68 Williams, J.M., Elce, Y.A., and Litsky, A.S. (2014). metatarsophalangeal joints in horses. Equine Vet. J. 19:
Comparison of 2 equine transfixation pin casts and the 295–298.
effects of pin removal. Vet. Surg. 43: 430–436. 2 Zacharias, J.R., Lescun, T.B., Moore, G.E., and
7
9 Wilson, D.G. and Vanderby, R. Jr. (1995). An evaluation
6 Van Sickle, D.C. (2007). Comparison of insertion
of fiberglass cast application techniques. Vet. Surg. 24: characteristics of two types of hydroxyapatite‐coated
118–121. and uncoated positive profile transfixation pins in
0 Wilson, D.G. and Vanderby, R. Jr. (1995). An evaluation
7 the third metacarpal bone of horses. Am. J. Vet. Res.
of six synthetic casting materials: strength of cylinders 68: 1160–1166.
in bending. Vet. Surg. 24: 55–59.
www.ajlobby.com
219
Part II
Specific Fractures
www.ajlobby.com
221
14
Fractures of the Distal Phalanx
Alan J. Nixon1,2, Norm G. Ducharme1,2, and Alicia L. Bertone3
1
2
3
Department of Veterinary Clinical Sciences, The Ohio State University, Columbus, OH, USA
Introduction and inflammation. The degree of lameness is initially severe

(grade 4 or 5). Digital pulses are often increased and worse
Fractures of the distal phalanx have been well character- on the affected side when the fracture is parasagittal. The
ized by several reviews in the literature.8,11,23,24,26,31,38,39 hoof is warm to the touch and sensitive to hoof tester pres-
Although fractures of the distal phalanx are uncommon sure over the entire hoof. Focal pressure over the fracture
(reported as 1.1% of total equine cases at one clinic),39 induces the most pain. Distal interphalangeal joint (DIP)
most equine practitioners will see these cases annually, effusion may be palpable and sometimes visible along the
particularly racetrack practices and practices specializ- dorsal aspect of the coronary band if the fracture is articu-
ing in lameness. Distal phalanx fractures have been lar. Differential diagnoses include foot abscess, puncture
classified into seven types (Figure 14.1), which often
wound, septic arthritis of the DIP joint, sole bruising, lami-
vary depending on breed and type of athletic activity. nitis, navicular fracture, and pedal osteitis, and can be ruled
Regardless of type, the forelimbs are affected in more out with diagnostic tests. Perineural anesthesia or DIP joint
than 80% of distal phalanx fractures.11 The typical signal- block, DIP joint synovial fluid analysis, radiographs, and
ment, etiology, clinical signs, treatment, and prognosis nuclear scintigraphy are all useful to establish the diagnosis.
depend on the fracture type. In three studies, race horses, When clinical signs are profound, a radiograph of the distal
particularly Standardbreds, had the highest incidence phalanx (60° dorsopalmar, lateral, and both oblique views)
of fractures of the distal phalanx. Articular parasagittal may be all that is necessary to confirm the diagnosis. If a
(type II) fractures were the most common.8,31,39 In a com- fracture is not radiographically apparent, which is often the
prehensive report of 274 horses in California, the largest case shortly after injury, nerve blocks can localize the foot
proportion (48%) of the fractures were solar margin as the source of the lameness. Arthrocentesis of the coffin
fractures (type VI) and were associated with laminitis or joint also can rule out septic arthritis as the cause of lame-
other distal phalangeal pathology.11 Quarter Horses and ness. Radiographs should be repeated in 10–14 days. If a
Thoroughbreds had the highest incidence in that study. fracture is present it may become apparent due to osteolysis
Fractures of the distal phalanx in foals are typically type along the fracture line. Nuclear scintigraphy of the distal
VII and have been described in detail.15,40 The clinical signs limb will demonstrate increased radioisotope uptake in the
are similar to those in adult horses with distal phalanx frac- distal phalanx if a fracture is present, but may not define the
tures, but the configuration of the fracture is unique to foals. fracture type (Figure 14.2). Computed tomography (CT)
and magnetic resonance imaging (MRI) give the best defi-
nition of the fracture configuration, but are rarely needed.
Diagnosis and Treatment Lameness and signs of hoof inflammation steadily
resolve over the first two to four weeks after injury.
Clinical signs in the acute phases are similar for all types of Horses usually walk soundly after four to eight weeks,
fracture of the distal phalanx. Lameness can worsen although they may be sensitive when turning. Types of
within the first 24 hours after injury, presumably as a surgical and medical therapy will be discussed under
result of increased hoof pressure secondary to swelling each fracture type.

www.ajlobby.com
222 Part II Specific Fractures
IV
I VII
II
VI
III
V (comminuted)
Figure 14.1 Illustration of distal phalanx fracture types I–VII.
(A) Fracture Types

(B) Palmar (plantar) process (type I) fractures are nonarticu-
lar fractures of the palmar or plantar process of the distal
phalanx (Figure 14.3). Most type I fractures exit the
proximal cortex of the distal phalanx, immediately adja-
cent to the joint surface. These fractures are reportedly
the second31,39 or fourth11 most common fracture after
types II, IV, and VI. The etiology of these fractures is
direct trauma to the hoof, especially the pounding
associated with racing on hard track surfaces in

(C) the Standardbred.31,39 They are also common in
Thoroughbreds, with similar etiology. Some type I frac-
tures may be secondary to fracture of ossified ungular
(lateral) cartilages, but this is much less common.33
Diagnosis is made by the presence of clinical signs and
elimination of the lameness with palmar digital perineu-
ral anesthesia. The digital nerve block need only be
applied to the affected side. Application of a bar shoe
with clips (or a rim shoe) and a full pad is recommended
during healing, but is rarely necessary for the rest of the
horse’s race career.11 Healing often progresses from the
distal perimeter of the phalanx and is slower at the proxi-
Figure 14.2 Scintigraphic appearance of distal phalanx fracture: mal edge of the fracture adjacent to the articular surface
(A) dorsopalmar, (B) solar, and (C) flexed lateral scintigraphic (Figure 14.4). This may be related to the more profuse
images of a type I distal phalanx fracture.
vascularity toward the perimeter of the phalanx.29
Healing is usually complete and bony union is radio-
The detailed radiographic, morphologic, and histo- graphically evident at a mean of 11 months.11 Uniaxial
logic appearance of the normal distal phalanx has digital neurectomy on the affected side can eliminate
been reported and reference to these sources can aid lameness and allow continued athletic performance dur-
in the detection of P3 abnormalities and fractures.15,18 ing healing.8 Since the DIP joint is not involved, this can
Uncertainty can occur in the interpretation of normal be accomplished soon after diagnosis (see Figure 14.4)
bone irregularities associated with vascular channels, and the horse returned to training without risk of osteo-
the crena, and the palmar (plantar) processes. arthritis in the joint.
Radiographic mock lines associated with the hoof wall Parasagittal oblique (type II) fractures are oblique,
add to the difficulty in accurately detecting fractures articular fractures of the palmar or plantar process of the
of the distal phalanx. distal phalanx (Figure 14.5). Type II fractures are the
www.ajlobby.com
(A) (B) (C)
Figure 14.3 Radiographs of a three‐year‐old Thoroughbred with an acute type I palmar fracture of the distal phalanx. The fracture is
evident on dorsopalmar 60° projections (A), but best characterized on (B) the dorsopalmar 60–lateral 45–medial oblique view and (C) the
lateromedial projection (arrow). This horse was treated by unilateral neurectomy and bar shoe with heel clips and returned to training
three weeks later.
Figure 14.4 Subacute to chronic type I (A) (B)

palmar fracture of the distal phalanx in the
forelimb of two Thoroughbred horses.
(A) The lameness history suggested that the
fracture was five months in duration.
Note the healing on the perimeter of the
phalanx. The fracture was treated by bar
shoe alone. (B) Type I fracture of three to
four weeks in duration. Healing has started
along the perimeter but is incomplete at
the proximal margin. Treatment included
unilateral neurectomy and bar shoe.
(A) (B)
(C)
Figure 14.5 Radiograph of an acute type II parasagittal fracture of the distal phalanx. (A) Dorsopalmar 60° projection shows fracture entry
to joint. (B) Dorsopalmar projection shows distal separation of fracture with weight bearing and congruent joint. (C) Standing MRI in
frontal plane reveals considerable displacement with malalignment at the subchondral bone plate (arrow).
www.ajlobby.com
most common type in several reports in which Conservative therapy consists of a full pad under a bar
Standardbreds were highly represented.8,23,31,39 The eti- shoe, with clips or a complete rim support to immobilize
ology and clinical signs are similar to those for type I the hoof wall (Figure 14.6). This should always be part of
fractures, except that joint effusion and pain on joint therapy regardless of whether surgery is performed.
flexion may be detectable because of the articular com- Shoeing is combined with box stall rest for four months,
ponent.8,11,12,31,39 The most appropriate treatment of followed by paddock exercise for eight months. Healing
these fractures is controversial. This is compounded by of type II fractures is slower than type I fractures, and
the variable fracture plane configuration and associated horses generally do not return to training until 12 months
joint involvement. Some type II fractures resemble a after injury. Healing was reported to be complete in 43%
type I fracture, but enter the extreme abaxial perimeter of horses and partial in 38% of horses within a mean of 12
of the joint. These generally heal satisfactorily with con- months.11 Partial healing was characterized by lack of
servative therapy. Other type II fractures resemble type bony union in the subchondral bone at the articular
III mid‐sagittal fractures, but enter the joint immediately surface, but healing of the solar margin and body of the
adjacent to the midline and are therefore parasagittal or distal phalanx. This may be related to the more profuse
type II. These more destabilized fractures take longer to digital vasculature in the perimeter of the distal phalanx
heal and have more symptoms related to the joint. compared to that closer to the joint surface.29 Digital
Conservative treatment as described for nonarticular neurectomy can alleviate pain from the fracture and
type I fractures is most commonly recommended.11,23,26 allow continued athletic performance, although DIP
The prognosis for return to athletic activity (particularly joint intraarticular medication such as sodium hyaluro-
racing) ranges from 50% to 63%.22,23,26,31,40 Rijkenhuizen nate, interleukin‐1 receptor antagonist protein (IRAP),
et al.26 reported on long‐term outcome in 69 horses of or corticosteroid therapy may be necessary to alleviate
several breeds with type II fractures, and found that box the pain of synovitis produced secondary to the articular
stall rest without hoof immobilization returned 100% of fracture. Digital neurectomy for most horses only par-
horses (19 of 19) to activity. However, only 70% (26 of tially alleviates pain in the DIP joint. Digital neurectomy
37) of horses managed conservatively with box stall plus within three weeks of surgery/injury and application of a
hoof immobilization were successfully returned to func- bar shoe with clips (or rim) and pads will often allow
tion. Surgical repair was utilized on only six horses and continued race training of horses with smaller, more
50% of these returned to work. Lag screw fixation of abaxial type II fractures. For young horses (aged one or
larger type II fractures is possible, yet no case series two years), conservative treatment (bar/rim shoe and six
have been reported.24 Surgical repair of oblique frac- months stall rest) and delay of training for one year have
tures is technically more difficult than mid‐sagittal frac- resulted in 50% of horses capable of training.11,31,39 In
tures because of the obliquity of the fracture line. older horses the prognosis is less favorable. In horses
Perpendicular placement of the lag screw is less predict- over three years of age, an economic decision to perform
able and fluoroscopic or radiographic control is vital. A a neurectomy immediately after injury can result in less
complete surgical description is given in the section on loss of income, a more comfortable horse, and satisfac-
surgical repair. tory healing of the fracture. Racing jurisdictions vary as
(A) (B) (C)
Figure 14.6 Bar shoe and full pad (A) with a forged rim (B) can be used to immobilize the hoof. (C) Similar stability but added support for
the hoof wall patch at screw insertion sites can be obtained through application of a bar shoe with quarter and heel clips and fiberglass
cast tape around the hoof capsule.
www.ajlobby.com
Figure 14.7 (A, B) Radiographs of a type III (A) (B)

sagittal fracture of the distal phalanx.
to the acceptability of digital neurectomy. Degenerative

joint disease of the DIP joint is a common sequela,
but can be managed by intraarticular medication and
long‐term application of a bar shoe.
Sagittal or axial fractures (type III) are articular mid‐
sagittal fractures of the distal phalanx (Figure 14.7). The
clinical signs and lameness are similar to those for type II
fractures, except that lateralizing signs are not apparent.
Type III fractures are uncommon and, according to some
studies, account for only 3–4% of distal phalanx frac-
tures.11,31 Internal fixation is recommended for this frac-
ture type and is described in the section on surgical
repair. A recent review of outcome in 27 type III fracture
cases indicated that 7 of 9 (78%) of horses repaired by lag
screw fixation returned to work.26 Other treatment
options include conservative therapy (corrective shoeing
and rest); however, because of the significant articular
component, this mode of therapy generally results in
osteoarthritis and an unsatisfactory outcome in many Figure 14.8 Lateromedial radiograph of a horse with an extensor
racehorses. Digital neurectomy is usually unsuccessful process (type IV) fracture of the distal phalanx.
because the pain of the fracture extends beyond the area
innervated by the palmar/plantar digital nerves.
Extensor process (type IV) fractures are articular can be treated with debridement at the time of arthro-
fracture fragments involving variable portions of the
scopic surgery.32 Large fractures of the extensor process
extensor process of the distal phalanx (Figure 14.8). can be repaired with lag screw fixation.10,12 Intraarticular
They may be displaced or nondisplaced and are almost and systemic medication are recommended to treat the
as common as type II fractures.11 The etiology of these synovitis postoperatively, including hyaluronic acid,
fractures is controversial and possibly multiple. Fractures autologous conditioned serum (IRAP), polysulfated gly-
associated with avulsion of the extensor process or cosaminoglycan, corticosteroids, and phenylbutazone.21
hyperextension of the coffin joint are probably most Comminuted (type V) fractures are comminuted or
common, but a separate center of ossification of the multiple, and generally secondary to osteomyelitis and
extensor process can produce a free osteochondral sequestra formation.1,3 Some can be secondary to acute
fragment at this site. Arthroscopic surgical removal is trauma and involve other adjacent structures, including
recommended, regardless of etiology, if lameness can be the DIP collateral ligaments, articular portion of the mid-
isolated to the DIP joint and a fragment identified on dle phalanx, and rarely the navicular bone (Figure 14.9).
radiographs.11 Subchondral bone cysts in the distal pha- They can be variable in presentation and prognosis, and
lanx can be associated with chronic type IV fractures and comprise 3% of the distal phalangeal fractures in one
www.ajlobby.com
(A) (B) (C)
Figure 14.9 Radiographs of a comminuted (type V) fracture of the distal phalanx, which developed when the horse was spooked on a
trail ride. (A) The dorsoplantar projection shows multiple oblique fractures of the distal phalanx (black arrows), a fracture of the navicular
bone (white arrow), and a fracture of the distal medial aspect of the middle phalanx (arrow head). (B) The oblique radiograph shows the
middle phalanx fracture more clearly. (C) the lateral projection indicates multiple comminuted fracture lines entering the joint. The exact
fracture numbers and configuration are not clear.
report.11 Identifying the various fracture planes may Palmar (plantar) process (type VII) fractures in foals
require three‐dimensional imaging such as CT or MRI are nonarticular fractures of the palmar or plantar pro-
(Figure 14.10). Surgical reconstruction may be possible if cess of the distal phalanx.7,11,15,40 The incidence of type
the distal phalanx is healthy enough to provide holding VII fractures in foals undergoing serial radiographic
power for screws. Treatment of osteomyelitis of the distal screening was found to be as high as 75%.7 A study in 17
phalanx includes local debridement of necrotic bone, Warmblood foals indicated that 100% had a type VII
ventral drainage of infected areas, and support of the palmar/plantar fracture, which would indicate that this
hoof with shoes, clips, and sole plates, to treat the osteo- is by far the most prevalent type of distal phalanx frac-
myelitis. Cancellous bone may be packed into the infected ture. Conformational abnormalities may be involved in
bone defect after debridement to enhance healing.3,16 the etiology of these fractures.7 Many show no lame-
Solar margin (type VI) fractures are nonarticular solar ness and radiographic healing commonly ensues. The
margin fractures of the distal phalanx (Figure 14.11). configuration differs from that of type I fractures in
Approximately one‐third of these fractures have no other that the fracture originates and ends at the solar mar-
bony abnormality detected in the phalanx and may be gin. In contrast, type I fractures extend from the solar
purely traumatic in origin.11 These fractures usually margin to the edge of the phalanx adjacent to the artic-
occur in Standardbred racehorses, and lameness resolves ular surface of the palmar (plantar) process at an
in 30–45 days. Radiographic healing occurred in all seven oblique angle,11,15,18,40 (see Figures 14.3 and 14.4).
cases evaluated in one study.11 Conservative treatment is Neither type I nor type VII fractures enter the joint, and
recommended, and includes a bar shoe and pad. Type VI all are managed conservatively.
fractures that are traumatic in origin have a good to Two cases involving frontal plane fractures as a result
excellent prognosis because they are small, nonarticular, of trauma rather than osteomyelitis have also been
and heal well. The majority of type VI fractures in a reported.19,34 These cases returned to function with
radiographic survey were considered to be a sequela to 6–14 months of conservative therapy.
laminitis or pedal osteitis.11 Resorption of the fracture
fragment can occur, creating a shortened, smaller distal
phalanx. Treatment is conservative, and varies with the Surgical Repair
primary disease in the distal phalanx.11 The prognosis
for these fractures is dependent on the severity of the Internal Fixation of Sagittal
primary disease. Trauma and penetrating injury to the and Parasagittal Fractures with Lag
sole can result in focal osteomyelitis (Figure 14.12).
These are generally more lame than strictly traumatic
Screws
type VI lesions. Debridement of the abscess and removal Fresh (less than five‐day‐old), closed sagittal articular
of bone sequestra can be done standing under sedation fractures of the distal phalanx (type II and type III frac-
with a tourniquet applied. The prognosis is good, but tures) are candidates for lag screw fixation, to provide
repeat surgery and delay in healing are common. improved stability and compression and to decrease the
www.ajlobby.com
(A) (B)
(C) (D)
(E) (F)
Figure 14.10 Standing MRI of the horse in Figure 14.9 has been used to identify the fracture planes in a type V fracture and has also
revealed additional fractures in the navicular bone and avulsion fragmentation of the middle phalanx. (A) Transverse T1 weighted images
show that the distal phalanx has two primary fracture planes, one in a frontal and another in an oblique plane (black arrows).
Comminuted separate pieces are also identified (white arrowheads). (B) The sagittal T1 weighted MRI further defines the frontal fracture
(black arrow) and proximal comminuted fragment at the joint surface (white arrowhead). (C–F) Additional fractures of the middle phalanx
(circled), displaced fractures of the distal phalanx (black arrows), and navicular bone fracture (white arrows) are identified.
articular gap that remains with conservative therapy. phalanx fractures).11,31 It is generally agreed that lag
Debate persists as to whether surgical intervention is screw repair is recommended for type III fractures in
the best choice; however, several reports have docu- horses older than three years to avoid the prolonged
mented successful outcome with surgical repair.8,9,24,26,27 convalescence.24 Further immobilization is recommended
Evidence‐based data indicating the optimal treatment with a rim shoe or bar shoe with clips and a pad,11,12,24,31
modality (i.e., comparing surgical to conservative treat- although a recent study suggested that hoof immobiliza-
ment) are limited,26 particularly in racehorses, largely tion was detrimental to outcome.26 Screw fixation of
because this fracture type is uncommon (3% of distal parasagittal (type II) fractures may also be indicated, but
www.ajlobby.com
requires more care in screw insertion to achieve appro- cases.9 Support for the use of double screws in sagittal and
priate screw angle and fracture compression.9,26,28 parasagittal distal phalanx fracture repair is also provided
Although single lag screw fixation has traditionally been by mechanical data, which revealed a lack of maintenance
recommended, two of the authors (Ducharme and Nixon) of reduction and stabilization with axial load on a single
have used double screw fixation in an effort to increase the screw repair.17 A single 4.5 mm screw applied using stand-
zone of the compression and add rotational stability.2,4,17 ard technique allowed considerable fracture distraction
Follow‐up to assess the additional risks of the added soft along the distal aspect of the fracture line during loading.
tissue injury of the laminae, drainage, infection, or added This was significantly reduced by use of a 5.5 mm cortical
surgical time of the double screw technique have not yet screw, suggesting the need for a larger single screw,17 or
been evaluated in a large case series. A recent report more importantly the use of two screws, one inserted
described lag screw fixation of distal phalanx fractures in nearer the articular surface and the other closer to the
16 horses, including application of two screws in five solar canal. Careful planning and intraoperative monitor-
ing, either by CT or fluoroscopy, become vital for accurate
placement of either screw.2,4,9,17,37 A cadaveric study also
indicated improved fracture fixation rigidity using a more
distal and palmar/plantar placement of a single screw.4
However, risk of penetration of the solar canal was
substantially increased and adds further indication to a
double screw stabilization, where both screws are placed
proximal to the solar canal.
The day before surgery, the hoof should be trimmed,
balanced, rasped, and cleaned. The wall surface must be
scrupulously clean and the sulci of the frog cleaned and
trimmed down to normal horn. The hair should be
clipped to above the fetlock. Soaking the hoof in nonir-
ritating disinfectant overnight may help reduce the risk
of infection. The horse is positioned in lateral recum-
bency with the affected limb uppermost for type III frac-
tures, or with the smaller portion of a parasagittal
fracture uppermost in type II fractures. After initial
aseptic preparation of the hoof, the sole and wall surfaces
are coated in tincture of iodine, dried, and a surgical
glove firmly adhered to the distal aspect of the hoof wall
with cyanoacrylate glue. A tourniquet is applied at the
mid third metacarpal/metatarsal (MC/MT3) level, and
the final aseptic preparation of the exposed hoof wall and
Figure 14.11 Dorsopalmar (30°) radiograph of a type VI distal
skin up to the fetlock completed. A sterile surgical glove
phalanx fracture with biaxial solar margin fractures (arrows) in a is applied over the existing glove, and an adherent iodine‐
horse with laminitis. coated plastic drape (Ioban™ 2, 3M Company, St. Paul,
Figure 14.12 Traumatic type VI distal

(A) (B)
phalanx fracture. (A) Dorsopalmar
radiographs show fragmentation with a
displaced fragment. (B) Lateral radiograph
shows displaced fragment of the distal
phalanx and a second less displaced
fracture of the perimeter of the phalanx.
www.ajlobby.com
Figure 14.13 Limb preparation for distal phalangeal

screw insertion. The foot is gloved along the distal
hoof wall to isolate the sole and aseptically prepared.
An adherent plastic drape (Ioban) is applied and
reinforced with Vetrap. The limb is inserted through
the rubber dam in an arthroscopy drape to provide a
totally enclosed sterile field with full access for
drilling, arthroscopy, and fluoroscopy. Arthroscopy
portals (A) have been used to guide fracture
reduction during single screw repair of a type II
fracture through a hoof wall defect (B). The core saw
(C)
(C) is being used to develop another hoof wall
window for lag screw repair of a concurrent
navicular fracture.
(B)
(A)
MN, USA) firmly adhered to the skin and gloved foot Double Screw Repair
using a spray‐on adhesive (Adapt 7730 Medical Adhesive The first screw is placed midway between the dorsal
spray, Hollister, Libertyville, IL, USA). A sterile Vetrap surface of the extensor process and the solar surface of
secures the adherent layers and the foot is then extruded the phalanx on the lateral view, and 3–5 mm closer to
through the aperture in a large arthroscopy drape the articular surface of the DIP joint (Figure 14.17). The
(Surgical Resources, Darlington, MD, USA; Figure 14.13). second screw is placed slightly more dorsal and
The surgical procedure is best performed under fluoro- 15–20 mm distal to the first. The proximity to the solar
scopic or radiographic control. Imaging is done with canal must be verified by fluoroscopy or radiography.
radio‐opaque markers or an instrument adjacent to the This canal contains the terminal arch vasculature where
hoof wall to ensure proper placement of the screw(s). lateral and medial palmar digital arteries anastamose.29
The solar surface of the distal phalanx is concave, so the
Single Screw Repair drilling of the second screw should avoid penetrating
The screw should be placed midway between the articular the solar surface of the phalanx (see Figure 14.17). The
surface and the solar canal on the lateral radiographic same fluoroscopic guidance is used to select the ideal
view. This location is verified by marker position on lateral position for removing hoof wall for placing the second
and dorsopalmar radiographic projections, or by hoof wall screw. Rarely, the two screws can be placed through the
scarification using a hemostat under fluoroscopic control same hoof wall window. A computer‐assisted surgical
(Figure 14.14A), or by positioning the 4.5 mm drill guide (CAS) technique has been reported for this method of
to show position and angle of drill entry (Figure 14.14B). repair in horses in two cadaveric studies.2,28 CAS was
The hoof wall is then removed using a 10 mm (3/8 in.) drill shown to greatly improve the accuracy of placement of
or core saw (Figure 14.15) to penetrate to the distal the screws in terms of decreasing the probability of
phalanx. The thickness of the hoof wall is obtained to articular and solar surface penetration, screw protru-
complete the measurements required to plan drill depth sion, and solar (semilunar) canal penetration.2,28
and screw length (Figure 14.16). In summary, the depth However, reports of outcome after CAS use in vivo for
from the outer hoof wall to the bone is determined, dou- distal phalanx screw fixation have not been published.
bled, and subtracted from a measurement of the width of Preoperative and intraoperative CT have both improved
the hoof at this location. This provides an estimate of accuracy of screw placement in distal phalanx repairs.9,37
screw length, and must be verified by oblique intraopera- Robotically assisted CT (EquimagineTM 4DDI, Four
tive radiographs or fluoroscopic imaging to ensure that Dimensional Digital Imaging, Holbrook, NY, USA) also
the screw tip does not emerge from the distal phalanx and allows accurate planning and frequent 3D evaluation of
irritate the overlying hoof wall and sensitive laminae (see intraoperative progress, and is slowly becoming more
Figure 14.14C–F). After final screw tightening, closure is widely available. Fluoroscopy has been vital when these
as described for the double screw technique. other modalities are not employed.
www.ajlobby.com
(A) (B)
(C) (D)
(E) (F)
Figure 14.14 Single screw insertion for type II fracture. (A) Intraoperative fluoroscopic image with a surgical instrument marking the
target drilling area for placement of the screw to immobilize a type II or III fracture. (B) The 4.5 or 5.5 mm drill guide can also be aligned to
verify appropriate position and angle under fluoroscopic guidance. A core saw can then be used to remove a hoof wall plug. (C) A 4.5 or
5.5 mm drill is used to provide a glide hole across the fracture line. (D) The pilot hole is drilled and the 4.5 or 5.5 mm tap inserted to just
emerge on the opposite side of the phalanx. (E) A 5.5 mm screw has been inserted to be several millimeters shorter than the width of the
bone (see Figure 14.16 for initial measurement). Note that the fracture gap at the articular surface has been reduced. (F) Final tightening
and intraoperative check on alignment of screw.
Once the appropriate location for the first screw is measurement of the width of the hoof at that location, as
identified, a 10 mm (3/8 in.) hole is drilled through the illustrated (see Figure 14.16). Placement of the screw is
hoof wall down to the lateral surface of the distal pha- not at the widest point of the distal phalanx. The hole
lanx, as described for the application of a single screw. should be drilled parallel to the joint surface, which is
The depth from the outer hoof wall to the bone usually perpendicular to the fracture line. A 4.5 or 5.5
should be determined, doubled, and subtracted from a mm cortical screw can be placed in lag fashion.
www.ajlobby.com
Figure 14.15 Core saw used to remove (A) (B)

hoof wall to provide access to the distal
phalanx and allow hoof wall repair by
reinserting the hoof wall dowel. (A) Core
saw cutting the hoof wall down to soft
tissue at fluoroscopically predetermined
site; (B) hoof wall retained in core saw;
(C) hoof wall core saved for reinsertion;
and (D) access for drilling and screw
insertion.
(C) (D)
(A) (B)
Figure 14.16 Internal fixation of a sagittal (type III) fracture with a single screw placed in lag fashion. (A) Measurements allow calculation
of screw length, followed by (B) insertion and verification by radiography or fluoroscopy. KEY: a = distance from hoof wall to the phalanx,
b = distance from phalanx surface to the fracture line, d = width of hoof at drill site, c = calculated length of tap hole (d−(2a + b)). Length
of the screw = (d−2a).
www.ajlobby.com
(A) (B)
(C) (D)
(E) (F)
Figure 14.17 Fluoroscopic images obtained to show the sequence in insertion of a second, more distal screw in the repair of a
parasagittal type II distal phalanx fracture. (A) A hemostat is used to identify the appropriate location for the second screw 15–20 mm
distal to the original screw. The core saw is then used to remove a 10 mm hoof wall plug. (B) The 4.5 or 5.5 mm drill guide is verified to be
appropriately positioned distal and slightly dorsal to the initial screw. The solar canal (sc) must be avoided distal to this drill insertion.
(C) The 4.5 or 5.5 mm glide hole is drilled across the fracture line. (D) The pilot hole is drilled with the 3.2 or 4.0 mm drill, again avoiding
the sc. (E) The hole is tapped and the second screw inserted. Note the additional compression at the joint surface (arrow) and the two
adjacent hoof wall defects (arrowheads). (F) Both screws are inserted proximal to the sc.
Biomechanical assessment of compression across the lateral and dorsopalmar (plantar) fluoroscopic image
fracture supports the use of 5.5 mm screws over 4.5 mm or radiograph is usually taken with the glide hole drill
screws,14,17 and suggests that 6.5 mm cancellous screws bit in place to ensure proper placement and depth
may even be preferable for distal phalanx repair.14 A (Figure 14.17C). The glide hole must cross the fracture
www.ajlobby.com
line to achieve compression. The drill sleeve is then of the distal phalanx can be manipulated from the artic-
inserted to assist with placement of the pilot hole. The ular surface under arthroscopic control for improved
measurement of screw length can be used to estimate reduction prior to screw placement (Figure 14.18).9,12,20
the length of the pilot hole and minimize the soft tissue Alternatively, alignment of the fracture at the articular
irritation on the far side of the phalanx. Real‐time fluor- surface can be manipulated under fluoroscopic control to
oscopic imaging during drilling is also helpful to deter- improve congruency. Recent fractures of the distal pha-
mine when the drill tip has just reached the far surface of lanx often compress well with two screws (Figure 14.19),
the distal phalanx (Figure 14.17D). Rotating the fluoro- and time to heal can be reduced by four to six months.
scopic head to ensure the most perpendicular beam axis Use of three‐dimensional fluoroscopy or portable CT
to the drill assists in this assessment. The pilot hole Airo TruCT; Mobius Imaging, Shirley, MA, USA is also
should be tapped and a screw, 4 or 5 mm shorter than gaining popularity for intraoperative guidance and veri-
that calculated, inserted (Figure 14.17E). Countersinking fication. Three‐dimensional imaging becomes increas-
should be kept to a minimum, because the distal phalanx ingly useful when screws are utilized for oblique
is soft cancellous bone and collapses under the screw parasagittal (type II) fractures, where the plane of screw
head, resulting in even distribution of compression insertion is not directly lateromedial.9,37 Use of standing
forces. If a fracture is significantly displaced, the halves CT has also been described in cadaver models to
(A) (B)
(C) (D)
Figure 14.18 Arthroscopically assisted realignment of a type II fracture. (A) Dorsopalmar and (B) oblique radiographs show fracture
separation (double arrow) and fracture malalignment at the palmar surface (arrow head) and distal weight‐bearing surfaces (arrow).
(C) Arthroscopic image showing fracture malalignment (arrow) and (D) return of alignment during manipulation for drilling.
www.ajlobby.com
(A) (B) Figure 14.19 (A) Dorsopalmar radiograph

of a distal phalanx with a type III fracture
repair using the double screw technique.
Note the position of the screws in relation
to the solar margin of P3. (B) Lateral
radiograph after repair of a type III fracture
using the double screw technique,
showing the desired position of the screws
and good fracture reduction.
improve the accuracy of screw placement in sagittal and to help stabilize the repair during walking. Horses should
parasagittal (oblique) fractures.37 be confined to box stall rest for two months, then
Complex fractures of other adjacent bones can be box stall with hand walking for two months. At four
identified on CT or MRI and addressed sequentially months, if the horse is sound, paddock turnout is recom-
(Figure 14.20). Arthroscopic assessment of the DIP joint mended for two months, to provide a total convalescence
provides access to middle phalanx avulsion pieces that time of six months. Radiographs at six months should be
can then be removed or stabilized using lag screw tech- used to verify that the fracture has healed sufficiently to
nique, depending on the extent of collateral ligament start riding. The horse should be maintained in a correc-
compromise. Arthroscopy also allows direct visualiza- tive shoe throughout its athletic career.
tion during screw insertion to the distal phalanx to assist
in fracture alignment. Preoperative assessment of collat- Complications
eral ligament integrity is useful to determine the need for Surgical complications include chronic drainage from
avulsed fragment reattachment and postoperative need the hoof defects that result in lameness when the hoof
for cast or cast bandaging. Concurrent fracture of the wall defect grows away from the screw head and nears
navicular bone (Figure 14.20) is rare, but can be addressed the solar margin, irregular keratinous masses resem-
by separate hoof wall penetration and lag screw insertion bling keratoma, infection of the screw with or without
(see Chapter 15). osteomyelitis, failure of the fracture to heal, and degen-
For closure, the depths of the drill holes in the hoof erative joint disease of the DIP.8,9,11,12,31 Serum drainage
are first covered with absorbable gelatin (Gelfoam®, without infection can occur if growth of the hoof soft
Pfizer, New York, USA), then a polymethylmethacrylate tissues is irritated or damaged by the screw head.
(PMMA) seal containing antimicrobials is placed. If As the hoof grows over the surgical site, drainage
the wall has been removed using a core saw, the hoof cannot occur and lameness results. This can be a

plug is replaced and secured with PMMA cement chronic problem that will not resolve until the screw is
(Figure 14.21). The PMMA or hoof wall plug can be removed. There is no urgency to remove the screw if
additionally sealed to the outside of the hoof wall with the hoof and underlying bone are not infected. The
cyanoacrylate or Gorilla® Glue (The Gorilla Glue Co., hoof wall can be opened focally over the screw head to
Cincinnati, OH, USA). allow transient drainage, and the screw can be removed
after the fracture has fully healed. When two screws
Postoperative Care are placed, lameness and radiographic lysis may be
Perioperative antibiotics such as penicillin and gentocin confined to only one of the two screws (Figure 14.22).
should be administered an hour before surgery and con- A contrast study may help confirm that only one of the
tinued for three to five days postoperatively. Regional two screws is causing the lameness, allowing the unin-
intravenous perfusion of antibiotics such as gentocin, volved screw to remain to compress the fracture.
amikacin, or meropenem provides higher local concen- Infected screws with surrounding bone lysis usually
trations and is preferred to systemic administration. Oral have to be removed before the fracture has completely
phenylbutazone is often administered for five to healed, because of the risk of infectious arthritis or sig-
seven days to provide analgesia and anti‐inflammatory nificant distal phalangeal osteomyelitis. Infection is
effects after surgery. The bar shoe with rim or heel and normally eliminated after screw removal and antibiotic
quarter clips should be applied at or shortly after surgery therapy. Although infectious arthritis is not a frequent
www.ajlobby.com
(A) (B) (C)
(D) (E) (F)
(G) (H) (I)
Figure 14.20 Repair of concurrent fractures in the foot (same case as Figures 14.9 and 14.10). (A) Arthroscopic assessment verifies an
avulsion (av) fracture of a portion of the medial collateral ligament (MCL) from the middle phalanx (MP). (B) After fracture removal the
distal phalanx becomes obvious. (C) The torn portion of the MCL is further trimmed. (D) Fracture alignment of the distal phalanx (DP) is
assessed before reduction (arrows), and (E) after reduction and screw insertion. (F) The larger fragments are stabilized by screw insertion,
but leave ongoing joint surface comminution (arrows). (G–I) postoperative radiographs showing DP repair, MP av fragment removal, and
navicular fracture repair. The re-inserted hoof wall plugs are evident in radiographs in parts H & I.
complication,9,13 it has occurred and requires aggres- degenerative joint disease is more likely to occur if the
sive joint lavage, screw removal, and local and systemic articular surface has not healed, is irregular, or infec-
antibiotic therapy. Fractures can still heal with con- tion and delayed union have occurred. If permanent
servative therapy after screw removal. Lameness from lameness develops, surgical arthrodesis with joint
www.ajlobby.com
(A) (B) (C)
Figure 14.21 Intraoperative images showing (A) replaced hoof wall plugs in the original sites, (B) followed by PMMA cement to secure
them, and finally (C) the use of cyanoacrylate to seal the PMMA onto the drill holes in the hoof wall.
Arthroscopic Removal of Extensor

Process (type IV) Fractures
Osteochondral fragments in the dorsal pouch of the DIP
joint that are small enough to be removed and are associ-
ated with lameness in the DIP joint should be explored
arthroscopically, the fragment removed, and the abnor-
mal cartilage debrided. Most commonly these fragments
represent chip fractures from the extensor process, and a
routine approach to the dorsal joint from either side of
the extensor tendon is satisfactory.20 Small rounded
osteochondral fragments originating from the extensor
process may be a form of osteochondrosis, but more
likely represent chronic small fracture fragments
(Figure 14.23). Fragments have been removed as a pre-
ventative measure, while others have associated clinical
lameness. The arthroscopic approach is similar in either
situation, although chronic fracture cases with lameness
Figure 14.22 Radiograph obtained six months after screw fixation often have dense synovial proliferation and some
of a sagittal fracture, showing bone lysis (arrows) involving only
the distal screw. The proximal screw can remain to assist in final
cartilage erosion, which can make development of the
fracture union. instrument portal difficult. Motorized synovial resectors
are helpful to establish the visual boundaries of the
fracture fragment (see Figure 14.23). Dissection of the
debridement and lag screw fixation of the DIP can fragment from synovial attachments and the common
salvage the horse (see Chapter 16).30 Internal fixation or long digital extensor tendon is accomplished with per-
using two screws generally improves the odds of frac- iosteal elevators, a curved serrated “banana” blade, or
ture healing, particularly at the articular margin, but radiofrequency probe. Most chronic fracture fragments
does not ensure a complication‐free postoperative can then be removed using rongeurs, although these
convalescence. Subsequent lameness from hoof wall fragments are fragile and often separate into smaller
irritation, bone lysis from excessive screw heat associ- pieces, which must not be overlooked. Intraoperative
ated with power insertion, or articular incongruency radiographs are important to ensure that no fragments
or other damage may still occur. remain.
www.ajlobby.com
(A) (B)
(C) (D)
Figure 14.23 Chronic extensor process fracture in a six‐year old Warmblood with low‐grade lameness. (A) Radiographic projection shows
the rounded osteochondral fragment. (B) Arthroscopic view showing synovial resector being used to expose the fragment and fracture
plane (arrows). Note the articular cartilage fibrillation over the dorsal surface of the middle phalanx opposing the fragment. (C) Fracture
bed in the extensor process after fragment removal. Fibrous tissue covers the fracture bed on the distal phalanx. (D) Postoperative
radiograph showing fracture bed and remodeling of the residual portion of the extensor process.
Large and more acute extensor process fractures can Perioperative systemic antibiotic therapy is used
be more difficult to remove. Splitting the fragment with for 24 hours, beginning within 1 hour of surgery,
an osteotome prior to retrieval, or removal by motorized because of the close proximity of the surgery site to
bone bur, may be required (Figure 14.24). Large extensor the hoof and the increased risk of contamination.
process fractures that have developed a fibrous union Sterile bandages are maintained after surgery for
and remodeling of the shape of the distal phalanx are not 14 days. Oral phenylbutazone will help reduce pain
candidates for internal fixation, and removal is generally and inflammation. Intraarticular hyaluronic acid and
required if surgery is to be attempted.5,6 Outcome after intramuscular polysulfated glycosaminoglycan therapy
removal of large fractures can be quite satisfactory, with may be indicated if synovitis or cartilage damage,
8 of 14 horses in one study returning to function.6 respectively, is encountered.20,21 Box stall rest for four
Resolution of symptoms was not associated with age, weeks and box stall rest with hand walking for an addi-
duration or severity of lameness, or size of fragment.6 tional four weeks are recommended. Corrective shoe-
Approaches to the palmar (plantar) aspect of the DIP ing to include a half‐round shoe and a degree pad to
joint have been used to retrieve fragments from the absorb concussion and increase hoof angle will both
middle phalanx,20,31,35,36 and rarely a fracture fragment minimize stress on the joint during exercise. The prog-
from the distal phalanx may displace into the volumi- nosis for long‐term athletic activity after fragment
nous palmar or plantar pouch and be accessible proximal removal is good; however, lameness may return several
to the distal sesamoid (navicular) bone.15,20,33 years after surgery.5,6,15,20,25,26
www.ajlobby.com
(A) (B) (C)
(D) (E) (F)
Figure 14.24 Chronic large extensor process fracture in a Thoroughbred racehorse. (A) Preoperative lateromedial radiograph showing the
fibrous nonunion with exostoses attempting to bridge the fracture. Note the step in the subchondral bone on the articular surface.
(B) Large oval bur (Notchplasty™, Dyonics, Smith & Nephew, Andover, MA, USA) being used to remove the bulk of the extensor process.
(C) Thin layer of bone and cartilage (arrows) remaining after bur debridement. (D) Rongeur being used to remove residual bone and
cartilage after debulking. (E) Defect in extensor process after debridement. (F) Postoperative radiograph on Day 1 showing removed
fracture fragment and residual abaxial and dorsal exostoses.
Internal Fixation of Extensor Process these dimensions are less common, and most fragments
Fractures with a Lag Screw can be removed arthroscopically.
Rarely, extensor process (type IV) fractures are large

enough to accept a lag screw without fragmentation,
and are too large to remove arthroscopically without Summary
causing joint instability or permanent soft tissue
damage. Surgical placement of a lag screw has been The treatment of fractures of the distal phalanx depends
successfully reported using an arthrotomy approach.10 on the fracture type. Surgical repair with application of lag
Longitudinal tenotomy allows access to the extensor screws is recommended in sagittal (type III) fractures and
process. Arthroscopic exposure and debridement of the for parasagittal (type II) fractures in mature adult horses.
articular edges followed by radiographic or fluoro- Large and more acute extensor process (type IV) fractures
scopic guided screw insertion allow accurate recon- may also derive benefit from internal fixation. Arthroscopic
struction of the joint congruity in recent fractures removal of small or chronic type IV fractures is recom-
(Figure 14.25). The angle of the screw should be per- mended if lameness is verified to originate within the cof-
pendicular to the fracture plane and avoid the solar fin joint. Digital neurectomy for type I and type II fractures
canal. Screw size varies with fracture dimension; how- can minimize the discomfort, allow continued racing, and
ever, a 4.5 mm screw is generally appropriate. The fixa- may be selected based on economic factors and local rac-
tion is subject to significant cyclical loading and most ing regulations. In all situations, including surgical cases,
3.5 mm cortical, 4.0 mm cancellous, and 4.0 mm malle- treatment with a bar shoe, clips, and full pad is recom-
olar screws will fatigue and bend or break. Fractures of mended, possibly for the rest of the horse’s career.
www.ajlobby.com
(C)
(A)
(B)
(D)
Figure 14.25 Lag screw technique for repair of an extensor process fracture. (A) Lateromedial radiograph showing a large extensor
process fracture with a step at the articular margin. (B) Preoperative planning showing drill angle, screw length, and depth to fracture line.
(C) Intraoperative radiograph showing arthroscopically monitored fracture alignment and screw insertion. (D) Follow‐up radiograph at
90 days. Source: Images courtesy Dr. I. Wright.
References
1 Anderson, B.H., Turner, T.A., and Kobluk, C.N. (1996). 5 Crowe, O.M., Hepburn, R.J., Kold, S.E., and Smith, R.K.
Treatment of a comminuted frontal‐plane fracture of the (2010). Long‐term outcome after debridement of distal
distal phalanx in a horse. J. Am. Vet. Med. Assoc. 209: phalanx extensor process fragmentation in 13 horses.
1750–1752. Vet. Surg. 39: 107–114.
2 Andritzky, J., Rossol, M., Lischer, C., and Auer, J.A. 6 Dechant, J.E., Trotter, G.W., Stashak, T.S., and
(2005). Comparison of computer‐assisted surgery with Hendrickson, D.A. (2000). Removal of large fragments of
conventional technique for the treatment of axial distal the extensor process of the distal phalanx via arthrotomy
phalanx fractures in horses: an in vitro study. Vet. Surg. in horses: 14 cases (1997–1998). J. Am. Vet. Med. Assoc.
34: 120–127. 217: 1351–1355.
3 Baird, A.N., Seahorn, T.L., and Morris, E.L. (1990). 7 Faramarzi, B., McMicking, H., Halland, S. et al. (2015).
Equine distal phalangeal sequestration. Vet. Radiol. Incidence of palmar process fractures of the distal
31: 210–213. phalanx and association with front hoof conformation in
4 Bindler, D., Koch, C., Gendron, K. et al. (2015). Evaluation foals. Equine Vet. J. 47: 675–679.
of a novel screw position in a Type III distal phalanx 8 Gabel, A.A. and Bukowiecki, C.F. (1983). Fractures of the
fracture model: an ex vivo study. Vet. Surg. 44: 829–837. phalanges. Vet. Clin. North Am. 5: 233–260.
www.ajlobby.com
9 Gasiorowski, J.C. and Richardson, D.W. (2015). Clinical distal phalanx in 48 standardbred horses. Aust. Vet. J.
use of computed tomography and surface markers to 77: 501–503.
assist internal fixation within the equine hoof. Vet. 24 Pettersson, H. (1976). Fractures of the pedal bone in
Surg. 44: 214–222. the horse. Equine Vet. J. 8: 104–109.
10 Haynes, P.F. and Adams, O.R. (1974). Internal fixation 25 Rick, M.C. (1990). Fractures of the distal phalanx.
of fractured extensor process of third phalanx in a In: Current Practice of Equine Surgery (ed. N.A.
horse. J. Am. Vet. Med. Assoc. 164: 61–63. White and J.N. Moore), 600–601. Philadelphia:
11 Honnas, C.M., O’Brien, T.R., and Linford, R.L. (1988). Lippincott.
Distal phalanx fractures in horses. A survey of 274 26 Rijkenhuizen, A.B.M., de Graaf, K., Hak, A. et al.
horses with radiographic assessment of healing in (2012). Management and outcome of fractures of the
36 horses. Vet. Radiol. 29: 98–107. distal phalanx: a retrospective study of 285 horses
12 Honnas, C.M., Vacek, J.R., and Schumacher, J. (1992). with a long term outcome in 223 cases. Vet. J.
Diagnosis and treatment of articular fractures of the 192: 176–182.
equine distal phalanx. Vet. Med. 87: 1208–1214. 27 Rose, R.J., Taylor, B.J., and Bellenger, C.R. (1979).
13 Honnas, C.M., Welch, R.D., Ford, T.S. et al. (1992). Internal fixation of fractures of the third phalanx in
Septic arthritis of the distal interphalangeal joint in 12 three horses. Aust. Vet. J. 55: 29–32.
horses. Vet. Surg. 21: 261–268. 28 Rossol, M., Gygax, D., Andritzky‐Waas, J. et al. (2008).
14 Johnson, K.A. and Smith, F.W. (2003). Axial compression Comparison of computer assisted surgery with
generated by cortical and cancellous lag screws in the conventional technique for treatment of abaxial distal
equine distal phalanx. Vet. J. 166: 159–163. phalanx fractures in horses: an in vitro study. Vet. Surg.
15 Kaneps, A.J., O’Brien, T.R., Redden, R.F. et al. (1993). 37: 32–42.
Characterization of osseous bodies of the distal phalanx 29 Schade, S.M., Arnoczky, S.P., and Bowker, R.M. (2014).
of foals. Equine Vet. J. 25: 285–292. The microvasculature in the equine distal phalanx:
16 Kasari, T.R., Taylor, T.S., Baird, A.N., and Morris, E.L. implications for fracture healing. Vet. Comp. Orthop.
(1992). Use of autogenous cancellous bone graft for Traumatol. 27: 102–106.
treatment of osteolytic defects in the phalanges of three 30 Schneider, R.K., Bramlage, L.R., and Hardy, J. (1993).
cattle. J. Am. Vet. Med. Assoc. 201: 1053–1057. Arthrodesis of the distal interphalangeal joint in two
17 Kay, A.T., Durgam, S., Stewart, M. et al. (2016). Effect horses using three parallel 5.5‐mm cortical screws.
of cortical screw diameter on reduction and Vet. Surg. 22: 122–128.
stabilization of type III distal phalanx fractures: an 31 Scott, E.A., McDole, M., and Shires, M.H. (1979). A
equine cadaveric study. Vet. Surg. 45: 1025–1033. review of third phalanx fractures in the horse: sixty‐five
18 Linford, R.L., O’Brien, T.R., and Trout, D.R. (1993). cases. J. Am. Vet. Med. Assoc. 174: 1337–1343.
Qualitative and morphometric radiographic findings 32 Scott, E.A., Snyder, S.P., Schmotzer, W.B., and Pool, R.
in the distal phalanx and digital soft tissues of (1991). Subchondral bone cysts with fractures of the
sound thoroughbred racehorses. Am. J. Vet. Res. 54: extensor processes in a horse. J. Am. Vet. Med. Assoc.
38–51. 199: 595–597.
19 McDiarmid, A.M. (1995). An unusual case of 33 Selberg, K. and Werpe, N. (2011). Fractures of the distal
distal phalanx fracture in a horse. Vet. Rec. 137: phalanx and associated soft tissue and osseous
613–615. abnormalities in 22 horses with ossified sclerotic
20 McIlwraith, C.W., Nixon, A.J., and Wright, I.M. (2015). ungual cartilages diagnosed with magnetic resonance
Arthroscopic surgery of the distal and proximal imaging. Vet. Radiol. Ultrasound. 52: 394–401.
interphalangeal joints. In: Diagnostic and Surgical 34 Sherlock, C.E., Eggleston, R.B., and Howerth, E.W.
Arthroscopy in the Horse, 4e, 316–343. Oxford, UK: (2012). Conservative management of a transverse
Mosby‐Elsevier. fracture of the distal phalanx in a Quarter Horse. J. Am.
21 Nixon, A.J. (1992). Intra‐articular medications. In: Vet. Med. Assoc. 240: 82–86.
Current Therapy in Equine Medicine (ed. N.E. 35 Vacek, J.R., Welch, R.D., and Honnas, C.M. (1992).
Robinson), 286–292. Philadelphia: WB Saunders Arthroscopic approach and intra‐articular anatomy
Company. of the palmaroproximal and plantaroproximal aspect
22 Ohlsson, J. and Jansson, N. (2005). Conservative of distal interphalangeal joints. Vet. Surg. 21:
treatment of intra‐articular distal phalanx fractures in 257–260.
horses not used for racing. Aust. Vet. J. 83: 221–223. 36 Vail, T.B. and McIlwraith, C.W. (1992). Arthroscopic
23 O’Sullivan, C.B., Dart, A.J., Malikides, N. et al. (1999). removal of an osteochondral fragment from the middle
Nonsurgical management of type II fractures of the phalanx of a horse. Vet. Surg. 21: 269–272.
www.ajlobby.com
37 Vanderweerd, J.M.E., Perrin, R., Laumois, T. et al. 39 Yovich, J.V., Hilbert, B.J., and McGill, C.A. (1982).
(2009). Use of computed tomography in standing Fractures of the distal phalanx in horses. Aust. Vet. J.
position to identify guidelines for screw insertion in the 59: 180–182.
distal phalanx of horses: an ex vivo study. Vet. Surg. 38: 0 Yovich, J.V., Stashak, T.S., DeBowes, R.M., and
4
373–379. Ducharme, N.G. (1986). Fractures of the distal phalanx
8 Yovich, J.V. (1989). Fractures of the distal phalanx in the
3 of the forelimb in eight foals. J. Am. Vet. Med. Assoc.
horse. Vet. Clin. North Am. Equine Pract. 5: 145–160. 189: 550–553.
www.ajlobby.com
242
15
Michael C. Schramme1 and Roger K.W. Smith2
1
Clinéquine, Campus Vétérinaire de Lyon, Marcy l’Étoile, France
2
Department of Clinical Sciences and Services, The Royal Veterinary College, London, UK
Incidence occur between 10 and 20 mm from the lateral or medial

extremity of the navicular bone.42,48 Lateral parasagittal
Navicular bone fractures are uncommon, with early fractures are most common.9 A recent study reported
reports estimating the incidence at between 0.09% a relative incidence for complete sagittal fractures of
and 0.25% of hospital populations.10,16,23,31,32 They 0.06% of horses examined over a 10‐year period at a
occur more often in forelimbs than hindlimbs.2,9,19,22 referral hospital. In contrast, fractures in the frontal and
Generally, there does not appear to be any breed transverse planes are highly unusual.17,27 Generally sagit-
or
discipline predilection, although one author has tal fractures are only minimally displaced, but widening
mentioned a higher incidence in racehorses,28
of the fracture gap results from separation and resorp-
while others believe they have observed a higher risk in tion of the fracture margins due to hypervascularity.42
jumping horses.16,31 Reports have appeared only spo- As the navicular bone is curved, there is a tendency
radically in the literature, first based on post‐mortem toward more separation at the palmar surface rather
identification,20,21,42,45 later on radiographic diagnosis than the dorsal surface of the bone.1
using Oxspring’s technique,16,40 and more recently on Chip fractures or separate osseous fragments at
the results of treatment.2,9,19,22,24,35,39,47 the distal border of the navicular bone have variously
been described as avulsion fractures, separate centers
of ossification, osseous metaplasia of the impar
Fracture Types ligament, or synovial osteoma, but pathological evi-
dence confirming their pathogenesis remains elusive
Fractures of the navicular bone have been classified (Figure 15.2).8,10,25,40 The fractures are ellipsoidal in
as simple complete fractures (sagittal, transverse, or shape, measure from 0.2 to 1.2 cm along their horizon-
frontal);1,2 chip or avulsion fractures of the distal, prox- tal axis, and are located at the lateral and/or medial
imal, medial, or lateral margins;3 and comminuted com- margins of the prominent palmarodistal lip (Margo lig-
plete fractures.10,28,42 In addition, congenital nonfusion amenti distalis) of the distal border of the navicular
of bipartite and tripartite navicular bones has also been bone. A corresponding concave “fracture” bed is usu-
described.3,14,26,33,41 ally present in the distal border opposite the fragment.
Simple complete fractures may be vertical in the Fragments occur bilaterally in approximately 50% of
sagittal or frontal plane, slightly oblique, or transverse. horses.40 Lateral fragments are more common than
Vertical and slightly oblique fractures in the sagittal medial fragments, but medial fragments tend to be
plane are by far the most common complete fracture of larger.25 These distal border fragments have been
the navicular bone (Figure 15.1). These fractures occur considered uncommon,25,40 though they are more com-
mostly abaxial to the central region of the sagittal ridge, monly found in horses with palmar foot lameness than
because the navicular bone is thicker in the center and in age‐matched control horses.6,34,44,46 In one study, dis-
tapers toward its lateral and medial extremities. Indeed, tal border fragments were identified in 3.4% of 1488
these parasagittal fractures have been documented to horses that underwent foot radiography.25 In another

www.ajlobby.com
(A) (B)
Figure 15.1 Radiographs of a right front navicular bone lateral parasagittal fracture. (A) Dorsoproximal‐palmarodistal oblique and
(B) palmaroproximal‐palmarodistal skyline views confirm the fracture in two projections. The fracture is less than two weeks old. There is
minimal displacement and the fracture margins are relatively sharply delineated.
distal border fragments was 19.3% in horses with foot

lameness and 6.2% in nonlame horses.44 Similarly, in a
more recent study, distal border fragments were evi-
dent in 33 of 377 (8.7%) of horses with foot lameness
and only 2 of 55 (3.6%) of normal horses.6 However, in
post‐mortem surveys of navicular bones from horses
with navicular disease, the reported incidence of distal
border fragments has ranged from 29% to 40%.34,46
Consequently, the true incidence of these osseous frag-
ments has likely been underestimated by radiography,
and both computed tomography and magnetic
resonance imaging (MRI) have since been shown to
have a better sensitivity than radiography for their iden-
tification.5,13,30,34 Distal border fragments are frequently
associated with other radiographic abnormalities
consistent with navicular bone pathology.8,25,47 Their
occasional presence on radiographs of the front feet
of sound horses makes interpretation of their clinical
significance difficult. In contrast, chip fractures of the
lateral or medial extremity (wing) of the navicular bone
Figure 15.2 Dorsoproximal‐palmarodistal oblique view of the have been reported infrequently and are always associ-
right front foot of a three‐year‐old Quarter Horse with foot ated with lameness (Figure 15.3).15,17,22,28
lameness. There is a large, separate osseous fragment (arrows) at Complete comminuted fractures are even less com-
the distolateral border of the navicular bone. mon than simple complete fractures (Figure 15.4). In one
report, comminution was present in 3 of 18 horses
study, distal border fragments were seen on foot radio- with complete navicular bone fractures.2 Comminution
graphs of 204 of 1648 horses (12%), 873 of which were usually follows a Y‐configuration on dorsopalmar
presented for prepurchase radiography and 776 for foot radiographs, and results in more dorsal and ventral

lameness.44 In this study, the radiographic incidence of displacement in comparison with simple fractures.2
www.ajlobby.com
Figure 15.3 Dorsoproximal 60° palmarodistal oblique view of the

Figure 15.5 Dorsoproximal‐palmarodistal oblique views of both
left front foot of a 12‐year‐old Quarter Horse with acute,
front feet of a five‐year‐old Warmblood. The horse passed a
moderately severe foot lameness. There is a fracture of the lateral
prepurchase examination four weeks previously, but had become
wing of the navicular bone (arrows), which could also be observed
slightly lame, especially on circles, as training was gradually
on the palmaroproximal‐palmarodistal (skyline) oblique view.
increased. There are parasagittal defects in both navicular bones
with evidence of chronic remodeling. This presentation is strongly
suggestive of multipartite navicular bones.
c ondition may have remained poorly recognized for a

long time.1,42,45 Indeed, the possibility of multipartite
navicular bones rather than their fracture has been
fostered again recently.14 An incidence of 1.5% was

reported for “clinically silent navicular fractures” during
radiographic screening of 200 Warmblood yearlings.19
Congenital multipartite sesamoid bones are occasionally
seen in other species.38 Although the equine navicular
bone develops from a single ossification center,29
aberrant formation from multiple ossification centers is
theoretically possible in the horse.38 Multipartite
navicular bones can be bi‐ or tripartite. Radiographically
multipartite navicular bones cannot be distinguished
from a chronic fracture, even with histology,41 except
that multipartite navicular bones are frequently bilateral
and fragments have smooth rounded contours with wide
radiolucent gaps between them. Scintigraphic assess-
Figure 15.4 T2*‐weighted frontal plane magnetic resonance ment may also be helpful to distinguish true fractures
image with fat saturation of a right fore navicular bone with a from separate centers of ossification. The presence of
comminuted fracture with an inverted Y‐shaped configuration.
degenerative bone changes such as cyst formation along
the lines of separation between the main fragments indi-
Although multipartite navicular bones (Figure 15.5) cates a fracture with persisting instability of the bone,
have been reported only sporadically in recent and is a potential cause of navicular bone lameness. The
years,3,4,14,26,41 the mention of bilateral fractures with histologic appearance of multipartite navicular bones
minimal lameness in older reports suggests that this closely resembles that of healing by fibrous union in
www.ajlobby.com
chronic navicular fractures.42 However, radiographically been proposed that neurectomy may predispose to
evident multipartite navicular bones do not have a his- fracture by overcoming the proprioceptive protection

tory of acute severe lameness, which makes the diagnosis normally afforded to the navicular bone, and thus making
of fracture very unlikely in these horses. uncoordinated movement of the supporting structures in
the foot more likely.9
Pathologic fractures of the navicular bone may also
Etiology occur following sepsis from a puncture wound into the
navicular bursa and the development of osteomyelitis of
Complete navicular bone fractures generally arise as a the navicular bone.22,26,28
consequence of acute, blunt trauma.9,10 Trauma may
consist of kicking the stall wall, slipping from a ramp, or
landing on a hard object. Rarely is the precise nature of Clinical Signs
the injury known. One author reported on two horses
with a foot stuck in a tramway line and another horse Clinical signs associated with complete navicular bone
stumbling in a pothole.16 The exact mechanism by which fractures may be dramatic and typical of a fracture,
mechanical forces overcome the structural integrity of although there is usually no heat or swelling to help
the bone remains unclear. It has been speculated that localize the problem. Most reports agree that lameness is
sudden violent pressure exerted via the middle phalanx sudden in onset and severe in character, either during
in a palmar direction onto the center of the navicular exercise or following some traumatic episode. In some
bone, while the navicular collateral ligaments and the cases, severe symptoms may not appear until a few
distal sesamoidean impar ligament are loaded during hours after the traumatic incident. In one study, h owever,
weight bearing, may result in sagittal fracture of the 12 of 25 horses with navicular bone fracture were pre-
navicular bone at its weakest point.42 Others have blamed sented with mild, chronic foot lameness, while fractures
asymmetric pressure of the deep digital flexor tendon on were identified in another 6 of 25 horses as part of a radi-
the palmar surface of the navicular bone during simulta- ographic screening protocol in sound horses.18 This may
neous torsion and extension of the distal interphalangeal illustrate that the lameness grade does not always help to
joint (DIP).45 As with many other fractures, the etiology distinguish multipartite navicular bones from chronic
is likely to be associated with acute uncoordinated move- fractures that have developed fibrous nonunion. In the
ment of structures in the foot relative to each other.48 acute period, horses are reluctant to place their full
However, at least one report describes 18 of 25 horses weight on the heel of the foot and may prefer to point the
with navicular bone fractures presenting with no or only affected foot forward. The amplitude of the digital pulses
mild chronic lameness and without a known history of is usually increased. Application of hoof testers is fre-
trauma. The authors rejected the theory of acute, severe quently resented, especially when pressure is applied to
traumatic fracture and proposed the possibility of the frog or when the heels are squeezed together,
“spontaneous fractures,” where sagittal “separations” in although this may vary between horses. Percussion of
the integrity of the bone develop inconspicuously, the frog is generally painful. Lower limb flexion tends to
without displacement or disturbance of the articular and be painful. These local pain responses will gradually
flexor surfaces of the bone.19 diminish with time and may all but disappear after
Many authors speculate that fractures may also occur several weeks or months. Lameness tends to improve
secondary to pathologic bone demineralization associ- reasonably quickly, after one to two weeks of rest, and
ated with navicular disease,17,24,26,36,37 especially in the may be merely mild to moderate, noticeable only when
forelimbs.2 This was not supported by other investiga- the horse is turned in the direction of the affected foot.
tors,1,9,22,42,45 who found no evidence of preexisting After two to three months, lameness may be solely visi-
navicular disease in their patients. It has been argued ble when the horse is trotted. The lack of specific clinical
that navicular bone fractures should be seen more signs and the improvement with rest may cause a delay in
frequently if navicular bone degeneration plays a signifi- the diagnosis of a fracture and thus significantly affect
cant role in the pathogenesis.47 This confusion about the outcome.9 Reported mean times to presentation
preexisting navicular bone degeneration may have arisen range from 45 days22 to 4.3 months.2 In one study, five
because prominent lucent zones develop rapidly along horses with a mean time to presentation of 90 days
the fracture line and the distal border of the navicular were only mildly lame at the trot (grade 2 out of 5), while
bone following the fracture, and may be present at the lameness in other horses with shorter times to presenta-
time of delayed radiographic diagnosis.12,41 tion ranged from grades 3 to 5 out of 5. As the affected
Several authors report navicular bone fractures in horses foot will frequently be rested continuously, it can become
that have undergone palmar digital neurectomy.1,9,45 It has overgrown and narrow at the heels with time.
www.ajlobby.com
Clinical signs associated with distal border fragments visible on a traditional skyline view, and lesion‐oriented
are nonspecific and identical to any other cause of chronic, oblique skyline projections may be n ecessary to clarify
mild to moderate foot lameness of insidious onset. the fracture configuration. Fresh fractures will show a
clean, well‐demarcated fracture line, although in time
this broadens and develops indistinct margins due to
Diagnosis mineral resorption and displacement. As these fractures
heal by fibrous union, there will be no evidence of filling
The diagnosis of fracture is based on history, local signs of the fracture gap, but new bone can often be seen on
of pain, results of diagnostic anesthesia, and radiographic the proximal surface of the navicular bone. Typical signs
examination. of delayed union are visible within a few months, includ-
Lameness is usually improved substantially following a ing absence of bony callus, and irregularity and increased
palmar/plantar digital nerve block, although minor width of the fracture line. The fracture line will generally
residual lameness is common. This may be either due to remain visible for the duration of the horse’s life.1,22,42,45,47
the severity of the acute lameness, or because of concur- A substantial proportion of horses will develop osteoar-
rent inflammation of the DIP joint, which may not be thritis of the DIP joint as a consequence of the intraar-
entirely desensitized with a palmar/plantar digital nerve ticular fracture,12 some as early as six weeks after
block. Under the latter circumstances, a more profound injury.22 The earliest sign of osteoarthritis consists of
response is usually seen following intraarticular analge- osteophyte formation at the level of the extensor process
sia of the DIP joint, a pastern ring block, or an abaxial of the distal phalanx and the dorsoproximal margin of
sesamoid nerve block. It is important, as with all cases of the navicular bone (Figure 15.6). It is important that the
acute severe lameness, to rule out the presence of an lateromedial projection is correctly positioned to allow
incomplete fracture prior to using diagnostic nerve careful s crutiny of these sites, as the concurrent pres-
blocks proximal to the level of the palmar/plantar digital ence of osteoarthritis will influence the choice of treat-
nerve block. In more chronic cases, lameness is less ment and the prognosis.
severe and can be abolished more easily with palmar Fractures must be differentiated from multipartite
digital or abaxial sesamoid nerve blocks. navicular bones; the latter affect both limbs symmetri-
Confirmation of the diagnosis is by radiography.10 cally and have smooth edges and wide radiolucent
A complete set of foot radiographs should be obtained, areas between the bone fragments (see Figure 15.5).33
including a lateromedial projection, a dorsoproximal‐
palmarodistal oblique projection with a horizontal
beam and the foot in a 60° high block (“upright pedal”),
and standing dorsopalmar and palmaroproximal‐
palmarodistal oblique (“skyline”) projections. In the
hindfoot, the upright pedal view may be best obtained as
a plantarodistal‐dorsoproximal oblique projection, with
the xray generator plantar to the foot and receiver on the
dorsum. Fractures are most conspicuous on upright
pedal and skyline views as a radiolucent line within the
body of the navicular bone (see Figure 15.1). Prior to
radiographs, the foot should be cleaned, trimmed, and
the sulci of the frog carefully packed with PlayDoh
(Hasbro, Pawtucket, RI, USA) to avoid linear air arti-
facts, which can strongly resemble the radiographic
appearance of a sagittal fracture. In case of doubt, the
frog clefts need to be repacked. If a suspected fracture
line extends beyond the margins of the navicular bone, it
represents a frog artifact and not a fracture. Moreover,
frog artifacts are only visible on the upright pedal pro-
jection, not on the skyline views. Consequently, a skyline
projection should always be obtained to confirm the
presence of the fracture in those cases where the frac-
ture line can be seen to run in the sagittal plane of the Figure 15.6 Osteoarthritis of the distal interphalangeal joint in a
horse seven weeks after sustaining a sagittal navicular bone
bone on the upright pedal projection (see Figure 15.1). fracture. There are osteophytes at the level of the dorsodistal
When a fracture has an oblique course relative to the surface of the middle phalanx and the dorsoproximal margin of
sagittal plane of the bone, however, it may not always be the navicular bone (arrows).
www.ajlobby.com
While some authors believe that multipartite bones can is sufficiently different from that associated with true
be differentiated from a fracture on the basis of history, fractures, to allow for confident differentiation between
age, and radiographic appearance, others disagree.38 both conditions based on quantitative analysis of radio-
Nuclear scintigraphic examination is generally definitive, nuclide uptake in the navicular bone. Even so, marked
and can often separate multipartite navicular bones from increase associated with sudden‐onset lameness tends to
fractures. Markedly increased radionuclide uptake in the be strongly suggestive of a fracture.
navicular bone in excess of that observed in navicular Distal border fragments can be difficult to identify on
disease is best appreciated on the solar view of the radiographs, especially when the distal border of the
affected foot. Scintigraphy can be particularly useful in navicular bone is projected over the DIP joint space or
horses that present with acute severe “fracture lame- the palmar articular margin of the distal phalanx.
ness,” in which a palmar digital nerve block does not In such cases, the distal border of the navicular bone can
produce unequivocal improvement in the degree of
be projected proximal to the DIP joint space by angling
lameness. Rather than proceeding with more proximal the radiographic beam of the upright pedal projection
nerve blocks, the clinician may consider it safer to per- downward by 10°. True chip fractures are associated
form a nuclear scintigraphic examination in order not to with a marked focal increase in radionuclide uptake at
risk aggravation of a potential incomplete fracture fur- the distal border of the navicular bone.19
ther proximal in the limb. It has been suggested that Although navicular bone fractures can be diagnosed
scintigraphy can also be helpful in differentiating true adequately with radiography, MR imaging has been able
fractures from nontraumatic distal border fragments to show that some fractures result in considerable dam-
(Figure 15.7).35 The degree of radionuclide uptake in age to the deep digital flexor tendon, with longitudinal
multipartite navicular bones has not been reported. tearing and entrapment of torn tendon tissue in the
Judging from the radiographic evidence of remodeling fracture gap (Figure 15.8). Such information may be
changes adjacent to the open fusion lines in multipartite of importance for the choice of treatment and the
navicular bones, however, it is likely that this condition prognosis.
also results in increased, though less marked, radionu-
clide uptake. It remains unknown whether this increase
(A)
(A)
(B)
(B)
Figure 15.8 (A, B) Two consecutive transverse T2*‐weighted

transverse magnetic resonance images with fat saturation of a
navicular bone with a comminuted fracture (the same case as
Figure 15.7 Lateral (A) and solar (B) nuclear scintigraphic views of Figure 15.4). The dorsal surface of the lateral lobe of the deep
the right front foot of a four‐year‐old Quarter Horse obtained two digital flexor tendon opposite the sagittal component of the
weeks after acute‐onset foot lameness. There is increased fracture is irregular as a result of laceration by the sharp margins
radionuclide uptake in the lateral half of the navicular bone. of the fracture. A hypointense lacerated flap of tissue arising from
Radiographs revealed the presence of a lateral parasagittal the dorsal surface of the deep digital flexor tendon protrudes into
fracture. the fracture gap (arrows).
www.ajlobby.com
Pathology may also play a role in the poor healing of navicular

bone fractures include the presence of synovial fluid
Post‐mortem examinations of fractured navicular bones from both adjacent synovial spaces, the lack of progeni-
have documented both the natural healing process tor cells from bone marrow, the absence of periosteum,
and the concurrent involvement of adjacent structures, and the poorly formed endosteum.22,42,45
in particular the deep digital flexor tendon.1,16,42,45,47
The surface of the tendon opposite the fracture line may
be fibrillated, grooved, scored, or lacerated,12 due to Treatment and Prognosis
palmar displacement of one of the fracture fragments
or due to palmar opening of the fracture line. In long‐ Management of complete navicular bone fractures can
standing fractures, chronic inflammation of the peri- either be by rest alone, rest with remedial shoeing
tendineum on the dorsal surface of the deep digital techniques, rest with external coaptation, palmar digital
flexor tendon results in dorsal protrusion of a ledge or neurectomy, or interfragmentary compression with
band of fibrous tissue into the fracture gap.45 These internal fixation.
fibrous adhesions have been described as persisting for
months or years after the fracture,1,45 causing permanent Rest
lameness. One author states that it is important in the
rehabilitation period to elongate or rupture these In analogy with fractures of the distal phalanx, prolonged
adhesions by a constantly increasing exercise load.1 stall rest has been advocated for horses with navicular
It has been stated that osteoarthritis of the DIP joint is bone fractures.22 Duration of stall rest may be an
an inevitable sequel of navicular bone fractures.12,16,45,48 important factor in determining whether the outcome is
However, not all horses with complete fractures of successful. In one report, a minimum of six months of
the navicular bone appear to develop osteoarthritis. stall confinement was recommended, as it took at least
One author observed no degenerative changes in the that long for clinical signs to resolve.22 Two of five horses
articular cartilage of the DIP joint, apart from the frac- in this study were able to return to their intended use,
ture line,42 while another reported healing of the dorsal both Standardbreds that raced at a lower level, with a
(articular) side of the fracture line with cartilage, in return to use after 11 months for one and 24 months for
contrast to widening of the palmar (bursal) aspect of the the other. In an earlier report, three of three horses
fracture.45 remained lame after six months and were euthanized.42
The natural healing process has been characterized as Osseous union has been reported in one horse after a
a fibrous union with an absence of bridging bone. This 13‐month rest period.16 According to another report,
fibrous union generally leads to continued interfrag- satisfactory bony union was achieved in one horse by a
mentary mobility, which can result in necrosis and combination of rest and pulsing magnetic field therapy.7
hemorrhage within the fibrous callus, indicating

reinjury.45 Stable fibrous union has been observed only
occasionally.1 It is generally accepted that the major
Rest and Remedial Shoeing
factors contributing to nonunion of a fracture are inad- Rest can be combined with remedial shoeing in an
equate immobilization, poor vascularity, and distraction attempt to reduce motion at the fracture site. Different
forces.1,16 The collateral distal sesamoidean (navicular types of corrective shoes have been advocated,1,2,19,22,39
suspensory) ligaments attach the wings of the navicular with some including a full bar and quarter clips and all
bone to the distal end of the proximal phalanx, and the including some method of heel elevation. The objective
distal sesamoidean (impar) ligaments attach it to the of quarter clips is to reduce expansion of the heels and
distal phalanx. Between these anchor points, the bone is eliminate the effect of the hoof mechanism during weight
loaded during weight bearing by the middle phalanx bearing. In the authors’ opinion, however, heel expansion
pushing it palmarly (plantarly) against the deep digital is more effectively prevented by a combination of quarter
flexor tendon, resulting in a shear force that acts to dis- clips and a hoof cast placed below the level of the coro-
tract the two navicular fragments.12,45 This repeated nary band, than by quarter clips alone. Heel elevation
motion may be enough to prevent revascularization19 lessens the navicular bone weight‐bearing contact with
and cause chronic reinjury and failure to develop a bony the middle phalanx, while decreasing the strain on the
union.45 The distal artery, a branch of the palmar digital deep digital flexor tendon. Contraction of the heels is an
artery, is the sole blood supply to the central region of expected sequel of remedial shoeing. One author advised
the navicular bone.29 However, it has been shown that 12° heel elevation by means of four 3° wedge pads on a flat
blood flow to fractured navicular bones is actually shoe combined with four months’ stall rest.39 After two
increased rather than decreased.42 Other factors that months, horses could start hand walking 15 minutes daily.
www.ajlobby.com
Horses were reshod each month, at which time one pad this time, treatment with remedial shoeing may allow
was removed, so that at four months they were shod nor- formation of a fibrous callus in the fracture and limit fur-
mally with flat shoes only.39 Four of four horses treated in ther damage to the deep digital flexor tendon from the
this way were able to return to riding exercise without abrasive fracture margins.19,28 Additionally, prolonged
lameness at four months.39 Another study used a bar shoe rest after neurectomy should be considered to allow the
with two quarter clips and heel calkins, and packing fracture to heal while preventing further damage to sur-
under a leather pad.1 The horses were given two months rounding structures from early overuse.16,31 However,
of stall rest and then free paddock turnout. Lunging exer- neurectomy is not without risk, and often ceases to be
cise was introduced at four months with the intent to effective after some time. In one report, lameness
break down fibrous adhesions between the navicular recurred in both horses between four and six months
bone and the deep digital flexor tendon, and overcome following palmar digital neurectomy due to pain arising
persistent lameness. Three of three horses treated in this from the DIP joint.45 Of five horses treated with neurec-
manner returned to their full use free of lameness at six tomy in another study, one returned to pleasure riding
months.1 In two other studies, five of eleven horses after 12 months and remained sound for 8 years, one suf-
were able to return to full use with rest and remedial fered subluxation of the DIP joint, and three experienced
shoeing.2,22 Bony union has not been documented with recurrence of lameness.22 In another study, the severity
remedial shoeing. of lameness decreased in all six horses that underwent
neurectomy, but two remained lame, two suffered recur-
rence of lameness after one year, and two were only suf-
Rest and External Coaptation ficiently sound for light riding.2 The reason for early
Immobilization of the distal limb in a flexed position in recurrence of lameness in most horses with navicular
a fiberglass cast has been proposed to relieve weight‐ fractures that undergo neurectomy is not entirely clear.
bearing stress on the navicular bone.17 According to the While osteoarthritis of the DIP joint certainly develops
author, acceptance of the cast requires exceptional patient in a proportion of cases as a consequence of the intraar-
compliance, but healing can occur after six months. ticular fracture12,16,35,48 (see Figure 15.6), there is little
In spite of this observation, the prognosis for pleasure mention of radiographic or pathologic evidence of osteo-
riding was said to be guarded with this technique.17 arthritis in previous reports. Overuse of the limb with
One report proposed the use of a 5–6 cm high wooden further damage to the deep digital flexor tendon from
wedge, attached to the foot with enough methylmeth- the fracture fragments is another possibility. In these
acrylate (Technovit® 6091, Kulzer, Wehrheim, Germany) cases, ascending tendonitis may affect the deep digital
to fill the entire solar surface. By allowing the methyl- flexor tendon within the digital flexor tendon sheath
methacrylate to set while the foot was non‐weight‐ proximal to the level of desensitization. Occasionally,
bearing, the hoof capsule was immobilized and the hoof continued damage may result in rupture of the deep digi-
mechanism eliminated.19 Subsequently, fiberglass cast- tal flexor tendon and instability of the distal phalanx.
ing tape was used to enclose the foot and wedge, while Long‐term stabilization with casts, splints, or special
staying clear of the coronary band. A 6 cm parallel shoes is required to allow fibrous tissue to bridge the
wooden block was applied to the contralateral foot to fracture gap and provide sufficient support to salvage the
avoid overloading the injured limb. The authors reported horse for pasture turnout only.28
bony union in four horses. They advised against using
this technique when a fracture gap of >5 mm was
present, as this was likely to result in protrusion of deep Internal Fixation
digital flexor tendon fibers into the fracture defect, There is general agreement that the prognosis for
thereby delaying or preventing healing.19 conservative treatment of navicular fractures is guarded
to poor for return to athletic performance.10,12,37
Consequently, it is logical to consider surgical fixation to
Palmar Digital Neurectomy achieve interfragmentary compression. For a long time,
Palmar or plantar digital neurectomy may provide the navicular bone defied attempts at internal fixation
effective desensitization of fractured navicular bones, because of the difficulties of inserting a screw accurately
but is appropriate only in those cases where lameness is into the long narrow bone buried deeply within the
abolished by a palmar digital nerve block. Neurectomy hoof, while avoiding penetration of the DIP joint or
can be used as a primary treatment or an alternative the navicular bursa. In the mid‐1980s, workers from the
treatment in cases that have not responded to conserva- Universities of Utrecht24 and Liverpool47 independently
tive management. Some authors recommend delaying developed drill jigs for inserting a cortical bone screw in
neurectomy for up to three months after injury. During lag fashion into fractured navicular bones.
www.ajlobby.com
Nemeth24 reported on a surgical technique using a structure, holding the foot still and stabilizing the natural
custom designed two‐point C‐clamp to align, direct, and flexibility of the hoof. It also allowed the DIP joint to be
implant a 50 mm long, 3.5 mm cortical screw precisely fixed in an extended position in order to stabilize the
along the transverse axis of the navicular bone of five navicular bone between a taut deep flexor tendon and
horses. The guide system was constructed of metal and the distal and middle phalanges during drilling. A drill
radiolucent nylon and the length of the arms was adjust- guide attached to the base plate was positioned over the
able. The C‐clamp was fixed to the hoof wall using two navicular bone with the help of Polaroid radiography.
3.5 mm threaded drill guides. A 2 mm drill guide could The author pointed out that there is only a 4–5 mm wide
be fitted inside the 3.5 mm drill guides. Fluoroscopy was straight core through which a screw can be placed with-
used to precisely align the drill guide with the long axis of out penetrating either the flexor or articular surface of
the navicular bone and for intraoperative imaging. the navicular bone, and that this straight core becomes
Internal fixation resulted in progressive narrowing of the narrower more proximally in the bone, limiting the screw
fracture zone, and bony union was reported in all five diameter in most horses to 3.5 mm or less. In small
horses. Four of the five horses had returned to work ponies, a 2.5 mm screw may be required. He further
between four months and one year after surgery. reported that the easiest site for screw insertion was
In a similar concept to Nemeth’s report,24 the technique proximally, on the curved portion of the end of the navic-
developed by Wyn‐Jones47 utilized a series of custom‐ ular bone, rather than distally, on the sloping part of the
made drill guides attached to a three‐point C‐clamp, bone. All the cases were given box rest for two months,
positioned on the foot with the help of fluoroscopy. The and walked out in hand for 20–30 minutes twice daily
author reported that accurate screw positioning was from the first day after surgery. The horses were allowed
consistently possible, and that early results in clinical free pasture access from eight weeks after surgery, and
cases had been promising, as long as the fracture was returned to work after four to six months. Follow‐up
acute and there was no evidence of osteoarthritis of the information indicated that 72% of the treated horses
DIP joint.48 were sound and had returned to full work, and 68% were
The largest series of navicular fractures treated by in work for at least three years after surgery.9 In spite of
internal fixation was reported by Colles, who described this high success rate, clinical soundness was often not
the use of a unique, custom‐designed jig for insertion of accompanied by bony union of the fracture. The progno-
a 3.5 mm cortical screw in the navicular bone in 40 horses sis was significantly better for fractures of less than four
(Figure 15.9).9,10 The drill jig was built around a solid weeks’ duration than for older fractures. Laterally located
vertical base plate that was mounted on a radiographic fractures also had a better outcome than those in the
cassette tunnel and to which the ground surface of medial half of the bone. Potential complications of the
the hoof was clamped. The drill guides were mounted on surgery included splitting of the fragment, breakage of a
the top edge of this plate. The base plate provided a rigid screw, inability to reduce the fracture resulting in a step
Figure 15.9 Left front foot positioned in a

(A) (B)
foot clamp with vertical base plate (A) and
radiographic cassette tunnel according to
Colles.6 A standard screwdriver is used
through the drill guide to place a 3.5 mm
cortical screw in lag fashion. The foot is
firmly anchored with the distal
interphalangeal joint in extension (B) in
order to stabilize the navicular bone
between the taut deep flexor tendon and
the distal and middle phalanges during
the procedure. Source: Courtesy of Dr Chris
Colles.
www.ajlobby.com
deformity (Figure 15.10), and poor stabilization of the were placed in lateral recumbency so that the smaller
fracture, possibly due to the failure to provide rotational portion of the fractured navicular bone was uppermost.
stability with one screw.9 We have found it beneficial to perform perineural analge-
More recently, we have reported the results of internal sia of the palmar nerves at the level of the proximal sesa-
fixation in 12 horses with sagittal navicular bone fractures moid bone to allow a lighter plane of general anesthesia.
treated with a modification of Wyn‐Jones’s technique.35 A foot brace mounted on a vertical bar was used to hold
Our fixation system consists of a foot brace to maintain the digit in an extended position throughout the surgery,
DIP joint extension and a custom‐made, three‐point C‐ in order to help reduce the fracture in a dorsopalmar
clamp (Figure 15.11). The C‐clamp accommodates a direction and immobilize it during repair (Figure 15.12).
series of custom‐made drill sleeves that can be positioned Next, the custom‐designed C‐clamp, which has three
directly over the navicular bone under radiographic con- adjustable fixation pins, was fitted over the foot. The
trol. The procedure utilized a specific sequence of steps. upper end of the C‐clamp has a tapped hole for introduc-
First, the foot was thoroughly cleaned by paring the solar tion of the custom‐made 3.5 and 8 mm threaded drill
surface and removing the periople from the hoof wall sleeves, and the lower end contains a targeting sight. A
with a hoof rasp. Hair was clipped up to the level of the fluoroscope was positioned vertically and centered in a
fetlock, and the pastern and foot were scrubbed and lateromedial direction on the navicular bone, so that the
soaked overnight in a sealed impermeable povidone‐ target sight and drill sleeve of the C‐clamp were aligned
iodine antiseptic bandage. At the time of surgery, horses directly over the medullary cavity of the navicular bone
(Figure 15.13). This was the most difficult and time‐con-
suming step of the procedure. An orthogonal view was
also performed to ensure that the clamp was positioned
at the appropriate proximodistal level. Digital radiogra-
phy can be used for the same purpose when fluoroscopy
is unavailable, but carries increased radiation hazard to
the operators. One of the authors (Smith) utilizes digital
radiography preferentially due to enhanced targeting
capabilities compared to fluoroscopy. Radiation protec-
tion is vital for both imaging modalities.
Once the C‐clamp had been accurately positioned, the
fixation pins were screwed into the hoof wall to secure
Figure 15.10 Fluoroscopic intraoperative dorsoproximal‐ the clamp in position. At this point the orientation of
palmarodistal oblique view of the left fore navicular bone the fluoroscope was changed to horizontal to provide a
following insertion of a 3.5 mm cortical screw. Interfragmentary
compression has resulted in distal displacement of the lateral dorsoproximal‐palmarodistal oblique view of the navic-
fragment, with step formation along the proximal border of the ular bone during the rest of the procedure. The 8 mm
navicular bone (arrow). threaded drill guide was then screwed into the upper
Figure 15.11 Custom‐made three‐point

C‐clamp with two custom‐made threaded
drill guides. (A) Fixation pins to anchor the
clamp in the hoof wall; (B) targeting sight
on far side of the C‐clamp; (C) threaded
hole on the near side of the C‐clamp;
(D) threaded 8 mm drill guide; and (E)
threaded 3.5 mm drill guide with 8 mm tip.
www.ajlobby.com
Figure 15.13 Lateromedial fluoroscopic image of the navicular

bone with the near‐side drill sleeve hole and the far‐side target
sight aligned directly over the center of the medullary cavity of
the navicular bone. As the C‐clamp is perfectly aligned, drilling
can commence.
Figure 15.12 A foot brace mounted on a vertical bar holds the

digit in an extended position during repair. A fluoroscope is
positioned vertically to produce a perfect lateromedial image of
the navicular bone during positioning of the C‐clamp.
end of the C‐clamp and an 8 mm hole drilled through

the hoof wall, the sensitive laminae, and the ungular
cartilage to the extremity of the navicular bone. Following
removal of the 8 mm drill guide, the 3.5 mm threaded
drill guide was screwed into the C‐clamp to fit with its
tapered, customized 8 mm tip into the 8 mm hoof wall
defect. A 3.5 mm drill was used to create the glide hole
that extended slightly across the fracture gap, as deter-
mined by fluoroscopic guidance (Figure 15.14). The
2.7 mm drill sleeve was then inserted into the custom‐
made threaded 3.5 mm drill guide and the 2.7 mm pilot
hole drilled to the far end of the navicular bone. Due to
the length of the drill sleeves, an extra‐long 2.7 mm drill
bit was required to reach the far side of the navicular
bone. The threaded drill guide was unscrewed from the
C‐clamp and the glide hole countersunk at the surface of
the navicular bone entry point. A depth gauge was used
to measure the total length of the drill hole and the
distance from the outer surface of the hoof wall to the
extremity of the navicular bone. A standard 3.5 mm tap
was used to tap the pilot hole. The appropriate‐length Figure 15.14 The three‐point C‐clamp is positioned and anchored
3.5 mm cortical screw was then selected, inserted, and on the foot. A standard 3.5 mm drill is used through the custom‐
tightened. The hole in the hoof wall was lavaged made threaded 3.5 mm drill sleeve to create the glide hole.
www.ajlobby.com
and packed with amikacin‐soaked gauze or gentamicin‐ with sepsis. Reduction was achieved in all cases, but was
impregnated cold‐setting methylmethacrylate bone often not considered complete in the more chronic
cement (DePuy CMW3 Gentamicin, DePuy, Johnson fractures. Radiographic follow‐up evaluation was

and Johnson, Warsaw, IN, USA) which was sealed to the available in eight horses. Incomplete bony union was
surrounding hoof capsule with superglue. The hoof was observed in five of eight horses and a flexor cortex defect
bandaged and the foot bandage covered with an impervi- developed in one other horse (Figure 15.16). Long term
ous layer. Postoperative antimicrobials were provided for follow‐up, ranging from one to nine years after surgery,
five days, and radiographs were taken to ensure accurate was available for eight horses. Four horses were sound
placement of the screw and to assess the degree of reduc- and returned to full work, while four other horses were
tion. The foot bandage was changed every two to three considered pasture sound but exhibited intermittent
days until it was felt that the hole in the hoof wall was lameness. None had been euthanized.
sealed with granulation tissue and a dry layer of superfi- The technique of screw fixation with a three‐point
cial keratinization. Horses were rested in a stall for three C‐clamp was recently compared with computer‐assisted
months and allowed free paddock turnout for an addi- surgery for insertion of 3.5 mm cortical screws into the
tional three months. A bar shoe with quarter clips was navicular bone of cadaver limbs.18 The computer‐
applied prior to paddock turnout. Following this time, assisted navigation system consisted of an isocentric
exercise was gradually resumed. C‐arm fluoroscope (Siremobil® Iso C3d, Siemens Medical
In horses with large feet (diameter of 7 in. or more), a Solutions, Erlangen, Germany), a navigation computer
4.5 mm screw can be used to achieve better interfrag- (Sun Microsystems, Mountain View, CA, USA), and
mentary compression. However, as our custom‐built an optoelectronic system (Medivision, Oberdorf,
three‐point C‐clamp only allows insertion of 3.5 mm Switzerland), with an optoelectronic infrared camera
screws, a different drill guide must be used. The DePuy (Optotrak® TM 3020, Northern Digital, Waterloo, ON,
Synthes Combined Aiming Device (DePuy Synthes Canada) and infrared light‐emitting diode markers for
Catalog #130.30, DePuy Synthes Inc., West Chester, PA, tracking the surgical instruments. Together, these com-
USA) is an adjustable two‐point C‐clamp that can be ponents work like a global positioning system. The sys-
positioned on the hoof in a similar manner, and has been tem software SurgiGATE 1.0 (Praxim‐Medivision,
used successfully by the authors to repair navicular bone Grenoble, France) offers different modes for planning,
fractures in large horses following the same sequence of alignment, verification, guidance, and real‐time imaging.
surgical steps (Figure 15.15). The authors concluded that computer‐assisted naviga-
Screws were accurately placed in all fractures, with no tion improved the precision of screw placement com-
screws entering either the DIP joint or navicular bursa.35 pared with the use of the three‐point C‐clamp as a drill
None of the 12 cases suffered complications associated guide. The most common errors of screw insertion were
Figure 15.15 The adjustable Combined Aiming Device (DePuy Synthes catalog #130‐30). This two‐point C‐clamp can be attached to the
hoof wall and allows insertion of a 4.5 mm cortical screw in the navicular bone of horses with large‐diameter feet.
www.ajlobby.com
(A)
(B)
Figure 15.17 Left fore navicular bone of a ten‐year‐old Peruvian

Figure 15.16 Two navicular bone fractures radiographed six to Paso stallion, who remained markedly lame six months after
eight months after surgery. Both horses were sound at the time of insertion of a 3.5 mm cortical screw. The screw position is too
the follow‐up examination. While the top navicular bone (A) was oblique, with several consequences: the head of the screw
considered to have developed a fibrous union, the fracture line is interferes with the palmar aspect of the lateral condyle of the
hard to discern in the bottom navicular bone (B), which has middle phalanx and has caused a focal area of bone resorption
formed a bony union. (black arrow); and there is a large defect in the palmar cortex of the
navicular bone due to bone resorption at the fracture line, possibly
caused by the lack of effective interfragmentary compression.
penetration of the distal border, disruption of the dorsal
articular surface, and dorsal protrusion of the screw head
(Figure 15.17). There was no difference in operating time intrathecal injections. Surgical removal of distal border
to screw insertion between either system.18 fragments has so far not been possible due to the inabil-
ity to access the distal reaches of the navicular bursa with
surgical instrumentation.
Treatment of Chip Fractures There is no satisfactory treatment for chip fractures of
the wings of the navicular bones, and palmar digital neu-
It is likely that distal border fragments form a poorly rec- rectomy may be the only satisfactory course for horses
ognized subcategory in the navicular disease complex. intended for return to athletic performance. The authors
There are strong indications that these fragments cause have successfully treated one such horse with a unilateral
lameness in their own right.44,46 Treatments used for navicular suspensory desmotomy ipsilateral to the side
classical navicular disease may also be helpful in resolv- of the chip fracture.
ing lameness associated with these fragments.
Corticosteroids such as methylprednisolone acetate
(Depo Medrol; 40 mg) or triamcinolone acetonide Treatment of Multipartite
(Kenalog® 10, Bristol‐Myers Squibb, New York, USA; Navicular Bones
6–10 mg), with or without added sodium hyaluronate
(Hylartin® V, Pfizer), can be administered into the DIP Lameness associated with multipartite navicular bones
joint or navicular bursa to suppress osseous inflamma- may be manageable with rest and limited turnout, as well
tion at the level of the “fracture bed” in the distal border as judicious medication with nonsteroidal anti‐
of the navicular bone.11,43,44,46 Following injection, the inflammatory drugs. Horses with multipartite navicular
horse should be rested for six to eight weeks, with bones may be able to enjoy limited use for trail‐riding
limited hand walking prior to resuming normal exercise. or hacking, but more strenuous exercise often leads to
A palmar digital neurectomy may be indicated to resolve recurrent lameness. Long‐term soundness can only be
chronic lameness in horses that are unresponsive to achieved with a palmar digital neurectomy.
www.ajlobby.com
Conclusions We regard internal fixation as the treatment of choice

for simple complete fractures, especially when recent.
Diagnosis of this relatively rare fracture can be challeng- Early intervention results in better reduction because of
ing because of minimal localizing signs. Radiography limited bone resorption and has a protective effect
confirms the presence of most fractures, although simple against the development of osteoarthritis. Should lame-
complete fractures, amenable to internal fixation, need ness persist after fracture repair, palmar digital neurec-
to be differentiated from multipartite navicular bones. tomy can still be considered.
References
1 Arnbjerg, J. (1979). Spontaneous fracture of the navicular (ed. M.W. Ross and S.J. Dyson), 304–305. Philadelphia:
bone in the horse. Nord. Vet. Med. 31: 429–435. WB Saunders.
2 Baxter, G.M., Ingle, J.E., and Trotter, G.W. (1995). 13 Dyson SJ. Comparison between radiological and
Complete navicular bone fractures in horses. In: magnetic resonance imaging lesions in the distal border
Proceedings of the American Association of Equine of the navicular bone with particular reference to distal
Practitioners, vol. 41, 243–244. Lexington, KY: AAEP. border fragments and osseous cyst‐like lesions. 2010;
3 Behrens, E. and Illesca, J. (1990). An unusual lameness Personal communication.
case: a case report. J. Equine Vet. Sci. 10: 53–54. 14 Feeney, D.A., Booth, L.C., and Johnston, G.R. (1980).
4 Benninger, M.I., Deiss, E., and Ueltschi, G. (2005). Tripartite navicular bone and navicular disease in a
Bipartite distal phalanx and navicular bone in an horse. J. Am. Vet. Med. Assoc. 177: 644–646.
Andalusian stallion. Vet. Radiol. Ultrasound 46: 69–71. 15 Frecklington, P.J. and Rose, R.J. (1981). An unusual case
5 Biggi, M. and Dyson, S. (2011). High‐field magnetic of fracture of the navicular bone in the hindlimb of a
resonance imaging investigation of distal border horse. Aust. Vet. Pract. 11: 57–59.
fragments of the navicular bone in horses with foot 16 Freudenberg, F. (1959). Uber Spontanfracturen des
pain. Equine Vet. J. 43: 302–308. Strahlbeins beim Pferd. (Spontaneous fracture of the
6 Biggi, M. and Dyson, S. (2012). Distal border fragments navicular bone in the horse.). Dtsch. Tieraerztl.
and shape of the navicular bone: radiological evaluation Wochenschr. 66: 57–61.
in lame horses and horses free from lameness. Equine 17 Furst, A. and Lischer, C. (2006). The foot. In: Equine
Vet. J. 44: 325–331. Surgery, 3e (ed. J.A. Auer and J.A. Stick), 1184–1217.
7 Boening, K.J. (1983). Behandlung einer Strahlbeinfraktur Philadelphia: PA, Saunders.
beim Pferd mit dem pulsierenden Magnetfeld 18 Gygax, D., Lischer, C., and Auer, J.A. (2006). Computer‐
(MF‐Therapie) (Treatment of a navicular bone fracture assisted surgery for screw insertion into the distal
in the horse with pulsing magnetic field therapy). sesamoid bone in horses: an in vitro study. Vet. Surg.
Tierarztl. Prax. 11: 483–486. 35: 626–633.
8 Claerhoudt, S., Pille, F., Vanderperren, K. et al. (2011). 19 Hertsch, B. and Koenigsmann, D. (1993). Die
Association between navicular bone fragmentation and Sagittalfrakturen des Strahlbeines beim Pferd – ein
shape in Belgian Warmblood horses. Vet. Comp. Beitrag zur Diagnose und Therapie (Sagittal fractures
Orthop. Traumatol. 24: 132–136. of the navicular bone in the horse – contribution to
9 Colles, C.M. (2001). How to repair navicular bone diagnosis and treatment). Pferdeheilkunde 9: 3–13.
fractures in the horse. In: Proceedings of the American 20 Kaser‐Hotz, B., Ueltschi, G., and Hess, N. (1991).
Association of Equine Practitioners, vol. 47, 270–278. Navicular bone fracture in the pelvic limb of two
Lexington, KY: AAEP. horses. Vet. Radiol. 32: 283–285.
10 Colles, C.M. (2011). Navicular bone fractures. Equine 21 LaFosse, E.G. (1754). Observations et decouvertes faites
Vet. Educ. 23: 255–261. sur des chevaux avec une nouvelle pratique sur la
11 Dabareiner, R.M., Carter, G.K., and Honnas, C.M. ferrure (Observations and discoveries in horses with a
(2003). Injection of corticosteroids, hyaluronate, and new practice on shoeing). Paris: Hochereau le Jeune.
amikacin into the navicular bursa in horses with signs 22 Lillich, J.D., Ruggles, A.J., and Gabel, A.A. (1995).
of navicular area pain unresponsive to other Fracture of the distal sesamoid bone: 17 cases
treatments: 25 cases (1999–2002). J. Am. Vet. Med. (1982–1992). J. Am. Vet. Med. Assoc. 207: 924–927.
Assoc. 223: 1469–1474. 23 Marolt, J., Pajtl, M., Geres, V., and Andrasi, N. (1962).
12 Dyson, S. (2003). Fracture of the navicular bone. In: Ueber aseptische Fracturen des normalen und
Diagnosis and Management of Lameness in the Horse veraenderten Strahlbeines beim Pferd (Aseptic
www.ajlobby.com
fractures of normal and altered navicular bones in the In: Proceedings of the American Association of Equine
horse). Dtsch. Tieraerztl. Wochenschr. 69: 133–135. Practitioners, vol. 17, 129–131. Lexington, KY: AAEP.
24 Nemeth, F. and Dik, K.J. (1995). Lag screw fixation of 36 Smythe, R.H. (1961). Fractures of the navicular bone.
sagittal navicular bone fractures in 5 horses. Equine Vet. Rec. 73: 1009.
Vet. J. 17: 137–139. 37 Stashak, T.S. (2002). Navicular (distal sesamoid) bone
25 Poulos, P.W., Brown, A., Brown, E., and Gamboa, L. fractures. In: Adams’ Lameness in Horses, 5e (ed. T.S.
(1989). On navicular disease in the horse. Vet. Radiol. Stashak), 680–682. Baltimore: Lippincott, Williams and
30: 54–58. Wilkins.
26 Reeves, M.J., Yovich, J.V., and Turner, A.S. (1989). 38 Toal, R.L. (2002). The navicular bone. In: Textbook of
Miscellaneous conditions of the equine foot. Vet. Clin. Veterinary Diagnostic Radiology, 4e (ed. D.E. Thrall),
North Am. Equine Pract. 5: 221–242. 295–305. Philadelphia: W.B. Saunders Co.
27 Richter, W. (1988). Strahlbeintransversalfraktur 39 Turner, T.A. and Malone, E. (1997). How to treat
(Transverse fracture of a navicular bone). Monatsh. Vet. navicular bone fractures. In: Proceedings of the
Med. 43: 808–809. American Association of Equine Practitioners, vol. 43,
28 Rick, M.C. (1990). Navicular bone fractures. In: 370–371. Lexington, KY: AAEP.
Current Practice of Equine Surgery (ed. N.A. White and 40 van de Watering, C.C. and Morgan, J.P. (1975). Chip
J.N. Moore), 602–605. Philadelphia, PA: Lippincott. fractures as a radiologic finding in navicular disease of
29 Rijkenhuizen, A.B., Németh, F., Dik, K.J., and the horse. J. Am. Vet. Radiol. Soc. 16: 206–210.
Goedegebuure, S.A. (1989). Development of the 41 van der Zaag, E.J., Weerts, E.A., van den Belt, A.J., and
navicular bone in foetal and young horses, including Back, W. (2016). Clinicopathological findings in horses
the arterial supply. Equine Vet. J. 21: 405–412. with a bi‐ or tripartite navicular bone. BMC Vet. Res.
30 Ruohoniemi, M. and Tervahartiala, P. (1999). 12 (74).
Computed tomographic evaluation of Finnhorse 42 Vaughan, L.C. (1961). Fracture of the navicular bone in
cadaver forefeet with radiographically problematic the horse. Vet. Rec. 73: 895–897.
findings on the flexor aspect of the navicular bone. 43 Verschooten, F., Desmet, P., Peremans, K., and Pivavet,
Vet. Radiol. Ultrasound 40: 275–281. T. (1990). Navicular disease in the horse: the effect of
31 Schleiter, H. and Dietz, O. (1957). Spontanfracturen des controlled intrabursal corticoid injection. J. Equine Vet.
Strahlbeines und Strahlbein‐Luxation beim Pferd Sci. 10: 316–320.
(Spontaneous fractures and luxation of the navicular 44 Verschooten, F., Pannekoek, M., De Clercq, T. et al.
bone in the horse). Berl. Muench. Tieraerztl. (2002). Osteochondral fragments at the distal border of
Wochenschr. 70: 409–411. the navicular bone: radiographical and clinical
32 Schmal, W. (1937). Über Strahlbeinfrakturen beim significance. In: Proceedings of the American
Pferd (Navicular bone fractures in the horse). Berl. Association of Equine Practitioners, vol. 9, 65.
Muench. Tieraerztl. Wochenschr. 39: 596. Lexington, KY: AAEP.
33 Schneider, R.K. and Stickle, R.L. (1987). Distal 45 Wintzer, H. and Daemmrich, K. (1967). Ueber
sesamoid fractures. In: Current Therapy in Equine Strahlbeinfracturen beim Pferd (Navicular bone
Medicine, 2e (ed. E. Robinson), 285. Philadelphia: W.B. fractures in the horse). Schweiz. Arch. Tierheilkd. 109:
Saunders Co. 487–496.
34 Schramme, M.C., Murray, R.M., Blunden, T.S., and 46 Wright, I., Kidd, L., and Thorp, B. (1998). Gross,
Dyson, S.J. (2005). A comparison between magnetic histological and histomorphometric features of the
resonance imaging, pathology and radiology in 34 navicular bone and related structures in the horse.
limbs with navicular syndrome and 25 control limbs. Equine Vet. J. 30: 220–234.
In: Proceedings of the American Association of 47 Wyn‐Jones, G. (1985). Fractures of the equine navicular
Equine Practitioners, vol. 51, 348–358. Lexington, bone. Vet. Annu. 25: 201–210.
KY: AAEP. 48 Wyn‐Jones, G. (1988). Fractures of the navicular bone.
35 Smith, R.K., Schramme, M.C., Archer, R.M., and May, In: Equine Lameness (ed. G. Wyn‐Jones), 241–245.
S.A. (2007). Surgical repair of navicular bone fractures. Oxford: Blackwell Scientific Publications.
www.ajlobby.com
257
16
Arthrodesis of the Distal Interphalangeal Joint
Chad J. Zubrod1 and Robert K. Schneider2
1
Oakridge Equine Hospital, Edmond, OK, USA
2
McKinlay Peters Equine Hospital, Newman Lake, WA, USA
Introduction The collateral ligaments of the DIP joint are located at

the dorsomedial and dorsolateral aspects of the joint
Although lameness associated with the coffin joint is a and limit the principal motion to flexion and extension
relatively common problem in performance horses, indi- in a sagittal plane. Shear and torsional forces are limited
cations for arthrodesis of the distal interphalangeal (DIP) by the collateral ligaments, and by the navicular bone
joint in horses are infrequent. Severe osteoarthritis, and its associated ligaments. The DIP joint capsule has a
injury to the collateral ligaments that results in joint large dorsal pouch under the extensor tendon and an
instability, rupture of the deep digital flexor tendon, extensive palmar/plantar pouch that can extend proxi-
septic arthritis, or chronic articular fractures can all
mally to almost the level of the proximal interphalangeal
cause chronic pain, making affected horses candidates joint when distended. The large joint pouches allow
for arthrodesis of the DIP joint (Figure 16.1).7,8 arthroscopic exploration even though the joint is encased
Arthrodesis of the joint should be considered when the in the hoof capsule.
lameness is unresponsive to other therapies and the Anatomically, there is a relatively small area of the
horse is bearing less than 50% of its normal weight on distal phalanx that will hold implants, and the hoof

the affected limb. Arthrodesis is considered at this capsule and lamina limit our ability to utilize dynamic
time in order to minimize the risk of contralateral limb compression plates (DCPs) to counteract the forces
laminitis. acting on this joint. The dorsal half of the articular s urface
Successful arthrodesis of the DIP joint of the horse pre- of the distal phalanx has sufficient bone density to with-
sents numerous challenges. Because it is a high‐motion stand the forces of internal fixation. The hoof capsule
joint, rigid internal fixation or prolonged external coap- encompasses the distal phalanx on all but the most proxi-
tation is necessary to allow bone to bridge the DIP joint. mal surfaces. Given this, the DIP joint must be approached
Rigid internal fixation is ideal; however, cases of sepsis or from the proximal aspect, or by traversing the hoof wall.
comminuted fracture may necessitate some variation of
prolonged external coaptation. The location of the DIP
joint within the hoof capsule presents additional chal- Arthrodesis Surgery
lenges for gaining access to the joint, and for creating an
aseptic environment in which to place implants. Surgery is performed with the horse in lateral recum-
bency with the affected leg uppermost. The limb should
be clipped from the coronary band to the proximal
Anatomy metacarpal/metatarsal region and the surface of the

hoof wall debrided with a rasp or sander. The sole of the
The DIP joint is a complex articulation composed of hoof should be thoroughly cleaned, scrubbed, and dried,
three bones: the middle and distal phalanges, and the and then covered with a latex glove that is adhered to
navicular bone. The primary load‐bearing articulation is the hoof wall with cyanoacrylate. The surgical site is
between the middle and distal phalanges; each of these aseptically prepared for surgery. The horse is adminis-
phalanges also articulates with the navicular bone. tered broad‐spectrum perioperative antimicrobials, and

www.ajlobby.com
(A) (B) Figure 16.1 Dorsopalmar (A) and

lateromedial (B) radiographs showing
severe joint collapse of the distal
interphalangeal (DIP) joint secondary to
chronic instability. Severe osteoarthritis is
an indication for arthrodesis of the
DIP joint.
nonsteroidal anti‐inflammatories. The distal limb is band.2 A synovial resector is used to remove the prolif-
routinely draped with an adhesive drape placed over erative synovium, and the articular cartilage is removed
the surgery site and bound to the latex glove enclosing with a motorized burr. Approaching the joint dorsally
the foot. and palmar/plantarly with the arthroscope allows for
The best approach for debridement of the articular car- fairly complete cartilage debridement. More of the artic-
tilage is under arthroscopic guidance, which allows the ular cartilage can be removed under arthroscopic guid-
most thorough cartilage removal.2 A routine arthroscopic ance than through an arthrotomy. Previously, the DIP
approach to the dorsal and palmar/plantar joint pouches joint was approached through a large dorsal incision to
is sequentially performed. The palmar/plantar surfaces debride the articular cartilage.7,8 This method of carti-
are debrided initially. The joint is predistended by insert- lage debridement is no longer recommended by the
ing an 18‐gauge needle into the dorsal pouch of the DIP authors. The arthroscopic approach also saves surgery
joint 2 cm lateral to midline and 3 cm proximal to the time, and incisional problems are less likely, compared to
coronary band. The joint is distended with sterile saline an arthrotomy.
and a 4 mm incision is created in the lateral palmaro/ Our preferred technique for internal fixation is to
plantaroproximal pouch of the joint, as described by utilize three lag screws placed from the palmar/plantar
Vacek et al.9 A conical obturator is used to insert the proximal surface of the middle phalanx and directed
arthroscope cannula into the joint axial to the ungual car- into the dorsoproximal portion of the distal phalanx.
tilage, palmar/plantar to the neurovascular bundle, abax- An 8–10 cm skin incision is made on palmar/plantar,
ial and dorsal to the deep digital flexor tendon and digital midline of the limb, from the proximal sesamoid bones
flexor tendon sheath, and proximal to the distal sesamoid distally to the heel bulbs (Figure 16.2). The incision is
(navicular) bone. The obturator is removed and the continued through the digital annular ligaments and
arthroscope inserted into the joint. Using a 3 in. spinal tendon sheath. Depending on the case, the deep digital
needle to verify accurate placement, an instrument portal flexor tendon is split longitudinally or can be transected,
is created in the same location on the medial side of the to gain exposure to the palmar/plantar surface of the mid-
joint. Visualization can be improved with a synovial dle phalanx. The soft tissues are retracted using a gelpi
resector to remove proliferative soft tissues. The articular retractor. The middle scutum attachment of the straight
cartilage can then be removed on the distal aspect of the distal sesamoidean ligament to the middle phalanx is
middle phalanx, proximal aspect of the distal phalanx (if identified with needles and confirmed with intraopera-
joint laxity exists), and dorsal surface of the navicular tive radiographs or fluoroscopy. A vertical stab incision is
bone with a motorized burr. A 3.85 or 5.5 mm oval or then created on the midline. The DIP joint is reduced and
spherical burr works well for arthroscopic cartilage held in a weight‐bearing position. A 3.2 mm drill bit is
debridement, especially in arthritic joints with severe car- used to drill through the middle phalanx from palmar/
tilage thinning. The arthroscope and instrument portals plantar proximal to dorsal distal, bisecting the distal
can be alternated as necessary to debride as much carti- condylar articular surface of the phalanx into distal

lage as possible. dorsal and palmar/plantar portions (see Figure 16.2).

The dorsal aspect of the joint is then approached, with Positioning is confirmed with fluoroscopy or radiographs
the arthroscope and instrument portals created 2 cm (Figure 16.3). Radiographic control is necessary to ensure
abaxial to midline, and 2 cm proximal to the coronary accurate placement of the drills and the transarticular
www.ajlobby.com
(A)
(B) (C)
Figure 16.2 Illustration showing lag screw fixation of the distal interphalangeal (DIP) joint. (A) Incision through digital sheath and deep
flexor to access the palmar/plantar middle scutum and proximal aspect of the middle phalanx. The direction of drilling is confirmed by
imaging and the first of three 5.5 mm cortical screws is inserted by drilling a 5.5 mm glide hole to the DIP joint space, followed by a 4.0
mm thread hole into the dorsal region of the distal phalanx. Radiographic or fluoroscopic monitoring of drill angle and depth is crucial.
(B) The hole is measured and tapped, and a 5.5 mm screw inserted. A second screw is then inserted alongside in a slightly diverging angle.
(C) The third screw is inserted and all screws are tightened. A cancellous bone graft can be added to dorsal and palmar regions of the joint
by arthroscopically guided delivery through a cannula.
screws that follow. A 4.5 mm drill can be used to make proximal surface of the middle phalanx. The hole is meas-
adjustments in the direction of the hole as necessary ured and tapped in a routine manner and a 5.5 mm corti-
based on radiographs. When the p osition of the 4.5 mm cal bone screw is inserted. Screw placement is c onfirmed
drill is appropriate, a glide hole in the middle phalanx is with fluoroscopy or radiographs (Figure 16.4). It is vital to
then created with a 5.5 mm drill. A drill sleeve insert recognize that this is a blind hole and the screws should
is placed in the 5.5 mm hole, and a 4.0 mm drill is then be sufficiently short to avoid contacting the bottom of the
used to create the thread hole in the distal phalanx. hole. Screws are typically 85–95 mm in length in most
A depth of 30 mm in the distal phalanx is sufficient in adult horses. Two additional screws are placed through
most horses, and avoids penetrating the lamina and hoof the palmar/plantar eminences of the middle phalanx in
wall. It is important to avoid the semilunar canal with the the same manner, one lateral and one medial to the cen-
implants. A countersink is used to create a uniform sur- tral screw (Figures 16.2 and 16.5). Once all three screws
face for the screw head to engage the palmar/plantar are in position, cancellous bone graft is harvested from
www.ajlobby.com
Figure 16.3 Lateral radiograph indicating the placement of the

initial 3.2 mm marker bit for the glide hole in the palmar proximal
aspect of the middle phalanx. Figure 16.5 Dorsopalmar radiograph showing the lateral to
medial spacing of the three transarticular lag screws used to
arthrodese the distal interphalangeal joint.
the ipsilateral tuber coxae and placed into the dorsal and
palmar/plantar recesses of the DIP joint.6 The cancellous
bone graft is placed through the arthroscopy portals using
a forceps and rongeurs, or a large bore egress cannula
with a suitably flat ended obturator. When split longitudi-
nally, the deep digital flexor tendon is apposed with
absorbable suture in a simple continuous pattern. In cases
where the deep digital flexor tendon was transected, the
ends are apposed with absorbable suture in a cruciate pat-
tern or a locking loop pattern. Palmarly/plantarly, the ten-
don sheath is closed with absorbable suture in a simple
interrupted or continuous pattern. Subcutaneous tissue
and skin incisions are closed routinely.
An alternative technique for arthrodesis has also been
described, using transarticular screws placed in a
dorsal–distal to palmar/plantar–proximal direction,

following fenestration of the dorsal hoof wall with a
9.5 mm drill.2 This approach also results in good bone
purchase in the dorsal aspect of the distal phalanx and
palmar/plantar aspect of the middle phalanx. Following
screw placement, the fenestrations in the hoof wall are
filled with antibiotic impregnated polymethylmeth-
acrylate (PMMA) and sealed with cyanoacrylate.
However, this approach results in disruption of the
Figure 16.4 Lateral radiograph showing three 5.5 mm screws
sensitive lamina, and theoretically leads to seating of
placed in a palmar–proximal to dorsal–distal direction to stabilize the head of the screw in the softer trabecular bone of the
the distal interphalangeal joint. distal phalanx, as opposed to dense cortical bone along
www.ajlobby.com
(A) (B) (C)
Figure 16.6 A dorsal locking compression plate (LCP) and transarticular cortical screw combination approach for distal interphalangeal
arthrodesis. (A) Preoperative radiograph showing severe arthritis with joint space collapse and incongruity. (B, C) Radiographs obtained
14 months after surgery showing advancing bony union after LCP application and transarticular screws. Source: Images courtesy Dr. Dean
Richardson.
the proximal perimeter of the middle phalanx. A further in a weight‐bearing position with the fetlock in extension.
variation of the dorsodistal to palmaroproximal tran- A transfixation pin cast can be used to increase weight
sarticular screw technique includes adding a dorsal DCP bearing on the affected limb when n ecessary (Figure 16.7).
or locking compression plate (LCP) to the axial midline The contralateral foot is fitted with impression material
in place of the center of the three cortical screws applied and a support shoe or wooden block to compensate for
in lag fashion (Figure 16.6). The plate is applied to bridge the additional height of the cast and support the bottom
the dorsal surface of the middle and distal phalanges, of the hoof. This encourages bilateral weight bearing and
and the independent lag screws inserted from the dor- improves use of the cast. The cast is changed and sutures
soproximal aspect of the middle phalanx to the palmar- removed at two weeks. The cast is changed every four to
odistal aspect of the distal phalanx. Bony union has six weeks depending on the horse’s comfort in the cast.
been complete in several cases, including one horse Transfixation pin casts are usually maintained for six
being actively ridden. weeks and followed by a standard half limb cast. Casts are
Arthrodesis of the DIP joint can be accomplished with- normally maintained for approximately eight to ten
out internal fixation when infection is present.3,4 In these weeks. Radiographs are taken at 90 days to evaluate the
horses the joint is approached dorsally and palmar/plan- progress of the fusion (Figure 16.8). If bone is present in
tarly with arthroscopy to debride the articular cartilage. the joint space, the horse can begin hand walking. The
The joint is packed with autogenous cancellous bone horse’s use of the limb and progression of the fusion
graft and antibiotic‐impregnated PMMA implants and determine how soon the horse can be turned out in a
the limb is placed in a half limb transfixation pin cast.3,7 small paddock (30 ft by 30 ft/9 m by 9 m). The horse can
The transfixation pin cast can result in substantially more typically be turned out in a small paddock around four
comfort than a standard half limb cast.3 The horse is usu- months following arthrodesis. The horse should not be
ally maintained in a transfixation pin cast for six weeks turned out to pasture until there is mature bone bridging
and then placed in a standard half limb cast for another the joint, which usually takes eight to nine months.
six weeks. The technique of using large cancellous bone Arthrodesis of the DIP joint is complicated by the
grafts and external immobilization to fuse joints in the anatomy and the concentration of weight‐bearing forces
distal limb of the horse has been reported.1 on the distal phalanx in the most distal aspect of the
Other methods for arthrodesis of the DIP joint have limb. For most cases, internal fixation has been limited
been reported; however, the authors do not recommend to lag screws without a dorsal plate, and this construct
these procedures.5 does not always provide rigid immobilization. As a
result, horses are not as comfortable following arthrode-
sis of the DIP joint as they are with other fusion proce-
Postoperative Care dures. This increases the risk of laminitis in the
contralateral limb, especially when the horse has been
Following surgery, the incisions are covered with a sterile treated for an extended time for chronic joint pain prior
nonadherent dressing, and a fiberglass cast is placed on to performing the arthrodesis. The implants in this fixa-
the limb from the carpus/tarsus distally. The limb is cast tion are subject to substantial bending forces which can
www.ajlobby.com
(A) (B) (C)
(D) (E)
Figure 16.7 Severe distal interphalangeal (DIP) instability may be counteracted with a combination of three transarticular cortical screws
and a transfixation cast. (A) Subluxation of the DIP with arthritis. (B, C) Radiographs at two months and (D, E) five months after repair using
transarticular screws and transfixation cast with pins applied in the distal MC3 region. Source: Images courtesy Dr. Jeff Watkins.
result in implant failure. Implant removal is only per- largely dependent on the duration of severe lameness
formed in cases which are complicated by infection. prior to arthrodesis, which can lead to contralateral limb
laminitis, and ultimately failure of the horse to be com-
fortable on one or both limbs. Horses having a DIP joint
Prognosis arthrodesis performed due to joint sepsis also have a
decreased prognosis, as the joint must be arthrodesed
Prognosis for successful arthrodesis of the DIP joint is without internal fixation, and the orthopedic infection
fair for achieving pasture comfort. It is important for must be eliminated. These factors should play an impor-
owners to realize that the horse will have a mechanical tant role in the decision‐making process when consider-
gait alteration even if it is pain free. The prognosis is ing arthrodesis of the DIP joint.
www.ajlobby.com
Figure 16.8 (A) Radiographs showing (A) (B)

preoperative distal interphalangeal joint
collapse and osteoarthritis, treated by
arthrodesis using three cortical
transarticular screws applied in lag manner
from a palmaroproximal approach. (B, C)
Radiographs three months postoperatively
show progressing joint fusion.
(D) Radiographs four months after surgery
show further new bone production and
better foot alignment after shoe
application.
(C) (D)
References
1 Bramlage, L., Holcomb, S., and Embertson, R. (1992). 5 Honnas, C., Vacek, J., and Schumacher, J. (1995).
Surgical technique for massive cancellous bone Arthrodesis of the distal interphalangeal joint in a horse
grafting for the treatment of end‐stage infectious using stainless steel baskets and transarticular 4.5‐mm
arthritis. In: Proceedings American Association cortical screws. Vet. Comp. Orthop. Traumatol. 8: 46–51.
of Equine Practitioners, vol. 38, 129–131. 6 Markel, M.D. (1996). Bone grafts and bone substitutes.
Lexington, KY: AAEP. In: Equine Fracture Repair (ed. A.J. Nixon), 87–93.
Busschers, E. and Richardson, D.W. (2006).
2 Philadelphia: WB Saunders.
Arthroscopically assisted arthrodesis of the distal 7 Schneider, R. (2004). Arthrodesis of the distal
interphalangeal joint with transarticular screws inserted interphalangeal joint of the horse. In: Proceedings
through a dorsal hoof wall approach in a horse. J. Am. American College of Veterinary Surgeons, vol. 33, 82–85.
Vet. Med. Assoc. 228: 909–913. Germantown, MD: ACVS.
Easter, J.L., Schumacher, J., and Watkins, J.P. (2011).
3 8 Schneider, R., Bramlage, L., and Hardy, J. (1993).
Transfixation cast technique for arthrodesis of the distal Arthrodesis of the distal interphalangeal joint in two
interphalangeal joint of horses. Vet. Comp. Orthop. horses using three parallel 5.5‐mm cortical screws.
Traumatol. 24: 62–67. Vet. Surg. 22: 122–128.
Honnas, C., Schumacher, J., and Kuesis, B. (1992).
4 9 Vacek, J., Welch, R., and Honnas, C. (1992).
Ankylosis of the distal interphalangeal joint in a horse Arthroscopic approach and intra‐articular anatomy of
after septic arthritis and septic navicular bursitis. J. Am. the palmaroproximal or plantaroproximal aspect of the
Vet. Med. Assoc. 200: 964–968. distal interphalangeal joints. Vet. Surg. 21: 257–260.
www.ajlobby.com
264
17
Fractures of the Middle Phalanx
Jeffrey P. Watkins
Introduction sesamoidean ligament, and the palmar ligament of the

pastern joint.
The middle phalanx is a short, compact bone interposed The proximal articular surface of the middle phalanx is
between the proximal and distal phalanges. Articulations concave in the dorsal to palmar (plantar) direction and
are formed proximally with the distal end of the proximal forms the trochlea on which the condyle of the proximal
phalanx at the proximal interphalangeal (PIP) joint phalanx articulates. The intimate attachment of the soft
(pastern joint) and distally with the distal phalanx and tissue structures, and the medial and lateral collateral
navicular bone forming the distal interphalangeal (DIP) ligaments and fibrous joint capsule, provide stability
joint (coffin joint). for this articulation. Kinematic analysis of horses at a
Numerous fibrous connective tissue structures overlie trot delineates flexion of the pastern during the initial
and are intimately attached to the middle phalanx. In the stance phase, with peak flexion occurring at 34% of the
forelimb the common digital extensor tendon, and in stance phase of the stride. Pastern extension occurs in the
the hindlimb the long digital extensor tendon, course later portion of the stance phase, peaking at about 65% of
distally over the dorsal aspect of the bone and have their the stance phase. The range of motion from peak flexion
ultimate insertion on the extensor process of the distal to extension reportedly ranges from 24° to 35° and the
phalanx. These tendons are closely adhered to the middle net joint moment is in the palmar aspect of the joint.4
phalanx as well as the dorsal joint capsules of the PIP and Forces acting on the palmar/plantar aspect of the middle
DIP joints. At the level of the PIP joint, the suspensory phalanx during weight bearing are likely complex, with
ligaments of the navicular bone course in a palmar (plan significant tensile forces acting at the palmar/plantar
tar) distal direction from their origin on the dorsodistal aspect of the joint to limit extension. These t ensile forces
aspect of the proximal phalanx to their insertion on the are transmitted to the palmar/plantar eminence of the
abaxial borders of the navicular bone. Proximally these middle phalanx via the insertions of the superficial digital
ligaments are located medial and lateral to the common flexor tendon, superficial distal sesamoidean ligament,
(long) digital extensor tendon and dorsal to the medial and palmar/plantar ligament of the pastern joint and
and lateral collateral ligaments of the PIP joint. On the fibrous joint capsule. If these attachments are disrupted,
palmar/plantar surface, the digital sheath and its con either from avulsion of their insertions or biaxial emi
tents overlie the middle phalanx. Within the digital nence fracture, weight bearing results in palmar/plantar
sheath, the deep digital flexor tendon courses distally to luxation or subluxation of the PIP joint (Figure 17.1).
insert on the solar surface of the distal phalanx. The deep The distal articular surface of the middle phalanx forms
layer of the digital sheath is adhered to the deep soft a condyle which allows flexion and extension at its artic
tissue structures forming the middle scutum, which
ulation with the distal phalanx and the navicular bone.
attach to the palmar/plantar e minences of the middle This joint is contained within the hoof capsule which, in
phalanx. These include the insertions of the superficial conjunction with the periarticular fibrous c onnective tissue
digital flexor tendon, the superficial (straight) distal attachments, contributes to the stability of the region.

www.ajlobby.com
there was a greater prevalence of forelimb injuries.6 The

variable configuration of middle phalangeal fractures
provides insight into the forces responsible for the injury.
Bone failure in tension results in a transverse fracture with
the fracture line oriented perpendicular to the direction of
the tensile forces. Palmar/plantar eminence fractures
generally assume this configuration, presumably second
ary to the tensile forces transmitted via the insertions of
the superficial digital flexor tendon, superficial distal
sesamoidean ligament, and palmar/plantar ligaments of
the pastern joint. Shear forces may also contribute when
distal displacement of the proximal phalanx occurs with
PIP joint extension and the forces of axial compression are
concentrated on the palmar/plantar aspect of the emi
nences. Such injuries might occur during an abrupt sliding
stop in a horse being used for reining competition or calf
roping. Comminuted fractures of the middle phalanx
would be expected to result from more complex forces.
These fractures probably occur when forces generated in
Figure 17.1 Radiograph demonstrating palmar luxation of the bone from axial compression, bending, and torsion
proximal interphalangeal joint subsequent to avulsion injury of occur with the hoof fixed relative to the digit.5 Shoes with
the palmar periarticular soft tissue support structures. caulks or rims intended to augment traction may increase
the risk of these injuries. However, no studies have deline
ated the impact that such devices have on the incidence
E tiology or configuration of middle phalangeal fractures.
Fractures of the middle phalanx are most common in

performing Quarter Horses.4–7,14 The preponderance
of Quarter Horses suggests abrupt stops, alone or in com
Fracture Types
bination with abrupt turns, may be the cause of injury,
Four main fracture configurations are described in mature
due to bending and torsional forces generated within
horses. These are (i) osteochondral chip fracture originat
the digit. These maneuvers are frequently performed by
ing from the axial aspect of the palmar proximal border of
horses engaged in western performance events, as well as
the bone; (ii) uniaxial fracture of the medial or lateral
by polo horses. Colahan et al. noted that the majority of
palmar (plantar) eminence; (iii) biaxial eminence fracture;
these fractures occurred in horses performing western
and (iv) comminuted middle phalangeal fracture.5,8,15,18–20
stock work.5 However, middle phalangeal fractures have
Simple fractures are those involving only the PIP joint,
also occurred during free paddock exercise.5,6
particularly those of the palmar/plantar eminences.
Colahan5 reviewed 47 fractures of the middle phalanx.
Comminuted fractures are characterized by multiple frag
Hindlimbs were fractured three times more commonly
ments and usually involve both the PIP and DIP joints.5
than forelimbs; 38 of these fractures were classified as
comminuted and 9 were palmar/plantar eminence frac
tures. Eminence fractures were found almost exclusively
in the hindlimb. This observation was supported by Palmar Osteochondral Fracture
Martin et al., where 10 of 11 horses with middle phalanx
fractures treated by PIP arthrodesis had caudal eminence Palmar osteochondral fractures have been reported infre
fractures affecting a hindlimb.14 Colahan found that quently.17,18,21 Based on their location, they appear to be
comminuted fractures were four times more prevalent partial avulsion injuries of the fibrous connective tissue
than caudal eminence fractures.5 Of the 38 comminuted attachments to this region, and probably occur secondary
fractures reported, 26 involved a hindlimb and 12 to hyperextension of the PIP joint. These fractures have
involved the forelimb. Fractures in the forelimb were been reported as a cause of lameness in Quarter Horses
more often comminuted, with 76% of hindlimb and 92% and Thoroughbred race horses.17,18,21 Palmar osteochon
of forelimb fractures being comminuted. Of the middle dral fragments have also been identified as an incidental
phalangeal fractures presented to the Texas Veterinary finding and careful evaluation of the patient is necessary
Medical Center, the majority of which were comminuted, to ascertain the significance of fragments in this location.
www.ajlobby.com
Anesthesia of the PIP joint will aid in determining if the Biaxial Palmar (Plantar) Eminence Fractures
fragment is of clinical importance. In most cases reported
in the literature, lameness resolved following anesthesia When distractive forces of sufficient strength are super
of the PIP joint.17,18,21 imposed on severe axial compression, biaxial palmar
Removal of palmar osteochondral fragments causing (plantar) eminence fractures of the middle phalanx may
lameness is recommended.17,18,21 The fragment can be occur. These fractures extend from near the junction of
removed from the palmar/plantar pastern via the digital the middle and palmar/plantar thirds of the articular
sheath,17,21 or using a direct palmar/plantar pouch arthro surface to the distal aspect of the palmar (plantar) emi
scopic approach.18 For the digital sheath approach, retrac nences. The fracture line often extends completely across
tion of the deep digital flexor tendon will expose the the bone in the frontal plane, separating the medial and
fibrous connective tissue attachments to the proximal lateral eminence as a single fragment from the parent
aspect of the middle phalanx. Using radiographic control, middle phalanx (Figure 17.2). Fragment displacement
the fragment is identified and dissected free. The arthro results from distraction by the superficial distal sesa
scopic approach via the PIP palmar or plantar pouch uses moidean ligament and superficial digital flexor tendon,
an instrument portal opposite the arthroscope entry, with and collapse of the proximal phalanx into the fracture
dissection of the fragment from attached soft tissues.18 line. Loss of palmar (plantar) support of the PIP joint
Intraoperative radiographs are necessary to confirm com results in palmar (plantar) luxation. The degree of PIP
plete fragment removal prior to reconstruction of the joint luxation and distal displacement of the proximal
overlying soft tissues. Following six to eight weeks of con phalanx will vary according to the severity of the initial
finement, controlled exercise can be resumed, with return injury and attempts by the horse to bear weight on the
to performance anticipated four to six months postopera limb before emergency coaptation is applied.
tively. In most cases reported, the affected horses returned Clinical signs include non‐weight‐bearing lameness
to their previous use following fragment removal.18 and palmar/plantar pastern instability. Manipulation of
the hoof induces pain and crepitation may be evident.
Swelling of the overlying soft tissues will be present, but
not dramatic, due to the close adherence, and the limited
Fractures of the Palmar amount and elasticity, of soft tissues covering the area.
(Plantar) Eminences These fractures are usually closed, since displacement
When the PIP joint is subjected to severe bending
forces directed in a palmar/plantar direction, extension
of the joint is opposed by the relatively inelastic
palmar/plantar connective tissues. If the forces of exten
sion are great enough, failure of these fibrous tissue
attachments (see Figure 17.1), or more commonly frac
ture of the palmar/plantar eminences of the middle
phalanx, may occur. Eminence fractures may be either
uniaxial or biaxial. With most uniaxial fractures, stabil
ity of the PIP joint is not compromised. Fragment size
varies from large osseous fragments, considered suita
ble for internal fixation by some authors, to smaller chip
fractures. Biaxial eminence fractures or, less commonly,
complete avulsion of the entire palmar/plantar fibrous
tissue attachments result in palmar/plantar instability
accompanied by subluxation or luxation of the PIP joint.
Uniaxial Palmar/Plantar Eminence Fractures

In the author’s experience, uniaxial eminence fractures
are less common than biaxial eminence fractures.
Although these fractures have been repaired by lag screw
Figure 17.2 Biaxial eminence fracture of the middle phalanx in
fixation,20 it is the author’s experience that better results a hindlimb with plantar luxation of the proximal
are obtained by primary arthrodesis of the PIP joint, as interphalangeal joint and distal collapse of the proximal
described in detail in Chapter 18. phalanx into the fracture line.
www.ajlobby.com
of the fracture fragment occurs into the dense fibrous luxation secondary to disruption of the palmar/plantar
connective tissue structures of the palmar (plantar)
support tissues, and biaxial eminence fractures.
aspect of the limb. Multiple attempts to support weight
on the limb and displacement of the sharp distal border
of the eminence may cause significant injury to the Comminuted Middle
digital sheath and the deep digital flexor tendon. Phalangeal Fractures
The primary concern in unstable middle phalangeal
fractures should be emergency stabilization of the
injured limb. With stability, further trauma to the injured
Introduction
structures and adjacent soft tissues can be minimized. Comminuted middle phalangeal fractures are four times
In addition, patient anxiety will be reduced and more prevalent than other fracture configurations.
radiographic evaluation will be facilitated. Although
In one report, approximately 75% of middle phalangeal
radiographs taken with the coaptation device in place fractures of the hindlimb were comminuted, and in the
may not provide excellent detail, films of adequate forelimb over 90% were comminuted.5
quality to assess the fracture and develop a treatment
plan can usually be obtained.
The fracture is immobilized by application of a modified Diagnosis
bandage cast, as originally described by Bramlage2 and Acute‐onset non‐weight‐bearing lameness, accompa
illustrated in Chapter 6. If a forelimb is affected, the limb nied by instability in the PIP joint region, is a character
is supported off the ground by an assistant, while a lightly istic clinical finding. Manipulation of the pastern region
padded bandage is applied extending from just distal to will demonstrate instability and crepitus, and induce a
the coronary band to the proximal aspect of the metacar painful response in most cases. Limited soft tissue swell
pus. A rigid splint such as polyvinylchloride (PVC) is ing occurs and, as previously discussed, most cases are
taped to the dorsum of the bandage to maintain alignment closed injuries. Emergency coaptation of the injured
of the dorsal cortices of the phalanges with the third meta limb should be the first priority. Diagnostic radiographs
carpus. The splint and bandage, including the hoof, are can then be taken with the limb immobilized.
then encased with fiberglass cast material. The same pro A detailed radiographic study is mandatory to
cedure is applied to hindlimb fractures, except the limb is delineate the extent of the injury. Multiple radiographic
best positioned with the toe resting on a platform to projections taken at different degrees of obliquity are
achieve alignment of the dorsal cortices of the phalanges necessary to establish the degree of comminution as well
and third metatarsus. With the fracture temporarily stabi as the articular nature of the fracture. In the author’s
lized, there is minimal chance that additional displace experience, there is usually severe comminution of the
ment of the fracture fragments will occur during transport proximal articular surface and subchondral region of the
to the hospital facility. Additionally, repair of closed middle phalanx (Figure 17.3). In addition, there is usually
fractures can be delayed to allow the patient to recover one or more major fracture line(s) extending into the
from transportation, and provide the surgical team ample
time to plan the procedure and assemble the necessary
equipment and ancillary help.
Further radiographic evaluation is completed once the
horse is under general anesthesia. The importance of
delineating the full extent of the injury with a complete
radiographic study cannot be overemphasized. Many
comminuted fractures appear to be only biaxial eminence
fractures on a lateral to medial radiographic projection.
Various methods have been reported for managing
biaxial eminence fractures. Arthrodesis of the PIP joint
using transarticular lag screw fixation or single dorsal
plate fixation have been successfully employed. However,
due to the inherent biomechanical weakness of these
techniques, the author advises against them. Rather,
double plate fixation as described for comminuted mid
dle phalanx fractures is the technique of choice when Figure 17.3 Photograph of comminuted middle phalangeal
managing any injury that results in substantial palmar/ fracture viewed following dorsal luxation of the proximal
plantar instability in the pastern region, including interphalangeal joint during surgery.
www.ajlobby.com
Figure 17.5 Palmar instability with proximal interphalangeal

luxation and distal displacement of the proximal phalanx into the
fracture line following comminuted middle phalangeal fracture.
Figure 17.4 Oblique radiograph of comminuted middle
phalangeal fracture demonstrating extension of fracture and
comminution of the distal articular surface of the middle phalanx.
Double Plate Fixation
Although success has been reported following direct
reduction and compressive fixation using a single
DIP joint (Figure 17.4). This fracture line often involves
dynamic compression plate (DCP),3,7 double plate fixa
articulation of the middle phalanx with both the distal
tion is the preferred treatment. Placing two small bone
phalanx and the navicular bone, and there may be com
plates abaxially provides a stronger, more stable, and
minution at the articular surface of the DIP joint. In the
fatigue‐resistant construct than other methods of inter
proximal comminuted portion of the middle phalanx,
nal fixation.6 The abaxial position of the plates also
biaxial eminence fracture with separation into medial
avoids impingement by the implants on the joint capsule
and lateral fragments results in palmar/plantar instabil
and the extensor process of the distal phalanx within
ity, subluxation, and distal displacement of the proximal
the DIP joint. Although double plate fixation requires
phalanx (Figure 17.5). Computed tomography is particu
slightly more exposure than other techniques, the
larly useful in defining the fracture planes, especially the
technical difficulty of the procedure is not substantially
extent of DIP joint involvement (Figure 17.6). Assessing
greater than application of a single dorsal plate.
the potential to adequately realign and compress the var
Positioning, limb preparation, and exposure for double
ious fracture planes in a comminuted fracture is vital in
plate fixation are similar to that described for arthrodesis
the decision on whether to repair or euthanize the horse.
of the PIP joint (Chapter 18). An inverted‐T skin incision
and inverted‐V incision in the extensor tendon are
utilized (Figure 17.7A,B). The extensor tendon is sharply
Treatment dissected from the underlying phalanges without
Management protocols reported for comminuted mid disturbing the attachment of the DIP joint capsule to
dle phalangeal fractures include distal limb cast coapta the dorsal aspect of the middle phalanx. Reflection of
tion, transfixation casting, and direct reduction with the extensor tendon exposes the dorsomedial and
compressive fixation.3,5,7,19 In the author’s opinion, direct dorsolateral aspects of the proximal and middle

reduction and double plate fixation is the method of phalanges. As the distal tendon segment is reflected, the
choice and provides the best prognosis for the vast PIP joint capsule is also reflected, exposing the articula
majority of middle phalanx injuries that result in palmar/ tion and facilitating transection of the medial and lateral
plantar instability. In the rare instance that massive collateral ligaments of the PIP joint. Using an instrument
comminution precludes internal fixation, transfixation placed into the articulation to provide leverage, the joint
casting should be considered. space is gradually opened as the collateral ligaments are
www.ajlobby.com
(A) (B) (C)
(D) (E) (F)
(G) (H)
Figure 17.6 Computed tomography (CT) used to define the fracture configuration of a comminuted middle phalanx fracture. (A–C)
Radiographs show multiple fracture lines. (D) Proximal and (E) distal transverse CT images show the entire fracture configuration. (F)
Reconstructed 3D image shows the displaced palmar axial fragment and adjacent fracture planes to assist in planning the repair. (G, H)
Postoperative Day 24 radiographs showing the double plate repair with several independent lag screws to add compression to the axially
located palmar fractures. Source: Images courtesy Alan Nixon.
www.ajlobby.com
(A) (B)
Common digital
extensor tendon
Skin
incision Transected tendon
Common digital
extensor tendon
(C)
(E) Flexion of
Common digital interphalangeal joint
extensor exposes fractured
tendon reflected middle phalanx
Fracture
lines
Plates Common digital

(D) extensor
tendon reflected
Second phalanx
Figure 17.7 (A–E) Approach for dorsal application of plates to stabilize a comminuted middle phalanx fracture. Only the distal screw hole
of each plate is used to engage the middle phalanx to avoid impingement on the structures of the distal interphalangeal joint and
phalanx. Where possible, an additional lag screw is placed between the plates and into the larger of the eminence fragments of the
middle phalanx.
progressively transected from dorsal to palmar/plantar Dorsal subluxation of the joint allows the surgeon to
until dorsal subluxation develops. The articular surfaces clearly identify the position and direction of the f racture
are exposed, allowing for removal of the articular carti lines in the proximal portion of the middle phalanx, as
lage and exposure of the subchondral bone of the PIP well as evaluate the size of the palmar/plantar eminence
joint and visualization of the fracture (Figure 17.7C). fragments and determine optimal angulation for screws
www.ajlobby.com
to gain maximal purchase in these fragments 5.5 mm cortex screws are used. Although cortex screws
(Figure 17.3). In most instances, there will be multiple could be placed in lag fashion, the author has discontin
fracture lines converging near the center of the articu ued this practice, due to the potential weakening of the
lation with the formation of a number of small fragments dorsal portion of the middle phalanx by drilling such a
in this area. Major fragments will be located more large hole. As previously noted, it is imperative that these
peripherally. Usually, the palmar (plantar) eminences screws engage the proximal aspects of their respective
are separated from the parent middle phalanx and eminence fragments and provide maximal purchase,
fractured into two major fragments. avoiding the much thinner distal aspect of the fragments.
A curette is utilized to completely remove the articular Drill hole preparation is accomplished with the joint
cartilage from both joint surfaces. Osteostixis of the flexed open to allow visualization of the fracture lines and
subchondral bone plate of the proximal phalanx is
ensure appropriate hole placement relative to the major
accomplished with a 2.5 mm drill bit. Osteostixis is not fracture fragments. Furthermore, placing these screws
performed in the fragments of the middle phalanx to with the joint flexed will stabilize the eminence fragments
avoid potentially weakening them, and because the in a more anatomic position, providing reduction and
fracture lines adequately expose the marrow elements of alignment of the palmar/plantar cortex and thereby mini
the middle phalanx. mize new bone formation along the fracture line. In addi
Prior to fixation, appropriate narrow plates, usually tion, stabilizing the eminence fragments in a near anatomic
three or four holes in length, are contoured to the nor position reestablishes the palmar/plantar tension band
mally aligned pastern region, with a single hole of each of soft tissues which attach along this perimeter.
plate positioned over the proximal aspect of the middle Following placement of the initial screw through each
phalanx. It is important to ensure that contouring pro of the plates and into the proximal aspect of the middle
vides for correct angulation of the distal screw into the phalanx, the pastern is realigned and a 5.5 mm cortex
proximal aspect of the respective eminence fragment. screw is inserted into the proximal phalanx through each
These screws must be angled slightly proximal and plate using the load position. Usually, the cortex screws
diverge abaxially, to traverse just below the subchondral are placed in the second plate hole proximal to the joint,
plate and gain maximal purchase in their respective emi allowing the screw in the proximal phalanx nearest the
nence fragments. If care is not taken to ensure the appro pastern joint to be a 5.0 mm locking screw. Once the cor
priate position of these screws, purchase in the eminence tex screws are fully tightened, the remaining holes are
will likely be inadequate, since the palmar/plantar emi filled with 5.0 mm locking screws using standard tech
nence fracture fragments become thinner as they propa nique. Use of two locking compression plates (LCPs)
gate distally into the palmar/plantar cortex of the middle generally provides a more stable fixation compared to a
phalanx. Contouring and twisting of the plate become pair of DCPs. However, the locked‐head design limits
especially important if locking implants are utilized, as the angulation of the vital distal‐most screw in each
locking screws cannot be angled, but require orthogonal plate. Angling a 4.5 or 5.5 mm cortical screw in the sec
placement to ensure that the threads in the screw head ond distal‐most plate hole across the PIP joint and into
are aligned with those of the locking hole in the plate. the middle phalanx can occasionally be accomplished to
Initial fixation consists of placing a single independent strengthen the repair. Supplemental lag screws applied in
screw, usually a 4.5 mm cortex screw, in lag fashion from a lateral to medial or oblique plane in the middle phalanx
the midline of the dorsal cortex of the middle phalanx can also provide compression of fracture planes entering
and extending into the largest of the palmar/plantar emi the DIP joint. Radiographic or fluoroscopic images of the
nence fragments. Ideally, this screw is positioned to sta completed fixation are taken prior to closure to ensure
bilize this fragment without compromising the ability of that the implants are positioned properly and that all
a second screw, placed through the appropriate plate, to screws are of the appropriate length (Figure 17.8).
gain adequate eminence purchase. Prior to drilling, the Intraoperative 3D fluoroscopic imaging can also be very
eminence fragment is reduced, using a combination of helpful in placing appropriate plate and lag screws.
distal limb flexion and, if possible, pointed reduction for Reconstruction of the surgical wound, bandaging, and
ceps, to aid reduction and maintain fragment position cast application are as described for pastern arthrodesis
during screw placement procedures. Radiographic/ (Chapter 18). Briefly, the overlying extensor tendon and
fluoroscopic control is mandatory to assess reduction dorsal branches of the suspensory ligament are recon
and implant positioning. structed with size 0 or 1 monofilament absorbable suture
The previously contoured plates are now affixed to the material. Complete soft tissue coverage of the implants
proximal aspect of the middle phalanx. If locking should be accomplished. The skin incision is closed with
implants are available, 5.0 mm locking screws are used in a simple interrupted pattern using size 0 nonabsorbable
the proximal region of the middle phalanx. Otherwise, monofilament suture or skin staples or both. Usually,
www.ajlobby.com
(A) (B) (C) (D)
Figure 17.8 (A) Dorsopalmar and (B) lateral to medial radiographs of comminuted middle phalangeal fracture. This is the same horse as
shown in Figure 17.4. (C, D) Intraoperative films showing completed fixation using two plates, a narrow dynamic compression plate and a
narrow locking compression plate. Note in (D) the purchase in the palmar eminences by the distal screws.
vertical mattress sutures are used to achieve partial c ontinue to be evident radiographically. Periosteal new
apposition, and skin staples are used to complete the bone formation should be evident. Stall confinement is
closure. Following reconstruction, a bandage consisting continued for a total duration of approximately three to
of a sterile nonadherent pad is applied and held in posi four months to allow the fracture and the arthrodesis
tion with sterile gauze covered with elastic adhesive tape. to develop adequate strength. As significant healing
A standard distal limb cast is then employed to protect becomes evident and the degree of lameness decreases,
the fixation postoperatively. hand‐walking exercise may be allowed. In most cases
Following surgery, the horse is confined to a stall and this can begin six to eight weeks after surgery.
monitored for evidence of complications associated with Radiographic evaluation should reveal complete con
the surgery or the development of cast sores. Radiographs solidation of the fracture lines and arthrodesis by four to
are usually taken through the cast within a few days of six months after surgery (Figure 17.9). Although some
surgery to document that the fixation is stable following residual lameness is likely to be present at this time, the
recovery. Traditionally, cast support is maintained for horse can begin to have short periods of unrestricted
four to six weeks after surgery, requiring one or two cast exercise. The duration of exercise is gradually increased
changes. In recent cases, we have replaced the initial cast until unrestricted pasture exercise can be allowed.
with a bandage cast two to three weeks after surgery. Returning the horse to performance should only be con
Radiographic examination prior to replacing the cast sidered after complete healing is evident radiographi
with a bandage cast should reveal no change in the posi cally, and lameness is minimal.
tion of the fracture fragments or implants. There may be
evidence of periosteal new bone formation indicative of Casting
a healing response; however, the amount of new bone Historically, open reduction and internal fixation were
formed is likely to be minimal. The bandage cast is usu considered contraindicated, because rigid stability was
ally changed every three to four days, reusing the cast not likely to be achieved and screws would be prone to
shell, and then replaced with a pressure wrap in three to open unseen fissure fractures.8 Consequently, cast
six weeks, depending on the patient’s progress. At that immobilization was advocated as the preferred method
time there should be evidence of fracture consolidation, of treatment. The suggested technique was to apply the
although the fracture lines and arthrodesis site will cast after distracting the fracture and bringing the
www.ajlobby.com
Figure 17.9 (A, B) Follow‐up radiographs (A) (B)

of horse with comminuted, biarticular
fracture demonstrating fracture healing
and completed arthrodesis of the proximal
interphalangeal joint. Note minimal
periosteal new bone formation indicating
stable fixation and the absence of
degenerative changes in the distal
interphalangeal joint. In this case, unlike
the fracture depicted in Figure 17.4, there
was no comminution at the distal
interphalangeal joint.
fragments into reduction. This was accomplished by column is intact, when the weight‐bearing column is
placing wires through the solar margin of the hoof at the disrupted the cast does not prevent significant fragment
white line and attaching these to a traction device. displacement and collapse secondary to axial compres
Traction was applied gradually, using radiographic con sion.15 Fragment displacement and distal collapse of the
trol to establish the least amount of limb distraction proximal phalanx into the fracture are likely. As the
needed to achieve the best anatomic result. With the proximal phalanx displaces distally, fracture fragments
limb held in this position, a standard distal limb cast was are forced outward, trapping the overlying soft tissues
applied which enclosed the hoof and extended to imme against the cast. Subsequent pressure necrosis may
diately below the carpus or tarsus. After recovery from result in an open and infected fracture. In addition, a
anesthesia and two to three days of ambulation, radio degree of malalignment secondary to contracture of the
graphs were taken through the cast to assess fracture flexor tendons is likely. Even if fragment displacement
reduction. If minimal displacement had occurred, then does not result in necrosis of the overlying soft tissues,
continued monitoring was indicated. The initial cast was the discomfort associated with instability predisposes to
replaced in 10–14 days, after soft tissue swelling had dis contralateral limb laminitis. For these reasons, immobi
sipated, to ensure close apposition of the cast to the digit. lization of these fractures using a standard distal limb
After the first cast was replaced, subsequent cast changes cast is not recommended.
were accomplished as needed. Cast immobilization was
continued until there was evidence of substantial radio Transfixation Casting
graphic healing, which usually exceeded three months. Distal displacement of the proximal phalanx into the
In one report, casting alone was utilized in 22 cases with fracture site can be limited by transfixation casting.15
comminuted middle phalangeal fracture. Follow‐up was Transfixation casts will effectively protect the area below
available on 18, which indicated a successful return to the pins from the forces of weight bearing. However,
function in 12 horses, with 2 returning to their intended loosening of the transfixation pins at the bone–pin
use and 10 salvaged for limited function.5 The average interface will occur and limit the effective duration of
duration of casting was 100 days in these cases. transfixation. Pin loosening results from a variety of
The major limitation of cast immobilization as the factors and if it occurs prior to adequate healing,

sole therapy for comminuted middle phalangeal frac displacement can result in malalignment. Fragment dis
tures is the inability of a standard distal limb cast to placement and malalignment can also be a consequence
effectively protect the fracture site from the axial forces of soft tissue contraction during the initial period of
of weight bearing. Although a cast significantly transfixation if the hoof is not adequately anchored
decreases strain in the proximal phalanx when the bony within the cast. Horses placed in transfixation casts are
www.ajlobby.com
very comfortable initially. However, once pin loosening return to athletic competition was 25% (2 of 8 horses)
begins, or if fragment displacement occurs due to soft with surgery and casting, compared to only 11% (2 of 18
tissue contraction, they experience increasing pain, horses) with casting alone. Importantly, severe degener
potentially predisposing them to support limb laminitis. ative joint disease developed in both the PIP and DIP
A major disadvantage to transfixation casting as a joints regardless of treatment method. For comminuted
primary choice for fracture management is the potential middle phalangeal fractures of the forelimb, 8 of 10
for secondary fracture through a pin hole in the third horses were salvaged, whereas only 10 of 23 horses with
metacarpus/metatarsus. The frequency of secondary hindlimb fractures were salvaged. However, none of the
fracture varies, but in one report, where transfixation horses with forelimb fractures were able to perform
was used to manage comminuted fractures of the athletically. Four horses with hindlimb fractures did
proximal and middle phalanges, 4 of 20 patients suffered go on to performance activities. In addition, the period
a catastrophic fracture of the cannon bone through of cast immobilization was approximately 30 days less
a transfixation pin hole.10 In another report on trans in horses where lag screw fixation was used compared
fixation casting, 14% of the patients fractured through a to horses managed exclusively with casts (average of
pin hole.11 66 days vs. 100 days).
In the author’s opinion, if internal fixation is not an Results of managing middle phalanx fractures using
option, transfixation casting offers the second best transfixation casts have been reported.10,11 However, the
modality for managing these fractures. Choosing trans specific details and actual outcomes are difficult to dis
fixation casting might be motivated by economic con criminate from other distal limb injuries included in
cerns, as initial costs are likely to be less than direct these reports. In the report by Lescun et al., a total of
reduction and compressive fixation. However, in most eight middle phalanx fractures were managed with
cases, the need for appropriate monitoring of the patient transfixation casting alone or in combination with addi
during the convalescent period, in conjunction with tional orthopedic fixation.11 Six of these patients were
multiple cast changes under general anesthesia, may discharged from the hospital and healed their fracture;
negate the initial cost benefits. With double plate fixa however, none of these patients was able to perform its
tion, savings in the postoperative period in the form of intended activities. There was no mention as to their
reduced hospitalization time, and number of casts and ability to function at a reduced activity level. Joyce et al.
anesthetic periods required, may result in less overall managed 14 middle phalanx fractures with transfixation
expense than transfixation casting. Further, the duration alone or in combination with internal fixation.10 Again,
of significant pain associated with the fracture will likely the specifics of management and outcome are difficult
be shorter and long‐term function may be better with to discern, as they are combined with fractures of the
open reduction and internal fixation. Lastly, double plate proximal phalanx. It appears that the majority of these
fixation does not impose the additional risk of secondary were treated with internal fixation combined with trans
fracture of the third metacarpus/metatarsus associated fixation casting. Overall, 70% of their cases were dis
with transfixation casting. charged from the hospital, and of the ten patients with
long term follow‐up, eight had mild residual lameness
and three of these were able to be ridden, albeit at a
Prognosis reduced activity level. The remaining two patients were
Casting in combination with open reduction and lag overtly lame at a walk, but able to ambulate comfortably
screw fixation of major fracture fragments was reported at pasture. However, results for fractures of the middle
in a group of nine horses, with follow‐up evaluation phalanx separate from fractures of the proximal phalanx
available for eight.5 Five horses in this group had success were not reported. Interestingly, results of transfixation
ful outcomes; i.e., they were discharged from the hospital cast alone or in combination with internal fixation are
and healed their fracture. Two horses were able to return only marginally better than those reported by Colahan
to athletic function and the remaining three horses were et al. using standard distal limb casts alone or in combi
considered pasture sound. Comparing surgically man nation with lag screw fixation.5 More of the patients
aged horses to those treated by casting alone identified reported by Colahan suffered from support limb lamini
several important considerations.5 Both techniques tis as a complication, whereas in the reports by Joyce
resulted in similar survival rates: 5 of 8 horses (63%) and Lescun, secondary fracture through a transfixation
treated by surgery and postoperative casting and 12 of 18 pin hole was more often responsible for patient
horses (67%) treated by casting alone survived. However, attrition.10,11
in the former group, a greater percentage of the salvaged Results following double plate fixation were initially
horses returned to athletic function compared to the reported in a small group of horses,6 and more recently
group treated exclusively by casting. Overall, successful in a larger case series of 30 horses.16 In all, the incidence
www.ajlobby.com
of morbidity and mortality of double plate fixation, com and contralateral limb laminitis. Postoperative cast
pared to either casting/transfixation casting alone or in immobilization will minimize the risk of acute fixation
combination with other methods of internal fixation, is failure associated with recovery from anesthesia.
substantially decreased. In our initial report of ten cases, Furthermore, the use of double plate fixation, where the
all patients survived and six were able to return to useful tension band effect of the palmar (plantar) soft tissue
function, albeit at a decreased level when compared to support structures is reestablished, decreases the
preinjury activities. Further experience by the author has potential for fatigue failure, and allows the period of
validated the utility of the technique, with radiographic postoperative cast support to be reduced. In the author’s
evidence of fracture healing by six months in 90% of the experience, implant failure with double plate fixation is
horses, and 15 of 25 horses followed long term being able rare.16
to return to function.16 Laminitis in the support limb, secondary to prolonged,
severe lameness in the fractured limb, is a risk associated
with any major fracture repair in adult horses. In the
Complications report by Colahan et al., laminitis was the major terminal
Complications associated with open reduction and complication.5 Ten failures were recorded, five of which
internal fixation of comminuted middle phalangeal were attributed to contralateral limb laminitis. A distinc
fractures include postoperative myopathy or injury,
tion between laminitis‐associated failure rates in horses
infection, failure of the bone–implant unit, and con treated by casting alone and those undergoing surgery
tralateral limb laminitis. It might be assumed that an was not provided. The risk of laminitis can be reduced by
increased rate of infection would be associated with minimizing the duration of severe lameness in the
plate fixation, similar to highly comminuted fractures affected limb. This objective is best accomplished by
of the proximal phalanx repaired by a widely invasive establishing stability at the fracture site, thereby allowing
technique.13 However, the infection rate using the skin an early return to weight bearing on the fractured limb.
flap approach appears to be acceptable. Only one of This is best accomplished with double plate fixation.
eight middle phalangeal fractures repaired by plate fix Although transfixation casting provides comfort initially,
ation was reported to have become infected, as opposed it has been the author’s experience that as the transfixa
to an infection rate of over 50% for proximal phalangeal tion pins loosen, lameness becomes evident, and once
fractures.3,7,13,19 With double plate fixation, one of ten the pins are removed, fracture‐associated lameness is
cases became infected,6 and substantial experience likely, depending on the degree of healing which has
with double plate fixation since that report confirms occurred prior to pin removal. Additional methods to
that the infection rate is well below the reported rate reduce the risk of support limb laminitis include provid
of postoperative infection following long bone frac ing support to the contralateral hoof with a heart bar
ture fixation.1,12,16 Minimally invasive repair has been shoe or similar device in conjunction with packing mate
described for stabilization of p astern subluxation,9 but rial in the palmar/plantar aspect of the sole. It is also
would seem unsuitable for major middle phalanx recon important to increase the functional length of the sup
struction where direct v isualization provides a significant port limb while the fractured limb is protected by a cast
advantage. Failure of fixation is also infrequent. The to compensate for the relative discrepancy in length
one reported case was predisposed by osteomyelitis between the two limbs.
References
1 Ahern, B.J., Richardson, D.W., Boston, R.C. et al. (2010). 4 Clayton, H.M., Singleton, W.H., and Lanovaz, H.L.
Orthopedic infections in equine long bone fractures and (2002). Sagittal plane kinematics and kinetics of the
arthrodeses treated by internal fixation: 192 cases pastern joint during the stance phase of the trot.
(1990–2006). Vet. Surg. 39: 588–593. Vet. Comp. Orthop. Traumatol. 15: 15–17.
Bramlage, L.R. (1983). Current concepts of emergency
2 Colahan, P.T., Wheat, J.D., and Meagher, D.M. (1981).
5
first aid and transportation of equine fracture patients. Treatment of middle phalangeal fractures in the horse.
Compend. Cont. Educ. Pract. Vet. 5: S564–S573. J. Am. Vet. Med. Assoc. 178: 1182–1185.
Bukowiecki, C.F. and Bramlage, L.R. (1989). Treatment
3 Crabill, M.R., Watkins, J.P., Schneider, R.K., and Auer,
6
of comminuted middle phalangeal fracture in a horse by J.A. (1995). Double plate fixation of comminuted middle
use of a broad dynamic compression plate. J. Am. Vet. phalangeal fractures in horses (1985–1993). J. Am. Vet.
Med. Assoc. 194: 1731–1734. Med. Assoc. 207 (11): 1458–1461.
www.ajlobby.com
7 Doran, R.E., White, N.A., and Allen, D. (1987). Use of 15 McClure, S.R., Watkins, J.P., Bronson, D.G., and
bone plate for treatment of middle phalangeal fractures Ashman, R.B. (1994). An in‐vitro comparison of
in horses: 7 cases. J. Am. Vet. Med. Assoc. 191: 575–578. standard short limb cast and three configurations of
8 Gabel, A.A. and Bukowiecki, C.F. (1983). Fractures of short limb transfixation casts in equine forelimbs.
the phalanges. Vet. Clin. North Am. Large Anim. Pract. Am. J. Vet. Res. 55: 1331–1334.
2: 233–260. 16 McCormick, J.D. and Watkins, J.P. (2017). Double plate
9 James, F.M. and Richardson, D.W. (2006). Minimally fixation for the management of proximal
invasive plate fixation of lower limb injury in horses: 32 interphalangeal joint instability in 30 horses
cases (1999–2003). Equine Vet. J. 38: 246–251. (1987–2015). Equine Vet. J. 49: 211–215.
10 Joyce, J.L., Baxter, G.M., Sarrafian, T.L. et al. (2006). 17 Modransky, P.D., Grant, B.D., Rantanen, N.W., and
Use of transfixation pin casts to treat adult horses with Corey, D.G. (1982). Surgical treatment of a palmar
comminuted phalangeal fractures 20 cases (1993– midsagittal fracture of the proximal second phalanx in
2003). J. Am. Vet. Med. Assoc. 229: 725–730. a horse. Vet. Surg. 11: 129–131.
11 Lescun, T.B., McClure, S.R., Ward, M.P. et al. (2007). 18 Radcliffe, R.M., Cheetham, J., Bezuidenhout, A.J. et al.
Evaluation of transfixation casting for treatment of (2008). Arthroscopic removal of palmar/plantar
third metacarpal, third metatarsal, and phalangeal osteochondral fragments from the proximal
fractures in horses: 37 cases (1994–2004). J. Am. Vet. interphalangeal joint in four horses. Vet. Surg. 37:
Med. Assoc. 230: 1340–1349. 733–740.
12 MacDonald, D.G., Morley, P.S., Bailey, J.V. et al. (1994). 19 Rick, M.C., Herthel, D., and Boles, C. (1986).
An examination of the occurrence of surgical wound Surgical management of middle phalangeal fractures
infection following routine orthopedic surgery and high ringbone in the horse: a review of 16 cases.
(1981–1990). Equine Vet. J. 26: 323–326. In: Proceedings of the American Association of
13 Markel, M.D., Richardson, D.W., and Nunamaker, D.M. Equine Practitioners, vol. 32, 315–321.
(1985). Comminuted first phalanx fractures in 30 Lexington, KY: AAEP.
horses: surgical vs. nonsurgical treatment. Vet. Surg. 14: 20 Turner, A.S. and Gabel, A.A. (1975). Lag screw fixation
135–140. of avulsion fractures of the second phalanx in the horse.
14 Martin, G.S., McIlwraith, C.W., Turner, A.S. et al. J. Am. Vet. Med. Assoc. 167: 306–309.
(1984). Long‐term results and complications of 21 Welch, R.D. and Watkins, J.P. (1991). Osteochondral
proximal interphalangeal arthrodesis in horses. J. Am. fracture of the proximal palmar middle phalanx in a
Vet. Med. Assoc. 184: 1136–1140. Thoroughbred. Equine Vet. J. 23: 67–69.
www.ajlobby.com
277
18
Arthrodesis of the Proximal Interphalangeal Joint
Jeffrey P. Watkins
Department of Large Animal Clinical Sciences, College of Veterinary Medicine & Biomedical Sciences,
Texas A&M University, College Station, TX, USA
Indications Osteochondrosis and Subchondral

Cystic Lesions
Conditions involving the proximal interphalangeal
(PIP) joint which necessitate arthrodesis are common. Developmental disease of the PIP joint is not frequent,
Clinical experience has shown that the PIP joint is par- but may manifest as SCL, OCD, or osteochondral
ticularly prone to develop osteoarthritis (OA), with fragmentation along the dorsal articular margin of the
progressive deterioration following a variety of initiat- middle phalanx. The most common manifestation is a
ing conditions. Although medical therapy can provide solitary SCL affecting the articular surface of the proxi-
temporary relief, in many instance lameness can only mal phalanx. The middle phalanx is affected less fre-
be resolved by arthrodesis, facilitated ankylosis, or quently. In some instances, these lesions will not be
spontaneous fusion. There are a wide variety of condi- accompanied by evidence of OA, similar to the typical
tions that ultimately lead to PIP OA. Developmental presentation for other SCL‐affected joints. Management
causes are uncommon, but osteochondritis dissecans of these patients is not well defined, but successful reso-
(OCD) and subchondral cyst‐like lesions (SCL) both lution of lameness has been achieved with therapy
occur in the PIP joint. The most frequent causes of PIP directed at the SCL rather than by arthrodesis. However,
joint OA are acute trauma, either external or internal, when accompanied by OA, a SCL‐affected PIP joint is
and chronic wear and tear. External traumatic injuries best managed by arthrodesis. OCD lesions in the pastern
are common and include periarticular and articular joint often result in advanced OA by the time of diagno-
lacerations. Internal trauma, secondary to excessive
sis, distinct from the typical clinical scenario for OCD in
weight‐bearing forces transmitted through the digit, high‐motion joints. The advanced nature of OA in these
causes fractures or periarticular soft tissue injuries, cases may make it difficult to be certain that OCD was
resulting in instability. Common fracture configura- the inciting cause. The typical presentation is a weanling
tions include uniaxial eminence, biaxial eminence, and to yearling with severe, bilateral OA of the PIP joint,
comminuted fractures of the middle phalanx. Less often in the hindlimbs. Arthrodesis is the only treatment
common are distal articular fractures of the proximal likely to alleviate lameness in affected individuals.
phalanx. Fractures of the middle phalanx and disrup- Osteochondral fragments of the proximal dorsomedial
tive soft tissue injuries often occur during high‐speed or dorsolateral margin of the middle phalanx are likely a
activities, especially those associated with rapid turns third manifestation of developmental disease of the PIP
and stops, and are especially common in western per- joint.9 Similar to joints which are commonly affected with
formance horses. However, they also can occur during developmental osteochondral fragmentation, there is no
less strenuous activities, and even in stall‐confined known traumatic incident or acute‐onset lameness typical
horses. Chronic internal trauma develops during proof traumatic chip fracture. Affected horses have been pri-
longed high‐speed maneuvers, but instead of overt fail- marily young adults presented for lameness. However,
ure, insidious injury to the soft tissue support structures, these fragments have also been reported as incidental
cartilage, and subchondral bone occurs and, as damage findings. Typically there is minimal OA accompanying

accumulates, progresses to OA. the lesion. Fragment removal by arthroscopic technique is

www.ajlobby.com
feasible.25 In some cases, performance may be possible with- tissue envelope. In some instances OA may be averted.
out therapy or with intraarticular medications. However, In cases which develop OA, an arthrodesis can be accom-
arthrodesis should be considered when OA is present. plished at a later date, generally at least eight weeks after
resolution of infection and adequate soft tissue healing
have occurred. However, when septic arthritis/osteomy-
Trauma and Osteoarthritis elitis is present as indicated by active bone lysis, the
The pastern region is a frequent site for external trauma, author prefers management by facilitated ankylosis.
especially when horses are kept in wire‐fenced enclosures Aggressive debridement with immediate direct reduc-
or yards made of panels that are not specifically designed tion and compressive fixation has been reported in
to prevent entanglement of the distal limb. Lacerations patients with established septic arthritis/osteomyelitis,
most commonly occur secondary to entrapment in wire with a reported success rate of 50%.11 However, a combi-
fences, and may be either periarticular or penetrate the nation of aggressive debridement, local antimicrobial
synovial structures of the digit, including the distal inter- therapy, cancellous bone grafting, and transfixation cast-
phalangeal (DIP) joint, digital sheath, and PIP joint, in ing has been successful in a high percentage of similarly
decreasing order of frequency. Although periarticular affected cases at our hospital. The most challenging situ-
wounds do not result in synovial infection or directly ation is when instability accompanies infection. In these
affect the articulation, they are frequently associated instances, maintaining alignment of the PIP joint during
with the development of progressive OA and lameness. initial therapy to combat infection can be difficult, and
Penetrating wounds of the PIP joint can be classified as in some cases malalignment with secondary contracture
either stable or unstable. Puncture wounds are not com- occurs (Figure 18.2). Reestablishing alignment may require
mon, but often go undetected until the patient becomes corrective ostectomy in conjunction with arthrodesis
severely lame once sepsis becomes established. In our once the infection has been resolved.
hospital, this most commonly occurs after a horse returns Non‐entrapping injuries to the PIP joint are less
from ranch work or trail riding where thorny plants have frequently encountered. Occasionally, a direct blow to
been encountered. Lacerations which disrupt the periar-
ticular support structures usually result from the limb
becoming entrapped. In some instances the wound
results from a sharp object and involves the deeper struc-
tures, and in others the skin is torn after the periarticular
support structure (usually a collateral ligament) is dis-
rupted and the articulation luxates (Figure 18.1).
Open injuries and PIP joint infections without osteoly-
sis are best managed in staged procedures. Initial therapy
is directed at resolving infection and healing the soft
Figure 18.2 Lateromedial radiographic projection showing

Figure 18.1 Open proximal interphalangeal joint secondary to malalignment from contracture of palmar support structures
entrapment, laceration, and disruption of the lateral collateral subsequent to an open luxation associated with disruption of the
ligament. medial collateral ligament.
www.ajlobby.com
(A) (B) (C)
Figure 18.3 Uniaxial palmar eminence fracture of the middle phalanx. Dorsopalmar (A), lateromedial (B), and oblique (C) projections
illustrate the eminence fracture. Note that alignment of the pastern joint is unaffected, indicating intact palmar/plantar support.
the region occurs, often the result of inadvertently phalanx (see Chapter 19), uniaxial eminence fracture
striking a solid object when attempting to kick. Fracture (Figure 18.3), and palmar/plantar subluxation. Horses
of a plantar eminence can result. More common are dis- with eminence fracture or palmar subluxation typically
ruptive injuries secondary to internal forces generated present for acute onset of moderate to severe lameness.
during performance activities. The direction and force of Manipulation of the digit is likely to induce pain; how-
loading dictate the configuration of the injury. Acute ever, crepitance and instability are usually not evident. In
overload with hyperextension, tensile loading of the pal- acute cases, radiographic evaluation prior to perineural
mar/plantar support structures, and axial compression anesthesia may prevent further injury to the area. If eval-
through the proximal phalanx to the palmar/plantar uation has been delayed substantially, chronic lameness
aspect of the middle phalanx result in eminence frac- will be the presenting complaint, associated with sec-
tures, or less frequently disruption of the soft tissue ondary OA.
attachments to the palmar/plantar scutum. The magni- Complete radiographic evaluation of the middle pha-
tude of the force will determine the degree of palmar/ lanx requires a minimum of a standard dorsopalmar
plantar instability. Acute overload associated with tor- (plantar), lateral to medial, and two 45° oblique views
sional forces results in comminution of the middle (dorsolateral‐palmaromedial oblique, DLPMO, and
phalanx. The degree of comminution and fragment dis- plantarolateral‐dorsomedial, PLDMO). Additional oblique
placement is commensurate with the magnitude of the views may be needed to further delineate some fractures.
forces and energy absorbed prior to fracture. Most mid- In acute uniaxial eminence fractures, the fracture will
dle phalanx fractures are closed injuries due to the dense be most clearly visualized on an oblique view. Rarely, a
fibrous tissue envelope overlying the area. Additional fracture line may be noted to traverse the length of the
details on middle phalanx fractures accompanied by middle phalanx and affect the DIP joint. Delineation of
PIP joint instability can be found in Chapter 17. DIP joint involvement is important in determining the
prognosis. In cases of chronic fracture, the fracture line
may be indistinct, and accompanying signs of degenera-
Fractures and Subluxation tive joint disease may not be evident. In cases of isolated
Disruptive injuries which are not accompanied by disruption of the palmar/plantar soft tissue support,
significant instability include osteochondral fractures
subluxation will be evident on a lateral to medial projec-
located on the palmar/plantar margin of the proximal tion with the limb loaded.
www.ajlobby.com
Surgical repair of uniaxial eminence fractures of suffi- likely due to the limitations already discussed, and
cient size to accommodate lag screw fixation has been lameness often persists as secondary OA develops. In
reported.6,31 The procedure is performed through an the author’s experience, arthrodesis is superior to lag
incision positioned directly over the affected eminence. screw fixation for enabling affected horses to return to
Direct visualization of the fragment and associated joint performance.
surface is not possible, since the eminence is deeply Secondary OA of the PIP joint is nearly always the end
invested in the tendinous, ligamentous, and joint capsu- result of the previously described injuries. The PIP joint
lar attachments. Screw placement is accomplished using is particularly unforgiving and significant articular or
meticulous intraoperative imaging to assist the surgeon periarticular insult consistently leads to progressive
in determining proper orientation for placement of a deterioration and lameness. However, primary OA,
single 4.5 mm cortical bone screw in lag fashion across where there is no evidence or history of an acute injury,
the fragment. Lag screw repair does not allow visualiza- is also quite common. In these cases, chronic use trauma
tion of the PIP joint, and therefore precise reconstruc- damages the articular surfaces and/or periarticular sup-
tion of the articular surface of the middle phalanx is port structures of the PIP joint. The combination of car-
difficult to achieve. Additionally, a single lag screw does tilage deterioration and microinstability results in a
not provide rotational stability of the fracture fragment, progressive cycle of cartilage degeneration and periar-
even when combined with postoperative cast immobili- ticular new bone formation. Eventually, complete ero-
zation. Furthermore, a single screw does not adequately sion of the cartilaginous surfaces occurs and is identified
counter the tensile forces on the fragment and incom- radiographically as decreased joint space, or complete
plete healing can result (Figure 18.4). collapse. Joint space collapse may be symmetric, when
In the initial report detailing three cases of lag screw cartilage loss is equal throughout the joint, or asymmet-
fixation of uniaxial eminence fractures affecting the ric, when cartilage loss is greater on one side of the joint
hindlimb, two horses returned to western performance (Figure 18.5). Mineralization in the periarticular support
and the third horse to western pleasure competition.31 structures is pronounced and likely represents an attempt
However, Colahan and coworkers report that only two of to increase joint stability by stiffening periarticular sup-
six horses with palmar or plantar eminence fractures port. Occasionally, it may be a response to primary injury
were capable of performing athletically following lag of these structures.
screw fixation.6 In general, fracture healing is unreliable, OA of the PIP joint is progressive. In early phases of
primary OA, as well as in mild cases of secondary OA,
medical therapy can be palliative and allow continued
function. Medical therapy includes a variety of systemic
and intraarticular anti‐inflammatory medication and
corrective shoeing. However, medical therapy becomes
less effective with time, and eventually intractable lame-
ness results. Repeated intraarticular medication and ath-
letic activity often lead to excessive periarticular new
bone formation, and in severe cases loss of subchondral
bone (Figure 18.6). If surgical arthrodesis is elected at
this point, the difficulty of the procedure is substantially
increased.
Diagnosis
The degree of lameness in patients with established PIP
joint OA can be quite variable. Some horses, particularly
when cartilage degeneration is symmetric and has not
yet exposed subchondral bone, may show only mild
lameness and can be quite functional, especially with
appropriate medical management. Lameness is often
severe when cartilage degeneration is asymmetric or
Figure 18.4 Nonunion of palmar eminence fragment following
becomes full thickness. Localizing clinical signs include
lag screw fixation. The horse was lame at admission and returned focal or generalized enlargement of the affected pastern
to performance following proximal interphalangeal arthrodesis. (Figure 18.7). Manipulation of the digit may cause pain
www.ajlobby.com
Figure 18.5 (A) Symmetric loss of cartilage

and joint space collapse. (B) Different case
(A) (B)
of proximal interphalangeal osteoarthritis
showing asymmetric joint space loss and
angular deviation.
Figure 18.7 Horse with classic generalized bony enlargement due

Figure 18.6 Advanced degenerative joint disease with to proximal interphalangeal osteoarthritis of the right forelimb.
subchondral bone loss subsequent to repeat intraarticular Source: Image courtesy Dr Ashlee Watts.
corticosteroid injection and continued use.
abolished with palmar/plantar digital perineural anes-
and flexion testing typically exacerbates the lameness. thesia, likely due to proximal migration of anesthetic
Confirmation of PIP joint disease in the early stages as and desensitization of the dorsal nerve branches.
the cause of lameness requires intraarticular anesthesia. Radiographic examination will demonstrate varying
It should be noted that lameness may dissipate or be degrees of narrowing of the PIP joint space, subchondral
www.ajlobby.com
bone erosion and sclerosis, and periarticular new bone Ethyl alcohol (70%) has been reported to effectively pro-
formation. When substantial subchondral bone erosion mote ankylosis in the tarsometatarsal joint without induc-
is noted and there is historical or physical evidence of a ing significant patient discomfort.27 However, there are no
penetrating injury to the region, deep infection should clinical studies that describe the results of treating clinical
be considered. OA of the distal tarsus with alcohol. The use of alcohol to
facilitate ankylosis of the PIP joint has been evaluated.34
Arthrodesis did not reliably develop when a single injec-
Arthrodesis tion of ethyl alcohol was used as the sole agent, or in com-
bination with percutaneous lag screw insertion and cast
With few exceptions, most conditions of the PIP joint are application.34 Although this is an attractive alternative to
best managed by arthrodesis. The goals of surgery are to arthrodesis, the PIP joint differs significantly from the dis-
establish sagittal and frontal plane alignment of the prox- tal tarsal joints. The PIP joint has a significantly greater
imal and middle phalanges, provide a mechanical and range of motion compared to the distal tarsus, which
biologic environment conducive to bony fusion, provide may impact its response to attempts at chemical ankylosis
maximum patient comfort, and allow an early return to and explain the difference in outcomes between studies
unprotected weight bearing. using MIA and alcohol in the PIP joint and distal tarsus.
Primary surgical arthrodesis is indicated in cases of Furthermore, if substantial cartilage is present at the time
established OA. Traumatic injuries that are good candi- of injection, as the cartilage rapidly degrades, motion may
dates for arthrodesis include mild subluxations (both be increased, since the periarticular support structures
dorsal and palmar/plantar), and simple fractures of the are not likely to stiffen at a comparable rate. Conversely,
proximal and middle phalanx which do not significantly when attempting chemical ankylosis in the presence of
disrupt the palmar/plantar support of the PIP joint. advanced OA, it may be impossible to adequately disperse
Comminuted and biaxial fractures of the middle phalanx the agent throughout the joint space. Although this is
or complete disruption of the palmar/plantar soft tissue acceptable in the distal tarsus, in a number of cases with
support structures of the PIP joint result in substantial advanced OA of the PIP joint, lameness has persisted
palmar/plantar instability. In these patients, the author when there are areas of incomplete ankylosis. The spot‐
advises double plate fixation, as described in Chapter 17. welding effect which seems to be adequate to return
patients with distal hock OA to performance may not be
Chemical Ankylosis sufficient in the PIP joint. A more recent retrospective
clinical study suggested that repeated ethanol injections
In recent years, there has been increased interest in are required for PIP ankylosis,5 compared to the single
management of PIP joint OA by nonsurgical proce- injection assessed previously.34 Additionally, the efficacy
dures, using chemical methods for facilitated ankylo- of ethanol injection is improved in moderate to advanced
sis.5,34 The ideal chemical agent for this purpose should arthritic PIP joints. However, response to injection was
be effective at destroying the articular cartilage suffi- slow, with a median time of eight months required to
ciently to allow transarticular bone formation. Other resolve the symptoms associated with PIP OA.5 Of 34
desirable features include minimally invasive adminis- horses assessed following ethanol injection, 17 (50%)
tration, lack of serious tissue damage if inadvertently became sound enough to work. Ethanol injection appeared
injected or leaked into the periarticular tissues, and to be an economical alternative for cases with moderate
minimal discomfort to the patient. Monoiodoacetate and advanced PIP arthritis, where a slow improvement in
(MIA) was the first chemical introduced for this pur- symptoms was tolerable, repeated injection expected, and
pose and its ability to induce ankylosis of the distal tarsal a 50% chance of residual lameness was acceptable.5
joints is well established. Although ankylosis reliably
develops, the injection elicits substantial pain in the
immediate post‐administration period. Interestingly, Laser‐assisted Minimally Invasive
when used experimentally in normal pastern joints to
evaluate its efficacy to induce ankylosis, it was ineffec-
Arthrodesis
tive.20 Although cartilage damage was substantial, it Removal of cartilage using percutaneous laser delivery
failed to penetrate the calcified cartilage zone, which followed by lag screw arthrodesis has recently been
effectively prevented transarticular bone formation. In described.33 The technique is only suitable for cases with
addition, complications with necrosis at the site of injec- advanced OA and symmetric joint space collapse, as pre-
tion in three of the eight horses resulted in infection, viously discussed. Needles are placed in the dorsal and
leading to premature termination of the affected horses. palmar/planter PIP joint pouches and laser energy from
All remaining horses were lame at the completion of the a diode laser used to vaporize the cartilage and contract
study, 24 weeks after MIA injection. the periarticular soft tissues. Three 5.5 mm cortex screws
www.ajlobby.com
are then inserted using lag technique through stab inci- Minimally Invasive Techniques
sions, under fluoroscopic or radiographic control. The There are a variety of methods reported to successfully
arthrodesis is accomplished using minimally invasive achieve PIP joint arthrodesis. Minimally invasive tech-
approaches, and laser‐assisted cartilage removal has niques are advocated by some surgeons to reduce the
been described to reduce postoperative lameness.33 risk of infection and maintain collateral ligament sup-
Postoperative cast support can be reduced or modified port, and thereby minimize or negate the need for
to a cast–bandage combination. Outcome in cases with postoperative cast immobilization.13 These techniques
advanced OA has been good, with rapid bony arthrodesis usually entail partial cartilage removal by passing a
and return of soundness, including cases where the pro- 5.5 mm drill bit, via stab incisions, across the joint in
cedure was simultaneously performed bilaterally. Results multiple locations to focally remove cartilage and expose
in cases without major joint space collapse have been subchondral elements.13 Compressive fixation is pro-
disappointing, with delayed union, persisting instability, vided by placing multiple transarticular screws via stab
and profound periarticular new bone production.33 incisions alone or in combination with an axially posi-
However, in selected cases with partial ankylosis and con- tioned plate. The screws are placed in lag fashion from
tinued lameness, it is an economical alternative to open the dorsal–distal aspect of the proximal phalanx into the
surgical repair. Description of its use in additional cases palmar/plantar–proximal aspect of the middle phalanx.
is required before it can be more widely recommended. However, because cartilage removal is not complete,
axial alignment is not reestablished in cases with asym-
metric cartilage degeneration. The consequence of
Surgical Arthrodesis malalignment in the phalanges is increased stress on
Anatomic Considerations the metacarpophalangeal and DIP joints, which may
The PIP joint is closely invested in dense fibrous connec- ultimately affect long‐term athletic performance.
tive tissues with minimal subcutaneous areolar tissue. Furthermore, the strength and stability of the construct
Dorsally, the common digital extensor tendon in the rely entirely on the implants in the early postoperative
thoracic limb, and the long digital extensor in the pelvic period. Where complete cartilage removal and tran-
limb, overlie and are adherent to the fibrous joint capsule. sarticular compressive fixation have been used, addi-
Abaxial to the dorsal extensor tendon are the suspensory tional strength and stability are achieved through
ligaments of the navicular bone and the collateral liga- interfragmentary friction between the subchondral bone
ments of the PIP joint. On the palmar/plantar aspect, the plates of the proximal and middle phalanges. The conse-
deep digital flexor tendon coursing through the d igital quences of incomplete cartilage removal have not been
sheath overlies the middle scutum, which is the fibrocar- established; however, reduced stability may negatively
tilaginous confluence of the straight distal sesamoidean affect patient comfort, reduce the fatigue life of the
ligament, palmar ligament of the pastern joint, and construct, and lead to incomplete arthrodesis. Preserving
fibrous joint capsule. The branches of the superficial the collateral ligaments during open approaches to PIP
digital flexor tendon attach abaxial to the middle scu- arthrodesis dramatically reduced the area of cartilage
tum. The condyle of the proximal phalanx articulates debridement (41.2% compared to 79.6%) in cadaver stud-
with the trochlea of the middle phalanx to form the PIP ies, which suggests that minimally invasive approaches
joint articulation, which relies completely on the periar- should be reserved for advanced arthritic cases.16
ticular dense fibrous connective tissues for stability.
Open Surgical Approaches
Surgical Objectives The open approach to the PIP joint allows removal of all
Surgical arthrodesis is intended to provide a mechanical articular cartilage from the proximal and middle phalan-
environment that will facilitate bony fusion, provide ges, with the exception of the very palmar/plantar aspect
maximal patient comfort, and allow an early return to of the middle phalanx. In cases with advanced OA, open-
unprotected weight bearing. A biologic environment ing the joint is complicated by periarticular new bone
consisting of an adequate blood supply and other requi- formation and, rarely, partial ankylosis. The decision to
site healing elements is also mandatory. In patients with open the joint in these situations is determined by the
significant malalignment between the proximal and mid- degree of difficulty and the need for axial realignment of
dle phalanges, surgery should reestablish the normal the phalanges. However, it has been the author’s experi-
weight‐bearing axis in both the sagittal and frontal ence that most OA‐affected PIP joints can be opened
planes. These goals can best be accomplished by an adequately to allow the removal of the remaining carti-
open approach with partial disarticulation of the PIP lage and perform osteostixis. In the rare instance when
joint, removal of all remaining cartilage, osteostixis, and the articulation cannot be opened, drilling across the
transarticular compressive fixation. joint space to effect partial cartilage removal and expose
www.ajlobby.com
subchondral elements is advised. Use of a 4.5 or 5.5 mm proximal aspects of the proximal phalanx. If additional
drill bit allows better removal of the PIP articular surface exposure is needed proximally, conversion of the inverted‐
when collateral ligaments are spared or the joint is suffi- V to an inverted‐Y incision is not advised. Rather, the
ciently ankylosed to prevent opening.2 Drilling the joint incision into the proximal tendon segment should be near
space is facilitated by fluoroscopy. The palmar/plantar the abaxial border of the extensor tendon. This arrange-
aspect of the joint is drilled from lateral to medial ment of skin and tendon incisions minimizes direct appo-
through an appropriately positioned stab incision. The sition of the skin and tendon incisions, which in the
dorsal aspect is drilled from dorsal to palmar/plantar author’s opinion reduces the risk of deep infection should
from the exposed dorsal joint space in multiple loca- minor skin dehiscence or a superficial infection develop
tions. A limited open approach to the dorsal aspects of postoperatively. Sharp dissection is necessary to elevate
the PIP joint has been described in advanced OA cases, the incised extensor tendon, which is closely adhered to
where opening the pastern is not necessary or possible.14 the underlying proximal phalanx and PIP joint capsule.
Shorter surgery and hospitalization times were evident As the incised tendon is elevated distally, the PIP joint
in a series of 11 horses, similar to techniques using laser‐ capsule is freed from its attachment to the proximal pha-
assisted ankylosis and minimally invasive implant inser- lanx, along with the extensor tendon. Ease of dissection
tion.33 The ideal approach to the PIP joint for arthrodesis is dependent on the amount of dorsal periarticular new
clearly depends on the severity of PIP OA. bone formation. In advanced degenerative joint disease,
new bone may become incorporated within the extensor
Surgical Technique tendon, making the dissection difficult. A sharp oste-
A tourniquet is generally avoided in order to derive max- otome is useful to carry out the distal dissection and may
imal benefit from perioperative antimicrobial prophy- be necessary to expose areas where new bone formation
laxis. A combination of an aminocyclotol and beta has invaded the tendon substance. For plate application,
lactam antimicrobials are administered intravenously the dissection is continued distally over the axial aspect of
30 minutes prior to induction of anesthesia. The horse is the middle phalanx. Once the dorsoproximal attachment
positioned in lateral recumbency with the affected leg of the pastern joint capsule is freed, abaxial dissection at
uppermost. Special care is taken to prepare the hoof by the bases of the V incisions into the dorsal aspects of the
removing the periople from the hoof wall. The distal collateral ligaments allows the PIP joint to be opened dor-
hoof and solar surface are isolated with a water‐impervious sally. Dorsal luxation of the PIP joint can be facilitated by
material. Hair is clipped with a #50 blade from the inserting a retractor between the proximal and middle
coronet to the mid‐metacarpal/metatarsal region. After phalanges for distraction. With sequential transection of
the limb is cleansed, the medial and lateral palmar/plantar the medial and lateral collateral ligaments, the articular
nerves are desensitized just proximal to the abaxial sesa- surfaces are better exposed. This approach provides
moid region. Regional anesthesia is repeated if needed at access for complete cartilage removal and, in fracture
the end of the procedure. The pastern region is prepared cases, allows precise delineation of fracture lines for opti-
for aseptic surgery and draped appropriately, including a mal screw placement.
sterile glove over the foot and the use of adhesive drapes Complete removal of the articular cartilage from the
impregnated with antiseptic. proximal and middle phalanx is accomplished with the
Exposure of the PIP joint begins with an inverted‐T joint flexed open and distracted to its maximal extent.
skin incision (see Figure 17.7 in Chapter 17). The longitu- Although power‐driven equipment has been advocated
dinal component of the incision is centered on the dorsal for this purpose, a curette will suffice. Removal of all
midline of the digit and extends distally from the proxi- accessible articular cartilage is important. Remaining
mal third of the proximal phalanx, ending about 2 cm cartilage will act as a barrier to the bridging of the joint by
proximal to the coronary band. The skin is then incised osseous tissue. Additionally, complete contact between
parallel and proximal to the coronary band, forming the the subchondral bone plates of the proximal and middle
horizontal component of the inverted‐T skin incision. phalanges ensures maximal compression and friction
Skin flaps are dissected abaxially, with care taken to pre- between the subchondral bone surfaces. Furthermore, in
serve the sparse subcutaneous tissue attachments to the patients with asymmetric cartilage loss resulting in either
dermis immediately superficial to the underlying exten- a varus or a valgus deformity, removal of the remaining
sor tendon. Dorsal branches of the digital artery and vein cartilage will reestablish axial alignment through the
will be encountered as the dissection of the medial and phalanges. Once cartilage removal is complete, the sub-
lateral skin flaps approaches the abaxial extents of the chondral bone plates of the proximal and middle phalan-
horizontal incision. The extensor tendon is incised in an ges are perforated with a 2.5 mm drill bit in multiple
inverted‐V configuration, with the base of the V near the locations to provide access to the vascular and cellular
abaxial aspects of the PIP joint and the apex in the mid to elements of the medullary bone (Figure 18.8).
www.ajlobby.com
the cortical bone on the palmar/plantar aspect of the

middle phalanx risks impingement on these structures.
Additionally, penetration of the palmar/plantar cortex
during preparation of the thread hole is likely to litter the
area with bone debris. Either of these consequences may
negatively affect outcome.30 To avoid the navicular
region, the screws can be angled to engage the palmar or
plantar eminences of the middle phalanx. However, with
eminence purchase, the screws cross the PIP joint pal-
mar/plantar to the center of rotation, sacrificing com-
pression of the dorsal aspect. Resultant micromotion at
the dorsal aspect of the PIP joint will cause pain and
stimulate excessive new bone formation. The new bone
may impinge on the DIP joint or the extensor tendon.
Furthermore, when the PIP joint flexes, during the first
Figure 18.8 Surgical repair with osteostixis of the subchondral
portion of the stance phase, screws placed palmar/
bone plates of the proximal and middle phalanges following plantar to the center of rotation will be subjected to
complete cartilage removal. increased bending forces. With cyclic loading, this could
increase the risk of fatigue failure of the construct.
In more recent years, small bone plates have been
Implant Choices incorporated into the arthrodesis construct. Although
In 1978, the technique of placing three parallel, tran- their use was initially reserved for fractures involving the
sarticular 4.5 mm cortex screws in lag fashion was PIP joint, especially middle phalanx fractures, plates are
introduced.24 Over the next three decades a number of now commonplace in routine PIP joint arthrodesis.12,15
variations have been evaluated. Variations include differ- The use of an axially positioned plate with transarticular
ent screw size, number of screws, and angulation of the 5.5 mm cortex screws abaxial to the plate and placed in
screws in the frontal plane.4,10,18 The variation with the lag fashion provides a more stable construct than tran-
most impact was increasing screw size from 4.5 to sarticular screws alone.7,28 Greater stability increases
5.5 mm. In adult metaphyseal bone, the holding power patient comfort immediately following s urgery, reducing
and tensile strength of a 5.5 mm cortex screw are about stress on the support limb and allowing cast removal in
50% greater than a 4.5 mm cortex screw.35 They also have the early postoperative period. Furthermore, the fatigue
over twice the area moment of inertia and are therefore life of the plate–screw construct is substantially greater,
substantially stiffer in bending. However, when tested in reducing the risk of construct failure that might occur
vitro to failure mode, no significant difference was delin- with an early return to unprotected weight bearing.8,28
eated between three 4.5 mm, three 5.5 mm, or two Initial reports utilized narrow dynamic compression
5.5 mm cortex screws in bending moment, stiffness, or plates (DCPs), varying in length from three to five
cycles to failure when PIP joint arthrodesis constructs holes.15,23 Currently, a three‐hole locking compression
with intact cartilage were tested in extension using three‐ plate (LCP) designed specifically for PIP joint arthrode-
point bending.3,21,32 However, the contribution of fric- sis (Figure 18.9) is preferred by the author. An axial plate
tional forces between the subchondral bone plates, in combination with abaxial transarticular screws pro-
generated by placing the screws in lag fashion, on the vides the most stable and fatigue‐resistant PIP joint
mechanical behavior of the construct is not accounted arthrodesis construct.7,8,23 In this configuration, the
for by this testing methodology. It is likely that there is screws cross the PIP joint approximately halfway
substantial advantage to three 5.5 mm screws, as they are between the center of rotation and the palmar/plantar
capable of generating significantly more compression,
and therefore greater interfragmentary frictional forces,
than three 4.5 mm or two 5.5 mm screws when placed in
lag fashion. It is important to note that for screws alone
to provide uniform dorsal to palmar/plantar compres-
sion across the PIP joint, they must cross the articulation
at, or very near, the instant center of joint rotation.
Figure 18.9 Three‐hole 4.5 mm locking compression plate
However, screws placed through the center of the joint designed specifically for proximal interphalangeal arthrodesis.
are on course to enter the region of the navicular bone The distal stacked combi hole provides minimal intrusion to soft
where it articulates with the middle phalanx. Purchase in tissues over the middle phalanx and distal interphalangeal joint.
www.ajlobby.com
(A) (B)
Figure 18.10 Dorsopalmar (A) and lateromedial (B) radiographic projections showing appropriate position of implants using an axial
locking compression plate and abaxial 5.5 mm cortex screws placed in lag fashion.
joint margin, compressing the palmar/plantar aspects screws do not extend beyond the palmar/plantar corti-
of the proximal and middle phalanges (Figure 18.10). ces of the proximal and middle phalanges.
Directing these screws into the palmar or plantar
eminences eliminates the risk of impingement on the Routine Plate Application
navicular region. Dorsal compression is achieved by After cartilage removal and osteostixis are complete, the
loading the plate, either through the dynamic compres- joint is realigned and a narrow three‐hole plate is con-
sion property of the plate or with the tension device. toured to the dorsal midline. Plate contouring is mini-
This combination of implants provides greater and more mized by removing the majority of dorsal new bone
uniform compression, and therefore stability, between which has formed secondary to OA, using an osteotome
the subchondral bone plates. In addition, the screws and rongeurs to level the proximal phalanx and the prox-
prevent open bending of the plate when the forces of imal aspect of the middle phalanx. Care must be taken to
weight bearing would extend the joint, and the plate avoid excessive distal dissection and bone removal, as
protects the screws from bending during the flexion the proximal insertion of the DIP joint capsule can be
phase of the stride. Some authors maintain that the inadvertently damaged. The plate is positioned with its
increased technical difficulty and duration of surgery solid middle section overlying the joint space, with the
required for plate–screw constructs are major draw- single‐hole end of the plate overlying the proximal aspect
backs to the procedure when compared with using only of the middle phalanx. The distal end of the plate is
5.5 mm screws. However, incorporating a bone plate positioned as proximal as possible on the middle pha-
into the arthrodesis requires minimal additional techni- lanx. However, it is important to ensure that the middle
cal expertise, and the extra time required is of little phalanx screw is placed just distal to the subchondral
significance with the quality of anesthesia available
plate and into the proximal palmar/plantar aspect of
today. Regardless of implant choices, precise positioning the middle phalanx. With the PIP joint arthrodesis LCP,
of the implants is important to the outcome. This is the end of the plate containing the stacked combi hole
best accomplished using real‐time image intensification must be bent slightly toward the middle phalanx to
during implantation. If fluoroscopic control is not avail- allow the orthogonally positioned locking screw to
able, intraoperative radiographic control is mandatory attain the appropriate position in the middle phalanx
to appropriately position the implants and ensure that (see Figure 18.10). With nonlocking plates, this is less of
www.ajlobby.com
a concern as the screw can be angled relative to the plate 4.5 mm narrow DCP and 5.5 mm cortex screws for PIP
hole. To ensure close approximation of the plate to the arthrodesis. Mechanical studies on cadaver specimens
bone when using the LCP, the push–pull device (see showed minor advantages to the use of the 4.5 mm LCP
Figure 8.9 in Chapter 8) is positioned through the compared to the 4.5 mm DCP as standalone implants
threaded hole just proximal to the joint and used to press for stabilization of the pastern.22,26 Use of just a single
the plate against the proximal phalanx. The distal 5.0 mm dorsal plate is generally inadequate for pastern arthro-
locking screw is placed and tightened in the middle pha- desis, and mechanical comparisons of the 4.5 mm
lanx. The most proximal screw in the plate is prepared limited‐contact dynamic compression plate (LC‐DCP)
for a standard cortex screw. Depending on the surgeons’ and the 4.5 mm LCP in combination with two 5.5 mm
preference, the proximal plate screw may engage both transarticular screws suggest that the LCP may provide
cortices or just the dorsal cortex of the proximal phalanx. a stiffer construct that better resisted bone displace-
The author prefers monocortical placement, but it ment.1 The biomechanical effect on construct stiffness
should be noted that in many Quarter Horses, a 4.5 mm varies in axial and torsional testing, with few differ-
screw must be used to allow appropriately short screw ences between the DCP and LCP when combined with
lengths due to the small medullary cavity in this location. two 5.5 mm transarticular screws tested in axial com-
In most instances the proximity of the palmar or plantar pression, but improved yield load and stiffness of the
cortex will not allow use of even the shortest 5.5 mm LCP construct under torsion.29 Either DCP or LCP
screw (24 mm) if placed in monocortical fashion. is acceptable in combination with two 5.5 mm tran-
The screw hole is prepared using the load guide to pro- sarticular screws, and at least one study evaluating
vide dynamic compression during screw tightening. integrity after cyclical load found no differences in fail-
Alternatively, with additional proximal dissection, the ure mode or sustained loads.36 From a clinical perspec-
tension device can be used for this purpose. In either tive, use of the LCP rather than the DCP, in combination
instance, plate compression is not applied until place- with a pair of 5.5 mm transarticular screws, may shorten
ment of the abaxial, transarticular screws has been the postoperative period in a cast and reduce hospitali-
completed. zation time.12
The transarticular screws are placed using standard Care during drilling, tapping, and screw placement is
lag technique for 5.5 mm cortex screws. As discussed vital during plate and lag screw insertion to avoid extend-
previously, direction of screws in the frontal plane is ing beyond the palmar/plantar cortices, particularly
dependent on whether screws alone or a plate–screw when the desired outcome is a return to athleticism.
construct is chosen. With a plate–screw construct, all Real‐time fluoroscopic control helps prevent technical
screws in the middle phalanx are directed into the errors. Appropriate images, including oblique views,
proximal eminence region, well proximal to the navicu- documenting the position of the screws in the palmar/
lar bone and associated structures. The transarticular plantar eminences should be evaluated prior to closure.
screws are positioned parasagittally, one on either side Screws that exit the palmar/plantar cortices should be
of the plate, and angled to engage their respective pal- replaced with screws of appropriate length.
mar/plantar eminence. It is important to adequately
countersink the dorsal cortex of distal P1 to ensure uni- Closure
form contact of the screw heads as they are tightened. Closure of the soft tissue envelope is routine. The tendon
In most cases, the measuring device will overestimate is apposed using #1 monofilament, absorbable suture.
the appropriate length for the transarticular lag If needed, a few tension‐relieving horizontal mattress
screws by 4–6 mm, and this should be considered when sutures can be used initially, but for the most part the
selecting the length of screw for initial placement.
author uses an inverted cruciate pattern. If there is excess
Modification after intraoperative radiography or fluor- tension, closure can be facilitated by having an assistant
oscopy may be required. After the transarticular screws forcibly extend the DIP joint by applying pressure to the
are fully tightened, plate application is completed. If toe region of the hoof. It is important to achieve a secure
using the dynamic compression feature of the plate, a closure without gaps. If subcutaneous tissues are availa-
4.5 or 5.5 mm screw (depending on the size of the horse) ble, they are apposed over the extensor tendon using a
is placed in the load position in the proximal plate hole simple continuous pattern. This is especially useful for
and fully tightened. The second hole of the plate should providing an additional soft tissue layer in the proximal
be filled with a 5.0 mm locking screw. If the tension aspect of the incision, where the apex of the tendon inci-
device is used, both screws in the proximal phalanx can sion is directly beneath the longitudinal component
be 5.0 mm locking screws, and these are applied with of the skin incision. The longitudinal skin incision is
the tension device fully loaded. Prior to availability of apposed using three or four tension‐relieving sutures in
the locking compression implants, the author used a combination with skin staples or a simple continuous
www.ajlobby.com
suture of monofilament nonabsorbable material. The may have contributed to complications, particularly frac-
horizontal skin incision proximal to the coronet is ture through the screw holes in the proximal phalanx.19
usually apposed with inverted cruciate sutures or other Currently, techniques leaving the dorsal cortex intact
mildly everting pattern. between screws are favored. These include both a modified
technique for normograde drilling as well as drilling the
Cast Support glide holes in the proximal phalanx in retrograde fashion.
The surgical wound is bandaged aseptically, followed by Appropriate screw angle in the dorsoproximal to
routine application of a distal limb cast. Although the palmarodistal direction for optimal fixation has been
surgical construct is protected by a cast, precautions previously discussed. The screws should cross the joint
during recovery are advisable to help ensure the patient’s just palmar (plantar) to the midpoint when viewed on a
safety and minimize the likelihood of injury to structures lateral to medial radiograph. With the appropriate proxi-
near the proximal aspect of the cast. This author prefers mal to distal angle of the screw, maximal purchase in the
to place the horse on a thick pad with the casted limb middle phalanx will be obtained and interfragmentary
uppermost and to control the recovery. In most cases, compression maximized. However, penetration of the
premature attempts to stand can be controlled by the palmar (plantar) cortex of the middle phalanx near its
judicious use of sedatives and physical restraint. Once distal articulation with the navicular bone must be
the patient has regained a state of consciousness compat- avoided.30 Fluoroscopic control is highly recommended
ible with standing, assistance is provided by means of to ensure that screw hole preparation and screw place-
head and tail restraints. ment are precise.
The cast has two primary functions: it protects the
bone–implant construct during recovery from anesthe-
sia, and immobilizes the soft tissue envelope to promote Postoperative Care
healing and reduce the likelihood of wound dehiscence.
In the past, when less stable forms of fixation were used to Postoperatively, perioperative antimicrobial therapy is
achieve arthrodesis, postoperative cast immobilization continued for a minimum of 48 hours, and in many
usually extended for six to eight weeks.4,19,24,30 In most instances antimicrobials are continued until postopera-
cases the initial cast was replaced between the second and tive Day 5. Although this extended period of intravenous,
third postoperative weeks, often with the patient under broad‐spectrum, bactericidal therapy may seem unwar-
general anesthesia. The increased morbidity and expense ranted, the location (near the foot) and configuration
associated with an extended period of cast immobility (inverted‐T) of the incision, the amount of soft tissue
and hospitalization were necessary to achieve reasonable dissection required, the presence of implants, and the
patient comfort when transarticular screws were used inability to monitor the incision due to the presence of
without the addition of an axial plate. Furthermore, early a cast justify an extended period of prophylaxis.
cast removal subjects screw constructs to higher loads, Phenylbutazone therapy is also continued for an extended
and the increased number of loading cycles could con- period postoperatively. In the immediate perioperative
tribute to fatigue failure of the screws or bone–screw period, 4.4 mg kg−1 is administered; however, the dose is
construct. Incorporating an axial plate into the construct reduced after 24 hours to 2.2 mg kg−1 twice daily.
provides significantly greater stability and markedly Depending on patient comfort, phenylbutazone may be
improves patient comfort. With increased patient com- discontinued or the dose further reduced during the
fort, early cast removal is feasible, since the patient is will- period of hospitalization. Most horses having arthrode-
ing to place substantial weight on the operated limb, sis using the plate–screw method will be fully weight
which reduces the likelihood of support limb laminitis. In bearing on the casted limb within the first few days fol-
addition, the risk of fatigue failure secondary to the lowing surgery, even on low doses of phenylbutazone.
increased load and number of loading cycles inherent Removal of the cast is accomplished standing under
with early, unprotected weight bearing on the arthrodesis sedation, approximately two weeks postoperatively. The
is significantly reduced when the plate–screw construct is limb is thoroughly cleaned and all sutures and approxi-
used. This reduces hospitalization time.12 mately half of the staples are removed. The incision is
covered with a sterile nonadherent pad held in place
with sterile gauze and secured with an elastic adhesive
Alternative Methods: Transarticular Lag bandage, ensuring that the bandage is adhered to the
Screw Arthrodesis skin proximally and the hoof distally to prevent outside
In the original description of PIP arthrodesis, a shelf was contamination. The distal limb is subsequently placed
created in the dorsal cortex of the proximal phalanx a few in a well‐padded pressure wrap. The initial post‐cast
centimeters proximal to the joint.24 Creating this shelf bandage is replaced in two to three days, at which time
www.ajlobby.com
the remainder of the staples are removed. The wound sodes of trotting can be initiated. If fusion is not yet com-
should be protected with a distal limb pressure wrap for plete, an additional 30–60 days of pasture exercise are
a total of three weeks after the cast is removed. recommended. Although most horses are back in work
The horse should be confined to a stall for three within 9–10 months after surgery, some will require a
months after discharge from the hospital. Exercise dur- more prolonged period of convalescence. It has been the
ing the initial six weeks is limited to daily hand grazing. author’s observation that soundness, as assessed by the
After six weeks, an escalating program of hand‐walking owner, often continues to improve between the first and
exercise is instituted. If possible, the patient should be second years following surgery.
walked twice daily, using 5–10‐minute sessions during
the first week. Each week, the duration of walking per
session can be increased by 5–10 minutes. Three months Complications
postoperatively, reevaluation is performed. Follow‐up
evaluation should include a brief assessment of the Open reduction and internal fixation (ORIF) for PIP
degree of lameness and a radiographic evaluation. Most arthrodesis has a number of potential complications.
horses will continue to be lame (grade 3/5) three months The two most serious are construct failure and infection.
after surgery, especially if trotted on a hard surface. Neither is common, consistent with the incidence of
Radiographs should reveal consolidation along the joint infection or construct breakdown when ORIF is per-
space; however, radiographic fusion is seldom complete formed on an elective basis in other locations. Construct
in adult horses (Figure 18.11). Providing there are no failure has been reported only for transarticular screw
obvious complications, most horses are allowed access to arthrodesis. The original description of transarticular
small paddock exercise in a gradual manner, starting ini- screw arthrodesis recommended forming a shelf in distal
tially with short, frequent turnouts. Over time, the dura- P1 to facilitate drilling and seating of the screw head.24
tion of free exercise is increased, with the goal of making This step in the procedure has long been abandoned and,
the transition from stall confinement with hand walking based on more recent literature, this seems to have sub-
to unrestricted pasture exercise within approximately stantially reduced the incidence of fracture along the
one month. drill holes in dorsodistal P1. However, in vitro fatigue
Return to work depends on the horse’s progress. In testing comparing transarticular, parallel screw con-
most cases, lameness will resolve or be minimal by about structs (without a shelf in distal P1) to axial plate/abaxial
six months after surgery, and a gradual return to perfor- screw constructs resulted in failure through screw holes
mance can be initiated. If obvious lameness is present at in distal P1 of the parallel screw arthrodesis in five of
this time, and radiographic fusion is evident (Figure 18.12), the six constructs, just as described in clinical cases
a program of extended walks under saddle with brief epi- of construct failure.8 However, in the plate–screw arthro-
(A) (B) (C) (D)
Figure 18.11 Typical postoperative radiographic appearance of mature horse approximately three months postoperatively:
(A) dorsopalmar; (B) lateromedial; (C) dorsolateral‐palmaromedial oblique (DLPMO); and (D) plantarolateral‐dorsomedial oblique (PLDMO)
projections showing complete cartilage removal and appropriate plate screw and lag screw position. Same case as Figure 18.5A.
www.ajlobby.com
(A) (B) Figure 18.12 Radiographic fusion

approximately six months postoperatively:
(A) dorsopalmar and (B) lateromedial
projections show bony union and
appropriate proximal and middle
phalangeal alignment.
deses, construct failure occurred in only one of the six intimate bone contact and the application of compres-
constructs and required a significantly greater number sion between the subchondral bone of the proximal and
of cycles to fail.8 Furthermore, in a retrospective study of middle phalanges at the pastern is not achieved with
58 axial plate/abaxial screw arthrodeses, there were no either technique. Islands of remaining cartilage after
instances of construct failure reported.15 drilling must degenerate and eventually be replaced by
As with any procedure requiring extensive exposure bone, which can take an extended period of time.
and implant fixation, there is a risk of infection. Studies Furthermore, stability is reliant to a greater degree on
documenting infection following internal fixation have the implants rather than augmented by frictional forces
noted lower risk with lag screw fixation than for fixation generated through compression of opposing subchon-
involving plate application.17 However, lag screw fixation dral bone surfaces. This is particularly important in
for fracture repair in most regions of the body is often cases where there is early OA with minimal to no col-
applied using minimally invasive procedures, which is lapse of the joint space and minimal periarticular stiff-
rarely the case in pastern arthrodesis, where an open ness or partial ankylosis. For these reasons, the author
exposure is advocated for cartilage removal and implant favors an open approach with exposure and complete
placement for both parallel screw and dorsal plate/ removal of the articular cartilage. If the degenerative
abaxial screw techniques. There have been reports of process is far advanced and the degree of preexisting
both arthrodesis techniques without infection as a ankylosis precludes articular exposure, the joint space
complication.18,19,23 Other reports, show nearly identical is drilled and a plate–screw arthrodesis proceeds as
infection/implant loosening rates of approximately 10% previously described. However, it has been the author’s
for both procedures.4,15 experience that although preoperative radiographs may
Reducing infection rates by using minimally invasive suggest an advanced degree of ankylosis and predict an
techniques is attractive, and there are reports of arthro- inability to expose the articular surfaces, it is often still
deses where the joint is not exposed for cartilage possible to successfully expose the articular surfaces for
removal and implants are placed percutaneously.13,33 complete cartilage debridement and osteostixis using
This is most appropriate in cases of advanced OA the open approach. Furthermore, it is relatively com-
accompanied by significant loss of joint space and par- mon for these types of cases to have significant angula-
tial ankylosis. In these cases, cartilage and subchondral tion through the joint due to asymmetric cartilage
bone can be partially debrided by drilling across the degeneration and joint space collapse (see Figure 18.6).
joint space with a 5.5 mm drill bit,13 or with a diode Removal of the remaining cartilage allows realignment
laser.33 However, complete cartilage removal allowing in the sagittal plane, normalizing force distribution
www.ajlobby.com
through the digit, which will improve long‐term out- be minimized by providing maximal dorsal stability
come and justifies the additional effort. by plate application.
A number of additional complications have been
associated with pastern arthrodesis, including toe ele-
vation, bone spur formation at the extensor process of Prognosis
the distal phalanx, and DIP arthrosis.19 Toe elevation
was noted in two horses which had undergone arthro- Success, defined as the patient attaining the owner’s
desis in a forelimb. Although damage or laxity to the desired level of serviceability following arthrodesis of the
deep flexor tendon could explain this occurrence, PIP joint, is highly probable. In four studies where the
there were no additional findings suggesting flexor ten- transarticular parallel screw method was employed for
don damage. Other possible explanations include dam- arthrodesis, success ranged from 46% to 85% in the fore-
age to the suspensory ligament of the navicular bone or limb and 83% to 89% in the hindlimb.4,19,23,30 In these
altered biomechanics of the digit, with the latter more case studies, 4.5 mm cortex screws were using in lag
likely. As the fetlock descends during the stance phase fashion and placed either parallel or in a slightly converg-
of the stride, the ability of the solar aspect of the toe to ing configuration. In general there appeared to be little
remain in contact with the ground may, in some horses, influence of factors such as age, use, duration of clinical
depend on the ability of the pastern joint to flex as the signs, or cause of OA on outcome. The one exception
fetlock and pastern regions drop and fulcrum over the seemed to be that horses with hindlimb lameness attrib-
heels. If flexion of the pastern is eliminated by arthro- utable to the pastern joint were more likely to have a suc-
desis, the fulcrum effect of the heels displaces the distal cessful outcome.4,19 Postoperatively, a fiberglass cast was
aspect of the middle phalanx dorsally into the extensor applied to protect the fixation during recovery and for
tendon and might cause the toe to elevate. If the exten- the first 6–12 weeks. Six weeks of cast immobilization
sor tendon is invaded by excessive new bone formation were initially reported to be adequate postoperative
associated with the arthrodesis, the loss of pliability support for routine PIP arthrodesis.10,24 However, in
could enhance this effect. This same mechanism likely subsequent reports, postoperative cast immobilization
contributes to exostosis formation at the insertion of ranged from 60 to 100 days and required multiple cast
the common or long digital extensor tendon on the applications.4,19,30 The duration of the postoperative
extensor process of the distal phalanx, as well as arthro- convalescent period was variable. Some horses were
sis of the DIP joint. Horses with long pasterns would be reported to be free of lameness as early as four months
predisposed, as would those with excessive new bone postoperatively.10,24 However, 10–12 months, and occa-
formation with invasion of the extensor tendon and sionally up to 18 months, were necessary for lameness to
subsequent tie‐down over the dorsal aspect of the pas- resolve in others.4,19 More recently, a series of horses
tern joint. These complications should be reduced by arthrodesed with two 5.5 mm cortex screws placed par-
minimizing secondary new bone formation, which is allel and in lag fashion demonstrated the superiority
best accomplished using the plate–screw method of of 5.5 mm screws over 4.5 mm screws.18 In that report,
arthrodesis. horses were maintained in a distal limb cast for a mean of
Implant associated lameness can occur if a screw pen- 27 days (range 5–78) and, in most cases, only a single
etrates the palmar (plantar) cortex of the middle phalanx cast was necessary. Although precise follow‐up informa-
and encroaches on the navicular region.30 Furthermore, tion was unavailable in this report, it was the author’s
even a properly positioned screw which is too long may impression that young horses returned to work between
cause persistent irritation to the soft tissue structures 3 and 6 months postoperatively, and older horses
and result in lameness. The importance of appropriate between 12 and 18 months.18
implant positioning and length cannot be overempha- There has been one study comparing results of tran-
sized. As previously discussed, the axial plate technique sarticular screws using three 5.5 mm screws, placed par-
reduces the likelihood of damage to the navicular region allel and in lag fashion, to axial plate/transarticular
and palmar/plantar aspect of the coffin joint. Adherence screw constructs using the DCP and LCP plates.12
to proper technique and intraoperative imaging are nec- Successful return to function was similar for DCP and
essary to ensure appropriate screw length and position, LCP combinations (82% and 79%, respectively), and
regardless of technique. Pain originating from the DIP both compared favorably to the three 5.5 mm screw
joint may also be associated with distal progression of technique (83%). Advantages of plate fixation included
excessive new bone formation on the dorsal cortex of the earlier cast removal and earlier discharge from the
middle phalanx. Prevention is through early intervention clinic. However, for performance horses, outcome was
and arthrodesis before new bone formation becomes significantly improved for arthrodesis of the hindlimb
exuberant. Postoperative new bone formation can best pastern compared to the forelimb (hindlimbs 33 of 45,
www.ajlobby.com
73%; compared to forelimbs 4 of 16, 25%). Outcome superior to previous reports using only transarticular
data for forelimb PIP arthrodesis in this study seems to screws. Combining the results of four previous studies
be lower than most previous reports using a combina- using only transarticular screws, 76 of 97 (78%) were con-
tion of axial plate and two transarticular screws, which sidered successful, including 28 of 41 (68%) forelimb and
suggests differing patient populations, criteria used to 48 of 56 (86%) hindlimb arthrodeses.4,19,23,30 In a more
gauge success, and surgical technique.12,15 In another detailed analysis of the results of the plate–screw arthro-
study, transarticular screw arthrodeses were compared deses, 24 of 28 (86%) horses intended for performance
to constructs that were supplemented with an axial (not breeding or pleasure riding) functioned at their
plate applied dorsally, following standard insertion of intended activity and at a level consistent with owner’s
the three 5.5 mm parallel transarticular screws.23 In that expectations, including 9 of 12 (75%) with affected fore-
report there was no difference in outcome between the limbs and 15 of 16 (94%) with hindlimb involvement.15 In
two techniques. However, the duration of immobiliza- this subset of horses, the time required to return to per-
tion in a cast was significantly less: a median of 5 weeks formance activities was a mean of 9.5 months (range
(range 2–7), compared to a median of 12 weeks (range 3–12). Mean duration of postoperative cast support for
6–14) for cases with screws alone. Furthermore, horses all horses in the study was 14 days (range 12–27), with
with the transarticular screws combined with a plate 93% of the horses requiring a cast for less than 15 days.
were considered sound after a median of 8 months The authors suggest that superior results following the
(range 6–12), compared to a median of 12 months axial plate/abaxial screw method may be related to
(range 8–24) in the cases repaired using transarticular increased stability of the construct, less impingement on
screws alone. the navicular region by the implants, and lower morbidity
Results of the axial plate/abaxial transarticular screw related to prolonged cast support. In addition, it was their
construct for arthrodesis have been reported for 58 limbs impression that horses with minimal radiographic signs
in 53 horses.15 Overall, 87% of the patients were able to of PIP joint degeneration appeared to have shorter conva-
return to their intended use, 81% with a forelimb and 95% lescence and were less likely to have excessive new bone
with a hindlimb affected. Outcomes in this study are formation around the PIP joint.
References
1 Ahern, B.J., Showalter, B.L., Elliott, D.M. et al. (2013). In injections: 34 cases (2006–2012). Equine Vet. J. 45:
vitro biomechanical comparison of a 4.5 mm narrow 442–447.
locking compression plate construct versus a 4.5 mm 6 Colahan, P.T., Wheat, J.D., and Meagher, D.M. (1981).
limited contact dynamic compression plate construct for Treatment of middle phalangeal fractures in the horse.
arthrodesis of the equine proximal interphalangeal joint. J. Am. Vet. Med. Assoc. 178: 1182–1185.
Vet. Surg. 42: 335–339. 7 Easter, J.L. and Watkins, J.P. (1998). An in‐vitro
2 Bras, J.J., Lillich, J.D., Beard, W.L. et al. (2011). Effect of a biomechanical evaluation of two techniques for
collateral ligament sparing surgical approach on proximal interphalangeal arthrodesis in the horse. In:
mechanical properties of equine proximal Proceedings of the Veterinary Orthopedic Society, vol.
interphalangeal joint arthrodesis constructs. Vet. Surg. 25, 29. Parker, CO: VOS.
40: 73–81. 8 Eastman, T.G. and Watkins, J.P. (2002). Fatigue
3 Carmalt, J.L., Delaney, L., and Wilson, D.G. (2010). properties of two techniques for arthrodesis of
Arthrodesis of the proximal interphalangeal joint in the proximal interphalangeal joint by cyclical load
horse: a cyclic biomechanical comparison of two and to failure. In: Proceedings American College of
three 5.5 mm parallel cortical screws inserted in lag Veterinary Surgeons, vol. 12, 481. Germantown, MD:
fashion. Vet. Surg. 39: 91–94. ACVS.
4 Caron, J.P., Fretz, P.B., Bailey, J.V., and Barber, S.M. 9 Fjordbakk, C.T., Strand, E., Milde, A.K. et al. (2007).
(1990). Proximal interphalangeal arthrodesis in the Osteochondral fragments involving the dorsomedial
horse: a retrospective study and a modified screw aspect of the proximal interphalangeal joint in young
technique. Vet. Surg. 19: 196–202. horses: 6 cases (1997–2006). J. Am. Vet. Med. Assoc.
5 Caston, S., McClure, S., Beug, J. et al. (2013). 230: 1498–1501.
Retrospective evaluation of facilitated pastern 10 Genetzky, R.M., Schneider, E.J., Butler, H.C., and Guffy,
ankylosis using intra‐articular ethanol M.M. (1981). Comparison of two surgical procedures
www.ajlobby.com
for arthrodesis of the proximal interphalangeal joint in compression plate and locking compression plate
horses. J. Am. Vet. Med. Assoc. 179: 464–468. constructs for proximal interphalangeal joint
11 Groom, L.J., Gaughan, E.M., Lillich, J.D., and Valentino, arthrodesis in the horse. Can. Vet. J. 56: 615–619.
L.W. (2000). Arthrodesis of the proximal 23 Schaer, T.P., Bramlage, L.R., Embertson, R.M., and
interphalangeal joint affected with septic arthritis in 8 Hance, S. (2001). Proximal interphalangeal arthrodesis
horses. Can. Vet. J. 41: 117–123. in 22 horses. Equine Vet. J. 33: 360–365.
12 Herthel, T.D., Rick, M.C., Judy, C.E. et al. (2016). 24 Schneider, J.E., Carnine, B.L., and Guffy, M.M. (1978).
Retrospective analysis of factors associated with Arthrodesis of the proximal interphalangeal joint in the
outcome of proximal interphalangeal joint arthrodesis horse: a surgical treatment for high ringbone. J. Am.
in 82 horses including Warmblood and thoroughbred Vet. Med. Assoc. 173: 1364–1369.
sport horses and Quarter Horses (1992–2014). Equine 25 Schneider, R.K., Ragle, C.A., Carter, B.G., and Davis,
Vet. J. 48: 557–564. W.E. (1994). Arthroscopic removal of osteochondral
13 James, F.M. and Richardson, D.W. (2006). Minimally fragments from the proximal interphalangeal joint of
invasive plate fixation of lower limb injury in horses: 32 the pelvic limb in three horses. J. Am. Vet. Med. Assoc.
cases (1999–2003). Equine Vet. J. 38: 246–251. 205: 79–82.
14 Jones, P., Delco, M., Beard, W. et al. (2009). A limited 26 Seo, J.P., Yamaga, T., Tsuzuki, N. et al. (2014). In vitro
surgical approach for pastern arthrodesis in horses with biomechanical comparison of a 5‐hole 4.5 mm locking
severe osteoarthritis. Vet. Comp. Orthop. Traumatol. compression plate and 5‐hole 4.5 mm dynamic
22: 303–308. compression plate for equine proximal interphalangeal
15 Knox, P.M. and Watkins, J.P. (2006). Proximal joint arthrodesis. Vet. Surg. 43: 606–611.
interphalangeal arthrodesis using a combination plate‐ 27 Shoemaker, R.W., Allen, A.L., Richardson, C.E., and
screw technique in 53 horses (1994–2003). Equine Vet. Wilson, D.G. (2006). Use of intra‐articular
J. 38: 538–542. administration of ethyl alcohol for arthrodesis of the
16 Kuemmerle, J.M. and Berchtold, S. (2013). Area of tarsometatarsal joint in healthy horses. Am. J. Vet. Res.
cartilage accessible to curettage for subsequent 67: 850–857.
arthrodesis of the equine proximal interphalangeal 28 Sod, G.A., Riggs, L.M., Mitchell, C.F. et al. (2010).
joint. Comparison of conventional and collateral An in vitro biomechanical comparison of equine
ligament sparing approaches. Vet. Comp. Orthop. proximal interphalangeal joint arthrodesis techniques:
Traumatol. 26: 489–492. an axial positioned dynamic compression plate and
17 MacDonald, D.G., Morley, P.S., Bailey, J.V. et al. (1994). two abaxial transarticular cortical screws inserted
An examination of the occurrence of surgical wound in lag fashion versus three parallel transarticular
infection following routine orthopedic surgery (1981– cortical screws inserted in lag fashion. Vet. Surg.
1990). Equine Vet. J. 26: 323–326. 39: 83–90.
18 MacLellan, K.N.M., Crawford, W.H., and MacDonald, 29 Sod, G.A., Riggs, L.M., Mitchell, C.F., and Martin, G.S.
D.G. (2001). Proximal interphalangeal joint arthrodesis (2011). A mechanical comparison of equine proximal
in 34 horses using two parallel 5.5 mm cortical bone interphalangeal joint arthrodesis techniques: an axial
screws. Vet. Surg. 30: 454–459. locking compression plate and two abaxial
19 Martin, G.S., McIlwraith, C.W., Turner, A.S. et al. transarticular cortical screws versus an axial dynamic
(1984). Long‐term results and complications of compression plate and two abaxial transarticular
proximal interphalangeal arthrodesis in horses. J. Am. cortical screws. Vet. Surg. 40: 571–578.
Vet. Med. Assoc. 184: 1136–1140. 30 Steenhaut, M., Verschooten, F., and De Moor, A.
20 Penraat, J.H., Allen, A.L., Fretz, P.B., and Bailey, J.V. (1985). Arthrodesis of the pastern joint in the horse.
(2000). An evaluation of chemical arthrodesis of the Equine Vet. J. 17: 15–40.
proximal interphalangeal joint in the horse by using 31 Turner, A.S. and Gabel, A.A. (1975). Lag screw fixation
monoiodoacetate. Can. Vet. J. 64: 212–221. of avulsion fractures of the second phalanx in the horse.
21 Read, E.K., Chandler, D., and Wilson, D.G. (2005). J. Am. Vet. Med. Assoc. 167: 306–309.
Arthrodesis of the equine proximal interphalangeal 32 Watt, B.C., Edwards, R.B., Markel, M.D. et al. (2001).
joint: a mechanical comparison of two parallel 5.5 mm Arthrodesis of the equine proximal interphalangeal
cortical screws and three 5.5 mm cortical screws. Vet. joint: a biomechanical comparison of three 4.5 mm and
Surg. 34: 142–147. two 5.5 mm cortical screws. Vet. Surg. 30: 287–294.
22 Rocconi, R.A., Carmalt, J.L., Sampson, S.N. et al. 33 Watts, A.E., Fortier, L.A., Nixon, A.J., and Ducharme,
(2015). Comparison of limited‐contact dynamic N.G. (2010). A technique for laser‐facilitated equine
www.ajlobby.com
pastern arthrodesis using parallel screws inserted in lag metacarpal and metatarsal bones: Part 2. Adult horse
fashion. Vet. Surg. 39: 244–253. bone. Vet. Surg. 14: 230–234.
34 Wolker, R.R., Wilson, D.G., Allen, A.L., and Carmalt, 6 Zoppa, A.L., Santoni, B., Puttlitz, C.M. et al.
3
J.L. (2011). Evaluation of ethyl alcohol for use in a (2011). Arthrodesis of the equine proximal
minimally invasive technique for equine proximal interphalangeal joint: a biomechanical comparison of
interphalangeal joint arthrodesis. Vet. Surg. 40: 3‐hole 4.5 mm locking compression plate and 3‐hole
291–298. 4.5 mm narrow dynamic compression plate, with
5 Yovich, J.V., Turner, A.S., and Smith, F.W. (1985).
3 two transarticular 5.5 mm cortex screws. Vet. Surg.
Holding power of orthopedic screws in equine third 40: 253–259.
www.ajlobby.com
295
19
Fractures of the Proximal Phalanx
Dean W. Richardson
Introduction is minimally traumatic, and reliably prevents future

problems associated with the chip’s presence. Surgical
Fractures of the proximal phalanx are common and take removal does not reverse degenerative changes in the
many configurations in athletic horses. They range from joint, nor does it preclude the possibility of further
simple chip fractures with an excellent prognosis to life‐ trauma along the dorsal rim of the proximal phalanx.
threatening comminuted fractures. Some specific lesions Axial osteochondral fragments involving the proximal
are more common in certain breeds and occupations, palmar/plantar aspect of the proximal phalanx are found
but most types of proximal phalangeal fractures have commonly in young Standardbreds and Warmbloods, but
been seen in virtually every type of horse. can be found in any breed.2,4,31,37 There is still some dis-
pute concerning their etiology, but their histologic appear-
ance indicates that they probably are avulsion fractures
occurring during skeletal development,6,26 along with the
Dorsal and Palmar/Plantar observation that they are identified commonly in horses
Chip Fractures that have not begun training. Most horses exhibit mild
lameness or lameness that is only evident at high speed.
The most common fracture involving the proximal pha- Effusion may be present and response to flexion is incon-
lanx is a chip fracture of the proximal dorsal rim.1,5,9,39 sistent. The most common location for fragments is in the
The lesion occurs frequently in racing Thoroughbreds, plantar medial aspect of the hindlimbs. If the fragment is
but is also seen in other racing breeds, and occasionally considered to be a clinical problem, it can be removed
in show horses and event horses. These intraarticular arthroscopically with excellent success (see Chapter 20).13
fractures are described in detail in Chapter 20. If excessive dissection is avoided during surgical
Diagnosis is made by history, physical signs, diagnostic removal of proximal palmar/plantar chip fractures, these
analgesia, and radiography. Good‐quality radiographs horses can begin walking exercise within two weeks and
are necessary to define small or minimally displaced jogging in six to eight weeks. Very large fragments that
fragments. Many dorsal chip fractures are managed require more dissection should receive three to four
medically with combinations of topical therapy, intraar- months of rest and controlled exercise.
ticular medications, and rest or adjustments in training.
Small nondisplaced chip fractures usually do not com-
pletely heal, but they may develop a fibrous union ade- Major Proximal Phalanx Fractures
quate to stabilize them and prevent clinical signs. Larger
chip fractures or those that are displaced may continue Nearly all major fractures of the proximal phalanx
to cause effusion and lameness despite medical therapy, involve a sagittal plane fracture propagating distally
and should be surgically removed. from the mid‐sagittal groove of the proximal joint
Surgical treatment of dorsal chip fractures has really surface.8,10–12, 14,15,17,19,21,22,32,36 Mechanically, it would
only one disadvantage: expense. The arthroscopic appear that compressive and torsional forces transmitted
removal of these fragments by an experienced surgeon from the sagittal ridge of the cannon bone through the

www.ajlobby.com
sagittal groove are involved. This has recently been veri- obliquely at the mid‐diaphyseal “waist” of the proximal
fied by finite element anlaysis.29 These fractures occur phalanx and propagate toward the lateral cortex.10,15,22,35 It
more commonly in the forelimbs and, although far more is imperative that a minimum of four views be taken in all
common in racehorses, do occur during other activities, cases to correctly define the fracture configuration.
including accidents at pasture.19
Diagnosis Fracture Types

The most common fracture is incomplete and extends Smaller Fractures of the Proximal Phalanx
only a short distance distally from the sagittal groove. Small proximal fractures treated with internal fixation
The lesion is difficult to identify without excellent‐qual- include palmar (plantar) process (wing) fractures,2,4
ity radiographs. Affected horses are usually painful to medial collateral ligament avulsion fractures, and short,
flexion and sensitive to digital palpation over the proxi- incomplete dorsal fractures.22,38 Palmar (plantar) process
mal dorsal aspect of the proximal phalanx. Lameness fractures are seen most clearly on the appropriate oblique
may be improved with perineural anesthesia at the abax- view (Figure 19.2) and may not have dramatic clinical
ial sesamoid level and will be eliminated with a low pal- signs. Internal fixation is usually only performed in acute
mar ring block. Local anesthesia should not be done if cases. Many horses either fracture a palmar (plantar)
there is a suspicion of an incomplete fracture of the prox- process as foals or weanlings or have a developmental
imal phalanx (Figure 19.1). Radiographs should include a disorder that leads to a fibrous union in this location.
well‐exposed dorsopalmar view and a perfect or slightly Screw fixation of such lesions is not usually helpful
underexposed lateral radiograph. The former, especially because of poor alignment and the well‐established
if taken in a slightly proximal to distal direction, reveals fibrous nonunion.
the fracture line, and the lateral view will show callus for- Medial collateral avulsion fractures are seen in young
mation immediately distal to the fetlock joint capsule horses, usually yearlings, and commonly result from a
insertion. Radiographs taken within a day or two of the pasture accident. The fragments are triangular in shape,
injury may be inconclusive, and films should be repeated involve the proximal joint surface of the proximal pha-
in 10–14 days if a fracture is suspected. lanx, and are best seen on the dorsopalmar (plantar)
Longer fractures arising in the mid‐sagittal groove either view (Figure 19.3). The collateral ligaments of the
extend straight distally toward the pastern joint, or turn fetlock have two anatomic bundles at their insertion.
(A) (B) (C)
Figure 19.1 Short incomplete fracture of the proximal portion of the proximal phalanx. (A) Dorsopalmar radiograph of a Standardbred
racehorse with a moderate lameness. (B) Close‐up view showing subtle lucency in the mid‐sagittal region. (C) Following a low palmar
nerve block, and routine jogging in hand, the pastern catastrophically failed. Always be suspicious of a possible incomplete fracture when
doing lameness examinations.
www.ajlobby.com
(A) (B)
Figure 19.2 Displaced proximal plantar fracture of the proximal phalanx. (A) Oblique radiograph showing the separation of the abaxial
plantar “wing” of the proximal phalanx. (B) Four‐month radiographic reevaluation following internal fixation with a single screw placed in
lag fashion. Larger or less stable fractures are treated with additional screws.
The fractures seen best on the dorsopalmar (plantar) scintigraphy because they may not be associated with
radiographic view involve the insertion of the more dor- obvious pain or swelling.
sal bundle. The fractures seen best on the oblique view Complete dorsal or frontal plane fractures (Figure 19.5)
are avulsions of the palmar bundle. The acute fracture may occur in both racehorses and pleasure horses.7,22,38
usually causes severe lameness, marked joint effusion, The principles and techniques for repair are similar to
and pain that is easily elicited on direct palpation. those used to stabilize simple sagittal plane fractures of
Unrecognized fractures in foals and weanlings often go the proximal phalanx. The prognosis for large displaced
on to fibrous union with few symptoms, and are not rec- dorsal‐plane fractures may be worse than similarly dis-
ognized until screening radiographs prior to sale as a placed sagittal fractures, because even a small incongru-
yearling or mature horse. ity in the repaired surface would be perpendicular to the
Incomplete dorsal‐plane fractures of the proximal axis of fetlock joint motion. It seems likely that the gen-
phalanx occur almost exclusively in the proximal aspect erally favorable prognosis for sagittal plane fractures
of the phalanx in the hindlimb of racing Thoroughbreds, propagating from the center of the mid‐sagittal groove is
presumably because the hindlimb is in near extension partially due to the somewhat protected position of the
when it strikes the ground. In the forelimb the fetlock is fracture line away from the intensely loaded broad sur-
already in slight dorsiflexion when it impacts, so a shear- faces of the joint.
ing effect on the dorsal perimeter of the proximal pha-
lanx is less likely (Figure 19.4). The fracture often involves Short Sagittal Fractures
more of the dorsolateral portion of the phalanx rather These fractures radiographically extend only 1–2 cm into
than fissuring in a perfectly dorsal plane, so that the the proximal phalanx, are inherently stable, and are
fracture line on radiographs is usually evident on the unlikely to become displaced in a horse that is confined
lateral‐medial and dorsomedial‐palmarolateral oblique to a stall. Therefore, rest alone is often adequate treat-
(DMPLO) projections. The distribution of this fracture ment, but persistence of the radiolucency is very com-
in Thoroughbreds in the UK is different, with a prepon- mon (Figure 19.6). It may be advantageous to place
derance of dorsomedial (20 of 22) rather than dorsolat- screws across the proximal phalanx, not only to com-
eral fractures of the proximal phalanx.38 Additionally, press the fracture plane and enhance bony union, but
the fracture occurred in the forelimb in five horses. The also to help decrease the chance of distal propagation of
different site predisposition presumably is driven by the fracture when the horse returns to work after four
the preference in the UK for racing over gallops with months of conservative therapy (Figure 19.7). It is not
few turns. Clinical signs are somewhat dependent on the proven, however, if internal fixation of stable, short sagit-
degree of displacement, with nondisplaced fractures tal fractures is truly beneficial. Unrepaired fractures
causing mild lameness. Many are first diagnosed with involving the hindlimbs are subjected to higher stresses
www.ajlobby.com
(A) (B) (C)
(D) (E) (F)
(G) (H)
Figure 19.3 Collateral ligament avulsion injuries of the proximal phalanx in the fetlock. (A–C) Examples of collateral avulsion fractures of
the proximal phalanx. In (C), the fracture was violent enough to avulse the fragment proximal to the sesamoid. Techniques for repair
depend on the size and instability, ranging from (D) a single small screw; (E, H) a screw and 3 mm pin; (F) a single screw and a 3.5 mm
tension band plate; to (G) multiple screws.
when the horse rises from recumbency, and may be more examination should precede perineural anesthesia, as
likely to become displaced in the conservatively man- diagnostic nerve blocks in a horse with this injury can lead
aged horse. to catastrophic consequences (see Figure 19.1).
The primary concern with short incomplete sagittal
fractures of the proximal phalanx is the need to be suspi- Sagittal and Sagittal‐spiral Fractures
cious about their presence. If a horse is very lame and there These fractures generally begin in the mid‐sagittal groove
is any suspicion whatsoever about the possibility of an and propagate distally. They have occasionally been
incomplete sagittal P1 fracture, diagnostic analgesia should referred to as parasagittal,34,35 but since they commence
only be used with extreme caution. Preferably, radiographic in the sagittal groove and follow the axial midline in a
www.ajlobby.com
(A) (B)
(C) (D)
Figure 19.4 Incomplete dorsal fractures of the proximal phalanx in the hind limbs, showing a variation in fracture position and visibility
on radiographs. (A) Dorsal frontal fracture best seen on the straight lateromedial projection. (B) More dorsolateral fracture configuration
evident on the dorsomedial‐palmarolateral oblique (DMPLO) view. (C, D) Small fracture repaired with a single screw. Care must be taken to
avoid the mid‐sagittal groove of the proximal phalanx.
sagittal plane, they seem to better fit the definition of a common articular fractures, like condylar fractures and
true sagittal fracture. Most propagate incompletely toward third carpal slab fractures, preexisting cartilage and sub-
the lateral side (Figure 19.8), or completely fracture chondral bone damage in sagittal P1 fractures is minimal.
through the lateral cortex (Figure 19.9), with many also
extending to the pastern joint. The distal propagation can
be in a spiral configuration (Figure 19.10), or in a more Comminuted Fractures
truly sagittal plane. These fractures are excellent candi- These range from fairly simple three‐piece fractures
dates for simple lag screw repair.15,30,34–36 Unlike other to the “bag of ice” injury. If internal fixation is being
www.ajlobby.com
(A) (B) (C)
Figure 19.5 Complete frontal plane fractures can be repaired with simple lag screw fixation. Although fewer screws may be successful,
the medial lateral width of the bone allows a broader pattern of screws and more strength to the repair.
should generally not be considered unless there is at

least one piece of intact bone spanning its length
(Figure 19.11).21 Additionally, internal fixation without
transfixation techniques is not recommended unless
more than 80% of the fragmented cortices can be ana-
tomically realigned so that they support weight. Finally,
extensive open reconstruction is not advisable if the frac-
ture is open.
Surgical Preparation
Preoperative medication should include nonsteroidal
anti‐inflammatory agents, and more potent analgesics if
the horse is experiencing a high degree of pain while
awaiting surgery. Fluid replacement is indicated in horses
that have been sweating profusely. Simple fractures can
be supported in a heavily padded bandage prior to sur-
gery, but comminuted or unstable fractures should be
stabilized preoperatively. A fiberglass cast supporting
the limb, with the dorsal cortices of the phalanges and
Figure 19.6 Chronic short sagittal fracture of the proximal
cannon bone aligned, is optimal, although a lightly pad-
phalanx. Persistent radiolucency of the fracture plane can make ded bandage with a rigid splint along the dorsum, or a
decisions concerning status difficult. Scintigraphy is useful to prefabricated splint (Kimzey Leg Saver Splint, Kimzey
assess how “active” such a fracture might be. Welding Works, Woodland, CA, USA), is an alternative.
General anesthesia should be induced with the horse
c onsidered, a full series of radiographs is essential for wearing these supports, and preferably using a sling or
preoperative planning. Three‐dimensional imaging— table‐side technique.
computed tomography (CT), magnetic resonance imag- Perioperative antimicrobials are always administered
ing (MRI), or 3D fluoroscopy—is enormously helpful if it to a horse undergoing open reduction and internal
is available. Reconstruction of a comminuted fracture fixation. Where the fracture is short and repair uses lag
www.ajlobby.com
(A) (B) (C)
Figure 19.7 An acute short sagittal fracture can be treated with simple lag screw fixation to ensure a consistent time frame for return to
exercise. The screw is inserted as close to the distal extent of the sagittal groove as possible.
screws placed through stab incisions, a broad‐spectrum acutely, the reduction can be performed and assessed
combination of antibiotics is given as a preoperative and arthroscopically. Horses are recovered in a light bandage.
postoperative dose. Horses with comminuted fractures Fracture healing requires approximately four months.
requiring more extensive exposure are usually treated The screw(s) does not require removal in most cases.
prophylactically for three days. In addition, a regional The prognosis for full recovery is excellent, even in
limb perfusion with an aminoglycoside is given at the chronic cases.22,38 In a recent study, 16 of 21 (76%) of
conclusion of surgery while the cast is being applied. Thoroughbred racehorses returned to racing at a similar
Horses with open fractures should have the wounds cul- level.38 More complex dorsal fractures of proximal P1
tured and maintained on appropriate antibiotics as long also occur, and can be treated with simple lag screw tech-
as clinically indicated. In addition to parenteral antibiot- nique if the configuration of the fracture can be accu-
ics, topical intraoperative lavage with fluids containing rately defined. CT can be useful for the repair, as can be
antibiotics is advisable. A broad‐spectrum combination arthroscopic guidance (see Figure 19.12).
of drugs not used systemically such as neomycin, baci- Complete displaced dorsal‐plane fractures of the prox-
tracin, and polymyxin B is effective and economical. Any imal phalanx also occur.7 Repair utilizes more and larger‐
fluid delivery system used for arthroscopy is ideal for diameter screws, but the techniques are similar to those
intraoperative lavage and lubrication/cooling of drills used for a sagittal fracture (see Figure 19.5). These more
and other instruments. substantial dorsal‐plane fractures have been seen in non‐
racehorses and as racing/training injuries. Although
there is no large series of cases reporting results, it is
Surgical Technique likely that the prognosis is not as good as a sagittal frac-
Dorsal Fractures ture because even slight malalignment of the articular
Short incomplete dorsal frontal‐plane fractures are usu- surface will injure the distal metacarpus.
ally repaired with one or two 3.5 mm lag screws (see
Figure 19.4), but more complex fractures will require Medial Collateral Avulsion Fractures
additional screws (Figure 19.12), and larger fractures will These fractures typically are sufficiently displaced that
need more and larger screws (see Figure 19.5). In nondis- open reduction may be required. Arthroscopic manipu-
placed fractures, screws are placed through stab inci- lation should be attempted initially, but can be quite dif-
sions using radiographic control. Care should be taken to ficult. The arthroscope needs to be sequentially inserted
correctly position the screw on the appropriate side of in both the dorsal and palmar (plantar) pouch to prop-
the midline and away from the mid‐sagittal groove. erly assess the articular component of the fracture. If the
Displaced fractures can be debrided and reduced through correct location for the implant (usually a 3.5 mm screw)
an extended arthrotomy on the abaxial margin of the can be identified accurately with needles and intraopera-
fragment, but arthroscopic debridement is also feasible tive imaging, the glide hole is drilled. The insert sleeve
unless it is a very chronic injury. If the fracture is treated placed in the glide hole can then be used as a handle to
www.ajlobby.com
(A) (B)
(C) (D)
Figure 19.8 (A, B) Radiographs showing a common configuration of a proximal sagittal fracture of the proximal phalanx that spirals
incompletely in a lateral direction. (C, D) Repair with three lag screws through stab incisions under radiographic guidance.
www.ajlobby.com
Palmar/Plantar Process (Wing) Fractures

These fractures also are repaired with lag screws if acute
(see Figure 19.2). Some are large enough to permit the
use of 4.5 mm screws, but most are treated with two
3.5 mm screws. Nondisplaced fractures are repaired
using radiographic control, and displaced fractures
require an extended palmar/plantar arthrotomy. The
screws must be directed slightly distally in order to avoid
the sagittal groove. Horses can usually be recovered in a
bandage, although a cast for a hindlimb fracture is pru-
dent. Horses are rested for at least four months before
returning to exercise. The prognosis is good if the frac-
ture is treated acutely, but often they occur in young ani-
mals and the diagnosis is delayed. Internal fixation of
chronic fractures is less reliably successful.
Nondisplaced Sagittal Fractures

Figure 19.9 Radiographs from different limbs of the same horse These should be repaired using standard lag screw
three years apart showing a common configuration of a proximal technique through 1 cm stab incisions. Although they
phalangeal fracture, with the fracture starting in a sagittal plane are not as strong as 5.5 mm screws, 4.5 mm screws are
and then propagating in an oblique plane toward the lateral
cortex. usually adequate for repair of these fractures. The
smaller screws have the advantage of allowing quick
correction of a stripped screw by replacement with a
manipulate the fragment into anatomic reduction. If the 5.5 mm screw. Lag screw principles are described in
articular margins of the fracture can be visualized, the detail in Chapter 9. Briefly, lag screw technique for a
procedure can be completed without a larger arthrot- 4.5 mm cortical screw commences by drilling a 4.5 mm
omy. If not, the edge of the fragment is determined by “glide” hole through the near cortex to or slightly
probing with a needle and a 3–4 cm curved skin incision beyond the fracture plane. A 3.2 mm drill insert center-
is made over the medial aspect of the proximal phalanx. ing sleeve is inserted into the glide hole and a 3.2 mm
A deep incision into the dorsal aspect of the fracture line bit is used to drill the far cortex. The opening to the
is made with a #15 scalpel. The fracture line is debrided glide hole is expanded by use of the countersink to
and accurately reduced at the joint surface. In some accommodate the underside of the screw head, and
cases, the avulsion elevates articular cartilage axial to the thereby prevent bending forces on the screw shaft
actual fracture line. Since the avulsed cartilage is unlikely beneath the head. The length of the hole is measured
to reattach, it should be trimmed to avoid the develop- with a depth gauge, and threads are cut in the 3.2 mm
ment of a loose flap in the weight‐bearing portion of the portion with a tap. A fully threaded 4.5 mm cortical
joint surface. Reduction may need to be maintained with screw is inserted and tightened. As the head of the
pointed forceps while one or two 3.5 mm lag screws are screw engages the outer surface of the near cortex, the
inserted. In cases of a very small fragment that is rota- fracture plane is compressed by the lag effect. Correct
tionally unstable, a single screw and a 2 mm pin are used positioning of the screws should be checked in two
(see Figure 19.3). Either direct exposure or imaging must planes with intraoperative radiographs or fluoroscopy.
be adequate to assure both accurate fracture reduction On the dorsopalmar projection, the proximal screw
and the exact location of the screw head. A screw that is should be positioned approximately 5–8 mm distal to
only slightly misplaced can impinge on the distal meta- the distal extent of the sagittal groove, and in the latero-
carpal/metatarsal condyle. The incision is closed rou- medial view, the screw should be placed in the middle
tinely and a cast applied for recovery from general of the bone’s dorsal‐palmar thickness (see Figures 19.8–
anesthesia. Horses are kept in a box stall for three months 19.10). This location is estimated by palpating the
or until there is radiographic evidence of healing. Horses extensor branch of the suspensory ligament as it trav-
are usually given six months’ rest before beginning exer- erses the proximal phalanx and placing the screw at the
cise. The prognosis depends on the amount of cartilage proximodorsal edge of the ligament, and at a level just
avulsed from the joint surface. Most horses develop distal to the palpable palmar/plantar wing of the proxi-
enough osteoarthritis that the prognosis for high‐level mal phalanx. The second screw is usually inserted
function following a displaced fracture of this configura- immediately palmar (plantar) distal to the extensor
tion is guarded. branch, about 18–20 mm distal to the first. If the initial
www.ajlobby.com
(A) (B) (C)
(D) (E) (F)
Figure 19.10 (A–C) Radiographs of a biarticular spiral sagittal fracture that commences mid‐sagittal in the sagittal groove of the proximal
phalanx and propagates to the lateral cortex and distal condyle. This fracture is slightly comminuted distally. (D–F) Repair with lag screws
should account for the spiraling fracture plane (cf. Figure 19.7). The middle two screws should have been placed more obliquely, angling
from a palmarolateral to dorsomedial direction.
screw’s position and trajectory are satisfactory, a screw- Making the stabs obliquely, parallel with the extensor
driver placed in its head will serve to help orient subse- branch, helps avoid injury to that structure. Another
quent screw insertion. option is to make a longer skin incision crossing and
Although the fundamentals of lag screw technique do exposing the extensor branch, followed by stab incisions
not change, placement of screws through small stab inci- to the surface of the bone. The surgery is expedited by
sions can be expedited by following several recom- maintaining a 3 mm smooth pin in the hole during the
mended procedures. After determining the correct exchange of guides and drills. It is always preferable to
location of the stab incision with either intraoperative drill the thread hole completely through the far cortex
needles and radiographs or preoperative staples, a single whenever using lag screw technique. This minimizes the
bold stab should be made for each screw, minimizing any chances of serious technical errors such as stripping of
lateral dissection. The #10 blade is inserted until it con- the threads, breaking the tap by impacting into a blind
tacts bone and then extended approximately 1 cm. drill hole, or failure to compress the fracture by use of a
www.ajlobby.com
Figure 19.11 Comminuted fractures of the proximal phalanx from different cases suitable for internal fixation. In all cases, there is a
clearly evident intact strut of bone extending from the metacarpophalangeal joint to the proximal interphalangeal joint.
screw that is slightly too long. The depth of the glide hole accurate measurement through a stab incision. Unlike
should be measured carefully with a ruler or intraopera- condylar fractures of the third metacarpal/metatarsal
tive films (preferable) to verify that the glide hole crosses bone, where the bone is uniformly very dense and a
the fracture plane. The proximal screw hole is counter- “short” screw (i.e., one that does not extend completely
sunk carefully, since that portion of the proximal phalanx to the far cortex) provides adequate holding power, prox-
is sharply contoured and screw bending will occur if its imal phalangeal fractures need screws to completely
head is not recessed at its proximal edge. The depth engage the opposite cortex. This is particularly impor-
gauge is always used to determine appropriate screw tant for the second screw distal to the fetlock joint: the
lengths, but preoperative and intraoperative radio- cortex in that region is relatively thin, making it prone to
graphic measurement should be used to verify screw stripping. Although there is no large series of cases yet
length and position, because soft tissues preclude a truly published comparing specific techniques, there may be a
www.ajlobby.com
(A) (B) (C)
Figure 19.12 Complex incomplete dorsal (frontal) fracture of the proximal phalanx. (A) Proximal three slices of a CT scan showing the
comminuted configuration. (B, C) Dorsoplantar and lateral radiographs showing the repair of both fracture components with two 3.5 mm
cortical screws placed in lag fashion in each.
mechanical advantage in using two screws in the wide, torsional stresses that occur in the hindlimb when the
more proximal portion of the phalanx, one in the pal- horse rises. The cast is removed after the horse has com-
mar/plantar‐proximal region, and the second in the pletely recovered from anesthesia and is replaced with a
dorsal‐proximal portion of the proximal phalanx. heavy bandage for two to three weeks, followed by a light
The number of screws placed depends on the radio- bandage.
graphic length of the fracture. It is not recommended to Convalescence for a horse following lag screw repair of
place screws distal to the visible portion of the fracture, nondisplaced sagittal fracture includes one month of
because spiraling of the fracture plane may exist and a screw stall rest followed by one month of hand walking, and a
could be inadvertently placed in an occult fracture line. This third month of limited turnout in a round pen or very
concern is especially appropriate for a typical sagittal frac- small paddock. If radiographs taken at the end of three
ture that breaks out laterally in the “waist” of the proximal months reveal good healing, the horse can be returned to
phalanx. An occult, inverted‐Y component to the fracture an exercise program. If the fracture line is still evident,
may occur in this location and a screw placed too close to it the horse should be rested for an additional six weeks.
may have adverse consequences (Figure 19.13). Even if there is a faint radiolucency at the joint surface at
The stab incisions are closed with simple interrupted the end of four to five months, the horse is returned to
sutures of monofilament nonabsorbable material or sta- work because a radiolucent line may persist indefinitely
ples. Although a fiberglass cast enclosing the foot and in some cases. Unlike condylar fractures, the presence of
extending to the proximal metacarpus affords optimal a small defect at the fracture line is not necessarily a bad
safety during recovery from anesthesia, most horses with prognostic sign. Screws rarely need to be removed from
forelimb phalangeal fractures can be safely recovered the proximal phalanx unless unusual lysis develops
from general anesthesia in a heavy bandage. Horses with around them, they are too long, or they are positioned
proximal phalangeal fractures in a hind limb should be too close to a joint surface.
recovered in a cast or rigid boot (Equine Bracing There are few complications with nondisplaced and
Solutions, Trumansburg, NY, USA), because of the high incomplete fractures of the proximal phalanx, other than
www.ajlobby.com
(A) (B) (C)
(D) (E)
Figure 19.13 An apparently simple sagittal‐oblique P1 fracture that had a radiographically silent medial component. (A) Preoperative
radiograph shows complete moderately displaced sagittal fracture. (B, C) Postoperative radiographs show lag screw repair with accurate
fracture reduction and fracture line compression. Four screws were placed perpendicular to the visible fracture plane. Fortunately, the
limb was protected in a cast during anesthetic recovery. (D, E) Six‐week follow‐up radiographs clearly reveal the presence of a more
complex fracture forming an inverted Y distal to the waist of the proximal phalanx. The fracture healed despite the error.
infection or catastrophic failure during recovery from be reduced under fluoroscopic/radiographic control,
anesthesia. Degenerative joint disease of the fetlock is more extensively displaced fractures are best reduced by
less common than that seen after condylar fractures, but directly observing the articular surface. This can nearly
still can be a cause of eventual clinical failure. always be done in a fresh fracture using arthroscopy
(Figure 19.14). If the fracture cannot be reduced under
arthroscopic observation, a 2 cm incision over the
Displaced Sagittal and Sagittal/Oblique proximal articular surface is usually adequate to allow
Fractures manipulation and reduction. If the fracture is older and a
Technically these fractures are repaired similarly to non- fracture hematoma or small fragments prevent complete
displaced fractures once anatomic reduction is achieved. reduction, the incision can be extended further along
Although a minimally displaced acute fracture can often the dorsal length of the fracture, splitting the extensor
www.ajlobby.com
Figure 19.14 Arthroscopic visualization of the dorsal aspect of a

sagittal fracture of the proximal phalanx. Both reduction and
compression of the fracture can be observed by arthroscopy of
the dorsal (shown) or palmar/plantar joint.
tendon. The fracture fragments can be pried apart for

debridement with curettes or dental picks. Large pointed
reduction forceps are then used to hold the fragments
reduced while the lag screws are placed. In most cases,
the lag screws are placed through separate stab incisions.
The incisions are closed with interrupted absorbable
sutures in the tendon and joint capsule followed by
routine subcuticular and skin sutures. A fiberglass cast,
molded plastic compression boot (Equine Bracing
Solutions) or splinted bandage is applied for recovery.
The postoperative care and time course are similar to
those for nondisplaced fractures. One major difference is
that some degree of joint stiffness can be anticipated if an
open reduction is necessary, and a greater proportion of
horses with displaced fractures will develop some degen-
erative joint disease of the fetlock and/or pastern joints.
Figure 19.15 Examples of moderately complex comminuted
Moderately Comminuted Fractures proximal phalanx fractures repaired by open reduction and screw
Fractures that have three or more major fragments with at fixation. The dorsopalmar and matched lateral or oblique
least one extending the full length of the bone are suitable radiographs for each case show the consistent features of the
candidates for internal fixation, provided that the smaller repair, including reconstruction of smaller fragments to a full
length strut of bone, placement of the dorsopalmar screws as
fragments can be reconstructed to allow enough cortical
proximal as possible in the medial and lateral portions of the
alignment that weight bearing is possible within a short bone, and lastly reconstruction of the fracture planes more distally
leg cast (Figure 19.15).18 Although it is possible to place with perpendicular screws. The more oblique fracture planes tend
multiple screws through stab incisions under radiographic to occur more distally in the bone.
www.ajlobby.com
or CT control, accuracy of the reduction is most easily of the near fragments. The fractures of the palmar (plan-
achieved with an open exposure. Arthroscopic guidance tar) wings are secured with dorsopalmarly directed lag
combined with intraoperative digital radiography or fluor- screws inserted approximately 1 cm distal to the proximal
oscopy is adequate in mildly comminuted and minimally joint surface. The sagittal plane fractures are repaired with
displaced fractures. However, inaccurate reduction leads lateral to medial screws placed distal to the dorsopalmar
to degenerative joint disease, potential malunion, and a screws (Figure 19.17). This compresses the sagittal frac-
weaker repair because of poor alignment of the cortices. ture close to the joint, but prevents a screw damaging the
An aggressive approach, exposing the proximal joint sur- sagittal groove. The additional screws used to repair the
face, is advocated if there is doubt about less exposure more distal portions of the proximal fragments and any
achieving accurate reconstruction.18 This generally nonarticular fragments are placed with the fragments
requires severing the collateral ligament and luxating the exposed to permit accurate screw positioning. The most
fetlock, although arthrotomy over the dorsal pouch may distal screws, adjacent to the pastern joint, may be most
be adequate to identify the major sagittal fracture plane. easily placed with the assistance of intraoperative radio-
Earlier reports, describing aggressive repair of commi- graphs or fluoroscopy. Considerable care should be taken
nuted proximal phalangeal fractures, mostly ended in fail- to make the reduction as accurate as possible in order to
ure due to infection and instability.21 Because of the failure prevent collapse of the fracture within the cast. Complex
of the previously used techniques, an alternative surgical fractures can be successfully repaired with multiple screws,
approach involving a long, curved flap incision is used, provided that there is a single strong strut (Figure 19.15).
rather than an “H” or “barn‐door” incision. Usually 4.5 mm screws are used in the major fragments
and 3.5 mm screws in the small fragments. Although the
Open Technique 5.5 mm screws are stronger, fragment splitting and diffi-
The horse should be positioned in lateral recumbency culty avoiding other screws are more of a problem. The
with the most comminuted portion of the bone upper- small screws also allow replacement with larger screws if
most. In the majority of cases, the intact strut is medial, one strips during tightening. Any cortical defects can be
so the affected limb is positioned uppermost. A tourni- augmented with a cancellous bone graft.
quet is not necessary. The skin incision is curved from The collateral ligament is repaired with interrupted
approximately 2 cm distal to the button of the splint sutures of #1 synthetic absorbable material. The remain-
bone, over the dorsal midline of the fetlock and proximal ing tissues (joint capsule and extensor tendon) are
phalanx, and back toward the proximal lateral margin of apposed with #0 simple interrupted or tension (near–
the middle phalanx (Figure 19.16). The subcutaneous tis- far/far–near or cruciate) sutures. Subcutaneous and sub-
sues are incised down to the level of the extensor tendon cuticular layers are usually closed with 2‐0 continuous
and joint capsule, and the skin and subcutaneous tissues synthetic absorbable sutures. The skin can be sutured or
are retracted as a single flap. A scalpel is used to transect stapled. Drains are not used. A fiberglass cast enclosing
the collateral sesamoidean ligament exposing the palmar the foot and extending to the proximal metacarpus is
(plantar) pouch of the fetlock. This incision is continued applied. The fetlock should be in slight extension and the
around the condyle at the joint level, severing the collat- heel elevated about 10–15°.
eral ligament and joint capsule until the proximal dorsal
margin of the fracture is exposed. The extensor tendon is Minimally Invasive Technique
split distally by inserting the scalpel in the fracture line. A It is feasible to reconstruct mildly displaced three‐ to
sharp elevator or scalpel is used to elevate the margins of five‐piece fractures using minimally invasive techniques,
the fragments. The dissection is facilitated by leveraged especially if preoperative CT imaging is available com-
manipulation with a Hohman elevator. Multiple planes bined with intraoperative fluoroscopy or digital radio-
of dissection should be avoided. The fetlock is luxated to graphic imaging. Arthroscopy can be used to verify
expose the proximal joint surface (Figure 19.17). The accuracy of articular realignment. Using preoperative
fracture planes are debrided of loose fragments and frac- and intraoperative imaging, the glide hole for the lag
ture hematoma. screw is drilled, and the centering sleeve is inserted and
The reconstruction of the fracture should begin at the used as a handle to manipulate the fragment. When the
proximal joint surface and continue distally, since the fet- fragment is aligned and reduced, large pointed reduction
lock joint surface is the most important structure to pre- forceps maintain this position as the remainder of the lag
serve. The fragment deepest in the incision should be screw procedure is completed. The joint surface should
repaired first, since it may be obscured by reconstruction clearly be seen to compress when the screw is tightened.
www.ajlobby.com
(A) (B)
Skin incision
Suspensory
ligament
Collateral ligament
CDE tendon
Lateral extensor
branch of the
suspensory
ligament
Severed collateral ligament
(C)
Severed half of
CDE tendon
Sesamoid
bone
Severed collateral
CDE tendon ligament
Fracture CDE tendon

P1
(D)
Lateral extensor
branch of the
suspensory
ligament
Severed
CDE tendon
Figure 19.16 (A–H) Open repair of a comminuted proximal phalanx fracture using fetlock luxation and articular reconstruction followed
by phalangeal stabilization. CDE, common digital extensor.
Minimally invasive repair of comminuted P1 fracture is Standing Repair

considerably more difficult when the fracture planes are Incomplete sagittal fractures of the proximal phalanx
nonorthogonal. Intraoperative CT guidance definitely can also be repaired in the standing sedated horse.30
affords the optimal means of assuring accurate screw Limb preparation, sedation, draping, and general surgi-
placement in more complex fractures, but is not exten- cal technique are similar to standing repair of lateral or
sively utilized due to the significant cost. spiral condylar fractures. Use of a battery‐powered drill
www.ajlobby.com
(E)
Sesamoid bone
Severed collateral
CDE tendon ligament
(F)
Screwdriver
Drill
(G)
Severed collateral
ligament
(H)
Lateral Cranial
Screwdriver
with quick coupler for exchange of drill bits and tap better reduced if the limb is briefly unweighted during
allows more maneuverability and avoids dealing with screw tightening.
the likely contamination of the air hose required for
gas‐powered drilling. A description of successful stand-
ing repair of incomplete sagittal fractures in 14 horses
Postoperative Considerations
indicated that 7 were stabilized with a single screw, Recovery from general anesthesia should employ tech-
suggesting that these were short incomplete fractures, niques to minimize the risk of additional trauma, and
while the remaining 7 required two or three screws.30 include deep foam mats, assistance with head and tail
The fracture reduction is achieved without reduction ropes, and judicious use of sedatives. The duration of
forceps, relying on the screw for both reduction and antimicrobial prophylaxis is usually less than 24 hours,
stabilization. The long incomplete fractures may be although horses with extensive soft tissue damage may be
www.ajlobby.com
et al.15 reported that 5 of 7 horses repaired after short

incomplete fracture raced again, and 26 of 39 (67%) of
horses with repaired long incomplete sagittal fractures
or sagittal fractures that exited laterally raced again.
However, sagittal fractures that entered the pastern joint
had a significantly reduced return to race (6 of 13; 46%).
A more recent report indicated that 11 of 12 horses (92%)
with repaired short incomplete fractures raced again.34
For long incomplete sagittal fractures, 49 of 86 horses
(57%) raced again after stabilization by screw fixation,
and this was only slightly reduced for long complete
(noncomminuted) fracture, where 6 of 12 (50%) raced
after repair.34 However, the prognosis for comminuted
fractures returning to race was poor, with none of the
three repaired horses returning to competition. A previ-
ous case series, including a larger proportion of commi-
nuted fractures, indicated that 33 of 36 (92%) of horses
with moderately comminuted fractures went on to
heal.18 The prognosis for athletic function after repair
of more severely comminuted proximal phalanx f ractures
is generally guarded.18,21,34
Figure 19.17 Open surgical repair using fetlock luxation. With
collateral ligament transection the proximal surface of the
comminuted fracture can be directly viewed, allowing accurate
reconstruction. In less displaced fractures, intraoperative imaging
Severely Comminuted Fractures
with CT and/or fluoroscopy/digital radiography may be adequate,
but manipulation and reduction are easiest with an open approach. Many fractures of the proximal phalanx involve such high
energy that the bone virtually explodes, leaving no possi-
treated for longer. Phenylbutazone should be continued as bility of internal fixation (Figure 19.18). Although a few of
needed; most horses require less than 2 g d−1 to remain these types of fracture eventually heal when managed
comfortable. The cast must be checked meticulously each with simple cast coaptation, a far greater number do not
day for evidence of discomfort, heat, or drainage. If the and the horse is eventually euthanatized because of com-
horse wears the cast well, it can be left on for four to six plications. The profound instability of these fractures
weeks. When the fracture repair is considered tenuous, a makes collapse within a simple cast inevitable if the horse
second cast should be applied for an additional four to six attempts to bear weight. Motion at the fracture delays
weeks. Concern about both the horse’s comfort and the union, and more importantly results in soft tissue compro-
stability of the repair should prompt a cast change at mise that can become serious. The small proportion of
10–14 days, under general anesthesia. Horses with simple horses that survive usually bear no weight at all on the cast
comminuted fractures that are stable and anatomically limb, and yet do not develop laminitis in the opposite limb.
reconstructed can have the cast removed early if neces- Transfixation techniques involving pins incorporated in a
sary. Final cast removal should be done with the horse fiberglass cast, or a true external fixator, are currently the
standing. Horses should be strictly confined to a stall until best means of immobilizing these fractures, preventing
there is radiographic evidence of fracture healing and collapse and maintaining the anatomic alignment of the
apparent return to normal strength of the digital flexors. limb. Locking plates have the potential to manage some
fractures that have generally been treated with transfixa-
tion techniques. Although these implants should be better
Prognosis
than traditional plates in this location, the poor soft tissue
Prognosis is largely defined by the complexity of the frac- coverage, poor vascularity, and complex fracture configu-
ture, including presence of comminution both proxi- rations, combined with the requirement for perpendicular
mally in the fetlock and distally when the proximal screw placement of locked screws, may limit their use.
interphalangeal joint is involved. Adequacy of reduction Use of transfixation techniques can be combined with
and stabilization then play a pivotal role in return to suc- minimally invasive internal fixation if it is feasible to
cessful limb function, including athletic activity. Short reconstruct major proximal articular fragments. In many
incomplete sagittal fractures have frequently returned severely comminuted and displaced fractures, however,
to racing after lag screw fixation.15,22,34 Holcombe the joint damage is so severe that long‐term comfort
www.ajlobby.com
(A) (B)
(C) (D)
Figure 19.18 Two examples of proximal phalangeal fractures that are not well suited for internal fixation. One fracture (A, B) is not as
comminuted but has no spanning strut, while the second (C, D) is severely comminuted. Even if partial reconstruction is done, fractures
like this should be managed with some form of transfixation device.
www.ajlobby.com
often involves ankylosis of both the pastern and fetlock polymethylmethacrylate ((Technovit®, Jorgensen Labs,
joints. In such cases, poor anatomic reduction of the Loveland, CO, USA) placed over the pin ends to protect
fetlock does not afford that much advantage. If the dam- the opposite limb from inadvertent damage.
age is very severe, it might be more prudent to debride In the third metacarpus/metatarsus of a mature horse,
the joint and place a cancellous graft early to push it the distal pin is typically placed at about the level of the
toward a stable fusion. Screws placed across the fetlock distal physeal scar. The second pin is placed just below
while it is still in transfixation also can help ankylosis the mid‐diaphysis if possible; there is general agreement
(Figure 19.19). that the risk of cannon bone fracture through the pin
holes is highest in pins close to the proximal end of the
Surgical Treatment cast. Slight dorsopalmar (plantar) obliquity of the pins
may have a slight mechanical benefit,23 but the most
Pin Cast Combinations important technical detail is to keep the pins as central as
These are technically simple, involve minimal instru- possible to avoid endosteal notching and significant
mentation, and have generally proven reliable.16,17,20,25,33 weakening of the bone.
Many surgeons have variations in techniques that are With a full‐pin technique, two centrally threaded trans-
successful, but most involve at least two pins completely fixation pins are inserted in a lateral to medial direction
traversing the bone and incorporated on both sides of through predrilled holes of smaller dimension. A 5.5 mm
the cast. Positive‐profile threaded pins (IMEX Veterinary, pilot hole is drilled with an electric or gas‐powered drill.
Longview, TX, USA) seem to remain stable for a longer A sharp 8.73 mm (11/32 in.) or 9.12 mm (23/63 in.) drill
time in equine bone compared to unthreaded pins. Care bit held in an oversized Jacobs chuck is used to enlarge
must be taken to drill directly through the center of the the hole by hand. The threaded pin is also inserted slowly
bone in order not to cut a notch in the endosteal surface by hand to minimize thermal damage at the pin–bone
of the dorsal or palmar (plantar) cortex, which may act as interface. After the fiberglass casting tape is applied an
a stress riser for complete fracture. It is preferable to drill acrylic polymer (Technovit) is molded over each pin end,
progressively larger holes to minimize thermal injury. and also covers the bottom of the foot. Because these
The final drill hole should be the same as the core of the fractures are extremely unstable, the foot must be aligned
positive‐profile pin. In dense equine cortical bone such and held securely during cast application. A wire loop is
as the third metacarpal/metatarsal bone, a tap should be placed through the hoof wall near the heel and tightened
used to cut threads for the commercially available posi- over a hoof rasp. The rasp serves as a handle for the hoof
tive‐profile pins. Newer designs of both pin and tap and allows the pastern to be held in alignment as the cast
appear to be superior,3 but have not yet been extensively is applied. The cast material can be placed over the hoof
used in clinical patients. Insertion of the threaded pin and allowed to harden with the rasp in place. After the
should be done slowly, usually by hand. It is helpful to cast hardens, the rasp can be withdrawn and a final roll of
modify an oversized Jacobs chuck by drilling a transverse fiberglass placed over the hoof and pastern. Usually six
hole through the pin extension. A second pin can be to seven rolls of 5 in. fiberglass are used, to provide a cast
placed through this hole to create a “T” handle that can that is thicker than a typical cast without pins.
be used to gain leverage as the pin is inserted. Commercial If half‐pins are used, the cortices are predrilled and
heavy‐duty T‐handle chucks also are available (Universal obliquely directed pins of slightly larger diameter are
Chuck with T‐Handle #393.10; DePuy Synthes, West inserted to engage both cortices of the bone. The pins are
Chester, PA, USA). Another alternative is to use a very placed obliquely in a staggered fashion along the dorso-
large pair of vise grips or pipe wrench to grasp the chuck medial and dorsolateral aspects of the bone. Typically,
handle. With a centrally threaded pin, it is important to four to six 3/16 or 1/4 in. pins are used with the half‐pin
be sure that the threads engage both cortices. technique, each engaging both cortices of the bone and
After the pins are in position, they can be cut with one surface of the fiberglass cast.
large bolt‐cutters. Large, long‐handled bolt‐cutters min- Horses are assisted for recovery from general anesthe-
imize the physical effort required to cut large pins and, sia. The cast is left in place for at least four to six weeks
most importantly, limit the tendency to twist the bolt‐ and changed under general anesthesia. Horses are usu-
cutters during the cut, which can result in premature pin ally kept on oral antibiotics while the pins are in place, in
loosening. The cast padding and casting tape are applied an effort to minimize pin tract infection. A second and
routinely, except that an assistant should slit the fiber- occasionally a third cast are usually needed. If pins
glass material if it does not tear as the tape is pulled over develop pin‐tract lysis and become loose, larger pins can
the sharp pin ends. About five to six rolls of 5 in. fiber- be placed in the same holes or additional half‐pins can be
glass cast material are typically used in a half limb trans- inserted. Cast duration is determined by radiographic
fixation cast. After the cast is hardened, the pins are cut progression of fracture healing and the comfort afforded
as close to the cast surface as possible and padding or by the pins. If the pins become infected and loose, the
www.ajlobby.com
(A) (B) (C)
(D) (E) (F)
Figure 19.19 (A, B) Severely comminuted proximal phalangeal fracture treated with minimal internal fixation and a pin cast. (C, D) Screws
(5.5 mm) placed across the joint combined with a cancellous graft may be placed while the transfixation pins are still stable. This may
result in a more rapid fusion of the fetlock joint. (E, F) In most horses with severely comminuted fractures, the pastern fuses spontaneously.
www.ajlobby.com
patient will become reluctant to bear weight. When the serve to effectively decrease the distance between the
decision is made to remove the pins, the cast is removed bone and the sidebars, thereby minimizing bending of
with the horse standing. The “far” side of the pin is asep- the pins.
tically prepared and then drawn/unthreaded through the Assisted recovery is vital. The pin–skin junction is
bone from the “near” side. A cast without pins is then cleaned and dried daily. A light bandage is placed loosely
nearly always maintained for at least another month. around the sidebars and proximal to the fixator to
exclude bedding. Most horses will wear the fixator com-
External Skeletal Fixator fortably for six to nine weeks, although some will wear it
An external skeletal fixator (Nunamaker External Fixator, even longer. The fixator can be removed with the horse
Nash Engineering, TN, USA) can be used to manage standing under mild sedation. The pins are cut with a
severely comminuted proximal phalangeal fractures and is hacksaw, and the medial side scrubbed with antiseptic
probably the method of choice if the fracture is open and before unthreading them from the lateral side. If radio-
badly contaminated.18,24,27,33 An external fixator allows graphs indicate the need, a cast is placed; usually, at least
wound management while still providing immobilization an additional four to six weeks in a cast is necessary.
of the fracture. Unfortunately, external fixators designed Fractures immobilized in the fixator, particularly open
for human use are not strong enough for use in adult fractures, are slow to heal and premature removal of sup-
horses. This led to the development of the Nunamaker- port will result in collapse of the pastern. Staged removal
Nash equine external fixator that does allow full weight of the fixator, changing to a pin cast combination after
bearing in distal limb fractures (Figure 19.20).24,28 the soft tissue injuries have been addressed, may be nec-
The foot is either nailed or glued to a thin metal shoe essary in many cases.
or plate that is subsequently secured to the foot plate of The most important complication with transfixation
the fixator. In the currently available commercial prod- techniques is fracture through a pin hole. This can occur
uct, placing two pins with tapered sleeves into the third with the pins in place or after removal. The greater
metacarpus/metatarsus is recommended. The sleeves moment arm on the end of the pins in an external fixator
may make fractures more likely in the fixator than in the
pin cast combination. However, the fixator provides the
advantages of adjustability and the opportunity to man-
age the soft tissues. Nevertheless, further optimization
of external fixators for horses is still required.
Fractures in Foals
Occasionally, foals stepped on by their dams will suffer
nonarticular fractures of the proximal phalanx, usually
Salter–Harris type II fractures. Many of these can be
treated with external coaptation, such as light fiberglass
casts or rigidly splinted bandages. General anesthesia or
heavy sedation is required. As with most Salter–Harris
type II fractures, it is important to position the foal to
place the metaphyseal spike uppermost, so that gravity
assists in closing the gap on the physeal component of
injury. There is always more instability of the fracture on
the physeal side than on the metaphyseal side of the frac-
ture. In neonates, as little as three weeks of coaptation is
usually adequate for fracture healing, but in older foals
a cast/splint may be necessary for five to six weeks.
Displaced fractures with long metaphyseal segments
should be managed with lag screw insertion and shorter
duration of external support (Figure 19.21). If the meta-
Figure 19.20 The Nunamaker–Nash external fixator has two pins
that are attached to the sidebars through conical sleeves in order
physeal spike is small, a screw and figure‐eight wire tech-
to minimize pin bending by functionally decreasing the bone to nique to span across the metaphyseal cortical fracture
sidebar distance. line (i.e., similar to a transphyseal bridge) can be used in
www.ajlobby.com
(A) (B)
(C) (D)
Figure 19.21 In foals with Salter–Harris type II fractures with long metaphyseal spikes, simple internal fixation with lag screws can help
maintain reduction and stability. The metaphyseal spike is usually lateral (A, B) or palmar/plantar lateral (C, D).
combination with external coaptation. These fractures healing is radiographically advanced and muscle/tendon
heal quickly enough that the problems of tendon laxity in strength has returned. Transverse mid‐diaphyseal frac-
the affected limb, or deformation of the contralateral tures occur occasionally in foals (and more rarely in
limb, can usually be avoided or managed successfully. older horses). A single plate with cast support is prefer-
There is negligible longitudinal growth remaining in the able if there is displacement or instability. Cast coapta-
proximal physis, so limb length disparities are not an tion alone can suffice if alignment is good in a young foal,
issue. The foals should be kept confined until fracture because they heal so quickly.
References
1 Adams, O.R. (1966). Chip fractures of the first phalanx of the plantar aspect of the proximal phalanx in horses:
in the metacarpophalangeal (fetlock) joint. J. Am. Vet. 19 cases (1981–1985). J. Am. Vet. Med. Assoc. 191:
Med. Assoc. 148: 360–363. 855–857.
2 Barclay, W.P., Foerner, J.J., and Phillips, T.N. (1987). 3 Bubeck, K.A., García‐Lopez, J.M., Jenei, T.M., and
Lameness attributable to osteochondral fragmentation Maranda, L.S. (2010). In vitro comparison of two
www.ajlobby.com
centrally threaded, positive‐profile transfixation pin 18 Kraus, B.M., Richardson, D.W., Nunamaker, D.M., and
designs for use in third metacarpal bones in horses. Ross, M.W. (2004). Management of comminuted
Am. J. Vet. Res. 71: 976–981. fractures of the proximal phalanx in horses: 64 cases
4 Bukowiecki, C.F., Bramlage, L.R., and Gabel, A.A. (1983–2001). J. Am. Vet. Med. Assoc. 224: 254–263.
(1986). Palmar/plantar process fractures of the 19 Kuemmerle, J.M., Auer, J.A., Rademacher, N. et al.
proximal phalanx in 15 horses. Vet. Surg. 15: 383–388. (2008). Short incomplete sagittal fractures of the
5 Colón, J.L., Bramlage, L.R., Hance, S.R., and proximal phalanx in ten horses not used for racing. Vet.
Embertson, R.M. (2000). Qualitative and quantitative Surg. 37: 193–200.
documentation of the racing performance of 461 20 Lescun, T.B., McClure, S.R., Ward, M.P. et al. (2007).
Thoroughbred racehorses after arthroscopic removal of Evaluation of transfixation casting for treatment of
dorsoproximal first phalanx osteochondral fractures third metacarpal, third metatarsal, and phalangeal
(1986–1995). Equine Vet. J. 32: 475–481. fractures in horses: 37 cases (1994–2004). J. Am. Vet.
6 Dalin, G., Sandgren, B., and Carlsten, J. (1993). Plantar Med. Assoc. 230: 1340–1349.
osteochondral fragments in the metatarsophalangeal 21 Markel, M., Richardson, D., and Nunamaker, D. (1985).
joints in Standardbred trotters; result of Comminuted first phalanx fractures in 30 horses:
osteochondrosis or trauma. Equine Vet. J. 16: 62–65. surgical vs nonsurgical treatments. Vet. Surg. 14:
7 Dechant, J.E., MacDonald, D.G., and Crawford, W.H. 135–140.
(1998). Repair of complete dorsal fracture of the 22 Markel, M.D. and Richardson, D.W. (1985).
proximal phalanx in two horses. Vet. Surg. 27: 445–449. Noncomminuted fractures of the proximal phalanx in
8 Dubs, B. and Nemeth, F. (1975). Treatment and 69 horses. J. Am. Vet. Med. Assoc. 186: 573–579.
prognosis of fractures of the first phalanx in the horse. 23 McClure, S.R., Watkins, J.P., and Ashman, R.B. (1994).
Schweiz. Arch. Tierheilk. 117: 299–309. In vitro comparison of the effect of parallel and
9 Elce, Y.A. and Richardson, D.W. (2002). Arthroscopic divergent transfixation pins on breaking strength of
removal of dorsoproximal chip fractures of the proximal equine third metacarpal bones. Am. J. Vet. Res. 55:
phalanx in standing horses. Vet. Surg. 31: 195–200. 1327–1330.
10 Ellis, D.R., Simpson, D.J., Greenwood, R.E.S., and 24 Nash, R.A., Nunamaker, D.M., and Boston, R. (2001).
Crowhurst, J.S. (1987). Observations and management Evaluation of a tapered‐sleeve transcortical pin to
of fractures of the proximal phalanx in young reduce stress at the bone‐pin interface in metacarpal
Thoroughbreds. Equine Vet. J. 19: 43–49. bones obtained from horses. Am. J. Vet. Res. 62:
11 Fackelman, G.E. (1973). Sagittal fractures of the first 955–960.
phalanx (P1) in the horse: fixation by the lag screw 25 Nemeth, F. and Back, W. (1991). The use of the walking
principle. Vet. Med. Small Anim. Clin. 68: 622–636. cast to repair fractures in horses and ponies. Equine
12 Fackelman, G.E. and Nunamaker, D.M. (1982). Manual Vet. J. 23: 32–36.
of Internal Fixation in the Horse. New York: 26 Nixon, A.J. and Pool, R.R. (1995). Histologic
Springer‐Verlag. appearance of axial osteochondral fragments from the
13 Fortier, L.A., Foerner, J.J., and Nixon, A.J. (1995). proximoplantar/proximopalmar aspect of the proximal
Arthroscopic removal of axial osteochondral fragments phalanx in horses. J. Am. Vet. Med. Assoc. 207:
of the plantar/palmar proximal aspect of the proximal 1076–1080.
phalanx in horses: 119 cases (1988–1992). J. Am. Vet. 27 Nunamaker, D.M. and Nash, R.A. (2008). A tapered‐
Med. Assoc. 206: 71–74. sleeve transcortical pin external skeletal fixation device
14 Gabel, A.A. and Bukowiecki, C.F. (1983). Fractures of for use in horses: development, application, and
the phalanges. Vet. Clin. North Am. Equine Pract. 2: experience. Vet. Surg. 37: 725–732.
233–260. 28 Nunamaker, D.M. and Richardson, D.W. (1991).
15 Holcombe, S.J., Schneider, R.K., Bramlage, L.R. et al. External skeletal fixation in the horse. In: Proceedings of
(1995). Lag screw fixation of noncomminuted sagittal the American Association of Equine Practitioners, vol.
fractures of the proximal phalanx in racehorses: 59 37, 549. Lexington, KY: AAEP.
cases (1973–1991). J. Am. Vet. Med. Assoc. 206: 29 O’Hare, L.M., Cox, P.G., Jeffery, N., and Singer, E.R.
1195–1199. (2013). Finite element analysis of stress in the equine
16 Joyce, J., Baxter, G.M., Sarrafian, T.L. et al. (2006). Use proximal phalanx. Equine Vet. J. 45: 273–277.
of transfixation pin casts to treat adult horses with 30 Payne, R.J. and Compston, P.C. (2012). Short‐ and
comminuted phalangeal fractures: 20 cases (1993– long‐term results following standing fracture repair in
2003). J. Am. Vet. Med. Assoc. 229: 725–730. 34 horses. Equine Vet. J. 44: 721–725.
17 Keller, H. (1976). Treatment and prognosis in 31 Pettersson, H. and Ryden, G. (1982). Avulsion fractures
conservative treatment of fractures of the first phalanx of the caudoproximal extremity of the first phalanx.
in the horse. Tierarztl. Prax. 4: 59–76. Equine Vet. J. 14: 333–335.
www.ajlobby.com
32 Ramzan, P.H. and Palmer, L. (2011). Musculoskeletal 36 Tetens, J., Ross, M.W., and Lloyd, J.W. (1997).
injuries in Thoroughbred racehorses: a study of three Comparison of racing performance before and
large training yards in Newmarket, UK (2005–2007). after treatment of incomplete, midsagittal fractures of
Vet. J. 187: 325–329. the proximal phalanx in standardbreds: 49 cases
3 3 Richardson, D.W., Nunamaker, D.M., and Sigafoos, (1986–1992). J. Am. Vet. Med. Assoc. 210: 82–86.
R.D. (1987). Use of an external skeletal fixation 37 Whitton, R.C. and Kannegieter, N.J. (1994).
device and bone graft for arthrodesis of the Osteochondral fragmentation of the plantar/palmar
metacarpophalangeal joint in horses. J. Am. Vet. proximal aspect of the proximal phalanx in racing
Med. Assoc. 191: 316–321. horses. Aust. Vet. J. 71: 318–321.
4 Smith, M.R.W., Corletto, F.C., and Wright, I.M. (2017).
3 38 Wright, I.M. and Minshall, G. (2017). Short frontal plane
Parasagittal fractures of the proximal phalanx in fractures involving the dorsoproximal articular surface of
thoroughbred racehorses in the UK: outcome of the proximal phalanx: description of the injury and a
repaired fractures in 113 cases (2007–2011). Equine technique for repair. Equine Vet. J. 50: 54–59.
Vet. J 49: 784–788. 9 Yovich, J.V. and McIlwraith, C.W. (1986). Arthroscopic
3
5 Smith, M.R. and Wright, I.M. (2014). Radiographic
3 surgery for osteochondral fractures of the proximal
configuration and healing of 121 fractures of the phalanx of the metacarpophalangeal and
proximal phalanx in 120 Thoroughbred racehorses metatarsophalangeal (fetlock) joints in horses. J. Am.
(2007–2011). Equine Vet. J. 46: 81–87. Vet. Med. Assoc. 188: 273–279.
www.ajlobby.com
320
20
Fractures and Luxations of the Fetlock
C. Wayne McIlwraith
Department of Clinical Sciences, College of Veterinary Medicine & Biomedical Sciences, Colorado State University,
Fort Collins, CO, USA
This chapter addresses osteochondral chip fragments of also be present on both (Figure 20.1). With the use of
the dorsal and palmar/plantar proximal phalanx, dorsal complete arthroscopic examination of the dorsal aspect of
frontal fractures of the proximal phalanx, lesions of the the joint, an increasing number of lesions are being recog
distal palmar metacarpus, and luxations of the fetlock nized on the proximal lateral eminence.22 Clinical signs
joint. Other fractures associated with the fetlock joint, may decrease with rest and become apparent again with
such as fractures of the metacarpal condyles, sesamoid exercise. Fragments have also been reported as incidental
bones, and sagittal and comminuted fractures of the findings on radiography without any clinical signs.18,19
proximal phalanx, are dealt with elsewhere in this book.
Pathogenesis
roximal Dorsal Osteochondral
P In most instances (at least in adult racehorses), the frag
Chip Fractures of the Proximal ment is considered to be the result of a fracture. These
Phalanx occur during racing or fast training and result from
compression of the dorsal proximal portion of the proxi
mal phalanx against the third metacarpal bone during
Introduction
extreme extension of the fetlock joint.28,43 As the load
Osteochondral fractures of the proximodorsal aspect of applied to the fetlock increases, the joint extends further
the proximal phalanx of the metacarpophalangeal joint and there is increased load applied to the proximal pha
are common in racehorses.8,20,22,51 All but 1 of 63 horses lanx, as well as the suspensory apparatus.4,43 At maximal
in a 1986 retrospective study51 reporting on arthroscopic weight bearing at racing speed, the fetlock hyperex
surgery for the removal of these fragments was a racehorse, tends. At full stance, the dorsal surface of the proximal
and in a larger study the vast majority were racehorses.22,51 phalanx is compressed by the dorsal articular surface of
However, cases of rounded fragments of long‐term dura the distal metacarpus, and the palmar/plantar apical
tion have recently been recognized in non‐racehorses region of the third metacarpus (MC3) contacts the
and may represent a different entity.10,22,28 proximal sesamoid bones and intersesamoidean liga
The typical signalment in a racehorse is the presence of ment, to produce compression and shear, as well as
synovial effusion in the fetlock joint, varying degrees of dorsal‐palmar bending in the distal metacarpus.43 It is
lameness, some local dorsal soft tissue swelling, and pain now well recognized that this traumatically induced
on flexion of the joint. The injury occurs typically during fragmentation is a result of subchondral bone disease,
strenuous exercise and clinical signs are most prominent including microcracks, more diffuse microdamage, and
during the first few days after injury. Lameness is mild to osteocyte necrosis (or apoptosis).23,24,35
moderate. The most common location for chip fractures Recognition of fragments that are rounded and chronic
is the proximal medial eminence of the proximal phalanx in weanlings and yearlings, as well as separated pieces
(Figure 20.1), but fragments are also seen on the proxi having an osteochondritis dissecans (OCD) appearance,
mal lateral aspect of the proximal phalanx22,51 and may is a different entity, but still treated the same.28 It is to be

www.ajlobby.com
(A) (B)
(C) (D) (E)
Figure 20.1 Lateral‐medial radiograph (A) and flexed lateral‐medial radiograph (B) of typical fragment (arrows) off the proximal medial
eminence of the proximal phalanx. Arthroscopic views before (C) and after elevation (D) of the same proximal P1 chip fragment.
Dorsomedial‐palmarolateral oblique (DMPLO) radiograph (E) of a different case showing fragments off both the lateral and medial
eminence of the proximal phalanx.
emphasized, however, that these have a typical appearance occurred was known for 50 of 63 horses. 51 Of these
and are recognized in young Thoroughbred racehorses 50 horses, the interval between injury and arthroscopic
prior to training. This developmental pathogenesis is surgery was less than 5 weeks for 13, 2–4 months for 23,
not considered to be the usual situation in the adult and more than 6 months for 14 horses.51 Most of these
racehorse, as has been implied by some authors.25 latter cases had not responded well to conservative treat
More recently, a report of proximal phalanx (P1) fragments ment and training had been discontinued. Currently,
in a series of 117 Warmblood horses has been reported, with better digital imaging and an awareness of the
and in this breed the fragments were proposed to be part significance of even minor fragmentation on the radio
of developmental orthopedic disease.10 graphs, cases are referred for surgical removal of small
proximodorsal fragments based on persistent clinical
symptoms and the radiographic evidence of small dorsal
Treatment fragmentation (Figure 20.2).
The treatment of choice when the fragment is causing
clinical signs is surgical removal using arthroscopic sur
gery.28 Although it has been proposed that most frac
Arthroscopic Surgery
tures will heal with time, and this is possibly true, no Osteochondral chip fragments in the dorsal pouch of the
follow‐up study on racing performance after this con metacarpophalangeal (metatarsophalangeal) joint are
servative regimen has been reported. It should also be removed using arthroscopic techniques.28 Distention of
noted that not all proximal dorsal fragments are undis the joint allows visualization of the distal dorsal aspect of
placed, and not all horses that suffer such a fracture are the metacarpus, the proximal dorsal rim of the proximal
rested immediately after it occurs. In an initial study on phalanx, the dorsal synovial pad (previously called the
the use of arthroscopic surgery, the training period villonodular pad) proximal to the metacarpal condyles,
during which proximodorsal phalanx fragmentation and the synovial membrane of the dorsal capsule.
www.ajlobby.com
(A) (B)
(C) (D) (E)
Figure 20.2 Lateral to medial radiograph (A) and dorsomedial‐palmarolateral oblique (DPLMO) radiograph (B) of subtle fragmentation of
proximal P1 (arrows). Arthroscopic views before (C) and after (D) removal of fragment. Defect after debridement (E) of defective cartilage
and bone.
Arthroscopic surgery for removal of fractures of the when the proximal portal is used, but they do not prevent
dorsal proximal aspect of the proximal phalanx is satisfactory examination.
performed with the horse under general anesthesia and All arthroscopic surgery in the dorsal pouch of the
in dorsal recumbency. The limb is clipped from the fetlock joint is performed with the same arthroscopic
coronet to the proximal metacarpal area, and the dorsal portal in the proximal lateral aspect of the dorsal pouch.
aspect of the fetlock is shaved and prepared for aseptic After a complete diagnostic arthroscopy, the osteochon
surgery. The limb is suspended and draped in a rack to dral fragments are removed. If a fragment is present on
maintain extension of the fetlock joint. The joint is dis the proximal lateral eminence, it is removed first. A lat
tended using approximately 30 ml of a sterile polyionic eral instrument portal is made after ascertaining the
solution. The arthroscopic portal is located in the proxi ideal positioning using a needle. The needle placement
mal lateral aspect of the distended dorsal joint pouch. is lateral and midway down the distended portion of
This proximally placed arthroscopic portal facilitates the joint capsule. If it is too high, the proximal rim of the
visualization of the lateral as well as medial proximal phalanx cannot be manipulated. After ascertaining the
eminences (Figures 20.3 and 20.4).28 An 8 mm skin inci ideal positioning for the portal, a #11 blade is used to
sion is made and a small incision continued through the make a stab incision, and the instrument is inserted. The
fibers of the joint capsule using a #11 scalpel blade. The fragment is elevated, removed, and the defect debrided
arthroscopic sleeve is then inserted through the joint (Figure 20.5). If a medial fragment is present, a medial
capsule using a blunt obturator. The direction of inser instrument portal is created in the same fashion as the
tion is initially perpendicular to the skin, and then lateral portal, using a needle initially to verify ideal
parallel to the joint surface of the metacarpus, to avoid positioning.
damage to this area. A complete examination of the dor Fragments are initially evaluated using a probe. The
sal aspect of the joint is made, including dorsal synovial arthroscopic manifestations of the fragments vary con
pad, metacarpal condyles and sagittal ridge, and the siderably, and cannot usually be predicted from the
proximodorsal aspect of the proximal phalanx. Synovial radiograph. In a fresh chip, the fracture line may be
villi can obscure part of the rim of the proximal phalanx evident and the fragment can be moved easily, and is
www.ajlobby.com
(A) (B)
CDE EDL
M L
Figure 20.3 Diagram (A) and photograph (B) of positioning of the arthroscope and instrument during surgery for a chip fragment off the
lateral eminence of the proximal phalanx. CDE, common digital extensor; EDL, extensor digitorum lateralis; L, lateral; M, medial.
Source: McIlwraith et al.28 Reproduced with permission of Elsevier.
(A) (B)
Figure 20.4 Diagram (A) and photograph (B) of positioning of the arthroscope and instrument during arthroscopic surgery for removal of a
chip fragment off the dorsal medial eminence of the proximal phalanx. Source: McIlwraith et al.28 Reproduced with permission of Elsevier.
attached only at the dorsal synovial membrane reflection. In some cases the proximodorsal rim of the proximal
Displacement of the fragment facilitates identification phalanx may only show a defect on lateromedial radi
and removal. Figures 20.5 and 20.6 illustrate the ographs, but an oblique radiograph will show a small
sequence of events in removing fragments from the fragment. Sometimes the fragment can be recognized
proximal phalanx. In other cases, the cartilage over only as roughening of the proximal phalanx. Occasio
the fragment is intact, and elevation is required to nally the fragment is embedded in the joint capsule, and
define the fragment. With larger fragments, the attach this situation can be recognized if the fragment projects
ments of the fragment at the joint capsule may be more into the joint; otherwise, such a density will probably
extensive and need sharp dissection. With more chronic not be found, and the final diagnosis of a capsular mass
chip fragments, the shape tends to be more rounded. is based on the absence of a fragment on arthroscopic
www.ajlobby.com
(A) (B) (C)
Figure 20.5 Arthroscopic views of removal of fragment from the proximal lateral eminence of proximal phalanx (this fragment is the one
depicted in Figure 20.1E). (A) After elevation, (B) after removal of fragment demonstrating defective tissue in the defect, and (C) after
debridement of defect.
(A) (B) (C)
(D) (E)
Figure 20.6 Arthroscopic removal of proximal medial dorsal P1 fragmentation. (A) Radiograph showing proximal fragment.
(B) Arthroscopic image of chip fragment with petechial hemorrhage. (C) Curved elevator positioned to separate the fragment from the
proximal medial aspect of the proximal phalanx. (D) Free fragment in rongeurs for removal. (E) Debrided defect after fragment removal.
examination despite its appearance on radiographs. After removal of the fragment, the defect remaining is
Finally, fragments may already be totally free within inspected, including the adjacent area of dorsal capsule,
the joint. to ensure that no fragments remain. This inspection
Ferris–Smith intervertebral cup rongeurs are com must involve palpation, as well as visualization, as frag
monly used to remove the fragments. Low‐profile ments can merge into the capsule. The defect commonly
4 × 10 mm Ferris–Smith rongeurs have the ideal combi has tags or raised edges of cartilage that can be removed
nation of strength and ability to access the fragment. with a pair of Ethmoid forceps or a curette. Debridement
Enclosing the fragment within forceps minimizes the of the bone is done carefully with a small 2‐0 curette,
risk of leaving fragments in the joint. Twisting of the with care taken not to damage the fibrous joint capsule.
instrument to ensure breakdown of soft tissue attach Variable degrees of articular cartilage damage on the
ments is carried out before withdrawal of the fragment. distal metacarpal or metatarsal surface may be noted
www.ajlobby.com
(A) (B)
(C) (D)
Figure 20.7 Chronic proximodorsal chip fracture of the proximal phalanx with secondary cartilage erosion of the dorsal aspect of the
MC3 condyle. (A) Lateromedial radiograph showing rounded chip fracture. (B) Arthroscopic image showing chip fracture and secondary
fibrillation and erosion of the sagittal ridge and medial condyle of MC3. (C) Probing of MC3 erosion to determine depth of cartilage loss
and need for debridement to subchondral deep bone. (D) Defect in proximal phalanx after fragment removal and curettage.
(Figure 20.7). In many cases no focal damage is apparent, commenced after two weeks (at the time of suture
but varying degrees of wear line formation are apparent. removal). Walking begins with 5 minutes a day and is
Full‐thickness erosion may be seen in severe cases. When increased each week by 5 minutes, up to 30 minutes a
the lesions are more severe, the prognosis is not as day at 2 months. With a simple, fresh fracture, the horse
favorable.22 In some instances, usually racing Quarter may return to training after 2 months. For horses with
Horses, the osteochondral fragment on the proximal more extensive involvement, the convalescence time
phalanx extends dorsally into the joint capsule and must be increased. The author makes no specific recom
requires sharp dissection for removal (Figure 20.8). mendations regarding intraarticular medication after
Using sharp dissection is considered critical to avoid surgery, but some veterinarians favor it. Underwater
undue trauma to the fibrous joint capsule that later can treadmilling is being increasingly used as a rehabilitation
result in mineralization. technique and is encouraged.
At the completion of surgery, the joint is flushed with
fluid by moving an open‐egress cannula over the site of
the defect. The skin portals are sutured and the leg band Results
aged. A sterile bandage is maintained for at least two The results of arthroscopic surgery for uncomplicated
weeks. cases of proximal phalangeal fractures have been excel
lent.22 If fractures are associated with severe capsulitis,
wear lines, osteoarthritis, or extensive fragmentation of
Postoperative Care the proximal phalanx, the prognosis decreases accord
The limb is bandaged for recovery from anesthesia. ingly, but there is still a high percentage of horses that
Phenylbutazone is administered perioperatively; how can race successfully. Kawcak and McIlwraith22 docu
ever, antibiotics are not used unless there has been a mented the results in 320 horses, where 446 osteochon
recent history of joint injection. Hand walking is dral fragments were removed from 417 fetlock joints;
www.ajlobby.com
(A) (B)
(C) (D)
Figure 20.8 Fragmentation of the proximal phalanx that extends more distally and involves a larger frontal component than normal in a
racing Quarter Horse. (A) Radiograph, (B) sharp dissection of capsular attachments from the fragment arthroscopically, (C) removal of the
fragment with Ferris–Smith rongeurs, and (D) after debridement of the defect back to healthy cartilage and bone.
295 of the horses were racehorses, including 181 fragments were found (19 horses) was 63.2%, compared
Thoroughbreds, 111 Quarter Horses, 2 Standardbreds, to those with single fragments per site (70.9%). Those
and 1 racing Arabian. A single metacarpophalangeal horses with a single forelimb involved returned to origi
joint was involved in 209 horses, while both metacar nal performance at a rate similar to horses with bilateral
pophalangeal joints were treated in 94. A single metatar forelimb chip fractures (52.9% and 53.4%, respectively).
sophalangeal joint was treated in 16 horses and 1 horse Neither of these differences was significant. Horses that
had surgery on all four joints. Fragmentation of the prox sustained chip fragmentation alone, without other
imodorsal aspect of the proximal phalanx was the only intraarticular changes in the fetlock joints, had a signifi
lesion in the fetlocks of 93 horses. There were concur cantly higher rate of return to use (86% compared to
rent lesions in the fetlock of 134 horses, which included 75%). The lower incidence of fragments in the Quarter
64 with wear lines, 11 with articular cartilage erosion, 13 Horse compared to the Thoroughbred is significant rela
with chronic proliferative synovitis, 3 with osteochon tive to the referral population. This difference could be
dritis dissecans, and 43 with a combination of these related to the distance raced, which in turn would
lesions. Carpal arthroscopy for removal of osteochon affect fatigue and the amount of hyperextension that
dral chips was also performed in 93 of the horses. Follow‐ the fetlock sustained.
up was available for 260 horses, which included 244 In a study done to examine the longevity of postopera
racehorses; 191 horses (73.5%) returned to their intended tive careers and quality of performance of 461
use, including 141 (54.2%) that returned to the same or a Thoroughbred racehorses after arthroscopic removal of
higher level of performance, and 50 (19.2%) horses that proximodorsal osteochondral fragments from the proxi
returned to performance but at a lower class. Moreover, mal phalanx, 659 chip fragments were removed from 554
18 horses (6.9%) developed another fragment, and 51 joints in 461 horses.7 Horses were presented for lame
(19.6%) horses did not return to their intended use. Of ness or decreased performance attributable to chip frag
the non‐racehorse group, 12 of 16 horses (75%) not only ments. Race records indicated that 89% of the horses
returned to their intended use, but also returned at the (411 of 461) raced after surgery, and 82% (377 of 461) did
same level of performance. The success rate when multiple so at the same or a higher class; 68% of the horses raced
www.ajlobby.com
in a stakes or an allowance race postoperatively. This yearlings, and is almost certainly osteochondrosis,6,18,49
study confirmed that the quantity and quality of perfor although there may be a concurrent later traumatic
mance were not diminished after arthroscopic surgery component in racehorses where the OCD displaces or
for proximodorsal fragments, and that surgical removal mineralizes in an irregular pattern. Given these similarities,
of a chip fragment preserved the economic value of a lesions that are most likely mineralized OCD fragments
racing Thoroughbred. Horses that raced before and after will be covered briefly here. Treatment is similar regard
surgery (258) had an average of 8.4 starts (median 6) less of etiology.
before surgery and 13 (median 7) after surgery. The aver Osteochondritis dissecans of the dorsal aspect of MC/
age time between surgery and first postoperative start MT3 can occur in both metacarpo‐ and metatar
was 189 days (median 169), and 87% of the horses racing sophalangeal joints, but it is more common in the
before surgery (224 of 258) returned to race at the same forelimbs. The lesions vary in their radiographic mani
or a higher class. The average earnings per start after festations, from a subchondral defect associated with
surgery were less than the average earnings before sur failure to mineralize the proximal aspect of the sagittal
gery in 61% of these horses and greater in 32%. The ridge to defects associated with fragments. In some
authors also considered the 11% postoperative failure cases, fragments break away completely from the pri
rate to be overly pessimistic due to various factors. It was mary lesion and become loose bodies. The presenting
noted that horses that did not race after surgery tended clinical signs include synovial effusion of the fetlock joint
to be older at the time of surgery, and had raced more with or without lameness. In most instances, the patients
times preoperatively. The authors concluded that the are weanlings to yearlings and quite often are presented
lack of return to racing was not related to chip incidence, for treatment prior to sale. In some instances, training
location, or size, as these did not differ between the raced and racing may have occurred before the symptoms
and retired groups. develop. Although the degree of lameness varies, a
positive response to a fetlock flexion test is usually elic
ited, and radiographs confirm the presence of lesions
Arthroscopic Removal associated primarily with the sagittal ridge and adjacent
condyle surface of MC/MT3.
of Proximodorsal Chip
Oblique radiographs should be taken as well as dor
Fractures in Standing Horses sopalmar (plantar) and lateral/medial radiographs
for the purpose of discerning the medial or lateral
This technique has been described and reported in 104 condyles of MC/MT3.29 Based on an initial study,52
horses.13 Given skill and technique, it is possible to mineralized and separated types of dorsal sagittal
perform arthroscopic surgery in the dorsal aspect of ridge OCD lesions were considered surgical diseases.
the fetlock joint with the horse sedated and standing. Unmineralized defects without fragmentation on the
However, the author would only recommend this if, for proximal aspect of the sagittal ridge were expected to
some reason, general anesthesia was not possible or mineralize and radiographically resolve. In a study of
convenient. 15 cases with simple unmineralized sagittal ridge
defects treated conservatively, 12 resolved clinically
and 8 of these showed remodeling of the lesions with
Osteochondral improvement on radiographic examination.29 In 8
Fragmentation Associated cases of mineralized OCD lesions where owners
with Osteochondrosis requested conservative management, 2 eventually
underwent surgery because of the persistent clinical
Dorsal Sagittal Ridge and Condyle signs.29 Clinical signs persisted in 5 others, but surgery
was further declined; the clinical signs improved in
Osteochondrosis
only 1 horse. In most of these cases where clinical signs
Osteochondral fragmentation of the dorsal sagittal ridge persisted, the fragmentation also progressed radio
and parasagittal dorsal condylar surface of MC3 or the graphically. It was clear too from this study that clini
third metatarsus (MT3) has been described as a manifes cal signs of effusion may appear before definitive
tation of osteochondrosis.52 Irregular mineralization can radiographic changes. Progression of some unmineral
develop in chronic cases, which can lead to the impres ized lesions was noted, not by the formation of osseous
sion that these may be traumatic fragmentation of the fragmentation, but rather because the lucent lesions
proximal surface of the sagittal ridge or dorsal condyle. became larger, particularly extending to the condyles
Similarly, fragmentation or incomplete mineralization of (seen on oblique‐view radiographs). Some cases of
the distal region of the sagittal ridge is well recognized in mineralized OCD lesions improved radiographically.
www.ajlobby.com
These were generally cases with small fragments that orsal Frontal Fractures
D
fused to the parent bone such that a spur resulted. of the Proximal Phalanx
Based on this data, arthroscopic surgery is considered
the appropriate treatment if mineralized fragments are These fractures are relatively uncommon. In one report
present. In other cases in which a defect only is detect they represented 9 of 123 (7.3%) of all fractures of the
able radiographically, the decision for surgery is based proximal phalanx (excluding proximodorsal chip frac
on the degree of clinical signs, the size and location of tures) that presented over an eight‐year period.26,27 Eight
the defect, and the planned use of the horse. of the nine fractures occurred in racing Thoroughbreds,
The arthroscopic approach is the same as that for frag and one in a Standardbred. A recent study also described
ments off the proximodorsal aspect of the proximal pha treatment of 22 short dorsal frontal fractures in 21
lanx or synovial pad proliferation, using a proximally or Thoroughbred horses.50 Prior to these reports, the frac
distally placed instrument portal, depending on the loca tures had been recognized only twice in the literature.11,28
tion of the fragment or loose body. In some cases, the One case series describes the fractures as occurring
OCD lesion is a defect within the sagittal ridge, and exclusively in the hind limbs;26,27 however, our experi
curettage is performed. More commonly, osteochondral ence and that of others indicates that these fractures also
fragments may be within the defect or have loose attach develop infrequently in the forelimb.50 The fracture
ments to the area. In these cases, the fragment is removed could result from biomechanical factors peculiar to the
and any defective articular cartilage is debrided. Loose hindlimb.26,27 Continued distal acceleration of the meta
fragments are located and removed from the dorsal com tarsus against the proximal phalanx, with the metatar
partment with rongeurs. Undermined cartilage may sophalangeal joint in an extended or slightly flexed
extend medial or lateral to the sagittal ridge of MC3 and position, may cause the fracture.26,27 The configuration
MT3, and it must be debrided. OCD can also occur only may be incomplete or complete, depending on propaga
on the dorsal surface of the metacarpal or metatarsal tion to the dorsal cortical surface of the proximal pha
condyles adjacent to the sagittal ridge. lanx. The dorsolateral aspect of the proximal phalanx is
involved most frequently,26,27 although paradoxically the
dorsomedial aspect is the more predisposed site in
Distal Sagittal Ridge Thoroughbreds in the UK.50
Osteochondrosis Complete fractures may be displaced or nondisplaced.
Complete displaced fractures should be treated surgi
Distal sagittal ridge OCD occurs commonly and almost
cally with lag screw fixation. Some nondisplaced frac
exclusively involves the forelimb fetlocks. Many of the
tures can heal with conservative treatment, particularly
same principles guiding treatment for OCD of the
when incomplete. However, complete nondisplaced frac
proximal aspect of the sagittal ridge can be used to
tures generally should be treated by lag screw repair, to
decide on the need for surgery of lesions in the more
reduce the risk of subsequent displacement and hasten
distal region. The lesions are frequently evident on
fracture healing (Figure 20.9).26,27 Chronic complete
yearling sales radiographs in horses that show no clini
fractures can also develop delayed union and require
cal symptoms. They are best visualized on dorsopalmar
removal or fixation (Figures 20.9).
and flexed lateral projections and appear as a nonmin
eralized void in the sagittal ridge. This may resolve
over time, but many can be subtly evident as a centrally
mineralized irregularity in the sagittal ridge in horses
actively racing. Trauma from race training can lead Surgery can be performed with the horse in dorsal or
to separation of these OCD lesions and protrusion lateral recumbency. After induction of anesthesia and
into the articulation. This can cause clinical symptoms preparation of the limb, arthroscopic examination of the
which often do not resolve without surgical debride joint is performed and any debris removed from the
ment.49 The principles for arthroscopic removal are fracture line. After debridement of the fracture bed
similar to more proximally located fragments, but the (when necessary), the fragment is compressed to the
joint must be flexed to expose the lesion, and the parent bone with a 2.7 or 3.5 mm cortical bone screw
instrument and on occasion the arthroscope entry (Figure 20.9) inserted using conventional lag screw
need to be more distally situated in the dorsal com technique. Large fractures need a 3.5 mm screw, and
partment.28,49 Outcome after surgical debridement is may need a second, more distally placed screw for effec
excellent, with one study indicating 13 of 14 horses tive stabilization. Good articular alignment and fracture
returning to athletic activity.49 reduction are necessary.
www.ajlobby.com
(A)
(B) (C)
(D) (E) (F)
Figure 20.9 Large dorsal frontal fracture of proximal phalanx. (A) Preoperative radiographic view of the fracture off the proximal lateral
aspect. (B) Arthroscopic view of fracture. (C) Placement of needle to ascertain center of fracture. (D) After lag screw fixation and
debridement of defective bone from fracture site. (E) Glide hole (3.5 mm) drilled through fracture and angled to traverse the proximal
phalanx distal to the sagittal groove. (F) Placement of a 3.5 mm diameter lag screw. (G) Lateromedial and (H) dorsomedial‐palmarolateral
oblique (DMPLO) radiographs of the same horse showing chronic unstable dorsofrontal fracture of the opposite fetlock where the
fragment was treated with removal. (I) Arthroscopic view of the frontal fracture prior to removal and debridement. (J) Arthroscopic view
of the frontal fracture following removal and debridement.
Arthroscopic surgery is performed with the limb in

Postoperative Care
extension using a standard arthroscopic approach to the
dorsal pouch. Examination of the joint will confirm the Horses are recovered from anesthesia with the limb in a
presence of the fracture (Figure 20.9). Needles are placed bandage that is maintained postoperatively. Stall rest is
to ascertain ideal positioning for the screw, a stab incision used in the initial period and hand walking commenced
is made, and a 2.7 mm hole (when placing 2.7 mm screws) two weeks after surgery. Phenylbutazone is administered
is drilled obliquely through the fracture fragment during the immediate perioperative period. Implants are
(Figure 20.9). The hole is generally perpendicular to the removed only if they cause clinical problems.
fracture line. Radiographs confirm appropriate positioning If the fracture remains nondisplaced, bony healing can
and that the glide hole extends beyond the fracture line. be anticipated with conservative treatment and success
A 2.0 mm pilot hole is continued beyond this. After coun ful performance should result. Displacement of a dorsal
tersinking and tapping, a 2.7 mm diameter, 36 mm long frontal fracture with development of secondary osteoar
cortical bone screw is placed to compress the fracture. thritis has been reported.26,27 Nonsurgical therapy in the
Further debridement is then performed along the frac form of stall rest with a heavy support wrap has been
ture line if appropriate. The manifestations of the fracture reported to result in healing of the fracture in four to
line vary, with some fractures requiring no bone debride six months,26,27 but the author has seen radiographic
ment and others needing bone removal comparable to healing in three months. In one report of 11 fractures in
slab fracture of the third carpal bone. 9 horses, 7 were incomplete and nondisplaced, 1 was
www.ajlobby.com
(G) (H)
(I) (J)
complete and nondisplaced, and 3 were complete and Axial Osteochondral Fragments
displaced.26,27 Complete, displaced fractures in two of the Proximal Palmar or Plantar
horses were repaired by open reduction of the fracture Aspect of the Proximal Phalanx
and lag screw fixation. The other seven were treated
nonsurgically. All horses were sound on the injured leg
within three to six months of injury. Follow‐up was
Introduction
obtained on all 9 horses: 2 were retired for breeding, Two types of palmar/plantar fragments of the proximal
5 performed at a level equal to or better than their previ phalanx have been described: (i) type I osteochondral
ous level of racing performance, 1 successfully entered fragments of the palmar/plantar aspect,15 or axial bony
combined training, and 1 returned to a lower level of fragments of the palmar/plantar part of the metacarpo‐ and
performance due to an unrelated forelimb lameness.26,27 metatarsophalangeal joint;18,19 and (ii) type II osteochon
In a recent study, 16 of 21 (76%) Thoroughbred race dral fragments of the palmar/plantar aspect of the fetlock
horses treated by lag screw repair returned to race at a joint,15 or ununited proximoplantar tuberosity of the
similar level.50 In the author’s cases treated with arthro proximal phalanx.18,19 These fragments are more common
scopic surgery and lag screw fixation, horses can be in the hindlimb fetlocks. Type I axial osteochondral frag
returned to training in two to three months. ments of the palmar‐plantar aspect of the fetlock joint,15
www.ajlobby.com
were initially reported as chip fractures2 and avulsion frac break in stride at fast speed.16 In one series of cases of 82
tures.39 Since that time, Foerner et al.15 suggested that this horses receiving lameness examination at admission, 17
condition is another manifestation of osteochondrosis (21%) horses had slight to moderate positive response on
based on its incidence and the age of occurrence of the hindlimb flexion. Synovial effusion of the metatar
fragments. However, more recent publications have sophalangeal or metacarpophalangeal joint was reported
argued for a traumatic etiology.9,34 Hindlimb fetlock joints in 19 of 119 (16%) of horses; 155 of 164 (95%) fragments
with plantar osteochondral fragments were collected from were in the metatarsophalangeal and 9 of 164 (5%)
21 horses (17 Standardbred trotters. 4 Swedish Warmblood involved the metacarpophalangeal joints.16 Fragment
riding horses), and the morphology of the osteochondral location was predominantly the medial plantar eminence
fragments and adjacent tissues studied by dissection, of the proximal phalanx (114 of 164) fragments (70%).
high‐resolution radiography, and histology.9 The frag Bilateral fragments were observed in 21 (18%) horses,
ments were attached to the short sesamoidean ligaments and 15 (13%) horses had concurrent medial and lateral
and had a smooth cartilage covering on the surface facing lesions within the same joint. Standardbred racehorses
the joint cavity. Histology showed no evidence of osteo represented 109 (92%) of those affected.16 In another
chondrosis. The authors suggested that the fragments series of 26 cases, 23 of the horses were racing
resulted from an outwardly rotated hindlimb axis, with Standardbreds and 3 were racing Thoroughbreds.48 The
subsequent point loading of the medial aspect of the fet most common reason for presentation in this series was
lock. Repeated high‐tension load on the short sesamoid an inability to run straight at high speeds. Only 8 horses
ean ligaments may cause avulsion of fragments of tissue presented for lameness, although on examination 19
with osteogenic properties from the proximal phalanx were lame. A positive flexion test was recorded in 90% of
into the ligament.42 This pathogenesis may explain frac affected fetlock joints and effusion was present in 48%.
tures of the plantarolateral aspect through action of the
lateral short sesamoidean ligament, but the outward
rotation may not influence lateral involvement. These
Treatment
fragments apparently develop early in life, and are often Criteria for surgery include a demonstrable lameness refer
detected by radiography before three months of age.6 able to the fetlock, and a radiographically visible fragment
A second study has been done on osteochondral frag (Figure 20.10). The fragment can be identified on the lateral
ments from the axial proximoplantar/proximopalmar and flexed lateral views. Dorsoplantar radiographs taken
region of the proximal phalanx in 38 joints from 30 horses: with the fetlock flexed have also been recommended,2 but
28 of 30 of the horses were Standardbreds and 28 of 30 the authors have not used this technique. For optimal defi
had low‐grade lameness. All but one of the horses had nition of the location of the lesion, however, a special
hindlimb involvement. Of 143 fragments removed, 71% oblique view with the radiographic tube head angled down
involved the medial aspect of the joint and the fragments ward at 30° is useful (Figure 20.10). Both oblique views are
had to be dissected from a covering of synovial tissue.34 essential, as lesions can be biaxial. Nonsurgical treatment
The histologic appearance of these fragments suggested usually lowers the horse’s performance.1
that they were the result of fracture rather than a manifes
tation of osteochondrosis, with an obvious fracture line
along one edge, and all having a region of short sesamoid
ean ligament attachment on the opposing end. Arthroscopic surgery is now the standard of care. Dorsal
or lateral recumbency can be used; the authors prefer
dorsal recumbency, as the instrument portal can con
Diagnosis veniently be made laterally or medially. Some flexion of
Radiographic features include the presence of a frag the joint by an assistant may be required for the entire
ment between the base of the sesamoid bone and the procedure. If the surgery is done in lateral recumbency,
proximal aspect of the proximal phalanx, and generally the side where the fragment is located should be upper
halfway between the sagittal groove and the lateral or most and the arthroscope and instrument approaches
medial eminence of the proximal phalanx. These may made from the same side. The arthroscope is placed in
not always be associated with a defined defect on the the plantar or palmar joint pouch, after distending the
proximal phalanx. Although initially the condition was joint. The arthroscope is positioned to visualize the dis
considered peculiar to the Standardbred,39 cases occur tal part of the joint with the limb flexed. After assuring
in Thoroughbreds and the condition is reasonably com the correct position with a needle (across the base of the
mon in Warmblood breeds. sesamoid bone), an instrument portal is made distal to
A history of low‐grade lameness is typical and often the arthroscopic portal (Figure 20.11), to allow instru
reported by the trainer to manifest as a rough gait or ment access transversely. Often, the fragment can be
www.ajlobby.com
(A) (B) Figure 20.10 Osteochondral

fragmentation of the proximal plantar
aspect of the proximal phalanx. Lateral to
medial view (A) and elevated oblique view
(B) of plantar proximal phalanx fragment.
(A) (B) Figure 20.11 (A) Diagram of arthroscopic

technique to remove a type I
osteochondral fragment of the plantar
aspect of the fetlock joint. (B) Dorsal‐
plantar intraoperative technique view.
Source: McIlwraith et al.28 Reproduced with
permission of Elsevier.
visualized; if not, a probe is used to define its location. of breakage. Electrocautery probes have been used more
Local synovial resection can aid visualization recently for this dissection.3,44
(Figure 20.12). The fragment is then separated from the The immediate postoperative care is the same as
soft tissue with a knife, such as a curved serrated “banana” for other arthroscopic procedures in the fetlock joint.
knife, and removed using a Ferris–Smith cup rongeur A period of two to three months’ rest before training
(Sontec Instruments, Englewood, CO, USA). Removal of resumes is recommended.
this fragment leaves a defect within the joint capsule and There have been two reports of treatment of these
short distal sesamoidean ligaments. Loose tags of tissue osteochondral fragments with follow‐up. Whitton and
are removed to ensure that all small fragments of bone Kannegieter48 reported on the outcome after arthro
have been eliminated. Debridement of the proximal scopic removal of fragments from 21 horses, of which 16
plantar defect in the proximal phalanx is sometimes had returned to racing: 12 horses had improved their
appropriate, but is not usually necessary. performance, while 3 horses showed no improvement,
This condition is one of the few in equine arthroscopic and 1 horse was retired for other reasons. Degenerative
surgery for which the use of sharp dissection is essential. changes within the fetlock joint were detected at surgery
Different instruments have been used, including a ten in 8 horses. Treatment was conservative in 4 horses: 1
otomy knife, a banana knife, a narrow bistoury, and an horse returned to its previous level of performance
Arthro‐Lok™ (Beaver‐Visitec International, Waltham, temporarily after intraarticular medication, 1 horse
MA, USA). We prefer a broad, flat blade. The disposable showed no improvement, and 2 horses were resting at
#11 or #12 blades should not be used because of the risk the time of the report.48
www.ajlobby.com
ACC 1 ACC 1
Plantar MtIll
P1
Fx
Ses
(A) (B)
Figure 20.12 Arthroscopic view of type I osteochondral fragment of the plantar aspect of the fetlock joint prior to (A) and after
(B) removal. Ses, sesamoid bone; Fx, fracture; P1, plantar aspect of proximal phalanx; Plantar MT3, plantar surface third metatarsus.
A larger case series of 119 horses (109 Standardbred walking is started at two weeks and gradually increased
horses) had follow‐up in 87 racehorses and 9 non‐ over the following six weeks. A period of two to three
racehorses.16 In 55 of 87 (63%) racehorses and 100% of months’ rest is recommended before training is resumed.
9 non‐racehorses, performance returned to preoperative
levels after surgery. Fragment numbers or distribution,
and concurrent OCD of the distal intermediate ridge of
the tibia or tarsal osteoarthritis, were not significantly
Type II Osteochondral
associated with outcome. Abnormal surgical findings, Fragmentation (Ununited
consisting of articular cartilage fibrillation or synovial Proximoplantar Tuberosity)
proliferation, were significantly (p < 0.001) associated of the Proximal Phalanx
with adverse outcome: these findings were documented
in 31% of the 32 horses without successful outcome, and Type II proximoplantar osteochondral fragments are
only 2% of the 55 racehorses with successful outcome.16 located on the abaxial tuberosity of the proximal phalanx
Arthroscopic excision of these fragments using elec and are predominantly extraarticular. Lameness is
trocautery probes has been described in 23 Standardbred uncommon. Type II or abaxial fragments are easily
racehorses.44 A 1.5% glycine solution in an Arthropump® recognized on conventional oblique radiographs

(Karl Storz SE, Tuttlingen, Germany) was used to main (Figure 20.13). Surgery is rarely indicated with type II
tain joint dissection. Transection was performed using loop osteochondral fragments due to the abaxial and extraar
probes alone or, alternatively, with hook electrocautery ticular location, and lack of specific lameness. This lesion
probes to dissect the fragment free prior to Ferris–Smith was seen on radiographic survey of 18 (2.4%) of 753
rongeur removal. In these 23 Standardbred racehorses, Standardbred yearlings.18,19 All fragments were in the
35 fragments in 28 joints were removed from either the pelvic limbs. The condition was seen laterally in 16 of the
left or the right hindlimb. Six had biaxial fragmenta 18 horses, while one horse had a medial and lateral
tion. An ipsilateral (n = 9) or contralateral (n = 26) trian tuberosity affected, and another had only the medial
gulation approach was used. The authors concluded that tuberosity affected. Lameness was not observed in any
the loops and probes can be safely used to excise osteo horse prior to first examination. On follow‐up examina
chondral fragments of the plantar proximal phalanx. tion, 12 lesions in 11 horses had united to the proximal
They considered dissection using electrocautery probes phalanx after 6–12 months. One horse was unchanged at
to be more precise and easier to perform than the previ seven months, and the remaining four had a radiographic
ously described sharp dissection technique. No follow‐up worsening in the condition, with the ununited proximo
was given. It has since been recognized that glycine is not plantar tuberosity being more distracted. Three of these
necessary for this procedure. four horses also had calcification of the distal sesamoid
Horses are recovered from anesthesia in a sterile band ean ligaments and periosteal proliferation, with two sub
age, which is maintained for three weeks. Sutures are sequently requiring surgery to remove the fragment.
removed at two weeks. Phenylbutazone is used periopera This gives an incidence of clinically significant disease in
tively, but antibiotics are not routine. For horses with type 2 of 16 radiographically identified horses (12.5%).
I fragments removed using arthroscopic surgery, hand Additionally, in 11 of 18 horses, type I osteochondral
www.ajlobby.com
(A) (B)
Figure 20.13 (A) Type II (abaxial) osteochondral fragmentation of the proximal phalanx. (B) Type I and type II fracture fragmentation in the
plantar aspect of the fetlock joint; both type I and type II fragments were removed arthroscopically in this case.
fragments in the plantar part of the metatarsophalangeal I

osteochondral fragments have been obtained with
joint were seen together with ununited proximoplantar arthroscopic surgery. For type II fragments, the low
tuberosities in the same pelvic limb, and the former numbers and lack of definition of the location of frag
could be an indication for surgery. ments preclude reliable prognostic figures.
Removal of type II fragments, if they are considered to
be a clinical problem, is achieved using an open tech
nique.5,15 A vertical 4 cm skin incision is made on the
abaxial surface of the fetlock joint at the level of the prox istal Palmar Metacarpal
D
imal tuberosity of the proximal phalanx, a prominent (Metatarsal) Fragmentation
portion of which is palpable dorsal to the palmar digital
artery, vein, and nerve. The incision is continued through This is a traumatically induced disorder that was initially
the distal part of the annular ligament of the fetlock and called osteochondritis dissecans of the metacarpus,21 a
the joint capsule immediately distal to the collateral sesa name that implies that this lesion is a developmental
moidean ligament and proximal to the proximal surface joint disease, which it is not. It has also been described as
of the proximal phalanx. The fetlock is flexed and a traumatic osteochondrosis of the palmar/plantar surface
retractor is used to expose the fracture. The fragment is of the condyle of the cannon bone.40 The condition
dissected free and removed. was initially described as palmar lesions in the equine
Lag screw fixation of a large fracture has been fetlock joint, based on radiographic examination of 15
reported,2 with two 3.5 mm cortical bone screws. The Thoroughbred horses two to ten years old that were
author has also used lag screw fixation to repair large examined for suspected fetlock lameness.37 The palmar
fractures that are not healing spontaneously. The conva lesions were identified on the lateromedial and flexed
lescent time for fractures removed using open approaches lateral projections, and were described as crescent,
or arthrotomy is four to six months. In one series of flattened, shallow concavity, deep concavity, oval, or
19 horses, 10 were treated using arthrotomy and all circular.37 Secondary joint disease, characterized by per
returned to full use, whereas in 7 treated intraarticularly iarticular osteophytes, marginal erosions, and narrowing
with corticosteroids, only 1 was able to return to full use. of the joint space, was seen in 20 of 21 fetlocks examined.
In another study of palmar/plantar process fractures in The degree of severity was subjectively classified as
15 horses, all horses that were treated surgically were minor in 10, moderate in 8, and severe in 2. The gross
sound within six months, and 14 returned to an equal or pathologic appearance of palmar metacarpal lesions var
better level of performance.5 Successful results with type ied from large cartilage ulcerations with extensive bone
www.ajlobby.com
necrosis, to smaller condylar lesions with small foci of osteocytic death, and plugging of canaliculi with debris.43
cartilage ulceration and bone necrosis. The lesions were The impact of loss of perfusion and osteocyte communi
all located palmar to the transverse ridge of the distal cation is presumed to be contributory to ongoing bone
metacarpus. Two of three horses monitored radiograph pathology. The appearance of microcracks in sub
ically in this study had a reduction in the size of large chondral bone and bone matrix follows, and these in
lesions after prolonged rest (40–56 weeks), but also had turn are followed by small and larger advancing cracks
some progression of secondary joint disease and their in the calcified cartilage.31 These lesions are the result
clinical signs became more severe (increased pain on of maladaptation, with the final result being bone and
flexion, reduced range of motion). Gull‐wing arthrosis, cartilage collapse. Comparisons have also been made
as reported by Rooney in 196941 and also reported by between athletic and nonathletic horses, which
Nilsson and Olsen in 1973,33 is considered to be a sepa revealed that differences in site‐specific microdamage
rate entity. The latter condition is due to chronic degen accumulation and associated remodeling were much
eration of the articular cartilage and is limited to the greater than differences in subchondral osteocyte
transverse ridge of the metacarpus.40 morphology.32 A scanning electron microscopic study
Distal palmar metacarpal fragmentation was initially of horses showed that the earliest microcracks appeared
termed osteochondritis dissecans based on similarities to develop in the sclerotic bone within 1–3 mm of the
to OCD in humans, which is primarily an osseous lesion calcified cartilage layer, and extended parallel to it in a
with secondary cartilage involvement.21,37 The lesion is regular branching line.36
now considered to be an injury due to hyperextension of Affected horses exhibit little joint effusion and heat in
the metacarpophalangeal joint.40 It has more recently the early stages. When training, they start out with a
been referred to as palmar osteochondral disease (POD), stilted gait, which improves as they warm up.14 With
to reflect location and a spectrum of disease progression. progression of the disease, the lesion on the palmar
Histologic studies show an area of acellular and surface of the metacarpus increases in size, with joint
apparently necrotic bone, surrounded by a border of effusion and pain on flexion and extension of the joint,
hypervascularity with large numbers of osteoblasts and and a progressive increase in the amount of lameness.
osteoclasts. Hyaline cartilage covering these areas was The diagnosis is conventionally confirmed with radio
often morphologically and histochemically normal. graphs (Figure 20.14). An examination of the metacarpo/
These authors hypothesized that microfracture was the metatarsophalangeal joint pathology of paired limbs of
etiology of the lesions, and that this microfracture was Thoroughbred racehorses with severe condylar fracture
secondary to subchondral sclerosis in this area.40 The
microfracture caused deprivation of blood supply and
necrosis. If the horse was rested, the area of necrosis
could be replaced by bone through contact healing.
Alternatively, the area of the subchondral fissure and
resultant hyperemia could collapse with the overlying
cartilage remaining intact, relieving the area of stress and
allowing revascularization; this was believed to have
been seen in at least one case in the study. The third pos
sibility was fragmentation and separation of the necrotic
bone and overlying cartilage from the viable bone.
A growing body of evidence indicates that these
lesions, as well as lesions elsewhere in the fetlock joint
(fractures and osteochondral chip fragmentation), are
the result of excessive stress from overuse, with chronic
repetitive small injury leading to accumulated microda
mage.43 In bone there is usually evidence of an attempt to
respond to injury by remodeling.45 It is unclear why
repair is so ineffective, but continued trauma, alteration
of blood supply, and severity of damage are considered to
be contributing factors.45 Compounding this is the lag
period between bone removal and bone formation, when
the remodeling bone has reduced strength. A sequence Figure 20.14 Palmar osteochondral disease in a four‐year‐old
of events has been proposed for the bone and calcified Thoroughbred, showing palmar flattening and subchondral
cartilage, starting with sclerosis of subchondral bone, erosion (arrow). Source: Image courtesy of Dr. Alan J. Nixon.
www.ajlobby.com
indicated that computed tomography (CT) was superior

to radiography for the detection of proximal fissures of
the distal MC/MT3, as well as small condylar cracks and
lucencies.30 More recently, CT evaluation of horses
under various exercise programs has shown differential
gradients that could be an early predictor of more severe
disease.
This condition is difficult to treat, since few if any sur
gical options are available that do not compromise other
vital structures. It is not possible to gain complete access
to the lesion and, based on experiences in other weight‐
bearing areas, it is questionable how much healing would
occur after curettage. The clinical signs will regress if
animals are rested, but return when training resumes. It
has been recommended that these horses remain in
training as long as possible, using supportive therapy
such as nonsteroidal anti‐inflammatory agents and
sodium hyaluronate, until the horse can no longer safely
continue. Postexercise physical therapy is also appropri
ate, and bisphosphonates such as Tildren® have been
used anecdotally. In the future, consideration might be
given to disarticulation of the equine fetlock for debride
ment of affected lesions, and potentially the use of some
osteochondral plug or grafting technique. An approach
to the fetlock, removing a bone block where the
collateral ligament attaches, has been described for
Figure 20.15 Stress radiograph showing metacarpophalangeal
experimental osteochondral allografting for resurfacing joint subluxation.
of the equine metatarsophalangeal joint.38 This has not
been evaluated in clinical cases.
norm.46 However, lameness and swelling may be the only

Luxation of the Fetlock Joint clinical sign when luxation does not occur or is not
detected because of spontaneous reduction.12,46,47 In
Lateral or medial luxation of the metacarpophalangeal these situations diagnosis can be delayed, particularly
or metatarsophalangeal joint can occur in association when instability is not detectable by palpation or radiog
with rupture of a medial or lateral collateral ligament, or raphy. Obviously, without appropriate treatment horses
an avulsion fracture (Figures 20.15 and 20.16). Two case could be prone to additional injury and luxation. The
series have been described46,53 and there have been other more recent introduction of ultrasonography as a diag
case reports.12,47 Each collateral ligament is composed of nostic aid in these cases greatly aids in earlier diagnosis
a superficial (long) and a deep (short) component. The and definition of the condition.46
long component is orientated vertically, from its origin The injury often occurs with the horse stepping in
proximal to the condylar fossa of the third metacarpal or a hole or trapping its foot between parallel pipes or
metatarsal bone to its point of insertion on the proximal a cattle guard. The luxation results as the animal
phalanx.46 The short component is oriented in a disto attempts to remove its foot. Horses can also luxate
palmar or distoplantar direction, from the condylar fossa their fetlock joint during high‐speed activity. Cases
to an insertion on the palmar or plantar process of the that do not have an obvious angular limb deformity, or
proximal phalanx, immediately caudal to the insertion of (worse) an open luxation, require careful clinical
the long component. examination, stress radiographs, and ultrasonography
Traumatic disruption of collateral ligaments results in to establish the diagnosis.
joint instability and an increased likelihood of osteoar On palpation, the fetlock can usually be reduced and
thritis. Early reports of collateral ligament injury were reluxated without a great degree of pain or evidence of
primarily limited to rupture and luxation, with obvious crepitation associated with the fracture. Radiographs
varus or valgus deviation, and have been reported as the should be taken to identify the presence of avulsion
www.ajlobby.com
(A) (B)
(C) (D)
Figure 20.16 Avulsion of the medial collateral ligament of the fetlock repaired with Kirschner wire and two 3.5 mm cortical screws. (A, B)
Preoperative radiographs show the avulsed fragment reflected proximally (arrows), associated with avulsion of the plantar portion of the
collateral. (C, D) Repair with Kirschner wire and two 3.5 mm screws three weeks postoperatively. Source: Image courtesy of Dr. Alan J. Nixon
and Ryland Edwards.
fractures or other damage. In some instances, an open mented with some form of surgical imbrication. Surgical
luxation will be present. These have been seen in association stabilization with polypropylene mesh or carbon‐fiber
with a board on a horse trailer falling out and the foot implants has been recommended as a means of improv
going through the trailer during transport. ing joint stability, compared to external immobilization
alone.12,47 Suture apposition of a ruptured collateral liga
ment was attempted in 3 cases of the 10 horses reported
Treatment by Yovich et al.53 A more recent series of 17 cases, in
The usual treatment for a closed luxation is casting. which all horses were managed by stall confinement,
Rarely, open repair and casting are required. There are limb immobilization, and gradual return to exercise,
insufficient numbers to say whether healing is aug concluded that closed reduction and immobilization
www.ajlobby.com
were effective as a treatment.46 The lateral CL was rup 5 horses (and a draining tract leading to osteomyelitis
tured in 11 horses; the medial CL was ruptured in 6. that was subsequently debrided in 1 other).
Ultrasonography was done on all cases and revealed ipsi An earlier series of 10 cases of open or closed luxation
lateral rupture of the short and long components of the of the fetlock joint included 5 closed and 5 open luxa
CL in 11, and rupture of only one component in 6. No tions.53 Horses with open luxations were treated by
biaxial ruptures were detected, but 9 horses had desmitis debridement of soft tissue, joint lavage, and cast immo
of the collateral ligament on the nonruptured side of the bilization. Suture apposition of a ruptured collateral liga
affected joint. All horses were lame (lameness score ment was attempted in three cases. Both closed and open
range 2–4/5). Joint instability was palpable in 9 horses; cases had a good prognosis for return to breeding status.
only 4 horses had episodes of joint luxation. Avulsion After treatment, 7 horses were used for breeding, 1 horse
fractures were identified on radiographs in 6 horses and was ridden for nine years, 1 horse remained lame and
using ultrasonography in an additional 2. Stress radio was euthanized, and 1 horse was lost to follow‐up.53
graphs revealed joint instability in 10 horses. Horses Stabilization of avulsed collateral insertion fragments on
were managed by stall confinement, limb immobiliza the proximal phalanx using screws or screw and pin
tion, and gradual return to exercise: 8 horses returned to combinations can also be used (Figure 20.16), and is also
riding, 2 resumed breeding, 2 were retired, 2 were euth described in Chapter 19.
anized (1 with severe injuries elsewhere and 1 that The prognosis for acute open luxations (treated with
re‐ruptured the collateral ligament 328 days after initial copious lavage and debridement of devitalized tissue
injury), and 3 were doing well 86–139 days after injury.46 and systemic antibiotics before being immobilized) will
This series indicates that prognosis for athletic use could depend on whether septic arthritis becomes estab
be better than originally believed. The duration of cast lished.17 An inverse relationship between the time of
immobilization ranged from 14 to 130 days (mean occurrence of injury and institution of treatment with
71 days). A mean of 2.3 casts/horse (range 1–4 casts) open joint injury has been previously reported.17 These
was used. Complications were limited to cast sores in cases generally require a longer period of casting.
References
1 Barclay, W.P., Foerner, J.J., and Philips, T.N. (1987). 7 Colon, J.L., Bramlage, L.R., Ence, S.R., and
Lameness attributable to osteochondral fragmentation Embertson, R.N. (2000). Qualitative and
of the plantar aspect of the proximal phalanx in horses: quantitative documentation of the racing
19 cases (1981–1985). J. Am. Vet. Med. Assoc. 191: performance of 461 Thoroughbred racehorses after
855–857. arthroscopic removal of dorsoproximal first
2 Birkeland, R. (1972). Chip fractures of the first phalanx phalanx osteochondral fractures (1986–1995).
in the metatarsophalangeal joint of the horse. Acta Equine Vet. J. 32: 475–481.
Radiol. Suppl. 29: 73–77. 8 Copelan, R. and Bramlage, L.R. (1983). Surgery of the
3 Bouré, L., Marcoux, M., Laverty, S., and Lepage, fetlock joint. Vet. Clin. North Am. Large Anim. Pract. 2:
O.M. (1999). Use of electrocautery probes in 221–231.
arthroscopic removal of apical sesamoid fracture 9 Dalin, B., Sandgren, B., and Carlsten, J. (1993). Plantar
fragments in 18 Standardbred horses. Vet. Surg. 28: osteochondral fragments in the metacarpophalangeal
226–232. joint in Standardbred trotters: result of
4 Brama, P.A.J., Karssenberg, D., Barneveld, A., and van osteochondrosis or trauma? Equine Vet. J. 16 (Suppl):
Weeren, P.R. (2001). Contact areas and pressure 62–65.
distribution on the proximal articular surface of the 10 Declercq, J., Martens, A., Maes, D. et al. (2009).
proximal phalanx under sagittal plane loading. Equine Dorsoproximal phalanx osteochondral fragmentation
Vet. J. 33: 26–32. in 117 Warmblood horses. Vet. Comp. Orthop.
5 Bukowiecki, C.F., Bramlage, L.R., and Gabel, A.A. Traumatol. 22: 1–6.
(1986). Palmar/plantar process fractures of the proximal 11 Dubs, B. and Nemeth, F. (1975). Treatment and
phalanx in 15 horses. Vet. Surg. 15: 383–388. prognosis of fractures of the first phalanx in the horse.
6 Carlsten, J., Sandgren, B., and Dalin, G. (1993). Schweiz. Arch. Tierheilkd. 117: 299–309.
Development of osteochondrosis in the tarsocrural joint 1 2 Edwards, G.B. and Vaughan, L.C. (1984). Use of
and osteochondral fragments in the fetlock joints of carbon fibre implants in the treatment of fetlock
Standardbred trotters. A radiological survey. Equine joint dislocation in two horses. Vet. Rec. 114:
Vet. J. 16: 42–47. 87–88.
www.ajlobby.com
13 Elce, Y. and Richardson, D.W. (2002). Arthroscopic 28 McIlwraith, C.W., Nixon, A.J., and Wright, I.M. (2015).
removal of dorsoproximal chip fractures of the Diagnostic and Surgical Arthroscopy, 4e. Edinborough:
proximal phalanx in standing horses. Vet. Surg. 31: Mosby/Elsevier.
195–200. 29 McIlwraith, C.W. and Vorhees, M. (1990). Management
14 Ferraro, G.L. (1990). Lameness diagnosis and treatment of osteochondritis dissecans of the dorsal aspect of the
in the Thoroughbred racehorse. Vet. Clin. North Am. distal metacarpus and metatarsus. In: Proceedings of the
Equine Pract. 6: 63–84. Association of American Equine Practitioners, vol. 35,
15 Foerner, J.J., Barclay, W.P., Phillips, T.N., and MacHarg, 547–550. Lexington, KY: AAEP.
M.A. (1987). Osteochondral fragments of the palmar/ 30 Morgan, J.W., Santschi, E.M., Zekas, L.J. et al. (2006).
plantar aspect of the fetlock joint. In: Proceedings of the Comparison of radiography and computed
American Association of Equine Practitioners, vol. 33, tomography to evaluate metacarpo/
739–744. Lexington, KY: AAEP. metatarsophalangeal joint pathology of paired limbs
16 Fortier, L.A., Foerner, J.J., and Nixon, A.J. (1995). of Thoroughbred racehorses with severe condylar
Arthroscopic removal of axial osteochondral fragments fractures. Vet. Surg. 35: 611–617.
of the plantar/palmar proximal aspect of the proximal 31 Muir, P., McCarthy, J., Radtke, C.L. et al. (2006). Role of
phalanx in horses: 119 cases (1988–1992). J. Am. Vet. endochondral ossification of articular cartilage and
Med. Assoc. 206: 71–74. functional adaptation of the subchondral plate in the
17 Gibson, K.L., McIlwraith, C.W., Turner, A.S. et al. development of fatigue microcracking of joints. Bone
(1989). Open joint injuries in the horse: a retrospective 38: 342–349.
study. J. Am. Vet. Med. Assoc. 194: 398–404. 32 Muir, P., Peterson, A.L., Sample, S.J. et al. (2008).
18 Grondahl, A.M. (1992). The incidence of bony Exercise‐induced metacarpophalangeal joint
fragments and osteochondrosis in the metacarpo‐ and adaptation in the Thoroughbred racehorse. J. Anat. 213:
metatarsophalangeal joints of Standardbred trotters. A 706–717.
radiographic study. J. Equine Vet. Sci. 12: 81–85. 33 Nilsson, G. and Olsson, S.E. (1973). Radiologic and
19 Grondahl, A.M. (1992). Incidence and development of pathoanatomic changes in the distal joints and
ununited proximoplantar tuberosity of the proximal phalanges of the Standardbred horse. Acta Vet. Scand.
phalanx in Standardbred trotters. Vet. Radiol. Suppl. 44: 23.
Ultrasound 33: 18–21. 34 Nixon, A.J. and Pool, R.R. (1995). Histologic
20 Haynes, P.F. (1980). Disease of the metacarpophalangeal appearance of axial osteochondral fragments from the
joint and metacarpus. Vet. Clin. North Am. Large Anim. proximoplantar/proximopalmar aspect of the proximal
Pract. 2: 33–60. phalanx in horses. J. Am. Vet. Med. Assoc. 207:
21 Hornoff, W.H., O’Brien, T.R., and Pool, R.R. (1981). 1076–1080.
Osteochondritis dissecans of the distal metacarpus in 35 Norrdin, R.W., Kawcak, C.E., Capwell, B.A., and
the adult racing Thoroughbred horse. Vet. Radiol. 22: McIlwraith, C.W. (1998). Subchondral bone failure in
98–106. an equine model of overload arthrosis. Bone 22:
2 2 Kawcak, C.K. and McIlwraith, C.W. (1994). 133–139.
Proximodorsal first phalanx osteochondral chip 36 Norrdin, R.W. and Stover, S.M. (2006). Subchondral
fragments in 320 horses. Equine Vet. J. 26: bone failure in overload arthrosis: a scanning electron
392–396. microscopic study in horses. J. Musculoskelet.
23 Kawcak, C.E., McIlwraith, C.W., Norrdin, R.W. et al. Neuronal. Interact. 6: 251–257.
(2000). Clinical effects of exercise on subchondral bone 37 O’Brien, T.R., Hornof, W.J., and Meagher, D.M. (1981).
of carpal and metacarpophalangeal joints in horses. Radiographic detection and characterization of palmar
Am. J. Vet. Res. 61: 1253–1258. lesions in the equine fetlock joint. J. Am. Vet. Med.
24 Kawcak, C.E., McIlwraith, C.W., Norrdin, R.W. et al. Assoc. 178: 231–237.
(2001). The role of subchondral bone in joint disease: a 38 Pearce, S.G., Hurtig, M.B., Bouré, L.P. et al. (2003).
review. Equine Vet. J. 33: 120–126. Cylindrical press‐fit osteochondral allografts for
25 Krook, L. and Maylin, G.A. (1988). Fractures in resurfacing the equine metatarsophalangeal joint. Vet.
Thoroughbred racehorses. Cornell. Vet. 78: 5–47. Surg. 32: 220–230.
26 Markel, M.D., Martin, B.B., and Richardson, D.W. 39 Pettersson, H. and Ryden, G. (1982). Avulsion fractures
(1985). Dorsal frontal fractures in the first phalanx in of the caudoproximal extremity of the first phalanx.
the horse. Vet. Surg. 14: 36–40. Equine Vet. J. 14: 333–335.
27 Markel, M.D. and Richardson, D.W. (1985). Non‐ 40 Pool, R.R. and Meagher, D.M. (1990). Pathologic
comminuted fractures of the proximal phalanx in 69 findings and pathogenesis of racetrack injuries. Vet.
horses. J. Am. Vet. Med. Assoc. 186: 573. Clin. North Am. Equine Pract. 6: 1–30.
www.ajlobby.com
41 Rooney, J.R. (1969). The Biomechanics of Lameness in 48 Whitton, R.C. and Kannegieter, J. (1994).
Horses. Baltimore: Williams & Wilkins Company. Osteochondral fragmentation of the plantar/palmar
42 Sandgren, B., Dalin, G., and Carlsten, J. (1993). aspect of the proximal phalanx in racing horses. Aust.
Osteochondrosis in the tarsal joint and Vet. J. 71: 318–321.
osteochondral fragments in the fetlock joint in 49 Wright, I.M. and Minshall, G.J. (2014). Identification
Standardbred trotters. 1. Epidemiology. Equine Vet. and treatment of osteochondritis dissecans of the distal
J. 16: 31–37. sagittal ridge of the third metacarpal bone. Equine Vet.
43 Santschi, E.M. (2008). Articular fetlock injuries in J. 46: 585–588.
exercising horses. Vet. Clin. Equine 24: 117–132. 50 Wright, I.M. and Minshall, G. (2018). Short frontal plane
44 Simon, O., Laverty, T.S., Bouré, L. et al. (2004). fractures involving the dorsoproximal articular surface of
Arthroscopic removal of axial osteochondral fragments the proximal phalanx: description of the injury and a
of the proximoplantar aspect of the proximal phalanx technique for repair. Equine Vet. J. 50: 54–59.
using electrocautery probes in 23 Standardbred 51 Yovich, J.V. and McIlwraith, C.W. (1986). Arthroscopic
racehorses. Vet. Surg. 33: 422–427. surgery for osteochondral fractures of the proximal
45 Stover, S.M. (2003). The epidemiology of phalanx in the metacarpophalangeal and
Thoroughbred racehorse injuries. Clin. Tech. Equine metatarsophalangeal (fetlock) joints in horses. J. Am.
Pract. 2: 312–322. Vet. Med. Assoc. 188: 273–279.
46 Tenney, W.A. and Whitcomb, M.B. (2008). Rupture of 52 Yovich, J.V., McIlwraith, C.W., and Stashak, T.S. (1985).
collateral ligaments in metacarpophalangeal and Osteochondritis dissecans of the sagittal ridge of the
metatarsophalangeal joints in horses: 17 cases (1999– third metacarpal and metatarsal bones in horses. J. Am.
2005). JAVMA 233: 456–462. Vet. Med. Assoc. 186: 1186–1191.
47 van der Harst, M.R. and Rijkenhuizen, A.B. (2000). The 53 Yovich, J.V., Turner, A.S., Stashak, T.S., and McIlwraith,
use of a polypropylene mesh for treatment of ruptured C.W. (1987). Luxation of the metacarpophalangeal and
collateral ligaments of the equine metatarsophalangeal metatarsophalangeal joints in horses. Equine Vet. J. 19:
joint: a report of two cases. Vet. Q. 1: 57–60. 295–298.
www.ajlobby.com
341
21
Fractures of the Proximal Sesamoid Bones
Ian M. Wright
Anatomic Considerations The suspensory ligament branches insert on the a pices

and abaxial surfaces of the proximal sesamoid bones.
Fractures of the proximal sesamoid bones are common The thickest part of their insertion is proximal and they
and vary from simple apical fractures to complex mid‐ thin progressively distally on the sesamoid bones. The
body and comminuted breakdown injuries. The p roximal ISL has little fibrillar/ligamentous form proximally,
scutum (scutum proximale) comprises the two proximal near the apices of the proximal sesamoid bones, while
sesamoid bones and the thick palmar/plantar or inter distally, adjacent to the bases of the proximal sesamoid
sesamoidean ligament (ISL). The latter encloses the bones, a distinct transverse fibrillar arrangement may be
palmar/plantar and axial surfaces of the proximal sesa visible arthroscopically. The collateral sesamoidean liga
moid bones. The fibrocartilaginous scutum extends prox ments arise from the abaxial surfaces of the proximal
imal to the proximal sesamoid bones between the two sesamoid bones and insert on the adjacent third meta
branches of insertion of the suspensory ligament. Distally carpal/metatarsal bones and proximal phalanges. They
it forms part of the origin of the straight and oblique distal are considered to provide axial stability to the s uspensory
sesamoidean ligaments. The articular surface of the prox apparatus.48
imal sesamoid bones is concave, and the palmar/plantar The distal sesamoidean ligaments are the functional
surface, which is covered by the fibrocartilaginous ISL, is continuation of the suspensory ligament to the proximal
convex. Proximal sesamoid bones in the forelimb are and middle phalanges. These comprise, from dorsal to
larger and more elongated than in the hindlimb.66 In palmar/plantar (and in corresponding ascending length),
their proximal three‐quarters, the abaxial surfaces of the medial and lateral short, cruciate, oblique, and the
proximal sesamoid bones are concave. unpaired straight distal sesamoidean ligaments. The dis
The proximal scutum is part of the suspensory appara tal sesamoidean ligaments originate from the base of the
tus, intercalated between the elastic suspensory ligament proximal sesamoid bones and the ISL. The short distal
proximally and the inelastic distal sesamoidean ligaments sesamoidean ligaments are subsynovial, with origins and
distally.14 As a unit, the suspensory apparatus functions insertions on the articular margins of the proximal sesa
to resist hyperextension of the metacarpophalangeal/ moid bones and proximal phalanx. The cruciate distal
metatarsophalangeal joints, to store loading energy and sesamoidean ligaments originate on the dorsal aspect of
to return this, in part, to the limb in the caudal weight‐ the base of the proximal sesamoid bones, and insert on
bearing phase of the stride.15 As part of the proximal the contralateral proximal palmar/plantar eminences of
scutum, the proximal sesamoid bones transfer the
the proximal phalanx. They are considerably thinner than
dynamic resistance to extension of the metacarpophalan the oblique and straight distal sesamoidean ligaments.
geal/metatarsophalangeal joints, which is generated by Palmar/plantar to the short and cruciate sesamoidean
the suspensory ligament, around the palmar/plantar ligaments, the origins of the oblique distal sesamoidean
angle of the joint. All fractures of the proximal sesamoid ligaments are separated by the straight distal sesamoid
bones must therefore be considered in light of the degree ean ligament. Each oblique ligament is tripartite96 and
of compromise of the suspensory apparatus that their dis has an inverted triangular shape. They insert midway
continuity creates and, where appropriate, the severity of down the abaxial palmar/plantar surface of the proximal
the articular deficit that also results. phalanx. The straight distal sesamoidean ligament

www.ajlobby.com
riginates from the bases of both proximal sesamoid

o which parallels the trabecular infrastructure evident on
bones and the fibrocartilage of the ISL. The paired origin radiographs.95 Although a poor blood supply has been
is triangular to trapezoid, while over the proximal pha suggested as one reason for poor healing of proximal
lanx the cross‐sectional shape is first rectangular and sesamoid bone fractures, it is possible that the intraosse
then oval. The straight distal sesamoidean ligament ous blood supply is substantial but as it is disrupted in
inserts in conjunction with the palmar/plantar ligaments fractures, healing may be compromised. These authors
of the proximal interphalangeal joint and branches of also speculated that since vascular channels are oriented
insertion of the superficial digital flexor tendon as the similarly to common fracture planes, these may act as
scutum medium on the fibrocartilaginous plate of the “stress risers.”95 The proximal sesamoid bones are inner
proximopalmar/plantar surface of the middle phalanx. vated by the sesamoidean nerve, which is a branch of the
This is the largest of the distal sesamoidean ligaments.87 palmar/plantar nerve that penetrates the abaxial surface
While the distal sesamoidean ligaments in total are con and continues into the intertrabecular spaces.22
sidered the functional continuation of the suspensory
ligament, each has separate stabilization functions with
respect to the metacarpophalangeal/metatarsophalan Etiology
geal joint.73
The proximal sesamoid bones are subject to compli Cancellous bone is weakest in tension104 and most
cated loading patterns, with tension forces exerted by sesamoid bone fractures are considered to result from
the suspensory apparatus and compressive forces on excessive tensile forces.10 However, the bones also expe
their dorsal surfaces from the metacarpal/metatarsal rience bending and compressive forces as the angle of
condyles.94,104 The forelimb proximal sesamoid bones the metacarpophalangeal/metatarsophalangeal joints
contact 42 ± 8% of the metacarpal condyles at a metacar change;76 all forces peak with maximal joint extension.
pophalangeal extension angle of 150° and 46 ± 1% at 120° Metacarpophalangeal/metatarsophalangeal hyperexten
of extension.26 Subchondral bone density is increased in sion, whether repetitively or as a single event, is thus
areas of contact.23,26 Finite element analysis to determine considered the principal causative factor in failure of the
stress patterns of forelimb proximal sesamoid bones con proximal sesamoid bones. No evidence of previous fatigue
firmed compressive stresses on the dorsal (articular side) fractures has been found in affected bones.54 Predisposing
and tensile stresses on the palmar/plantar sides of the factors include musculotendinous fatigue, poor confor
bones.94 The distal articular part of the bone e xperienced mation, shoeing practices, foot imbalance, track surfaces,
the largest compressive stress, while the highest‐tensile and poor conditioning.10,15,28,45,104 Osteoporosis was pur
stress patterns were present in the proximal part of the ported to be a major pathogenetic influence in proximal
bones, consistent with the sites of apical fractures. sesamoid bone fractures in two horses following protracted
The proximal sesamoid bones are composed of dense periods (32 and 39 days) of cast immobilization.56 Some
cancellous bone with two primary systems of trabeculation abaxial fractures can be caused by external trauma.
arranged in longitudinal and radial fashions.34,104 The In light of the function of the proximal sesamoid bones
mechanical properties of cancellous bone are closely and principal etiology of their fractures, concurrent
related to its structure,104 which in turn remodels (adapts) desmitis of the suspensory and/or distal sesamoidean
in response to changes in its mechanical environment. ligaments is common.43 This, in turn, can have implica
Stress‐adaptive remodeling of the proximal sesamoid tions with respect to treatment, convalescence, and
bones in response to training has been demonstrated prognosis. Ultrasonographic evaluation is therefore rec
experimentally.104 This included decreased porosity. ommended in all cases which have athletic expectations.
Mechanical properties of cancellous bone vary inversely Fatigue, accumulated strain during a race, and bone
with porosity.104 There is an increase in the amount of degeneration from chronic sesamoiditis have been impli
bone and a decrease in the amount of intertrabecular space cated in the fracture.14,15 However, predisposition by
in proximal sesamoid bones in response to exercise.66 sesamoiditis was not substantiated in a longitudinal
The blood supply to the proximal sesamoid bones study of two‐year‐old Standardbreds in training.38 It has
arises from multiple branches of the medial and lateral also been suggested that uneven foot placement or a sud
palmar/plantar digital arteries.95 The vessels enter the den twist of the leg could result in sesamoid fracture.14
sesamoid on the palmar/plantar abaxial surface and Preexisting suspensory apparatus injury has been
travel in abaxial to axial, proximal to distal, and palmar/ associated with catastrophic suspensory apparatus inju
plantar to dorsal directions. It is suggested from this that ries.20,21,43,44 Preexisting suspensory desmitis has also
the axial portion of the proximal sesamoid bones is per been reported to increase the risk of suspensory appara
fused last.24 The major branches of the interosseous ves tus failure, together with use of horseshoe pads, periods
sels are found in bony canals with a radial orientation of ≥60 days without racing or timed workout, and recent
www.ajlobby.com
high‐intensity exercise.42 Horses having had between been seen in studies of sesamoid bones examined after
two and five previous races also had a high risk for sesa catastrophic failure using voxel‐based morphometry of
moid and suspensory injury. micro‐computed tomography scans.89 Training influ
Post‐mortem examinations of 90 racehorses on tracks ences the site of failure of the suspensory apparatus. In a
in Oklahoma in 1999 and 2000 found that the severity of mechanical study using cadaver limbs from six trained
underrun heels was significantly greater in horses with and six untrained horses, where each was tested to sus
catastrophic suspensory apparatus injuries. There was pensory apparatus failure,15 20 (83%) of the limbs from
no association with the use of toe grabs.6 A series of 121 trained horses failed within the proximal sesamoid
horses with forelimb proximal sesamoid bone fractures bones, including 17 (71%) apical fractures, 2 (8%) basilar,
euthanized on Californian racetracks between 1999 and and 1 (4%) mid‐body fracture; a typical distribution for
2002 were compared with 148 horses without sesamoid sesamoid fractures in most clinics. The limbs from
fractures euthanized on the same racecourses. Those untrained horses failed consistently through the suspen
with sesamoid fractures were more likely to be intact sory ligament. Additionally, the load at failure was
males, spend more time in active training and racing, greater in trained horses.15 In Thoroughbreds, the proxi
complete more events, train and race longer since their mal sesamoid bones undergo stress‐adaptive remodeling
last lay‐up, have higher exercise intensity during the during training.104 The cancellous bone in trained horses
12 months prior to death, and have greater cumulative had less porosity and theoretically greater strength than
distances for their careers.3,5 There was no association in untrained horses. The zone just distal to the apex, a
between proximal sesamoid bone fractures and the use common site for fracture, had the lowest porosity. A
of toe grabs, although other studies by the same investi study in British Thoroughbred racehorses also found no
gators had shown these to be risk factors in suspensory evidence to suggest that catastrophic sesamoid fractures
apparatus failure42,52 and fatal musculoskeletal injury.52 were predisposed by accumulated microfracture in the
Toe grabs delay breakover and may increase the length of affected bones.54 This suggests that major fractures of
the lever arm of the ground reaction force on the fetlock, the sesamoids are not related to bone fatigue.
thus increasing strain on the suspensory apparatus.
A recent post‐mortem study in Thoroughbred race
horses examined the incidence of suspensory ligament Incidence
(SL) and distal sesamoidean ligament (DSL) injury in
association with suspensory apparatus failure or meta Fractures of the proximal sesamoid bones are most com
carpal lateral condylar fracture in California racehorses.43 mon in Standardbreds, although they occur frequently in
Specimens from 327 Thoroughbred racehorses were racing Thoroughbreds, Quarter Horses, hunter jumpers,
sectioned within the SL body and branches, and oblique and other breeds. In Standardbreds, hindlimbs are
and straight DSLs. The investigators found moderate the most frequently involved, while in Thoroughbreds
lesions in 16% and milder lesions in 77% of racehorses. sesamoid fractures are common in both forelimbs and
There was a correlation between the presence of moder hindlimbs.14 In Thoroughbred racehorses, fractures
ate lesions and more substantial suspensory apparatus of the proximal sesamoid bones are the principal cause
breakdown. These findings suggest that monitoring the of catastrophic suspensory apparatus failure.12,29,31,47
suspensory ligament by ultrasonography may help avoid Forelimb proximal sesamoid bones were the commonest
catastrophic breakdown. site of catastrophic (resulting in death) musculoskeletal
Training strengthens the suspensory ligament,15 and injury in Thoroughbred horses racing in California in
even though stress‐adaptive remodeling of the proximal 1991.29 These had an equal forelimb distribution in
sesamoid bones occurs,104 it is postulated that the ses horses being trained, but a dominance of left forelimb
amoid lags behind the ligament, making the proximal injuries when racing. In overlapping studies, fractures of
sesamoid bone the weakest part of the suspensory appa the proximal sesamoid bones were the commonest single
ratus in skeletally immature horses. The preventative injury.30,31 Further studies of catastrophic injuries in
effect of gradually increasing free exercise on proximal Thoroughbreds racing in California confirmed that frac
sesamoid bone fractures in foals is well recognized by tures of the forelimb proximal sesamoid bones were the
farm managers, and is supported by experimental work commonest injury.47 A similar observation was made in
which indicated that exercise increases bone mineral racing Quarter Horses. Suspensory apparatus failure was
density in foals’ proximal sesamoid bones.23 Bone again the commonest cause of catastrophic injury of
mineral density is positively correlated with breaking Thoroughbreds racing and training in California. These
strength and modulus of elasticity.46 Despite this, an authors identified dorsopalmar foot imbalance (under
overall increase in bone mineral density and changes in run heels with a heel angle at least 5° less than the toe
the pattern of increased bone mineral accumulation have angle) and reduced sole area as predisposing factors.53
www.ajlobby.com
The forelimb suspensory apparatus was the most fre (16%) being next most common; 60% of fractures
quent site of injury for Thoroughbreds racing in were classified as simple, 24% comminuted, and 16%
Kentucky.71 Injuries of the left fore proximal sesamoid as avulsion. No age or gender associations were found.
bones were significantly more frequent than the right. Osteophytes, enthesophytes, and vascular channels were
Sesamoid injuries also were more frequently catastrophic detected less in fractured proximal sesamoid bones than
than noncatastrophic. Forelimb proximal sesamoid in their intact counterparts.
bones were the most common site of catastrophic injury
in Thoroughbreds on Kentucky racetracks between 1994
and 1996,21 and in Quarter Horses in Texas and New Fracture Classification
Mexico between 1995 and 1998.20 A study of fatal distal
limb fractures among Thoroughbreds racing in the UK In addition to the standard terms of fracture descrip
found that biaxial proximal sesamoid bone fractures tion, fractures of the proximal sesamoid bones are clas
were the most common injury on artificial surfaces (0.39 sified according to their location in the bone.9,10,14,33,35,65,86
per 1000 starts).70 The incidence on these surfaces was Fractures have been defined as mid‐body if the distal
also more than 10 times that seen on the turf for flat fragment measured between 25% and 75% of the total
races in the UK. Other authors have made similar obser proximodistal length of the bone, as determined on dor
vations.55,99 In the USA, where most races are on dirt sopalmar/plantar radiographs.16 In terms of functional
tracks, biaxial sesamoid fractures are the single most compromise, treatment options, and prognosis, this
common catastrophic injury.47,71 These observations appears valid and has been adopted for this chapter.
suggest that interactions between hoof and track surface Thus, fractures involving the proximal quarter of the
are significant to this injury; the foot slides f urther before bone are defined as apical, fractures involving the mid
stopping on nonturf surfaces, resulting in greater fetlock dle 50% of the bone as mid‐body, and fractures involving
extension and tensile forces on the sesamoids.70 the distal quarter of the bone as basilar. A retrospective
Fractures of the proximal sesamoid bones are most evaluation of 54 proximal sesamoid bone fractures not
common in racing Thoroughbreds and Standardbreds.35 associated with breakdown injury showed a distribution
In this series, basilar fractures were most common in of 44 (81%) apical, 3 (7%) mid‐body, 2 (4%) basilar, and
Thoroughbreds, with a similar incidence to apical frac 5 (8%) other configurations.15 This is considered to
tures. In Standardbreds apical fractures were most preva be a reasonable across‐the‐board representation of
lent. Proximal sesamoid bone fractures predominantly incidence. Fractures occurring in foals have different
occurred in the forelimbs, with a 74% overall preponder management implications and therefore will be consid
ance (88% in Thoroughbreds and 61% in Standardbreds). ered as a separate group.
The medial sesamoid was most commonly affected in
either forelimb. In Japan, where racing is clockwise, the
medial sesamoid was fractured 70% of the time in the left Fractures in Foals
fore, and the lateral sesamoid fractured 80% of the time
when the right forelimb was involved.97 Fractures of the proximal sesamoid bones are common
The incidence of specific fracture sites was reported in injuries in foals up to two months of age.28,74 Fore‐ and
a study of 328 racing Thoroughbreds euthanized in hindlimbs can be affected. Fractures can be uniaxial or
California between 1999 and 2002.4 Fractures were biaxial and affect single or multiple limbs. They probably
detected in 251 proximal sesamoid bones of 136 horses result from foals attempting to keep up with their dams
(41.5%), and of these 109 (80%) were biaxial. There were when galloping. Foals which are weak or have been sub
no significant overall left:right or medial:lateral differ ject to restricted exercise appear predisposed. Anecdotal
ences. The fractures comprised 24 apical, 109 mid‐body evidence suggests that firm ground conditions also can
(84 horses), 81 basilar (70 horses), 7 abaxial, and 30 axial be involved. Given these causes, management practices
configurations (29 horses). The prevalence of mid‐body can limit their incidence.
and basilar fracture reflects the study population of The proximal sesamoid bones are not fully mineralized
horses destroyed as a result of injury. Basilar fractures until three months of age. Thus, juvenile fractures may
were most common in the medial sesamoid bone, and involve partially or sometimes exclusively the cartilage
axial fractures in the lateral sesamoid; 20 of the 30 horses precursor. Radiographs will therefore either underesti
with axial sesamoid fracture had concurrent fracture of mate or fail to identify fracture damage.17 A wide variety
the lateral condyle of the third metacarpal bone. A com of fracture configurations can result (Figures 21.1–21.3).
plete transverse fracture orientation was most common Lameness is variable in degree and not always recog
(40%), with oblique (22%) and transverse fractures with nized in affected animals, even on well‐managed farms.
an additional longitudinal split in the fracture fragment Joint distension can also be highly variable, even with
www.ajlobby.com
Figure 21.1 Minimally displaced apical (A) (B)
fracture of a forelimb medial proximal
sesamoid bone in a four‐week‐old foal.
(A, B) Dorsopalmar and dorsomedial‐
palmarolateral oblique (DMPLO)
projections at presentation, and (C, D)
after four weeks of restricted exercise.
(C) (D)
Figure 21.2 Moderately displaced basilar

(A) (B)
fracture of a forelimb medial proximal
sesamoid bone in a five‐week‐old foal.
(A, B) Dorsopalmar and dorsomedial‐
projections initially; (C, D) healing after
five weeks of restricted exercise.
(C) (D)
www.ajlobby.com
(A) (B) (C)
(D) (E) (F)
Figure 21.3 Bilateral comminuted fractures of forelimb medial proximal sesamoid bones in an 11‐week‐old foal. (A–C) Right fore
radiographic projections; (D–E) left fore projections. Note the asymmetric positions of the bones in the dorsopalmar projections,
reflecting the degree of suspensory apparatus compromise.
marked articular involvement. Radiographs in the acute In contrast to adults, biaxial fractures of the proximal
phase frequently underestimate fracture severity; frac sesamoid bones that disable the suspensory apparatus in
tures may be nondiscernible or have radiologically silent foals can be managed successfully without recourse to
comminution. arthrodesis of the metacarpophalangeal joint.45 The
Nondisplaced or minimally displaced fractures heal rap clinical presentation is similar to that described in
idly with exercise restriction (Figures 21.1 and 21.2). Even adults, and without early flexed limb support there is a
markedly displaced juvenile fractures can heal without comparable risk of digital vascular compromise. These
interference. Restricted exercise is vital to minimize fur fractures have been treated successfully by application of
ther displacement. Juvenile sesamoid fractures can result dorsal splints for periods of four to six weeks, which
in proximodistally elongated and frequently quite distorted allow formation of a fibrous union.45 The joint can then
proximal sesamoid bones (Figure 21.4); the greater the be gradually allowed to extend over a three‐ to four‐
degree of comminution and displacement, the greater the week period, before progressively increasing exercise.
deformity of the healed bone. Affected animals commonly Analgesia in the form of phenylbutazone reduces the risk
are sound with little external indication of the injury. of overload complications in the contralateral limb.45
Application of casts or bandages is counterproductive, as it Marked sesamoid distortion is inevitable and athletic
can induce profound laxity in the suspensory apparatus. function unlikely.
www.ajlobby.com
Figure 21.4 Elongated forelimb lateral

(A) (B)
proximal sesamoid bone found on presales
radiographs of a Thoroughbred yearling;
this is believed to be the result of a “healed”
displaced juvenile fracture. (A) Dorsopalmar,
(B) slightly flexed lateromedial, (C)
dorsolateral‐palmaromedial oblique
(DLPMO), and (D) dorsomedial‐
radiographs reveal the healed elongated
sesamoid bone.
(C) (D)
In another report of 18 foals with fractures of the with equal left:right hindlimb distribution, and 26 (19%)
proximal sesamoid bones, 17 occurred in forelimbs and were bilateral. There were more left than right forelimb
one in a hindlimb.28 Four forelimbs involved bilateral fractures. There was no overall medial:lateral difference
fractures; 11 of 18 foals had fractures of a single sesa in incidence, but in forelimb fractures alone, 9 out of 10
moid bone and 9 of these were medial. Of these foals, 15 involved the medial sesamoid. The majority of the horses
were less than two months of age. Most had a history of were not lame at presentation.85 Hindlimb apical frag
“galloping to exhaustion” which frequently followed ments were the most common sesamoid fracture in an
periods (days) of box stall confinement. Lameness was extensive radiographic screening series of Thoroughbred
variable, but digital pressure over the affected proximal yearlings submitted for sale in Kentucky.51 Enthesophyte
sesamoid bones, and fetlock flexion, were consistently formation on the forelimb proximal sesamoid bones was
resented. Of 12 foals that had reached training age, 6 associated with a reduced likelihood of racing, and in
trained and 3 raced.28 the hindlimbs was a cause of reduced performance, but
Enlarged proximal sesamoid bones, consistent with there was no significant association between sesamoid
fractures occurring as foals, were seen in 6 of 753 fractures or elongated proximal sesamoid bones and per
Standardbred trotters in a yearling radiographic survey.37 formance.50 Despite these results, markedly enlarged
A further 4 animals had radiologically identifiable apical proximal sesamoid bones generally are considered nega
fractures. None was related to earnings at the end of the tive prognostic features with respect to racing potential.
horse’s three‐ and four‐year‐old racing season. Similarly, It is possible that some of these horses with elongated
fractures of the proximal sesamoid bones can be found sesamoid bones had previously been identified, and
in presales radiographs of Thoroughbred yearlings.85 were therefore not presented for sale or had radiographs
A substantial portion of these are previously unrecognized submitted to the repository.92 This “select” group of sales
foal fractures. In a series of 151 cases with apical frac yearlings may therefore skew the data and improve the
tures, 139 (92%) occurred in hindlimbs.85 These occurred apparent prognosis.
www.ajlobby.com
Apical Fractures immediately following clinical examination. Longstanding

apical fractures may need localization by regional or
Incidence and Location intraarticular analgesia. A number of proximal sesamoid
bone fractures will be improved by analgesia of palmar/
Apical fractures are the most common fracture of the plantar nerves at an abaxial sesamoid level, but lameness
proximal sesamoid bones in both Standardbreds and in most is abolished or improved by local analgesia of
Thoroughbreds.10,49,81,84,93,102 They occur most often in palmar and palmar metacarpal nerves at a distal meta
the hindlimbs of Standardbred horses10,11,93,102 and in carpal level (button of splint bone) in the forelimb, or
the forelimbs of Thoroughbreds.35,101 No medial‐lateral plantar with plantar and dorsal metatarsal nerves at a
predisposition has been described in Thoroughbreds. similar level in the hindlimb. Apical fractures can be
However, 61 of 109 apical fractures of the sesamoid bones bilateral with clinical asymmetry.
in Standardbreds occurred in the lateral sesamoid of the Most apical fractures are recognized on standard lat
right hindlimb, which was significantly greater than all eromedial, dorsopalmar/plantar, dorsolateral‐palmar/
other bones.93 In another series of apical proximal sesa plantaromedial oblique, and dorsomedial‐palmar/plan
moid bone fractures in 43 Standardbred horses, 37 (86%) tarolateral oblique radiographic projections (Figures 21.5
involved the hindlimbs; 34 (79%) involved the lateral and and 21.6A). However, the profiles of the apices and bases
9 (21%) the medial proximal sesamoid bone.102 However, of the proximal sesamoid bones can be enhanced further
in contrast to the earlier study,93 17 (40%) involved the by a 20° proximal‐distal obliquity of standard laterome
left lateral sesamoid bone and 14 (33%) the right lateral dial and oblique projections. Lateral 20° proximal‐
sesamoid. Hindlimb lateral proximal s esamoid bones of medial distal oblique and medial 20° proximal‐lateral
racing Standardbreds have been reported to have greater distal oblique projections enhance evaluation of the
radiopharmaceutical uptake,79 which suggests increased apices of medial and lateral proximal sesamoid bones,
stress remodeling activity on this side. Histologic exami respectively.
nation has shown that while some fractures appear acute, Ultrasonographic evaluation of the suspensory liga
many have chronic features, including ischemic necrosis ment is prudent, as the degree of ligament compromise
of cancellous bone, and fibrosis and remodeling in the is prognostically significant and may guide rehabilitation
fracture line, consistent with chronic adaptive failure.72 It (Figure 21.6B,C). Nuclear scintigraphic evaluation may
has also been suggested that since the junction of the differentiate old nonunion fractures that are not active or
proximal and middle one‐third of the proximal sesamoid a cause of lameness from fractures that remain active.10
bone experiences the maximum remodeling activity, this Radiologic features of fracture chronicity are similar to
area is predisposed to fracture.104 other locations, with rounded fracture margins and lack
In a series of apical sesamoid fractures in Thor of infrastructure in the fracture fragments. However, cal
oughbred horses in training, 49% (41 out of 84) lus production often is minimal at this site, potentially
occurred in two‐year‐olds, 26% in three‐year‐olds, 15% due to the lack of periosteal covering of the sesamoid
in four‐year‐olds, and 10% in older horses.84 Hindlimbs bones. In some animals, entheseous new bone may
were most frequently affected (64%; 54 out of 84), with be evident on the abaxial margins of the fracture.
equal left:right distribution, and 15% were bilateral. In Additionally, apical sesamoid fractures do not appear to
forelimb sesamoid fractures, 18 out of 30 (60%) involved induce substantial radiologic features of degenerative
the right fore and 12 out of 30 (40%) the left fore. There joint disease in the associated fetlock joint.
was no overall difference in medial versus lateral sesa
moid distribution, but 19 out of 30 (63%) of forelimb
proximal sesamoid bone fractures were medial; 19
Treatment
horses (23%) had clinically recorded suspensory liga Removal of unstable apical fragments is advocated, as
ment desmitis. conservative management is less successful in returning
horses to athletic performance.9,10,65,75,81 The surgical
trauma associated with the removal of stable longstand
Diagnosis ing fractures, with fibrous or fibro‐osseous union to the
Apical fractures are almost always articular10,65 and in parent bone, may outweigh any potential benefits from
the acute phase produce distension of the metacar removal and second‐intention healing, and these
pophalangeal/metatarsophalangeal joint. This may not fractures should be managed conservatively. Some large
persist in fractures of long duration. Lameness varies apical fragments (approaching one‐third of the bone)
and can diminish rapidly. Animals with acute fracture may benefit from reconstruction with a proximal‐distal–
frequently also exhibit pain on local digital pressure. oriented lag screw (as described for proximal mid‐body
Many are therefore diagnosed on radiographic examination fractures; Figure 21.7).
www.ajlobby.com
(A) (B) (C)
(D) (E) (F)
Figure 21.5 Acute apical fracture of the medial proximal sesamoid bone, with multiple small proximally displaced comminuted
fragments. (A) Preoperative lateromedial radiograph. (B) Arthroscopic removal of the principal apical fragment of bone seen in (A), viewed
from a contralateral arthroscope portal, showing sharp dissection of the displaced fragment hinged on the suspensory ligament insertion
and fibrocartilaginous scutum. (C) Fracture bed following fragment removal; (D) debridement of the parent bone; (E) debridement of the
disrupted suspensory ligament insertion; and (F) completion of debridement.
Apical fragment removal by arthrotomy was first The fragment is palpated with a probe to assess its
reported in 1956,19 and arthroscopic removal in 1989.68 stability and degree of attachment before commencing
The technique has subsequently been refined, described removal. Sharp dissection of the fragment is performed
in surgical texts,60 and almost universally adopted. with straight and curved arthroscopy knives (3.5 mm
Horses may be positioned in dorsal60 or lateral recum pointed knife and 3.5 mm hook knife, Karl Storz
bency;84 the author prefers dorsal recumbency. Veterinary Endoscopy, Goleta, CA, USA; or Beaver
Application of an Esmarch bandage and tourniquet is blade, Beaver Surgical Products, Franklin Lakes, NJ,
occasionally useful and it may be positioned over the USA). Shallow progressive cuts should be made using
proximal metacarpus/metatarsus or proximal to the
the fragment surface as a guide to minimize trauma to
carpus/tarsus. A more proximal tourniquet minimizes the suspensory ligament. A curved, sharp elevator
the potential for interference with instrument manipula (McIlwraith‐Scanlan or Foerner elevator, Sontec
tion. The author employs contralateral arthroscope and Instruments, Englewood, CO, USA) can be employed to
ipsilateral instrument portals (Figure 21.5), although separate the axial attachment to the ISL and to elevate
some surgeons prefer ipsilateral arthroscope and instru the fragment. The remaining suspensory ligament
ment positions. Most fragments require dissection from attachment is sectioned with arthroscopic scissors (Hook
the fibrocartilaginous scutum, ISL, and insertion of the scissors, Sontec Instruments). Once free, the fragment
suspensory ligament branch. Instrument portals should can be removed with appropriately sized Ferris–Smith
be positioned sufficiently proximal to permit axial and rongeurs.59 A degree of debridement to remove palmar/
abaxial access to the intraarticular apex of the bone. plantar osteochondral debris and disrupted suspensory
www.ajlobby.com
(A) (B) (C)
(D) (E) (F)
Figure 21.6 Chronic minimally displaced apical fracture of the sesamoid bone. (A) Lateromedial radiograph of a longstanding apical
fracture; and (B) transverse and (C) longitudinal ultrasound images demonstrating minimal compromise to the suspensory ligament
branch. The fracture is identified as an abnormally positioned echogenic mass with a shadowing defect in transverse image, and by an
abnormal osseous contour and discontinuity in longitudinal scan. (D) Contralateral arthroscopic images of the fracture seen in (A),
showing fibrillated cartilage adjacent to the fracture; note also the fibrous degeneration of the hyaline cartilage covering the fragment.
(E) Insertion of a probe into the fracture plane demonstrating instability. (F) Fibrous tissue covering the fracture bed in the parent bone
revealed following fragment removal.
ligament fibrils usually is required. Small rongeurs and was recommended. Of 14 horses, 10 raced postopera
closed spoon curettes are appropriate for the former, and tively and 1 was in training. Their postoperative perfor
suction punch forceps or a motorized synovial resector mance compared reasonably with other reports. Glycine
for the latter.59 In longstanding injuries, stable scar tissue as a low conductive solution is no longer necessary,
often develops over the fracture bed, which should be and Teflon‐ or ceramic‐coated electrocautery probes
preserved (Figure 21.6). At the end of the procedure, allow the use of standard isotonic polyionic irrigating
additional debris can be removed by lavage before skin solutions.11 However, concerns have been expressed
portals are closed. regarding “tissue dieback” following electrocautery.
Use of electrocautery probes for ligament division has The author therefore recommends dorsal recumbency,
been described as an aid to dissection and to reduce use of an Esmarch bandage and tourniquet, and sharp
intraoperative hemorrhage.11 These authors reported dissection.
use of hook and loop meniscectomy electrodes (Linvatec Removal is followed by fibrous reattachment of the
Corporation, Lago, FL, USA) for arthroscopically suspensory ligament to the sesamoid bone, which is gen
guided dissection of apical fragments. Joints were erally stronger than the existing fibrous union between
distended with 1.5% glycine. The results obtained in 18 the apical fracture and parent bone surface.14 Use of peri
Standardbred racehorses were reported using both ipsi‐ operative antimicrobial and analgesic drugs varies with
and contralateral arthroscopic approaches. The latter surgeon preference. Bandaging of the fetlock provides
www.ajlobby.com
(A) (B) (C)
(D) (E)
Figure 21.7 Repair of a large apical fracture of a medial proximal sesamoid bone. (A) Lateromedial and (B) dorsomedial‐palmarolateral
oblique (DMPLO) radiographic projections at presentation. (C) Lateromedial, (D) DMPLO, and (E) dorsopalmar projections 10 weeks post‐
surgery; note the screw trajectory.
support to the fetlock and continues for two to four weeks and nine months, depending on the extent of sus
weeks. Bandage support and the postoperative exercise pensory apparatus damage. Horses with small fragments
regimen should optimize healing of the fracture bed, ISL, removed can return to training in two to three months,
scutum, and suspensory ligament insertion. In cases with but with larger fragments involving more of the suspen
small defects and little or no associated suspensory liga sory ligament insertion, the animal should be rested for
ment desmitis, bandaging requirements are minimal at least six months.75
(generally until skin sutures are removed) and return to The literature also supports postoperative bandaging
work can be expeditious. By contrast, where 25% of the for two to four weeks.81 Authors have recommended
proximal sesamoid bone mass is lost, with corresponding four weeks of box rest, with hand walking from two
compromise of the ISL and suspensory ligament inser weeks post‐surgery.81,84 This is often followed by four to
tions, a Robert Jones bandage to reduce mobility and to twelve weeks of free pasture exercise.81 However, a more
apply counterpressure is appropriate for anesthetic graduated, controlled exercise program is often benefi
recovery and several weeks afterward. Counterpressure cial. Length of convalescence largely is empiric, but may
is likely to assist in the initial stages of second‐intention be guided by ultrasonographic monitoring of the affected
healing to minimize hemorrhage and control granulation suspensory ligament branch.68,81 Removal of apical frag
until fibrometaplasia ensues. Controlled exercise, in the ments from Standardbreds102 and Thoroughbreds84 was
form of walking, is recommended to modulate the early‐ followed by return to racing in 9 months (range 3–27)
healing tissue. Exercise should gradually progress in load and 243 days (range 36–700) post‐surgery, respectively.
characteristics, avoiding sudden changes, through to However, such data frequently can reflect the seasonal
normal training or work. This can vary between four organization of racing.
www.ajlobby.com
Results only 9 of 19 (47%) cases with forelimb medial sesamoid

fracture went on to race, compared to 17 of 21 (81%)
In one series of 80 Standardbreds treated by arthrotomy hindlimb medial sesamoid fracture cases; 10 of 10 (100%)
and removal of apical sesamoid fragments, 40 raced of horses with forelimb lateral sesamoid fractures raced
postoperatively and had similar earnings, starts, and post‐surgery. The presence of suspensory desmitis in the
order of finish scores pre‐ and post‐injury.93 Horses affected limb also had a negative association with post
that had raced before injury had better performances operative performance; 63% of horses with suspensory
after surgery; 60% of horses undergoing surgery within desmitis raced post‐surgery compared to 77% without.
30 days of injury returned to racing, which was sig Overall, the results in this series were better than results
nificantly better than when surgery was delayed. reported for removal by arthrotomy.
Concurrent suspensory ligament desmitis significantly In assessing the racing performance of 151 Thorough
lowered the prognosis for a horse with an apical sesa breds less than two years of age who had apical sesamoid
moid fracture; 36% of horses raced following surgery fragments removed arthroscopically, 84% (123 out of
and their racing performance was poor. Additionally, of 147) raced postoperatively, and there was no difference
29 horses with apical sesamoid fracture treated non between their performance and that of maternal
surgically, only 10 (37%) raced after injury, compared siblings.85 However, horses with forelimb sesamoid
to the 21 (69%) who had raced before sustaining the fractures were less likely to race than those with fractures
fracture. Their performance also was significantly in the hindlimbs (55% versus 86%, respectively), and
poorer post‐fracture than previously. These results are horses with a fracture of a forelimb medial sesamoid
in accord with the original observations made by were less likely to race and had poorer performance
Churchill,19 where arthrotomy for fragment removal than horses with a sesamoid fracture in any other loca
improved the prognosis for future racing in Standard tion or limb.
breds if (i) the injury occurred while the horse was A recent study suggested that the size of the apical ses
racing or training at racing speed, as opposed to before amoid fracture fragment did not alter the outcome in
the horse was conditioned to racing speed;93 (ii) the Thoroughbred racehorses.49 The study included 110
fragment was smaller than one‐third of the total sesa weanlings and yearlings, and 56 horses in training, that
moid bone volume;19,93 and (iii) the fracture fragment underwent surgery to remove apical PSB fractures.
did not involve more than one‐fourth of the abaxial There was no significant relationship between fracture
(suspensory ligament insertion) surface of the bone.14 size or configuration and average earnings per start, or
All authors agree that concurrent suspensory desmitis number of starts, after surgery. These findings refute a
reduces the prognosis for return to training and long‐held view that horses that undergo surgery to
racing.65,75,93 It has also been suggested that in Standard remove larger apical fractures of the PSBs perform less
breds, removal of apical fragments from one limb can satisfactorily than those horses with smaller fragments.
still be complicated by sesamoid fracture in the con
tralateral hindlimb on return to training.33
In a series of 43 Standardbreds102 treated by fragment
removal (35 by arthrotomy and 8 arthroscopically), the Apical‐Abaxial Fractures
postoperative performance of horses with apical frac
tures in the forelimbs was worse than the hindlimbs, Location
but the dimensions of the fragment and degree of sus
pensory ligament damage did not affect outcome.102 Of This fracture configuration involves the apical quadrant
16 horses that had raced before surgery, 14 (88%) raced and a variable portion of the abaxial margin of the proximal
postoperatively, compared to only 15 of 27 horses (56%) sesamoid bone. These fractures are articular and may be
that had not raced pre‐injury. Overall, 29 of 43 (67%) simple, but more commonly are comminuted. The amount
started at least one race post‐surgery, and of these 79% of suspensory ligament insertion disarmed by the fracture
(23 out of 29) raced more than five times. is determined by the length of the abaxial p ortion, and
Similarly, for Thoroughbreds with apical fragments the dorsopalmar/plantar depth of the fragment(s). Apical‐
removed arthroscopically, 65 out of 84 (77%) of horses abaxial fractures are most common in the forelimbs and
≥2 years of age started a mean of 12 times after surgery.84 most involve the medial sesamoid bone.91
Of those that had raced previously, 31 out of 38 (82%)
raced back at the same or at an improved level.84 Horses
with medial sesamoid fractures were less likely (26 out of
Diagnosis
40; 65%) to race postoperatively, compared to those with In the acute phase, lameness usually is marked and
lateral fractures (35 out of 39; 90%). Analyzed further, accompanied by distension of the metacarpophalangeal/
www.ajlobby.com
metatarsophalangeal joint, with soft tissue swelling adja the need for protracted convalescence determined by
cent to the affected suspensory ligament branch. Severity the severity of suspensory ligament compromise.
of lameness frequently diminishes in the subacute phase,
although joint distension usually will persist, together
with thickening of the suspensory ligament branch. In Results
the chronic phase, the suspensory enlargement can be In a series of 47 fractures involving the abaxial margin of
the most obvious clinical feature. Most apical‐abaxial the proximal sesamoid bones, 22 apical‐abaxial fractures
fractures of the proximal sesamoid bones are identified were reported.91 Of 17 Thoroughbred and Quarter
on standard dorsopalmar/plantar, lateromedial, dorsolat Horse racehorses, 10 (59%) returned to race after arthro
eral‐palmar/plantaromedial oblique and dorsomedial‐ scopic removal, 5 at the same and 5 at a reduced level.
palmar/plantarolateral oblique radiographic projections
(Figures 21.8 and 21.9). Substantially down‐angled
(50–60°) skyline obliques (proximal 60° lateral‐distomedial
and proximal 60° medial‐distolateral oblique projections)
Abaxial Fractures
have been described to image the abaxial margins of
Abaxial fractures generally are regarded as avulsions of
medial and lateral proximal sesamoid bones, respec
the suspensory ligament,75,81 although extreme dorsal
tively.65,67 These projections frequently provide informa
surface abaxial fractures can involve more articular sur
tion not available from the standard projections regarding
face and little suspensory insertion. Abaxial fractures
articular involvement and comminution of apical‐abaxial
can be articular or nonarticular, resulting in variable
and abaxial fractures of the proximal sesamoid bones
metacarpophalangeal/metatarsophalangeal joint disten
(Figures 21.8D and 21.9D). Additional information can
sion.91 All cases will have some degree of disruption of
also be obtained from dorsolateral 50° proximal‐palmar/
the associated suspensory ligament branch. Most occur
plantaromedial distal oblique and dorsomedial 50°
in the forelimbs and the majority of fractures involve the
proximal‐palmar/plantarodistal oblique projections

medial proximal sesamoid bone.91
frequently described as elevated obliques.25 Ultrasono
graphy will quantify the degree of suspensory ligament
compromise (Figure 21.9). Diagnosis
Clinical signs with nonarticular fractures generally local
ize to the insertion of the suspensory ligament branch with
Treatment evidence of desmitis. Standard radiographic p rojections
Conservative management of apical‐abaxial fractures usually will identify the presence of an abaxial fracture,
results in poor functional healing. Fragment distraction is although this may not be seen in profile. Skyline proxi
common and persistent lameness results. This frequently molateral‐distomedial and proximomedial‐distolateral
can be severe, and may even preclude animals from oblique projections, and dorsal proximolateral‐palmar/
breeding. Occasionally, simple fractures are of sufficient plantarodistal medial and dorsoproximal medial‐palmar/
size that reconstruction and internal fixation are appro plantarodistolateral elevated oblique radiographic pro
priate. This is achieved in a manner similar to that jections, are good indicators of articular involvement
described for repair of large abaxial fractures, but involves and help identify comminution.67 Without these radio
a more proximal location and proximodistal trajectory graphic projections, confident assessment of an articular
for the proximal screw (Figure 21.8). component to a fracture frequently cannot be made
The majority of apical‐abaxial fractures of the sesamoid (Figures 21.10–21.12).
bones, including all comminuted fractures, are optimally The prognosis generally is related to the severity of dam
treated by arthroscopic removal of the fracture frag age to the suspensory ligament insertion.14 These authors
ments. The approach is similar to removal of apical quad also considered many abaxial fractures to be associated
rant fractures, but necessitates additional abaxial and with some degree of sesamoiditis, and the more severe
distal dissection of the suspensory ligament a ttachment. the sesamoiditis, the poorer the prognosis. It has been
This frequently reveals marked fibrillar d isruption, which reported that abaxial fractures that have chronic osseous
necessitates additional soft tissue debridement. Defects changes on radiographs usually have degenerative changes
remaining can be extensive, but the symptomatic improve at the suspensory ligament insertion.72 These include
ment that follows strongly supports surgical removal. remodeling and replacement of the normal transitional
Perioperative and postoperative care and convalescence zone of fibrocartilage by osteoporotic bone, disorganized
are similar to those described for apical fractures, with the fibrocartilage, and moderately vascularized fibrous tissue.
requirement for immobilization, counterpressure, and The orderly pattern of collagen fibers is lost.
www.ajlobby.com
(A) (B) (C) (D)
(E) (F) (G) (H)
(I) (J) (K) (L)
Figure 21.8 Large apical‐abaxial fracture of the medial sesamoid of the right hindlimb repaired by two 2.7 mm cortical screws
placed using lag technique. (A) Lateromedial, (B) dorsoplantar, (C) dorsomedial‐plantarolateral oblique (DMPLO), and (D) proximal
60° medial‐distolateral skyline preoperative radiographs of the large apical‐abaxial fracture. Note that this animal had also a
longstanding asymptomatic (juvenile) fragment of the ipsilateral plantar process of the proximal phalanx. (E) Intraoperative
radiograph illustrating arthroscope position and needles used to guide implant placement, and (F) repair with two 2.7 mm cortical
screws. (G, H) Ipsilateral arthroscopic appearance of the fracture at initial evaluation, and following reduction and repair. (I–L)
Lateromedial, dorsoplantar, DMPLO, and proximal 60° medial‐distolateral skyline radiographs of the fracture taken three weeks
post‐surgery.
www.ajlobby.com
(A) (B) (C) (D)
(E) (F) (G)
Figure 21.9 Acute, comminuted, and displaced apical‐abaxial fracture of a medial sesamoid bone suitable only for fragment removal.
(A) Lateromedial, (B) dorsopalmar, (C) dorsolateral‐palmaromedial oblique (DLPMO), and (D) proximolateral‐distomedial oblique
preoperative radiographic projections defining the comminuted nature of the fracture. (E) Longitudinal ultrasound image demonstrating
significant compromise to all but the most abaxial portion of the suspensory ligament branch and loss of ligament tension following
fracture displacement. (F, G) Contralateral arthroscopic views, at evaluation and following fragment removal and debridement of the
sesamoid bone and disrupted suspensory ligament.
(A) (B) (C)
Figure 21.10 Nonarticular abaxial fracture of a medial sesamoid bone in the forelimb. Surgery is unnecessary. Radiographs including the
(A) dorsopalmar, (B) dorsomedial‐palmarolateral oblique (DMPLO), and (C) proximolateral‐distomedial skyline projections define the
palmar abaxial location (arrows), without joint involvement.
www.ajlobby.com
(A) (B) (C)
(D) (E) (F) (G)
Figure 21.11 Large articular abaxial fracture of a forelimb medial sesamoid bone, suitable for arthroscopic removal. Radiographs define
the fracture, including (A) dorsopalmar, (B) dorsolateral‐palmaromedial oblique (DLPMO), and (C) proximolateral‐distomedial skyline
projections. Note the dorsal intraarticular position on the skyline. Arthroscopic images obtained from a contralateral palmarolateral portal
show (D) probe evaluation of the fragment displaced from the abaxial margin of the medial sesamoid bone; (E) dissection from the
suspensory ligament insertion with a fixed blade knife; (F) removal of disrupted ligament with a synovial resector; and (G) inspection of
the debrided fracture site.
Treatment Reconstruction by internal fixation of large abaxial

Nonarticular fractures should be allowed to heal by fractures is indicated, both to restore the articular sur
fibrous union. Three to six months’ rest have been rec face and to conserve the suspensory branch insertion.
ommended.14,33,81 These horses will often perform suc Lag screw fixation secures the fracture, using 3.5 or
cessfully.10 However, in some cases chronic pain can 2.7 mm diameter cortical screws inserted through stab
result from recurrent tearing of the fibrous insertions. incisions in the suspensory ligament insertion. Fracture
As an alternative, and using the rationale applied to api delineation can be made by an ipsilateral palmar/plantar
cal fragments, removal of nonarticular fragments allows pouch arthrotomy, or preferably by arthroscopic visuali
second‐intention healing of the suspensory ligament zation. Intraoperative radiographs in two planes are
branch to the fracture bed. An open surgical approach important in order to assess drill/implant trajectories.
with longitudinal separation of the suspensory ligament Between one and three screws are utilized, depending
branch insertion has been described.40 Horses are on fracture size and configuration. Following routine
positioned in lateral recumbency, with the affected sesa wound closure, the fracture repair should be protected
moid bone uppermost. Use of an Esmarch bandage and during recovery by a cast enclosing the foot and extend
tourniquet is almost mandatory for satisfactory visuali ing to the proximal metacarpus/metatarsus. The limb
zation. Postoperative management and convalescence should be cast in a weight‐bearing position. The cast is
are determined by the degree of suspensory ligament maintained for recovery from general anesthesia; how
compromise, as previously discussed. ever, additional postoperative cast immobilization is of
www.ajlobby.com
(A) (B) (C)
(D) (E)
Figure 21.12 Longstanding articular abaxial fracture of a forelimb medial proximal sesamoid bone. Radiographs show the smooth‐
margined poorly mineralized fracture, including (A) dorsopalmar, (B) dorsolateral‐palmaromedial oblique (DLPMO), and (C) dorsomedial‐
palmarolateral oblique (DMPLO) projections. (D) Arthroscopic appearance from a contralateral palmarolateral portal at evaluation, and
(E) following fragment removal. Note the fibrous tissue covering of the fracture bed, which was not debrided further.
questionable use, and is usually at the surgeon’s discre insertion varies widely, and determines the amount of
tion. Fracture healing is monitored radiographically and ligament that will require division from the fracture
exercise modulated in line with osseous union. Current fragments to permit removal. A variety of fixed‐blade
experience suggests that a return to training should not cutting instruments are suitable, generally determined
be anticipated for at least six months. by the surgeon’s personal preferences.59 The author uses
Articular abaxial fractures which are not amenable to the same instrumentation as detailed for apical frag
repair should be removed arthroscopically (Figures 21.11 ment removal.
and 21.12). Horses can be positioned in dorsal or lateral
recumbency. The author recommends dorsal recum
bency with contralateral arthroscope and ipsilateral Results
instrument portals; other surgeons utilize ipsilateral The prognosis for abaxial fractures is predominantly
arthroscope and instrument portals.91 The joint should determined by the degree of disruption of the suspen
be partially flexed and use of an Esmarch bandage and sory ligament insertion.75 In one series, 15 of 18 (83%)
tourniquet is indicated. A standard arthroscope portal is Thoroughbred and Quarter Horse racehorses returned
created at the proximal margin of the palmar/plantar to racing after arthroscopic removal, 11 at the same and
pouch.60 The optimum instrument portal location is 4 at a lower level of performance.91 These horses also
determined by the fracture configuration and defined by had more starts, earned more money, and had more
percutaneous needle insertion. Damage to the suspensory wins/places compared to a similar population with
www.ajlobby.com
apical‐abaxial fractures. In this series, horses with usually is resented. Most complete fractures are
proximodistally longer fragments also had reduced readily identified on standard radiographic projections
performance compared to shorter fragments. (Figures 21.13 and 21.14). Lameness is variable in
horses with incomplete fractures. In the acute phase,
incomplete fractures may be radiologically silent.81
Radiographs can be repeated after 7–10 days and/or
Uniaxial Mid‐body Fractures scintigraphic examination performed to provide addi
tional diagnostic information.
Incidence and Location
Mid‐body fractures are primarily racehorse injuries and
are seen with relatively equal frequency in Standardbreds
Treatment
and Thoroughbreds. They can occur in training or Conservative and Non-Reconstructive
racing. Mid‐body fractures involve between 25% and Management
75% of the distal to proximal length of the bone, as meas Fracture healing with conservative management is poor.
ured on dorsopalmar/plantar radiographs. They may be This has been ascribed to (i) absence of a periosteum; (ii)
further classified as proximal mid‐body if the distal lack of adequate periosteal and endosteal blood supply;
fragment is 50–75% of the total proximodistal length of (iii) marginal primary blood supply; (iv) minimal
the bone, and distal mid‐body if it is 25–49% of the extraosseous blood supply from adjacent soft tissues; or
length.16 Mid‐body fractures can be transverse (horizontal) (v) continuous distracting forces acting across the frac
or oblique. Proximodistal displacement can occur sym ture.9,14,39,76 A number of treatment options appear in
metrically or with rotation to produce greater dorsal the literature and are principally of historical interest.
(articular), palmar/plantar, or abaxial fracture gaps. Surgical removal of either fragment destroys or results in
Comminuted fragments also can be found in or adjacent marked disruption of the suspensory apparatus.14,39
to the principal fracture. Conservative management usually results in fragment
In a series of 25 cases, a forelimb sesamoid was separation due to the distracting forces of the suspensory
involved in 21 of the horses, and the hindlimb in only apparatus.76 Fibrous14,39,75 or fibro‐osseous healing may
four.16 Fractures of the medial sesamoid bone were ensue, but generally is inadequate for athletic endeavor.9,10
significantly more common than the lateral in the fore Desmotomy of the ipsilateral branch of the suspensory
limbs (20 out of 21), while all 4 mid‐body fractures in the ligament to reduce distracting forces on the fracture was
hindlimb (including 1 bilaterally) were lateral. Fractures reported in 10 horses.88 This met with limited success
were proximal mid‐body in 7 and distal mid‐body in 18 and was never widely adopted, as it appeared to create
horses. Configuration was transverse in 18 and oblique another point of failure on return to exercise. There has
in 7 horses. Oblique fractures were proximal‐axial to been no evidence of a contribution to fracture healing by
distal‐abaxial in 5 horses, and proximal‐abaxial to dis therapeutic cautery, or local or systemic administration
tal‐axial in 2 horses. In 19 horses (76%), displacement of anti‐inflammatory agents.14 Immobilization has been
was greatest palmar/plantaroabaxially rather than on recommended for nondisplaced fractures using a cast or
the dorsoaxial aspect. Distal fractures were more likely Kimzey splint for six to eight weeks, and with a total con
to have greater displacement than their proximal valescence of six to eight months.33 Immobilization can
counterparts. be used also for displaced fractures, but is likely to result
In a second series, mid‐body fractures occurred most in fibro‐osseous union only, and degenerative joint
commonly in the forelimbs of Thoroughbreds, with the disease is inevitable.
highest incidence in the right fore.39 In Standardbreds
there was an approximately equal distribution between
fore‐ and hindlimbs, but the left hindlimb was most Compression Screw Fixation
Although use of compression screws to repair mid‐body
common. Of 25 fractures (15 Standardbreds and 9

fractures has been advocated for many years,1,32,40,41
Thoroughbreds), 24 occurred during training or racing.39
technical difficulties and lack of published case studies
resulted in limited surgical adoption. The AO proximal
sesamoid clamps offered a novel solution to some of
Diagnosis the technical problems associated with reduction and
Uniaxial, complete mid‐body fractures produce marked repair of an asymmetrically curved pyramidal structure.
lameness with joint distension. Soft tissue swelling However, these were cumbersome and restricted flexibil
often develops over the affected sesamoid and associ ity of screw placement. Two clamps were needed, one with
ated suspensory ligament branch. Digital pressure lateral left/medial right configuration and a second with
www.ajlobby.com
medial left/lateral right pitches. They are no longer made. Standard lag screw insertion follows, with judicious use
The sesamoid clamp was designed to simultaneously of a countersink to optimize contact between the screw
maintain reduction and act as a drill guide. Removable head and the proximal fragment.
sleeves permitted insertion of a 4.5 mm screw without For insertion of distal to proximal screws, the open
moving the clamp. Additionally, once the fracture was skin incision is similar to that described for proximal
reduced and secured, the clamp also permitted abaxial screw insertion, and a stab incision is made to divide the
inclination of the sesamoid bone, which reduced impinge junction of the middle (oblique) and superficial (straight)
ment of the drill on the heel bulb.32 Use of a C‐clamp distal sesamoidean ligaments down to the middle of the
(DePuy Synthes, West Chester, PA, USA) to aid correct base of the sesamoid bone. If there is little or no radio
screw placement also has been advocated, but not widely logic displacement and good articular congruency, then
adopted.27,100 standard lag screw fixation with a single 4.5 mm or one
Like other fractures, the size of the fragments and ori or more 3.5 mm cortical screws follows. With displace
entation of the fracture plane(s) are the principal deter ment and/or unstable fractures, a glide hole can be
minants of optimum screw orientation. Distal mid‐body created to the fracture plane and reduction effected by a
fractures are most logically repaired with distal‐ to Kirschner wire and drill sleeve. Reduction can be main
proximal‐oriented screws and proximal mid‐body frac tained with large pointed r eduction forceps, but these
tures with proximal to distal screws. If the fracture plane should be seated sufficiently palmar/plantar to the
is horizontal/transverse, these rules of thumb apply. articular surface to avoid the natural tendency toward
However, with oblique fractures this orientation also bending of the bone along its dorsal (concave) surface.
must be considered. A fracture coursing from proximal‐ In all distal to proximal screw placement techniques,
axial to distal‐abaxial is most favorably repaired from impingement of the drill on the heel bulbs can be a frus
proximal to distal with an ipsilateral (abaxial) approach; tration, and in some cases can compromise implant
this offers the potential to place the screw close to location and trajectory. There is a natural fossa at the
perpendicular to the fracture plane, which cannot
base of the proximal sesamoid bones between the ori
be achieved from a basilar approach. Fractures with a gins of oblique and straight distal sesamoidean liga
proximal‐abaxial to distal‐axial orientation can be ments that is the ideal location for the screw head.65,76
compressed by screws passing (ipsilaterally) from distal However, without modest countersinking, screw head
to proximal, or contralaterally from proximal to distal, point contact and all of the disadvantages associated
following trajectories approximately parallel to the abax with it remain. If the surgeon considers it desirable, a
ial surface of the bone (see Figure 21.14). Screws with an small amount of cancellous bone can be packed into any
inappropriate trajectory can result in fragment shift, remaining osseous defect before screw tightening.14,76
articular incongruency, and malunion. Determination Use of two 3.5 mm screws has advantages in providing
of glide hole depth and approximate screw length from rotational stability. The bones’ pyramidal shape with a
preoperative radiographs is useful. concave dorsal surface requires the surgeon’s attention
An open technique for lag screw fixation using direct to the dorsopalmar/plantar trajectory of implants,
visualization of the fracture by arthrotomy has been which should have a distopalmar/plantar to proximo
described.14,32,76,81 The latter descriptions involve a sin dorsal orientation in order to maximize bone purchase
gle, dorsally based, curved incision extending from the while avoiding trauma to the articular surface.
proximal pouch of the metacarpophalangeal/metatar A technique for arthroscopic visualization has recently
sophalangeal joint over the affected proximal sesamoid been reported.16 Using the technique described, a single
bone to the proximal quadrant of the proximal phalanx. 4.5 mm cortical screw is inserted in a distal to proximal
A palmar/plantar pouch arthrotomy follows. For proxi orientation (see Figure 21.13). The center of the base
mal to distal screw placement, a vertically oriented stab of the sesamoid bone is located and drill trajectory
incision is made through the fibrocartilaginous scutum determined by a percutaneous needle (e.g., 18 gauge/
and suspensory ligament insertion 5 mm palmar/plantar 1.2 mm × 3.5 in./85 mm) passed palmar/plantar to the
to the sesamoid articular surface. Following creation of a neurovascular bundle through the distal sesamoidean
4.5 or 3.5 mm glide hole to the fracture plane, an appro ligaments. Its position is assessed and modified by radi
priately sized Kirschner wire is inserted and the drill ographic/fluoroscopic examination in dorsopalmar/
sleeve for the thread hole is passed over it. The proximal plantar and lateromedial planes. A short (stab) incision
fragment can then be manipulated with varying degrees is then made along this trajectory to the base of the
of joint flexion to effect reduction. If this is reasonably sesamoid, the oblique and straight sesamoidean liga
stable then the thread hole can be drilled, but if neces ments bluntly separated with a hemostat, and a 4.5 mm
sary, large AO reduction forceps can be applied between drill guide passed. The drill guide position and trajectory
the base and apex of the bone to provide increased stability. are confirmed radiographically. A glide hole is then
www.ajlobby.com
(A) (B) (C)
(D) (E)
(F) (G)
(H) (I)
(J) (K)
Figure 21.13 An acute, transverse, mid‐body fracture of a forelimb medial sesamoid bone repaired with a single 4.5 mm cortical screw.
Radiographs show the transverse distracted fracture, including (A) lateromedial, (B) dorsomedial‐palmarolateral oblique (DMPLO), and
(C) dorsopalmar projections. Measurements of the proximodistal lengths of the basilar fragment and the contralateral sesamoid bone are
calculated on the dorsopalmar view. (D–G) Determination of drill site and trajectory for distal to proximal repair using needle placement
and subsequent lateral and dorsopalmar radiographs. (H) “Surgeon’s‐eye” view of drill trajectory and (I) arthroscopically guided reduction.
(J, K) Radiographic evaluation of the glide and thread holes, respectively.
www.ajlobby.com
(L) (M)
(N)
(O) (P) (Q) (R)
(S) (T) (U) (V)
Figure 21.13 (Continued) (L) Screw insertion and (M, N) radiographic confirmation of screw length, trajectory, and compression of the
fracture. (O–R) Arthroscopic images of the fracture from an ipsilateral portal, showing initial evaluation of the fracture, emergence of the drill
through the distal fragment, use of a Steinmann pin in the drill guide to effect reduction, and sesamoid articular surface appearance
following screw insertion and tightening, respectively. (S, T) Dorsopalmar and lateromedial radiographs with the limb immobilized in a cast
14 days post‐surgery. (U, V) Radiologic appearance following cast removal 30 days post‐surgery.
created to the fracture plane, a 3 mm Steinmann pin can be performed as necessary through an instrument
inserted, and a 3.2 mm drill insert sleeve passed over the portal created at the level of the fracture, through the
pin. A long drill sleeve is necessary, because if the trajec collateral sesamoidean ligament. Fracture reduction is
tory is correct, the skin to fracture plane distance in achieved by a combination of joint flexion and manipula
horses over 400 kg body weight is usually >50 mm. The tion, utilizing the 3.2 mm drill sleeve and Steinmann pin.
articular surface is evaluated from an ipsilateral proximal Once satisfactory, the pin is withdrawn and a 3.2 mm
arthroscopic portal (see Figure 21.13).60 Removal of hole drilled into the apical fragment, taking care to
comminuted fragments and debridement of the fracture minimize protrusion of the drill bit into the suspensory
www.ajlobby.com
(A) (B) (C)
(D) (E)
(F) (G) (H)
(I) (J) (K)
Figure 21.14 Nondisplaced, proximal‐abaxial to distal‐axial mid‐body fracture of a forelimb medial proximal sesamoid bone. Radiographs
define the oblique fracture angle, including (A) dorsopalmar, (B) dorsomedial‐palmarolateral oblique, (DMPLO) and (C) proximal dorsomedial‐
distal palmarolateral oblique projections. (D) Intraoperative dorsopalmar radiographs showing the contralateral proximal palmar pouch
arthrotomy and depth gauge in place. (E) Insertion of a 3.5 mm cortical screw. Follow‐up radiographs showing four‐week (F) dorsopalmar,
(G) DMPLO, and (H) proximal dorsomedial‐distal palmarolateral oblique projections, and the same views (I–K) 22 weeks postoperatively.
www.ajlobby.com
ligament insertion. Additional stability can be provided Transfixation/Hemicircumferential Wire

by application of large AO reduction forceps. The use of wire to repair mid‐body fractures of the prox
Standard lag screw insertion technique follows. The imal sesamoid bones was first described in 1991, using
base of the proximal sesamoid bone is concave dorsal to initially circumferential and later hemicircumferential/
palmar/plantar and (centrally) concave mediolaterally. transfixation techniques.57 The circumferential tech
Countersinking the screw heads was not reported in the nique was associated with high postoperative morbidity,
original publication. This is necessarily a balance between with complications of wire slippage and breakage.
optimizing the conditions for the implant and minimiz Hemicircumferential wiring was developed to avoid
ing trauma to the distal sesamoidean ligaments. Judicious these wire complications, and modifications to insertion
use of countersinking along the sesamoid base is used by published.77,81
the author. The depth of soft tissue precludes accurate The initial surgical approach and palmar/plantar
use of the depth gauge. In nondisplaced fractures the arthrotomy are similar to that employed for lag screw
length of the affected sesamoid bone is the best determi fixation. However, this is followed by desmotomy of the
nant of screw size, and in displaced fractures the length palmar/plantar annular ligament to open the digital
of the intact contralateral counterpart along the trajec flexor tendon sheath. Retractors are then passed dorsal to
tory of the implant is used. Intraoperative radiographic the digital flexor tendons to expose the fibrocartilage‐
monitoring is essential throughout. At the end of the covered palmar/plantar surface of the fractured sesamoid
procedure, the joint is lavaged and skin portals closed bone. A 14‐gauge needle is pushed from the abaxial mar
routinely. gin of the distal articular surface of the sesamoid bone to
The authors describe use of this technique in 10 horses, emerge axially along the bone’s p almar/plantar margin
with lag screw fixation by arthrotomy in a further 6 within the digital flexor tendon sheath. A 20–30 cm
animals; 13 horses had single 4.5 mm cortical screws length of 1.25 mm (16‐gauge) wire is passed through the
placed, 1 horse was repaired with two 4.5 screws, 1 with needle and retrieved from the digital flexor tendon
a single 3.5 mm screw, and 1 with three 3.5 mm screws.16 sheath. Viewed through the arthrotomy, a short stab inci
An arthroscopic approach to lag screw fixation provides sion is made at the level of the middle of the proximal
similar advantages over open/arthrotomy approaches at fragment, through the suspensory ligament insertion to
other locations, although implant placement is not com the abaxial surface of the bone. Through this, a 2.5 mm
pletely arthroscopically guided. Implant position and drill tract is made in a dorsal abaxial to palmar axial
trajectory are both determined radiographically. direction (i.e., parallel to the wire at the base of the bone).
The repair is protected by a cast enclosing the foot and If possible, the drill should not emerge from the palmar/
extending to the proximal aspect of the metacarpus/ plantar fibrocartilage into the digital flexor tendon
metatarsus, with the limb in a weight‐bearing position sheath. This then can be penetrated by a 14‐gauge/2 in.
(see Figure 21.13S,T). Cast support varies from two days (50 mm) needle inserted along the same path as the drill,
to eight weeks.14,16,39,65,76,81 Antimicrobial medication and the free end of the wire, within the digital sheath at
principally is determined by surgeon’s preferences. the base of the bone, is inserted into the bevel of the nee
Osseous healing is monitored radiographically and a dle. This is withdrawn and the wire is redirected to be
controlled exercise regime modulated by bony union and passed distally along the intraarticular abaxial surface of
the horse’s clinical progress. A return to work/training is the bone to complete the loop to its distal end. A cancel
unlikely before six months postoperatively. lous bone graft can be inserted at this point, either through
Application of a headless, variable‐pitch, self‐tapping, the articular defect or abaxially. The wire ends are tied
tapered compression screw (Acutrak™, Acumed and tightened carefully to avoid creation or exacerbation
Corporation, Beaverton, OR, USA) has been reported.27 of articular incongruency. Even twisting of the wire using
This measures 5 mm at its base and 4 mm at its apex, and the FastTight wire tightener (DePuy Synthes) is recom
was compared to a 4.5 mm cortical screw inserted in a mended. Excessive wire is cut off and the twisted end is
lag technique to repair osteotomized c adaveric forelimb turned toward the bone to reduce irritation of adjacent
proximal sesamoid bones. There were no significant soft tissue. The author has employed a similar technique
differences in failure characteristics. The authors which substitutes arthroscopic guidance for metacarpo/
recommended consideration of the variable‐pitch metatarsophalangeal arthrotomy (Figure 21.15).
screw for clinical use on the grounds of reduced soft In all arthrotomy approaches through the proximal
tissue impingement and improved biocompatibility. palmar/plantar outpouching of the metacarpophalan
However, to date it has not been widely adopted. geal/metatarsophalangeal joint, the surgeon should be
A hybrid locking plate has also been under development cognizant of the palmar/plantar arteriovenous arch. This
for mid‐body sesamoid fractures, but has not entered lies in close proximity to the proximal capsule reflection.
clinical practice.2 Intraoperative hemorrhage is controlled by tourniquet,
www.ajlobby.com
(A) (B) (C) (D)
(E) (F) (G) (H)
(I) (J) (K) (L)
Figure 21.15 Acute basilar fracture of a forelimb medial proximal sesamoid bone with sagittal comminution of the distal fragments
treated with hemicerclage wire. Radiographs useful in identifying the comminuted fragments include (A) dorsopalmar, (B) lateromedial,
(C) dorsomedial‐palmarolateral oblique (DMPLO), and (D) dorsoproximomedial‐palmarodistolateral oblique projections. Although
measuring just less than 25% of the proximodistal length of the bone, fractures of this size compromise the suspensory apparatus to the
same degree as mid‐body fractures. (E) Intraoperative dorsopalmar radiograph showing ipsilateral arthroscope position and hemicerclage
wire in position; a marker needle has been inserted in the transverse fracture plane. (F) Dorsopalmar radiograph with hemicerclage wire at
the completion of surgery. (G) Dorsopalmar and (H) lateromedial radiographs with the limb immobilized in a cast 10 days post‐surgery.
(I) Dorsopalmar and (J) lateromedial radiographs eight weeks post‐surgery; note the periarticular swelling (arrow), which is common with
sesamoid wiring. (K, L) Radiographs 12 weeks post‐surgery, showing progressive healing.
www.ajlobby.com
but limiting trauma to this plexus will reduce postopera of the transfixation wire–repaired limbs exceeded
tive hemorrhage. those of the lag screw–repaired specimens. However, a
Routine wound closure follows, including selective clo fracture gap preceded failure in most of the wire‐repaired
sure of the joint and digital flexor tendon sheath. Cast constructs. All intact limbs failed through the suspen
support is recommended for anesthetic recovery and for sory and/or distal sesamoidean ligament. These authors
varying periods postoperatively, as determined by indi observed that it was “virtually impossible to place
vidual case management. Wire breakage has been transfixation wires without a slight amount of slack”;
reported, but is rare with 1.25 mm wire.77 The principal second‐intention healing is therefore inevitable with
concern with this technique is the uncontrolled reduc this technique. The second experiment compared the
tion. Accurate reduction has been described as difficult,77 techniques in osteotomized cadaver medial proximal
and frequently not obtained. “Gap” or second‐intention sesamoid bones.103 A distal to proximal 4.5 mm lag screw
healing ensues, with subsequent proximodistal elonga and 1.25 mm diameter wire, respectively, were employed
tion of the bone and the risk of delayed union. and limbs were loaded under static axial compression
Ultra‐high molecular weight polyethylene cable (1 mm) (metacarpophalangeal extension) to failure or 5000 N.
was compared with 1.25 mm (16‐gauge) stainless‐steel There was no significant difference in mean yield between
wire in mid‐body osteotomized cadaveric forelimbs.80 the two techniques. However, evidence of fracture gap
These authors also developed an endoscopically guided widening with the wire technique suggested that inter
fixation technique. The polyethylene fiber cable had a fragmentary compression was less than the screw repair
greater tensile strength than stainless‐steel wire and technique. In light of this, it was considered likely that
withstood cyclic loading better than stainless‐steel wire ultra‐high molecular weight polyethylene cable would
or cable; it also had superior handling characteristics.80 provide greater monotonic tensile strength than a single
The cable resulted in reduced gap formation compared 4.5 mm cortical screw but allowed the fracture to gap.80
to the original transfixation method.57 However, to date Fracture distraction and gap formation after hemicir
these results have not been tested in vivo. cumferential wiring also are compounded, in vivo, by the
With the endoscopic technique, the level of the drill interposition of soft tissues between bone and wire.
hole in the apex of the bone is determined by ipsilateral Additional disadvantages to wire fixation techniques
arthroscopic assessment. A drill aiming device (Micro include irritation of the tendon sheath, wire migration,
Vector Drill Guide System, Smith and Nephew Endoscopy, and impingement on adjacent soft tissues.16
Andover, MA, USA) is positioned via a stab incision
through the skin and suspensory ligament insertion. A
2.5 mm drill hole is then created with the previously Autologous Corticocancellous or
described dorsal abaxial to palmar axial orientation, exit Cancellous Bone Grafts
ing the fibrocartilage‐covered surface of the sesamoid Autologous corticocancellous and cancellous bone grafts
bone in the digital flexor tendon sheath. Under tenoscopic are considered to aid fracture healing by osteoinduction
guidance, wire/cable is passed through the hole , into the and osteoconduction.57,103 Additionally, cancellous bone
tendon sheath, and directed out of the digital flexor grafts have been shown to improve vascularization of
tendon sheath just distal to the base of the contralateral healing callus in proximal sesamoid osteotomies.57 Use
proximal sesamoid bone. It is then directed back into the of autologous cancellous grafts was described in the
sheath and through a catheter placed in a dorsal abaxial to repair of basilar fractures of the proximal sesamoid
palmar axial orientation along the base of the proximal bones, and the technique and rationale are applicable to
sesamoid bone. The wire/cable is secured abaxially. These mid‐body fractures.63 The grafts could be the sole tech
authors also described a suture technique using a single nique or used to augment internal fixation procedures.
proximodistally oriented mattress suture, performed via a Originally, installation was recommended through the
palmar arthrotomy, but this does not appear to have been ISL.61,63 This involves transection of the palmar/plantar
applied clinically. annular ligament immediately palmar/plantar to the
Two studies compared the mechanical characteristics affected proximal sesamoid bone, and opening the digi
of lag screw fixation and hemicircumferential/transfixa tal flexor tendon sheath. The digital flexor tendons are
tion wire techniques.100,103 The first compared load to retracted, the fracture located with a needle, and the ISL
failure characteristics of intact proximal sesamoid bones divided to expose the fracture gap. This is then filled
and mid‐body osteotomized bones, repaired by either with cancellous bone before the wound is closed
distal to proximal lag screw fixation with 4.5 mm cortical routinely. As described, it is highly invasive and trauma
screws, or 1.02 mm (18‐gauge) stainless‐steel wire tizes the digital flexor tendon sheath and its contents. In
applied in a standard hemicircumferential technique in the author’s hands, the grafted cancellous bone limits
cadaver forelimbs.100 The load to failure characteristics fracture reduction and has not contributed to healing.
www.ajlobby.com
One text recommends use of autologous cancellous bone trajectory. Proximal/abaxial to distal 3.5 mm cortical
grafts, but emphasizes that only a small amount of bone screws were used in 8 cases of proximal mid‐body frac
is needed, utilizing little more than that extruded from tures. The number of 3.5 mm screws varied from a single
the drill flutes of a 5.5 or 6.5 mm drill passed through a screw in 1 horse, two screws (5 horses), and three screws
short skin incision into the tuber coxa.81 (2 horses). Of 15 Standardbreds, 9 raced at a mean of 12.4
Cortical, corticocancellous, or cancellous autogenous months postoperatively, albeit with overall reduced
bone grafts have been compared in experimental (osteot performance compared with their preinjury levels. Of 9
omized) mid‐body and basal fractures of forelimb proxi Thoroughbreds, 5 raced at a mean of 10.2 months after
mal sesamoid bones.62 Many of the fracture sites suffered surgery and 1 competed in non‐racing events; the small
thermal necrosis at the time of osteotomy. Nonetheless, numbers precluded confident postoperative perfor
based on radiographic and microangiographic observa mance comparisons. Radiologic evidence of preoperative
tions, the authors considered that autogenous grafts con degenerative joint disease appeared to be a negative
tributed to healing, with corticocancellous grafts suitable prognostic indicator in Thoroughbreds, but not in
for the repair of displaced fractures, and cancellous grafts Standardbreds. All surgically repaired sesamoid bones
the choice for augmenting repair of nondisplaced frac healed, with progressive degenerative joint disease devel
tures. An alternative technique in which autologous can oping in only 2 horses. However, abaxial (entheseous)
cellous bone grafts were inserted into mid‐body fractures new bone was identified in 14 cases. There was no corre
via an abaxial approach or through the palmar/plantar lation in this series between fracture duration or lack of
arthrotomy has been described,14 which avoided invasion preinjury starts with case outcome. Early postoperative
of the digital flexor tendon sheath and trauma to the ISL. failure of constructs occurred in 2 horses. In another
However, no results were published. These authors also report, 10 of 15 horses with mid‐body or large basilar
reported use of cancellous bone grafts in conjunction fractures were sound following circumferential (5) or
with lag screw fixation, but again no results were availa hemicircumferential/transfixation (10) repair techniques,
ble. It has been suggested that refracture can occur fol with 5 horses competing at the same or an improved level
lowing use of grafting techniques as the sole treatment after surgery.57
modality.33 Better techniques for reduction and internal The most recent paper reports the results obtained in
fixation of sesamoid fractures have reduced the need for 25 horses with unilateral mid‐body proximal sesamoid
supplemental bone grafts. bone fractures repaired using hemicircumferential
wiring or interfragmentary lag screw fixation.16 The
Postoperative Care latter included distal to proximal and proximal to distal
Cast support for recovery from anesthesia and in the screw placements and both open (arthrotomy) and
subsequent days to weeks is universally recommended. arthroscopically guided repair techniques. Lag screw
A study of cadaveric limbs found that no repairs, using fixation improved fracture reduction in 14 of 16 horses,
either transfixation wires or lag screw fixation, failed compared to 2 of 9 horses repaired by hemicircumfer
when metacarpophalangeal angles were less than 140°, ential wiring. There was no difference in reduction
providing support for the use of a cast.100 The period of between open and arthroscopically repaired fractures.
cast immobilization varies between individual surgeons, In 2 horses, wire removal was performed six months
with some suggesting maintenance for two to four weeks postoperatively. Radiographic evidence of fracture
and others encouraging early removal followed by use of healing was identified in follow‐up examination from
Robert Jones bandages or a cast–bandage combination.81 2 to 14 months, but 7 of 8 horses radiographed at least
Generally, horses are confined to a stall for eight weeks 6 months after surgery had some radiolucency remain
and this is followed by a gradually increasing, controlled ing in the original fracture plane. Of 16 horses with
exercise program. The average time for return to train screw fixation, 7 (44%) raced after surgery, compared to
ing is 10–12 months.39,57,75 The implants do not need none of the 9 horses with wire repairs. This contrasts to
removal in the absence of infection or wire breakage and an earlier publication which reported that 6 of 15 (40%)
migration. returned to race after wire repair.57 All of the horses that
raced had reduction improved by the repair. It was con
cluded that repair technique and degree of reduction
Results significantly influenced the outcome of horses with uni
Lag screw fixation augmented by autologous cancellous lateral mid‐body fractures.16
bone grafts has been reported in 25 horses with 27 mid‐ Two case series noted abaxial enthesophyte formation
body sesamoid fractures.39 Of these, 17 fractures were postoperatively, but this appeared to be unrelated to
repaired with single 4.5 mm cortical screws, 16 in a distal p erformance/outcome.16,39 Regardless of technique,
to proximal direction, and 1 with a proximal to distal the prognosis for racing following single mid‐body
www.ajlobby.com
proximal sesamoid bone fractures remains guarded, margination adjacent to the base of the affected s esamoid.
and those returning to racing usually compete in a lower Most acute fractures raise sufficient clinical concern to
class of race.75 warrant radiographic examination without further
investigation, while chronic fractures may be diagnosed
following local analgesic techniques.
Most fractures are recognized on standard radio
Basilar Fractures
graphic projections. However, 20° proximodistal oblique
projections will profile the bases of the lateral and medial
Incidence and Location proximal sesamoid.25 Some small, axial fragments can be
Basilar fractures are much less common than their api radiologically silent in all projections. This area of the
cal counterparts. They are usually uniaxial, but occa proximal sesamoid bone cannot be imaged in profile on
sionally can be bilateral. The incidence in published any projection. Ultrasonographic evaluation of distal
series varies from 6% to 24% of all proximal sesamoid sesamoidean ligaments is prudent in all cases, and since
bone fractures.35,69,90 A wide range of fracture configu healing of the distal sesamoidean ligaments is a limiting
rations are encountered, including small dorsal (articu factor to recuperation, this can be a useful management
lar) chip or sliver fractures that can detach from any and prognostic guide. Occasionally, full‐thickness frac
part of the dorsal margin of the sesamoid base, trans tures will extend into the digital flexor tendon sheath,
verse articular fractures that involve the whole distal where ultrasonography provides the best currently avail
margin of the bone, and similar nonarticular palmar/ able assessment.
plantar basilar fragments. Comminution of complete
basal sesamoid fractures is common and frequently
underestimated by radiography. Many have a single ver Treatment
tical (sagittal) component to create a (often asymmetric)
“T” configuration (Figures 21.15 and 21.16). These are Repair
poor candidates for screw fixation and carry a corre The approach and technique are as described for distal
spondingly poor prognosis for return to athletic activity. to proximal lag screw fixation of mid‐body fractures.
Small articular fragments involve little of the origins of Careful evaluation of high‐definition radiographs is
the distal sesamoidean ligaments, but as the fracture important to identify comminution (frequently sagittal).
extends further palmar/plantar, correspondingly more Comminution may preclude lag screw fixation, or
of the distal sesamoidean ligaments are compromised. necessitate multiple, frequently smaller (3.5 mm instead
Nonarticular fractures generally are considered to be of 4.5 mm) implants. The thin fragment profile of many
avulsions of the distal sesamoidean ligaments and basal fractures often precludes safe lag screw fixation.65
are embedded within these or resultant scar tissue Chronic fractures may have become osteopenic/
(Figure 21.17). Basilar fractures are more common in osteoporotic and can split when screws are tightened.10
Thoroughbreds than Standardbreds,14,69,81 and the Hemicircumferential/transfixation wiring is more attrac
majority of basilar fractures occur in the forelimbs tive in these circumstances (Figure 21.15), but has its
(88%69; 100%90). Although limb affliction is inconsistent own technical difficulties, and in most surgeons’ hands
between series, the medial sesamoid bone is more often has produced inferior results in returning horses to
affected than the lateral.69,90 athletic activity. As with repaired mid‐body fractures,
limiting postoperative fetlock extension and thus dis
tracting forces on the repair are important. Application
of a cast is recommended for recovery from general
Diagnosis anesthesia and in the early postoperative period.
The degree of lameness accompanying basilar fracture is Osseous union is possible by six months, with return to
roughly proportional to the amount of compromise to training by nine months. Screws remain in situ unless
the distal sesamoidean ligaments created by the fracture. complications arise.10
Articular fractures are accompanied, in the acute phase, Comparison of bone grafts in an experimental sesamoid
by joint distension. Digital pressure occasionally local basilar osteotomy model treated by autologous cancellous,
izes pain to the area. Large fractures which disrupt sig cortical, or corticocancellous bone grafts, and untreated
nificant portions of the origin of the distal sesamoidean “control” osteotomies, showed that grafted bones healed
ligaments usually will result in swelling adjacent to the and reestablished the vascularity of both proximal and
ligaments, as a result of hemorrhage and the inflamma distal fragments. Osseous healing and subsequent remod
tory response. With time, acute inflammatory features eling occurred most rapidly with the cancellous grafts.63
subside and are replaced by firm thickening with lack of Untreated fractures remained unstable for longer, with
www.ajlobby.com
(A) (B) (C)
(D) (E) (F)
(G) (H) (I)
(J) (K)
Figure 21.16 A thin comminuted basilar fracture of a forelimb lateral proximal sesamoid bone suitable for removal. The fracture is visible
on all radiographic views, including (A) dorsopalmar, (B) lateromedial, and (C) dorsolateral‐palmaromedial oblique (DLPMO). Arthroscopic
visualization of the fracture from a contralateral (palmaromedial) portal: (D) initial inspection of the fracture; (E) determination of an
instrument portal with a percutaneous needle; (F) use of a probe to evaluate the fracture; (G) dissection of fragments from the distal
sesamoidean ligaments; (H) fracture site following fracture removal and debridement; (I) assessment of the debrided parent bone and
distal sesamoidean ligaments with the arthroscope passed through the instrument portal adjacent to the fracture site. (J) Dorsopalmar
and (K) lateromedial radiographs with the limb supported in a cast 14 days post‐surgery, confirming fragment removal, defining the size
of the resultant deficit, and illustrating sesamoid stability.
www.ajlobby.com
Figure 21.17 Chronic, nonarticular (A) (B)

fragmentation of the base of a hindlimb
medial sesamoid bone. (A) Lateromedial
and (B) dorsomedial‐plantarolateral
oblique (DMPLO) radiographic projections
show the rounded fracture edges and
fracture bed on the sesamoid. Note the
degree of metatarsophalangeal extension
present in this animal.
the majority remaining as nonunions 40 weeks after lesion arthroscope passed through the instrument portal, to
creation; these horses also had more degenerative changes verify that all debris has been removed. Cast support in
in their metacarpophalangeal joints. Eight clinical basilar recovery from general anesthesia may be required when
fractures were treated with cancellous bone grafts inserted a large portion of the base of the proximal sesamoid bone
through the ISL via the digital flexor tendon sheath. Of 8 has been removed.
clinical cases, 4 (50%) resumed training 40 weeks post‐
surgery; 2 became jumpers, 1 a polo pony, and the other Nonarticular Fragments
became a broodmare. Until recently, the majority of nonarticular fragments
were managed conservatively (Figure 21.17), relying on
Removal of Articular Fractures second‐intention healing at sites of avulsion. It has gen
Arthroscopic removal of articular basal fragments usu erally been considered that surgical trauma, and specifi
ally is the treatment of choice. This may be performed cally damage to the adjacent intact distal sesamoidean
with the horse in dorsal or lateral recumbency, with ipsi ligaments, outweighed any potential advantages that
lateral arthroscope and instrument portals if the horse is accrued from fragment removal.10,14 An extra‐articular,
in lateral and either an ipsilateral or contralateral arthro palmar/plantar open approach to the base of the proxi
scope portal when in dorsal. An Esmarch bandage and mal sesamoid bones64 also offers poor surgical visibility.
tourniquet are helpful. The arthroscope is inserted in a An open, transthecal approach for nonarticular frag
conventional palmar/plantar pouch approach with the ment removal has been described, and results in 11 fore
joint in a semiflexed position.60 An instrument portal is limb and 5 hindlimb fractures in 11 horses reported.13
created through the articular outpouching just distal to Eight forelimb fragments were medial and three lateral.
the collateral sesamoidean ligament, so that instrument Three hindlimb fragments were lateral and two medial.
trajectories are alongside and parallel to the base of the On the basis of their anatomic location, these authors
proximal sesamoid bone.60 The dorsopalmar/plantar considered these fractures to be avulsions of the origin of
length of the fragment is assessed on preoperative radio the oblique distal sesamoidean ligament. All horses were
graphs, and will determine the extent of division of the lame preoperatively, and 5 of the 11 had been rested for
sesamoidean ligament origin necessary for fragment six months or more without resolution of the lameness.
removal (Figure 21.16). The extent of disruption of the Surgery was performed in lateral recumbency with the
distal sesamoidean ligaments will determine the progno affected limb uppermost. The digital flexor tendon
sis. Small fragments from the dorsal articular rim have sheath was distended and incised through the proximal
no distal sesamoidean ligament attached, or serve only as digital annular ligament. Self‐retaining (Gelpi) retractors
an origin to the thin, short distal sesamoidean ligaments, were used to reflect the digital flexor tendons, and the
whereas large fragments involving the whole dorso fragment(s) located by needle passage through the
palmar/plantar thickness of the bone include origins for straight distal sesamoidean ligament. It was then dis
all of the distal sesamoidean ligaments, and removal is sected from within the distal sesamoidean ligaments and
contraindicated. Fragment dissection, removal, and removed using Ferris–Smith arthroscopic rongeurs.
debridement are carried out using the same instruments Fragment removal was confirmed by intraoperative radi
and techniques as described for apical fractures. With ography. The defect in the distal sesamoidean ligament
fragments of substantial dorsopalmar/plantar thickness, was allowed to heal spontaneously. The digital flexor
it can be useful to visualize the fracture with the tendon sheath, proximal digital annular ligament, subcutis,
www.ajlobby.com
and skin were closed conventionally in layers. A com racing after surgical removal was 8.6 months. Improved
pressive dressing was applied and routine perioperative postinjury performance was associated with fragment
antimicrobial medication employed. If there were no removal, absence of comminution, minimal displacement,
incisional complications, these authors medicated the and shorter dorsopalmar dimensions. The relationships
digital flexor tendon sheath with hyaluronic acid and with fragment size and displacement were believed to be
corticosteroid after suture removal. Following 60 days’ associated with the degree of compromise of the distal
box rest, the animals commenced a graduated exercise sesamoidean ligaments. These authors recommended
program. Total convalescence was six months. First‐ detailed preoperative ultrasonographic evaluation of
intention wound healing took place in 10 of 11 cases; one horses to develop a prognosis and guide postoperative
wound dehisced without compromising the digital flexor management. Others have considered there to be an
tendon sheath. Follow‐up was available in 10 horses, inverse relationship between fragment length and height
of which 9 returned to their previous (mixed) level of and the likelihood of returning to racing.65
performance. A further study90 reported outcome following arthro
An ultrasound‐assisted arthroscopic approach for scopic removal of basilar fragments, where 12 of 24 (50%)
removal of nonarticular basilar sesamoid fragments in racehorses returned to racing and made at least two
Thoroughbred yearlings has recently been described as a starts, while a further 9 horses started only once. In this
less invasive technique to allow fragment removal.8 series, outcome appeared unrelated to fragment size or
Basilar sesamoid fragments identified during presale presence of comminution. The mean convalescence
radiographic examination of seven yearlings without time for horses that raced was 10 months.90
clinical symptoms were removed using a palmar/plantar
arthroscopic approach to the fetlock joint and ultra
sonographic guidance for precise localization of the Sagittal/Axial Fractures
extraarticular position of the fragment. Complete frag
ment removal was accomplished with radiofrequency Sagittal fractures are invariably axial. They range from
probe dissection and retrieval with a rongeur. No intra‐ narrow slivers into the intersesamoidean space to frac
or postoperative complications occurred. At 6–8 months tures extending into the middle one‐third of the bone.
follow‐up, no fragments or bony proliferation at the base All reported cases have involved the lateral sesamoid
of the sesamoid were observed on radiographs. The and occurred in association with displaced fractures of
authors concluded that ultrasonographic guidance could the lateral condyle of the third metacarpal or metatarsal
be used to facilitate localization, dissection, and confir bones (Figure 21.18); to the author’s knowledge, these
mation of removal of basilar fragments of the proximal have never been found with nondisplaced fractures
sesamoid bone. Long‐term information was not availa of the metacarpal condyle. Axial fractures are thought
ble, but this technique may be another option for nonar to be avulsions by the ISL. This results from meta
ticular basilar sesamoid fragments. carpophalangeal/metatarsophalangeal joint instability
resulting from the lateral condyle fracture and loss of
functional lateral collateral ligament support. Axial
Results fractures usually have a crescent configuration, and
Cancellous bone grafts have been successfully used in most have a slender rim of articular surface, while some
experimentally induced basilar fractures,62,63 but in clini fracture palmar to the articular margin. The fractures
cal cases results were less favorable.69 Horses with basilar usually are identified only on dorsopalmar radiographic
fractures that are minimally displaced have a better projections (Figure 21.18A). In the acute phase, the
prognosis than those with moderate displacement; this fracture gap can be narrow and/or superimposed on the
has been attributed to the degree of compromise to the condylar fracture. Flexed d orsopalmar and proximodis
distal sesamoidean ligaments.69 Although the prognosis tally oblique dorsopalmar projections can confirm the
for basilar fractures has been considered to be guarded fracture by projecting the axial margins of the proximal
to poor irrespective of the treatment modality,33 more sesamoid bones away from the sagittal ridge of the third
recent publications have offered greater optimism. In metacarpal bone and/or overlying fracture lines in the
one series, 30 of 51 (59%) of horses raced after sustaining lateral condyle. Digital image manipulation also can aid
basilar fractures, and of these 21 (41%) won or were in identifying the fracture.
placed.69 Treatment by fragment removal allowed 73% There are two reports of axial sesamoid fracture in
(16 of 22) of horses to race, with 57% dropping in class. the literature. The first drew attention to axial fractures
Only 48% (14 of 29) of horses treated conservatively or of the lateral sesamoid bone occurring concurrently
by internal fixation reconstruction went on to race, with with fractures of the lateral condyle of the third meta
87% dropping in class. The average time to return to carpal bone in two horses.7 Both developed severe
www.ajlobby.com
Figure 21.18 Axial sagittal fracture of the

(A) (B)
lateral proximal sesamoid bone (arrow
heads) associated with a long displaced
fracture of the lateral condyle of a third
metatarsal bone. (A) Dorsoplantar
radiographic projection; (B) arthroscopic
visualization of the fracture (small arrows)
via an ipsilateral arthroscopic portal. Note
the radiologically undetected distal
comminution (large arrow) with minimal
disruption of the articular cartilage
proximally. ISL, intersesamoidean
ligament; LS, lateral sesamoid.
degenerative joint disease within three months of invariably forelimbs) with the solar surface of the hoof
injury and repair of the condylar fracture. Another flat on the ground (Figure 21.19). Hemorrhage accompa
series of three horses described axial fractures of the nies these injuries and produces marked soft tissue swell
lateral sesamoid bone associated with displaced frac ing. Fracture fragments frequently can be palpated and
tures of the ipsilateral condyle of the third metacarpal sometimes are subcutaneous. The palmar neurovascular
bone. In two horses the condylar fractures were bundle can be stretched or lacerated by the fracture frag
repaired, but the animals remained lame and devel ments, as the metacarpophalangeal joint hyperextends
oped degenerative joint disease.36 A case report also to a point of irreversible damage; vascular integrity is
describes damage to the deep digital flexor tendon as a critical to prognosis. If disrupted, distal limb ischemia,
result of axial sesamoid fracture, which reduces the including hoof capsule detachment, and infection are
prognosis even further.82 common sequelae. Application of emergency support at
Arthroscopic evaluation of axial fractures is warranted this stage is essential if the animal’s life is to be saved (see
(Figure 21.18B), but to date features that may modify the Chapters 5 and 6). The palmar metacarpophalangeal
prognosis have not been identified. With appropriate joint and ISL are invariably disrupted, resulting in conti
management of the metacarpal fracture, affected horses nuity with the digital flexor tendon sheath. The fracture
can be comfortable for retirement and/or breeding pur margins can traumatize the dorsal surface of the deep
poses. Rarely, the degenerative articular changes that digital flexor tendon, and in severe cases result in com
inevitably follow can be debilitating, particularly in plete tendon laceration.72 Most biaxial fractures develop
breeding stallions. Fractures with sufficient mediolateral acutely.72 Diagnosis usually is clinical, while standard
width to make repair feasible are occasionally detected, radiographic projections, obtained after emergency
but the extent of concurrent joint damage usually is suf support has been applied, define the fracture configu
ficient to preclude return of athletic function. ration. Proximal fragments which retain suspensory
ligament attachment are usually displaced proximally
(Figure 21.19).
iaxial Mid‐body and/or
B Ankylosis of the metacarpophalangeal joint is neces
Comminuted Fractures sary for salvage, and this is optimized by surgical arthro
desis (see Chapter 23). If this is neither appropriate nor
Biaxial mid‐body and/or comminuted fractures cause affordable, then euthanasia on humane grounds is justi
acute, severe lameness. The limb usually is non‐weight‐ fied. Expedient pain relief, which is usually only achieved
bearing, but if loaded results in marked hyperextension by surgical arthrodesis, is necessary to reduce the risk
of the metacarpophalangeal joint (these are almost of overload complications in the contralateral limb.
www.ajlobby.com
(A) (B) Figure 21.19 Fetlock breakdown injury

with comminuted, displaced, biaxial
fractures of the forelimb proximal sesamoid
bones in a three‐year‐old Thoroughbred.
(A) Lateromedial and (B) dorsopalmar
projections show the numerous large
fragments of the shattered sesamoids, and
small comminuted fragments scattered
throughout the region indicative of the
gross soft tissue disruption that is
associated with such injuries. Although the
animal was unwilling to load the leg, note
the hyperextended metacarpophalangeal
joint produced by limb weight only.
(A) (B) (C)
Figure 21.20 Fragmentation of the abaxial margins of forelimb medial proximal sesamoid bones caused by external trauma in three
cases. Dorsolateral‐palmaromedial oblique (DLPMO) radiographic projections illustrating (A) concurrent fragmentation of the ipsilateral
palmar process of the proximal phalanx (note the gas in the metacarpus, indicative of concurrent penetration of the digital flexor tendon
sheath); (B) sharply marginated acute sesamoid fragmentation; and (C) marked osteolysis, disrupted infrastructure, and adjacent new
bone, indicative of an established infective process.
The most frequent of these is laminitis, which often treatment of choice. External skeletal fixation with a can
results in loss of the animal. Before a satisfactory tech cellous bone graft has been reported as an alternative,78
nique for metacarpophalangeal arthrodesis was devel but has not been adopted in clinical practice.
oped, the complication rate associated with these injuries
was high, with 16 of 18 Thoroughbred horses with trau
matic disruption of the suspensory apparatus being euth Fractures Caused
anized.12 Infection of the metacarpophalangeal joint was by External Trauma
reported in three closed cases, which was considered
likely to have been predisposed by vascular compromise. Fractures caused by external trauma usually involve
Repair of biaxial fractures has been reported,75 but has the palmar/plantar abaxial surfaces of the proximal
not been widely adopted. Surgical arthrodesis (Chapter 23) sesamoid bones (Figure 21.20). They commonly are
is technically demanding and necessarily expensive; it accompanied by open wounds, and so frequently are
also carries significant morbidity risks, but remains the contaminated and contused. The palmar/plantar
www.ajlobby.com
annular ligament and digital flexor tendon sheath may recommended. The prognosis is determined by associ
also be involved. ated soft tissue involvement. Most of these fractures
The most common etiology is hoof/shoe interference, occur palmar/plantar to the suspensory ligament inser
which can be self‐inflicted (most commonly forelimbs tion and, with little or no ligament or tendon sheath
and medially), or caused by other horses when one involvement, the prognosis generally is favorable.
horse runs into the rear of another during racing. Use and choice of perioperative antimicrobial drugs
Hyperextension of the fetlock joint sufficient to strike in contaminated surgery sites are still debated. In
the ground during maximal athletic activity may be the presence of infective processes, most surgeons
another cause of sesamoid fractures.10 Osteomyelitis now advocate regional intravenous or intraosseous
and/or sequestration are common sequelae, and acute, administration techniques, in addition to systemic
surgical removal with debridement of adjacent tissues is administration.18,58,83,98
References
1 Adams, O.R. (1974). Lameness in Horses, 3e, 219–225. 10 Bertone, A.L. (2002). The fetlock. In: Adams’ Lameness
Philadelphia: Lea & Febiger. in Horses, 5e (ed. T.S. Stashak), 768–799. Philadelphia:
2 Almeida da Silveira, E., Levasseur, A., Lacourt, M. et al. Lippincott Williams & Wilkins.
(2014). Biomechanical testing of a hybrid locking plate 11 Bouré, L., Marcoux, M., Laverty, S., and Lepage,
fixation of equine sesamoid osteotomies. Vet. Comp. O.M. (1999). Use of electrocautery probes in
Orthop. Traumatol. 27: 107–112. arthroscopic removal of apical sesamoid fracture
3 Anthenill, L.A., Gardner, I.A., Pool, R.R. et al. (2010). fragments in 18 Standardbred horses. Vet. Surg. 28:
Comparison of macrostructural and microstructural 226–232.
bone features in Thoroughbred racehorses with and 12 Bowman, K.F., Leitch, M., Nunamaker, D.M. et al.
without midbody fracture of the proximal sesamoid (1984). Complications during treatment of traumatic
bone. Am. J. Vet. Res. 71: 755–765. disruption of the suspensory apparatus in
4 Anthenill, L.A., Stover, S.M., Gardner, I.A. et al. (2006). Thoroughbred horses. J. Am. Vet. Med. Assoc. 184:
Association between findings on palmarodorsal 706–715.
radiographic images and detection of a fracture in the 13 Brokken, M.T., Schneider, R.K., and Tucker, R.L. (2008).
proximal sesamoid bone of forelimbs obtained from Surgical approach for removal of non‐articular
cadavers of racing Thoroughbreds. Am. J. Vet. Res. 67: basesesamoid fragments of the proximal sesamoid
858–868. bones in horses. Vet. Surg. 37: 619–624.
5 Anthenill, L.A., Stover, S.M., Gardner, I.A., and Hill, A.E. 14 Buckowiecki, C.F., Bramlage, L.R., and Gabel, A.A.
(2007). Risk factors for proximal sesamoid bone (1985). Proximal sesamoid bone fractures in horses:
fractures associated with exercise history and horseshoe current treatments and prognoses. Compend. Contin.
characteristics in Thoroughbred racehorses. Am. J. Vet. Educ. Pract. Vet. 7: 684–698.
Res. 68: 760–771. 15 Bukowiecki, C.F., Bramlage, L.R., and Gabel, A.A.
6 Balch, O.K., Helman, R.G., and Collier, M.A. (2001). (1987). In vitro strength of the suspensory apparatus in
Underrun heels and toe‐grab length as possible risk training and resting horses. Vet. Surg. 16: 126–130.
factors for catastrophic musculoskeletal injuries in 16 Busschers, E., Richardson, D.W., Hogan, P.M., and
Oklahoma racehorses. In: Proceedings of the American Leitch, M. (2008). Surgical repair of mid‐body proximal
Association of Equine Practitioners, vol. 47, 334–335. sesamoid bone fractures in 25 horses. Vet. Surg. 37:
Lexington, KY: AAEP. 771–780.
7 Barclay, W.P., Foerner, J.J., and Phillips, T.N. (1985). 17 Butler, J.A., Colles, C.M., Dyson, S.J. et al. (2000). Foot
Axial sesamoid injuries associated with lateral condylar pastern and fetlock. In: Clinical Radiology of the Horse,
fractures in horses. J. Am. Vet. Med. Assoc. 186: 2e, 124–126. Blackwell Science.
278–279. 18 Butt, T.D., Bailey, J.V., Dowling, P.M. et al. (2001).
8 Barrett, E.J. and Rodgerson, D.H. (2014). Ultrasound Comparison of 2 techniques for regional antibiotic
assisted arthroscopic approach for removal of basilar delivery to the equine forelimb: intraosseous
sesamoid fragments of the proximal sesamoid bones in perfusion vs intravenous perfusion. Can. Vet. J. 42:
horses. Vet. Surg. 43: 712–714. 617–622.
9 Bertone, A.L. (1996). Fractures of the proximal sesamoid 19 Churchill, E.A. (1956). Surgical removal of fracture
bones. In: Equine Fracture Repair, 1e (ed. A.J. Nixon), fragments of the proximal sesamoid bone. J. Am. Vet.
163–171. Saunders. Med. Assoc. 128: 581–582.
www.ajlobby.com
20 Cohen, N.D., Dresser, B.T., Peloso, J.G. et al. (1999). 33 Foerner, J.J. and McIlwraith, C.W. (1990). Orthopaedic
Frequency of musculoskeletal injuries and risk factors surgery in the racehorse. Vet. Clin. North Am. Equine
associated with injuries incurred in Quarter Horses Pract. 6: 147–177.
during races. J. Am. Vet. Med. Assoc. 215: 662–669. 34 Freddi, M. and Soana, S. (1980). Microarchitecture and
21 Cohen, N.D., Peloso, J.G., Mundy, G.D. et al. (1997). arterial supply of the proximal sesamoid bones (ossa
Racing‐related factors and results of prerace physical sesasamoidea proximalia) in the horse. Clin. Vet. 103:
inspection and their association with musculoskeletal 109–114.
injuries incurred in thoroughbreds during races. J. Am. 35 Fretz, P.B., Barber, S.M., Bailey, J.V., and McKenzie, N.T.
Vet. Med. Assoc. 211: 454–463. (1984). Management of proximal sesamoid bone
22 Cornelissen, B.P., Brama, P., Rijkenhuizen, A.B., and fractures in the horse. J. Am. Vet. Med. Assoc. 185:
Barneveld, A. (1998). Innervation of the equine mature 282–284.
and immature proximal sesamoid bone by calcitonin 36 Greet, T.R. (1987). Condylar fracture of the cannon
gene‐related peptide and substance P‐containing bone with axial sesamoid fracture in three horses. Vet.
nerves. Am. J. Vet. Res. 59: 1378–1385. Rec. 120: 223–225.
23 Cornelissen, B.P., van Weeren, P.R., Ederveen, A.G., and 37 Grondahl, A.M., Gaustad, G., and Engeland, A. (1994).
Barneveld, A. (1999). Influence of exercise on bone Progression and association with lameness and racing
mineral density of immature cortical and trabecular performance of radiographic changes in the proximal
bone of the equine metacarpus and proximal sesamoid sesamoid bones of young standardbred trotters. Equine
bone. Equine Vet. J. Suppl.79–85. Vet. J. 26: 152–155.
24 Dabareiner, R.M., Watkins, J.P., Carter, G.K. et al. 38 Hardy, J., Marcoux, M., and Breton, L. (1991). Clinical
(2001). Osteitis of the axial border of the proximal relevance of radiographic findings in proximal
sesamoid bones in horses: eight cases (1993–1999). sesamoid bones of two‐year‐old standardbreds in their
J. Am. Vet. Med. Assoc. 219: 82–86. first year of race training. J. Am. Vet. Med. Assoc. 198:
25 Dik, K.J. (1985). Special radiographic projections for 2089–2094.
the equine proximal sesamoid bones and the 39 Henninger, R.W., Bramlage, L.R., Schneider, R.K., and
caudoproximal extremity of the first phalanx. Equine Gabel, A.A. (1991). Lag screw and cancellous bone
Vet. J. 17: 244–247. graft fixation of transverse proximal sesamoid bone
26 Easton, K.L. and Kawcak, C.E. (2007). Evaluation of fractures in horses: 25 cases (1983–1989). J. Am. Vet.
increased subchondral bone density in areas of contact Med. Assoc. 199: 606–612.
in the metacarpophalangeal joint during joint loading 40 Hickman, J. (1964). Veterinary Orthopaedics.
in horses. Am. J. Vet. Res. 68: 816–821. Philadelphia: J.B. Lippincott Co.
27 Eddy, A.L., Galuppo, L.D., Stover, S.M. et al. (2004). 41 Hickman, J. (1976). The treatment of some fractures of
A biomechanical comparison of headless tapered the forelimb in the horse. Equine Vet. J. 8: 30–33.
variable pitch compression and AO cortical bone 42 Hill, A.E., Gardner, I.A., Carpenter, T.E., and Stover,
screws for fixation of a simulated midbody transverse S.M. (2004). Effects of injury to the suspensory
fracture of the proximal sesamoid bone in horses. Vet. apparatus, exercise, and horseshoe characteristics on
Surg. 33: 253–262. the risk of lateral condylar fracture and suspensory
28 Ellis, D.R. (1979). Fractures of the proximal sesamoid apparatus failure in forelimbs of Thoroughbred
bones in thoroughbred foals. Equine Vet. J. 11: 48–52. racehorses. Am. J. Vet. Res. 65: 1508–1517.
29 Estberg, L., Stover, S.M., Gardner, I.A. et al. (1996). 43 Hill, A.E., Gardner, I.A., Carpenter, T.E. et al. (2016).
Fatal musculoskeletal injuries incurred during racing Prevalence, location and symmetry of noncatastrophic
and training in thoroughbreds. J. Am. Vet. Med. Assoc. ligamentous suspensory apparatus lesions in
208: 92–96. California Thoroughbred racehorses, and association
30 Estberg, L., Stover, S.M., Gardner, I.A. et al. (1996). of these lesions with catastrophic injuries. Equine Vet. J.
High‐speed exercise history and catastrophic racing 48: 27–32.
fracture in thoroughbreds. Am. J. Vet. Res. 57: 44 Hill, A.E., Stover, S.M., Gardner, I.A. et al. (2001). Risk
1549–1555. factors for and outcomes of noncatastrophic
31 Estberg, L., Stover, S.M., Gardner, I.A. et al. (1998). suspensory apparatus injury in Thoroughbred
Relationship between race start characteristics and risk racehorses. J. Am. Vet. Med. Assoc. 218: 1136–1144.
of catastrophic injury in thoroughbreds: 78 cases 45 Honnas, C.M., Snyder, J.R., Meagher, D.M., and Ragle,
(1992). J. Am. Vet. Med. Assoc. 212: 544–549. C.A. (1990). Traumatic disruption of the suspensory
32 Fackelman, G.E. (1978). Compression screw fixation of apparatus in foals. Cornell Vet. 80: 123–133.
proximal sesamoid fractures. J. Equine Med. 46 Jeffcott, L.B., Buckingham, S.H.W., McCarthy, R.N.
Surg.32–39. et al. (1988). Non‐invasive measurement of bone: a
www.ajlobby.com
review of clinical and research applications in the metacarpophalangeal and metatarsophalangeal joints.
horse. Equine Vet. J. Suppl. 6: 71–79. In: Diagnostic and Surgical Arthroscopy in the Horse,
47 Johnson, B.J., Stover, S.M., Daft, B.M. et al. (1994). 4e, 111–174. Elsevier.
Causes of death in racehorses over a 2 year period. 61 McIlwraith, C.W. and Turner, A.S. (1987). Cancellous
Equine Vet. J. 26: 327–330. bone grafting of a mid‐body or basal proximal
48 Kainer, R.A. (2002). Functional anatomy of equine sesamoid bone fracture. In: Equine Surgery Advanced
locomotor organs. In: Adams’ Lameness in Horses, 5e Techniques, 1e, 115–119. Lea and Febiger.
(ed. T.S. Stashak), 1–72. Philadelphia: Lippincott, 62 Medina, L. and Morgan, J.P. (1984). Nongrafted and
Williams & Wilkins. grafted osteotomies of the proximal sesamoid bones of
49 Kamm, J.L., Bramlage, L.R., Schnabel, L.V. et al. (2011). the horse: a radiographic study. Vet. Radiol. 25: 78–85.
Size and geometry of apical sesamoid fracture 63 Medina, L.E., Wheat, J.D., Morgan, J.P., and Pool, R.
fragments as a determinant of prognosis in (1980). Treatment of basal fractures of the proximal
Thoroughbred racehorses. Equine Vet. J. 43: 412–417. sesamoid bone in the horse using an autogenous
50 Kane, A.J., McIlwraith, C.W., Park, R.D. et al. (2003). bone graft. In: Proceedings of the American
Radiographic changes in Thoroughbred yearlings. Part Association of Equine Practitioners, vol. 26, 345–380.
2: associations with racing performance. Equine Vet. J. Lexington, KY: AAEP.
35: 366–374. 64 Milne, D. and Turner, A.S. (1979). Lateral (Churchill)
51 Kane, A.J., Park, R.D., McIlwraith, C.W. et al. (2003). approach to proximal sesamoid bone. In: An Atlas of
Radiographic changes in Thoroughbred yearlings. Part Surgical Approaches to the Bones of the Horse, 36–51.
1: prevalence at the time of the yearling sales. Equine Philadelphia: Saunders.
Vet. J. 35: 354–365. 65 Nixon, A.J. (2006). Phalanges and the
52 Kane, A.J., Stover, S.M., Gardner, I.A. et al. (1996). metacarpophalangeal and metatarsophalangeal joints.
Horseshoe characteristics as possible risk factors for In: Equine Surgery, 3e (ed. J.A. Auer and J.A. Stick),
fatal musculoskeletal injury of thoroughbred 1217–1238. Saunders.
racehorses. Am. J. Vet. Res. 57: 1147–1152. 66 O’Brien, T.R., Morgan, J.P., Wheat, J.D., and Sutter, P.F.
53 Kane, A.J., Stover, S.M., Gardner, I.A. et al. (1998). Hoof (1971). Sesamoiditis in the Thoroughbred: a
size, shape, and balance as possible risk factors for radiographic study. J. Am. Vet. Radiol. Soc. 12: 75–87.
catastrophic musculoskeletal injury of Thoroughbred 67 Palmer, S.E. (1982). Radiography of the abaxial surface
racehorses. Am. J. Vet. Res. 59: 1545–1552. of the proximal sesamoid bones of the horse. J. Am. Vet.
54 Kristoffersen, M., Hetzel, U., Parkin, T.D., and Singer, Med. Assoc. 191: 264–265.
E.R. (2010). Are bi‐axial proximal sesamoid bone 68 Palmer, S.E. (1989). Arthroscopic removal of apical and
fractures in the British Thoroughbred racehorse a bone abaxial sesamoid fracture fragments in five horses. Vet.
fatigue related fracture? A histological study. Vet. Surg. 18: 347–352.
Comp. Orthop. Traumatol. 23: 336–342. 69 Parente, E.J., Richardson, D.W., and Spencer, P. (1993).
55 Kristoffersen, M., Parkin, T.D., and Singer, E.R. (2010). Basal sesamoidean fractures in horses: 57 cases
Catastrophic biaxial proximal sesamoid bone fractures (1980–1991). J. Am. Vet. Med. Assoc. 202: 1293–1297.
in UK Thoroughbred races (1999–2004): horse 70 Parkin, T.D., Clegg, P.D., French, N.P. et al. (2004).
characteristics and racing history. Equine Vet. J. 42: Horse‐level risk factors for fatal distal limb fracture in
420–424. racing Thoroughbreds in the UK. Equine Vet. J. 36:
56 Malone, E.D., Anderson, B.H., and Turner, T.A. (1997). 513–519.
Proximal sesamoid bone fracture following cast 71 Peloso, J.G., Mundy, G.D., and Cohen, N.D. (1994).
removal in two horses. Equine Vet. Educ. 9: 185–188. Prevalence of, and factors associated with,
57 Martin, B.B. Jr., Nunamaker, D.M., Evans, L.H. et al. musculoskeletal racing injuries of thoroughbreds.
(1991). Circumferential wiring of mid‐body and large J. Am. Vet. Med. Assoc. 204: 620–626.
basilar fractures of the proximal sesamoid bone in 15 72 Pool, R.R. and Meagher, D.M. (1990). Pathologic
horses. Vet. Surg. 20: 9–14. findings and pathogenesis of racetrack injuries. Vet.
58 Mattson, S., Bouré, L., Pearce, S. et al. (2004). Clin. North Am. Equine Pract. 6: 1–30.
Intraosseous gentamicin perfusion of the distal 73 Redding, W.R. (1996). Distal sesamoidean ligament
metacarpus in standing horses. Vet. Surg. 33: 180–186. injuries and desmitis of the accessory ligament of the
59 McIlwraith, C.W., Nixon, A.J., and Wright, I.M. (2015). deep digital flexor tendon. The equine athlete; tendon,
Instrumentation. In: Diagnostic and Surgical ligament and soft tissue injuries. In: Proceedings of the
Arthroscopy in the Horse, 4e, 5–27. Elsevier. Dubai International Equine Symposium (ed. N.W.
60 McIlwraith, C.W., Nixon, A.J., and Wright, I.M. (2015). Rantanen and M.L. Hauser), 227–240. Matthew R.
Diagnostic and surgical arthroscopy of the Rantanen Design.
www.ajlobby.com
74 Reesink, H.L. (2017). Foal fractures: osteochondral 87 Schneider, R.K., Tucker, R.L., Habegger, S.R. et al.
fragmentation, proximal sesamoid bone fractures/ (2003). Desmitis of the straight sesamoidean ligament
sesamoiditis, and distal phalanx fractures. Vet. Clin. in horses: 9 cases (1995–1997). J. Am. Vet. Med. Assoc.
North Am. Equine Pract. 33: 397–416. 222: 973–977.
75 Richardson, D.W. (1999). Fractures of the proximal 88 Sevelius, F. and Tufvesson, G. (1963). Treatment for
sesamoid bones. In: Equine Medicine and Surgery, 5e fractures of the sesamoid bones in horses. J. Am. Vet.
(ed. P.T. Colahan, J.G. Mayhew, A.M. Merritt and J.N. Med. Assoc. 142: 981–988.
Moore), 1565–1571. Mosby. 89 Shi, L., Wang, D., Riggs, C.M. et al. (2011). Statistical
76 Richardson, D.W. (2000). Proximal sesamoids: screw analysis of bone mineral density using voxel‐based
fixation. In: AO Principles of Equine Osteosynthesis, 1e morphometry—an application on proximal sesamoid
(ed. G.E. Fackelman, J.A. Auer and D.M. Nunamaker), bones in racehorses. J. Orthop. Res. 29: 1230–1236.
85–90. Davos Platz, Switzerland: AO Publishing. 90 Southwood, L.L. and McIlwraith, C.W. (2000).
77 Richardson, D.W. (2000). Proximal sesamoids: tension Arthroscopic removal of fracture fragments involving a
band wiring. In: AO Principles of Equine Osteosynthesis, portion of the base of the proximal sesamoid bone in
1e (ed. G.E. Fackelman, J.A. Auer and D.M. horses: 26 cases (1984–1997). J. Am. Vet. Med. Assoc.
Nunamaker), 93–98. Davis Platz, Switzerland: AO 217: 236–240.
Publishing. 91 Southwood, L.L., Trotter, G.W., and McIlwraith, C.W.
78 Richardson, D.W., Nunamaker, D.M., and Sigafoos, R.D. (1998). Arthroscopic removal of abaxial fracture fragments
(1987). Use of an external skeletal fixation device and of the proximal sesamoid bones in horses: 47 cases
bone graft for arthrodesis of the metacarpophalangeal (1989–1997). J. Am. Vet. Med. Assoc. 213: 1016–1021.
joint in horses. J. Am. Vet. Med. Assoc. 191: 316–322. 92 Spike‐Pierce, D.L. and Bramlage, L.R. (2003).
79 Ross, M.W. (1998). Scintigraphic and clinical findings Correlation of racing performance with radiographic
in the Standardbred metatarsophalangeal joint 114 changes in the proximal sesamoid bones of 487
cases (1993–1995). Equine Vet. J. 30: 131–138. Thoroughbred yearlings. Equine Vet. J. 35: 350–353.
80 Rothaug, P.G., Boston, R.C., Richardson, D.W., and 93 Spurlock, G.H. and Gabel, A.A. (1983). Apical fractures
Nunamaker, D.M. (2002). A comparison of ultra‐high‐ of the proximal sesamoid bones in 109 Standardbred
molecular weight polyethylene cable and stainless steel horses. J. Am. Vet. Med. Assoc. 183: 76–79.
wire using two fixation techniques for repair of equine 94 Thompson, K.N. and Cheung, T.K. (1994). A finite
midbody sesamoid fractures: an in vitro biomechanical element model of the proximal sesamoid bones of the
study. Vet. Surg. 31: 445–454. horse under different loading conditions. Vet. Comp.
81 Ruggles, A.J. and Gabel, A.A. (1998). Injuries of the Orthop. Traumatol. 7: 35–39.
proximal sesamoid bones. In: Current Practice of 95 Trumble, T.N., Arnoczky, S.P., Stick, J.A., and Stickle,
Equine Surgery, 2e (ed. N. White and J.N. Moore), R.L. (1995). Clinical relevance of the microvasculature
403–408. Saunders. of the equine proximal sesamoid bone. Am. J. Vet. Res.
82 Russell, T. and Hall, M. (2011). Axial sesamoid fracture 56: 720–724.
causing deep digital flexor tendon damage in a horse. 96 Vanderperren, K., Ghaye, B., Snaps, F.R., and Saunders,
Vet. Rec. 168: 50. J.H. (2008). Evaluation of computed tomographic
83 Scheuch, B.C., Van, H., Wilson, W.D. et al. (2002). anatomy of the equine metacarpophalangeal joint. Am.
Comparison of intraosseous or intravenous infusion for J. Vet. Res. 69: 631–638.
delivery of amikacin sulphate to the tibiotarsal joint of 97 Watanabe, T. (1985). Localized lesions of bone in the
horses. Am. J. Vet. Res. 63: 374–380. fetlock joint and their diagnosis by xeroradiography in
84 Schnabel, L.V., Bramlage, L.R., Mohammed, H.O. et al. racehorses. Centaur 2: 79–84.
(2006). Racing performance after arthroscopic removal 98 Whitehair, K.J., Blevins, W.E., Fessler, J.F. et al. (1992).
of apical sesamoid fracture fragments in Thoroughbred Regional perfusion of the equine carpus for antibiotic
horses age ≥2 years: 84 cases (1989–2002). Equine Vet. J. delivery. Vet. Surg. 21: 279–285.
38: 446–451. 99 Williams, R.B., Harkins, S., Hammon, C.J., and Wood,
85 Schnabel, L.V., Bramlage, L.R., Mohammed, H.O. et al. J.L. (2001). Racehorse injuries, clinical problems and
(2007). Racing performance after arthroscopic removal fatalities recorded in British racecourses from flat
of apical sesamoid fracture fragments in Thoroughbred racing and National Hunt racing during 1996, 1997
horses age <2 years: 151 cases (1989–2002). Equine Vet. J. and 1998. Equine Vet. J. 33: 478–486.
39: 64–68. 100 Wilson, D.A., Keegan, K.G., and Carson, W.L. (1999).
86 Schneider, R.K. (1979). Incidence and location of An in vitro biomechanical comparison of two fixation
fractures of the proximal sesamoid bones and proximal methods for transverse osteotomies of the medial
extremity of the first phalanx. Proc. Am. Assoc. Equine proximal forelimb sesamoid bones in horses. Vet.
Pract. 25: 157–158. Surg. 28: 355–367.
www.ajlobby.com
101 Wirstad, H.F. (1963). Fractures of the proximal compression fixation methods for midbody
phalangeal sesamoid bones. Vet. Rec. 75: 509–513. proximal sesamoid bone fractures in horses.
102 Woodie, J.B., Ruggles, A.J., Bertone, A.L. et al. (1999). Vet. Surg. 29: 358–363.
Apical fracture of the proximal sesamoid bone in 04 Young, D.R., Nunamaker, D.M., and Markel, M.D.
1
standardbred horses: 43 cases (1990–1996). J. Am. Vet. (1991). Quantitative evaluation of the remodelling
Med. Assoc. 214: 1653–1656. response of the proximal sesamoid bones to training‐
1 03 Woodie, J.B., Ruggles, A.J., and Litsky, A.S. (2000). related stimuli in Thoroughbreds. Am. J. Vet. Res. 52:
In vitro biomechanical properties of 2 1350–1356.
www.ajlobby.com
378
22
Fractures of the Condyles of the Third Metacarpal
and Metatarsal Bones
Ian M. Wright1 and Alan J. Nixon2,3
1
2
3
Anatomy The anatomic relations of the third metacarpal and

metatarsal bones are of greater importance to the man
The third metacarpal and metatarsal (MC/MT3) bones agement of diaphyseal fractures (Chapter 24), but sur
develop from three ossification centers: epiphyses geons must be cognizant of the positions of the second
proximally and distally with an intervening body. The prox and fourth metacarpal and metatarsal bones and the
imal epiphysis unites with the body before birth.25 The course of the dorsal (great) metatarsal artery in repair of
nutrient foramen of the diaphysis of the mature third meta proximally propagating fractures of the c ondyles. Aside
carpal bone is palmar at the junction of the proximal and from the digital extensor tendons, the dorsal and abaxial
middle one‐thirds and medial to the midline. The nutrient surfaces of both bones have no soft tissue covering except
artery, a branch of the medial palmar metacarpal artery skin and thin metacarpal/metatarsal fascia. Periosteal
(and, in turn, the radial artery), enters here.26 It is accompa hemorrhage associated with fractures therefore often can
nied by a corresponding vein and a trunk from the palmar be seen and usually can be palpated. Displaced fractures
metacarpal/deep branch of the lateral palmar nerve.27 The also may be identified by palpation alone.
blood supply to the dorsal periosteal surface of the third The metaphyseal and epiphyseal anatomy for third
metacarpal bone is supplied by small medial and lateral metacarpal and metatarsal bones is similar. The distal
dorsal metacarpal arteries and innervation from the medial epiphyses consist of two condyles separated by a sagittal
cutaneous antebrachial and dorsal branch of the ulnar ridge, which is angled slightly laterad from palmar/plan
nerves.26,27 Distal to the second and fourth metacarpal tar to dorsal. The medial condyle is larger in both medi
bones, the diaphysis of the third metacarpal bone becomes olateral and dorsopalmar/plantar planes. Its distal
mediolaterally wider and the dorsal contour flatter. articular surface is perpendicular to the long axis of the
The third metatarsal bone is approximately 16–17% bone, while that of the lateral condyle has a slight proxi
longer than its metacarpal counterpart,25,38 which equates mal axial incline. The articular surfaces of both condyles
to approximately 50 mm in a mature Thoroughbred. The bear a slight lateromedial transverse or (frontal plane)
nutrient foramen is plantar, slightly medial to the midline, ridge at their most distal point. This has been referred to
and just distal to the junction of the proximal and second as the transverse ridge. The epiphysis dorsal to this has a
quadrants. The nutrient artery and satellite vein arise larger diameter (and therefore less convex articular sur
from the proximal deep plantar arch, formed by the face) than palmarly/plantarly; the former represents the
medial plantar and perforating tarsal arteries.26,38 The contact area for the proximal phalanx and the latter for
neural elements are believed to derive from the deep the proximal sesamoid bones when the joint is maxi
branch of the lateral plantar nerve via the plantar meta mally extended. Immediately abaxial to the palmar/plan
tarsal nerves. The periosteal blood supply of the dorsal tar surface of the sagittal ridge are the condylar grooves.
third metatarsal bone comes from branches of the small These are inconsistent and variable indentations that run
dorsal metatarsal artery II and large dorsal metatarsal parallel to the sagittal ridge and palmar/plantar to the
artery III (great metatarsal artery). transverse ridge.

www.ajlobby.com
22 Fractures of the Condyles of MC/MT3 379
The distal articular surfaces cover an angle of arrangement could explain the common course of many
a pproximately 220°.13 Natural movement is restricted fractures of the lateral condyle.10 Clinical observations
almost entirely to flexion and extension. Easton suggest that this has some merit. Fractures of the lateral
and Kawcak showed that as the metacarpophalangeal/ condyle which are abaxial often curve toward the
metatarsophalangeal joint extends (loads), the proportion epicondylar eminence or metaphyseal cortex—the

of the third metacarpal bone that contacts the proximal orientation of abaxial epiphyseal trabeculae. By contrast,
sesamoid bones increases, while that contacting the prox fractures that originate close to the sagittal ridge com
imal phalanx decreases.14 The purported site of origin of monly remain sagittal and have a greater propensity to
fractures of the metacarpal/metatarsal condyles on the proximal propagation, following the vertically oriented
palmar/plantar surface is in the contact area of the proxi axial trabeculae.
mal sesamoid bones and, as speed increases, the propor This work offers an explanation for fracture propaga
tion of load borne by the sesamoid bones and suspensory tion in the epiphyseal spongiosa, but does not provide
apparatus increases compared to the axial skeleton.90 The information with respect to the subchondral bone itself
subchondral bone is thicker in the palmar/plantar region (in which fractures are thought to arise), and therefore
than it is dorsally, although this varies between and within ultimate pathogenesis. Epiphyseal trabecular bone
both the condyles and individual horses. The underlying density increases distally toward the subchondral bone,
trabeculae are oriented in a converging manner toward particularly in the palmar/plantar quadrants.76,98
the center of the epiphysis.90 Exercise increases mineralization and subchondral bone
The abaxial nonarticular surface of both condyles density and is associated with trabecular thickening in
contains an irregular fossa from which the majority of the metacarpal condyles.41,75,98 The increase in bone
the collateral ligaments of the metacarpophalangeal/ density that accompanies training has been shown to
metatarsophalangeal joints originate. This is bordered occur in a pattern that runs obliquely from the disto
proximally by an epicondylar eminence, which is situ palmar/plantar subchondral bone dorsoproximally.20
ated at the level of the original distal metaphyseal growth The disparity in density between the dorsal and palmar/
plate and represents an important palpable landmark in plantar halves of the epiphyses increases with intense
fracture repair. Complete closure of the growth plate training.98
occurs between 10 and 18 months, with functional clo
sure between 6 and 8 months.25
In material terms, subchondral bone is a ductile fiber‐ E tiology and Pathogenesis
reinforced composite material; collagen fibers provide
reinforcement within the bone matrix.86 Computed Fractures of the distal condyles of the third metacarpal
tomography (CT) of cadaveric specimens demonstrated and metatarsal bones have been described as being
that the subchondral bone is most dense in the palmar/ almost exclusive to racehorses,83 where worldwide they
plantar regions of the medial and lateral condyles in both are the most common long bone fracture. Although
third metacarpal and metatarsal bones, particularly in occurring most frequently in racing Thoroughbreds,
their axial half. The lateral condyle usually is more dense less frequently in Standardbreds, and occasionally in
than its medial counterpart. A narrow zone of less dense Quarter Horses, they occur also in polo ponies,5 and
bone separates the palmar/plantar axial regions of the are seen also in other sport horses moving at speed.
condyles from the sagittal ridge, which also is less dense. The original suggested causes of condylar fractures
This juxtaposition creates a substantial mediolateral included rotational forces applied to the palmar aspect of
density gradient76 and similar variations in mechanical the condyles during maximal extension of the fetlock.2
properties, including elastic modulus, yield stress, and An alternative explanation was that during the stance
energy to failure (toughness).80,81 In the distal epiphysis phase of the stride, the proximal phalanx was stationary
of the third metacarpal bone, the trabecular infrastruc (the phalanges being fixed by the foot), while the third
ture is anisotropic.90,98 The principal epiphyseal trabecu metacarpal bone rotated from lateral to medial on its
lae are robust plates running in a sagittal plane, with long axis.78 There is little pathologic evidence to support
fewer and less substantial mediolateral connections.10 either theory. One author suggested that fractures of the
Small blood vessels are found between the sagittal planes. lateral condyle resulted from unequal loading during
This structure gives maximum strength and protection high‐speed turns, but this is not consistent with clinical
in the sagittal plane (in which the bone rotates), but practice.68 Acute bone failure resulting from unbalanced
offers minimal resistance to fracture propagation in this loading with the concentration of force on one condyle
plane. The authors noted also that in specimen prepara has also been proposed.83 The potential contribution of
tion, the overlying mineralized cartilage tended to asymmetric suspensory apparatus loading was demon
cleave in the sagittal plane. They concluded that this strated in a cadaver study by Le Jeune et al.43 In isolated
www.ajlobby.com
limbs under compressive load, loss of integrity of the thinning of the calcified c artilage layer have been identi
medial branch of insertion of the suspensory ligament fied histologically in a post‐mortem study of horses with
increased surface bone strains in the lateral condyle of fractures of the lateral condyle; however, preexisting
the third metacarpal bone.43 There also is epidemiologic abnormalities were not found in all horses.87 Additionally,
evidence for an association between suspensory liga palmar subchondral osteonecrosis with varying degrees
ment desmitis and subsequent development of fractures of overlying cartilage compromise has been recognized
of the lateral condyle.32 However, if this was genuine, in the contralateral limbs to those with fractured con
suspensory desmitis would be recognized as a common dyles. This is, of itself, a clinical entity in horses in train
postoperative problem when horses returned to training. ing that can result in lameness and loss of performance.
This has not been described. Mechanical failure as a Ischemic change has been reported in these lesions,57,67
result of the distribution of forces in the limb appears together with associated subchondral failure and microf
more plausible. A question of familial predisposition has ractures extending into remodeled epiphyseal bone.55
also been raised,16 but is unproven. However, fractures of the metacarpal and metatarsal
Chondral and osteochondral erosive lesions, described condyles frequently occur in the absence of osteochon
at the time as traumatic osteochondrosis,42,67 were sug dral erosions.16,74 At post mortem, six of seven
gested as predisposing lesions. However, these are found Thoroughbreds with catastrophic fractures of the lateral
distally, immediately palmar/plantar to the transverse condyle of the third metacarpal bone exhibited distal
ridge, and appear anatomically distinct from the site of comminution. Focal osteoporosis was evident adjacent to
initiation of fractures.77 Post‐mortem examination of the comminution, with marginal microfractures in the
spontaneously occurring fractures also failed to support subchondral bone. Both features were identified in two of
coexistence.16,74 two contralateral limbs with grossly normal overlying
Fractures of the metacarpal and metatarsal condyles articular cartilage.87
are not associated with recognized traumatic events, Scanning electron microscopy and microradiography
occur during high‐speed exercise, are site specific, and have demonstrated linear defects in the articular carti
follow repeatable courses. Given these features, they can lage and underlying subchondral bone in the palmar/
be considered to be stress or fatigue fractures. The plantar condylar grooves of Thoroughbreds which had
fractures begin in the subchondral bone of the palmar/ undergone varying degrees of training.77 In some cases,
plantar articular surface,16 allegedly as a result of fatigue CT revealed continuation of these into the epiphyseal
damage at sites of perturbed bone remodeling.66,87 The bone. At a microscopic level there was substantial mod
fractures propagate for varying distances through bone eling and remodeling in the adjacent densified epiphyseal
that has undergone adaptation in response to training.77 bone.77 As a result, these authors proposed that parasag
Cortical bone modulation by exercise and subsequent ittal fractures of the metacarpal/metatarsal condyles
mechanisms of failure are well established.18,79 It is now arise from preexisting palmar/plantar condylar groove
recognized that the response of subchondral bone is sim defects. These defects in the condylar grooves were con
ilar. It adapts to load and areas of higher load are associ firmed histologically.12 Two scanning electron micro
ated with increased subchondral bone density.14 The scopic studies of catastrophic displaced fractures of third
palmar regions of the metacarpal condyles, particularly metacarpal and metatarsal bones confirmed consistently
laterally, are commonly identified as sites of increased branching microcracks, which were most marked in
metabolic activity in Thoroughbred horses in train thickened compact bone of the palmar/plantar condylar
ing.11,84 The palmar/plantar subchondral bone of the groove.69,86 There were also cracks in horses without
metacarpal/metatarsal condyles in horses in training fractures which had undergone training.69 Both groups
exhibits intense remodeling and densification.76,95 This concluded that fractures of the metacarpal and metatar
has, erroneously, been described as sclerosis (hardening), sal condyles result from accumulation and coalescence of
which infers mechanical properties that have not been microcracks in the condylar groove to produce a longer
demonstrated. High‐intensity exercise has been shown to and wider dominant defect. Further evidence comes
result in increased bone density in metacarpal condyles, from the presence of lesions in the contralateral limbs of
particularly palmarly.75 This group also recognized linear horses which suffered catastrophic fractures of the lateral
defects in the overlying subchondral bone and mineral condyle of both third metacarpal and metatarsal bones.61
ized cartilage.76 Semi‐quantitative CT of the distal aspect Again, these were most common in the parasagittal
of the third metacarpal or metatarsal condyles from grooves and included visible fissures. These authors also
horses with lateral condylar fracture indicated increased noted separate osteochondral erosions palmar/plantar to
bone density in both the fractured and opposite limbs, the transverse ridges.61
but a significant bone density heterogeneity in the frac As most fractures of the metacarpal/metatarsal con
tured limb.45 Microfractures, zones of osteoporosis, and dyles occur in two‐ and three‐year‐old horses5,16,37,46,73,100
www.ajlobby.com
rather than older Thoroughbred racehorses, this process The risks of fatal condylar fractures in Thoroughbred
may represent failure of adaptation rather than cumula racehorses were reported to be 7 times more likely
tive fatigue. One group has proposed a different patho with low toe grabs and 17 times more likely with regular
genesis for fractures that originate in the condylar groove toe grabs.39 However, this was not substantiated in a
(i.e., adjacent to the sagittal ridge) compared to those later study which found no association with the use of
which have a more abaxial origin.11 The former are sug toe grabs.32
gested to result from a stress increase effect and the latter In the UK, a survey of fractures of racing Thoroughbreds
to be associated with resorption lacunae. in Newmarket found the incidence of condylar fractures
Current theories of pathogenesis offer the intriguing and sagittal fractures of the proximal phalanx to be equal,
possibility that, with detection of pre (clinical) fracture each accounting for 15% (37 of 245) of cases.6 Another
changes, at least some fractures of the metacarpal/meta review indicated that 25% of all catastrophic injuries
tarsal condyles might be prevented or their progression occurring during racing throughout the UK were due to
halted. The potential contributions of magnetic reso fractures of the metacarpal and metatarsal condyles.49
nance imaging (MRI)89,91,92 or CT54,93 to this goal is clear. Subsequent studies identified the lateral condyle of the
Histologic examination following MRI of limbs from third metacarpal bone as the single commonest cata
horses with condylar fracture indicated significant cor strophic injury.59,60 The 75 catastrophic fractures of the
roboration of moderate to severe disease stages evident lateral condyles of the third metacarpal and metatarsal
on MRI, supporting the use of MRI for screening of bones in the UK represented one per 4167 starts.61 The
symptomatic horses.65 frequency of condylar fracture was highest (approxi
mately five times) in hurdle and National Hunt flat races.
This contrasts with a lower incidence of fractures of the
Incidence and Risk Factors metacarpal/metatarsal condyles in Thoroughbreds in
flat race training and racing. Additionally, the frequency
Fractures of the condyles of the third metacarpal and of condylar facture was lowest on turf courses. Parkin
third metatarsal bones are the commonest long bone et al. evaluated risk factors associated with 98 cata
fracture of horses in training.19 Although many are ame strophic fractures of the lateral condyles of the third
nable to treatment, they remain a frequent cause of fatal metacarpal and third metatarsal bones, and found asso
injury in training and racing,17,37,49,60,96 or at the least a ciations with firm ground, longer races, increased num
protracted absence from training and racing.53 Fractures bers of horses, and amateur jockeys.60 Additionally,
of the metacarpal condyles accounted for approximately horses which did not begin racing until three or four
25% of all catastrophic injuries suffered by Thoroughbred years of age, were in their first year of racing, or had not
horses in training and racing in California between 1990 previously trained at a fast gallop were at increased risk.
and 1992.37 Of those identified, 54 of 60 (90%) involved These latter categories suggest that lack of training and
the lateral condyle and 6 (10%) were medial. These adaptation are important predisposing factors. Fractures
were second only to fractures of the proximal sesamoid of the metacarpal and metatarsal condyles are therefore
bones as a cause of death during the study period. In a not necessarily cumulative stress injuries, but result from
concurrent study,17 20 of 78 (26%) catastrophic racetrack failure of a more complex balance of factors. A different
injuries involved fractures of the metacarpal condyles, study indicated that 90% of horses developing condylar
and 4 of 78 (5%) were fractures of the metatarsal c ondyles, fractures were two‐ and three‐year‐old Thoroughbreds,
together making these the most common life‐ending which is a fair representation of the case population in
injury in a one‐year (1992) study period.17 Additionally, the reporting clinic.16 Most fractures were acquired dur
metacarpal fractures were the single largest cause of ing training, rather than racing, and between April and
breakdown on New York Racing Association tracks October, which is the UK turf flat racing season.
between 1986 and 1988, accounting for 30% of the total The incidence of condylar fractures in forelimbs is
number of injuries.53 approximately twice that in hindlimbs.5,16,35,37,46,51,73,74,100
Suspensory apparatus injury, prolonged training, and Although trends to sidedness have been reported,61,73
recent high‐speed work were cited as significant risk fac metanalysis of the principal series in the literature suggest
tors for catastrophic fractures of the metacarpal condyles that right and left limbs appear equally affec
in horses racing and training in California.32 This also ted.5,16,35,51,61,73,100 Additionally, in the UK (where racing
supports the role of accumulated microdamage in the is both clockwise and anticlockwise) there has been no
pathogenesis of condylar fractures. It has been reported association between limb affliction and race direction,61
that condylar fractures often occurred when dirt track and in Hong Kong, where training and racing are clock
conditions were fast and when a horse was moving up wise, there is no left/right difference in incidence (Riggs,
in racing class.69 The influence of shoeing is unclear. personal communication). All studies report a greater
www.ajlobby.com
number of condylar fractures in males than females fractures, at least in the acute phase, may in reality be
(approximately 2:1).5,16,35,51,73,74,100 Fractures of the medial complete.100 Additionally, radiography may not identify
condyle are less common than lateral, with reported fre displacement in a dorsopalmar/plantar plane.16 However,
quencies between 5% and 35% of the total.5,16,46,73,100 classification permits grouping for management deci
However, medial condyle fractures are more likely to sions and to compare treatment protocols.
propagate into the diaphysis.4,16,35,82,97,100 Fracture classification also has important pro
Fractures of the metacarpal and metatarsal condyles gnostic implications: all authors agree that nondisplaced
can be bilateral, or involve both fore‐ and hindlimbs, fractures have a better prognosis than displaced frac
which may present concurrently or sequentially.16,100 tures.16,46,73,101 This is confounded in Thoroughbreds,
Even when concurrent, these may be clinically and/or particularly females, where some horses which would be
radiologically asymmetric; in suspected cases clinical capable of racing following injury are, for economic rea
assessment of all four fetlocks, and at least bilateral radi sons, retired to stud; results therefore are skewed toward
ographic examination, is recommended. lower return to racing in this subgroup.101
Condylar fractures of the third metatarsal bone are
more common in Standardbreds than Thoroughbreds,
but also are more likely to be medial.5,71,72 Gender and Principles of Fracture
age also were not associated with fracture distribution Management and Healing
among limbs.46
Condylar fracture healing presents special issues. These
include varying contact with the proximal phalanx and
Fracture Types and proximal sesamoid bones, and the compromise to articu
Classification lar stability that accompanies disruption of the origin of
the collateral ligament and joint capsule.
Fractures of the metacarpal and metatarsal condyles may Primary or direct bone healing in condylar fractures is
be unicortical, involving the palmar/plantar subchondral ideal, and requires accurate reduction of the fragments
bone, or bicortical. Fractures are classified as complete if and almost complete stability.28,50 Secondary bone heal
they extend through to the periosteal surface of the met ing involves intramembranous and endochondral ossifi
aphysis or diaphysis of the bone and incomplete if they cation and leads to callus formation; callus is produced in
do not. Complete fractures can be nondisplaced or response to interfragmentary movement.15,50 In reality,
displaced. Displacement may involve abaxial, proximo what we aim to achieve with repair is a combination of
distal, dorsopalmar/plantar, or rotational movement. the two processes, with the balance moved as far as pos
Frequently there is a combination of these. Incomplete sible toward primary healing.
fractures should not be described as displaced even if
there is a demonstrable fracture gap at the articular
surface. Fractures which extend into the metacarpal/ Fractures of the Palmar/
metatarsal diaphysis are described as propagating. These Plantar Subchondral Bone
are of two types. The first remain in a sagittal or parasag
ittal plane into the diaphysis, and the second begin in this
plane and then spiral to change orientation to oblique or
Diagnosis
frontal planes. Propagating fractures are much more Some horses present with lameness of acute onset and
common medially than laterally,4,16,36,97 but this is not moderate severity after completing a race or training
invariable. Comminution is seen only with complete session. Others are found in lameness investigations of
fractures.5 horses in training. It is a rare injury in other sport horses.
Fractures of the lateral condyle vary in position from Fore‐ or hindlimbs can be affected. Moderate distension
the sagittal ridge to narrow fragments less than 10 mm of the metacarpophalangeal/metatarsophalangeal joint
from the abaxial margin.16 Fractures which commence is common but not consistent. Increased arterial pulse
axially, whether medial or lateral, usually are longer than amplitudes may be detected in palmar/plantar arteries at
those which arise abaxially.35,83,100 Thus, propagating an abaxial sesamoid level; this frequently is misinter
fractures of the lateral condyle usually originate close to preted as indicative of a more distal lesion but, unlike the
the sagittal ridge,35,36 and fractures of the medial condyle latter, the arterial pulse amplitudes in the palmar/plantar
almost invariably commence immediately adjacent to digital arteries in the pastern region usually are
the sagittal ridge.16,97 not increased. In some animals digital pressure over the
Differentiation between fracture types may not always affected distal palmar/plantar third metacarpal/
be clear‐cut. Many apparently radiologically incomplete metatarsal bone is resented. These fractures are entirely
www.ajlobby.com
(A) (B)
Figure 22.1 Flexed dorsal 35° distal‐plantar proximal oblique (D35° Di‐PlPrO) projection (A) of a fracture of the medial plantar
subchondral bone of a third metatarsal bone at diagnosis, and (B) demonstrating good healing and osseous organization following
six weeks of restricted exercise.
intraarticular and there is no periarticular hemorrhage flexed dorsal‐palmar projection (dorsal 35° distal‐palmar/
or swelling. Either medial or lateral condyles can be plantar proximal oblique), which draws the sesamoids
affected and fractures can be bilateral but clinically proximally and away from the distal extremity of the
asymmetric. Bilateral radiographic examination is there metacarpal condyles.64 This images the palmar/plantar
fore always recommended. Some unicortical fractures condyles through the less dense palmar/plantar pro
will be radiologically silent in the acute phase and clinical cesses of the proximal phalanx (Figures 22.1 and 22.2).
signs, including lameness, can resolve with only a few An alternative is the dorsal 25° distal‐palmar/plantar
days of stall rest. If possible, suspicious cases should be proximal oblique projection. Additionally, for hindlimb
assessed scintigraphically or monitored radiographically studies, a flexed plantar‐dorsal projection is useful to
to minimize the risk of fracture propagation. limit magnification and lessen artifacts associated with
In most cases the fractures are identified on various obliquity. Until the advent of these techniques to image
dorsopalmar/plantar radiographic projections. The the palmar/plantar condyles, most unicortical palmar/
“standard” dorsopalmar/plantar projection of the meta plantar fractures were unrecognized. They are therefore
carpophalangeal/metatarsophalangeal joint is a dorsal underrepresented in published series of c ondylar frac
20° proximal‐palmar/plantar distal oblique, which sepa tures. However, even with the aid of these projections,
rates the most distal articular margin of the third meta these unicortical fractures frequently are radiologically
carpal and third metatarsal bones from the distal silent for 7–10 days.
borders of the proximal sesamoid bones. A dorso Fracture may be confined to the metacarpal/
palmar/plantar projection to image the palmar/plantar metatarsal condyle or extend into the palmar/plantar
condyles has been described by Hornof and O’Brien.33 metaphyseal cortex. Unicortical fractures do not extend
This projection requires the limb to be placed forward further proximally. They arise, almost invariably, imme
and supported on a block to allow a horizontal X‐ray diately adjacent to the sagittal ridge, i.e., within the
beam to obtain an image at approximately 125° to the condylar fossa. When radiologically apparent, acute

long axis of the third metacarpal/metatarsal bone. This fractures are linear, parasagittal, and sharply margin
images the palmar/plantar condyles, but these are ated. Fractures of longer duration, or those that mani
superimposed on the proximal sesamoid bones, obscur fest after a period of progressive subchondral failure,
ing detail of the fracture. The preferred technique is the are poorly marginated.
www.ajlobby.com
(A) (B)
(C) (D)
Figure 22.2 Radiographs of a third metatarsal bone with fracture of the medial plantar subchondral bone. (A) Dorsoplantar (DPl) and
(B) flexed dorsal 35° distal‐plantar proximal oblique (D35° Di‐PlPrO) projections at diagnosis. Note better definition of the fracture in the
flexed D35° Di‐PlPrO projection. (C) DPl and (D) lateromedial projections at surgery following screw insertion. Note the lateral to medial
screw trajectory, which is permitted by the distal metacarpal/metatarsal epiphyseal density; this facilitates surgical positioning and
limb/screw alignment.
www.ajlobby.com
Nuclear scintigraphy is often useful, where increased Additionally, as current evidence suggests that condy
radiopharmaceutic uptake can precede radiologic identi lar fractures result from confluence and progression of
fication of palmar/plantar fractures. Increased uptake subchondral/epiphyseal microcracks, it is possible that a
usually is confined to the affected condyle and generally transcondylar screw may be effective in protecting cracks
can be seen to be greatest on the palmar/plantar side. from cyclic stresses, thereby preventing progression of a
However, results in horses in training must be interpreted dominant crack into a complete fracture.69 This is logi
cautiously; nuclear scintigraphy is a sensitive indicator of cal, but as yet clinically unproven.
changes in subchondral bone activity, but lacks specific
ity in discerning normal osseous remodeling from dam
age.41 MRI may offer an additional imaging modality.89 Results
Standing three‐dimensional imaging using MRI or stand Return to racing after conservative management of pal
ing CT systems provides a sensitive means to diagnose mar/plantar fractures of MC/MT3 is quite likely, with 8
and develop a treatment plan for unicortical fractures. of 12 (67%) horses racing in one study,16 and all 5 horses
If such fractures are in the differential following clinical returning to training and 4 of these racing at the same
evaluation, the authors recommend radiographic and/ level in a second report.40
or scintigraphic examinations before local anesthesia
techniques. As a general rule, unicortical palmar/plantar
fractures do not respond to local anesthesia of the pal
mar/plantar digital nerves at or distal to a mid‐pastern Bicortical Incomplete
level. However, a positive response can be obtained fol Fractures
lowing local infiltration of the palmar/plantar nerves at an
abaxial sesamoid level. Lameness usually is abolished by
Diagnosis
local analgesia of the palmar and palmar metacarpal
nerves at a distal metacarpal site, or a similar level in Bicortical fractures usually present with acute, severe
the hindlimb. Intraarticular analgesia of the metacar lameness at the end of a race or training session.
pophalangeal/metatarsophalangeal joint usually is posi Forelimbs are more commonly affected than hindlimbs
tive and may entirely abolish the lameness. and occasionally fractures can be bilateral. Some horses
also have fractured lateral condyles of both third meta
carpal or third metatarsal bones as successive injuries.
Treatment Clinical signs include progressive distension of the
Most palmar/plantar fractures heal spontaneously with affected metacarpophalangeal/metatarsophalangeal joint
rest40 (see Figure 22.1), and if horses are removed from due to intraarticular hemorrhage. This may be the only
training it is rare for the fracture to progress. In some palpable abnormality with short fractures that do not
horses, follow‐up radiographs may reveal apparent progress beyond the proximal capsular reflection onto
proximal extension and mediolateral widening of the the third metacarpal/metatarsal bone. Longer fractures
fracture. However, this is likely a result of osseous resorp can result in periosteal hemorrhage that may be clinically
tion rather than progressive discontinuity. A number of evident over the distal lateral metacarpus/metatarsus.
empiric regimens have been employed. Most involve Digital pressure at this site may be resented. Flexion of the
an initial period of box rest; 30–60 days has been metacarpophalangeal/metatarsophalangeal joint is usu
recommended.40 This is followed by a graduated con ally but not invariably painful.
trolled exercise program, with resumption of training at With such a suggestive history and clinical features,
not less than 120 days. Radiologic healing of palmar/ immediate radiographic examination is mandatory.
plantar subchondral bone can be protracted. Frequently Most fractures are apparent in dorsopalmar/dorsoplan
this does not correlate with clinical features and, in the tar and flexed dorsopalmar/dorsoplantar projections.
absence of radiologic evidence of progressive osseous The full extent and precise configuration of the fracture
disruption, an escalating controlled exercise program is may not always be obvious on acute‐phase radiographs.
considered the optimal stimulus for healing. Frequently, slightly oblique dorsopalmar/plantar pro
Some fractures become delayed unions and others jections with the primary beam in a dorsal 5–15° medial‐
recur on resumption of exercise. These cases respond palmar/plantar lateral oblique (D5–15° M‐Pa/PlLO)
well to compression with a single 4.5 mm cortical screw angle will highlight the fracture plane (Figure 22.3). The
in the epicondylar fossa. With careful intraoperative fracture can originate immediately adjacent to the sagit
imaging, the screw can be placed slightly palmar/plantar tal ridge or at any point abaxial to this. Axial fractures
in the fossa (Figure 22.2). This is inserted as described for tend to propagate further proximally, while the more
bicortical incomplete fractures. abaxial fractures are shorter and have greater lateral
www.ajlobby.com
(A) (B) (C)
(D) (E)
Figure 22.3 Incomplete fracture of the lateral condyle of a third metatarsal bone. (A) Dorsoplantar (DPl) and (B) dorsal 5° medial‐plantar
lateral oblique (D5° M‐PlLO) projections at diagnosis; (C) dorsoplantar (DPa) projection with measurements of bone width and glide hole
(distance to the fracture plane) depths determined at the proposed sites of implant placement. (D) Intra‐operative DPl projections with
percutaneous needles to determine the sites of implant placement, and (E) following insertion of two 4.5 mm cortical screws.
obliquity, curving toward the epicondyle. Radiologically, be considered the result of fracture propagation. Several
some incomplete fractures may approach or even appear authors caution against making the distinction between
to enter the endosteal side of the cortex. Differentiation incomplete and complete nondisplaced fractures.16
between these and complete nondisplaced fractures is Additionally, some authors consider that fractures that
difficult and may require more time for complete dis extended ≥75% of the distance from the distal articular
ruption of the lateral cortex to become apparent. This surface to their projected metaphyseal or diaphyseal exit
may develop even after internal fixation and should not point should be considered complete, even if radiologic
www.ajlobby.com
evidence is lacking.100 Almost all incomplete fractures Timing of Surgery

are simple. Concurrent articular fragmentation is rare; The timing of surgical intervention is still debated and
this was recognized in only 1 of 53 cases in one report.100 often depends on the surgeon’s preference. Some prefer
As the majority present acutely, fracture lines are to wait and allow the acute inflammatory response (hem
sharply marginated. In the author’s practices, radiologic orrhage) to subside. Others advocate a 12–24‐hour delay
evidence of preexisting degenerative changes such as to minimize the purported increased anesthetic risks
densification and loss of trabecular infrastructure is that may accompany an anxious horse after racing or
uncommon. transport. In the authors’ opinion, the risks of fracture
propagation (potentially to become complete and dis
placed) and the relief of pain and anxiety that accompa
Treatment nies repair outweigh these potential concerns, and
prompt fracture repair is recommended.
Some incomplete fractures will heal satisfactorily with
out internal fixation. However, given the difficulty in
Preoperative Planning and Preparation
radiographic definition between complete and incom
A comprehensive assessment of radiographs is impor
plete fractures, surgical compression of the fracture
tant for the surgeon to develop an accurate three‐
should be considered to minimize the articular deficit
dimensional mental model of the fracture. For complex
and improve the quality of hyaline cartilage repair,52 and
fractures, dorsal and palmar/plantar cortical fracture
reduce the risk of fracture propagation. Most impor
lines can be drawn on an anatomic specimen and
tantly, fracture repair provides effective analgesia, which
compared to each radiographic projection to verify the
minimizes secondary complications with contralateral
fracture configuration.
limb overload. Successful surgical repair also minimizes
The optimum position and direction of implants can
the period of confinement, and reduces the risk of refrac
then be marked on radiographs. Measurements of bone
ture.8 Given the risk–benefit ratio, surgical repair usually
width and depth of glide hole need to be recorded for
is the treatment of choice.
each point (Figure 22.3). Measurements made on appro
priately calibrated digital radiographs are reliable and
Nonsurgical Management provide a dependable guide during surgery.
Nonsurgical management is provided by stall confine Horse shoes should be removed to protect the horse,
ment. Some surgeons recommend conservative manage personnel, and anesthetic recovery box during recovery
ment for short incomplete fractures and surgical repair from general anesthesia. However, if a cast is to be
for longer fractures. Immobilization with a cast, bandage applied, then the shoe can be left on the contralateral
cast, or bandage to the proximal metacarpal or metatarsal limb to reduce the limb‐lengthening and asymmetric
level is intuitively logical, but demonstrable benefits are effect of a cast. The shoe can be covered by tape to pro
lacking. Repeated radiographic examinations are recom vide protection. If the contralateral limb is unshod and a
mended to check healing, dictate exercise, and allow sur cast is to be fitted only for anesthetic recovery and a day
gical repair if a delayed union develops. or two postoperatively, the limb‐length discrepancy can
The time frame for spontaneous fracture healing be tolerated. When casts are to be maintained for a more
varies. Most veterinarians recommend box stall rest for protracted period, fitting a contralateral shoe while the
four to eight weeks, and if radiologic healing is satisfac horse is recumbent is ideal. Some surgeons use solar
tory this is followed by a similar period of progressive support materials on the contralateral foot. Most are
walking exercise. Riding or restricted area turnout then silicone based and can be made to varying degrees of
follows. Resumption of training is not usually recom rigidity (see Chapter 49). Objective assessment of their
mended until approximately 24 weeks following injury. contribution is lacking.
It has been suggested that horses receive stall rest for Incomplete fractures may gain little benefit from exter
90 days and, if radiographic examination at this time nal support prior to surgery or during induction. However,
indicates healing, then a rehabilitation exercise program in light of the uncertain differentiation between incom
can be commenced.83 If healing is unsatisfactory, then a plete and complete nondisplaced fractures, some form of
further 30–60
days’ confinement is recommended. support is recommended. This may be a Robert Jones
Current thinking suggests that this is excessive and bandage, compression boot, or bandage cast. Additionally,
indeed may be counterproductive, since micromove the counterpressure that these provide improves comfort.
ment promotes healing.15,50 Additionally, in the authors’ Controlled induction of anesthesia is important for all
view, fractures which do not exhibit radiologic evidence fracture patients. A “squeeze door” works well. If the
of a progressive healing process at this time are delayed horse is freestanding, it should be positioned against a
unions, and lag screw fixation is required. wall of the induction box with the affected limb away
www.ajlobby.com
from the wall. Head and tail ropes and two or three addi origin of the collateral ligament is spread along its long
tional people are required to keep the horse from falling axis with hemostats. Standard lag screw technique fol
away from the wall. The horse should be allowed to sink lows. The epiphyseal bone is very dense and frequent
back, maintaining all four limbs in the sagittal plane, to cleaning of the drill flutes and use of irrigating fluid over
reach sternal recumbency. It can then be rolled over with the bit are important. The thread hole should be drilled
the injured limb suitably supported. with particular caution, as undue bending or pressure on
the 3.2 mm drill bit can result in breakage. With this sce
nario, removal is not generally possible or advocated. An
Surgical Technique alternative, less mechanically desirable screw location
Repair uses minimally invasive (percutaneous) lag screw becomes necessary. The surgeon should also prevent the
technique. Horses can be positioned in dorsal or lateral drill bit protruding excessively into the trans cortex fossa
recumbency. The authors use lateral recumbency and the medial collateral ligament.
with the affected limb uppermost. Use of an Esmarch Countersinking the distalmost screw is controversial.
bandage and tourniquet to the level of the proximal met Some authors suggest that it should be avoided because
acarpus/metatarsus is optional. The limb should be per the fossa is already concave and countersinking can dam
fectly horizontal, i.e., parallel with the operating room age the collateral ligament.8,48 However, there is a marked
floor, with no rotation, to optimize drill (and therefore incongruity between screw head and bone surface, par
implant) alignment. The distal limb can be supported at ticularly at the recommended site for screw insertion.
the foot or pastern, but intraoperative radiographs may Point contact not only compromises compression, but
be facilitated by leaving the foot mobile. The natural ten also predisposes to screw bending or breakage. A coun
dency for hindlimbs to rotate outward is alleviated by tersink therefore should be used. Osseous debris that
placing support beneath the calcaneus. This needs to be interferes with the depth gauge and subsequent screw‐
varied with each case to eliminate rotation. Failure to do head seating should then be removed by spreading the
so frequently results in screws inserted in an oblique soft tissues over the drill tract, and copiously flushing
dorsoplantar plane. with irrigating fluid. Swath left in the soft tissues also can
Preoperative planning is important to optimize implant result in enlarging mineralized foci. These have no func
location, screw length, and glide hole depth. Since the tional significance, but are unsightly.
majority of screws will be placed with straight lateral to The epiphyseal bone is dense and frequent backing‐up
medial trajectories, measurements of the bone width at of the tap during cutting of the threads is vital. A finger
these points is a good guide to required screw lengths. placed over the contralateral epicondylar fossa will help
Comparison of the radiologically determined hole depth detect protrusion of the tap, as the bone is so dense
with that measured at surgery also acts as a check on drill that a decline in resistance when the tap emerges is often
trajectory. not appreciated. Inadequate tapping of the trans cortex
The distal screw is most critical and is always placed can cause screw‐tip binding during final tightening of
first. This should be positioned in the center of the bone, the screw, particularly for 5.5 mm screws. The hexagonal
at the junction of the proximal and middle thirds of the screw head then may strip out in an attempt to seat
epicondylar fossa (Figures 22.3 and 22.4). This site has the screw in the dense bone. The authors therefore
also been described as between the deepest part of the recommend that the tap thoroughly exits the far cortex
fossa and elevation of the tubercle.73 A reduced rate of before the screw is inserted. Power tapping is not advo
return to racing and reduced number of races postopera cated at this site. Self‐tapping screws can be difficult to
tively have been reported when screws are placed closer insert in this location, tighten prematurely, and hence are
to the distal articular surface.5,46 This may be due to lack at increased risk of shearing. One of the authors (Nixon)
of compliance of the implant itself or as a result of favors use of 5.5 mm screws at this distal site, although
subchondral stiffening. Compression of the fracture is implant strength has not been documented to be a limit
optimized if the screw is midway between the dorsal and ing factor to repair. The leading three revolutions of the
palmar/plantar articular surfaces, and perpendicular to cutting teeth of the 5.5 mm tap are tapered and do not
the bone in both proximodistal and lateromedial planes. cut a 5.5 mm diameter thread hole until the fourth and
This demands surgical skill, aided by experienced oper subsequent threads are exiting the trans cortex. This
ating room assistants, and is optimized by meticulous makes complete exit of the 5.5 mm tap essential for a uni
limb positioning and intraoperative radiography. formly threaded cortex. For most fractures, screw spac
A longitudinal 10 mm skin incision is made, followed ing of 22 mm on center is ideal. The more proximal
by a longitudinal stab incision through the collateral liga screws are placed as the individual fracture length dic
ment to the bone surface, using a #11 or #15 blade. The tates at 20–30 mm intervals (Figures 22.3 and 22.4).
www.ajlobby.com
(A) (B)
(C) (D)
Figure 22.4 Incomplete fracture of the lateral condyle of a third metacarpal bone. (A) Dorsopalmar (DPa) projection at presentation,
(B) intraoperative DPa projection using percutaneous needles to confirm the proposed sites of implant placement, and (C) following
insertion of three 4.5 mm cortical screws. (D) DPa projection eight weeks postoperatively demonstrating progressive fracture healing.
A small amount of periosteal new bone is evident adjacent to the heads of the proximal two screws.
www.ajlobby.com
(A) (B) (C)
(D) (E) (F)
Figure 22.5 Long incomplete fracture of the lateral condyle of a third metacarpal bone. (A) Dorsopalmar (DPa) projection at presentation.
(B) Intraoperative DPa projection with needles to confirm the proposed sites of implant placement and (C) with three 4.5 mm and one
(proximal) 3.5 mm cortical screws in situ. (D) DPa and (E) lateromedial projections taken 10 days postoperatively. (F) DPa projection
13 weeks post‐surgery demonstrating good fracture healing and osseous reorganization.
Short fractures may need only a single 4.5 mm lag screw the distal screw. Intraoperative radiographs verify distal
in the epicondylar fossa, while others may extend suffi and subsequent screw placement, and are vital for less
ciently proximally to require up to four screws for ade experienced surgeons.
quate compression (Figure 22.5). These screws should all Screws are tightened with finger torque force.
be central in the medullary canal of the bone and aligned Increasing the force will not compensate for suboptimal
parallel to the most distal screw. Appropriate guidance implant position, and can shear the screw head, particu
can be obtained by leaving a screwdriver in the head of larly when countersinking is inadequate. Excessive
www.ajlobby.com
c ompression beneath the screw head may also lead to in this model, and while other studies have indicated that
local osteonecrosis with resorption. Once all screws 5.5 mm screws have superior holding power,99 these con
have been placed, their lengths, spacing, and trajecto cepts have not been tested in vivo.
ries are radiographically verified (Figures 22.3–22.5). Abaxial fractures, close to the lateral margin of the
Adjustments to length can be made as necessary. Screws condyle, may be complete or incomplete. It has been
which are inadequately countersunk can also be removed cautioned that incomplete fractures in this location are
and the cortical depression deepened. A final check on not repaired because of the risk of fracturing the frag
tightness is then performed, using caution to avoid ment when the screw is tightened.83 Fractures which
stripping of the threads in the bone. have a width of less than 10 mm are not suitable for repair
In the absence of other intraarticular lesions, arthro with 4.5 mm screws, but can readily be repaired with
scopic evaluation of the metacarpophalangeal/metatar 3.5 mm cortical screws placed in lag technique. Screw
sophalangeal joint during repair of incomplete fractures location and use of a countersink are all similar. The
is not necessary. Nondisplaced fractures do not result in surgeon should be particularly cautious in drilling
intraarticular comminution and cartilage disruption the thread hole, as the 2.5 mm bit is easily broken in the
usually is minimal. Some can have tearing of the dorsal dense epiphyseal bone. Also, the bone density is such
and/or palmar/plantar joint capsule. Additionally, some that screw length need not span the whole medial con
surgeons believe that articular lavage to remove hemor dyle to achieve good repair. The 3.5 mm screw should be
rhage is beneficial. inserted carefully to avoid shearing the head as the
The collateral ligament often prevents close contact implant tightens; fingertip pressure only is applied.
between the head of the depth gauge and the counter Irritation of the collateral ligament by the head of the
sunk hole, and the screw inserted is subsequently too screw has been speculated to be a cause of lameness and
long. The distance between the epicondylar fossae meas cited as an indication for implant removal. This has not
ured on preoperative radiographs is a more accurate been proven; however, in an attempt to circumvent the
guide to required screw length, subtracting 2 mm for potential problem, use of the headless bi‐pitched Herbert
appropriate countersinking, provided that the digital screw,31 and variable‐pitch Acutrak® (Acumed, Beverton,
radiographs are calibrated appropriately. A measured OR, USA) compression screws, has been reported.22–24
depth that exceeds this measurement may indicate drill Neither has been adopted widely. Both are made of tita
tract obliquity, and intraoperative radiographs should be nium alloy, which has a lower modulus of elasticity than
used to assist in correction. the stainless‐steel AO screws. The screws are placed in
Appropriately placed implants usually compress acute the same locations as described earlier, and inserted in
fractures to the point of obliterating the fracture in dor accord with manufacturers’ instructions and published
sopalmar/dorsoplantar radiographs. There usually will techniques. The bi‐pitched Herbert screw was reported
be less radiologic evidence of compression of longer to have produced good reduction in nine Thoroughbreds
standing or delayed union fractures. with a range of injuries including displaced fractures.
At the end of the procedure, skin closure only is Five horses raced again, with a mean convalescent time
necessary. Sutures or staples of the surgeon’s preference of 10 months.31 The Acutrak Plus® and 4.5 mm AO corti
are used, ensuring that frayed dermis or periligamentous cal screws were compared in a cadaveric model of frac
tissue is debrided or covered. tures of the lateral condyle of the third metacarpal bone.
The Acutrak produced less interfragmentary compres
sion, but there were no other significant differences in
Variations in Technique mechanical test data.23,24 This group subsequently
Mechanical properties of conventional 4.5 mm and reported repair of 16 nondisplaced fractures of the lateral
5.5 mm cortical screws have been compared with simi condyle of the third metacarpal (11) and third metatarsal
lar‐diameter shaft screws with 20–25 mm unthreaded (5) bones with a modified Acutrak equine screw. No
shafts using blocks of cadaver epiphyses of third meta complications were recorded, and 11 of 16 (69%) horses
carpal and third metatarsal bone.70 Screws with raced postoperatively with a mean convalescent time of
unthreaded shafts provided greater resistance to shear, 10 months (all comparable with conventional repair).22
but there was no significant difference between 4.5 and
5.5 mm screws, where the bone crushed and failed Postoperative Care
around the screw shaft. Screws with shafts may thus have The need for a cast for recovery from general anesthesia
some advantage in repair of fractures of the metacarpal has not been determined definitively. However, one author
and metatarsal condyles, but there appears little benefit (Wright) uses a cast with the limb in an extended/weight‐
in resistance to shear when using 5.5 mm compared to bearing position, enclosing the hoof and extending to the
4.5 mm implants. Screw pullout strength was not tested proximal metacarpus/metatarsus. This should include the
www.ajlobby.com
metacarpal/metatarsal tuberosity proximally to provide limit of the fracture (see Figure 22.5). This is thought
sufficient support to the distal third metacarpal/metatar to indicate that the fracture was complete, but that its
sal bone. It is rationalized that, correctly applied, there are lateral cortical exit was not radiologically discernible.
no demonstrable disadvantages, the cost of the cast is
modest, and disruption of the repair in recovery resulting Complications
from not applying a cast is likely to be catastrophic. The most serious complication is articular trauma
Additionally, it may provide support in cases that have caused by poor drill alignment, with penetration of the
occult complete condylar fractures. Casts usually can be articular surface over the medial condyle. This should be
removed within the first 24–48 hours post‐surgery, and a suspected when there is a lack of correlation between
compression bandage is applied. Other surgeons (Nixon) the measured drill hole depth and the lateromedial width
use modified Robert Jones bandages incorporating a poly of the bone determined on preoperative radiographs.
vinylchloride (PVC) splint to the elbow or compression Radiographic investigation with both dorsopalmar/
boots for recovery from general anesthesia. plantar and lateromedial projections verifies and aids
Bandaging is maintained at least until skin sutures are correction of drill misdirection. One of the authors
removed, generally 10–12 days postoperatively. The (Nixon) routinely uses intraoperative fluoroscopy or dig
authors frequently continue bandage use for up to four ital radiography to check drill alignment in both planes
weeks after surgery. Subjectively, this appears to reduce during the initial drilling for the first screw.
swelling, subsequent scar tissue formation, and pain. Premature tightening, usually of the most distal screw,
Postoperative exercise is modulated by clinical and can result from an inadequately tapped thread hole or
radiologic progress. If both are satisfactory, then walking from osseous debris within the tract. It occurs more com
can be introduced and gradually increased approxi monly with 5.5 mm screws. As soon as this is recognized,
mately four weeks after surgery. Trotting usually can be the screw should be backed out and the hole flushed; the
added after eight weeks of walking, and cantering eight screw can then be reinserted. Once the thread hole is
weeks later. With careful clinical and radiologic monitor engaged, advancing this screw two times followed by one
ing, some horses have successfully returned to training half turn back (in a tap‐like manner) can assist insertion.
with shorter convalescent periods. If this fails, then the hole should be retapped using a fin
Zekas et al. reported guidelines of one month of box ger over the medial condylar fossa to feel for emergence.
stall rest followed by one month of box rest with hand The screw should never be forced, as the dense bone will
walking; thereafter exercise was modulated in line with cause it to bind and break, or, for 5.5 mm screws, the hex
radiologic fracture healing.101 A minimum of four months’ screw head can be stripped internally.
postoperative rest from training was recommended by Screw breakage invariably is due to insertional error.
Bassage and Richardson.5 In this series the mean time The screw should be removed if any portion still pro
from fracture to first race was 253 days (8.4 months). trudes to be grasped, otherwise overdrilling of the broken
shaft with a hollow reamer (DePuy Synthes, West Chester,
Fracture Healing PA, USA) and removal with a screw extraction bolt should
Osseous resorption in the palmar/plantar subchondral be done (see Chapter 8), although reaming to provide
bone adjacent to the fracture line commonly develops in access to a broken shaft is far from benign. Nonprotruding
the initial two months after fracture. Radiologically this screws may be left in situ if a new screw can be inserted
may manifest as the reappearance of a fracture line, sufficiently adjacent to duplicate compressive function.
usually distal to the most distal screw, which appeared Intraoperative radiographs are critical to insert a new
obliterated on radiographs taken at the end of surgery or, screw as close as possible to the optimum site. The epi
alternatively, apparent widening of a fracture line that condylar fossa permits little safe dorsopalmar/plantar
remained at this level (Figure 22.4). The palmar/plantar variation in screw location; replacement screws therefore
subchondral bone is slowest to heal. Complete disap usually have to be placed proximal or distal to the broken
pearance of the fracture line can take many months, and implant. The former may compromise compression,
if the remaining fracture heals with good osseous reor while the latter may irritate the subchondral bone.
ganization, then this should not delay the rehabilitation Suboptimal fracture compression can result from errors
program. Most of these fracture lines slowly disappear in screw location, such an insertion of the distal screw
from proximal to distal, but occasionally, adjacent to the through the epicondylar eminence rather than in the
sagittal ridge, a small narrow linear defect will remain in fossa, or an oblique trajectory. Screws may strip the thread
the palmar/plantar subchondral bone. hole due to overdrilling of the glide hole or overtightening
Most repaired fractures will unite by primary bone of the screw. If 4.5 mm cortical screws are employed, then
healing (see Figures 22.4 and 22.5). Periosteal callus the surgeon can substitute a 5.5 mm screw. In order to
sometimes will form proximal to the previous radiologic reestablish a lag effect, the glide hole needs to be redrilled
www.ajlobby.com
to 5.5 mm. Marking the drill with a sterile marker or on the distal lateral diaphysis. This is generally apparent
elastic band can be useful to avoid overdrilling. A stripped within an hour of fracture (see Figure 5.19A).
3.2 mm thread hole does not need to be redrilled with a Most fractures are readily identified on radiographs
4 mm drill; a thread can be cut with direct passage of the (Figures 22.6 and 22.7). Scrutiny of flexed dorsopalmar
5.5 mm tap. The head of the 5.5 mm screw is the same as or dorsal 35° distal‐palmar/plantar proximal oblique
the previously created countersunk fossa. (D35° Di‐Pa/Pl Pr oblique) “Hornoff”33 projections is
Postoperative radiographs may reveal osseous resorption important to detect distal comminution, which in one
beneath a screw head. This commonly is asymmetric with series was recognized in 8 of 43 (19%) nondisplaced frac
respect to the head and appears indicative of inadequate tures.100 This usually takes the form of a distally based
countersinking. It generally is of no clinical consequence. wedge. A range of fracture lengths from 50 to 135 mm
Additionally, periosteal new bone can develop adjacent has been reported; for preoperative planning this equates
to screw heads with no obvious cause (see Figure 22.4). to between two and four screws.
Sometimes this can produce visible swellings at the screw
site. Similar exostoses can be present medially, particularly Treatment
if the tip of the screw(s) protrudes. Although unsightly,
these are not generally of functional significance. Complete fractures are inherently unstable and surgical
management is recommended. This applies even if horses
Implant Removal are retired from racing. The consequences of contralateral
Unless there are implant‐related complications, screw limb overload, possible displacement, and malunion are
removal is rarely required,101 and the conclusion that significant. In an extensive published series, all (43 of 43)
there was no consistent difference in postoperative per complete nondisplaced fractures were repaired.101
formance between horses that had screws removed and Percutaneous lag screw insertion is recommended for
those in which the screws were left in situ has been rein repair. At the proximal margin, thin (<10 mm) proximal
forced.5,51 It has been suggested that postoperative lame “spikes” should be repaired with smaller, usually 4.5 or
ness in some horses might result from the presence of 3.5 mm diameter cortical screws (Figure 22.7).
implants. As a consequence a regimen of elective removal In nondisplaced fractures, palmar articular fragments
four months after repair was recommended.56,73 However, can be compressed with the principal fracture. They
it is our opinion that screw removal should only be con appear to be viable and can heal, although some look
sidered where significant lysis has formed beneath the sclerotic with darkened non-viable zones. It has been
screw head and intraarticular anesthesia rules out fetlock suggested that some might resorb,73 but this has not
joint disease as the cause. been the authors’ experience.
Where radiographs exclude palmar/plantar comminu
Results tion, the requirement for arthroscopic evaluation of
the metacarpophalangeal/metatarsophalangeal joint is
All authors have reported favorable outcomes for the debatable. However, it is minimally invasive, there may
majority of horses with incomplete fractures, whether the be intraarticular debris that could be removed, and hem
fractures are surgically repaired or managed conserva orrhage can be lavaged from the joint. Additionally, it
tively. These included 9 of 10 (90%), 14 of 16 (87%), and 5 may identify concurrent lesions such as tearing of the
of 5 (100%) of horses managed conservatively, and 9 of 11 joint capsule and facilitate their treatment. Assessment
(82%), 26 of 35 (74%), and 71 of 86 (83%) of horses with of the articular surfaces also can be of prognostic value.
surgically repaired fractures returned to racing.5,73,101 A In most circumstances, potential benefits outweigh any
more favorable outcome has been reported for third met disadvantages.
atarsal fractures, where 28 of 30 (93%) of horses with sur Use of external support for recovery from general anes
gically repaired fractures raced, compared to 43 of 56 thesia varies with the size and location of the fracture, but
(77%) with fractures of the third metacarpal bone.5 mostly with the preferences and prior experiences of the
surgeon. Some prefer casts, bandage casts, PVC splints
Complete Nondisplaced over a bandage, compression boots, or Robert Jones
bandages. All these have their protagonists and are
Fractures
employed successfully in varying circumstances.
Diagnosis Fracture Healing
The clinical presentation of complete nondisplaced The information on rate and appearance of healing of
fractures is similar to incomplete fractures, but there is incomplete fractures is also pertinent to complete dis
usually clinically discernible hemorrhage at the exit point placed fractures (see Figures 22.6 and 22.7). Reduced
www.ajlobby.com
(A) (B)
(C) (D)
Figure 22.6 Complete, nondisplaced fracture of the lateral condyle of a third metacarpal bone. (A) Dorsopalmar (DPa) projection at
presentation and (B) intraoperative DPa projection following repair by the percutaneous insertion of two 4.5 mm and one 3.5 mm
(proximal) cortical screws. (C) DPa and (D) lateromedial projections 16 weeks post‐surgery following a progressive controlled exercise
program before the animal recommenced canter exercise.
www.ajlobby.com
(A) (B) (C)
Figure 22.7 Long, complete fracture of the lateral condyle of a third metacarpal bone. (A) Dorsal 15° medial‐palmar lateral oblique
(D15° M‐PaLO) projection at presentation. Intraoperative dorsopalmar projections during repair by an open approach (B) using needles
to confirm the proposed sites of implant placement and (C) following repair by the insertion of two 4.5 mm (distal) and two 3.5 mm
cortical screws.
radiodensity (osteolysis) along the fracture line in the Displaced Fractures of the
lateral condyle is more commonly encountered in
Lateral Condyle
complete fractures compared to those that are incom
plete (Figure 22.8). This feature can persist for many The fracture displacement is usually proximal and abax
months and appears unrelated to the fracture gap. It ial. Most displaced fractures remain closed, but rarely
generally resolves with time and appears unrelated the instability is sufficient to perforate the skin.
to ultimate outcome. It may be associated with the inter
rupted blood supply that must accompany the fracture.
There is usually little marginal callus produced by
Diagnosis
repaired fractures. Affected animals usually exhibit severe lameness, with
rapidly developing soft tissue swelling of the distolat
eral metacarpus/metatarsus and distension of the
Results metacarpophalangeal/metatarsophalangeal joint due
In one series73 4 of 6 (67%) and in a larger series101 24 of to intraarticular hemorrhage (see Figure 5.33).
40 (58%) horses with complete nondisplaced fractures Thorough clinical appraisal is important, as bilateral
raced after surgery. In the latter series more horses with fractures occasionally are encountered.
fractures of the third metatarsal bone raced, and their Dorsopalmar/plantar, lateromedial, both oblique, and
convalescent time post‐surgery (time to first race) was flexed dorsopalmar/plantar projections will identify and
shorter than similar fractures of the third metacarpal define most displaced fractures. However, additional
bone. A further study reported that 19 of 25 (76%) and radiographic projections may be necessary to define the
16 of 47 (34%) Thoroughbreds with repaired fractures full extent of the damage and the potential presence of
of the lateral condyles of third metatarsal and third complicating injuries such as axial fracture of the lateral
metacarpal bones, respectively, raced after surgery.5
proximal sesamoid bone,3,30 which have a negative impact
However, no distinction was made between nondis on prognosis for athletic function (Figure 22.9). Other
placed and displaced fractures, which may have influ fractures of the proximal sesamoid bones and proximal
enced the return rate. phalanx also have been recognized concurrently.61
www.ajlobby.com
(A) (B)
(C) (D)
Figure 22.8 Incomplete fracture of the lateral condyle of a third metacarpal bone. (A) Dorsopalmar projection at presentation; (B) repair
with two 4.5 mm and one 3.5 mm cortical screws; (C) radiological appearance 10 weeks post‐surgery with evidence of reduced
radiodensity in the fracture fragment; and (D) persistent loss of radiodensity in the lateral condyle 28 weeks after repair and 17 weeks after
screw removal.
www.ajlobby.com
(A) (B)
Figure 22.9 Displaced fracture of the lateral condyle of a third metatarsal bone, with (A) proximal and distal comminution visible on the
dorsoplantar projection, and (B) an axial fracture of the lateral proximal sesamoid bone (arrows), highlighted on the flexed dorsal 35°
distal‐plantar proximal oblique (D35° Di‐PlPrO) projection.
Displaced fractures may be simple or comminuted. length of displaced fractures has varied little (82–85 mm)
Comminution can occur at the proximal margin, between reported series.5,61,73
where cortical fragments of varying sizes can detach
(Figures 22.9 and 22.10).16 This was recorded post mor
tem in 33 of 75 (44%) catastrophic fractures,61 and with a Treatment
clinical incidence of 20–24%5,100 in two further series.
Distal articular comminution also can occur (see There are no circumstances under which displaced
Figure 22.9). Careful scrutiny of radiographs sometimes fractures can satisfactorily be managed without reduc
will reveal fine radiodensities in dorsal and/or palmar/ tion and stabilization. Temporary support should be
plantar compartments, which usually is indicative applied at diagnosis and maintained through induction
of intraarticular osseous or osteochondral debris. of general anesthesia. Limbs are placed in an extended
Macroscopic articular comminution was found at post‐ (weight‐bearing) position and supported by a cast,
mortem examination of 6 of 7 (86%) and 28 of 54 (52%) bandage cast, compression boot, or reinforced Robert
catastrophic displaced fractures involving the lateral Jones bandage, as previously described.
condyle of third metacarpal bones,61,87 and in 5 of 21
(24%) similar fractures of the third metatarsal bone.61 In Surgical Repair
the latter series, the site of comminution was almost Surgical reduction and repair should always be advised
equally distributed between dorsal and palmar/plantar for displaced fractures unless the animal is to be
articular surfaces. In evaluation of 125° dorsopalmar euthanized for economic reasons. Animals treated

projections of displaced fractures, one group suspected conservatively remain subject to pain and suffer with
19 of 45 (42%) of having palmar/plantar comminution,73 severe degenerative osteoarthritis of the fetlock.
while another recognized articular fragmentation in 13 At surgery, the principal goal is reconstitution of articular
of 46 (28%) displaced fractures.101 congruency. Whenever possible, the fracture gap should be
It has been suggested that displaced fractures of the eliminated, but cartilage surfaces should always be opposed
third metatarsal bone generally originate more abaxially as closely as possible to minimize articular deficits that
than corresponding fractures of the third metacarpal require second‐intention healing. Additionally, displaced
bone, but there was little difference between their range fractures usually result in intraarticular osseous debris.
or mean proximodistal lengths.61 Interestingly, the mean Occasionally this is radiologically identifiable, but often it
www.ajlobby.com
(A) (B)
(C) (D)
Figure 22.10 Long displaced fracture of the lateral condyle of a third metatarsal bone with proximal comminution. (A) Dorsoplantar
(DPl) projection at presentation; (B) arthroscopic evaluation of the fracture from a dorsolateral portal; (C) progressive reduction by
manipulation; (D) fracture reduced and secured prior to repair; (E) DPl projection: fracture secured with AO large reduction forceps and
needles used to determine drill sites; (F) repair with three 4.5 mm and one 3.5 mm cortical screws; and (G) six weeks post‐surgery: note the
small proximal defect at the site of removed comminution.
is silent. Arthroscopic removal, piecemeal for larger frag reduced and stabilized; expedient repair is therefore advo
ments and by directed lavage for smaller debris, is highly cated. Some surgeons recommend a short (24–48 hours)
desirable. Other articular lesions such as fragmentation of delay aimed at reducing the risks of general anesthesia
the dorsal margin of the proximal phalanx and tearing of associated with the stress of recent workout, shipping,
the joint capsule and/or dorsal plica that can accompany or dehydration. However, objective evidence to support
displaced fractures can also be identified, assessed, and this premise is lacking, and in the authors’ practices
appropriately treated during arthroscopic examination. no correlation between anesthetic, anesthetic recovery,
The timing of surgery is important. Displaced fractures or postoperative complications have been associated
are unstable and highly destructive to articular tissues until with acute surgical intervention. Repair also is the most
www.ajlobby.com
(F) (G)
(E)
effective means of providing analgesia and reducing skin incision is 2–3 cm long, centered over the palpable
anxiety. Given this, the authors advocate repair as soon as proximal spike of the fracture, to allow removal of small
surgical and anesthetic considerations permit. comminuted pieces and assist in fracture alignment.
Reduction of chronically displaced fractures which have Fracture hemorrhage is removed. Small proximal commi
granulation tissue or subsequent early callus formation is nuted fragments can be discarded. These usually are par
difficult. Despite radical exposure and debridement, per tial‐thickness fragments from the lateral cortex. Larger
fect articular congruity can be impossible to achieve, and fragments can be repaired with small (3.5 or 2.7 mm diam
the joint surfaces generally are extensively traumatized; eter, frequently unicortical) screws placed in lag technique.
large articular cartilage defects commonly develop on the Occasionally, nondisplaced comminuted fragments will
lateral proximal sesamoid bone. These cases have a hope be found and can be managed similarly.
less prognosis for return to work. However, debridement, Reconstruction of the articular surface congruity
reduction, and lag screw repair will optimize the animal’s is critical to resumption of an athletic career. It also is
quality of life and humane longevity. desirable for salvage cases to minimize ongoing articular
Repair of displaced fractures is optimized with the trauma and osteoarthritis. Reduction generally is
horse in lateral recumbency. Use of an Esmarch bandage accomplished by extension of the metacarpophalangeal/
and tourniquet can expedite surgery, but in some cir metatarsophalangeal joint together with downward
cumstances will reduce limb mobility sufficiently to pressure on the foot, i.e., an adductory force. A proximal
inhibit fracture reduction. The limb should be supported fulcrum is vital to accomplish this maneuver. The appli
at the carpus or tarsus distally; a cupped limb support cation of torque by twisting the foot also can be of assis
into which the fetlock fits is ideal, as this will permit tance in some cases. This effect should be monitored
manipulation during surgery to effect reduction. Support and directed by concurrent arthroscopic evaluation
only under the foot or pastern exacerbates the fracture of the dorsal articular surface of the lateral condyle
displacement, and reduction will often require removal (Figure 22.10). Additional adjustment can be made fol
of the distal limb support to allow retraction of the frac lowing creation of the distal glide hole by manipulation
ture fragment. A perfectly horizontal (parallel with the with a 3 mm Steinman pin inserted through the 3.2 mm
ground) limb position aids perpendicular drill and there drill sleeve. Once articular congruency has been
fore implant trajectories, and cannot be stressed enough. obtained, the fracture can be fixed by application of large
An open lateral approach is advocated to assess AO reduction forceps while drilling commences or
the extraarticular proximal portion of the fracture. The progresses (Figure 22.10). One of the authors (Nixon)
www.ajlobby.com
routinely commences with palmar/plantar pouch through the fracture plane,1 which limits the possibility
arthroscopy and debris removal prior to entry to the of return to racing.
dorsal pouch for arthroscopically verified fracture Substantial full‐thickness cartilage defects of the lateral
reduction. Flexion for palmar pouch arthroscopy should proximal sesamoid bone are commonly found with dis
be carried out judiciously, as this can exacerbate fracture placed fractures of the lateral condyle. These usually
displacement. Palmar/plantar comminution almost involve the axial half of the bone and pieces of cartilage
invariably is distal on the metacarpal/metatarsal con may be found within the joint. Arthroscopic evaluation
dyle, and access u sually will require an instrument portal has revealed varying degrees of tearing or disruption of the
through the collateral sesamoidean ligament.47 Large joint capsule in both dorsal and palmar/plantar compart
pyramidal, comminuted fragments at this site that can ments. This was considered likely to have resulted from
be reduced should be conserved and compressed in the continued galloping with an unstable joint; however, we
principal repair, especially if they have maintained any have identified this in horses with nondisplaced fractures.
cartilage connection. These remain viable, heal and Closure of large incisions utilizes continuous patterns
remodel, and carry only a slightly reduced prognostic of absorbable material such as Polyglactin 910 (Vicryl™,
outlook compared with simple fractures.101 Others, Ethicon, Somerville, NJ, USA) in the metatcarpal/
which create incongruity, should be removed. metatarsal fascia and subcutis, followed by stainless‐
Radiographic confirmation of reduction is vital prior steel staples or nonabsorbable monofilament sutures in
to insertion of implants. However, it can be inferior to the skin. Wound healing generally is uneventful.
arthroscopic visualization of the articular surfaces in assess
ing congruency; some dorsopalmar/plantar and rotational Postoperative Care
displacements may not be recognized radiographically. An Application of a cast for recovery from general anesthe
intraoperative radiograph or fluoroscopic examination at sia is highly recommended. This should enclose the
this time will also guide or check proposed drill/implant foot and extend to the level of the distal row of carpal/
locations (Figure 22.10). Once adequately reduced, repair tarsal bones, with the metacarpophalangeal/metatar
follows a similar sequence to nondisplaced fractures. sophalangeal and interphalangeal joints in extension.
Arthroscopically guided reduction and fixation are impor The optimum period of cast immobilization is debata
tant; however, soft tissue healing is never a limiting factor, ble. With reasonable technique, the fracture repair is not
and visualization of the extraarticular portions of the frac reliant on external immobilization. However, soft tissue
ture by open mini‐incision over the proximal spike of the healing may be enhanced by a short period of cast
fracture can be valuable in verifying perfect reduction and support. One text recommended two to three days

guiding appropriate implant placement (Figure 22.10). followed by a padded bandage for at least three weeks.83
One of the authors (Nixon) and other published A cast–bandage combination may also be useful for one
reports employ 5.5 mm cortical screws as the distal to two weeks after removal of cast support.
implant.101 However, many surgeons, including the other Perioperative antimicrobial drugs are given to horses
author (Wright), do not consider that the 5.5 mm screw with closed fractures for a brief period in accord with
adds to the fixation. Thin proximal portions of the individual surgeons’ preferences. Administration should
fracture may be repaired by smaller (usually 4.5 or
commence preoperatively, and extend for enough time to
3.5 mm diameter) screws. Unicortical fixation often is control organisms that potentially can contaminate the
adequate in the dense bone of the diaphysis. If bicortical site at surgery or in the postoperative period. This is dic
fixation with small screws is preferred, then the far cor tated by predisposing factors such as hemorrhage at the
tex should be drilled, tapped, and screw inserted cau fracture, surgery time, extent of open dissection, number
tiously to minimize the risk of instrument or implant of screws, and any pulmonary compromise associated
breakage. with general anesthesia. However, the p otential benefits
In some cases fragmentation in the fracture line pre must be tempered against potential con sequences of
cludes reduction. In this situation an arthroscope portal changes in intestinal flora. Acutely treated open fractures
is made dorsally, directly over the fracture. Such frac are contaminated, and antibiotic a dministration is nec
tures are sufficiently unstable that the arthroscope can essary. Combinations of antimicrobials with a broad
be passed into the fracture, and comminuted fragments spectrum of activity are indicated (Chapter 7).
removed to evacuate the fracture gap using dorsal Skin staples (or sutures) are removed at 12–14 days.83
and/or palmar instrument portals. With this technique, Occasionally, some days or even weeks postoperatively,
most palmar/plantar margins of the fracture can be small sinuses can develop associated with subcutaneous
assessed. The technique is superior to open removal or subcuticular sutures, portions of which may be
www.ajlobby.com
extruded. Removing the material usually will resolve the is possible to have good reduction of the extraarticular
problem and antimicrobials are not necessary. portion of the fracture and for radiographs to fail to
Postoperative stall confinement has been recom identify slight, usually dorsopalmar/plantar or rotational
mended for a minimum of 90 days.83 However, current displacement. Lameness, reduced range of motion, poor
athletic rehabilitation protocols suggest that this is postoperative performance, and ultimately osteoarthritis
excessive; hand‐walking exercise may be introduced result.
from 30 to 45 days post‐surgery and a gradually ascend The trauma and resultant hemorrhage that accompany
ing controlled exercise program instituted. In general, displaced fractures may predispose to wound dehis
convalescence is longer than with nondisplaced frac cence and infection. Bacteriologic culture is indicated,
tures. A mean time from surgery to the first race for but not always reliable. Broad‐spectrum antibiotics
complete fractures (displaced and nondisplaced frac are often selected based on common susceptibility
tures were not separated) of 275 days (9 months) has patterns.
been reported.5 Other authors have recommended a Screw removal is indicated only if implants are impli
more protracted convalescence for horses with palmar/ cated in the infective process. A decision has to be made
plantar comminution or osteolytic lesions.73 In the between early screw removal and loss of compression,
absence of complications referable to implants, screws and the potential that the screw may potentiate and har
generally are not removed. bor the infective process and jeopardize the case out
come. Retaining the screw and use of medical treatment
for at least the initial four weeks aid in fracture union.
Fracture Healing
With good reduction, simple displaced fractures can Later screw removal is then dictated by persisting dis
heal with primary union (see Figure 22.10). Periosteal charge or osteolysis beneath the screw head.
callus may be produced proximally where the fracture
exits the diaphyseal cortex. Most callus appears to be Results
produced with fractures that have a long intracortical
component (spike). The callus can be limited by small, Return to racing after repair of displaced fractures has
proximally placed lag screws (see Figure 22.10). Large been poor, but has improved in more recent retrospec
distal wedge‐shaped comminuted fragments in the pal tive studies. In a series reported in 1983, 12 of 38 (32%)
mar/plantar subchondral bone can retain viability, heal, repaired fractures raced following injury, while 0 of
and remodel if compressed adequately by fixation of 6 conservatively managed fractures raced following
the primary fracture. Osseous resorption along the injury.73 In another study, 3 of 17 (18%) horses with
fracture line in the distal subchondral bone occasion displaced fractures raced following repair.16 An
ally develops and can be more obvious than with non improved success rate was reported in 1999,101 when
displaced fractures. This may persist for a protracted 25 of 43 (60%) horses with displaced fractures raced
period and even terminate in a lucent defect resembling following surgery. In this series more horses with frac
an osseous cyst‐like lesion. Cystic lesions in the adja tures of the third m etatarsal bone raced, and these had
cent subchondral bone of the proximal phalanx can be a reduced convalescent period compared with similar
rare complications of the healing process and carry a fractures of the third metacarpal bone. Improved
poor prognosis for return to training and racing. implants and surgical techniques may explain the more
favorable results obtained in the latter series, and
arthroscopically guided reduction may further improve
Complications results in future case series.
Concurrent fractures of the proximal sesamoid
bones,5,73,101 particularly axial/sagittal fractures of the
lateral proximal sesamoid bone, diminish the prospects
for athletic soundness.3,5,16,30,73 Comminuted fragment Propagating Fractures
presence and removal101 are associated with diminished of the Medial Condyle
postoperative performance. The severe articular insult
that accompanies displaced fractures results in more Most fractures of the medial condyles of the third
degenerative joint disease than with nondisplaced metacarpal and third metatarsal bones arise close

fractures.73 to the sagittal ridge and either are confined to the
Articular incongruity is the most common complica palmar/plantar subchondral bone or are bicortical and
tion. Arthroscopic evaluation has helped avoid this. It propagate proximally into the diaphysis. Fracture
www.ajlobby.com
propagation may occur as part of the initial osseous a “spiral.”4,16,75,94,97 In a series of 18 propagating medial
failure or may be occult and become obvious later. condyle fractures, 6 (33%) remained parasagittal. These
Two forms of fracture propagation are recognized. In all terminated within the middle third of the diaphysis.
the first, the fractures in both dorsal and palmar/plan The remaining 12 (67%) had a spiral configuration
tar cortices remain sagittal or parasagittal (Figures 22.11 beginning sagittally and turning into an oblique frontal
and 22.12), and in the second, these change orientation plane in the middle third of the diaphysis. Fractures
to oblique and/or frontal planes (Figure 22.13) and form in both third metacarpal and third metatarsal bones
(A) (B) (C)
(D) (E) (F) (G)
Figure 22.11 Parasagittal propagating fracture of the medial condyle of the third metatarsal bone. (A) Dorsoplantar (DPl) projection;
(B) repair using four 4.5 mm cortical screws with lateral to medial trajectories; (C, D) radiographs taken 12 days after surgery to assess the
presence of further fracture lines before cast removal; and (E) radiographic appearance following cast removal. Note the incision length, as
depicted by skin staples, to permit evaluation of the diaphysis. (F) DPl projection five weeks post‐surgery, and (G) 24 weeks post‐surgery.
www.ajlobby.com
Figure 22.12 Parasagittally propagating fracture (A) (B)

of the medial condyle of the third metacarpal
bone. (A) Dorsopalmar (DPa) projection; (B) repair
by insertion of four 4.5 mm cortical screws with
medial to lateral trajectories; (C) DPa projection to
assess further propagation prior to cast removal;
and (D) DPa projection four weeks post‐surgery.
(C) (D)
f ollowed a similar pattern. Typically, the palmar/plantar the proximal third of the diaphysis have a less predictable
fracture coursed laterally at the level of the distal course, seven remaining in a frontal plane and four
portion of the lateral splint bone, while in the distal turning back into an oblique configuration.97 Rarely
diaphysis the fracture in the dorsal cortex remained fractures extend into the carpometacarpal or tarsomet
parasagittal.97 Fractures which spiral from parasagittal atarsal joint.4
to frontal usually do so in the middle third of the Other fracture configurations have been reported,
diaphysis. Some appear to terminate there, while others including proximomedial propagation of the fracture in
turn again as the fracture progresses more proximally, the palmar/plantar cortex and a mid‐diaphyseal “Y” con
to develop an oblique orientation. This frequently then figuration.16,44,71 Fractures in the middle of the diaphysis
turns back to spiral in the opposite direction to that can be complex and, when exposed to bending and tor
found distally, i.e., the fracture line in the dorsal cortex sional forces, they can become complete. Unstable dis
propagates laterally and the palmar/plantar fracture placement is instantaneous and usually catastrophic.
progresses medially. Spiral fractures that extend into Occult (radiologically silent) fractures can develop into
www.ajlobby.com
(A) (B) (C) (D)
(E) (F) (G) (H)
Figure 22.13 Medial spiral fracture of a third metacarpal bone. (A) Dorsopalmar (DPa) and (B) dorsal 60° medial‐palmar lateral oblique
(D60° M‐PaLO) projections demonstrating progressive change in the fracture plane (arrows) from sagittal to frontal as the fracture
extends proximally. (C) Needles placed at proposed implant sites following open lateral evaluation of the fracture. (D) Repair effected by
insertion of eight 4.5 mm cortical screws following the spiraling fracture plane. (E, F) DPa and lateromedial projections five days post‐
surgery; the skin staples indicate the length and orientation of the surgical wound and screw trajectories change to remain perpendicular
to the determined fracture plane. Note that the cast extends to the level of the third carpal bone. (G–I) Radiological monitoring of healing
four weeks post‐surgery; note impingement of the second metacarpal bone by the third screw. (J, K) Radiographs taken 26 weeks post‐
surgery and 11 weeks following screw removal.
www.ajlobby.com
(I) (J) (K)
catastrophic fractures at almost any time in the first four training or racing. Affected horses often are more
to six weeks. Previously identified fractures also appear distressed than those with nonpropagating fractures.

to be capable of both acute and insidious propagation. Lameness is profound and usually involves toe‐only
The principal i nciting force to acute propagation is rising foot–ground contact. Rapid distension of the metacar
from recumbency, which exerts maximal bending force pophalangeal/metatarsophalangeal joint is common.
on the bone. Horses often resent digital pressure dorsomedially in the
Fractures of the medial condyle have been reported to distal third of the diaphysis and both medial and lateral to
be more common in the third metatarsal bone than the the extensor tendons in the middle third of the diaphysis.
third metacarpal bone.46 However, in one series 21 of 43 Pitting soft tissue swelling may form over the palmar/
(49%) involved the third metacarpal bone and 22 of 43 plantar lateral diaphysis where the palmar/plantar frac
(51%) the third metatarsal bone,16 and in another series ture plane extends laterally adjacent to the splint bone
16 of 21 (76%) involved the third metacarpal bone and (see Figure 5.19B&C). This hemorrhage can be differenti
only 5 of 21 the third metatarsal bone.100 The propensity ated from that associated with fractures of the lateral
for spiral propagation also varies between fore‐ and condyle by its palmaro/plantarolateral rather than lateral
hindlimbs. In one series, medial condyle fractures location, and more proximal location (fractures of the
spiraled more frequently in the hindlimb (21 of 22 frac lateral condyle invariably exit distal to the splint). Routine
tures), compared to the forelimb (11 of 21 fractures).16 radiographs described previously for condylar fractures
By contrast, a different study indicated that all fractures need to be supplemented by complete assessment of the
with a spiral configuration involved the third metacarpal entire diaphysis. Multiple radiographic projections, with
bone.100 Breed may affect which hindlimb is affected. In slight angle changes, are used to map the fracture
15 propagating fractures of the medial condyle of the configuration by following the fractures in both dorsal
third metatarsal bone, left and right limbs were equally and palmar/plantar cortices. Despite this, one study
affected in Standardbreds, but in Thoroughbreds 6 of 9 reported that the configurations of only 1 of 12 (8%) spi
were left hindlimbs. This was thought to reflect anti ral and 5 of 6 (83%) parasagittal propagating fractures
clockwise training and racing regimes.71 were predicted accurately by r adiography.97 The preop
erative use of CT provides clear advantage in defining
fracture configuration and is indicated in most medial
Diagnosis condyle fractures (Figure 22.14). Standing robotic CT has
Propagating fractures almost invariably cause acute, the distinct advantage of providing three‐dimensional
severe lameness, either during or immediately following fracture configuration information to guide treatment
www.ajlobby.com
(A) (B) support may be provided by a cast that extends to

the level of the third carpal or central tarsal bones,
or alternatively a full limb cast may be applied.
Contralateral limb overload is common, and laminitis is
the principal short‐term concern. In the medium to
long term (weeks to months), degenerative joint disease
in the proximal interphalangeal and/or metacar
pophalangeal/metatarsophalangeal joint is a common
complication of contralateral limb overload, and results
in permanent lameness. Onset of laminitis can be
acute, often recognized by a shift in weight bearing to
the fractured limb. Alternatively, laminitis can be more
insidious.
Without surgical stabilization, medial condylar frac
tures also can continue to propagate to become complete
and catastrophic.16 This predominantly involves
hindlimbs;56 however, the authors have also encountered
propagation and displacement of propagating fractures
of the third metacarpal bone. This risk can be reduced
but not eliminated by a cast applied standing and cross‐
tying the horse. Morbidity and the risk of catastrophic
failure remain, nevertheless, and contralateral limb over
load laminitis and degenerative joint disease have been
documented.16,71,73
A case study44 described two spiral fractures and one
sagittally propagating fracture of the medial condyle of
the third metatarsal bone that were stabilized by
fiberglass cast application up to the tarso‐metatarsal

Figure 22.14 Computed tomography of propagating medial joint. Casts were applied standing and horses were cross‐
condylar fracture of the third metacarpus. (A) Three‐dimensional tied for between 27 and 44 days. Two horses returned
reconstruction showing dorsal fracture crack propagation from to training and the other developed degenerative joint
medial sagittal to dorsomedial aspect of the third metacarpus. (B)
Palmar image showing fracture line deviation from medial sagittal
disease in the metatarsophalangeal joint.44
to palmarolateral. The palmar fracture line re-emerges on the
dorsolateral aspect of MC3 in (A). Surgical Repair
Repair of medial propagating fractures is almost
universally recommended as the treatment of choice,
but carries inherent risks. These fractures can propagate
choices before the horse is anesthetized. Fracture lines to become complete and catastrophic at any stage,
are also identified at surgery which extend proximal to including presurgery, during recovery from anesthesia,
those seen radiologically;71 in one series this was found or in the postoperative period.5,71 The technique selected
in 9 of 18 (50%) cases.97 Even CT may underestimate for fracture repair is dictated by the extent of the spiral
the extent of propagating fractures. These may become component, appearance of acute detour in fracture line
apparent 4–10 days after the primary repair, and may propagation to form a “Y” or “T” component, and the
require additional screw fixation to improve the degree previous experiences of the surgeon. One of the authors
of lameness. (Nixon) has had catastrophic breakdown after lag screw
fixation of spiral fractures, and prefers plate fixation or
Treatment lag screw insertion in the standing horse. General anes
thesia with lag screw insertion has been the treatment
Nonsurgical Management choice for the other author (Wright), with plate fixation
Some propagating fractures can heal without surgical reserved for clearly Y or T fractures. Plate fixation can
intervention.21,44,73 This avoids the risks associated consist of a single plate, often supplemented with several
with general anesthesia and recovery, but is associated distal independent screws, a single spiral plate to follow
with sufficiently high morbidity and mortality rates that the contour of the fracture, or double plating for unstable
it cannot generally be recommended. Rigid external Y or T fractures.
www.ajlobby.com
Preoperative Preparation Lag Screw Repair – Open

Preoperative planning is important and should include Lateral Approach
screw placement based on fracture configuration and An open lateral approach generally allows the surgeon
screw length and glide hole depth measurements. At least to see the spiral fracture as it propagates in the dorsal
the distal three screws should be placed in a lateromedial cortex and as the palmar component exits from the
orientation. Further proximally, the fracture configura palmar/plantar cortex into the lateral cortex.97 Direct
tion will determine screw lengths, but a guide can be fracture observation enables the surgeon to insert
obtained from appropriate radiographic projections. screws in a biomechanically optimal position along the
Temporary external coaptation should be applied in all entire length of the fracture.
cases in which a propagating fracture is a differential. The horse is positioned in lateral recumbency with the
This can be life‐saving (see Chapter 5). Commercial affected limb uppermost, extended, and horizontal.
compression boots frequently do not extend sufficiently Identification of fracture lines is facilitated by application
proximally to support the full length of the metacarpus/ of an Esmarch bandage. A tourniquet is then applied in
metatarsus. A bandage cast or splinted Robert Jones the distal antebrachium or crus. The limb should be fixed
bandage is preferred. These should extend to the level of in an extended position prior to this procedure, as the
the third carpal or central tarsal bones. Repair of propa tourniquet will cause limb flexion, which can compro
gating fractures should be undertaken with minimal mise drill alignment. Outward rotation of hindlimbs is
delay. In most cases analgesics offer minimal relief until controlled by support under the point of the hock. Skin
the fracture is compressed. Horses should remain preparation and draping should permit access to the
supervised and/or cross‐tied, as rising from recumbency fetlock joint and the whole length of the metacarpus/
presents a major risk for catastrophic displacement. metatarsus, including medial, dorsal, and lateral cortices.
Induction of anesthesia is safest with the horse posi A distolateral to proximodorsal curvilinear incision
tioned with the nonfractured side against the wall of the is made from the level of the metacarpophalangeal/
induction box. Two handlers ensure that the horse can metatarsophalangeal joint to a point on the diaphysis
slide down the induction box wall, while a third person proximal to the radiologically determined termination of
controls the fractured limb. Loading can be removed the fracture. Proximal to the joint capsule and collateral
entirely from a forelimb by flexing the carpus and ligament and lateral to the extensor tendons, the incision
supporting the distal limb as the animal begins to sink to is continued through the metacarpal/metatarsal fascia
the ground. Hindlimbs are more difficult to safely con and periosteum. This is reflected to permit inspection
trol, but should be kept under the horse’s body, making of the metacarpal/metatarsal cortex for fracture lines
particular effort to avoid limb abduction. (Figure 22.15). Preservation of the periosteum has
Figure 22.15 Open lateral approach to a spirally propagating fracture of the medial condyle of a third metacarpal bone. The periosteum
has been exposed and the lateral digital extensor tendon reflected with handheld retractors. The dorsal fracture line maintains a sagittal
course to the mid‐diaphysis before deviating medially (arrows). The palmar fracture line emerges from the lateral interosseous space in
the mid‐diaphysis (arrow heads) before coursing proximomedially.
www.ajlobby.com
advantages to bone healing in some circumstances.7,34 through the tendon substance, as incorporation will
However, in this situation it precludes identification of result in the formation of binding adhesions.
fracture lines, and as a consequence should be reflected up
to the lateral interosseous space between splint and MC/ Open Medial Approach
MT3, and beneath the lateral and common or long digital In a minority of cases with spiral configurations, the
extensor tendons. Hand‐held retractors are necessary to fracture in the palmar/plantar cortex will propagate
reflect the tendons and periosteum. Dissection extends medially while the dorsal defect remains parasagittal.
proximally until the fracture lines terminate; this fre This is usually apparent radiologically.97 In these cases a
quently is more proximal than the radiologically evident medial approach is appropriate, and should allow identi
limits.71,97 Subperiosteal and intracortical hemorrhage is fication of the fracture in both dorsal and palmar/plantar
common distally, but proximally fracture lines frequently cortices. Repair can then be effected using similar
are identified only as fine linear defects in the cortex. procedures to those described for the more commonly
Distal screw location and insertion are similar to those performed lateral approach. A medial approach is appro
described previously for nondisplaced fractures of the priate also for repair of propagating fractures of the
lateral condyle of MC/MT3. The distal aspects of medial condyle that remain sagittal or parasagittal (see
the third metacarpal and third metatarsal bones have a Figure 22.12).
dense medullary structure and thick cortices, particu
larly medially, so there is no perceptible difference Percutaneous Repair
in compression obtained by lag screw fixation of Two case series have reported percutaneous lag screw
a medial condylar fracture from the lateral aspect. repair of eight4 and nine85 propagating fractures with
Most medial condylar fractures originate adjacent to the medial4 and lateral85 approaches. One series described
sagittal ridge and leave substantial bone stock for the repair in three spiral MT3 and four sagittal MC3 frac
threaded screw engagement. tures,4 and the other comprised spiral fractures in three
Although the course of spiral fractures sometimes can MC3 and six MT3 bones.85 Neither group experienced
be predicted from preoperative radiographs and may fol catastrophic postoperative failure. By contrast, another
low predictable lines, radiographs are unreliable.97 study using a similar repair technique reported cata
Further propagation and/or inadequate repair with strophic fractures in 2 of 12 horses during recovery from
catastrophic consequences have been reported.16,71
anesthesia, and 3 of the 12 horses within four days of sur
Preoperative CT scan has emerged as a fast and reliable gery.71 All of the postoperative catastrophic fractures
screen between induction of anesthesia and surgical involved a mid‐diaphyseal Y configuration with varying
exposure. Intraoperative CT has also been described. degrees of comminution. As two dimensional radiologic
Cortical screws are inserted at 25–35 mm intervals, prediction of fracture configuration is generally poor and
using standard lag screw technique, from the epicondy prone to errors in interpretation,71,97 in the absence of
lar fossa to the proximal limit of the identifiable fracture CT mapping percutaneous fracture repair under general
(see Figures 22.11 and 22.13). Use of 4.5 mm screws is anesthesia is not recommended.
generally satisfactory (Wright), although one of the
authors prefers 5.5 mm screws, particularly in the distal Plate Fixation
aspect. When the fracture is visible in both cortices, Application of a neutralization plate to resist bending
screws are placed halfway between the fracture lines and forces and thus catastrophic propagation can be necessary
angled perpendicular to the anticipated fracture plane. If in those fractures with a mid‐diaphyseal Y or more com
the fracture is visible in the dorsal cortex only, screws are plex configuration.9,29,36 It also should be considered for
angled dorsolateral to palmar/plantaromedial to follow cases in which the fracture configuration cannot be deter
the spiral configuration of the fracture. Drilling should mined. The plate is used to increase the stability of the
avoid impingement on the second metacarpal/metatar repair and therefore lead to a reduction in catastrophic
sal bone. Intraoperative radiography may be used as postoperative fracture propagation. However, restoration
required, but should be performed at least once to check of distal articular congruency with lag screw fixation
screw lengths and trajectories. Screw number varies remains a critical initial step. A second surgery for plate
with fracture length. Four screws were used in parasagit removal is required if the horse is intended to race. Three
tal fractures and between five and nine screws in spiral case series involving dorsolateral,9,29 or dorsal,101 broad
fractures described in the literature.97 dynamic compression plates (DCPs) or locking compres
Wound closure includes metacarpal/metatarsal fascia, sion plates (LCPs) have been described.
subcutis/intradermal, and skin. The fascia may include For application of lateral, dorsolateral, or dorsal plates,
reflected periosteum; this is fragile and attempts at iso the horse is positioned in the same manner as a lateral lag
lated repair are futile. The extensor tendons should be screw approach. Two 4.5 or 5.5 mm cortical screws
apposed by suture of surrounding fascia, rather than are inserted distally from lateral to medial using lag
www.ajlobby.com
(A) (B) (C)
(D) (E) (F)
Figure 22.16 Plate repair of an unstable spiral condylar fracture in a three‐year‐old Thoroughbred colt, same case as Figure 22.14.
(A–C) Dorsopalmar, dorsomedial‐palmarolateral oblique, and lateromedial projections showing a complex, highly unstable, spiral third
metacarpal fracture extending from the metacarpophalangeal joint to the carpometacarpal joint. (D, E) Repair with a single 5.5 mm
independent cortical screw and a 13‐hole dynamic compression plate spiraled to track the fracture defined in the computed
tomography in Figure 22.14A. (F) Radiograph on day 14, showing good fracture reduction and screws of appropriate length to avoid
binding the second metacarpal into the repair.
www.ajlobby.com
technique, and using the landmarks described previ (A)

ously. A 10‐ or 12‐hole broad DCP, broad limited‐contact
dynamic compression plate (LC‐DCP), or LCP is then
applied to the lateral or dorsolateral diaphysis. This can
be done by an open approach or by a less invasive tech
nique following creation of a subcutaneous tunnel.36
Spiraling the laterally applied plate to follow the spiral of
the dorsal fracture line from dorsal to dorsomedial/
medial has been described,29 using either DCP or LCP
implants (Figure 22.16). The LCP does not rely on bone–
plate friction (contact) for stability and is superior but
expensive. Distal plate screws can also be placed in a lag
technique if permitted by the fracture configuration.
Fluoroscopy is essential if using the less invasive (B)
technique.
Repair of 22 propagating fractures of the metacarpal/
metatarsal condyles using minimally invasive percutane
ous plate osteosynthesis (MIPPO) has been reported.36
These comprised 10 medial MT3, 9 medial MC3, and 3
lateral MC3 fractures. Plates (DCP or LC‐DCP) were
inserted through 3 cm incisions made 2–3 cm distal to
the carpometacarpal or tarsometatarsal joint at the
intended proximal location of the plate. Incisions
extended through skin and metacarpal/metatarsal fascia
to the periosteum. A plate‐passing device fashioned by
sharpening the end of a broad DCP and fixing a handle
to the opposite end was used to create a tunnel for the
plate. Once it was positioned, stab incisions were made
over individual screw holes located by palpation and
aided by an overlying plate used as a guide. Fluoroscopy (C)
was used throughout to monitor screw placement. The
distal parasagittal portion of the fracture was repaired
initially, using two to four lateral to medial 4.5 mm corti
cal screws placed in a standard lag technique. A 10–14‐
hole broad DCP or LC‐DCP was then placed on the
dorsolateral surface of the third metacarpal/metatarsal
bone. When the fracture configuration permitted, distal
plate screws were placed in a lag technique. Sixteen
horses recovered from general anesthesia in a pool‐raft
system,88 and six in an Anderson sling (CDA Products,
Potter Valley, CA, USA). Postoperative exercise included
stall rest with hand walking for two months, followed by Figure 22.17 Minimally invasive locking compression plate
one month of restricted paddock turnout. (LCP) application to a spiral medial condylar fracture of the third
Use of a straight dorsolateral plate or a spiraled lateral metacarpus with an unstable Y configuration (see Figure 22.18).
to dorsolateral plate has been described for propagating (A) A distal 2 cm incision allows entry of forceps to expand a
MC/MT3 fractures.29 Most plates were implanted using subtendinous tunnel over the lateral and dorsolateral aspects of
the metacarpus. The fluoroscopy imaging system is incorporated
a minimally invasive approach, but the entry incision into the field to allow periodic assessment of reduction and
was located distally and the subcutaneous tunnel was screw placement. (B) The spiraled LCP is inserted using two
formed by an LCP with a handle fashioned on one end by stacked drill guides to form a handle. (C) Stab incisions allow
threading on two plate‐holding inserts (Figure 22.17). threaded drill guide insertion to provide locking screws that
Application of a contoured DCP was considered more follow the spiral of the dorsal fracture from sagittal to frontal
planes.
simple and cost‐effective than an LCP. Additionally,
www.ajlobby.com
working through stab incisions and dissecting beneath the epiphyseal and metaphyseal portions of the fracture
and around the lateral extensor tendon for threading in were repaired. Standard lag screw technique was uti
the locking screw drill guide can be laborious and com lized, with two or three 4.5 mm cortical screws. Both
pounded by soft tissues entrapped in the locking screw medial and lateral approaches were used, but the latter
threads. However, the LCP is more tolerant of inade was recommended. Final screw tightening is performed
quate plate contouring since it does not rely on plate- with the limb raised to maximize compression. A coun
bone contact for stability, and is therefore the plate of tersink was not used in the epicondylar fossa. The
choice for minimally invasive repair. The initial plate authors recorded profuse osseous hemorrhage during
screws in the LCP application should still be cortical drilling and with use of the countersink. The horses
screws (Figure 22.18), as for most LCP repairs, and sev were discharged from the clinic seven days after sur
eral additional screws along the plate should be cortical gery. No postoperative complications were reported.
screws applied using lag technique before application Treated horses received four months’ box stall rest
of the locked screws. Spiraling the plate provides con followed by one month of walking before paddock

sistent cortical screw insertion perpendicular to the frac turnout. Return to pretraining preparatory exercise

ture line to maximize compression and avoid inadvertent commenced an average of seven months postopera
entry of a cortical screw tip into the palmar or palmaro tively. All four animals raced again.63
medial fracture plane (Figure 22.18).29 The second case series described standing repair of
Plates are removed from horses which are intended diaphyseal propagating fractures of nine MC3 and four
to return to work; standing removal three months fol MT3 bones.82 These comprised six medial and one lat
lowing implantation has been recommended.29,36,101 eral spiral, and one medial and five lateral sagittal frac
Under sedation and regional analgesia, the screws are tures. The first five cases were sedated with detomidine
removed percutaneously. A separate identical plate hydrochloride and butorphanol tartrate, followed by
intermittently applied to the skin is useful as a guide to incremental boluses; in the subsequent eight cases this
screw head location during skin incision for screw was followed by a steady detomidine infusion. Both peri
removal. An incision is made at the proximal margin of neural and field local analgesic techniques were used.
the plate to permit elevation with a curved osteotome or Surgery was performed with the horse restrained in
chisel. It is then grasped (with vice grips or similar) and stocks. Cortical screws (4.5 mm) were inserted percuta
withdrawn. Following routine wound care, the horse neously using lag technique under radiographic guid
receives a further 60 days of walking exercise, followed ance. These were oriented lateral to medial in fractures of
by one month of paddock turnout before returning to the lateral condyle and vice versa. Between two and five
training. screws were used. All were countersunk except the most
distal in the condylar fossa. One fracture propagated cat
Standing Repair astrophically three days post‐surgery.82 The potential
Standing repair with radiographically guided percutane benefits accrued from avoiding general anesthesia (par
ous lag screws has been reported to eliminate the risk of ticularly recovery) are significant.71,72 This technique
catastrophic failure during recovery from general anes merits consideration, but compromises in the surgical
thesia.58,62,63,82 The limitations already described for environment are marked.
percutaneous screw repair still apply. In one study only
the radiologically identifiable portions of the fracture in Postoperative Care
the epiphysis and metaphysis were repaired,63 while in A pool system has been reported to reduce the com
another the diaphysis was included.82 A few horses plication rate associated with recovery from general
required implant removal. anesthesia (see Chapter 43).56,88 In the absence of a
Perez‐Olmos et al.63 described standing repair of pool or similar recovery system, the repaired limb is at
three medial and one lateral propagating fracture in substantial risk. Fractures that spiral are particularly
three MC3 and one MT3 bones. Horses were heavily susceptible to dorsopalmar/ plantar bending forces.
sedated with 10 mg each of detomidine hydrochloride These are inevitable as the horse rises. Efforts there
and butorphanol tartrate. Local analgesia of palmar/ fore should be made to limit struggling or explosive
plantar and palmar metacarpal/plantar metatarsal and activity during assisted recovery. A quiet recovery with
dorsal metatarsal nerves at proximal metacarpal/meta as few as possible attempts to stand is highly desirable.
tarsal (subcarpal/subtarsal) sites was supplemented by Well‐designed rope (head and tail) assisted recovery
subcutaneous ring blocks at the same level with mepiv systems operated by experienced p ersonnel can make a
acaine hydrochloride. Under radiographic guidance, valuable contribution (see Figure 43.1).
www.ajlobby.com
(A) (B) (C)
(E)
(D)
Figure 22.18 Plate repair of a propagating spiral fracture of the medial condyle of the third metacarpus in a three‐year‐old Standardbred
filly. (A, B) Dorsopalmar and flexed dorsopalmar projections show a parasagittal medial condyle fracture that deviates into an
asymmetrical Y configuration (arrows; arrowheads). (C) Dorsomedial‐palmarolateral oblique projection indicates multiple fracture lines
propagating proximally from the condylar fracture. (D, E) Surgical images shows minimally invasive locking compression plate (LCP)
application of locking drill guides for insertion of locked screws in the plate to follow the spiral contour. (F, G) Postoperative radiographs
on Day 1 showing spiral LCP application. Screw insertion into the second metacarpus has been avoided.
www.ajlobby.com
(F) (G) The term of cast immobilization varies. Restoration

of joint function requires the period of external immo
bilization to be minimized. This is paramount for full
limb casts, which should be removed 24–48 hours after
recovery from anesthesia, unless radiographs through
the cast indicate further propagating fracture planes
not adequately compressed by the plate or independent
screws.29 Where fractures do extend proximally beyond
the radiologically and surgically identified level, cast
support is recommended for two to four weeks. By this
time occult fracture line healing is likely to be radio
graphically recognizable through the cast. Reported
cast periods varied between means of 585 and 16 days
postoperatively.97
Marked symptomatic improvement should be expected
immediately postoperatively in all cases. Deteriorating
lameness demands prompt investigation. Nonsteroidal
anti‐inflammatory drugs provide adequate analgesia
and dose and duration vary on a case‐by‐case basis.
Phenylbutazone is the authors’ drug of choice.
Following cast removal, horses are confined to box
stalls for a period of not less than four weeks. Fracture
healing is monitored radiographically. Walking exer
cise commences when there is reasonable osseous
union and then gradually increased in intensity over an
eight‐week period. Commencement of walking exer
cise should not be delayed until osseous reorganiza
tion. This is a slow process that takes many months. In
Figure 22.18 (Continued) most horses it also requires the stimulus of exercise.
Reorganization includes reformation of uniform corti
cal density, remodeling, and corticalization of callus
with reestablishment of medullary cancellous infra
Full limb casts have been suggested for recovery structure (see Figures 22.11–22.13). Increasing periods
from general anesthesia.8,29,56,71 In one of the authors’ of ridden work dictated by radiographic progression of
experience (Wright), the difficulty in recovery that
healing are recommended as a further stimulus to
these impose and biomechanical complications that adaptation. Canter exercise usually can commence
they create preclude their safe use. However, full limb from approximately six months post‐surgery.
casts were successfully utilized in 8 of 30 horses in a
recent report, although half limb casts were preferred Complications
in an additional 18 horses.29 Half limb casts extending Instrument or implant breakage was recorded in 4 of 23
to the carpus or tarsus minimize bending forces on the (17%) cases during MIPPO.36 In 2 of 18 horses operated
metacarpus/metatarsus during recovery from general by a lateral approach for screw insertion, an oblique dor
anesthesia83 and have been used successfully.29,85,97 The solateral to palmaromedial screw in the mid‐diaphysis
authors recommend the use of casts, applied in a engaged the second metacarpal bone (see Figure 22.13).97
weight‐bearing (extended) distal limb angle. These Both horses were lame postoperatively, with clinical
enclose the foot and extend to the level of the third car signs localizing to this site, and both became sound after
pal or central tarsal bones (Figure 22.13). It is believed screw removal. Poor drilling and screw insertion tech
that this proximal location of the casts contributes nique can also fracture off a portion of the medial splint,
by transferring force from the metacarpus/metatarsus resulting in callus and delayed return to function.
to the carpus/tarsus. There were no failures using Postoperative fracture propagation following percutane
this technique in 27 reported cases.85,97 The authors do ous lag screw fixation was reported in 21.4% of cases in
not cross‐tie horses with repaired fractures supported one series16 and 42% in a second series of propagating
by a cast. fractures of the third metatarsal bone.71
www.ajlobby.com
No wound complications were reported with percu fixation under general anesthesia85 are not clear. One
taneous screw fixation.63,82,85 One of 18 horses treated group noted that the convalescent period for forelimbs
by the open lateral approach developed incisional drain (mean 14.2 months) was greater than for hindlimbs (mean
age that resolved following antimicrobial medication.97 7.8 months).82 Seven spiral fractures of MC/MT3 bones
Incisional infections were reported in 2 of 23 propagat treated by plate application had a mean time from surgery
ing fractures repaired by MIPPO, both following plate to their first race of 13.3 months.101
removal.36
Implant Removal
Results
In the authors’ experience, screws placed in laterome Pooling data in the literature indicated that of 30 horses
dial trajectories do not require removal unless associ repaired by plate application to third metacarpal/meta
ated with complications. Screws that are placed tarsal bones, 6 of 8 (75%) repaired by an open tech
obliquely and inadvertently impinge on the splint bones nique101 and 10 of 22 (45%) repaired by MIPPO36 raced
commonly require removal (see Figure 22.13). These following surgery. In the MIPPO series, 14 of 22 cases
can fracture the splint bone and, even without splint (64%) returned to training. Horses repaired using stand
fractures, usually will be associated with lameness, pro ing lag screw techniques fared better, with 4 of 4,63 10 of
liferative new bone formation, and pain on digital pres 16 (63%),62 and 8 of 13 horses (62%)82 racing following
sure at the emergent site(s). Additionally, screws that surgery. Standing repair was less satisfactory for third
engage dorsal and palmar/plantar cortices in repair of metacarpal medial condylar fracture, with only 2 of 5
fractures which have spiraled into frontal or oblique (40%) horses returning to race, compared to 8 of 11 (73%)
planes also require removal (see Figure 22.13). Fixation with lateral condylar fractures of MC/MT3.62 A series of
of dorsal and palmar/plantar cortices may result in MC3 and MT3 fractures repaired by percutaneous screw
lameness when horses return to training, due to insertion commencing lateral to medial resulted in 6 of 9
increased translational motion of the dorsal and palmar (67%) horses returning to training and 5 of 9 (56%) rac
cortices during intense activity.56,97 If animals are in less ing.85 A lateral open technique resulted in 14 of 18 (78%)
athletically demanding pursuits, then these are of little horses returning to training and 5 of 18 (28%) racing
or no consequence. after surgery.97
Elective implant removal is determined by fracture
healing and osseous reorganization, including recorti
calization of defects and reestablishment of corticomed Propagating Fractures
ullary demarcation. Neither has to be complete, but both of the Lateral Condyles
should be well established. When implants are removed,
some surgeons recommend that the most distal screw(s) Proximally propagating fractures of the lateral condyles
remain. This is said to reduce the risk of refracture in the are less common than those occurring medially, but cli
slow‐healing, palmar/plantar subchondral bone and nicians should be alert to their potential and associated
adjacent epiphysis. However, “refracture” has been seen clinical signs (Figure 22.20). Like their medial counter
in this location and in the contralateral condyle, despite parts, they originate close to the sagittal ridge. A spiral
leaving the distal screws in place (Figure 22.19). Standing component was evident in 2 of 81 (2.5%) fractures of the
removal has been suggested in order to avoid the risks of lateral condyles16 and the lateral condyle was involved
recovery from a second general anesthesia,56 and in one in 2 of 8 (25%) spiral fractures of the third metacarpal
series screws were removed from 3 of 9 cases in this bone.100 They were also recorded in 6 of 75 (8%) cata
manner. In a second series, screws were removed from 5 strophic fractures of the lateral condyles.61
of 18 (28%) horses, a mean of 144 days after repair. This Fractures of the lateral condyles of the third metacarpal/
was done under general anesthesia and horses recovered metatarsal bones that originate close to the sagittal ridge
in half limb casts.97 and reach the metaphysis should receive similar diagnos
tic and management considerations as those outlined for
Convalescence fractures of the medial condyle (Figures 22.20 and 22.21).
For propagating condylar fractures, the time from surgery
to the first race has been remarkably consistent in the lit
erature: open lateral approach with lag screw fixation Complex Fractures
11.6 months,97 less invasive plate fixation 11.6 months,36
and standing lag screw repair 11.8 months.82 The rea On occasion, and usually with conservatively managed
sons for the rather longer mean convalescent period fractures, only part of the fracture may heal. These
(14.5
months) recorded for percutaneous lag screw almost invariably include the diaphyseal and sometimes
www.ajlobby.com
(A) (B) (C)
(D) (E) (F)
Figure 22.19 Additional fracture through a previously healed condylar fracture. (A) Propagating fracture of the medial condyle of a third
metatarsal bone. (B) Healing three weeks after repair with four 4.5 mm cortical screws with lateral to medial trajectories. (C) Fracture of the
lateral condyle from the articular surface to the distal screw 14 months later. (D) Repair of the lateral fracture by insertion of a 3.5 mm
cortical screw. (E, F) Postoperative appearance on flexed dorsal 35° distal‐plantar proximal oblique (D35° Di‐PlPrO) projection and
lateromedial projection, respectively, 10 weeks after repair of the lateral fracture.
www.ajlobby.com
(A) (B) (C)
(D) (E) (F)
Figure 22.20 Spiraling propagating fracture of the lateral condyle of a third metacarpal bone. The animal presented with minimal weight
bearing on the affected limb and with pain on digital pressure over the lateral condyle and mid‐dorsal diaphysis. (A) A dorsopalmar
projection demonstrated an apparently incomplete fracture of the lateral condyle; however, careful scrutiny indicates a proximally
propagating (dorsal) parasagittal fracture (arrows). This was confirmed by open surgical evaluation, which revealed a spiral component to
the fracture. (B) Repair effected by insertion of six 4.5 mm cortical screws. (C, D) Radiographs six weeks post‐surgery illustrating the healing
propagating fracture and implant orientation. (E, F) Radiographs 26 weeks post‐surgery before screw removal.
metaphyseal components of fractures, with radiological Uncommonly, fractures of the metacarpal/metatarsal

nonunion or delayed union persisting in the epiphysis condyles can be biaxial (Figure 22.23). These usually are
(Figure 22.22). The symptomology associated with these comminuted, complicated by additional lesions, and,
is highly variable, but repair is advocated, particularly if when displaced, may become open. Fractures of the meta
resumption of athletic activity is required in order to carpal/metatarsal condyles also can present in conjunction
minimize the risk of propagation and refracture. Good with other severe, frequently catastrophic fractures
results have been obtained with standard lag screw tech (Figure 22.24). Salvage in such circumstances can be sur
niques (Figure 22.22). gically challenging and commonly is unsuccessful.
www.ajlobby.com
(A) (B) (C)
(D) (E) (F)
Figure 22.21 Spiraling fracture of the lateral condyle of a third metacarpal bone (arrows) in (A) Dorsopalmar projection. (B) Fracture
compressed with two AO large reduction forceps and needles placed at projected sites of screw placement. (C) Repair effected with
nine 4.5 mm cortical screws to follow the identified fracture plane. (D, E) Radiographic evaluation 14 days post‐surgery. Note extension of
the cast proximal to the carpometacarpal joint. (F) Radiographic evaluation four weeks post‐surgery, and (G, H) radiographs 24 weeks
post‐repair and six weeks following screw removal.
www.ajlobby.com
(G) (H)
(A) (B) (C) (D)
Figure 22.22 (A) Propagating fracture of the medial condyle of a third metacarpal bone initially managed conservatively. (B) Radiologic
appearance after 12 weeks of restricted exercise; the diaphyseal portion of the fracture exhibits good evidence of healing, while the
metaphyseal and epiphyseal portions exhibit characteristics of a delayed or nonunion. (C) Repair with a single 4.5 mm cortical screw with
a lateral to medial trajectory. (D) Healing at eight weeks post‐surgery.
www.ajlobby.com
(A) (B)
Figure 22.23 Biaxial fractures of third metacarpal condyles in (A) dorsopalmar (DP) and (B) flexed dorsal 35° distal‐palmar proximal
oblique (D35° Di‐PaPrO) projections; the lateral fracture is comminuted proximally and distally and is accompanied by an axial fracture of
the ipsilateral proximal sesamoid bone (arrows). The fracture in the medial condyle is more apparent in the flexed DP projection.
Figure 22.24 Comminuted displaced fracture of the lateral condyle of a third metatarsal bone with a comminuted, collapsing fracture of the
lateral aspect of the proximal phalanx, mediolateral proximal sesamoid bone dehiscence, and subluxation of the metatarsophalangeal joint.
www.ajlobby.com
References
1 Adams, S.B., Turner, T.A., Blevins, W.E., and Shamis, 13 Dyce, K.M., Sack, W.O., and Wensing, C.J.G. (2002).
L.D. (1985). Surgical repair of metacarpal condylar Textbook of Veterinary Anatomy, 3e, 568–605.
fractures with palmar osteochondral comminution in Philadelphia: Saunders.
two Thoroughbred horses. Vet. Surg. 14: 32–35. 14 Easton, K.L. and Kawcak, C.E. (2007). Evaluation of
2 Alexander, J.T. and Rooney, J.R. (1972). The increased subchondral bone density in areas of contact
biomechanics, surgery and prognosis of equine in the metacarpophalangeal joint during joint loading
fractures 1967–1971. In: Proceedings of the American in horses. Am. J. Vet. Res. 68: 816–821.
Association of Equine Practitioners, vol. 18, 219–236. 15 Einhorn, T.A. (1998). The cell and molecular biology
Lexington, KY: AAEP. of fracture healing. Clin. Orthop. Relat. Res. 355S:
3 Barclay, W.P., Foerner, J.J., and Phillips, T.N. (1985). 7–21.
Axial sesamoid injuries associated with lateral condylar 1 6 Ellis, D.R. (1994). Some observations on condylar
fractures in horses. J. Am. Vet. Med. Assoc. 186: 278–279. fractures of the third metacarpus and third
4 Barr, A.R.S., Sridhar, B., and Denny, H.R. (1989). Long metatarsus in young Thoroughbreds. Equine Vet. J.
incomplete longitudinal fractures of the third 26: 178–183.
metacarpal and metatarsal bone in horses. Vet. Rec. 17 Estberg, L., Stover, S.M., Gardner, I.A. et al. (1998).
124: 580–582. Relationship between race start characteristics
5 Bassage, L.H. and Richardson, D.W. (1998). Longitudinal and risk of catastrophic injury in Thoroughbreds:
fractures of the condyles of the third metacarpal and 78 cases (1992). J. Am. Vet. Med. Assoc. 212:
metatarsal bones in racehorses: 224 cases (1986–1995). 544–549.
J. Am. Vet. Med. Assoc. 212: 1757–1764. 18 Evans, G.P., Behiri, J.C., Vaughan, L.C., and Bonfield,
6 Bathe, A.P. (1994). 245 Fractures in Thoroughbred W. (1992). The response of equine cortical bone to
racehorses: results of a 2‐year prospective study in loading at stain rates experienced in vivo by the
Newmarket. In: Proceedings of the American galloping horse. Equine Vet. J. 24: 125–128.
Association of Equine Practitioners, vol. 40, 175–176. 19 Ferraro, G.L. (1990). Lameness diagnosis and treatment
Lexington, KY: AAEP. in the Thoroughbred racehorse. Vet. Clin. North Am.
7 Baumgaertel, F., Buhl, M., and Rahn, B.A. (1998). Equine Pract. 6: 63–84.
Fracture healing in biological osteosynthesis. Injury 29: 20 Firth, E.C. and Rogers, C.W. (2005). Musculoskeletal
SC3–SC6. response of 2‐year‐old Thoroughbred horses to early
8 Bertone, A.L. (2002). The metacarpus and training. Conclusions. N. Z. Vet. J. 53: 377–383.
metatarsus. In: Adams’ Lameness in Horses, 5e 21 Foerner, J.J. and McIlwraith, C.W. (1990). Orthopaedic
(ed. T.S. Stashak), 800–830. Baltimore: Lippincott, surgery in the racehorse. Vet. Clin. North Am. Equine
Williams & Wilkins. Pract. 6: 147–178.
9 Bowman, K.F., Sweeney, C.L., and Tate, L.P. Jr. (1987). 22 Galuppo, L.D., Simpson, E.L., Greenman, S.L. et al.
Compression bone plating of a medial condylar fracture (2006). A clinical evaluation of a headless, titanium,
of the third metatarsal bone in a Thoroughbred filly. variable‐pitched, tapered, compression screw for repair
J. Am. Vet. Med. Assoc. 190: 305–307. of nondisplaced lateral condylar fractures in
10 Boyde, A., Haroon, Y., Jones, S.J., and Riggs, C.M. Thoroughbred racehorses. Vet. Surg. 35: 423–430.
(1999). Three dimensional structure of the distal 23 Galuppo, L.D., Stover, S.M., and Jensen, D.G. (2002).
condyles of the third metacarpal bone of the horse. A biomechanical comparison of equine third
Equine Vet. J. 31: 122–129. metacarpal condylar bone fragment compression and
11 Cruz, A.M. and Hurtig, M.B. (2008). Multiple screw upshot strength between headless tapered
pathways to osteoarthritis and articular fractures: is variable pitch and AO cortical bone screws. Vet. Surg.
subchondral bone the culprit? Vet. Clin. Equine 24: 31: 201–210.
101–116. 24 Galuppo, L.D., Stover, S.M., Jensen, D.G., and
12 Drum, M.G., Kawcak, C.E., Norrdin, R.W. et al. (2007). Willits, N.H. (2001). A biomechanical comparison of
Comparison of gross and histopathologic findings with headless tapered variable pitch and AO cortical bone
quantitative computed tomographic bone density in the screws for fixation of a stimulated lateral condylar
distal third metacarpal bone of racehorses. Vet. Radiol. fracture in equine third metacarpal bones. Vet. Surg.
Ultrasound 48: 518–527. 30: 332–340.
www.ajlobby.com
25 Getty, T. (1975). Equine osteology. In: Sisson and 36 James, F.M. and Richardson, D.W. (2006). Minimally
Grossman’s The Anatomy of the Domestic Animal, invasive plate fixation of lower limb injury in horses: 32
5e (ed. R. Getty), 255–348. Philadelphia: cases (1999–2003). Equine Vet. J. 38: 246–251.
W.B. Saunders Co. 37 Johnson, B.J., Stover, S.M., Daft, B.M. et al. (1994).
26 Ghoshal, N.G. (1975). Equine heart and arteries. In: Causes of death in racehorses over a 2 year period.
Sisson and Grossman’s The Anatomy of Domestic Equine Vet. J. 26: 327–330.
Animals, 5e (ed. R. Getty), 554–618. Philadelphia: W.B. 38 Kainer, R.A. (2002). Functional anatomy of equine
Saunders Co. locomotor organs. In: Adams’ Lameness in Horses, 5e
27 Ghoshal, N.G. (1975). Equine nervous system: spinal (ed. T.S. Stashak), 1–72. Lippincott, Williams &
nerves. In: Sisson and Grossman’s The Anatomy of Wilkins.
Domestic Animals, 5e (ed. R. Getty), 665–688. 39 Kane, A.J., Stover, S.M., Gardner, I.A. et al. (1996).
Philadelphia: W.B. Saunders Co. Horseshoe characteristics as possible risk factors for
28 Giannoudis, P.V., Einhorn, T.A., and Marsh, D. (2007). fatal musculoskeletal injury of Thoroughbred
Fracture healing: the diamond concept. Injury 38 (54): racehorses. Am. J. Vet. Res. 57: 1147–1152.
53–56. 40 Kawcak, C.E., Bramlage, L.R., and Embertson, R.M.
29 Goodrich, L.R., Nixon, A.J., Conway, J.D. et al. (2014). (1995). Diagnosis and management of incomplete
Dynamic compression plate (DCP) fixation of fracture of the distal palmar aspect of the third
propagating medial condylar fractures of the third metacarpal bone in five horses. J. Am. Vet. Med. Assoc.
metacarpal/metatarsal bone in 30 racehorses: 206: 335–337.
retrospective analysis (1990–2005). Equine Vet. J. 41 Kawcak, C.E., McIlwraith, C.M., Norrdin, R.W. et al.
46: 695–700. (2000). Clinical effects of exercise on subchondral bone
30 Greet, T.R.C. (1987). Condylar fracture of the cannon of carpal and metacarpophalangeal joints in horses.
bone with axial sesamoid fracture in three horses. Am. Vet. J. Res. 61: 1252–1258.
Vet. Rec. 120: 223–225. 42 Krook, L. and Maylin, G.A. (1988). Fractures in
31 Herthel, D.J., Moody, J.L., and Lauper, L. (1995). Thoroughbred race horses. Cornell Vet. 78: 1–133.
The repair of condylar fractures of the third 43 Le Jeune, S.S., Macdonald, M.H., Stover, S.M. et al.
metacarpal bone and the third metatarsal bone (2003). Biomechanical investigation of the association
using the Herbert compression screw in between suspensory ligament injury and lateral
nine Thoroughbred racehorses. Equine Pract. 17: condylar fracture in Thoroughbred racehorses.
6–12. Vet. Surg. 32: 585–597.
32 Hill, A.E., Gardner, I.A., Carpenter, T.E., and 44 Lloyd, D., Johanson, C., and Phillips, T.J. (2008).
Stover, S.M. (2004). Effects of injury to the Treatment of medial condylar fractures of the third
suspensory apparatus, exercise, and horseshoe metatarsus in three horses with fiberglass casts
characteristics on the risk of lateral condylar under standing neuroleptanalgesia. Vet. Rec. 162:
fracture and suspensory apparatus failure in 586–589.
forelimbs of Thoroughbred racehorses. Am. J. Vet. Res. 45 Loughridge, A.B., Hess, A.M., Parkin, T.D., and
65: 1508–1516. Kawcak, C.E. (2017). Qualitative assessment of
33 Hornof, W.J. and O’Brien, T.R. (1980). Radiographic bone density at the distal articulating surface of the
evaluation of the palmar aspect of the equine third metacarpal in Thoroughbred racehorses with
metacarpal condyles: a new projection. Vet. Radiol. and without condylar fracture. Equine Vet. J. 49:
21: 161–167. 172–177.
34 Horstman, C.L., Beale, B.S., and Conzemius, M.G. 46 Martin, G.S. (2000). Factors associated with racing
(2004). Biological osteosynthesis versus traditional performance of Thoroughbreds undergoing lag screw
anatomic reconstruction of 20 long‐bone fractures repair of condylar fractures of the third metacarpal or
using an interlocking nail: 1994–2001. Vet. Surg. 33: metatarsal bone. J. Am. Vet. Med. Assoc. 217:
232–237. 1870–1877.
35 Jacklin, B.D. and Wright, I.M. (2012). Frequency 47 McIlwraith, C.W., Nixon, A.J., and Wright, I.M. (2015).
distributions of 174 fractures of the distal condyles Diagnostic and surgical arthroscopy of the
of the third metacarpal and metatarsal bones in 167 metacarpophalangeal and metatarsophalangeal joints.
Thoroughbred racehorses (1999‐2009). Equine Vet. J. In: Diagnostic and Surgical Arthroscopy in the Horse,
44: 707–713. 4e, 111–174. Saunders.
www.ajlobby.com
48 McIlwraith, C.W. and Turner, A.S. (1987). Equine 62 Payne, R.J. and Compston, P.C. (2012). Short‐ and
Surgery Advanced Techniques, 71–77. Philadelphia: long‐term results following standing fracture repair in
Lea and Febiger. 34 horses. Equine Vet. J. 44: 721–725.
49 McKee, S.L. (1995). An update on racing fatalities in 63 Perez‐Olmos, J.F., Schofield, W.L., McGovern, F. et al.
the UK. Equine Vet. Educ. 7: 202–204. (2006). Standing surgical treatment of spiral
50 McKibbin, B. (1978). The biology of fracture healing in longitudinal metacarpal and metatarsal condylar
long bones. J. Bone Joint Surg. 60‐B: 150–162. fractures in 4 horses. Equine Vet. Educ. 18: 309–313.
51 Meagher, D.M. (1976). Lateral condylar fractures of the 64 Pilsworth, R.C., Hopes, R., and Greet, T.C.R. (1988). A
metacarpus and metatarsus in horses. In: Proceedings of flexed dorso‐palmar projection of the equine fetlock in
the American Association of Equine Practitioners, vol. demonstrating lesions of the distal third of the
22, 147–154. Lexington, KY: AAEP. metacarpus. Vet. Rec. 122: 332–333.
52 Mitchell, N. and Shepard, N. (1980). Healing of 65 Pinilla, M.J., Tranquille, C.A., Blunden, A.S. et al.
articular cartilage in intra‐articular fractures in rabbits. (2017). Histological features of the distal third
J. Bone Joint Surg. 62‐A: 628–634. metacarpal bone in Thoroughbred racehorses, with
53 Mohammed, H.O., Hill, T., and Lowe, J. (1991). and without lateral condylar fractures. J. Comp.
Risk factors associated with injuries in Thoroughbred Pathol. 157: 1–10.
horses. Equine Vet. J. 23: 445–448. 66 Pool, R.R. (1999). Multidisciplinary investigation of the
54 Morgan, J.W., Santschi, E.M., Zekas, L.J. et al. (2006). aetiopathogenesis of parasagittal fractures of the third
Comparison of radiography and computed metacarpal and metatarsal bones of Thoroughbreds.
tomography to evaluate metacarpo/ Equine Vet. J. 31: 96.
metatarsophalangeal joint pathology of paired limbs 67 Pool, R.R. and Meagher, D.M. (1990). Pathogenic
of Thoroughbred racehorses with severe condylar findings and pathogenesis of racetrack injuries. Vet.
fracture. Vet. Surg. 35: 611–617. Clin. North Am. Equine Pract. 6: 1–29.
55 Norrdin, R.W., Kawcak, C.E., Capwell, B.A., and 68 Pratt, G.M. (1982). The response of highly stressed
McIlwraith, C.W. (1998). Subchondral bone failure in bone in the racehorse. In: Proceedings of the American
an equine model of overload arthrosis. Bone 22: Association of Equine Practitioners, vol. 28, 31–37.
133–139. Lexington, KY: AAEP.
56 Nunamaker, D.M. (1999). Diseases of the metacarpus 69 Radtke, C.K., Danova, N.A., Scollay, M.C. et al. (2003).
and metatarsus: fractures of the third metacarpal and Macroscopic changes in the distal ends of the third
third metatarsal bones. In: Equine Medicine and metacarpal and metatarsal bones of Thoroughbred
Surgery, 5e (ed. P.T. Colahan, I.G. Mayhew, A.M. racehorses with condylar fractures. Am. J. Vet. Res. 64:
Merritt and J.N. Moore), 1587–1594. Maryland 1110–1116.
Heights: Mosby. 70 Rahm, C., Ito, K., and Auer, J. (2000). Screw fixation
57 O’Brien, T.R., Hornof, W., and Meagher, D.M. (1981). in lag fashion of equine cadaveric metacarpal and
Radiographic detection and characterisation of the metatarsal condylar bone specimens: a biomechanical
palmar lesions in the equine fetlock joint. J. Am. Vet. comparison of shaft and cortex screws. Vet. Surg. 29:
Med. Assoc. 178: 231–237. 564–571.
58 O’Brien, T. and Hunt, R.J. (2014). Recent advances in 71 Richardson, D.W. (1984). Medial condylar fractures of
standing equine orthopedic surgery. Vet. Clin. North the third metatarsal bone in horses. J. Am. Vet. Med.
Am. Equine Pract. 30: 221–237. Assoc. 185: 761–765.
59 Parkin, T.D.H., Clegg, P.D., French, N.P. et al. (2004). 72 Richardson, D.W. (2006). The metacarpal and
Horse‐level risk factors for fatal distal limb fracture in metatarsal bone. In: Equine Surgery, 3e (ed. J.A. Auer
racing Thoroughbreds in the UK. Equine Vet. J. 36: and J.A. Stick), 1231–1253. Philadelphia, PA:
513–519. Saunders.
60 Parkin, T.D.H., Clegg, P.D., French, N.P. et al. (2004). 73 Rick, M.C., O’Brien, T.R., Pool, R.R., and Meagher, D.
Race‐ and course‐level risk factors for fatal distal limb (1983). Condylar fractures of the third metacarpal bone
fracture in racing Thoroughbreds. Equine Vet. J. 36: and third metatarsal bone in 75 horses: radiographic
521–526. features, treatments, and outcome. J. Am. Vet. Med.
61 Parkin, T.D.H., Clegg, P.D., French, N.P. et al. (2006). Assoc. 183: 287–296.
Catastrophic fracture of the lateral condyle of the third 74 Riggs, C.M. (1999). Aetiopathogenesis of parasagittal
metacarpus/metatarsus in UK racehorses – fracture fractures of the distal condyles of the third metacarpal
descriptions and pre‐existing pathology. Vet. J. 171: and third metatarsal bones – review of the literature.
157–165. Equine Vet. J. 31: 116–120.
www.ajlobby.com
75 Riggs, C.M. and Boyde, A. (1999). Effect of exercise on 87 Stover, S.M., Deryck, H.R., Johnson, B.J. et al. (1994).
bone density in distal regions of the equine third Lateral condylar fracture histomorphology in racehorses.
metacarpal bone in 2‐year‐old Thoroughbreds. Equine In: Proceedings of the American Association of Equine
Vet. J. 30: 555–560. Practitioners, vol. 40, 173. Lexington, KY: AAEP.
76 Riggs, C.M., Whitehouse, G.H., and Boyde, A. (1999). 88 Sullivan, E.K., Klein, L.V., Richardson, D.W. et al.
Structural variation of the distal condyles of the third (2002). Use of a pool‐raft system for recovery of horses
metacarpal and third metatarsal bones in the horse. from general anaesthesia: 393 horses (1984–2000).
Equine Vet. J. 31: 130–139. J. Am. Vet. Med. Assoc. 221: 1014–1018.
77 Riggs, C.M., Whitehouse, G.H., and Boyde, A. (1999). 89 Tapprest, J., Audigie, F., Radier, C. et al. (2003). Magnetic
Pathology of the distal condyles of the third metacarpal resonance imaging for the diagnosis of stress fractures
and third metatarsal bones of the horse. Equine Vet. J. in a horse. Vet. Radiol. Ultrasound 44: 438–442.
31: 140–148. 90 Thomason, J.J. (1985). The relationship of structure
78 Rooney, J.R. (1974). Distal condylar fractures of the to mechanical function in the third metacarpal bone
cannon bone in the horse. Mod. Vet. Pract. 55: of the horse, Equus caballus. Can. J. Zool. 63:
113–114. 1420–1428.
79 Rubin, C.T. and Lanyon, L.E. (1982). Limb mechanics 91 Tranquille, C.A., Murray, R.C., and Parkin, T.D. (2017).
as a function of speed and gait: a study of functional Can we use subchondral bone thickness on high‐field
strains in the radius and tibia of horse and dog. J. Exp. magnetic resonance images to identify Thoroughbred
Biol. 101: 187–211. racehorses at risk of catastrophic lateral condylar
80 Rubio‐Martinez, L.M., Cruz, A.M., Gordon, K., and fracture? Equine Vet. J. 49: 167–171.
Hurtig, M.B. (2008). Structural characterization of 92 Tranquille, C.A., Parkin, T.D., and Murray, R.C. (2012).
subchondral bone in the distal aspect of third Magnetic resonance imaging‐detected adaptation
metacarpal bones from Thoroughbred racehorses via and pathology in the distal condyles of the third
micro‐computed tomography. Am. J. Vet. Res. 69: metacarpus, associated with lateral condylar fracture
1413–1422. in Thoroughbred racehorses. Equine Vet. J. 44:
81 Rubio‐Martinez, L.M., Cruz, A.M., Gordon, K., and 699–706.
Hurtig, M.B. (2008). Mechanical properties of 93 Trope, G.D., Ghasem‐Zadeh, A., Anderson, G.A.
subchondral bone in the distal aspect of third et al. (2015). Can high‐resolution peripheral
metacarpal bones form Thoroughbred racehorses. quantitative computed tomography imaging of
Am. J. Vet. Res. 69: 1423–1433. subchondral and cortical bone predict condylar
82 Russell, T.M. and Maclean, A.A. (2006). Standing fracture in Thoroughbred racehorses? Equine Vet. J.
surgical repair of propagating metacarpal and 47: 428–432.
metatarsal condylar fractures in racehorses. Equine 94 Turner, A.S. (1977). Surgical repair of fractures of the
Vet. J. 38: 423–427. third metatarsal bones in a Standardbred gelding.
83 Schneider, R.K. and Jackman, B.R. (1996). Fractures of J. Am. Vet. Med. Assoc. 171: 655–658.
the third metacarpus and metatarsus. In: Equine 95 Whitton, R.C., Trope, G.D., Ghasem‐Zadeh, A.
Fracture Repair, 1e (ed. A.J. Nixon), 179–194. et al. (2010). Third metacarpal condylar fatigue
Philadelphia: Saunders. fractures in equine athletes occur within previously
84 Shepherd, M.C. and Pilsworth, R.C. (1997). Stress modelled subchondral bone. Bone 47: 826–831.
reactions to the plantarolateral condyles of MtIII in 96 Wilson, J.H., Howe, S.B., and Jensen, R.C. (1993).
UK Thoroughbreds: 26 cases. In: Proceedings of the Injuries sustained during racing at racetracks in the
American Association of Equine Practitioners, vol. 43, US in 1992. In: Proceedings of the American Association
127–131. Lexington, KY: AAEP. of Equine Pracitioners, vol. 39, 267–268. Lexington,
85 Smith, L.C.R., Greet, T.C.R., and Bathe, A.P. (2009). KY: AAEP.
A lateral approach for screw repair in lag fashion 9 7 Wright, I.M. and Smith, M.R.W. (2009). A lateral
of spiral third metacarpal and metatarsal approach to the repair of propagating fractures of the
medial condylar fractures in horses. Vet. Surg. 38: medial condyle of the third metacarpal and
681–688. metatarsal bone in 18 racehorses. Vet. Surg. 38:
86 Stepnik, M.W., Radtke, C.K., Scollay, M.C. et al. (2004). 689–695.
Scanning electron microscopic examination of third 98 Yoshihara, T., Keneko, M., Oikawa, M. et al. (1989).
metacarpal/third metatarsal bone failure surfaces in An application of the image analyser to the soft
Thoroughbred racehorses with condylar fracture. Vet. radiogram of the third metacarpus in horses. Jpn. J. Vet.
Surg. 33: 2–10. Sci. 51: 184–186.
www.ajlobby.com
99 Yovich, J., Turner, A.S., and Smith, F.W. (1985). metatarsal condyles in 135 horses in central Kentucky
Holding power of orthopaedic screws in equine third (1986–1994). Equine Vet. J. 31: 304–308.
metacarpal and metatarsal bones. Part II: Adult horse 01 Zekas, L.J., Bramlage, L.M., Embertson, R.M.,
1
bones. Vet. Surg. 14: 320–324. and Hance, S.R. (1999). Results of treatment of
00 Zekas, L.J., Bramlage, L.M., Embertson, R.M., and
1 145 fractures of the third metacarpal/metatarsal
Hance, S.R. (1999). Characterisation of the type and condyles in 135 horses (1986–1994). Equine Vet. J.
location of fractures of the third metacarpal/ 31: 309–313.
www.ajlobby.com
425
23
Arthrodesis of the Metacarpo/
Metatarsophalangeal Joint
Larry R. Bramlage
Introduction degenerate limb for protection of the opposite limb from

overload laminitis.
There are two primary indications for surgical arthrode- Voluntary splinting of the fetlock joint by the horse is not
sis of the fetlock joint: anatomic crippling of the joint to possible. It is a totally passive joint, particularly during full
the point that joint function is disabled and weight bear- extension.3 If weight bearing occurs, the fetlock joint will
ing is not possible, and functional crippling of the joint move, because the horse has no muscular control to reduce
to the extent that joint function cannot occur without joint motion and therefore cannot decrease the pain and
excessive pain and the horse chooses not to use the joint. aid in healing. Pain in a joint is the product of the arthritis
Conditions that result in anatomic crippling of the fet- and motion of the joint. It is preferable to eliminate or
lock joint include traumatic disruption of the suspensory mitigate the arthritis, but if degeneration is irreversible,
apparatus of the fetlock joint, permanent nonresponsive the only option is to eliminate the motion by surgical fusion
flexor contraction or laxity, fractures of the distal of the joint (arthrodesis). If the motion is eliminated in a
aspect of the third metacarpus/metatarsus (MC/MT3) painful end-stage joint, the pain is eliminated.
or proximal phalanx that cannot be reconstructed to the Degeneration of the articular surface of the sesamoid
point of function, and severe angulation as a result of bones and asymmetric degeneration of one of the con-
growth deformity or malunion of a traumatic injury.4,6,9 dyles of the distal aspect of MC/MT3 and proximal
Conditions that cause functional crippling include previ- aspect of the proximal phalanx, to the point of asymmet-
ous infectious arthritis or ongoing degenerative arthritis ric collapse of the joint surface, are particularly difficult
that has resulted in destruction of the joint and causes conditions for the horse to survive because of the pain,
such severe pain within the fetlock joint on weight bear- and the horse will choose not to use the limb (Figure 23.1).
ing that the horse chooses not to use the joint because of With this scenario, arthrodesis to protect the opposite
the pain. In both conditions, the necessary goal is to limb is indicated. Any severely painful fetlock joint that
restore function in the affected limb to prevent laminitis creates markedly asymmetric weight bearing and
from overload weight bearing in the opposite good limb. increased weight bearing of the opposite limb can be an
Degenerative arthritis of the fetlock joint to the point indication for fetlock arthrodesis.
that pain‐free weight bearing cannot occur happens pri- Advanced fetlock degenerative joint disease frequently
marily in cases where previous infectious arthritis or has a chronic history, with more recent exacerbation
rapidly progressing degenerative arthritis has created prompting the decision for surgical fusion of the joint. A
severe arthritic change, and comfortable weight bearing standard series of four radiographs reveals the extent of
is not possible. In most natural occurrences of slow joint dysfunction. Extensive periarticular osteophyte
degeneration of the fetlock joint, the process is accompa- production, subchondral sclerosis with areas of lysis, and
nied by ankylosis, which attempts to eliminate the pain collapse of the joint space are common radiographic fea-
by stiffening the joint naturally through elimination of tures (see Figure 23.1). Marked narrowing of the medial
joint motion. However, if degeneration occurs more rap- joint space predominates, resulting in varus angulation
idly than the horse can accommodate and the horse of the fetlock. These horses continue to clinically deteri-
refuses to use the joint, then arthrodesis can be used as a orate and many joints are fused simply to improve the
means of reestablishing pain‐free weight bearing on the pain status of the horse.

www.ajlobby.com
Anatomic crippling of the fetlock joint disables it to

the point that the horse cannot bear weight, even if it
chooses to try. Traumatic disruption of the suspensory
apparatus of the fetlock joint is the most common exam-
ple of this situation. This involves rupture of one of the
components of the suspensory apparatus. The damage
can occur (i) to the suspensory ligament proximal to the
sesamoid bones; (ii) through the sesamoid bones with
fractures of both sesamoids; (iii) below the sesamoids
through the distal sesamoidean ligaments; or (iv) through
combinations of these that disable both the medial and
lateral halves of the suspensory apparatus.
Diagnosis
Appropriate diagnostic radiographs and clinical examina-
tion are performed to assist in the decision for surgery. A
complete series of fetlock radiographs provides informa-
tion relative to the extent of end‐stage degenerative joint
disease, or alternatively, in horses suffering breakdown
Figure 23.1 Dorsopalmar radiograph obtained prior to injuries, radiographs indicate the region of the suspensory
arthrodesis to treat intractable lameness associated with apparatus that has been disrupted. Fracture and distrac-
advanced degenerative joint disease. The joint has collapsed tion of both the lateral and medial sesamoid bones in the
medially, resulting in varus angulation to the distal limb. fetlock are the most common catastrophic suspensory
apparatus disruption (Figure 23.2). Radiographs confirm
(A) (B)
Figure 23.2 Dorsopalmar (A) and lateromedial (B) radiographs of a horse with comminuted fracture of both lateral and medial proximal
sesamoid bones, resulting in complete disruption of the suspensory apparatus.
www.ajlobby.com
23 Arthrodesis of Metacarpo/Metatarsophalangeal Joint 427
Figure 23.3 Comminuted fracture of the sesamoid bones with

concurrent tearing of the intersesamoidean ligament, allowing
abaxial displacement of one of the sesamoids.
Figure 23.4 Fetlock breakdown associated with rupture of the

the bony disintegration and allow evaluation of other suspensory ligament proximal to the fetlock, resulting in distal
regions of the fetlock which may also be fractured. displacement of the proximal sesamoid bones, and
hyperextension of the joint.
Dorsopalmar, lateromedial, and both oblique projections
provide information on the integrity of remaining por-
tions of the sesamoid bones. Larger basal portions are par-
ticularly useful in the reestablishment of the distal Preoperative radiographs also frequently define the prog-
sesamoidean tension band when incorporated into the nosis more clearly. Involvement of the suspensory ligament
arthrodesis repair by lag screw attachment of these frag- generally provides a more favorable prognosis than distal
ments to the palmar surface of the third metacarpal con- sesamoidean tears. Additionally, suspensory ligament inju-
dyle. Fractures of both proximal sesamoids are generally ries can often be managed without surgery, and both of
comminuted, with considerable separation of the sesa- these factors are critical to the surgical decision.
moid fragments (Figure 23.2). The fetlock is concurrently
hyperextended. Separation of major portions of the sesa-
moids can also develop, with rupture of the intersesa- irst Aid and Preoperative
F
moidean ligament (Figure 23.3). Support
Where the sesamoid bones are intact, the radiographic
position of these bones in relation to the joint is vital in Appropriate first aid splinting and support of the fetlock
determining whether the suspensory ligament or the distal joint after traumatic disruption of the suspensory appara-
sesamoidean ligaments are disrupted. Distal displacement tus are particularly important to prevent hyperelongation
of the sesamoid bones implicates release of the proximal of the digital arteries, which supply blood to the foot.7
support of the suspensory ligament (Figure 23.4), com- Immediate care following acute fetlock breakdown inju-
pared to a proximal location of the bones which is char- ries frequently dictates whether fetlock arthrodesis is an
acteristic of distal sesamoidean ligament disruption option for salvage. Rapid swelling of the adjacent soft tis-
(Figure 23.5). Ultrasonographic examination can provide sues and hyperextension of the fetlock result in tension
additional information concerning the degree of damage to on the palmar neurovascular structures. Uncorrected,
the suspensory ligament or distal sesamoidean ligaments. this can lead to avascular necrosis of the distal limb, and
www.ajlobby.com
Adequately treated in the acute phase, many horses

can be removed to a surgical facility for definitive X‐rays
and an adequate discussion of the options for treatment.
The lack of support on the palmar/plantar aspect of a
limb with an injured suspensory apparatus overstretches
the vessels, encouraging thrombosis if hyperextension
is allowed to persist. Therefore, splinting to prevent
the hyperextension and align the bony column of the
MC/MT3 and phalanges is imperative.
Contraindications for fetlock arthrodesis include avas-
cularity of the distal limb (indicated by a cold limb that
does not bleed when punctured with a needle), preexist-
ing serious infection, lack of the potential for a second
career, and laminitis in the opposite limb to the point
that the horse cannot survive, even if the arthrodesis is
successful. If the vascular damage to the limb distal to
the injury is so severe as to preclude survival of the foot
and other structures, there is no point in fusing the fet-
lock joint. Surgery should be delayed to allow appropri-
ate therapy to restore normal blood supply to the distal
limb, if possible. The author recommends anticoagulants
and antithrombotics such as heparin, plavix, aspirin, and
pentoxifylline. After a viable blood supply is restored,
surgery can take place.
Preoperative anti‐inflammatory agents such as phenylb-
utazone (4.4 mg kg−1 twice a day) are started immediately
after injury. If surgery is a likely option, preoperative anti-
biotics are commenced at least two hours before induc-
tion. The presence of questionable vascularity to the limb
Figure 23.5 Rupture of the distal sesamoidean ligaments with increases the need for broad‐spectrum antibiotics, and
disruption of the suspensory apparatus and proximal
longer courses of therapy than would otherwise be neces-
displacement of the proximal sesamoid bones.
sary. Intravenous potassium penicillin (30 000 U kg−1) or a
cephalosporin (cefazolin 11 mg kg−1), combined with an
eliminate the possibility of salvage. Reputable racetracks aminoglycoside such as gentamicin (2.2 mg kg−1 intrave-
and many attending veterinarians carry splints that pro- nously) or amikacin (7 mg kg−1 intravenously), are fre-
vide support to the distal limb, and particularly prevent quent choices. Antibiotic regimens such as these are
fetlock extension, thereby protecting the blood supply to expensive and, combined with the cost of surgery and
the limb distal to the fetlock. Splints that prevent hyper- prolonged aftercare, result in a substantial investment in
extension reduce the tension on the structures of the back salvaging the horse. Where surgery is selected, 12–24 hours
of the limb.8 If unsupported weight bearing is allowed can safely elapse to allow the stress of the injury to dissipate
with traumatic disruption of the suspensory apparatus, and the horse to recover from transportation, provided
overstretching of the arteries and thrombosis of the blood that the limb has been well protected since injury.
supply frequently occur. First aid support for the limb, Questionable areas of skin may declare themselves within
which aligns the dorsal cortex and prevents extension of an additional 72 hours.
the fetlock joint, and antithrombotic therapy are impor-
tant to protect the blood supply for survival of the foot
and support the healing of the primary injury. Where Treatment
commercially available splints such as the Leg Saver
(Kimzey Welding Works, Woodland, CA, USA), or the
Farley compression boot (Equine Orthotics, Indian
Suspensory Ligament Disruption
Harbour Beach, FL, USA) are unavailable, a board splint Primary suspensory ligament rupture is not usually an
or a bandage–cast combination that immobilizes the fet- indication for surgical intervention. Fibrosis can resolve
lock in a neutral or flexed position can be used. Techniques an injury to the suspensory ligament, unless total disrup-
for first aid bandaging are described in Chapters 5 and 6. tion occurs and the ends of the ligament are partially or
www.ajlobby.com
totally separated. Primary suspensory ligament rupture is Fetlock Arthrodesis

more often treated by confinement with external splint-
ing acutely, and then intermittent splinting only if needed Resolution of suspensory apparatus injuries through or
to aid in the fibrosis and to protect the vasculature. Splints below the sesamoids cannot occur by healing of the sus-
suitable for long‐term fetlock stabilization include band- pensory apparatus. Splinting works very well temporarily;
aging and a heel‐elevated Kimzey splint. Unless progress the horse is able to use the limb for ambulation, but during
toward a pain‐free weight‐bearing limb is so slow that standing all the weight is carried on the opposite good
laminitis becomes a possibility, surgery is not necessary, limb. Without arthrodesis to restore pain‐free weight
because the horse can restabilize an injured suspensory bearing, few horses survive this injury. Most develop
ligament with fibrosis to restore functionality. Splinting contralateral laminitis and eventually are euthanized.
should decline to a minimum to encourage weight bear- Fusion of a fetlock joint does not allow athletic activity
ing on the injured limb as soon as possible. to resume on recovery. The procedure is solely for
More supportive therapy such as cast immobilization is salvage for pasture activity for a broodmare, stallion, or
ill advised, because it tends to weaken the flexor tendons valued retiree. If the horse has no value in a second
and makes it more difficult to return the limb to weight career as a brood animal or companion, euthanasia is
bearing after immobilization. With a disabling injury to recommended. The long‐term goals of the surgery are to
the suspensory apparatus, the flexor tendons are the only allow comfortable weight‐bearing activity and to protect
intact support structures palmar/plantar to the fetlock the other limbs from overload weight bearing. If irre-
joint, and weakening them with a period of cast immobi- versible laminitis is already present in the opposite limb,
lization makes collapse of the fetlock on return to weight then the surgery has little hope of salvaging the horse. If
bearing a certainty. If the injury causes such chronic pain laminitis is present but has not reached the irreversible
that the contralateral good limb is at risk, surgery should state, then the surgery can help save both limbs, because
be undertaken before the good limb begins to fail. it will quickly restore comfort to the injured limb, which
will aid in the treatment of the laminitic limb.
Comminuted Fracture
of the Proximal Sesamoid Bones Surgical Approach
Fractures through the sesamoid bones separate the The horse is anesthetized and placed in lateral recum-
proximal suspensory ligament insertions from the base bency with the affected limb uppermost. The limb is
of the sesamoid and the distal sesamoidean ligament prepped for aseptic surgery from the coronary band to
attachments. Tension on the proximal sesamoid frag- the carpus. A tourniquet is not used. A dorsolateral skin
ments by the suspensory ligament and traction on the incision is made from 4 cm below the carpus, following
distal sesamoidean fragments created by weight bearing the path of the lateral digital extensor tendon to the fet-
separate the bone fragments, and this distraction pre- lock joint, and then is curved dorsally along the extensor
vents healing. The divided sesamoids prevent the sus- branch of the suspensory ligament to the midline, just
pensory apparatus from supporting the fetlock (see proximal to the pastern joint (Figure 23.6). The incision
Figures 23.2 and 23.3), with catastrophic consequences. is carried through the skin and subcutaneous tissue. The
Therefore, primary arthrodesis of the fetlock joint is the tendon of the lateral digital extensor and the extensor
treatment of choice for comminuted sesamoid fractures. branch of the suspensory ligament are split longitudi-
nally. The periosteum, transected tendon and ligament,
joint capsule, subcutaneous tissue, and skin are all
Distal Sesamoidean Ligament reflected as a unit from lateral to medial, exposing the
Rupture dorsal surface of the fetlock joint and dorsal cortex of
Rupture of the distal sesamoidean ligaments from the MC/MT3 and the proximal phalanx. The soft tissues are
base of the sesamoids is always accompanied by proxi- not separated, but rather elevated as one layer.
mal displacement of the sesamoid bones (see Figure 23.5),
a hallmark indication of complete disruption of the sus-
pensory apparatus due to detachment of the suspensory
Plate Application
ligament and sesamoids from the distal sesamoidean The plate is then fitted to the contour of the dorsal sur-
ligaments. Healing of the injury cannot occur, because face of MC/MT3 and the proximal phalanx. In many
support to the fetlock joint is lost permanently and the instances, and especially in horses with some promi-
fetlock remains hyperextended. Surgical arthrodesis is nence to the joint capsule insertion on the dorsal surface
the best solution for this injury. of the proximal phalanx, the attachment region of the
www.ajlobby.com
Skin incision Fetlock luxated
(C)
(A) Split lateral extensor tendon
2 mm drill bit
(D)
Common digital Tension-band wire
extensor tendon Wire passer
(B)
Condylar osteotomy
Condyle osteotomy lag screws Tension-band wire

(E)
14-hole dynamic
Sesamoid lag screw compression plate
Figure 23.6 Surgical technique for fetlock arthrodesis.
joint capsule is flattened with a chisel or osteotome, to for most horses, with the 16‐hole plate being useful in
facilitate contouring of the plate to maximize the contact horses with very long cannon bones.
between plate and bone. A locking compression plate Three or four of the distal‐most holes of the plate are
can be used, but is not essential.2,5 Normally, a 14‐ or 16‐ located over the dorsal surface of the proximal phalanx
hole broad limited‐contact dynamic compression plate for insertion of screws into the proximal phalanx. The
(LC‐DCP; DePuy Synthes, West Chester, PA, USA) is next two holes from the distal extremity of the plate are
used, depending on the size of the horse. The length of placed on either side of the joint and are later used to lag
the plate is determined by the need to obtain purchase screw through the plate and across the articulation. The
on the majority of MC/MT3 without leaving a stress remaining portion of the plate is allowed to extend up
concentrator directly in the middle of the bone. Ending MC/MT3. The plate is contoured and positioned on the
the plate immediately under the top of the cast is also dorsal surface of the bone to maximize the metal to bone
undesirable, because the abrasion of the top of the cast contact. The plate is attached initially to the proximal
increases soft tissue problems over the surface of the phalanx, with the fetlock joint in approximately 15° of
plate postoperatively. The 14‐hole plate is appropriate extension. It is especially important to ensure that the
www.ajlobby.com
fetlock joint is totally reduced and that both condyles of

MC/MT3 are in contact with the proximal phalanx when
initially positioning the plate on the proximal phalanx,
because this will determine the alignment of the long
axis of the plate on the cannon bone. The majority of
screws placed through the plate are 4.5 mm cortical bone
screws, but the most distal hole in the plate and the holes
immediately proximal and distal to the joint are filled
with 5.5 mm cortical bone screws, because these screw
locations undergo the most stress on weight bearing.
Following contouring and application of the plate to
the proximal phalanx, the joint is luxated and the artic-
ular surface is exposed to allow debridement of the
cartilage from the metacarpal/metatarsal condyles and
proximal phalanx. The joint is luxated by transection of
the soft tissues including the collateral ligament of the
lateral aspect of the fetlock joint, or condylar osteotomy
and luxation of the fetlock. It is the author’s preference to
perform a condylar osteotomy with a bone saw and reat-
tach it with a cortical bone screw, rather than transecting
the soft tissue, which must later be sutured. Osteotomy
detaches the joint capsule and collateral ligament with-
out disrupting their substance. After medial luxation
of the fetlock joint, the articular cartilage is removed
from the distal end of the metacarpus and proximal
Figure 23.7 Arthrodesis of the fetlock in osteoarthritis case with
aspect of the proximal phalanx. The distal end of MC/
intact suspensory apparatus. The sesamoid bones have been
MT3 is then fenestrated with 2.0, 2.5, or 3.2 mm drill attached to the metacarpus by lag screws. Source: Radiographs
holes to allow access to the metaphyseal blood supply reprinted with permission from the American Association of
and the mesenchymal cells of the subchondral marrow. Equine Practitioners, 2009 Proceedings of the Annual Meeting,
Las Vegas, Nevada.
Palmar/Plantar Tension Band

distance proximal to the fetlock joint. These holes are
Reconstruction drilled between the anticipated sites for plate screws in
After the fetlock joint articular surface has been elimi- order to avoid damage to the wire during later screw
nated, the palmar tension band support to resist exten- placement. The wire is then threaded through the proxi-
sion and stabilize the fetlock is placed. The method used mal phalanx, passed up the palmar/plantar aspect of the
varies according to the type of fetlock injury. If the sus- proximal phalanx by means of a wire passer, crossed
pensory apparatus of the fetlock joint is intact, then behind the fetlock joint, and threaded through the third
transfixing the sesamoids to the palmar/plantar aspect of metacarpus/metatarsus to exit on the lateral aspect of the
MC/MT3 and tightening the distal sesamoidean liga- bone. Two wires are normally placed along the same path.
ments by extending the joint will provide palmar/plantar Once the wires are in place and any slack removed, the
support to aid the plate in resisting extension of the fet- fetlock luxation is reduced and the joint placed in slight
lock joint (Figure 23.7). If the sesamoid bones are to be flexion while the wires are twisted on the lateral surface of
used for lag screw fixation, their articular surface must the third metacarpus/metatarsus to create the tension
be denuded of articular cartilage before realignment of band. Placing the limb in flexion when the wires are
the fetlock joint. twisted allows the wires to tighten during extension of the
If the suspensory apparatus has been disrupted, then it fetlock joint as the plate screws are inserted and tightened
must be replaced. The sesamoids are rarely useful in the into the third metacarpus. This technique ensures that
fixation, and the palmar aspect of the limb must be sup- tension is generated in the wires, and therefore compres-
ported with a “figure‐eight” tension band wire placed on sion across the entire joint, during subsequent plate
the palmar/plantar aspect of the fetlock and adjacent attachment. The drilling for subsequent plate screws near
bones (Figure 23.8). The tension band wire is placed by the fetlock joint level must not strike the taught wires
drilling a transverse hole through the mid‐region of the spanning the palmar aspect of the joint or wire breakage
proximal phalanx and another in the metacarpus a similar can be immediate.
www.ajlobby.com
screws are sequentially inserted into the dorsal aspect of

the third metacarpus/metatarsus until all holes in the
plate are filled. The tension device is removed prior to
insertion of the most proximal screw. The author uses a
5.5 mm screw immediately proximal to the fetlock joint,
because of the amount of stress applied to this screw
during loading of the limb. The last screws to be inserted
are in the fifth and sixth holes from the distal extremity
of the plate, and these are inserted as lag screws across
the fetlock joint to increase the intraarticular compres-
sion, if they can be placed without excessive angulation.
The screw in the fifth hole is angled proximally through
the proximal phalanx and into the metacarpus, and the
sixth screw is angled distally through the distal metacar-
pus and into the proximal phalanx when possible.
Two additional lag screws are then placed across
the joint through the proximal phalanx from distal to
proximal into the distal MC/MT3, one on either side of
the plate, to broaden the area of compression across the
fetlock joint and increase the rotational stability of the
fixation. These screws are inserted as lag screws to obtain
maximum compression between the joint surfaces.
Palmar Support to the Pastern

Disruption of the distal sesamoidean ligament region of
Figure 23.8 Dorsopalmar and lateral to medial radiographs show the suspensory apparatus often allows palmar subluxation
the long‐term follow‐up of the successfully fused fetlock using the of the pastern (Figure 23.9), which may need to be
tension band wire for palmar support. Source: Radiographs addressed by inserting a separate tension band behind the
reprinted with permission from the American Association of
Equine Practitioners, 2009 Proceedings of the Annual Meeting, Las
pastern joint (Figure 23.10). This can include high‐tensile
Vegas, Nevada. metal cable or more flexible high‐density polyethylene
marine cable. The author prefers the 4 mm high‐density
polyethylene which is available from many marine supply
If the sesamoid bones are to be used in the repair of the companies. Marine cable is inelastic and can be gas steri-
suspensory apparatus function, rather than tension band lized to prepare it for use.
wires, the luxation is reduced and the limb is held in The palmar pastern support is inserted while the fet-
slight flexion during insertion of two 4.5 mm cortical lock is still luxated for the passage of the fetlock tension
bone screws, placed in lag fashion through MC/MT3 band wires. The polyethylene cable is threaded through a
into the sesamoid bones. Each screw is placed through second transverse 4 mm drill hole in the proximal pha-
the distal end of the third metacarpus/metatarsus and lanx adjacent and parallel to the hole for the palmar fet-
penetrates the center of the sesamoid bone to lag the lock wire (Figure 23.10B). The cable will then be crossed
sesamoids to the palmar/plantar surface of the metacar- behind the pastern and directed dorsally through two
pal/metatarsal condyle. Extension of the fetlock tightens independent and parallel dorsopalmar drill holes in the
the distal sesamoidean ligaments to form a tension band middle phalanx, to exit and be tied on the dorsal face of
on the palmar/plantar aspect of the limb. the middle phalanx (Figure 23.10). To facilitate this, a stab
Once the tension band has been established and the incision is made through the skin into the digital flexor
luxation reduced, the plate is further attached to the tendon sheath and through the deep digital flexor tendon
proximal phalanx by up to four screws in the phalanx, in the back of the limb at the level of the pastern joint.
and then depressed to the surface of the third metacar- The cable is initially passed lateral to medial through the
pus/metatarsus. A tension device is used to increase the proximal phalanx drill hole and retrieved dorsally from
tension on the plate and place compression across the the medial and lateral aspect of the proximal phalanx.
fetlock joint by creating tension in both the palmar ten- The two ends are then redirected palmarly using a wire
sion band support and the plate. The tension device is passer inserted through the deep digital flexor tendon
placed proximal to the plate, using a unicortical screw to portal, and crossed between the middle scutum and pal-
provide device fixation, and then tightened. The plate mar surface of the condyles of the proximal phalanx as
www.ajlobby.com
(A) (B)
Figure 23.10 Radiographs showing stabilization of a pastern

subluxation after fetlock arthrodesis to stabilize rupture of the
distal sesamoidean ligaments. (A) Dorsopalmar radiograph five
weeks following fetlock arthrodesis and pastern stabilization
using a 4 mm marine cable. Two dorsopalmar‐oriented drill holes
Figure 23.9 Subluxation of the pastern following rupture of the are evident in the middle phalanx (arrows) to allow passage of the
distal sesamoidean ligaments and subsequent fetlock arthrodesis. cable. (B) A lateromedial drill hole (arrow) allows an anchor point
for the cable in the proximal phalanx.
they exit through the stab incision in the deep flexor on

the back of the limb. Two dorsal to palmar/plantar holes valuable means of providing soft tissue coverage over the
are drilled through the middle phalanx, using independ- plate, especially in the traumatized limb where consider-
ent stab incisions in the skin over the dorsal aspect of the able soft tissue swelling is present. Placing antibiotic
phalanx, and one strand of the cable retrieved through laden bone cement beads alongside the plate is optional,
each of the drill holes with the aid of a wire loop that is depending on skin condition and contamination. Once
passed through the dorsal stab incision and forced to exit the incision has been sutured, a cast is placed on the dis-
through the deep digital flexor tendon incision, exterior- tal limb up to the carpus or tarsus for recovery from
ized out the back of the leg, and loaded with a strand of anesthesia and to protect the implants from cyclic load-
the cable. After retrieving both strands from the back of ing in the postoperative period. The horse is assisted to
the leg, the cable is pulled tight with the pastern flexed rise following general anesthesia.
and knotted on the dorsal face of the middle phalanx to
form the tension band. The free ends of the knot are fur-
ther secured by tying suture around them to prevent Postoperative Management
unraveling. The pastern tension band cable is tied after
the fetlock is reduced and before the tension band wires Suction drainage is maintained until the serous drainage
for the fetlock stabilization are twisted. The remainder of from the limb subsides, and the surgical site is free from
the fetlock arthrodesis is then performed. accumulated fluid. The horse is maintained on intrave-
nous antibiotics for a period of time dictated by the
amount of damage to the soft tissues. This may vary from
Closure two to three days to several weeks. Initial choice of antibi-
A suction drain is placed alongside the plate to exit prox- otics depends on the preference of the surgeon and the
imally, and closure occurs sequentially using the lateral degree of contamination of the limb, and can be modified
digital extensor tendon, the subcutaneous tissue, and by culture results from the wound in instances where
finally the skin to close over the plate. Use of the extensor contamination accompanied the injury. Phenylbutazone
tendon for anchorage of the deep layer of sutures is a (2.2–3.3 mg kg−1) is normally used postoperatively to
www.ajlobby.com
c ontrol soft tissue swelling and aid in pain relief. The first after the injury. The first is easily diagnosed, but the
cast is used for recovery from general anesthesia and to second is impossible to predict.
protect the fixation for approximately two weeks. If soft Rupture of the distal sesamoidean ligaments, which dis-
tissue damage was extensive, the cast can be changed ear- ables the superficial (straight) distal sesamoidean ligament
lier. Periods of cast removal, with only bandage or cast– support to the middle scutum and pastern joint, results in
bandage support, allow treatment of soft tissue problems instability of the pastern joint and partial or complete pal-
and can be safely used with this type of fixation, since the mar subluxation of the pastern (see Figure 23.9). This
cast is primarily to prevent cyclic damage to the implants damage to the pastern joint causes discomfort postopera-
and is not necessary for stability. After the initial two‐week tively in any horse with a ruptured suspensory apparatus.
period, the cast is removed and replaced. The second cast It sometimes causes the horse to use the opposite limb for
is frequently placed as a cylinder, allowing the foot to exit continuous weight bearing, which will predispose the foot
from the bottom of the cast. This allows the horse to use to laminitis. The insertion of palmar/plantar pastern ten-
the limb with some tension on the flexor tendons, which sion band support helps avoid this problem.
helps to prevent the flaccidity of the flexor tendons that Other postoperative complications that are not unique
often accompanies cast immobilization. Limited tension to this surgical procedure, such as infection of the fixa-
and early movement are especially important in situations tion, can also cause discomfort and reluctance of the
where the tendons have been badly traumatized. horse to use the limb. Infection of the fixation is com-
Postoperative restriction of exercise normally consists mon in cases of traumatic disruption of the suspensory
of stall rest for two months, with follow‐up radiographs apparatus, because in most instances the trauma also
at that time to determine the degree of healing. If radio- damages the skin. This damage can be a combination of
graphs indicate that the arthrodesis is stable and the soft internal injury from the fractured sesamoid fragments,
tissues’ appearance is acceptable, a period of restricted and external injury from the galloping horse collapsing
exercise such as hand walking and/or small confined the fetlock joint onto the race track and the racing sur-
paddock activity is used prior to free exercise in a large face abrading the soft tissue. Routine methods to avoid
paddock or field. The most important facet in the gradu- overload of the opposite limb are always indicated when
ated return to exercise is the accommodation of the adja- this type of surgery is being considered.1,4,7
cent articulations, such as the pastern joint, to having a Implant removal is indicated only in instances where
fused fetlock joint. These joints must take additional infection of the implants causes fistula formation and
stress that was previously absorbed by the fetlock joint. drainage. Although a solid bony union can form in many
This adaptation takes approximately 30 days, and is then of these horses, drainage can still persist until implant
followed by free‐choice exercise. removal.
Complications Results
The most significant complication associated with this In a retrospective study of the results of fetlock arthrode-
surgery is laminitis in the contralateral limb. The devel- sis, 34 of 52 horses (65%) with fusion of the fetlock joint
opment of laminitis is precipitated by the lack of com- survived to be allowed unrestricted activity.1 The results
fortable weight bearing in the injured limb, which may were better for horses where fetlock arthrodesis was the
be the result of numerous factors, including instability of primary initial treatment, rather than in situations where
fixation if the implants are not inserted appropriately, conservative treatment was tried initially and the fetlock
and factors related to the injury, such as avascularity arthrodesis was elected as a last resort. The prognosis
caused by damage to the vessels. Vascular insult can vary was also better in horses where arthrodesis was used to
from being a minor problem resulting only in delay of treat degenerative arthritis, rather than horses with rup-
wound healing, to being significant enough to result in ture of the suspensory apparatus. Degenerative arthritis
sloughing of the hoof wall or complete necrosis of the results in deterioration of the joint and pain, but no
distal limb. structural inadequacies.
Avascularity of the injured limb generally results from The prognosis for successful return of pain‐free weight
damage to the arteries of the distal limb as they course bearing to the limb with degenerative arthritis of the fet-
around the sesamoid region. Lack of adequate vascular lock depends on the health of the opposing foot. If the
perfusion can develop in two forms: immediate avascu- opposite weight‐bearing foot is in good physical condi-
lar necrosis causes the limb to become and remain cold; tion, with no evidence of laminitis, the success rate is very
or transient avascularity results in reperfusion injury to high. If the limb has already shown evidence of laminitis
the foot and loss of skin or hoof wall around two weeks and distal rotation of the phalanx, the prognosis drops in
www.ajlobby.com
proportion to the extent of damage. The prognosis follow- to that associated with degenerative arthritis. A blanket
ing suspensory apparatus breakdown is determined by prognosis cannot be provided, since the amount of addi-
the severity of the injury. Complete rupture with vascular tional injury and its severity limit the outcome more than
damage results in delayed healing and possibly loss of the the provision of stable internal fixation. Stable internal
distal aspect of the limb as a result of avascularity. Minor fixation is easily obtained with this method of arthrodesis
disruption of the suspensory apparatus with no signifi- if careful attention is paid to surgical technique and the
cant soft tissue damage can result in a prognosis similar established principles of internal fixation.
References
1 Bramlage, L. (1985). Arthrodesis of the metacarpophalangeal a retrospective study of 31 cases (2004–2006). Equine Vet. J.
joint: results in 52 horses. Vet. Surg. 14: 45. 39: 401–406.
2 Carpenter, R.S., Galuppo, L.D., Simpson, E.L. et al. 6 McDiarmid, A. (1999). Acquired flexural deformity of
(2008). Clinical evaluation of the locking compression the metacarpophalangeal joint in five horses associated
plate for fetlock arthrodesis in six thoroughbred with tendonous damage in the palmar metacarpus.
racehorses. Vet. Surg. 37: 263–268. Vet. Rec. 144: 475–478.
3 Drevemo, S., Johnston, C., Roepstorff, L. et al. (1999). 7 Mudge, M.C. and Bramlage, L.R. (2007). Field fracture
Nerve block and intra‐articular anaesthesia of the management. Vet. Clin. North Am. Equine Pract.
forelimb in the sound horse. Equine Vet. J. 30 (Suppl): 23: 117–133.
266–269. 8 Pearce, S.G., Boure, L.P., Bolger, A. et al. (2004). Effect of
4 Kelmer, G. and Wilson, D.A. (2007). Bilateral heel elevation on forelimb conformation in horses. Aust.
metatarsophalangeal arthrodesis for severe congenital Vet. J. 82: 558–562.
flexor tendon laxity and metatarsophalangeal luxation in 9 Whitehair, K.J., Adams, S.B., Toombs, J.P. et al. (1992).
a miniature horse. Equine Vet. Edu. 19: 547–550. Arthrodesis for congenital flexural deformity of the
5 Levine, D.G. and Richardson, D.W. (2007). Clinical use metacarpophalangeal and metatarsophalangeal joints.
of the locking compression plate (LCP) in horses: Vet. Surg. 21: 228–233.
www.ajlobby.com
436
24
Fractures of the Third Metacarpal/Metatarsal
Diaphysis and Metaphysis
Robert K. Schneider1 and Sarah N. Sampson2
1
McKinlay Peters Equine Hospital, Newman Lake, WA, USA
2
Fractures of the Diaphysis and manipulation of the limb should be performed before

assessing the horse’s gait, as further damage could be
Fractures of the third metacarpal and metatarsal (MC/ caused by moving the horse. The affected limb is usually
MT3) bones are the most common major long bone frac- unstable and crepitus can be palpated. Depending on the
ture in horses, and account for a third of all long bone duration of the injury, swelling may or may not be present.
fractures.12 Diaphyseal fractures are the most prevalent A tentative diagnosis of a fracture can be made based
type and are often catastrophic events in the adult horse, on the non‐weight‐bearing lameness and the palpable
because the high energy required to initiate the fracture instability. Radiographs are necessary to characterize the
frequently causes comminution of the hard, brittle adult configuration of the fracture, but because the fracture can
bone (Figure 24.1). Catastrophic diaphyseal fractures in easily become open with movement of the limb, the limb
racehorses have also been shown to be preceded by stress should be stabilized as quickly as possible before radio-
fracture.5 Transverse and short oblique fractures, usually graphs are taken (see Chapter 6).
related to external trauma, occur more commonly in The fractured MC/MT3 can be stabilized with a
young foals (Figure 24.2). Due to the minimal soft tissue Robert Jones bandage and the application of rigid splints
coverage, these fractures are frequently open, either on the lateral and palmar/plantar aspects of the limb.
from external injury or from penetration of the skin by Two splints at 90° angles are necessary to counteract
underlying bone, and infection and sequestrum forma- both dorsopalmar/plantar and lateromedial bending
tion are common complications in this instance. The forces. Polyvinylchloride (PVC) pipe is an effective, inex-
cannon bone is almost entirely cortical bone with poor pensive splint material; it is light‐weight, strong, and can
vascularity, which results in high susceptibility to bacte- be penetrated by X‐rays. Splints on the forelimb should
rial penetration if the skin barrier is broken.3 When an extend from the ground to the elbow. On the hindlimb,
unstable metacarpal/metatarsal shaft fracture is sus- due to the natural bend of the tarsus, the plantar splint
pected, the horse should be kept calm and stationary can only extend from the ground to the level of the point
until an examination can be performed. Appropriate of the hock. The lateral splint should extend proximally
bandaging and splinting can then be applied. Detailed to the level of the stifle joint. This lateral splint can be
information on routine fracture management and splint- made from strong aluminum rod that can be conformed
ing, and first aid specifically for emergency racetrack to the angle of the hock and secured to the tibia proxi-
situations, are described in Chapters 5 and 6. mally and to the limb distal to the hock. Splints should be
secured to the limb with nonelastic tape to avoid loosen-
ing. Appropriate splinting is vital to successful fracture
Diagnosis treatment. Splinting of the fracture protects the limb
The diagnosis of a shaft fracture of MC/MT3 can usually from further trauma and minimizes the chance that a
be made from the clinical signs. These horses present with closed fracture will become open. If movement of the
an acute non‐weight‐bearing limb. Careful palpation fractured ends of the bone can be minimized, less

www.ajlobby.com
24 Fractures of MC/MT3 Diaphysis and Metaphysis 437
(A) (B) (C)
Figure 24.1 (A) Lateral view of a severely comminuted fracture of the third metatarsus in an adult pony with plantarodistal displacement
of the proximal portion. (B) Dorsoplantar view with mild lateral displacement of proximal fragment. (C) Double‐plate fixation was
performed using a craniolateral 16‐hole broad limited‐contact dynamic compression plate and a craniomedial 11‐hole narrow dynamic
compression plate.
eburnation of the bone occurs. Eburnated bone is diffi- minimal soft tissue coverage and minimal ligament
cult to accurately reduce, since there is a lack of interdigi- attachments, the frequent damage to surrounding vascu-
tation of the fracture ends after the ends become smooth. lature, and the frequent occurrence of penetrating
Following proper splinting, radiographs are necessary wounds. The optimal form of treatment should stabilize
to assess the fracture configuration. The joint above and the fracture to allow weight to be supported by the
below the fracture should always be included to evaluate injured limb. However, fixation methods that permit full
the integrity of the articular surfaces. A minimum of four weight bearing are limited. The treatment of choice and
views should be obtained: lateromedial, dorsopalmar/ the most stable form of therapy for MC/MT3 fractures is
plantar, and both oblique projections. If the horse has internal double‐plate fixation. Double‐plate fixation is
been transported to a referral center, further radiographs usually necessary in foals and always necessary in adults.
may be indicated to determine if additional damage The location of the plates is determined by fracture type
occurred during transport. and location. Other methods that are employed include
full limb cast in the forelimb and cast to the distal tarsus,
transfixation pin cast, or a combination of internal fixa-
Treatment Methods tion and a cast or transfixation pin cast. Casts are often
There are several treatment options for MC/MT3 dia- not indicated after internal fixation in smaller foals.
physeal fractures. Factors that play a role in selection of
the treatment method include the age, weight, sex, tem- Repair with Internal Fixation
perament, value, and intended use of the animal, as well Two plates are necessary to provide adequate stabiliza-
as the fracture configuration, vascular insult, and tion in adults and frequently in foals. The dynamic com-
whether the fracture is open or closed. Metacarpal and pression plate (DCP) and the limited‐contact dynamic
metatarsal diaphyseal fracture repair is complicated by compression plate (LC‐DCP) have mostly been replaced
www.ajlobby.com
Figure 24.2 Transverse fracture of the third metatarsus of a young

pony foal that is in close proximity to the nutrient foramen.
Fractures in this area may cause damage to the vascular supply
through the nutrient foramen.
by the locking compression plate (LCP) in equine frac-

ture fixation. When cost issues are paramount, the LC‐
DCP still has a role. Originally designed for human use Figure 24.3 Transverse fracture of the third metatarsus, repaired
to limit the development of osteoporosis under the plate, with two broad dynamic compression plates of different lengths
spanning the area of comminution to act as a buttress.
the LC‐DCP design has been shown to have the same
bending stiffness as the DCP and a 50% increase in the
uniformity of the bending stiffness. The LC‐DCP has the along the entire length of the diaphysis and metaphysis
same amount of metal at each cross‐section along its and should span areas of comminution to act as a but-
length, which gives it uniform bending stiffness, in con- tress (Figure 24.3). The two plates should be different
trast to the DCP that has stress risers at each screw hole. lengths and end at different levels on the bone to protect
However, the LCP has been reported to be superior to against stress concentration and subsequent fracture at
the LC‐DCP in static overload and cyclic fatigue tests the ends of the plates.
under palmarodorsal four‐point bending.20 Clinically, Anesthetic induction should be as smooth as possible,
the LCP has been shown to be acceptable for long bone with the limb protected by a splint and the horse’s weight
fracture repair and has advantages over the DCP when supported until it is on the floor. Plating the affected
used in more comminuted fractures.10 bone with DCPs or LCPs can be performed in either dor-
The plates used for long bone fracture repair are placed sal or lateral recumbency based on surgeon preference.
at 90° angles to each other to oppose bending forces. Wire can be placed in the hoof wall to enable slow and
Following the principles of internal fixation, one plate continuous traction on the limb if it is necessary for frac-
should be placed on the tension surface. All sides of MC3 ture reduction. Aseptic technique is essential in prepar-
are compressed at various stages when the horse walks,21 ing the patient and the surgeon for this type of surgery.
therefore the plates can be applied on any surface of the Long bone fracture repair is most commonly per-
bone except for the palmar surface, where soft tissues formed in lateral recumbency and the decision to use
preclude placement. The plates are usually placed dorsal a tourniquet is based on surgeon preference. Either a
and lateral or dorsal and medial, based on the fracture dorsomedial or dorsolateral approach to the bone is

configuration. The tension side of the MT3 bone is the employed. A curvilinear skin incision that extends
dorsolateral surface, so plates are most often applied from the carpometacarpal (tarsometatarsal) joint to the
dorsal and lateral on this bone. The plates should extend metacarpo/tarsophalangeal joint is created (Figure 24.4).
www.ajlobby.com
Skin incision Lateral digital extensor tendon

(A)
Common digital extensor tendon
Butterfly fragment
(B)
Drill
(C)
Screwdriver
Lag screw
(D)
Figure 24.4 (A–G) Surgical approach and repair of a metacarpal fracture with a large butterfly fragment. (A) Curvilinear palmarly based
skin incision; (B) Separation of the common and lateral digital extensor tendons; (C) Drilling a glide hole for stabilization of the butterfly
fragment to one parent bone end; (D) Fixation of the butterfly fragment to both ends of the bone provides stable fracture reduction.
The incision is curved at its proximal and distal ends, the underlying bone. For the forelimb, some surgeons
with the free edge of the flap located over the dorsal prefer to separate the plane between the lateral and com-
aspect of the bone. Areas of poor vascularity and open mon digital extensors, which can still be securely sutured
wounds should be avoided to decrease the chance of closed at the end of the procedure to cover the implants.
infection. Due to the strength of the closure that can be The extensor tendon and overlying fascia are elevated
obtained when the extensor tendon is split, the dorsolat- from around the bone with blunt dissection, preserving
eral approach is preferred. When making this approach, as much of the periosteal attachment to the bone
the tendon (lateral digital extensor–forelimb, long digital as possible. With every fracture there is damage to the
extensor–hindlimb) is incised longitudinally to expose periosteum, and there is no need to preserve periosteum
www.ajlobby.com
(E)
Lag screws
Drill
(F)
(G)
Lateral digital extensor tendon
Common digital extensor tendon
Figure 24.4 (Continued). (E) The first plate is applied to the dorsal surface in neutralization or limited compression; (F) A plate screw can
also be inserted across a fracture line using lag technique to further secure the butterfly fragment; (G) A second plate is applied laterally or
medially, directly over the butterfly, remaining screws inserted in the dorsal plate, and tendons apposed.
that has already been elevated from the bone. However, outer cortical bone are exposed. Osteomyelitis and
stripping healthy periosteum from the bone is to be sequestration are common complications following sur-
avoided, because it disrupts blood supply and removes gical repair of open MC/MT3 fractures.
the protective covering from the bone. Attached perios- Reduction of MC/MT3 fractures can be difficult.
teum should be preserved and the plates applied over the Comminuted fractures with large butterfly fragments
periosteum. If infection develops and the periosteum has are reconstructed into two‐piece fractures by lag screw
been removed, more of the Haversian systems of the fixation of the free fragments to the proximal or distal
www.ajlobby.com
(A) (B) (C)
Figure 24.5 (A) Closed comminuted third metatarsal fracture with a large butterfly fragment in a foal. The radiograph was obtained while
the limb was protected by a splint. (B) Repair with two broad dynamic compression plates. The three screws in the center of the dorsal
plate are placed as lag screws. Two screws in the center of the plate are 4.5 mm screws; the remainder are 5.5 mm screws for added
strength. (C) Fracture healing at six months. Moderate callus formation at the fracture site indicates that motion was present despite
anatomic reconstruction and stabilization with two plates.
piece of bone (Figure 24.5). The fracture is then reduced determined by the size of the horse. If the skin cannot be
by alignment and interdigitation of the proximal and dis- closed over two broad DCP or LC‐DCP plates, a broad
tal fragments. This can be accomplished in some cases and a narrow plate are used. The use of 5.5 mm cortical
by tenting the two ends of the fracture out of the surgical screws is recommended whenever possible, but is very
wound until the proximal fragment can be interdigitated important in the proximal two holes and distal two holes
with the distal fragment. Then, the two fragments are of each plate. It is not always possible to place 5.5 mm
pushed back into the wound, while the surgeon tries to screws in every hole, because they cannot be angled to
achieve axial alignment of the bone. Another method of avoid fracture lines, to function as lag screws, or to avoid
reduction is to apply traction to the distal limb while a other screws as easily as 4.5 mm cortical screws. In a large
bone reduction forceps is used to axially align the two adult horse, use of the bigger, stronger dynamic condylar
fragments. Rotation of the distal limb and Hohmann screw (DCS) plate might be considered.1 Application of
retractors may also help position the fragments in better the DCS plate is only possible in a lateromedial (frontal)
alignment. Overpowering the limb with traction is not as plane, due to the minimum manufactured length (55 mm)
effective as some of the other manipulations, but should of the large 12.5 mm lag screw in the DCS system. Even
still be considered to achieve reduction. Simple trans- then, preoperative measurements should be obtained to
verse fractures can be the most difficult to reduce and ensure that the lateromedial width of MC/MT3 is more
hold in alignment, because the ends of the bone are fre- than 60 mm.
quently eburnated. Once the fracture is aligned and During application of the plates, a screw that crosses a
reduced, a lag screw is usually used to hold the fracture fracture line should be placed as a lag screw to generate
in place until the plates can be applied. interfragmentary compression (see Figure 24.4). Studies
Following reduction, the plates are contoured and have shown that 5.5 mm cortical screws have a greater hold-
applied to the bone. The type of plates selected is ing power and tensile strength than 4.5 mm cortical screws
www.ajlobby.com
in adult equine bone.23 In addition, 5.5 mm cortical screws the LC-DCP still takes advantage of the multidirection
had a similar holding power to 6.5 mm cancellous screws in compression and improved screw insertion angles for frac-
metaphyseal bone of foals, and had a greater holding power ture reconstruction and later stability. LCP plates, on the
than 4.5 mm cortical screws in foal diaphyseal bone.22 Due other hand, should not be luted, since the LCP relies on the
to the density of adult equine cortical bone, power tapping locking‐head screw fully tightening in the threaded combi
of screw holes is often performed in an effort to reduce sur- hole in the plate, and PMMA may interfere with this pro-
gical time. One study has shown that there is no difference cess. Moreover, the strength of the fixation in an LCP con-
in the holding power of 5.5 or 4.5 mm cortical screws when struct does not rely on maximizing contact and friction
power tapping or hand tapping. Intraoperative radiographs between plate and bone, but rather is derived from the
are recommended to assess fracture reduction, implant rigid fixed angle between the locked screw and the plate.
positioning, and appropriate screw length. Once the plates are in place and all the screws are tight-
Application of two LCPs for MC/MT3 fracture repair ened, the surgical incision is closed. Antibiotic laden
has become increasingly common. The versatility of frac- PMMA beads or small cylinders can be placed between
ture reconstruction and compression using cortical screws or either side of the plates if they do not hamper tissue
applied through the compression portion of the combi closure. If the extensor tendon has been split, the tendon
hole, followed by enhanced fixation stability by additional is sutured with 0 or 2‐0 polydioxanone sutures (PDS II) in
locked screws, provides rigid fixation with better resist- a continuous pattern. If the tendon has not been split, the
ance to cyclic fatigue. The possibility of minimally invasive subcutaneous tissue is opposed. Skin closure is important
plate insertion for some fractures, combined with less and is usually accomplished with 0 or 2‐0 prolene in a
need for perfect plate contouring, allows less disruption of vertical mattress pattern, splitting the thickness of the
the soft tissue envelope and increases the potential for skin with the near pass of the suture. This pattern pro-
improved fracture healing. Fractures that need consider- vides strength and good apposition of the skin edges. A
able reduction and temporary stabilization with lag screws weak skin closure can be a future source of infection to
or forceps are not candidates for minimally invasive the underlying implants in metacarpal/metatarsal frac-
approaches, but the LCP still has advantages in open‐plate ture repairs, because there is very little soft tissue between
fixation repairs. Use of the push–pull device during initial skin and bone. Stainless‐steel staples are not recom-
plate application to the bone is one significant improve- mended for similar reasons. The limb is supported in a
ment in the LCP system and provides maintenance of large Robert Jones bandage or a full limb cast, depending
fracture reduction during insertion of the initial cortical on the size of the patient and the stability of the repair.
screws, which will then draw the plate onto the bone and Prophylactic antibiotics are recommended as well as
provide compression across the fracture lines. Locking‐ intraoperative lavage with antibiotic solutions. Closed
head screws can then be applied to the remaining combi suction drains may or may not be used based on surgeon
holes to enhance the rigidity of the plate repair. preference and the health of the surrounding skin and soft
Any defects remaining in the cortical bone after reduc- tissue. They are not routinely recommended. If a drain
tion and fixation should be filled with autogenous can- is used, antibiotic treatment should be continued until
cellous bone. Cancellous bone facilitates bone formation the drain is removed 24–72 hours after the surgery.
at the fracture site. The most common sites to obtain Phenylbutazone (4.4 mg kg−1) is administered intrave-
cancellous bone in the equine species are the iliac crest nously and continued orally for several days after surgery.
and the fourth and fifth sternebrae. The donor site is Recovery from anesthesia should be assisted in an
selected according to positioning of the patient, with the attempt to prevent abnormal forces on the limb and fail-
iliac crest easily accessible in lateral recumbency and the ure of the fixation. Raft or swimming pool recovery sys-
sternebrae easily accessible in dorsal recumbency. Both tems may be beneficial to this process, but they are not
sites can be utilized if necessary (for additional informa- readily available in most hospitals. Head and tail rope
tion see Chapter 11). assistance should be considered a minimum for most
Plate luting with polymethylmethacrylate (PMMA) has adult horses recovering from MC/MT3 fracture repairs.
been utilized in the equine species to add further stability Healing of a shaft fracture of MC/MT3 requires at least
to the internal fixation when using DCP plates.15 After the 90 days. The horse should be in a stall until follow‐up radi-
plate has been applied, the screws are loosened to allow ographs demonstrate that the fracture has healed. The
PMMA to be applied under the plate and within the screw most likely and severe complication is infection and it fre-
holes. Studies have shown that plate luting increases the quently results in failure of the bone to heal (Figure 24.6).12
fatigue life of plate and screw fixation more than three- In some cases, even though the bone heals, failure results
fold.15 Therefore, other than in small foals, plate luting can because of breakdown in the opposite limb (foals), or lam-
be beneficial in protecting screws against fatigue failure initis in the opposite foot (adults), due to excessive weight
and breakdown of the fixation. Luting LC‐DCP constructs bearing on the good leg. If the fracture heals without com-
abrogates the value of the limited contact surface, but using plication, the implants should be removed in horses and
www.ajlobby.com
Figure 24.6 (A) Transverse open fracture of (A) (B) (C)

the third metacarpus in a foal. Although
easier to repair than the fracture in
Figure 24.5, the presence of contamination
increases the risk of infection. (B)
Dorsopalmar radiograph of the repair
60 days following surgery. The limb recently
developed swelling and the incision is now
open and draining. (C) Lateral radiograph
reveals a large sequestrum. The fracture did
not heal due to the infection and the foal
was euthanized. This is a frequent result if
osteomyelitis develops in metacarpal/
metatarsal fractures repaired with plates
and screws, even in foals.
foals that are sound and whose intended use involves ath- the limb to the cast. Two transcortical pins placed in the
letic performance. This is especially true of race horses distal aspect of the radial metaphysis or diaphysis have
because of the cyclic stresses that occur in the third meta- been shown to increase survival compared to horses in
carpus and metatarsus during high‐speed performance. which more than two pins were used.9 Transfixation pin
Staged plate removal is often preferred, although the deci- casts significantly decrease bone strain measured in the
sion to remove the second plate is frequently made after limb distal to the pins, and are reported to decrease bone
review of intraoperative radiographs, when fracture heal- displacement when compared to a standard full limb
ing can be assessed without the additional plate obscuring cast.6,7 Multiple transfixation pins are recommended for
the fracture site. The overall success of MC/MT3 bone distributing the load and avoiding stress concentration at
fracture repair using internal fixation has been reported to one bone–pin interface. The pins are placed through
be 62–67%.2,12 In one study, 52% of horses were able to be small stab incisions and are inserted by hand after pre-
used for their intended use after fracture repair, although drilling a hole at low speed (less than 150 rpm) with a
82% of these were foals.2 drill bit slightly smaller than the pin. Once the pins have
been placed, they are cut 2–3 cm from the skin and a
Other Treatment Methods fiberglass cast is applied to the limb. As the casting tape
Fracture location and configuration, the presence of is applied, small holes are cut in the casting tape to allow
infection, and open wounds are the most common rea- the cast material to slide over the pins. Once the cast has
sons to choose another method of fracture treatment. had a few minutes to set, PMMA acrylic (Technovit,
Closed reduction and external fixation with a transfixa- Jorgensen Laboratories, Loveland, CO, USA) can be used
tion pin cast are a viable option when internal fixation is to fill small spaces between the cast material and the pin.
not possible. Transfixation pin casts have been used to The acrylic material is also used to cover the ends of the
manage MC/MT3 fractures that are not amenable to pins and protect against the sharp edges of the pins
surgical repair with plates.4 A recent study reports a 67% damaging the opposite limb when the horse lies down.
success rate with fractures of the metacarpus and meta- The PMMA also seals the pin within the cast and mini-
tarsus.9 Pins are placed through the proximal MC3 or the mizes the pin’s exposure to the stall environment.
distal radius from lateral to medial across the bone and Casts with transfixation pins placed in MC3, MT3,
incorporated in a fiberglass cast. The pins act to transfer and the distal radius have been used to manage open
weight‐bearing loads from the proximal bony column of or severely comminuted fractures (Figure 24.7). With
www.ajlobby.com
(A) (B) (C)
(D) (E) (F)
Figure 24.7 Open comminuted fracture in a foal repaired by transfixation cast. (A) Radiograph showing short oblique open diaphyseal
fracture of the third metacarpus in a foal. (B) The skin loss and severe contamination necessitated repair with a transfixation pin cast.
(C, D) Two transfixation pins were placed in the distal radius and incorporated into a full limb cast. (E, F) Excellent healing of the fracture is
apparent at six weeks post‐surgery. Source: Radiographs courtesy Dr. Jeffrey Watkins.
www.ajlobby.com
time, almost all transfixation pins loosen due to infec- Specialized implants such as the DCS plate and the
tion and/or bone resorption at the bone–pin interface. dynamic hip screw (DHS) plate have application in
When this occurs, the pins are removed and another equine fracture repair.1 These implants are particularly
fiberglass cast is applied until fracture healing has useful for fractures near the end of the bone, because
occurred. In many cases, transfixation casts are used in they are stronger than broad DCPs. The DCS has a barrel
combination with other fracture treatments like can- at one end that is directed at a 95° angle to the plate, and
cellous bone grafting. Casts can also be used to protect the DHS has a barrel at one end that is directed at 130°,
weak methods of internal fixation that align and reduce 135°, 140°, 145°, or 150° to the plate. More detail on these
the fracture, but cannot adequately support weight‐ plates is included in Chapter 8. A large 12.5 mm lag screw
bearing loads (Figure 24.8). is placed into the smaller segment of fractured bone and
A report of the combination of transfixation pins with the plate barrel fits over this lag screw. More stability is
a walking cast as the primary repair method revealed achieved compared to DCPs due to the increased pur-
reasonable success rates in the treatment of MC/MT3 chase of implant in the small metaphyseal component of
fractures.14 Of horses treated in this manner, 46% could the bone. Familiarity with the equipment and application
be used for breeding and light riding, but horses rarely methods for these implants is necessary prior to their use
returned to work or competitive sporting events. Further (for application detail, refer to Chapter 9).
investigation of fracture healing with transfixation pin Euthanasia should still be seriously considered in
casts is warranted. horses with open, severely comminuted MC/MT3 frac-
tures (Figure 24.9). Although treatment methods have
improved considerably in the last 30 years, limitations
remain in adequately stabilizing these types of fractures
(A) (B)
and in dealing with the microorganism burden arising
through the original open defect.
Figure 24.8 (A) Severely comminuted proximal third metacarpal

fracture in an adult miniature horse. (B) Two transfixation pins
were placed in the distal radius, as adequate stabilization was not Figure 24.9 Severely comminuted open fracture of the third
possible with internal fixation provided by the lag screws. Source: metacarpus in an adult horse. Euthanasia is currently the
Radiographs courtesy Dr. Jeffrey Watkins. recommended treatment for this horse.
www.ajlobby.com
Complications and Prognosis
Serious complications can occur in both the affected and
contralateral limbs. Contralateral limb laminitis is com-
mon and often can lead to euthanasia of the patient. The
most effective method of preventing laminitis is to pro-
vide stable fixation of the fracture as soon as possible, to
allow the affected limb to be at least partially weight
bearing. Analgesics, contralateral limb frog support, and
bedding the stall deeply to encourage the horse to lay
down all help prevent laminitis.
The prognosis depends on the stability of the fixation.
The prognosis is generally poor in mature horses because
more comminution is likely. In addition, the greater
weight of adult horses increases the stress on the implant
and on the contralateral limb. The best prognosis exists
in foals and small horses with closed fractures that are
amenable to stable internal fixation. If bony union occurs
and an athlete is the desired outcome, implant removal is
usually then necessary.
Fractures of the Proximal
Metacarpus
Fractures of the proximal metacarpus are usually incom-
Figure 24.10 Linear proximal metacarpal fracture (arrows) in a
plete longitudinal fractures.13 The most common frac-
horse with a history of recurrent episodes of severe lameness.
ture occurs in the palmar cortex and the fracture line
extends from the carpometacarpal joint distally along
the axis of the bone (Figure 24.10).11,13,18 There are unu- necessary to make an accurate diagnosis. The dorsopalmar
sual variations of this fracture that extend further into projection is usually the only view that demonstrates
the bone, with the fracture propagating laterally. These the fracture. Underexposed radiographs or those with
fractures tend to occur in young performance horses. motion will not allow the fracture to be seen. Nuclear scin-
Short longitudinal fractures also occur on the dorsal tigraphy can also be helpful in making the diagnosis.13
aspect of the proximal third metacarpal. These dorsal Horses with this fracture will have a dramatically
fractures have only been reported in Standardbred increased uptake of technetium in the proximal MC3.
horses (pacers).19 However, radiographs are still necessary to make an
accurate diagnosis of a fracture. Horses that tear the
origin of the proximal suspensory ligament from the
Diagnosis bone will have similar signs, and also will have increased
The diagnosis of fractures of the proximal MC3 can be uptake in the same area on a nuclear scan. If an
difficult, especially those in the palmar cortex.13 There is incomplete fracture is suspected, high‐quality digital
no palpable heat or swelling in the limb. Horses with radiographs and repeat radiographs at two weeks will
these fractures typically have acute, severe lameness of confirm or rule out a fracture. Standing magnetic reso-
relatively short duration. The severe lameness can nance imaging (MRI) or computed tomography (CT)
resolve in several days and some horses resume training may occasionally be necessary to define the fracture
only to become lame again. In one report of 55 cases, plane and develop a better treatment plan.
73% had a lameness that was more severe when trotting Horses with incomplete fracture of the dorsomedial,
in a straight line compared to circles.13 The diagnosis proximal MC3 frequently have a small protuberance and
is usually made by localizing the source of pain to are painful to firm pressure on the fracture location.
the carpus (intraarticular block of the middle carpal These fractures can only be seen on the dorsolateral‐
joint) or the palmar proximal MC3 (infusion of the area palmaromedial oblique or lateromedial views of the
of origin of the suspensory ligament with local anesthetic). carpus. Again, high‐detail radiographs are necessary to
High‐detail radiographs of the proximal metacarpus are make the diagnosis.
www.ajlobby.com
Treatment Prognosis
Horses with incomplete fractures of the proximal MC3 Horses with fracture of the proximal metacarpus have a
should be managed with rest; 90 days of rest is usually good prognosis for returning to soundness and perfor-
required for complete healing of the fracture. Horses can mance. Follow‐up data on a study including 55 horses
be returned to protected exercise such as swimming or indicated that 98% returned to athletic function.13
an aqua‐treadmill at 60 days. However, the horse should Although the fracture always enters the carpometacar-
not return to a regular training program until radio- pal joint, there is no displacement, and therefore little
graphs demonstrate that the fracture is healed. This may chance for subsequent osteoarthritis in this low‐motion
take as long as 120 days. joint. This fracture always heals if the horse is given
Surgical repair of these fractures has been reported, adequate rest.
but is generally not recommended. Surgical repair is
more of a consideration in horses that are chronically
lame or have atypical fractures that are more extensive Fractures of the Proximal
and propagate toward the lateral or medial cortex Third Metatarsus
(Figure 24.11). Horses with this fracture are more lame
and will support very little weight on the injured limb. Fractures of the proximal MT3 occur on the dorsomedial
Accurate placement of lag screws increases patient aspect of the bone.16 They are uncommon and occur
comfort and decreases the risk of further propagation with the highest incidence in Standardbred racehorses.
of the fracture. Multiple oblique radiographs are nec- These fractures propagate distally from the tarsometa-
essary to define the fracture configuration. Preoperative tarsal joint 2–4 cm into the MT3 bone and toward the
or intraoperative CT has also been utilized to establish dorsomedial cortex. They are incomplete, longitudinal
the diagnosis and ensure accurate screw insertion fractures caused by repeated cyclic loading of the bone.
(Figure 24.12). Lag screws are usually placed through Standardbreds may be predisposed because they train
small stab incisions using intraoperative radiographic many miles on hard surfaces.
control. Incomplete fractures of the proximal metatarsus can
be difficult to diagnose.16 There is very little swelling in
the area and an intraarticular block of the tarsometa-
tarsal joint does not always eliminate the lameness.
The horse may be sensitive to direct pressure over the
(A) (B) fracture, but its response can be difficult to assess on
the inside of a rear limb. High‐quality radiographs are
required to demonstrate the fracture. The diagnosis
can be made from nuclear scintigraphy, because there
are no other problems that will cause local uptake
of technetium in this location. Radiographs will con-
firm the diagnosis; the dorsolateral‐plantaromedial
oblique or lateromedial views will best demonstrate
the fracture.
Incomplete fractures of the proximal MT3 are man-
aged with rest alone, similar to incomplete fractures of
MC3. Compression can be achieved by insertion of lag
screws across the fracture; however, screw fixation is not
generally necessary to heal fractures in this location.
Horses with this fracture are confined to a stall and
healing is evaluated on follow‐up radiographs taken at
90 days.
Horses with a fracture of the proximal MT3 have a
Figure 24.11 (A) Atypical propagating fracture of the proximal good prognosis. Even chronic fractures have healed
metacarpus in a two‐year‐old Standardbred racehorse with severe when the horse is given adequate rest. Distal tarsitis or
lameness following a race. (B) Surgical repair with osteoarthritis of the tarsometatarsal joint can occur
interfragmentary screws. Screws were not inserted distally in the
fracture due to the proximity of the nutrient foramen. The screws secondary to this fracture. This problem can be success-
were removed after the fracture healed and the horse fully managed in many horses with anti‐inflammatory
subsequently competed in more than 100 races. medications.
www.ajlobby.com
(A) (B)
(C) (D) (E)
Figure 24.12 Radiographs showing a longitudinal palmar fracture (arrows) of the third metacarpus in a two‐year‐old Thoroughbred.
Lameness had been intermittently severe and was unresolved after two months of stall confinement. (A) Dorsopalmar radiograph
and (B) standing robotic computed tomographic image confirm the palmar location and length of the fracture. (C, D) Dorsopalmar
and lateromedial radiographs two days after insertion of two 4.5 mm screws in the palmar cortex. (E) Dorsopalmar radiograph
60 days after repair showing resolution of the fracture. The horse returned to training 90 days after surgery. Source: Images
courtesy Alan Nixon.
www.ajlobby.com
(A) (B)
(C) (D)
Figure 24.13 Incomplete nondisplaced distal diaphyseal/metaphyseal fracture of the third metatarsus in a two‐year‐old Thoroughbred
racehorse. (A, B) Dorsoplantar and lateral radiographs show the fracture line with callus formation (arrows). (C, D) Radiographs obtained
three weeks prior to the diagnostic images show subtle signs of a nondisplaced incomplete fracture (C, arrows), including minimal plantar
callus formation (D, white arrow). The horse went on to make a complete recovery and race. Source: Images courtesy Alan Nixon.
Fractures of the Distal fixation of the metaphyseal spike portion (the Thurstan–

Diaphysis and Metaphysis Holland sign or fragment) to the remainder of the
metaphysis, and short‐term coaptation (see Figure 4.8 in
Fractures of the distal physis of MC/MT3 in foals often Chapter 4). This provides stabilization of the displaced
include a metaphyseal spike, forming a Salter–Harris physis and epiphysis without invading the growth plate.
type II fracture. These can often be managed by lag screw Additionally, continued growth from the entire distal
www.ajlobby.com
physis of the metacarpus/metatarsus can be expected, Often, the initial acute lameness goes without diagnosis,
which is particularly important in foals less than four and there are few if any radiographic signs of a transverse
months of age. The metaphyseal spike can be reattached crush fracture (Figure 24.13). The lameness generally
to the remainder of the metaphysis using 6.5 mm par- diminishes, and radiographic examination is requested
tially threaded cancellous screws, often with washers, or due to increased bony swelling around the distal diaphy-
with 5.5 mm cortical screws applied in lag fashion.8 A seal region of MC/MT3, immediately proximal to the
report of successful repair in three foals, including con- fetlock (see Figure 24.13). The initial radiographs can
tinued longitudinal growth, was recently published.8 often be normal (Figure 24.13).
In adult racehorses, a syndrome of nondisplaced distal Treatment includes continued stall and later small
diaphyseal/metaphyseal transverse fracture has been paddock rest. A minimum of 90 days’ rest from race
recognized.17 These fractures are relatively uncommon, training is required before return to work. Healing by
involve the distal region of MC3 or rarely MT3, and bony callus and later remodeling result in complete heal-
generally do not result in catastrophic breakdown.
ing and a good prognosis.
References
1 Auer, J.A. (1988). Application of the dynamic condylar metacarpal, third metatarsal, and phalangeal fractures
screw (DCS) – dynamic hip screw (DHS) implant system in horses: 37 cases (1994–2004). J. Am. Vet.
in the horse. Vet. Comp. Orthop. Traumatol. 1: 18–25. Med. Assoc. 230: 1340–1349.
2 Bischofberger, A.S., Furst, A., Auer, J. et al. (2009). 10 Levine, D.G. and Richardson, D.W. (2007). Clinical use
Surgical management of complete diaphyseal third of the locking compression plate (LCP) in horses: a
metacarpal and metatarsal bone fractures: clinical retrospective study of 31 cases (2004–2006). Equine
outcome in 10 mature horses and 11 foals. Equine Vet. J. Vet. J. 39 (5): 401–406.
41 (5): 465–473. 11 Lloyd, K.C.K., Koblik, P., Ragle, C. et al. (1988).
3 Bramlage, L.R. (1983). Long bone fractures. Vet. Clin. Incomplete palmar fracture of the proximal extremity
North Am. Large Anim. Pract. 5: 285–310. of the third metacarpal bone in horses: Ten cases
4 Easter, J.L., Honnas, C.M., and Watkins, J.P. (1994). (1981–86). J. Am. Vet. Med. Assoc. 192: 798–803.
Transfixation cast repair of an open cannon bone 12 McClure, S.R., Watkins, J.P., Glickman, N.W. et al.
fracture in a foal. Equine Pract. 16 (10): 16–23. (1998). Complete fractures of the third metacarpal or
5 Gray, S.N., Spriet, M., Garcia, T.C. et al. (2017). metatarsal bone in horses: 25 cases (1980–1996). J. Am.
Preexisting lesions associated with complete diaphyseal Vet. Med. Assoc. 213: 847–850.
fractures of the third metacarpal bone in 12 13 Morgan, R. and Dyson, S. (2012). Incomplete
Thoroughbred racehorses. J. Vet. Diagn. Invest. 29: longitudinal fractures and fatigue injury of the
437–441. proximopalmar medial aspect of the third metacarpal
6 Hopper, S.A., Schneider, R.K., Johnson, C.H. et al. bone in 55 horses. Equine Vet. J. 44: 64–70.
(2000). In vitro comparison of transfixation and 14 Nemeth, F. and Back, W. (1991). The use of the walking
standard full limb casts for prevention of displacement cast to repair fractures in horses and ponies. Equine
of a mid‐diaphyseal third metacarpal osteotomy site in Vet. J. 23: 32–36.
horses. Am. J. Vet. Res. 61: 1633–1635. 15 Nunamaker, D.M., Richardson, D.W., and Butterweck,
7 Hopper, S.A., Schneider, R.K., Ratzlaff, R.H. et al. (1998). D.M. (1991). Mechanical and biological effects of plate
Effect of different full‐limb casts on in vitro bone strain luting. J. Orthop. Trauma. 5: 138–145.
in the distal portion of the equine forelimb. Am. J. Vet. 16 Pilsworth, R.C. (1992). Incomplete fracture of the dorsal
Res. 59: 197–200. aspect of the proximal cortex of the third metatarsal bone as
8 Klopfenstein Bregger, M.D., Fürst, A.E., Kircher, P.R. et al. a cause of hind‐limb lameness in the racing Thoroughbred:
(2016). Salter–Harris type II metacarpal and metatarsal a review of three cases. Equine Vet. J. 24 (2): 147–150.
fracture in three foals: Treatment by minimally‐invasive 17 Ramzan, P.H. (2009). Transverse stress fracture of the
lag screw osteosynthesis combined with external distal diaphysis of the third metacarpus in six
coaptation. Vet. Comp. Orthop. Traumatol. 29: 239–245. Thoroughbred racehorses. Equine Vet. J. 41: 602–605.
9 Lescun, T.B., McClure, S.R., Ward, M.P. et al. (2007). 18 Ross, M.W., Ford, T.J., and Orsini, P.G. (1988).
Evaluation of transfixation casting for treatment of third Incomplete longitudinal fracture of the proximal
www.ajlobby.com
palmar cortex of the third metacarpal bone in horses. 21 Turner, A.S., Mills, E.J., and Gabel, A.A. (1975). In vivo
Vet. Surg. 17: 82–86. measurement of bone strain in the horse. Am. J. Vet.
19 Ross, M.W. and Martin, B.B. (1992). Dorsomedial articular Res. 36: 573–579.
fracture of the proximal aspect of the third metacarpal 22 Yovich, J.V., Turner, A.S., and Smith, F.W. (1985).
bone in Standardbred racehorses: seven cases (1978– Holding power of orthopedic screws in equine third
1990). J. Am. Vet. Med. Assoc. 201: 332–335. metacarpal and metatarsal bones. Part I. Foal bone.
20 Sod, G.A., Mitchell, C.F., Hubert, J.D. et al. (2008). Vet. Surg. 14: 221–229.
In vitro biomechanical comparison of locking 3 Yovich, J.V., Turner, A.S., and Smith, F.W. (1985).
2
compression plate fixation and limited‐contact Holding power of orthopedic screws in equine third
dynamic compression plate fixation of osteotomized metacarpal and metatarsal bones: Part II. Adult horse
equine third metacarpal bones. Vet. Surg. 37: 283–288. bone. Vet. Surg. 14: 230–234.
www.ajlobby.com
452
25
Third Metacarpal Dorsal Stress Fractures
Alan J. Nixon1,2, Sue Stover 3, and David M. Nunamaker 4
1
2
3
Department of Anatomy, Physiology & Cell Biology, University of California, Davis, CA, USA
4
Kennet Square, PA, USA
Introduction or both MC3s following high‐speed work. Pressure with the

thumb or forefinger over the dorsal or dorsomedial aspect
Metacarpal stress fractures are a complication and conse- of the MC3 region elicits a reaction. Occasionally the
quence of the “bucked shin complex,” and are a frequent soreness develops a day after intense work or the first race.
occurrence in three‐year‐old Thoroughbred race These are the principal signs of bucked shins or dorsal met-
horses.5,9,13,14 This condition commences in two‐year‐old acarpal disease. The acuteness of the clinical signs and the
healthy sport horses, usually Thoroughbred or Quarter reluctance of the animal to run, or to allow palpation of the
Horse racehorses, during their initial intensive training for area, reflect the severity and acute onset of the problem.
racing. Prevalence figures for bucked shins, which occur Variations in severity of pain and disability occur and often
in the majority of two‐year‐olds as dorsal periostitis, reach indicate more chronic or less profound periostitis. Physical
as high as 80%.9 Most resolve with reduced or altered examination will reveal swelling and tenderness on the
training regimens, although some require rest through the dorsal or dorsomedial aspect of MC3. New bone formation
remainder of the two‐year‐old season. The more serious may be palpable and may be evident on radiographs.
consequence of bucked shins is a stress or saucer fracture, Extensive periosteal new bone formation may delay return
which results from fatigue failure of the dorsal, and pre- to training in two‐year‐old Thoroughbreds (Figure 25.1).
dominantly dorsolateral, cortex of the third metacarpal Diagnosis of stress fractures requires careful radiog-
bone (MC3). Stress fractures are usually detected in three‐ raphy using computed radiography (CR) or digital
year‐olds and may represent the effect of stress accu- radiography (DR) techniques, and occasionally nuclear
mulation and sudden increase in porosity associated scintigraphic confirmation or reevaluation (Figure 25.2).
with a return to training. The term stress fracture itself is With the recent improvements in the sensitivity of
a misnomer, but seems to imply fracture after repeated digital radiographs, there has been improved detection
stress to the bone. It has become so well established in the of stress fractures. The lateral‐medial and oblique
literature that it seems relevant to continue with the term. projections 10–15% off true lateral‐medial (DM75PLO)
are most useful, although a complete series of views is
vital to detect other fracture lines or irregularities in
Diagnosis fracture plane configuration.
Bucked Shins Stress Fractures

The diagnosis of bucked shins is often made by history and Most cortical stress fractures occur on the dorsolateral
simple physical findings. The trainer or owner frequently cortex of MC3, and propagate in a palmaroproximal to
makes the diagnosis for the veterinarian. History and clini- dorsodistal direction within the cortex (so‐called tongue
cal examination indicate tenderness or soreness of the left fractures; Figure 25.3A). Rarely the fracture propagates

www.ajlobby.com
(A) (B)
Figure 25.3 Radiographic appearance of dorsal cortical fractures.

(A) Dorsodistal angled focal cortical stress fracture of the third
metacarpus. (B) Saucer fracture, with extensive periosteal reaction,
proximal (arrow) and distal aspects (arrowheads) of the saucer
fracture.
the same dorsal cortex are also possible (see Figure 25.1),

Figure 25.1 Radiograph of the third metacarpus in a horse with as are fractures of the metaphyseal region of MC3, either
severe bucked shins and several small dorsal cortical fractures.
distally or proximally (Figure 25.4).
Pathogenesis (Nunamaker)
An understanding of the etiology, pathomechanics, and
pathogenesis of bone fatigue failure in the Thoroughbred
racehorse would be helpful in determining treatment
modalities and training regimens.10 Generations of clini-
cians have been taught that bucked shins were the result of
microfractures on the dorsal surface of MC3. These microf-
ractures were thought to be the result of fatigue injuries
that occurred when the animal ran at high speed or during
short striding while leaving the starting gate. The microfrac-
tures were thought to form callus over the injured area
and these fractures would heal through the incorporating
callus. The amount of callus (periosteal new bone forma-
tion) that formed over the area seemed to be quite variable.
Investigations by Nunamaker et al. have proposed a
Figure 25.2 Nuclear scintigraphic imaging of a recurrence of a
focal dorsal cortical stress fracture of the third metacarpus. different understanding for the etiology of bucked shins,
Radiographs were not adequate to provide information as to the with the pathomechanics suggesting a methodology for
best course of treatment. decreasing the incidence of this condition.11–13 These
studies, when taken together, have been used to form a
in the other direction, angling from a proximodorsal hypothesis describing the generation of bucked shins.
entry on the dorsal cortex, distally toward the endosteal In vitro studies of cyclic fatigue of bones from
surface. It is uncommon to have a true “saucer”‐shaped Standardbred and Thoroughbred racehorses have shown
fracture (see Figure 25.3B). Multiple stress fractures in that the material properties of these horses’ bones are
www.ajlobby.com
(A) (B)
Figure 25.4 (A) Proximal stress fracture (cherry splint or cherry fracture) of the proximal aspect of the third metacarpus. (B) Progressive
healing with 60 days’ rest from race training.
12 000 Figure 25.5 These data show the relationship

μ strain of Standardbred and Thoroughbred racehorse
bone subjected to fully reversed cyclic loading
Fitted line to failure. The fitted line shows the average
10 000 expected strains/number of cycles to failure.
Failure of bone would be expected to the right
and above this line, with the bone remaining
intact below and to the left of this line. Since
8 000
young Thoroughbred racehorses have been
μ strain
shown to have strains on their third metacarpus

between 5000 and 6000 micro‐strain, it would
6 000 be expected that these horses would have
problems with bucked shins within about
50 000 cycles. Older horses with lower strains
would be expected to have many more cycles
4 000 prior to fatigue failure, since their strains are in
the 3000 micro‐strain range.
2 000
100 1 000 10 000 100 000 1000 000
Cycles
similar.11 Strains/number of cycles data have been it would follow that whenever the bone strain changes its
developed that show the relationships of cyclic deforma- magnitude or direction, the bone responds accordingly.
tion to bone failure (Figure 25.5). In vivo strain gauge Slow work adapts the bone to slow work. Fast work
measurements have shown that young horses have adapts the bone to fast work, since the speed at which
higher strains on their MC3 when running fast com- the animal works controls the magnitude and direction
pared to older horses (>5 years).13 Interestingly, the of the strain input. Furthermore, in vitro studies have
direction of the principal strains in the Thoroughbred shown that adult horses have stiffer bones than do young
racehorse MC3 seem to change (up to about 40°) with horses. The inertial properties important in dorsal‐pal-
increasing speed. Since most people believe that bone is mar bending of MC3 are also increasing as the horse
modeled and/or remodeled in relation to the magnitude grows older, up to five years of age.12 Changes in bone
and direction of the strain in the bone (Wolff ’s law), then stiffness of more than 25% between right and left MC3s
www.ajlobby.com
have been measured in young horses that have bucked Short, higher‐speed works are included two times a week
their shins.11 at the end of the gallops, with the distances slowly increas-
The hypothesis proposed by Nunamaker and col- ing from a furlong to a half mile. Every time the speed is
leagues10 indicates that high‐strain cyclic fatigue causes increased, the distance is decreased, so that the cycle
decreased bone stiffness in vivo just as it does in vitro. repeats itself. Using these ideas for training allows the bone
The decreasing stiffness causes the bone to respond by to model its shape to resist the large loads of high‐speed
increasing its inertial properties, first using woven or racing without sudden decreases in its stiffness.
lamellar‐type bone and later using fiber bone. Lamellar Changes in bone shape and internal architecture occur
bone can be formed at a rate of 1–2 μm per day. Fiber via modeling and remodeling. Bone modeling occurs by
bone can be formed much faster, so if the stiffness adding bone to surfaces, mostly endosteal or periosteal.
decreases quickly enough, the bone changes from the This bone apposition is important in changing the inertial
lamellar bone formation to the periosteal type (fiber properties of the bone to resist bending in the dorso-
bone) that we recognize as “pathologic.” This condition is palmar direction. Bone remodeling involves the reconsti-
recognized as bucked shins. However, the bone is not tution of the internal architecture of the bone cortex. The
pathologic at all and the change is probably a normal phases of remodeling that are most important in this dis-
response to this decrease in bone stiffness. Microfractures cussion are the phases of resorption, when the porosity of
may occur in vivo as they do with in vitro cyclic fatigue, the bone increases, and apposition, when the resorption
but the periosteal response is related to the change in holes are again filled in. During the remodeling phase,
stiffness, not to the microcracks themselves. The more bone strength decreases when the porosity increases.
the bone is cycled, the more stiffness is lost, and the High‐strain cyclic fatigue during periods of bone resorp-
more periosteal new bone is formed. This explains the tion may accelerate the loss of stiffness described earlier
variable amount of periosteal new bone that is seen radi- and can hasten bucked shins. This seems to be exactly
ographically. Therefore, the radiographic determination what happens when an animal is taken out of work and
of periosteal new bone formation may be important in rested and then returned to race training. The most typi-
determining if a particular animal may continue training. cal situation is in the two‐year‐old racehorse that con-
The MC3 with a lot of periosteal new bone formation is tracts an upper respiratory problem and training is
considered to have lost significant stiffness and may need stopped for 10–21 days. Following bone activation, resorp-
to stop its training so that the bone can remodel. The tion occurs, and the porosity of the bone may be increas-
MC3 with little periosteal new bone may be a candidate ing just when the animal is returned to training or racing.
for continued training with significant modifications. This is a time when the animal is very vulnerable to high‐
If the proposed hypothesis that high‐strain cyclic strain cyclic fatigue. Training should be modified; gener-
fatigue causes decreased bone stiffness is true, then pre- ally the animal is moved backward in its training program
vention of bucked shins should be possible and desirable. to slower speeds and shorter distances.
Almost all of the horses that develop metacarpal stress Histologic examination of specimens from horses in
fractures (saucer fractures) bucked their shins earlier in training has shown that bone remodeling is confined to
their careers. True prevalence figures are not available, the medial and lateral cortices. Dorsally and dorsolater-
but only approximately 12% of the horses that buck their ally, the bone does not turn over significantly. High‐
shins go on to develop these saucer fractures.10 If the strain cyclic fatigue accumulates in these dorsal and
incidence of bucked shins could be decreased, then the dorsolateral cortices, and it is these areas that develop
incidence of saucer fractures would in turn decrease. incomplete cortical fractures. When horses are removed
Revised training regimens are designed to decrease the from training, this area may start remodeling to replace
number of high‐strain cycles, while at the same time intro- the stressed bone material, but the bone would be more
ducing the bone to the environment in which it must sur- susceptible to high‐strain cyclic fatigue if the resorption
vive. This is accomplished by changing the classic training areas have not filled in with new, uncycled bone prior to
programs that gradually increase the exercise distance and the resumption of training.
intensity of a horse to gallops of 2 miles per day, with
breezes at 7, 10, or 14 days. Classically, these high‐speed
workouts are gradually increased so that the animals are Treatment
breezing the distance of their race, with works of a half mile
or more being common. The revised training program is
aimed at decreasing the distance galloped, usually to 1 mile.
Bucked Shins (Nunamaker, Nixon)
Slow‐speed jogging for conditioning is detrimental to the Since the need for treatment can in large part be elimi-
bone, because the principal strain directions in the bone nated, at least in theory, by changing exercise programs
are rotated up to 40° from those in the fast working gait. to reduce the incidence of bucked shins and stress
www.ajlobby.com
f ractures, a large portion of this chapter has been focused remodeling. Extracorporeal shock wave therapy has
on prevention.10 Anecdotal reports of success using this been increasingly used for treatment of bucked shins and
type of training program to reduce bucked shins have even some cortical stress fractures. The principal effect
been described.11 Controlled prospective clinical trials has been reduced lameness, potentially associated with
are needed to prove efficacy. Treatment of these condi- reduced nociceptive fibers in the dorsal MC3 soft tis-
tions is aimed at returning the animal to race training sues.7 This may reduce the delay in return to training and
and racing as quickly as possible. However, patience is racing. Considerable controversy surrounds the impact
needed. Shortcuts in treatment often mean the resump- and potential hazards that shock wave therapy may have
tion of signs of bucked shins or stress fracture, and delays for cortical bone. Increase in microcracking has been
in the return to active training. evident in dorsal MC3 cortical bone exposed to radial
Approximately one‐half of the horses that present with shock wave therapy.2 Combined with preexisting stress‐
acute bucked shins can continue to train.8 Rest and anal- induced bone injury, there has been legitimate concern
gesics are used for short intervals (5–10 days) before of catastrophic failure. These studies have prompted rac-
training is continued. Cold water hosing, cold coming jurisdictions to rule against shock wave therapy for
presses, or cold pressure bandages (Game Ready®, bucked shins within 7–14 days of racing.
CoolSystems, Concord, CA, USA), combined with Periosteal scraping has also been suggested as either a
phenylbutazone and stall rest, should be continued
prophylactic or treatment procedure for bucked shins.15
until the animal’s shins can be palpated without eliciting In a controlled study of 170 Thoroughbreds, 85 were pro-
pain. Application of penetrating nonsteroidal anti‐ phylactically treated by periosteal scraping, while a con-
inflammatory drugs (NSAIDs) such as diclofenac sodium trol group of 85 were untreated.15 Those horses undergoing
(Surpass®, Idexx Pharmaceuticals, Westbrook, ME, USA) the periosteal scraping procedure had significantly
to the skin surface will quickly reduce the focal pain. The reduced incidence of bucked shins, and when bucked
dorsal surface of the MC3 bone will not be free from pain shins did develop, it was later in the training program after
for four to six weeks if training is continued. The training more breeze miles. The mechanism of action of periosteal
program that led to the development of bucked shins scraping has not been determined. Despite the frequent
should be scrutinized. Since fatigue is related to high‐ use of periosteal scraping as a prophylactic method, its
strain cyclic loading, the number of cycles must be efficacy after bucked shins have developed is unknown.
decreased. This will usually mean reducing daily gallop- Since some horses will rebuck their shins, even after
ing distance by half. Since bone modeling and remode- their convalescence. It is important to evaluate the train-
ling are related to the strain magnitudes and principal ing schedule. Long‐distance, slow jogging is probably
directions, high‐speed works of short duration must be detrimental to the reshaping of MC3 for racing. Track
maintained. The horses should have short (1/2–2‐furlong) surfaces that are hard will give a faster response than
works at the end of their gallops twice a week. Speed and those that are soft. This can be both good and bad, so the
distance are introduced slowly, with constant monitor- surface that the animal will race on must be considered
ing of the animal’s condition. When speed is increased, when developing the training program. Some successful
distance is decreased correspondingly, at least initially. racehorses from Europe that are racing on grass may
The other half of the horses that present with bucked buck their shins when introduced to the harder North
shins may not be suitable for the modified training regi- American dirt tracks.
men. These horses seem to have decreased bone stiff-
ness, and additional training will only exacerbate the
condition. Many of these animals will already have large
Stress Fractures
periosteal bone changes on their dorsal cortex at the Stress fractures (saucer fractures) are usually seen six
time of presentation. Radiographs may be helpful in months to one year following the initial bucked shin
evaluating these cases. Rest will provide time for bone problem. Cortical bone in horses that buck their shins
remodeling. The fatigued bone will eventually be does not remodel in the dorsal or dorsolateral aspect of
replaced by noncycled, secondary osteons. The time MC3.10 This bone is undergoing high‐strain cyclic load-
required for this remodeling is approximately 110 days. ing and will fatigue. If the bone is not replaced through
Shortening this interval may be possible in some cases, remodeling, then failure (fracture) will occur. This fail-
since the amount of bone that is needed to turn over is ure can be the incomplete stress fracture, or may be the
presently unknown. catastrophic midshaft fracture associated with a high‐
Treatment modalities such as freeze firing or even tra- speed breakdown injury during a race. A recent study
ditional firing are still common treatments. Their effects of complete diaphyseal MC3 breakdown injuries in
on the soft tissue and peripheral innervation of the limb 12 horses indicated preexisting callus and stress frac-
are more understandable than their effects on bone ture.4 Moreover, the opposite forelimb MC3 also had
www.ajlobby.com
evidence of stress fracture, with concurrent radio- based on their previous experiences. However, there
graphic lesions in 10 of the 12 horses. Since nearly all of has been an increasing trend to avoid the use of oste-
the animals that develop saucer fractures have experi- ostixis as a sole treatment, and to combine the place-
enced bucked shins, the best treatment would be pre- ment of a unicortical screw with additional perforation
vention. However, when presented with one of these drilling on either side of the screw insertion. Inserting a
incomplete dorsal cortical fractures, the veterinarian bone screw provides better assurance of an expeditious
must be able to treat it. resolution of the fracture line.
Incomplete cortical stress fractures develop on the
dorsal or dorsolateral portion of MC3. The horse Surgical Technique
shows lameness and soreness on physical examination. Screw insertion can be done standing or in the anesthe-
Most horses with cortical stress fractures of MC3 are tized animal, depending on surgeon preference, facili-
three‐year‐olds. The fracture is verified by radiographs ties, radiographic equipment suitable for radiographic
(Figures 25.3 and 25.4). Conservative treatment control, and the physical condition of the surgeon. Skin
involves rest and analgesics initially, with gradual staples or hypodermic needles are placed to begin the
return to exercise by walking and jogging. Shock wave radiographic control of drill locations. The most com-
therapy, magnetic surface applications, and occasion- mon stress fracture angles from proximopalmar to dis-
ally counterirritation and firing are used. Radiographs todorsal to exit on the dorsolateral aspect of the lower
are repeated at monthly intervals and race training is mid‐metacarpal region. Many fractures do not have a
resumed when the fracture line disappears. Most prob- radiographically visible entry to the proximopalmar
lems are related to horses where the fracture line does endosteal surface of the dorsal cortex (Figure 25.6A).
not disappear. In these horses, repeated radiographs However, the presence of an endosteal protuberance
show no change in the appearance of the fracture, and suggests an endosteal exit (Figure 25.6A), which can be
surgical intervention may be indicated. confirmed with computed tomography (CT) advanced
Several surgical treatments have been advocated, imaging. Many horses have a palpable cortical protuber-
including single screw fixation through both dorsal and ance where the fracture exits distodorsally. The surgery
palmar cortices, single screw fixation through only the site is prepared and draped, and a 4 cm linear incision,
dorsal cortex, multiple screws through only the dorsal or or the use of a series of stab incisions, allows the entry of
through both cortices, screw fixation combined with a 2.5 mm cortical drill. Radiographic monitoring is used
drill perforation of the adjacent cortex (Figure 25.6), and to ensure that the drill is angled across the fracture line
cortical drilling through and around the fracture (oste- (Figure 25.6B). This is followed by limited additional
ostixis1,5,16). Targeted drill holes throughout the dorsal drilling if osteostixis is also employed (Figure 25.6C).
cortex proximal and distal to the fracture, as defined by Otherwise the 2.5 mm pilot hole is tapped with a 3.5 mm
areas of increased radionucleotide uptake on scintigra- tap and an 18–22 mm long 3.5 mm diameter cortical
phy, have also been advocated. All treatments have their screw is inserted and tightened (Figure 25.6C,D). Lag
proponents, although single screws through both corti- screw principle, by overdrilling the proximal dorsal
ces have been abandoned in most situations, since rela- aspect of the cortex, is generally not performed, since
tive motion between the dorsal and palmar cortices this is not a true compressible fracture. However, a large
seems to cause bone resorption around the screw, with case study did report the successful application of the
resulting pain. lag screw principle, inserting 4.5 mm cortical screws in
Surgical treatment is generally selected for most cor- 116 racehorses.6 Minor countersinking of the dorsal
tical stress fractures on the dorsal and dorsolateral por- cortex is important, since the screw is nearly always
tion of MC3. Fractures in the very proximal or very inserted at an angle to the bone surface, and can bend
distal portions of MC3 (cherry fractures) are less com- beneath the screw head when countersinking is omitted.
mon (see Figure 25.4), and can often be treated with Conversely, excessive countersinking should be avoided,
conservative measures, including controlled exercise since bone can grow into the screw head and complicate
and further rest from active race training. Focused screw removal.
shock wave treatment may induce healing of some frac- The use of a single 3.5 mm cortical screw across the
tures. Current surgical treatment involves either corti- fracture, supplemented by two to four osteostixis
cal drilling (osteostixis),1,5,16 or the insertion of one or holes surrounding the screw in a diamond pattern
two 3.5 mm unicortical bone screws.3 The use of a sin- (Figure 25.6D), provides the best chance of prolonged
gle cortical screw, inserted across the fracture, can stimulation of stress fracture filling (Figure 25.6E). For
often be supplemented by several 2.5 or 3.2 mm drill long oblique stress fractures (Figure 25.7A), a second
holes, both proximal and distal to the screw insertion screw can be inserted 8–10 mm away from the original
site.3 Surgeons generally have a preferred technique screw (Figure 25.7B), and additional osteostixis holes
www.ajlobby.com
(A) (B) (C)
(D) (E)
Figure 25.6 Radiographs of a recurrence of a cortical fracture previously drilled in a three‐year‐old Thoroughbred. (A) The fracture has
periosteal and endosteal callus. (B) Treatment included cortical screw insertion and limited osteostixis. A skin staple provides the initial
radiographic landmark. (C) A 3.5 mm cortical screw was inserted across the fracture line. (D) A dorsopalmar radiograph indicates two
osteostixis drill holes adjacent to the cortical screw. (E) Healing has progressed at 60 days. The screw was removed 80 days postop.
www.ajlobby.com
(A) (B) on the floor. Draping is completed by application of a

large (55 cm) adhesive drape that seals to the glove on
the foot and extends proximally to encase the limb up
to the carpus (Figure 25.9). The surgical approach can
then follow that described for the procedure in the
anesthetized horse. Thorough radiographic monitoring
is essential.
Dorsal cortical stress fractures can also develop
obliquely through the dorsal cortex (Figure 25.10).
Following the principles of screw insertion across the
fracture plane, cortical screws can be inserted obliquely
into the dorsal cortex, to stabilize the intracortical
fracture plane. There is little published information con-
cerning these unusual dorsal cortical fracture configura-
tions. In a small number repaired by one of the authors
(Nixon), routine removal of the screws has been followed
by return to training without recurrence.
Screw removal is always required, usually 70–80 days
after screw insertion, depending on fracture healing, as
most will cause pain during resumption of strenuous
exercise. The screws are usually removed standing, and
45–60 days additional paddock exercise instituted before
recommencing training. Removal is often performed
regardless of whether evidence of a residual fracture line
can be identified on radiographs. Removal can generally
be done in the standing, sedated animal, under local
anesthesia. A small stab incision is made over the palpa-
Figure 25.7 (A) Lateromedial radiographs showing a long oblique ble screw head or the bony protuberance it has induced.
dorsal cortical fracture. (B) Radiographs showing treatment with
two 3.5 mm cortical screws and limited osteostixis proximal and A needle is inserted to establish the position of the screw
distal to the screws. head if it is not readily identified by palpation. The soft
tissues are separated with a hemostat and the screw head
cleaned of residual fibrous tissue. It is vital to fully engage
used in a diamond or hexagon pattern. Osteostixis the hexagonal screwdriver into the depths of the head
perforations outside the perimeter of the fracture do before applying torque, or the shallow 3.5 mm screw
little to assist in healing, and exuberant drilling often head will be stripped. Use of an unworn screwdriver is
leads to exuberant periosteal and endosteal bone deposi- also recommended. The screw is backed out and the stab
tion (Figure 25.8). Additionally, the drill tracts must con- incision closed with a stainless‐steel staple, monofila-
verge on the medullary cavity, rather than crease along ment suture, or Steri‐StripsTM (3M Healthcare, St. Paul,
the endosteal surfaces of the lateral or medial cortex MN, USA). At least 60 days are required for bony
of MC3 (Figure 25.8), which provides a stress riser to filling of the screw hole before recommencing training
catastrophic fracture in recovery. following screw removal.
Osteostixis and screw insertion can be performed Several large case studies describing the results of lag
standing, using sedation and regional neural block. screw fixation for dorsal cortical stress fractures have
Perineural anesthesia of the medial palmar nerve at the been published.3,6 In the larger study of 116 racehorses,
proximal metacarpal level, and the lateral branch of the 83% raced after 4.5 mm lag screw fixation, including
ulna nerve over the distal‐lateral perimeter of the acces- 63% having five or more race starts.6 Additionally, 29%
sory carpal bone, is adequate for standing dissection of these horses had an improved performance index
and screw insertion. An additional ring block over the and earnings per start, while 45% of horses had similar
dorsal proximal aspect of MC3 is occasionally added. earnings and performance index. Another study indi-
The solar surface of the foot and hoof must be cleaned cated that use of a single 3.5 mm screw and concurrent
thoroughly. The entire metacarpus and phalangeal drilling techniques provides a high likelihood of frac-
region, from the carpus distally, is clipped and prepared ture healing (98%),3 and in a series of 63 dorsal cortical
for aseptic surgery. The foot is elevated and enclosed by fractures, only 2 recurred, and none had catastrophic
a sterile glove, then let back onto a sterile towel spread failure.
www.ajlobby.com
(A) (B) (C)
Figure 25.8 (A) Radiographs showing an unusual dorsal cortical fracture, with a proximodorsal to palmarodistal orientation. (B) Treatment
was done standing using a 2.5 mm drill bit to perforate multiple sites across the fracture. (C) One of the drill lines engages the lateral
cortex in error (arrow), which provides a stress riser.
The most comprehensive study of osteostixis for

MC3 cortical stress fractures evaluated 53 horses treated
by perforation drilling.1 Of these animals 47 (88.7%)
returned to racing; however, 3 experienced catastrophic
failure of MC3 while racing or during training. Osteostixis
can be used successfully to heal dorsal cortical fractures.
It is conjectured that the multiple perforations through
the quiescent fracture plane provide vascular and osteo-
genic stimulus to fill in the fracture gap. Postoperative
CT after osteostixis confirms this stimulus, but not
necessarily enough to reliably result in stress fracture
healing (Figure 25.11). It has declined in popularity
due to the overabundance of callus that forms after
overzealous drilling. Seemingly, this results in predispo-
sition to refracture through the massively thickened
dorsal cortex.
Use of multiple screws placed from dorsal to palmar
cortex (Figure 25.12) has also been largely abandoned.
Removal of the screws prior to return to training was
necessary, and excessive callus was also frequently
encountered.
Conservative Treatment
Figure 25.9 Preparation for standing dorsal cortical fracture Nonsurgical treatments involve controlled exercise,
repair with cortical screw insertion and limited osteostixis. Plastic
adhesive drapes are applied and proximal and distal hand towels
directed at trying to remodel bone and heal the frac-
are secured with sterile VetrapTM (3M Healthcare). A sterile glove ture. In these cases it is important that the exercise not
over the foot can substitute for the distal hand towel. subject the animal to the possibility of catastrophic
www.ajlobby.com
(A) (B) (C)
(D) (E) (F)
Figure 25.10 (A) Dorsopalmar radiograph showing an oblique dorsal cortical stress fracture. (B) Higher magnification of the fracture.
(C, D) Dorsopalmar and lateromedial radiographs obtained the day of surgery showing that two 3.5 mm screws confined to the dorsal
cortex have been inserted across the fracture line. (E, F) Dorsopalmar and lateromedial radiographs 10 weeks after surgery, showing
progressive healing of the fracture line with minimal callus. The screws were removed and the horse returned to training 60 days later.
www.ajlobby.com
(A) (B)
(C)
Figure 25.11 (A, B) Sequential computed tomography (CT) slices through a previously
(four months) drilled dorsal cortical fracture. The horse was lame on return to exercise,
and further workup was requested. (C) Given the CT findings, a cortical screw was
inserted and an additional two osteostixis holes drilled proximally and distally.
www.ajlobby.com
(A) (B) fracture of MC3. The timing of return to high‐speed

exercise and eventual racing is a difficult decision for
those involved in both the surgical and nonsurgical
treatment of these incomplete cortical fractures. One
review followed 53 of these horses that were treated
using osteostixis.1 Although 47 of these animals
returned to racing, 3 of them had catastrophic failure of
their involved MC3 bones while racing or in race train-
ing. Predisposition to fracture through stress riser
action has been shown acutely with clustered 4‐ or 7‐
hole patterns of 2.7 and 3.5 mm drill tracts.17 Why this
seemingly persists long into the rehabilitation phase is
unknown, but provides a cautionary note beyond the
obvious concern of recovering osteostixis cases from
general anesthesia.
It is apparent that much remains to be learned about
the bucked shin complex, and its fracture sequelae,
but understanding the pathogenesis seems to be help-
ful in decreasing its incidence. This is preferable to
treating cases, due to the economics of lost training
and racing days from this injury, as well as our inabil-
Figure 25.12 (A) Lateromedial and (B) dorsopalmar radiographs ity to predict the outcome of various treatments in
showing multiple cortical screws inserted across a dorsal cortical
specific cases.
fracture. The technique of binding the dorsal and palmar cortex of the
third metacarpus has largely been replaced by unicortical fixation.
References
1 Cervantes, C., Madison, J.B., Ackerman, N., and Reed, cortical stress fractures of the third metacarpal bone in
W.O. (1992). Surgical treatment of dorsal cortical 116 racehorses. Equine Vet. J. 42: 586–590.
fractures of the third metacarpal bone in Thoroughbred 7 McClure, S.R., Sonea, I.M., Evans, R.B. et al. (2005).
racehorses: 53 cases (1985–1989). J. Am. Vet. Med. Evaluation of analgesia resulting from extracorporeal
Assoc. 200: 1997–2000. shock wave therapy and radial pressure wave therapy in
2 Da Costa Gomez, T.M., Radtke, C.L., Kalscheur, V.L. the limbs of horses and sheep. Am. J. Vet. Res. 66:
et al. (2004). Effect of focused and radial extracorporeal 1702–1708.
shock wave therapy on equine bone microdamage. Vet. 8 Moyer, W. and Fisher, J.R.S. (1991). Bucked shins:
Surg. 33: 49–55. effects of differing track surfaces and proposed training
3 Dallap, B.L., Bramlage, L.R., and Embertson, R.M. regimens. In: Proceedings of the American Association
(1999). Results of screw fixation combined with cortical of Equine Practitioners, vol. 37, 541–561. Lexington,
drilling for treatment of dorsal cortical stress fractures of KY: AAEP.
the third metacarpal bone in 56 Thoroughbred race 9 Norwood, G.L. (1978). The bucked shin complex in
horses. Equine Vet. J. 31: 252–257. Thoroughbreds. In: Proceedings of the American
4 Gray, S.N., Gray, S.N., Spriet, M. et al. (2017). Preexisting Association of Equine Practitioners, vol. 24, 319–336.
lesions associated with complete diaphyseal fractures of Lexington, KY: AAEP.
the third metacarpal bone in 12 Thoroughbred 10 Nunamaker, D.M. (1996). Metacarpal stress fractures.
racehorses. J. Vet. Diagn. Invest. 29: 437–441. In: Equine Fracture Repair (ed. A.J. Nixon), 195–199.
5 Hanie, E.A., Sullins, K.E., and White, N.A. (1992). A Philadelphia: Saunders.
follow‐up of 28 horses with third metacarpal unicortical 11 Nunamaker, D.M., Butterweck, D.M., and Black, J.
stress fractures following treatment with osteostixis. (1991). In vitro comparison of Thoroughbred and
Equine Vet. J. 11 (Suppl.): 5–9. Standardbred racehorses with regard to local fatigue
6 Jalim, S.L., McIlwraith, C.W., Goodman, N.L., and failure of the third metacarpal bone. Am. J. Vet. Res.
Anderson, G.A. (2010). Lag screw fixation of dorsal 52: 97–100.
www.ajlobby.com
12 Nunamaker, D.M., Butterweck, D.M., and Provost, M.T. 15 Plevin, S. and McLellan, J. (2014). Does periosteal
(1989). Some geometric properties of the metacarpal scraping of the third metacarpal bone reduce the
bone: A comparison between the Thoroughbred and incidence of “bucked shins” in young Thoroughbred
Standardbred racehorse. J. Biomech. 22: 129–134. racehorses? Equine Vet. J. 46: 560–566.
13 Nunamaker, D.M., Butterweck, D.M., and Provost, M.T. 16 Specht, T.E. and Colahan, P.T. (1990). Osteostixis
(1990). Fatigue fractures in Thoroughbred racehorses: for incomplete cortical fracture of the third
relationships with age, peak bone strain and training. metacarpal bone. Results in 11 horses. Vet. Surg.
J. Orthop. Res. 8: 604–611. 19: 34–40.
4 Nunamaker, D.M. and Provost, M.T. (1991).
1 7 Specht, T.E., Miller, G.J., and Colahan, P.T. (1990).
1
The bucked shin complex revisited. In: Proceedings Effects of clustered drill holes on the breaking strength
of the American Association of Equine Practitioners, of the equine third metacarpal bone. Am. J. Vet. Res.
vol. 37, 757–762. Lexington, KY: AAEP. 51: 1242–1246.
www.ajlobby.com
465
26
Fractures of the Small Metacarpal
and Metatarsal (Splint) Bones
Alan J. Nixon1,2 and Lisa A. Fortier1
1
2
Introduction Distal Fractures

The second and fourth metacarpal/metatarsal (splint) Clinical Signs and Pathogenesis
bones are small, somewhat vestigial weight‐bearing
bones, but are frequently a cause of lameness and Distal splint bone fractures commonly present with con-
secondary damage to adjacent structures such as the current suspensory ligament desmitis, although they can
suspensory ligament or proximal articulations. Anatomic also be a coincidental finding on radiographic examina-
arrangement varies between the lateral and medial tion. Standardbreds are more frequently affected than
splint bones, predominantly in the articulation with the Thoroughbreds.9 Forelimbs are more frequently involved
carpal or tarsal bones, but also in the shape and contact than hindlimbs. Direct trauma to the distal portion of the
regions with the suspensory ligament. The medial splint splint bone is common, and often results from external
bone supports the predominant weight‐bearing axis of impact to the lateral splint due to its exposed location, or
the second carpal or tarsal bones, and, unlike the lateral interference of the opposite foot with the medial splint.
splint bone, the medial splint does not appreciably share Lameness is transitory, but swelling frequently remains
this load with the proximal aspect of the third metacar- and can increase as fibrous and bony callus forms.
pus/metatarsus (MC/MT3). Pressure over the fracture or the adjacent suspensory
Direct fractures of the second and fourth metacarpal ligament with the limb unweighted often elicits a reac-
or metatarsal bones are common and may be caused by tion. Radiographs are definitive (Figure 26.1). Distal
external trauma such as a kick or other impact injury, or splint bone fractures are rarely open or comminuted, and
internal forces associated with hyperextension of the typically do not spontaneously heal, but rather remain as
fetlock or desmitis of the suspensory ligament. The splint viable nonunions (Figures 26.2 and 26.3). Acute fractures
bone can be fractured anywhere along its length, generally appear radiographically as simple complete
although fractures secondary to suspensory desmitis are distal shaft slight oblique fractures (see Figure 26.1).
often distal. The consequences of exuberant callus con- Later, callus can form, producing a visible blemish on the
versely have more significant impact in the middle and limb, and often compressing the adjacent suspensory
proximal thirds of the splint bone. ligament (see Figure 26.3). In chronic cases, it becomes
Management of splint bone fractures varies depending much less clear if the splint callus and associated p hysical
on location (distal third, body, or proximal third), and if swelling are the cause of lameness. In these cases, local
the fracture is open or closed. Horses with splint bone infiltration with anesthetic or use of regional perineural
fractures commonly present with concurrent desmitis of blocks is required.
the intraosseous (suspensory) ligament. Palpation and The etiology of distal splint bone fractures also includes
ultrasonography of the intraosseous ligament should be excessive tension in the interosseous ligaments that attach
performed in all cases presenting with a splint bone the splint bones to MC/MT3, and the soft tissue band
fracture, because the extent of suspensory ligament that extends from the distal aspect of the splint bones in a
desmitis will often be the limiting factor dictating return distal direction toward the proximal sesamoid bones.
to athletic performance. There is significant anatomic variability in this band of

www.ajlobby.com
Figure 26.1 Acute distal splint bone fracture in a Thoroughbred

racehorse. Figure 26.3 Chronic displaced malunion of the distal splint bone in
a Thoroughbred racehorse. Removal above the callus was required.
(A) (B)
ligamentous tissue.7 There is also speculation that if this
band of soft tissue is long and the distal splint bones curve
away from the parent MC/MT3, increased strain is gener-
ated when the fetlock is in extension, rendering a horse
more susceptible to fractures of the distal splint bone.7,13
Fracture of the distal portion of the splint bones also
commonly develops due to pressure from an adjacent
suspensory desmitis lesion (Figure 26.4).13 Fetlock
f lexion has been shown to induce abaxial motion of the
distal aspect of the splint bones, which is presumed to
be exacerbated by the enlarged soft tissue volume after
suspensory desmitis. This theory is supported by clini-
cal data which show that 81% of Standardbreds and 67%
of Thoroughbreds with fractures of the distal extremity
of the splint have suspensory desmitis.3 Ultrasonographic
examination in addition to radiography is clearly
indicated in splint bone fracture cases.
Treatment
The necessity of removing a fractured distal portion of
the splint bone remains controversial. Many simple frac-
tures can go on to a functional fibrous or bony union
without residual lameness. However, the risk of exuber-
Figure 26.2 Chronic splint bone fracture with nonunion and ant callus and prolonged convalescence is minimized by
proliferative callus. (A) Preoperative dorsomedial to plantarolateral
early removal of the distal fractured portion. Symptomatic
projection shows displaced splint and callus formation. Soft tissue
shadow also suggests enlarged suspensory branch, which was fractures of the distal portion of the splint bone should
confirmed by ultrasonography. (B) Same radiographic projection be surgically treated by excision of the distal fragment.
after distal fracture removal. The surgical procedure is simple and often can be
www.ajlobby.com
26 Fractures of Small Metacarpal and Metatarsal Bones 467
(A) (B) (C)
(D) (E) (F) (G)
Figure 26.4 (A–C) Chronic active medial splint bone fracture with displacement and irregular bony exostoses. (D–G) Ultrasound
examination shows suspensory desmitis of the medial branch. (D) ultrasound image in the longitudinal plane demonstrating irregularity
of the splint bone margin. Images (E), (F), and (G) show a medium sized hypoechogenic region within the medial branch of the
suspensory ligament with (E) obtained just distal to the splint bone and (F) and (G) slightly more proximal.
erformed in the standing horse. An Esmarch bandage

p fractured distal segment. Excision of the periosteum
and tourniquet are rarely necessary for distal fragment reduces postoperative new bone formation at the surgery
removal, but may be helpful if the horse is under general site.4 The fractured portion is then grasped on its distal
anesthesia, as it can decrease surgery time by negating button with a penetrating towel clamp or similar instru-
the occasional bleeding from the fibrous callus and distal ment and elevated, allowing for sharp division of the
ligament attachments. If under general anesthesia, the interosseous ligament that binds the fracture fragment to
horse is placed in lateral recumbency with the affected the adjacent MC/MT3. Where fracture callus has devel-
splint bone uppermost. An incision is made directly over oped or the distal splint bone has fused to MC/MT3, an
the distal fragment, extending for 2 cm proximal to the osteotome or gouge can be used in a distal to proximal
palpable callus or mobile fracture fragment. The under- direction to elevate the fracture fragment. If more than
lying fascial plane is separated and the periosteum over the extreme distal portion of the splint bone is involved,
the splint exposed. A deeper incision is made on the an osteotome is likely to be required, since fusion of
dorsal and palmar/plantar surface of the splint, to remove the splint bones to MC3 occurs spontaneously in 78% of
periosteum along with the bulge of the callus and the all horses two years or older.10 Additionally, use of an
www.ajlobby.com
(A) (B) performance for horses with d istal splint bone fractures
is generally good, but depends on the extent of concur-
rent suspensory ligament d
esmitis. Cosmetic outcome is
typically excellent.
Body Fractures
Clinical Signs
Fractures of the body or middle third of the splint bone
are most commonly the result of known external trauma
such as a kick or other impact injury.1 The lateral splint
bones are more exposed and therefore more commonly
involved in traumatic fractures, compared to the medial
splint bones. However, the medial splint bones are
susceptible to impact fracture from interference by the
opposite foot, as well as simple exostoses from detach-
ment to MC/MT3 that are then further traumatized by
the opposite foot. The suspensory ligament should be
examined for damage by palpation and ultrasonographic
assessment, but it is less likely to be involved than in
cases with distal splint bone fracture. The obvious
exception involves chronic splint fractures that have
developed exuberant callus which can adhere to or
impinge on the suspensory ligament (Figure 26.6).
Figure 26.5 Pre‐ and postoperative radiographs showing (A)
chronic splint bone fracture with extensive callus, and (B) oblique
Fractures of the middle and proximal regions of the
ostectomy cut leaving a beveled end to the proximal splint bone. splints are frequently open, and their configuration is
highly variable, ranging from simple to highly commi-
nuted. Conservative management of mid‐body splint
steotome from proximal to distal may also be required
o bone fractures, such as bandaging, splints, casting, and
to provide a smooth amputation across any callus on enforced rest, can be successful, but often results in
MC/MT3. excess callus formation despite treatment, which
After the fracture fragment is removed, smoothing impinges on the suspensory ligament, resulting in lame-
with a bone rasp, large spoon curette, or osteotome is ness. Open, infected fractures can be successfully
used to remove any remaining callus and irregularities treated with oral or intravenous antibiotics and regional
of the fracture bed on the proximal fragment. When limb perfusion, but if the infection recurs after cessation
the fracture involves a more substantive portion of the of antimicrobial therapy, then further radiography to
shaft of the splint bone, a beveled osteotomy at 45° identify and assist in removal of associated sequestra is
becomes more important for functional and cosmetic indicated. After control of the acute infection, removal
outcome (Figure 26.5). Care should be taken to avoid of the entire distal splint bone with mid‐body commi-
iatrogenic trauma to the suspensory ligament and neu- nuted fragments and new exuberant callus can then be
rovascular bundle during dissection. The tourniquet safely accomplished with less likelihood of wound
should be removed and vessels cauterized or ligated dehiscence or recurrence of proliferative new bone.
prior to closure. Additional diagnostic techniques and surgical proce-
The fascia over the bone void is firmly reapposed with dures are required to treat adhesions between splint
#0 resorbable suture material, and the subcutaneous and callus and the suspensory ligament, or excessive callus
skin layers are closed routinely. Any free hemorrhage is formation leading to impingement on the suspensory
forced out of the deeper tissue layers before final suture ligament. Palpation of the limb in an unweighted posi-
closure. A pressure bandage should be applied to mini- tion allows separation of the suspensory ligament from
mize accumulation of blood or serum in the dead space. the axial border of the splint, and subsequent detection
Perioperative antibiotics are generally not necessary, but of adhesive bands or bony exostoses on the axial surface
a preoperative and single postoperative dose of potassium of the fractured splint. Local infiltration of anesthetic
penicillin is used if dead space is expected to be pre- just proximal to the callus should improve the lameness
sent after closure. The prognosis for return to athletic and support the diagnosis more than a high four‐point
www.ajlobby.com
Figure 26.6 Chronic fracture of the middle (A) (B) (C)

third of the splint bone, showing callus
healing and significant exostosis formation
around the suspensory ligament.
Radiographic projections, including
(A) lateromedial, (B) medial oblique, and
(C) dorsopalmar, show circumferential
mineralization surrounding the suspensory
ligament.
Figure 26.7 Chronic fracture of the (A) (B) (C)

middle third of a forelimb medial splint
bone. (A, B) Dorsopalmar and slightly
oblique dorsopalmar radiographic
projections show the axial intrusion of the
callus onto the suspensory ligament
(arrows). (C) Dorsomedial to
palmarolateral view shows residual
fractures and exostosis formation.
perineural nerve block. High‐detail digital dorsopalmar determining the extent of damage to the suspensory
radiographic projections will often suggest the pres- ligament. In complex cases that are not clear‐cut on
ence of callus extending axially into the area of the ultrasonographic examination, computed tomography
suspensory ligament (Figure 26.7). Ultrasonography should be performed to detail the three‐dimensional
of the suspensory ligament and callus can be helpful in configuration of the callus.
www.ajlobby.com
Treatment (A)
Surgical treatment for fractures of the body or middle
third of the splint bone requires a longer skin incision
and deeper dissection, but follows the same principles
defined for removal of distal splint bone fractures. Open
exposure and amputation by oblique osteotomy immedi-
ately proximal to the fracture callus allows removal of the
fractured distal portion of the splint, including the frac-
ture and callus, leaving a clean proximal portion of splint
to support the carpal or tarsal bones. Accurate dissection
and careful hemostasis controls callus reformation. An
Esmarch bandage should be used to allow maximal surgi-
cal site visibility and minimize inadvertent damage to the
suspensory ligament. Sharp dissection includes perios-
teum along the dorsal and palmar/plantar edge to allow (B)
removal of all periosteum attached to splint and callus
(Figure 26.8). Segmental ostectomy of the abnormal por-
tion of a splint bone, leaving the unaffected proximal and
distal segments undisturbed, has also resulted in success-
ful return to performance.8 If a sequestrum is removed,
aggressive curettage of the involucrum and infected soft
tissues, coupled with copious lavage, should be performed
prior to closure of the incision. Bacterial culture and anti-
biotic sensitivity of infected soft tissue or bone fragments
are warranted. If adhesions between the remaining splint
bone and suspensory ligament were present, they should
be sharply dissected. To prevent adhesion reformation, an
adhesion barrier such as cross‐linked sodium hyaluronate Figure 26.8 Removal of mid‐body fractured splint and massive
(equitrXTM, SentrX Animal Care, Salt Lake City, UT, callus. (A) The dissection includes sharp incision of the attached
periosteum along dorsal and palmar borders (white arrows).
USA) should be placed between the splint bone and sus- (B) The osteotome is angled obliquely distally but also palmarly
pensory ligament. Radiographic monitoring in the early to ensure callus removal adjacent to the suspensory ligament.
postoperative period, often at four weeks, is useful to
detect recurrence of proliferative bone around the trauma to the dorsal metatarsal artery as it penetrates
osteotomy site. Infiltration of the affected site with between the splint and MT3 in the distal region of the
triamcinolone acetonide (6–10 mg) should be instituted dissection. Residual internal (axial) callus can be removed
immediately, and repeated in two weeks if necessary. with a bone rasp. Interpositional hyaluronan sheets
For removal of hindlimb lateral splint bone fractures, are used to separate and minimize adhesion formation
the dorsal metatarsal artery located between the splint between the ostectomy site and suspensory ligament. The
and MT3 must be carefully identified and avoided. At the prognosis for return to athletic function and cosmetic
site of the callus, it can be totally obscured by dense outcome are typically excellent.1,8
fibrous tissue. Careful dissection using sharp and blunt
division from the visible proximal aspect of the obscured
vessel allows safe splint and callus delineation for removal. roximal Splint Bone
P
A periosteal elevator is used to gently separate the sus- Fractures
pensory ligament from the splint bone and focal fracture
callus. Occasional sharp dissection with a #15 scalpel
Clinical Signs
blade may also be required, but must be done with
extreme caution to avoid palmar metacarpal/ plantar Most proximal splint bone fractures involve the lateral
metatarsal vessels. The splint osteotomy should be per- splint, similar to fractures of the middle third of the
formed with the osteotome angled palmarly to maximize splint, and result from kicking out and striking an object,
callus removal, but precise positioning of the leading or getting the limb trapped in a feeder, gate, door, or
corner of the osteotome is required to avoid shredding of fence. Lameness and swelling are often profound, but
the suspensory ligament (Figure 26.8). Dissection and improve quickly with first aid measures. Comminution is
separation of the hindlimb lateral splint must also avoid frequent, and skin wounds often communicate with the
www.ajlobby.com
(A) (B)
Figure 26.9 Hindlimb entrapment in a feed bunk resulting in an

open splint bone fracture and septic tarsometatarsal/distal
intertarsal joints. (A) The major wounds on the lateral aspect of the
hock were debrided and partially closed with sutures with
embedded Penrose drains, the joint flushed, and an ingress drain
placed in the dorsal joint recess for antibiotic administration.
(B) The dorsolateral to plantaromedial radiograph shows the
multiple comminuted fragments and fracture plane entering the
head of the splint and tarsometatarsal joint. Figure 26.10 Dorsolateral to plantaromedial radiographic
projections of an open comminuted fracture of the lateral splint
bone, showing maintenance of general fracture alignment and a
fracture fragments (Figure 26.9). Involvement of the location sufficiently distal to be isolated from the tarsal joints.
tarsometatarsal joint can follow, and open wounds rap-
idly develop into suppurative wounds with concurrent the fourth carpal by the third metacarpal bone, and has
septic arthritis. Radiographs show the configuration and been reported in eight horses with comminuted open
extent of the fracture, and should include multiple fractures, with five horses becoming sound for their
oblique projections to define the fracture planes and intended purpose.2
possible involvement of the tarsal joints (Figure 26.10).
Use of CT may be useful for complex splint bone frac-
tures. Proximal splint bone fractures are the most com-
Treatment
plex splint fracture to treat and the surgery is complicated Proximal splint bone fractures are tension fractures, and
by the need to provide residual fragment stabilization by the ligamentous attachments on the abaxial surfaces of
internal fixation.12 Removal of more than two‐thirds of the proximal splint make the palmar/plantar abaxial
the medial splint or more than three‐quarters of the surface the tension side and the appropriate surface for
lateral splint can lead to displacement of the remaining stabilization by implant fixation. Single or multiple lag
proximal bone, loss of support for the opposing joint sur- screw fixation of the remaining portion of the head of
face, and persistent lameness. Establishing the risk of the splint bone after distal splint amputation is easy to
displacement after amputation of more than two‐thirds accomplish (Figure 26.11), and has been described in 11
of the splint also includes an evaluation of the extent of horses.12 However, screw fixation alone resulted in bone
bone callus around a fracture that may unite the residual failure in 4 horses and implant failure in 2 horses. Only 2
proximal portion to MC/MT3, which may allow removal of 11 horses treated with screw fixation returned to their
of a greater proportion of the splint. Since the medial intended use. Single‐point fixation of the residual splint
splint supports all of the second carpal/tarsal bone axial allows rotation around the screw and the possibility of
weight, complete removal of the splint bone is not rec- splint malalignment or screw breakage (Figure 26.12).
ommended. The importance of full articular support of Therefore, neutralization plating is recommended.
the carpus by the second metacarpus is demonstrated General guidelines for selection of cases for plate fixa-
through the increased incidence of severe carpometa- tion include those where 5 cm or less of the proximal
carpal osteoarthritis in horses where the articulation is splint bone remains and those with comminuted frac-
congenitally absent.11 Conversely, complete excision of tures of the proximal splint bone. The medial splint bone
the fourth metacarpal bone leaves residual support for tends to be more unstable due to minimal load sharing,
www.ajlobby.com
(A) (B)
Figure 26.11 Removal of all but 2 cm of the lateral hindlimb splint
bone, followed by stabilization with a single 4.5 mm cortical screw.
Rotational instability can result in poor fragment retention. Figure 26.12 The amount of force required to resist avulsion and
rotation of the proximal aspect of the splint bone after
amputation of the distal portion of the bone. (A) Screw fixation
results in all the load on one screw. (B) Plate fixation distributes
but lateral splint displacement after ostectomy can also the load over a series of screws. Source: Peterson et al.12
develop. If the necessity for plate fixation is unclear or Reproduced with permission of John Wiley and Sons.
borderline, plating is recommended, since anatomic
reduction of a splint bone that becomes displaced post- considered even in the face of contamination or con-
operatively is exceptionally difficult and incomplete trolled infection, to h
asten fracture repair and avoid loss
reduction will lead to chronic lameness (Figure 26.13). of stability between the proximal splint bone and oppos-
The hindlimb lateral splint bone is particularly prone ing carpal/tarsal bone articulation. Although earlier
to open comminuted fracture after the horse kicks out reports suggested that most plated infected splint frac-
and strikes a sharp object (see Figure 26.9). Contamination tures failed or required revision,6,12 use of regional limb
of the fracture site is inevitable. Presentation is fre- perfusion and local depot forms of antibiotics may
quently sufficiently delayed that the fracture site becomes improve control of the spread of infection in potentially
infected. For open fractures in the proximal quarter of the infected fractures (Figure 26.14).
lateral splint, extension to joint sepsis is common, and
should be evaluated and aggressively treated. Most con- Splint Bone Plating
taminated or infected proximal fractures are moderately Commonly used plates (Figure 26.15) include a 3.5 mm
stable, and can initially be treated by local lavage, regional reconstruction plate, the 3.5 mm semitubular plate, and
intravenous perfusion, and joint flush. Debridement and the 3.5 mm narrow limited‐contact dynamic compression
removal of free devitalized bone fragments allow antimi- plate (LC‐DCP; DePuy Synthes, West Chester, PA, USA).
crobials to penetrate the fracture and callus that begins to The plate is principally loaded in tension and a semitubu-
form around the remaining fragments. Many horses with lar plate, despite its thin wall and poor resistance to bend-
contaminated, comminuted fractures of the proximal ing, can be very satisfactory for stabilizing the residual
lateral splint bone can be returned to function by con- proximal portion of the splint bone (Figures 26.16 and
servative therapy.5 Where internal fixation is necessary, 26.17). The 2.4 and 3.5 mm locking compression plates
several weeks of wound management and antimicrobial (LCPs) are now available (DePuy Synthes), and are also
therapy allow delayed stabilization by plate fixation in suitable for splint bone stabilization, although use of an
a less infected environment. Plate fixation should be LCP for splint stabilization seems to add little to the
www.ajlobby.com
(A) (B) (C)
Figure 26.13 Displacement of residual splint bone after fracture and distal portion amputation. (A) Proximal comminuted fracture of the
fourth metacarpal bone; (B) displacement after removal of the fracture and distal portion of the splint; and (C) attempt to realign and
stabilize proximal fragment. Source: Modified from Doran.5 Reproduced with permission of Elsevier.
repair, given that most of the screws will need to be

cortical rather than locked. The 2.4 or 3.5 mm locking
compression dorsal‐distal radius plate accepts two screws
on the nontapered end, and should be considered to
increase purchase in the proximal splint bone. Any of the
plates should be contoured to follow the slope from the
splint bone down onto MC/MT3. Ideally, at least two
plate screws should be placed in the splint bone and three
into MC/MT3.
The surgical approach for plate application is similar
to that described for middle third (body) fractures,
although radiographic guidance is useful in the repair of
proximal splint bone fractures to assess reduction and
implant placement (Figure 26.17). If a sequestrum or
other nonseptic devitalized bone is present, it should be
removed and the area should be aggressively debrided
and lavaged prior to plate implantation. A needle is used
to identify the proximal aspect of the splint bone and
the joint space. The ligamentous attachments on the
proximal splint bone are incised longitudinally and judi-
ciously spread to enhance plate–bone interface contact.
Theoretically, this is not necessary when placing an LCP,
but if the fracture is comminuted, then dissection of
the ligamentous attachments will increase visibility of
Figure 26.14 Plate fixation of an open infected fracture of the the fracture configuration and help guide implant place-
hindlimb lateral splint bone. Polymethylmethacrylate (PMMA) ment. Ideally, the plate screws will only engage the splint
beads were placed at surgery to control the local suppurative
reaction. Dorsoplantar radiograph obtained two years after plate
bone, but in most fractures increased purchase using the
fixation shows healed stable residual splint bone with PMMA near cortex of MC/MT3 will be needed to achieve stable
beads (arrows) still in place. fixation (Figure 26.17). Plates with stronger plate stock,
www.ajlobby.com
(A)
(B)
(C)
(D)
Figure 26.15 Small plates for equine splint bone fracture repair. (A) One third tubular; (B) 3.5 mm reconstruction plate; (C) 3.5 mm narrow
limited‐contact dynamic compression plate; and (D) 3.5 mm locking compression plate, shown en face (left) and oblique underside and end
views (right).
(A) (B) (C) (D)
Figure 26.16 Fracture of the proximal third of the lateral splint bone with massive callus. (A, B) Preoperative appearance of the limb
seven months after kicking out and striking a door. (C) Dorsolateral to plantaromedial oblique radiograph shows the exuberant callus and
planned ostectomy line immediately proximal to the fracture. (D) Dorsoplantar projection shows that the callus is predominantly external
and does not protrude appreciably into the suspensory ligament.
such as the 3.5 mm reconstruction plate and the 3.5 mm p revent adhesion formation. These interpositional

dynamic compression plate (DCP), can be used instead layers are inserted as folded dry membrane and secured
of the one‐third tubular plate (Figure 26.18), and pro- by suturing the subcutaneous tissue over the surface
vide better resistance to motion or fragment rotation (Figure 26.19). Other HA composite films such as HA‐
beneath the plate. However, the wraparound effect of carboxymethylcellulose sheets (Seprafilm®, Genzyme
the one‐third tubular plate provides additional stability Biosurgery, Framingham, MA, USA) generally do not
to prevent the proximal fragment splitting with subse- prevent suspensory ligament adhesion.
quent fixation failure. Closure of the incision includes careful apposition of
After implant placement, the adjacent suspensory fascia over the residual splint bone and plate. Elimination
ligament can be isolated from the osteotomized residual of dead space in the distal region of the shaft and button
splint bone end and edge of the plate by sheets of of the splint is vital to avoid hematoma formation, with
cross‐linked hyaluronate (HA) membrane (equitrX) to secondary calcification and adhesions. Small Penrose
www.ajlobby.com
(A) (B)
(C) (D)
(E) (H) (I)
(F)
(G)
Figure 26.17 Intraoperative views of horse in Figure 26.16. (A) Extensive dissection has allowed the splint bone to be freed from the
interosseous ligaments distally and an osteotome used to divide the callus and bony union with the third metatarsal (MT3). Note the dorsal
metatarsal artery coursing along the dorsal edge of the dissection (arrows). (B) Removed splint still covered with periosteum. (C) Application
of a 3.5 mm one‐third tubular plate contoured to fit over the ostectomized splint and down onto MT3. (D) Plate in place with all screws
engaging MT3. (E) Cross‐linked hyaluronate (HA) membrane (inset F), being folded and inserted between the residual splint and the head of
the suspensory ligament. (G) HA membrane in place. (H, I) Postoperative radiographs showing preservation of more splint than expected
compared to the preoperative plan. The callus was removed and the fracture line was not discernible (see A). On intraoperative radiographs
the original fracture line was just evident (between the second and third screws from the proximal end of the plate), hence a plate was still
considered an appropriate stabilizing implant.
www.ajlobby.com
(A) (B) (C)
(D) (E)
Figure 26.18 Plate fixation of proximal splint bone fractures in three cases. (A) Extreme proximal medial forelimb splint fracture; and
(B) reconstruction plate application. (C) Proximal splint fracture in an 11‐year‐old Oldenburg gelding after amputation and stabilization
with a contoured 3.5 mm dynamic compression plate. (D, E) Radiographs of 3.5 mm limited‐contact dynamic compression plate repair of
lateral forelimb splint fracture in a Warmblood mare.
drains can be used, but are best avoided when metal Proximal splint bone trauma can occasionally result in
implants are in place. Accurate wound closure and longitudinal fracture that extends into the head of the
direct pressure from bandaging should be adequate. splint and associated carpometacarpal or tarsometatarsal
Subcutaneous and subcuticular layers maintain tight articulation (Figure 26.20). These fractures are generally
tissue apposition. Skin sutures or staples are routine. not open and are good candidates for plate fixation.
www.ajlobby.com
(B) (C)
(A)
(D)
(E) (F)
(G) (H)
Figure 26.19 Semitubular plate repair of infected proximal splint bone fracture in Figure 26.10. (A, B) Radiographs 14 weeks postoperatively
show stable fixation. (C) Return of lameness was associated with suspensory adhesion to repair. (D) Second surgery separated the
suspensory origin from the repaired splint bone head and inserted hyaluronate membrane into defect (HA). Steps in adhesion repair
include (E) identification of the existing adhesions (between arrows); (F) after division of adhesions; (G) placing HA membrane; and
(H) membrane in position to separate suspensory and original splint repair. Routine closure over the HA membrane then followed.
www.ajlobby.com
(A) (B) Figure 26.20 (A) Longitudinal fracture

of the proximal portion of the splint bone.
(B) 10‐hole 3.5 mm dynamic compression
plate applied to stabilize the fracture.
Ideally, the screws should stay confined to
the fourth metacarpus, but this may not
always be practical. Source: Modified from
Doran.5 Reproduced with permission of
Elsevier.
Ideally, a small semitubular or 3.5 mm LC‐DCP can be severing the interosseous ligament between splint and
applied using several cortical screws lagged through the MT3 as the separation continues proximally. Flushing of
plate initially to compress across the longitudinal frac- the distal tarsal joints in cases with residual infection
ture, and the remainder applied to engage both cortices from open comminuted fractures should be considered.
of the splint bone. With appropriate care and radio- Closure of the extensive dead space requires a three‐
graphic monitoring, all screws can avoid engaging the layer closure, starting with deep fascia and tarsal reticu-
adjacent MC/MT3, which allows continued independent lum proximally, and followed by subcutaneous and skin
motion of the splint and MC/MT3 bone (Figure 26.20). layers. Use of a Penrose drain may be required, and it
should exit distally. Fastidious bandaging with rolled
Fourth Metatarsal Complete Removal gauze sponges over the incision is required for preven-
Complete removal of the lateral splint bone in the tion of seroma or abscess.
hindlimb has been successfully used to treat open com-
minuted fractures of the proximal portion of the fourth Postoperative Care
metatarsus.2,5 The proximal weight‐bearing support
provided to the fourth tarsal bone by the head of the lat- External coaptation is not necessary for postoperative
eral splint is quite minor, and the extensive ligament management of most proximal splint bone fracture repairs.
attachments reattach to the third metatarsus after splint Postoperatively, pressure bandages should be maintained
removal. Return to function occurred in five of eight for the first week to minimize seroma formation, and anti-
horses treated by complete fourth metatarsal excision. microbial therapy should be maintained for 3–5 days.
An Esmarch bandage and good tourniquet above the Horses should be confined to box stall rest for the first 30
hock make this surgery less tedious. The surgical days, at which time radiographic examination will dictate
approach is extensive, with a skin incision extending further exercise recommendations. Most horses can start
2 cm beyond the proximal and distal ends of the splint. graded walking exercises, increasing over eight weeks.
The dorsal metatarsal artery extending along the dorsal
edge of the splint and dipping between the splint
and MT3 near the distal quarter must be identified and
Results
preserved. Complete excision of the splint bone and Results suggest that return to athletic performance after
covering periosteum is accomplished by sharp incision proximal splint bone repair is fair, with 6 of 11 horses
of the fascia and periosteum along the plantar and dorsal treated by plate fixation returning to their intended
edges of the lateral splint. Removal commences distally, use.2,12 For horses treated with lag screw fixation, the
www.ajlobby.com
results were poor, with only 2 of 11 returning to their persistent infection was present. Outcome after complete
intended use.12 Plate removal does not appear to be splint bone excision suggests that it should be considered
necessary for return to athletic performance, and plates for highly comminuted hindlimb lateral splint bone
or individual plate screws were removed only when fractures.2
References
1 Allen, D. and White, N.A. (1987). Management of fractures in consideration of fascial attachments. Schweiz. Arch.
and exostosis of the metacarpals and metatarsals II and IV Tierheilkd. 147: 473–481.
in 25 horses. Equine Vet. J. 19: 326–330. 8 Jenson, P.W., Gaughan, E.M., Lillich, J.D., and Bryant, J.E.
2 Baxter, G.M., Doran, R.E., and Allen, D. (1992). (2004). Segmental ostectomy of the second and fourth
Complete excision of a fractured fourth metatarsal bone metacarpal and metatarsal bones in horses: 17 cases
in eight horses. Vet. Surg. 21: 273–278. (1993‐2002). J. Am. Vet. Med. Assoc. 224: 271–274.
3 Bowman, K.F., Evans, L.H., and Herring, M.E. (1982). 9 Jones, R.D. and Fessler, J.F. (1977). Observations on
Evaluation of surgical removal of fractured distal splint small metacarpal and metatarsal fractures with or
bones in the horse. Vet. Surg. 11: 116–120. without associated suspensory desmitis in
4 Caron, J.P., Barber, S.M., Doige, C.E., and Pharr, J.W. Standardbred horses. Can. Vet. J. 18: 29–32.
(1987). The radiographic and histologic appearance of 10 Les, C.M., Stover, S.M., and Willits, N.H. (1995).
controlled surgical manipulation of the equine Necropsy survey of metacarpal fusion in the horse.
periosteum. Vet. Surg. 16: 13–20. Am. J. Vet. Res. 56: 1421–1432.
5 Doran, R.E. (1996). Fractures of the small metacarpal 11 Malone, E.D., Les, C.M., and Turner, T.A. (2003).
and metatarsal (splint) bones. In: Equine Fracture Repair Severe carpometacarpal osteoarthritis in older Arabian
(ed. A.J. Nixon), 200–207. Philadelphia: W.B. Saunders horses. Vet. Surg. 32: 191–195.
Company. 12 Peterson, P.R., Pascoe, J.R., and Wheat, J.D. (1987).
6 Harrison, L.J., May, S.A., and Edwards, G.B. (1991). Surgical management of proximal splint bone fractures
Surgical treatment of open splint bone fractures in in the horse. Vet. Surg. 16: 367–372.
26 horses. Vet. Rec. 128: 606–610. 13 Verschooten, F., Gasthuys, F., and De, M.A. (1984). Distal
7 Jackson, M., Geyer, H., and Furst, A. (2005). Anatomy of splint bone fractures in the horse: an experimental and
the splint bones and their surrounding area particularly clinical study. Equine Vet. J. 16: 532–536.
www.ajlobby.com
480
27
Fractures of the Carpus
C. Wayne McIlwraith
Department of Clinical Sciences, College of Veterinary Medicine & Biomedical Sciences, Colorado State University,
Fort Collins, CO, USA
Introduction (including 349 Quarter Horses, 220 Thoroughbreds,

5 Appaloosas, and 6 Standardbreds).45 Standardbreds
The carpus is a complex joint consisting of seven bones are rare in the author’s area, so this is not a true reflection
within the articulation, all of which can sustain fractures. of the overall incidence of osteochondral fragmentation
In addition, the distal articular surface of the radius is a in Standardbred horses. A series of carpal chip fractures
major part of the articulation and also sustains fractures. in Standardbreds has been published more recently.38
The motion and biomechanics of the carpal joints are The most notable difference between Standardbreds and
complicated.8,9,51 Various factors may lead to nonphysio- other racehorses is that while they are predisposed to
logic loading of the carpal bones, including fatigue, poor fragmentation of the distal portion of the radial carpal
conformation (Figure 27.1) or shoeing, and poor racing bone and proximal portion of the third carpal bone,
surfaces. Such abnormal loading can lead to synovitis, they rarely develop fragments in the antebrachiocarpal
capsulitis and articular damage, osteochondral chip frag- joint.38,51 The specific locations of osteochondral
mentation, slab fractures of an individual carpal bone, or fragments are depicted in Tables 27.1 and 27.2.45

collapsing, comminuted fractures of the carpal bones, The most common location for chip fragmentation was
which can, in turn, cause instability of the carpus. Horses the distal aspect of the radial carpal bone, as previously
that sustain osteochondral chip fractures or simple slab reported.51,52,63 This was followed by the proximal inter-
fractures can commonly be treated with arthroscopic mediate carpal bone, proximal radial carpal bone, and
surgery and return to full athletic soundness. Injuries that distal lateral aspect of the radius. The fractures were
cause destabilization within the carpus are also indica- equally distributed between the left and right joints
tions for surgery, but the aim is to restore axial weight‐ of Quarter Horses, but significantly more frequent in
bearing ability and to salvage the animal for breeding, the right carpus of Thoroughbreds. Previous reports
rather than athletic activity.8 describe an increased incidence of fractures in the right
forelimb in Thoroughbreds.52,63 There were significantly
more fractures in the right middle carpal joint compared
Osteochondral Chip Fractures with the left middle carpal joint, but no significant differ-
(Fragments) ence between the left and right antebrachiocarpal joints.
Significant differences exist between Thoroughbreds
and Quarter Horses in the relative frequency of fracture
Incidence and Location location; the proximal intermediate carpal bone was
Osteochondral chip fractures of the equine carpus are fractured more frequently in Quarter Horses, and the
common in racehorses. In a study of Thoroughbred proximal third carpal bone was fractured more frequently
racehorses in the UK, it was the third most frequent in Thoroughbreds.
musculoskeletal injury for horses in active training, after Published incidence data45 do not support earlier
tibial stress fracture and fracture of the proximal pha- statements that chip fractures are breed related, with
lanx.56 In one series published by the author, 580 of 591 the Thoroughbred being more prone than the Quarter
horses with osteochondral chip fracture were racehorses Horse.63 Carpal chip fractures are very common in

www.ajlobby.com
Table 27.1 Location of carpal chip fractures in carpal joints of 591

racehorses (principally Thoroughbred and Quarter Horse).
Midcarpal (intercarpal) joints (540 joints)

Distal aspect of radial carpal bone 475
Distal aspect of intermediate carpal bone 106
Proximal aspect of third carpal bone 60
641
Antebrachiocarpal (radiocarpal) joints (460 joints)
Proximal aspect of intermediate carpal bone 273
Proximal aspect of radial carpal bone 168
Distal lateral aspect of radius 167
Distal medial aspect of radius 96
Proximal aspect ulnar carpal bone 1
705
Site total 1346
45
Source: McIlwraith et al.
racing Quarter Horses.45 Further, our data contrast

with another study in which the third carpal bone was
reported as the most common site in Thoroughbreds,68
but that study included only 57 horses. Previous stud-
ies reported that antebrachiocarpal joint fractures
Figure 27.1 Back‐in‐the‐knee conformation in Thoroughbred were three times more common in the left carpus than
racehorse about to undergo arthroscopic surgery for removal of the right, whereas fractures involving the middle c arpal
chip fragmentation. joint were seen twice as frequently in the right carpus.51
Table 27.2 Specific location of carpal chip fractures in racing Thoroughbreds and racing Quarter Horses.
Thoroughbreds Quarter Horses
Left Right Left Right
Midcarpal
Distal aspect of radial carpal bone 64 (34.4%) 85 (36.3%) 136 (32.7%) 158 (37.3%)
Distal aspect of intermediate carpal bone 15 (8.1%) 14 (6.0%) 29 (7.0%) 36 (8.4%)
Proximal aspect of third carpal bone 10 (5.4%) 22 (9.4%) 8 (1.9%) 19 (4.5%)
89 121 173 213
Antebrachiocarpal
Distolateral aspect of radius 30 (16.1%) 35 (15.0%) 53 (12.7%) 37 (8.7%)
Distomedial aspect of radius 17 (9.1%) 21 (9.0%) 32 (7.7%) 26 (6.1%)
Proximal aspect of intermediate carpal bone 30 (16.1%) 36 (15.4%) 97 (23.3%) 100 (23.6%)
Proximal aspect of radial carpal bone 20 (10.7%) 21 (8.9%) 60 (14.4%) 48 (11.3%)
Proximal aspect of ulnar carpal bone 0 (0.0%) 0 (0.0%) 1 (0.2%) 0 (0.0%)
97 113 243 211
Total 186 234 416 424
Source: McIlwraith et al.45
www.ajlobby.com
(A) (B)
(C) (D)
Figure 27.2 Radiographic appearance (A, B) and arthroscopic appearance before (C) and after (D) removal of distal radial carpal bone chip
fragment (arrow) that is barely discernible on preoperative radiographs. Diagnostic arthroscopy was performed because of return of
lameness problems 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 new intraarticular fragmentation was
the real indication for arthroscopic surgery.
This has been related to stresses induced with counter-

clockwise racing. The author’s data45 indicated that
Clinical Signs
although there were more fractures in the right middle Affected horses present with synovial effusion and
carpal joint than the left, there was no difference in frac- varying degrees of lameness. In cases of osteochondral
ture frequency between antebrachiocarpal joints in fragmentation with minimal associated damage, the
either breed.45 This is interesting when it is considered main clinical sign is that the horse jogs with a wide‐based
that most Quarter Horses do not race through a stance. Bilateral chip fragments are common, particularly
turn. Routinely radiographing both carpal joints and in the Quarter Horse. Lack of sensitivity has been noted
arthroscopy of suspicious lesions could mean that more in the use of radiographs to demonstrate some fragments,
fragments are being found in the contralateral limb, and to determine the amount of associated cartilage dam-
nullifying left‐versus‐right differences. age (Figure 27.2).45
www.ajlobby.com
Pathogenesis remodeling and bone f ormation in radial and third carpal

bone from raced Thoroughbred horses (n = 14) and non-
It has been suggested that chip fractures are generally a raced Thoroughbred horses (n = 11)64 showed that while
secondary complication affecting joint margins altered there is a net increase in bone formation in racehorses,
by osteoarthritis (OA).54 It has been proposed that chip there is additionally an increase in bone collagen synthe-
fractures of the joint margin arise from at least two sis and remodeling, particularly within the trabecular
different processes. First, they can arise from fragmen- regions of the bone. The increase in bone density would
tation of the original tissue of the joint margin. This lead to greater stiffness, particularly in the carpal bones,
lesion starts as progressive subchondral bone sclerosis and failure of the “stiffer” cortical bone may result from its
induced by repetitive trauma of training and racing, lack of support from the rapidly remodeling and structur-
with eventual damage of articular cartilage because of ally weakened underlying trabecular bone.
the noncompliant subchondral bone. Eventually the It is now generally accepted that microdamage leads to
sclerotic bone undergoes ischemic necrosis. Second, the clinical osteochondral fragmentation seen in the car-
fragments can arise within the base of periarticular pus, and observations at arthroscopic surgery confirm
osteophytes that form in OA.54 More recently, consider- the presence of subchondral bone disease surrounding
able research has recognized that pathologic changes in and potentially preceding fragmentation (Figure 27.3).
the subchondral bone that precede fragmentation are For this reason, the author now prefers using the term
not simply those of subchondral bone sclerosis. Work at “fragment” rather than “fracture” for the osteochondral
Colorado State University has shown that microdamage pieces that are created, as they are truly pathologic
in the subchondral bone can develop early when horses fractures and occur as a consequence of microdamage.
are exercised and trained on the treadmill.30 In addi- In some instances the lesion appears as a “fresh” fracture
tion, post‐mortem examination of racehorse joints line through an articular surface with no visible sub-
(euthanized for catastrophic injury in another limb) has chondral change, but in most instances subchondral
demonstrated the range of microdamage to include not change can be seen arthroscopically, and it certainly
only microfractures, but also primary osteocyte death.49 exists at the microscopic level.41
Not only is the mechanical support of the articular Fatigue of supporting soft tissue structures allowing
cartilage lost when subchondral bone microdamage
hyperextension, extreme speed, poor racing surfaces,
progresses to macrodamage, but cytokine release from faulty conformation, and improper hoof trimming and
the bone may also potentially influence the state of the shoeing have all been cited as contributing to the develop-
articular cartilage.31 ment of abnormal compression on the dorsal surface of
Even more recently, other possible early events leading the carpal bones. In vitro kinematic studies in the carpus
to microdamage in exercising horses have been assessed. have suggested that the radial carpal bone moves as an
Comparison of the mineral components of the carpal independent unit, and that a concentration of kinetic
bones, post‐translational modifications of the c ollagenous energy along the distal and medial aspect of the carpus
matrix, and concurrent changes in biomarkers of collagen
(A) (B)
Figure 27.3 (A) Arthroscopic appearance of subchondral bone disease on third carpal bone. It is considered that such disease precedes
osteochondral fragmentation. (B) Diseased wedge of bone associated with a distal lateral radius fracture.
www.ajlobby.com
during weight‐bearing predisposes the region to injury.38,51 levels35 in synovial fluid of horses with osteochondral
It has been suggested by Bramlage9 that most of the carpal fragments, which reflects an upregulation of the inter-
bones articulate in a way that allows some of the axial load leukin‐1 cascade that has been previously demonstrated
to be transmitted transversely to carpal ligaments, and to promote OA in the horse.21
that the hinge nature of the m iddle carpal joint limits
hyperextension. As a result, injuries to the middle carpal
joint are mostly derived from chronic supraphysiologic Surgery
loads. On the other hand, acute supraphysiologic loads are All osteochondral chip fragments are operated using
more likely to injure the antebrachiocarpal joint, due to its arthroscopic technique, which has been extensively
susceptibility to hyperextension as a rotating joint. Other described elsewhere.42,45 The equine carpal joints have
authors have speculated that the palmar soft tissue struc- been the most frequent locations for arthroscopic surgi-
tures may aid in counteracting carpal hyperextension, and cal procedures. Removal of osteochondral fragments
that jogging Standardbreds for several miles per day could from either carpal joint involves triangulation techniques
condition the palmar ligaments and protect the antebra- using two portals that remain consistent for all fracture
chiocarpal joint from fragmentation. locations. A lateral arthroscopic portal is made between
the extensor carpi radialis tendon and common digital
extensor tendon and their associated sheaths. A medial
Treatment portal is made approximately 5 mm medial to the exten-
sor carpi radialis. These portals are also made halfway
Arthroscopic surgery for the removal of these osteo- between the articular surfaces of the bones. Skin i ncisions
chondral fragments is indicated for the immediate relief are made in the appropriate location prior to distention
of clinical signs, and prevention of further development of the joint to avoid any compromise to the extensor
of OA. Carpal chip fragments cause pain by tugging on tendon sheaths. The position of the arthroscope and
synovial membrane attachments, induction of synovitis instrument relative to the appropriate lesion is illustrated
from release of debris, and damage to the opposing in Figure 27.4, using the distal radial carpal bone chip
articular surface. These factors can contribute to a fracture as an example. The arthroscope is placed
cycle of OA which can become self‐perpetuating if through the lateral portal with the lens angled proximally
surgical intervention is not timely. Other factors enter and the instruments are brought through the medial
into case selection for surgery, particularly the athletic portal.42 Generally, for a fragment on the medial side
ability of the horse and economics. The ideal surgical of the joint, the arthroscope passes through the lateral
candidate is the proven racehorse that has recently portal and the instruments enter through a medial portal.
sustained an osteochondral fragment. Unfortunately,

the “economics of the industry” preclude many horses
undergoing surgery. The judicious use of intraarticular
short‐acting corticosteroids can be defended on a one‐
or two‐time basis when it involves either triamcinolone
acetonide (Vetalog™, Zoetis, Parsippany, NJ, USA)23
or betamethasone esters (Celestone™, Merck & Co.,
Whitehouse Station, NJ, USA).20 However the use of
6‐alpha‐methylprednisolone acetate (Depo‐Medrol™,
Zoetis) in the carpal joint with chip fragmentation can
no longer be defended,22 and it is also now recognized
that chip fragmentation of the distal aspect of the radial
carpal bone quickly produces secondary OA, whereas
fragments in the antebrachiocarpal joint are more for-
giving. In any case, repeated injection of corticosteroids
and long‐term continued racing without surgical inter-
vention are very difficult to defend.
The ability of chronic carpal chip fragmentation to
result in progressive OA is not just mechanically based.
Both synovitis and diseased cartilage and bone release
cytokines and other inflammatory mediators that can
Figure 27.4 Diagram illustrating the arthroscopic approach to
cause progression of the disease.35,41 This has mainly remove a fragment from the distal aspect of the radial carpal
been a clinical observation, but has recently been v erified bone. Source: McIlwraith et al. 2015.42 Reproduced with
biochemically, with evidence of elevated interleukin‐6 permission of Elsevier.
www.ajlobby.com
(A) (B) (C)
Figure 27.5 Preoperative radiograph (A) and arthroscopic view of direct removal of osteochondral fragment from proximal intermediate
carpal bone, during removal (B) and after debridement (C). Direct removal is preferred with such fragments, because elevation risks the
fragment becoming totally loose.
(A) (B) (C)
Figure 27.6 (A) Flexed lateral to medial radiograph of distal radial carpal bone fragment; (B) arthroscopic view after the fragment has
been elevated before removal, and (C) following completion of debridement.
For lesions on the lateral side of the joint, the arthroscope Carpal chip fragments can be divided into four categories
is placed through the medial portal and the instrument is and the techniques used for their removal vary accordingly:
positioned through the lateral portal.
A diagnostic arthroscopic examination is always per- 1) Recent fragments that are mobile on palpation.
formed first. An egress cannula is placed through the Immediate insertion of the grasping forceps is per-
instrument portal previously made using a #11 scalpel formed, the fragment is grasped, the forceps are
blade. The egress is then opened to allow flushing of the rotated to free soft tissue attachments (if these are sig-
joint if visualization is less than optimal. After the view is nificant), and the fragment is removed. The most com-
cleared, the egress needle is closed and can then be used monly used forceps are 4 × 10 mm cup Ferris–Smith
to manipulate the fragment and ascertain its mobility. intervertebral disk rongeurs. Nearly all proximal inter-
Alternatively, a probe can be used. The initial diagnostic mediate carpal bone fragments are removed in this
examination is done with closed distention (care is fashion, as elevation can easily lead to them becoming
needed to maintain the ingress fluid pressure at a rela- loose bodies (Figure 27.5).
tively low level, as there is no free flow from the instru- 2) Fragments with synovial membrane and fibrous
ment portal at this stage). A complete examination of capsular attachments preventing chip displacement
each joint can be made through a single arthroscopic with initial probing. In this case, a periosteal elevator
portal; however, the arthroscope may be exchanged is used to separate the fragment from the parent bone
to the opposite portal if lesions are being removed (Figure 27.6). Ideally the fragment should not be
from both sides of a joint. Arthroscope and instrument completely separated, as it then becomes a loose body
positioning for removal of fragments in the various and is more difficult to retrieve.
locations in the carpus have been described extensively 3) Longstanding fragments with early bony r eattachment.
elsewhere.42 These cases are uncommon and in most instances the
www.ajlobby.com
bone is soft and the fragments are still removed with the middle carpal joint usually signals a poor prognosis,
Ferris–Smith rongeurs. If there is sclerotic bone pre- and is most commonly secondary to chronic distal radial
sent, tapping an elevator with a mallet or using a carpal bone fragmentation (with or without previous
4 mm osteotome may be necessary. Either way, this intraarticular therapy; Figure 27.7). The antebrachiocar-
manipulation is done under arthroscopic visualiza- pal joint is much more forgiving, and chronic fragmenta-
tion, with an assistant striking the osteotome with a tion and spurring can be present without significant
mallet to free the fragment from the parent bone. articular cartilage loss. Removal of osteophytes can be
4) Chip fragments with extensive bone reattachment and done with Ferris–Smith rongeurs (if the bone is relatively
a bony proliferative response. The bone proliferative soft), but in other instances a motorized burr is more
response usually consists of osteophytes and in many appropriate. These cases are poor surgical candidates
instances these can be removed.42 Where these cases and palliative treatment is generally more appropriate.
have proceeded to extensive loss of articular cartilage, the
Once the fragment is removed, the defect is debrided
prognosis is very poor and it is uncommon to do surgery
(see Figures 27.5 and 27.7). Undermined cartilage or flakes
on such cases. There is also a difference between these
of cartilage at the edge of the lesion are removed using a
changes in the middle carpal joint compared to the ante-
bone curette and forceps. Soft defective bone in the base
brachiocarpal joint. Extensive osteophyte formation in
of the defect is commonly recognized and is also curetted.
(A) (B)
(C) (D)
Figure 27.7 (A) Preoperative radiograph showing severe osteophyte formation on distal radial and distal intermediate carpal bones in
a roping horse with chronic change following untreated osteochondral fragmentation. Arthroscopic views (B) before and (C) after removal
of osteophytosis from radial carpal bone, and (D) postoperative radiograph. The extraarticular exostosis is never removed.
www.ajlobby.com
(A) (B) (C)
(D) (E)
Figure 27.8 (A) Radiographs and (B) arthroscopic views of grade II fragmentation of the distal aspect of the radial carpal bone before and
(C) after debridement. (D) Grade 4 osteochondral fragmentation of the distal radial carpal bone on initial visualization, and (E) after
removal and debridement of defect.
Kissing lesions are evaluated and only debrided if there Grade 2. Loss of 30% of articular cartilage from the visible
is separated or defective articular cartilage and bone. A articular surface of affected bone; see Figure 27.8A–C.
simple partial‐thickness defect in the articular cartilage, Grade 3. Loss of 50% or more of articular cartilage from
with the deeper zone of cartilage firmly attached to sub- the visible surface of the affected bone.
chondral bone, is not an indication for debridement. Grade 4. Significant subchondral bone loss with loss
Debridement of articular defects is based on our current of cuboidal bone support at the dorsal aspect
knowledge of articular cartilage healing.41,44 While there (Figure 27.8D–E). Details of arthroscopic technique
is no healing of a partial‐thickness defect, debridement of and individual differences with carpal fragments asso-
that lesion to a full‐thickness defect is considered inap- ciated with the various carpal bones are available in
propriate because of the poor healing response. Defects detail elsewhere.42
generally heal with fibrocartilage in the base, but fibrous
After debridement, the joint is flushed by opening the
tissue at the surface. It has also been recognized on fol-
egress cannula and manipulating the tip, both in the area
low‐up data that significant articular cartilage loss can be
of the lesion and also to the opposite side of the joint,
sustained without compromising the return to athletic
where debris will commonly accumulate. Extensive syn-
activity.45 To further define how articular cartilage loss
ovectomy is rarely carried out in carpal joints with chip
affects the prognosis; four grades of articular damage in
fractures. Occasionally, pieces of synovial membrane
the carpus have been defined:45
are removed for visualization purposes rather than
Grade 1. Minimal additional cartilage loss (extending therapeutic reasons. At the completion of irrigation of
less than 5 mm from edge of defect left by osteochon- the joint, the portals are closed using skin sutures only.
dral fragment; see Figure 27.6). The carpus is bandaged with a sterile nonadhesive
www.ajlobby.com
ressing and adhesive gauze bandage. A full padded leg

d
bandage is then used on the limb during recovery from
anesthesia.
Lag Screw Fixation of Osteochondral Chip

Fractures
Arthroscopically guided screw fixation of large chip frac-
tures can be an alternative to removal in select cases.67
This is based on the premise that reconstruction of artic-
ular surfaces is preferable to creation of a large osseous
defect (grade 4 lesion). Potential candidates should have
a fragment of sufficient size to allow screw insertion, and
have adequate bony structure in the chip to warrant
screw reconstruction. Most chip fractures suitable for
reattachment are repaired with 2.7 mm cortical screws,
although on occasion these may be sufficiently large to
accommodate a 3.5 mm diameter screw. The latter may
be employed in the repair of frontal plane fractures of the
third carpal bone that extend only partway toward the
carpometacarpal joint before exiting to the dorsal sur-
face (so‐called partial slabs). Chip fractures of the dorso- Figure 27.9 A horse undergoing underwater treadmilling for
distal margin of the radial carpal bone, dorsoproximal rehabilitation following arthroscopic surgery of the carpus.
margin of the third carpal bone, and the intermediate
facet of the distal radius have been repaired using 2.7 mm
diameter screws in 33 horses.67 Delineation of the frac- and Johnson, New Brunswick, NJ, USA) are used. Horses
ture margins with needles is performed in a manner sim- are placed on phenylbutazone preoperatively, which
ilar to that described for the repair of larger slab fractures. is continued for three to four days postoperatively.
Most fractures that are amenable to screw fixation will Perioperative antibiotics are not usually administered
exit the bone within the capsular reflection and/or asso- unless there is concern about previous and recent intraar-
ciated intercarpal ligaments. This point can be deter- ticular injection. It has been shown that only 100 Staph
mined, if necessary by radiographically guided needle aureus organisms are required to cause infection during
placement. The position for screw placement is defined intraarticular injection of an equine joint,27 and if there has
by insertion of an 18‐gauge spinal needle, and in most been previous intervention in the joint within two to three
instances is within the synovial cavity, therefore the drill- weeks, the use of prophylactic antibiotics is appropriate.
ing process and insertion of implants can be performed The skin sutures are removed 10–12 days after surgery,
under direct arthroscopic visualization. The 2.7 mm and hand walking for 5 minutes a day commenced. Hand
glide hole is drilled through the fracture fragment to walking is increased by 5 minutes each week up to
cross into the parent bone, and a 2 mm drill then used to 30 minutes a day at 2 months, at which time the horse
complete the thread hole. The hole is then tapped, coun- may be turned out. Horses recovering from removal of a
tersunk, and an appropriate length screw inserted and fresh single chip fragment can recommence training at
tightened. A radiograph is obtained to confirm appropri- this stage. Rehabilitation using underwater treadmill
ate screw length and direction. exercise has become increasingly popular, and is recom-
mended by the author (Figure 27.9).32 It generally extends
over a 30–45‐day period, and commences 30–45 days
after surgery (some rehabilitation centers prefer not to
Postoperative Care start until 60 days). A determination of the validity of
There are no special requirements for recovery from anes- these rehabilitation procedures is currently ongoing.28
thesia following removal of osteochondral chip fragments. The total time from surgery to training varies from two
A padded bandage is used for recovery to minimize any to four months, depending on the amount of associated
trauma to the carpal joints. At the first bandage change, damage to the joint. There is a trend toward earlier
a light bandage of a TelfaTM pad (Kendall, Covidien‐ return to full training due to various factors, including a
Medtronic, Minneapolis, MN, USA), a sterile 4 in. Kling recognition of the low morbidity of surgery, recognition
bandage (Kendall), and Elastikon® adhesive tape (Johnson of the fact that we are not waiting for cartilage repair, and
www.ajlobby.com
the potential for other injuries following a long lay‐up Horses.45 We believe that return to successful racing at
period.11 Water treadmilling is particularly valuable in the same level or higher is a more realistic criterion, and
the lay‐up, since it can maintain bone mass to avoid at least eliminates the variables of the horse’s ability.
stress and catastrophic fractures, as well as suspensory When horses were separated into four categories of
ligament injuries, all of which have been recognized after articular damage, performance in the two most severely
coming back from a lay‐up period.28,32 affected groups was significantly inferior. Successful
Complications from arthroscopic surgery are rare. return to racing at an equal or better level was found
Intraarticular infection is very rare (and usually comes in 133 of 187 horses with grade 1 damage (71.1%), 108
from a horse losing a bandage or getting the incisions of 144 horses with grade 2 damage (75%), only 41 of
contaminated soon after surgery). Subcutaneous infec- 77 horses with grade 3 damage (53.2%), and 20 of 37 horses
tions have occurred (associated with the same factors of with grade 4 damage (54.1%). The success rate in cases
exposure) and these are treated by suture removal. with grade 1 and grade 2 lesions was significantly greater
Synovial effusion (usually low‐viscosity hemorrhagic than in cases with grade 3 and grade 4 lesions (P < 0.01).45
fluid) will persist postsurgically when there is extensive Refragmentation in grade 3 and grade 4 cases was quite
cartilage damage.42 Such cases have been successfully common, and also osteophytosis and enthesitis on the
managed with intraarticular polysulfated glycosamino- dorsal aspect of the carpal bones. Although there have
glycan (PSGAG).69 Recent research suggests that the been no specific follow‐up studies since this initial one
“normalization” of these joints postoperatively can be over 20 years ago, a study on palmar carpal osteochondral
attributed to effectiveness of PSGAG to inhibit acute fragments in 31 horses also reported on prognosis related
synovitis.24 Hyaluronan has also been used to treat per- to dorsal carpal bone lesions (using the same grading sys-
sistent joint effusion, and has recently been shown to tem), demonstrating that 53–54% of horses with grade 3
have long‐term chondroprotective effects.24 or grade 4 damage raced successfully.26 This study also
indicated that most horses with palmar carpal debris had
a reduced prognosis compared to earlier studies, where
Results of Surgery
horses with similar grades of dorsal carpal bone and carti-
Compared to arthrotomy, the benefits of arthroscopic lage loss, but without palmar debris, performed better.
surgery include increased diagnostic accuracy (and The results of surgery were also assessed in relation-
therefore more definitive treatment of the condition), ship to the location of the fracture.45 Only horses with a
less tissue damage and improved cosmetic appearance of single site involved (or the same site bilaterally) could be
the joint, more complete irrigation of the joint and elimi- included (187 Quarter Horses, 133 Thoroughbreds). The
nation of debris, decreased postoperative pain, ability distal aspect of the radial carpal bone had the poorest
to operate multiple joints concurrently, and improved prognosis in Thoroughbreds, which was related to the
performance after surgery.42,45 Follow‐up information
amount of secondary cartilage damage commonly asso-
has shown that the overall functional ability and cos- ciated with these fragments. The worst prognosis in
metic appearance of the limbs is excellent. Quarter Horses was seen with fragments associated with
Postsurgical follow‐up information has been reported the proximal surface of the third carpal bone, followed
for 445 racehorses (Thoroughbreds and Quarter by the distal aspect of the radial carpal bone.45
Horses).45 After surgery, 303 (68.1%) raced at a level Healing of carpal chip fractures after lag screw stabili-
equal to or better than preinjury level, 49 (11.0%) had zation was satisfactory in 26 of 28 horses with available
decreased performance or still had problems referable to follow‐up data.67 Of the 28 horses, 23 (82%) returned to
the carpus, 23 (5.2%) were retired without returning to racing, with a mean convalescent time of 10 months; 19
training, 28 (6.3%) sustained another chip fracture, 32 of 28 horses (68%) raced at the same or better level of
(7.2%) developed other problems, and 10 (2.2%) sus- competition. Given that the majority of these repaired
tained collapsing slab fractures while racing. There are fractures would have been grade 4 defects after chip
no comparative data at the present time to support the removal, which has been associated with a 55% return to
supposition that operated horses are more prone to fur- racing, screw fixation appears to be a useful technique
ther chip fractures or more severe carpal injuries. for large fractures that would leave a significant articular
Comparing the results of arthroscopic surgery in our defect if removed. It should be recognized, however, that
series of cases with the results of arthrotomy is difficult the delay in return to racing will be longer than after chip
because of the variable methods used in the past to assess fracture removal.
success.43 Earlier reports considered return to competi- A retrospective study of 176 Standardbred horses that
tion or starting in one race as a success.36,68 Using these had arthroscopic surgery for carpal chip fracture removal
criteria, the success rate based on our 1987 report would has been published.38 Chip fragmentation of the proxi-
be 88.6% for Thoroughbreds and 88.8% for Quarter mal third carpal bone and the distal radial carpal bone
www.ajlobby.com
occurred with equal frequency (49.2% and 49.6%,

respectively), and chip fractures involving the antebra-
chiocarpal joint were rare.38 Trotters had significantly
more third carpal bone lesions than radial carpal bone
lesions when compared to pacers. Following surgery,
74% of horses had at least one start. Pacers were signifi-
cantly more likely to have at least one start after surgery
than were trotters. However, median earnings per start
significantly decreased after surgery, while median
race mark significantly increased after surgery. It was
concluded that the majority of Standardbreds would be
useful racehorses following carpal arthroscopy; however,
most earn less money per start, and many race at a lower
class. There was no data on prognosis relative to location
of fragment or grade of lesion.
Analysis of the surgical findings in 178 Standardbred
horses having diagnostic arthroscopy of the middle car-
pal joint after confirmation of the site of lameness by
intraarticular anesthesia indicated a preponderance of Figure 27.10 Avulsion fragment associated with medial palmar
cartilage, ligamentous, and synovial membrane lesions.37 intercarpal ligament in middle carpal joint being treated for slab
fracture of a frontal slab fracture involving both radial and
Carpal osteochondral fragmentation was infrequent. Of intermediate facets of third carpal bone.
the 270 operated middle carpal joints in the 178 horses,
84 had cartilage erosion on the radial carpal bone and
154 had cartilage erosion of the third carpal bone. a vulsion fragments involving the distal attachment to
Additionally, 88 had tearing of the medial palmar inter- the third carpal bone are uncommon, but do occur.41
carpal ligament (PICL), while osteochondral fragmenta- Most of the time these fragments are recognized at
tion was identified on only 12 radial carpal and 35 third arthroscopy during repair of a frontal slab fracture of
carpal bones. This longitudinal study highlights the pre- the third carpal bone (most frequently involving both
ponderance of cartilage and soft tissue injuries compared radial and intermediate facets; Figure 27.10).
to chip fragmentation as a cause of middle carpal joint The LPICL runs from the distal palmar aspect of the
lameness in Standardbreds. ulnar and intermediate carpal bones to the palmar aspect
of the third and fourth carpal bones. The dorsal aspect of
the LPICL can be examined arthroscopically. Tears of
Avulsion Fragments this ligament occur occasionally, but not nearly as com-
Associated with Palmar monly as those of the MPICL.42 Most injuries to the
Intercarpal Ligaments LPICL are avulsion fractures from the ulnar carpal bone
(Figure 27.11). In a study of 37 cases of lateral PICL avul-
sion in horses,5 these avulsion fragments of the LPICL
Introduction and Treatment involved a discrete fragment associated with the liga-
Both PICLs connect the proximal and distal row of car- mentous origin on the ulnar carpal bone. Avulsion frag-
pal bones, one medially (MPICL) and one laterally ments of the MPICL have only been diagnosed by
(LPICL). The MPICL runs from the radial carpal bone arthroscopic examination, compared to avulsion frac-
to the second and third carpal bones, and, although tures of the LPICL which were evident on radiographs,
described initially as a single entity,40 has since been were associated with forelimb lameness and clinical
recognized as consisting of two branches.53 A medial signs referable to the carpus, and were then confirmed
branch extends from the palmar aspect of the radial arthroscopically.5 Removal of avulsion fractures of the
carpal bone to the palmar fossa of the second carpal LPICL is done using a dorsomedial arthroscope portal
bone, and a lateral branch with the same origin inserts and a dorsolateral instrument portal with the carpus
on the palmar synovial fossa of the third carpal bone. almost maximally flexed.5,42 For large avulsion frag-
The dorsal aspect of the MPICL can be evaluated ments, an instrument portal between the common and
arthroscopically, but the majority of the ligament is lateral digital extensors may be required. Dissection of
inaccessible. Visible frayed fibers of the MPICL are the fragment from the body of the ligament can be
trimmed using a synovial resector or biopsy rongeurs. accomplished using a curved banana blade or small flat‐
While injury to the substance of the MPICL is the ended periosteal elevator, and is followed by removal
most common problem encountered arthroscopically,40 with ethmoid or patella rongeurs (see Figure 27.11).
www.ajlobby.com
(A) (B) (C)
(D) (E) (F) (G)
Figure 27.11 Lateral palmar intercarpal ligament avulsion fracture from the ulnar carpal bone. (A) Dorsolateral to palmaromedial oblique,
(B) dorsal 20° lateral‐palmar medial oblique, and (C) dorsopalmar projections show the varying appearances of the fracture (arrows),
depending on projection. Two fragments are visible in (A) and (C). (D) Arthroscopic images show the pair of fragments (1, 2) associated
with avulsion of the lateral palmar intercarpal ligament (LPICL). (E) Dissection of the fragments. (F) Removal of the fragments with
rongeurs. (G) Fracture bed after fragment removal showing residual intercarpal ligament insertion on the palmar medial corner and
palmar midline portion (arrows) of the ulnar carpal bone.
Avulsion fragments of the MPICL have been removed removed.15,34,42,66 In two case series, involving 10 and
on occasion. More commonly they are left in situ, as they 25 horses, it was clear that early diagnosis and removal
are a minor part of the total joint pathology associated of solitary palmar carpal fragments improved the
with collapsing frontal slab fractures of the third carpal outcome.34,66 A larger series of 31 racehorses with multi-
bone that usually involve both radial and intermediate ple palmar carpal osteochondral fragments and debris
facets. Beinlich and Nixon5 reported on the outcome has been reported recently.26 These authors presented
after treatment of 37 horses with avulsion fragments of good evidence that debris fragments are typically the
the lateral PICL from the ulnar carpal bone; 26 had sur- result of extensive pathologic changes in the dorsal
gery and 9 were treated conservatively. For those treated aspect of the joint, and represent a poor prognostic indi-
with arthroscopic fragment removal, 20 of 22 horses cator for future athletic performance.26 It is therefore
(91%) for which follow‐up information was available critical to differentiate between the two types of palmar
returned to work. For the 9 horses treated conservatively, fragmentation, since the prognosis for palmar debris is
only 5 returned to work.5 Further, 12 horses having poor,26 while that following removal of solitary palmar
arthroscopic fragment removal had LPICL avulsion fragmentation is good.34
without concurrent osteochondral fragmentation in the
same or additional joints; follow‐up was available for 9 of
these horses, of which 8 returned to athletic work.
Incidence
Small discrete osteochondral fragmentation can
involve any of the palmar surfaces of the carpal bones,
Osteochondral Fragments with the radial carpal bone being most frequently
in the Palmar Aspect involved.34,42 In a recent description of discrete palmar
of the Carpal Joints carpal fracture in 25 horses, 17 (68%) had fragmenta-
tion involving the antebrachiocarpal joint, 7 (28%) had
fragmentation involving the middle carpal joint, and
Introduction 1 (4%) had fragmentation involving the carpometacar-
Discrete osteochondral fragments from the palmar pal joint.34 The proximal aspect of the radial carpal
aspects of the carpal bones have been recognized and bone was the most commonly affected site (12 of
www.ajlobby.com
well as in the palmar aspect. Definitive diagnosis is made

by radiographic examination.
Treatment
Arthroscopic removal of proximal palmar radial carpal
bone fragments can be done through a palmaromedial
approach to the antebrachiocarpal joint, which gives
access to the palmar perimeter of the radial carpal bone
and caudal aspect of the radius (Figure 27.13).14,34,42,66
The dorsal regions of the antebrachiocarpal joint are
usually examined first, and concurrent damage to
the articular surface of the radius and proximal
radial and intermediate carpal bones is debrided.
The arthroscope portal is then made in the distended
palmaromedial outpouching of the antebrachiocarpal
joint.14 An instrument portal is developed adjacent to
the arthroscopic portal, and motorized equipment
used to remove synovial proliferation and provide bet-
ter visualization of the fragment.14,34 Discrete frag-
Figure 27.12 Radiographs of multiple palmar osteochondral ments are then removed with straight or upbiting
fragments (arrows), recognized following recovery from rongeurs. Palmar fractures that involve the proximal
anesthesia for colic surgery.
aspect of both radial and intermediate carpal bones
have also been described.34 Three‐dimensional imag-
30 fragments), f ollowed by the accessory carpal bone (6 ing with computed tomography (CT) provides consid-
of 30). The palmar surfaces of the ulnar and fourth car- erable help in determining the fracture origin site
pal bones were involved less frequently. Large partial and the best approach for removal (Figure 27.14).
slab fractures of the palmarolateral surface of the inter- The medial aspect of the proximal perimeter of the
mediate carpal bone also occur and are difficult to intermediate carpal bone can be visualized using a pal-
access for arthroscopic removal or reattachment.15,34,42 maromedial approach to the antebrachiocarpal joint.
In cases of single palmar fragmentation, they are extru- Synovial resection often reveals fragments that have
sion or compression injuries often associated with detached from the i ntermediate carpal bone and local-
anesthetic recovery (Figure 27.12). All 10 cases reported ize in the radial fossa along the caudal perimeter of the
by Wilke et al.66 involved the palmaromedial aspect of distal radius (see Figure 27.14). Fragments in other
the radial carpal bone, and many developed due to locations are approached as described,14,34,42 followed
hyperflexion of the carpus during anesthetic recovery. by development of an adjacent instrument portal,
In the series of cases by Getman et al.,26 only 7 of 31 synovial resection to develop a working space, and
cases were considered to be primary lesions involving identification and removal of the fragment.
the palmar aspect of the carpal bones; in 6 of these In the series described by Getman,26 palmar osteo-
horses the fragments were on the proximal aspect of chondral fragments were removed in only 13 of 31
the radial carpal bone and 1 was on the proximal aspect horses (41.9%). Horses with primary lesions on the dis-
of the third carpal bone. Other cases were considered todorsal aspect of the radial carpal bone or dorsal aspect
to have debris fragments in the palmar pouch second- of the third carpal bone (dorsal compartment) were
ary to more extensive fragmentation in the dorsal more likely to have multiple small palmar fragments
aspect of the joint. than one or two fragments.26 All horses with slab frac-
tures of the third carpal bone had multiple palmar debris
fragments, and all had a smaller grade of palmar frag-
Diagnosis ments. Horses with the largest dorsal lesions (i.e., grades
Clinical signs are referable to the carpal joints, and vary 2 and 3) were significantly more likely to have the small-
from acute swelling and progressive lameness with dis- est (grade 1) palmar fragments. Horses with primary
crete palmar fragmentation, to more insidious lameness lesions of only the proximal palmar aspect of the radial
and fibrosis in many instances, where fragmentation is carpal bone were significantly more likely to have one
present in the dorsal compartment of the carpal joint as palmar fragment than two or multiple fragments.
www.ajlobby.com
(A) (B)
(C) (D)
Figure 27.13 Palmar fracture of the radial carpal bone in a horse six weeks following recovery from general anesthesia for colic surgery.
(A) Dorsomedial to palmarolateral oblique and (B) lateral to medial radiographs show a large solitary fracture of the palmar aspect of the
radial carpal bone. (C) At surgery the fracture is isolated from synovial attachments and split into two prior to removal. (D) Debrided
fracture bed and the distal medial aspect of the radius after fracture removal. Source: Images courtesy Dr. Alan J. Nixon.
Results evidence of OA, 8 (57%) returned to function after sur-

Results in 10 horses with palmar fracture of the radial gery. When separated by joint involved, 12 of 17 horses
carpal bone suggest that the simple fractures of the pal- (71%) with antebrachiocarpal joint fragments and 6 of 7
mar perimeter should be removed as soon as they are horses (86%) with middle carpal joint fragments returned
identified.66 Cases where the damage was confined to to their previous use.
only the area of the fragment and where the fragment In the series of 31 cases surgically treated by Getman
was removed soon after injury tended to have less OA et al.,26 multiple palmar fragments were diagnosed in 50%
and did better after arthroscopic surgery. In a follow‐up of the horses. Assessing data from all 31 horses indicated
study of 25 horses, 19 (76%) were sound after surgery and 52% returned to racing, 48% returned to racing and earned
returned to their intended use, 4 (16%) were considered money, and 32% had at least five or more starts. All horses
pasture sound, and 2 were euthanized (because of severe with multiple fragments had significantly less earnings
postoperative OA or long bone fracture during recovery per start, and lower performance index values after
from anesthesia).34 Of the 14 horses with preoperative surgery, than those with one fragment. Horses with palmar
www.ajlobby.com
(A) (B) (C)
(D) (E) (F)
(G) (H)
Figure 27.14 Palmar fractures of the radial and intermediate carpal bones. (A) Dorsopalmar and (B) lateromedial radiographs identify
fractures (arrows) in the palmar aspect of the antebrachiocarpal joint. (C) Preoperative computed tomography shows multiple fractures on
the palmar aspect of the radial carpal bone (white arrows), a fracture bed on the proximal aspect of the intermediate carpal bone (black
arrows), and the displaced large fragment off the intermediate carpal bone located in the radial fossa. (D) The surgical procedure starts
with exploration and debridement of the dorsal compartment of the antebrachiocarpal joint, which is then temporarily closed with towel
clamps, and followed by the palmar medial approach with arthroscope and instrument portals adjacent to each other. (E) Arthroscopic
appearance of cartilage erosion on the dorsal distal aspect of the radius. (F) Palmar fragments being elevated for removal from the radial
carpal bone, and (G,H) intermediate carpal bone. Source: Images courtesy Dr. Alan J. Nixon.
fragments less than 3 mm in diameter were significantly Carpal Slab Fractures
less likely to return to racing and have five starts or to win
money after surgery compared to horses with larger frag-
ments. The authors concluded the reason for horses with
Introduction
multiple small fragments having a poorer prognosis was Slab fractures refer to fractures through an entire carpal
associated with these being secondary to more severe bone (the proximal joint surface to the distal joint sur-
damage in the dorsal compartment.26 On the other hand, face). They may occur in a frontal or a sagittal plane,
horses with one or two large palmar fragments usually and most commonly involve the third carpal bone. The
had these fragments as primary lesions, and these are the radial, intermediate, and fourth carpal bones are less
most appropriate cases for arthroscopic removal. frequently affected.
www.ajlobby.com
Incidence and 17% affecting both carpi. The third carpal bone was
most frequently affected.
In a survey of 371 third carpal bone fractures in 313
horses,61 the distribution included 93 frontal plane slab
fractures of the radial facet, 35 large frontal plane slab Diagnosis
fractures involving both radial and intermediate facets,
The clinical signs vary from mild to severe non‐weight‐
13 frontal slab fractures of the intermediate facet, and 13
bearing lameness. Synovial effusion is consistently
medial corner fractures of the radial facet (considered
present. A full series of radiographs, including a skyline
partial sagittal slab fractures by this author). Subdivision
view of the third carpal bone, is essential.
of third carpal slab fractures to types 1–8 has been
described,61 but anatomical divisions are better recog-
nized. Frontal slab fractures are commonly differentiated
into displaced or undisplaced, as this has been consid-
Treatment
ered relevant to surgical management. It is also impor- For the purposes of discussion of repair, slab fractures of
tant to distinguish “routine” slab fractures from the carpus will be divided into the following categories:
“collapsing” slab fractures, where the radial carpal bone
1) Frontal slab fractures of the radial facet of the third
drops into the fracture gap and progressive collapse of
carpal bone
the carpus may be anticipated.19
2) Frontal slab fractures of the radial and intermediate
The radial facet is the most common location for fron-
facets of the third carpal bone
tal slab fractures of the third carpal bone, and is also the
3) Sagittal slab fractures of the third carpal bone
usual location for sagittal slab fractures. The high inci-
4) Combination frontal and sagittal plane fractures of
dence of fractures in the radial facet may be related to
the third carpal bone
the hinge‐like function of the middle carpal joint, which
5) Frontal fractures of other carpal bones
impacts the radial carpal bone onto the radial facet
6) Comminuted (collapsing slab fractures).
of the third carpal bone during loading of the limb in
the close‐packed extended position.61 Additionally, the All carpal slab fractures in racehorses are considered to
medial location of the radial facet exposes it to larger be surgical candidates, given appropriate economics and
forces during exercise, while the intermediate facet is racing ability. Previous statements that undisplaced third
protected by expansion of the articulation between the carpal bone slab fractures do not require surgery need
third and fourth carpal bones when the intermediate qualification.46 Healing may occur in some cases, but
carpal bone is loaded against the distal row of carpal progressive osteoporosis of the slab fragment and devel-
bones.8,9 In another report, frontal slab fractures of the opment of OA are seen more commonly. In one report,
third carpal bone were reported in 72 Thoroughbreds where undisplaced was defined as a fracture line of less
and 61 Standardbreds, and 87% of these involved the than 1 mm in width, 12 Standardbreds were treated with
radial facet.62 The forelimbs were equally affected in rest and 10 eventually raced; 8 of the 10 raced well.62
Standardbreds (35 right, 38 left); however, the right However, in the author’s experience, undisplaced frac-
third carpal bone predominated in Thoroughbreds tures with a fracture line of less than 1 mm are uncom-
(48 right, 34 left). In a survey of the author’s cases, both mon. One report concluded that even incomplete frontal
Thoroughbreds and Quarter Horses showed a prepon- plane fractures in the radial facet of the third carpal bone
derance of slab fractures in the right third carpal bone should be repaired by lag screw fixation.59 Radiographic
(70% and 67.7%, respectively), and this would be con- healing of the fracture was complete by four months in
sistent with more severe loading of the medial side of 11 of 16 (69%) of the fractures, and 11 of 13 (85%) of the
the right carpal joint. In a fourth series of frontal frac- affected horses raced again.59 Horses with minimally dis-
tures of the third carpal bone, the right forelimb was placed slab fractures are excellent candidates for surgery.
affected in 24 of 31 Thoroughbred horses (77.4%).39 The Frontal slab fractures with some displacement are defi-
fractures typically occurred at high speed (racing or nite candidates for surgery, although the outcome is
training) and among these 31 horses, intraarticular more variable. Whether the horse can return to athletic
corticosteroids had previously been administered in
activity is related to the amount of associated articular
20 (64.5%).39 Finally, in a study of catastrophic muscu- damage, which influences the extent of OA that devel-
loskeletal injuries in 314 racing Quarter Horses, the ops. When fractures involve both facets, surgery is essen-
carpus was fractured in 24% of cases, second only to tial for restabilization of the fracture.
fractures of the fetlock region, the latter representing In this author’s opinion, sagittal slab fractures should
40% of the overall catastrophic fractures.60 The right also be repaired by lag screw fixation, and this has now
carpus was predominantly affected (67% of the carpal been confirmed by others.33 While sagittal slabs require
breakdowns), compared to 17% involving the left carpus a skyline radiograph for demonstration, arthroscopic
www.ajlobby.com
examination has shown that these slab fractures are

mobile. Conservative management of a series of 12 of CD ECR
these fractures resulted in return of function in 7.18 The
author has treated cases that had not healed with con-
servative therapy, but later were successfully treated with
lag screw fixation. A case report describes a filly with a
sagittal slab fracture of the medial aspect of the third car- 3
pal bone treated conservatively with four months’ rest.25
4
Follow‐up radiographs revealed that OA developed in 2
the middle carpal joint, and when an attempt was made
to train the filly a chip developed in the antebrachiocar-
pal joint, ending in retirement from racing. More
recently, surgical and nonsurgical management of sagit-
tal slab fractures of the third carpal bone in 32 racehorses
has been reported, and horses treated surgically were
more likely to race after treatment than horses treated
U 1 R
without surgery.33
Surgery
Figure 27.15 Diagram demonstrating position of arthroscope
Frontal Slab Fracture of Radial Facet and placement of needles during fixation of a frontal plane slab
of the Third Carpal Bone fracture in the third carpal bone under arthroscopic visualization.
CD, common digital extensor tendon; ECR, extensor carpi radialis
Surgical repair in all cases uses arthroscopic technique as tendon; 2,3,4, second, third, and fourth carpal bones; U,I,R, ulnar,
described by Richardson,57 with some modifications.42 intermediate, and radial carpal bones. Source: McIlwraith et al.
Surgery is performed with the horse in dorsal recumbency. 2015.42 Reproduced with permission of Elsevier.
A lateral arthroscopic portal and a medial instrument por-
tal are used, and a diagnostic examination of the joint is
performed. The slab fracture is visualized, the fracture line of at least 2 mm for countersinking and 2 mm for fracture
debrided with a curette, and the fracture site and joint irri- compression is recommended. The 4.5 mm screw is then
gated. The carpus is then placed in maximal flexion. placed to compress the fracture (Figure 27.16). The use
Under arthroscopic visualization, two 18‐gauge needles of one or two 3.5 mm screws has been described.57
are placed into the middle carpal joint medial and lateral Although there are advantages to the 3.5 mm screw,
to the fracture slab and adjacent and parallel to the third including limited need to countersink and less promi-
carpal bone. A spinal needle is then placed midway nence of the screw head, the larger, stronger 4.5 mm
between these two needles, close and parallel to the proxi- screw is preferred, except for smaller slabs (Figure 27.17).
mal articular surface of the third carpal bone, and directed Further radiographs are obtained to verify screw length
across the midpoint of the fracture as close to 90° as pos- and direction. After screw fixation, the arthroscope is
sible (Figure 27.15). Another needle is placed in the carpo- reintroduced to the joint to visualize the fracture reduc-
metacarpal joint and a flexed lateral radiograph is obtained. tion and to remove any additional debris. Sutures are
The needle placement as visualized in the joint determines placed only in the skin incisions.
the lateromedial site of screw placement (halfway along If stability of the carpus will not be compromised,
the slab). The needle placement on the radiograph dictates removal of the slab fragment is considered when the
the direction to ensure that it is approximately midway fragment is thin, the fracture is comminuted, or there is
proximodistal and parallel with the third carpal bone. A a large wedge of fractured bone at the fracture site.
stab incision is made with a #10 scalpel blade and a 4.5 mm Removal of the slab fragment may be accomplished by
glide hole is drilled through to the fracture line. A 3.2 mm arthrotomy or arthroscopy. The arthroscopic technique
drill sleeve is inserted and a 3.2 mm hole is drilled into the is quite difficult, involving sharp dissection. A curved
parent third carpal bone. The 3.2 mm drill bit should go blade is necessary to sever the most distal attachments.
close to but not exit the palmar cortex of the third carpal Removal is most easily achieved with an arthrotomy
bone. Drill exit is not damaging, provided that it does not medial to the extensor carpi radialis tendon. Sharp dis-
extend into the palmar carpal ligament, but may deposit section is required to sever the joint capsule attachments
drill swath debris into the palmar joint pouch. The depth to the third carpal bone fracture.
of the hole is measured, tapped, and a screw of appropriate The use of a cannulated Herbert screw has been
length selected. Since this is often a blind hole, subtraction described for compression of experimentally created
www.ajlobby.com
fracture fragment compression compared with screws

appropriately placed in lag fashion, the probable difficulty
of removing the screw if required for implant‐related com-
plications, and the necessity of learning a new technique
for inserting the screw type in the dense bone of horses.29
Frontal Slab Fractures of Intermediate

Facet of Third Carpal Bone
These fractures are less frequent, but when encountered
are treated using arthroscopic technique. The technique
is the same as described for radial facet fractures, except
that the arthroscope is placed in the medial portal and
the instruments through the lateral arthroscopic portal.
Care is also needed to avoid damage to the extensor carpi
radialis tendon and its sheath during incision and inser-
tion of drills and guides. A 3.5 mm screw is favored for
these fractures.41
Frontal Slab Fractures of Radial

Figure 27.16 Lag screw fixation of frontal slab fracture involving and Intermediate Facets of Third Carpal
radial facet of third carpal bone.
Bone
These frontal fractures involve both the radial and inter-
third carpal bone slab fractures (osteotomies),48 and mediate facets of the third carpal bone (Figure 27.18). If
more recently the use of the Acutrak 2™ (AT) screw these fractures are not comminuted and do not involve a
(Acumed, Beaverton, OR, USA) has been reported for collapsing component, they may be repaired similarly to
treating frontal slab fractures of the third carpal bone in radial facet slab fractures.42 The arthroscope is placed
horses.29 Like the Herbert screw, the AT screw is cannu- through the lateral portal and the fracture debrided. The
lated, which facilitates accurate placement over a guide fracture is reduced using carpal flexion. The needles are
pin and helps maintain adequate fracture reduction placed in the same fashion as previously described, but
during drilling, and screw insertion. The AT screw is a two 4.5 mm screws are placed (one through each facet) to
titanium alloy, cannulated, headless, variable‐pitch, self‐ provide sufficient stabilization (Figure 27.19). In general,
tapping, taper compression screw. In an in vitro study10 these slab fractures occur in a more palmar position than
using simulated third carpal bone slab fractures repaired radial facet slab fractures.
with either 4.5 mm AO cortical or 4.5 mm AT compres-
sion screws, insertion variables such as drilling torque, Sagittal Fractures of Third Carpal Bone
tapping (AO) versus screw insertion (AT) torque, and Partial slab fractures that enter into the junction between
maximum screw torque were found to be comparable the second and third carpal bones are removed using
between screw types. The mechanical shear testing arthroscopic technique. When the sagittal fracture line
variables recorded for yield and failure were also com- parallels the second–third carpal articulation, lag screw
parable; however, the AO‐repaired constructs had fixation is performed using an oblique 3.5 mm cortical
significantly greater initial shear stiffness. bone screw. The fracture is defined preoperatively using
Fixation of third carpal bone frontal plane slab fractures a skyline radiograph (Figure 27.20).50 The fracture line
with the AT screw system was reported in 17 racing should be seen to traverse the third carpal bone from
Thoroughbreds.29 Of 15 horses that raced before injury, the proximal to the distal articular surface on a dorso-
12 returned to racing. Average days to first start was medial‐palmarolateral radiographic projection, to con-
349.3 ± 153.9 days. Horses that returned to racing had firm it as a sagittal slab fracture and avoid confusion
more starts after repair (median 6.5 versus 3.5; p = 0.04), with other sagittal plane injuries of the third carpal
and did not have decreased earnings per start (median bone, including subchondral lucencies, corner fractures,
$2432 versus $3061; p = 0.3). The cannulated screw was and comminuted fractures.33 The arthroscope is placed
accurate to place, prevented the need for countersinking, through the lateral portal and the fracture line visual-
decreased the possibility of fragment splitting, and elimi- ized and manipulated so that any loose cartilage and
nated screw head impingement on dorsal soft tissue while bone debris is removed (Figure 27.20). A single needle is
achieving stable fixation. Possible disadvantages of the placed from the medial side to define the junction of
AT screw system were cited as less potential for initial second and third carpal bones and allow exact positioning
www.ajlobby.com
(A) (B)
(C) (D)
(E)
Figure 27.17 (A, B) Preoperative radiographs of third carpal frontal slab fracture repaired with 3.5 mm screw. Arthroscopic views
(C) before and (D) after lag screw fixation. (E) Postoperative radiograph.
www.ajlobby.com
(A) (B)
(C)
(D) (E)
Figure 27.18 (A–D) Radiographs of collapsing frontal slab fracture involving both facets of third carpal bone. (E) Radiograph taken under
anesthesia prior to fixation.
of the cortical bone screw. As a generalization, the Combination Frontal and Sagittal

screw is placed immediately alongside the junction of Fractures of the Third Carpal Bone
the second and third carpal bones at the dorsal face, to Concurrent frontal and sagittal plane fractures of the
provide maximum compression along the fracture line third carpal bone occur predominantly in racehorses.
without incorporating the second–third carpal bone Most combination or complex fractures of the third
articulation in the compression fixation. A stab incision carpal bone do not result in collapse of the carpus, unless
is made to allow identification of the second and third the frontal plane fracture is substantially d isplaced.
carpal bone junctions, and a 3.5 mm drill guide placed Diagnosis usually hinges on identifying a fracture in both
equidistant between the proximal and distal borders of the lateromedial and dorsomedial to palmarolateral
the third carpal bone. The drill direction angles in as oblique radiographic projections. Skyline radiographs of
near a frontal plane as possible. Intraoperative moni- the distal row are vital in further identifying the combina-
toring of placement of the screw is difficult and careful tion fracture (Figure 27.21). Sequential repair of the two
arthroscopic assessment of the direction of the screw is fracture planes can return these horses to athletic activity,
critical for compression (Figure 27.20). Following fixa- provided that the articular surface of the third carpal bone
tion of the fracture, the joint is lavaged and the skin is relatively intact without additional comminution.
portals closed. Arthroscopic examination identifies the two fracture
www.ajlobby.com
planes, and allows debridement of any cartilage and bony c ortical screw. The placement and direction of the 3.5 mm
debris from the frontal plane fracture. The carpus is flexed screw allow the screw shaft to traverse the third carpal
and the frontal plane fracture reduced and s tabilized with bone proximal to the screws in the frontal plane fracture
one or two 3.5 or 4.5 mm cortical screws placed in lag (see Figure 27.21). If the 3.5 mm screw path cannot avoid
fashion as previously described. The sagittal fracture the screws stabilizing the frontal plane fracture, a shorter
remains relatively nondisplaced and is addressed after lag 3.5 mm cortical screw can suffice. Depending on the frac-
screw repair of the frontal plane fracture. Repair of the ture stabilization, horses are recovered either in a band-
sagittal fracture is accomplished with a single 3.5 mm age, or a bandage sleeve cast with the fetlock free to flex.
(A) (B)
(C) (D)
Figure 27.19 Lag screw fixation of collapsing frontal slab fracture involving both facets of third carpal bone. (A) With carpal flexion during
surgery showing displaced fractured portion requiring further reduction distally. (B) Fracture reduced and needles placed; (C) skyline view
of spinal needle centrally; (D) 3.2 mm drill guide placed through glide hole; (E) skyline radiograph after placement of two 4.5 mm cortical
screws in lag fashion. Because of comminution and a gap on the medial side, the screws were placed in the central portion and the lateral
portion of the fracture. (F) Arthroscopic view looking down medial portion of fracture to carpometacarpal joint after debridement. (G)
Lateral portion of fracture in intermediate facet of third carpal bone. (H) Medial portion of fracture after reduction and fixation with loss of
bone due to fragmentation in the proximal aspect creating defect. (I) Arthroscopic view of portion of fracture in intermediate facet after
reduction. (J) Intraoperative radiograph showing fixation of slab fracture.
www.ajlobby.com
(E) (F)
(G) (H)
(I) (J)
www.ajlobby.com
(A) (B)
(C) (D)
(E)
Figure 27.20 (A) Preoperative skyline radiographic view of sagittal slab fracture of third carpal bone. Arthroscopic views of fracture,
(B) before debridement, (C) with spinal needle placed across center of fracture, and (D) after screw fixation. (E) Postoperative radiograph
showing accurate screw placement with screw head adjacent to second–third carpal bone junction.
www.ajlobby.com
(A) (B)
(C)
Figure 27.21 Complex third carpal fracture repair. (A) Preoperative dorsoproximal to dorsodistal skyline radiograph indicates a frontal
(arrowheads) and sagittal plane fracture (arrow) of the third carpal bone. (B) Postoperative skyline and (C) dorsopalmar radiographs show the
fracture repair using two 3.5 mm cortical screws applied in lag fashion to stabilize the frontal plane fracture, and a single 3.5 mm cortical
screw to compress the sagittal plane fracture. The screw inserted to stabilize the sagittal plane fracture is placed immediately proximal to the
two screws in the frontal plane fracture. Source: Images courtesy Dr. Alan Nixon.
Sagittal Slab Fractures of Other Carpal arthrotomy was used. Sagittal fractures may also occur
Bones along with comminuted fractures and/or carpometacar-
Sagittal slab fractures may also occur in the intermediate, pal luxation. In these instances, the fourth carpal fracture
radial, ulna, and fourth carpal bones. These fractures is not always specifically addressed.
have generally broken into the adjacent intercarpal artic-
ulation and have been treated by removal of the fragment Frontal Slab Fractures of Other Carpal
using arthroscopic technique.45 Surgical treatment of Bones
sagittal slab fractures of the fourth carpal bone has been Frontal slab fractures in locations other than the third
described.3 The results of surgery in these cases were carpal bone are uncommon. When they occur, they
poor, but presentation of the patients was delayed and usually involve the radial carpal bone. These fractures
www.ajlobby.com
(A) (B)
(C) (D)
Figure 27.22 (A, B) Preoperative radiographs and (C) computed tomography of a two‐year‐old racehorse with a palmar fracture (arrows)
of the radial carpal bone. Measurements show anticipated screw length. (D) Arthroscopic view shows the fracture fragment being
aligned and a needle (in left of image) used to plan the lag screw repair. C2, second carpal bone; Crad, radial carpal bone; Fx, fracture
fragment. (E) Postoperative radiographs show the repair using several 3.5 mm cortical screws applied in lag fashion. Source: Images
courtesy Dr. Alan Nixon.
are generally undisplaced or relatively undisplaced, and line. Needles are placed in both joints, a smooth elevator
can be treated conveniently with lag screw fixation using or obturator is used to lever the fractured slab into posi-
arthroscopic technique.42 Both the midcarpal and ante- tion, and one or several 4.5 mm cortical bone screw
brachiocarpal joints are examined arthroscopically using placed in lag fashion using the same techniques as
a lateral portal to assess the amount of joint damage, described for radial facet fractures of the third carpal
remove debris, and ascertain the position of the fracture bone. More palmar variations of frontal slab fracture of
www.ajlobby.com
(E) the radial carpal bone can also occur. There is less bone
for the threaded portion of the lag screw and accurate
placement into the palmar portion of the radial carpal
bone is critical. Very thin palmar slab fractures of
the radial carpal bone can be repaired using 3.5 mm cor-
tical screws placed in a palmar to dorsal orientation
(Figure 27.22). Arthroscopic assessment and visualiza-
tion during screw insertion are accomplished using a
palmaromedial approach.14,42
Frontal slab fractures of the intermediate and fourth
carpal bones have also been described and treated
with arthrotomy. The results were unsatisfactory.3
Arthroscopically assisted lag screw repair of an interme-
diate carpal bone large palmar frontal fracture allowed
good fracture reduction and stabilization (Figure 27.23).
Similarly, smaller frontal plane partial slab fractures of
the intermediate carpal bone can be reduced under
arthroscopic visualization and repaired using several
3.5 mm cortical screws (Figure 27.24). Preoperative CT
is useful in defining the fracture plane and developing
the plan for lag screw fixation.
(A) (B)
Figure 27.23 (A) Preoperative radiographs showing a large palmar slab fracture of the intermediate carpal bone associated with recovery
from general anesthesia. Screw length and trajectory are planned on the preoperative lateromedial radiographs. (B) Postoperative
radiograph showing fracture stabilization using partially threaded 6.5 mm cancellous screws. Source: Images courtesy Dr. Alan Nixon.
www.ajlobby.com
(A) (B)
(C) (D)
Figure 27.24 (A) Preoperative radiographs and (B) computed tomography showing multiple frontal plane fractures of the intermediate
carpal bone in a Thoroughbred racehorse. (C) Arthroscopic visualization and fracture line debridement are followed by reduction and
stabilization (D) using a curved hemostat to maintain positioning during insertion of 3.5 mm cortical screws in lag fashion. (E, F) Postoperative
radiographs show reduction of both fracture planes. Source: Images courtesy Dr. Alan Nixon.
Comminuted Collapsing Fractures lameness, and frequently palpable instability. The most
The primary indication for surgery in comminuted common radiographic manifestations are an unusually
fractures is to reconstruct bones that have lost their
large third carpal slab fracture with collapse of the proxi-
weight‐bearing ability and developed axial instability and mal row of carpal bones into the distal row, or slab fracture
anatomic deformity of the joint. Indicators of instability of multiple bones (Figure 27.25). Carpometacarpal luxa-
include valgus, varus, or palmar deformation, with severe tions (usually with proximal splint fractures and carpal
www.ajlobby.com
(E) (F)
fractures) are another cause of carpal destabilization. carpal instability has been reported.12 The filly was main-
Treatment is undertaken for salvage; return to athletic tained in a full limb cast for 15 days, followed by a tube
activity is not expected in these cases. cast for 14 days, and subsequently a full limb bandage
When there are comminuted fractures of the third car- with a caudal splint for 21 days. This resulted in a pas-
pal bone and/or additional fractures causing collapse of ture‐sound filly six months after surgery. For additional
the distal row of carpal bones with instability, arthrode- information on carpal arthrodesis, see Chapter 28.
sis is needed. Partial carpal arthrodesis leaving the ante-
brachiocarpal joint functional is the best option, if there
is confidence that there is no disease in the antebrachio-
Postoperative Care and Results
carpal joint and/or no instability. Figure 27.25 illustrates Slab fractures treated with arthroscopy are recovered
a case where partial arthrodesis using locking compres- from anesthesia in a padded bandage and treated as for
sion plates (LCPs) was performed. A partial carpal other arthroscopic surgeries. External support such as a
arthrodesis to repair an unstable comminuted carpal sleeve cast is used only when there has been significant
fracture had been previously described by Auer et al.2 instability within the carpus. When the repair is more
The use of the LCP system offers improved stability. The extensive, the use of perioperative antibiotics (broad
use of partial carpal arthrodesis to preserve antebrachio- spectrum) is also appropriate. All patients receive non-
carpal joint mobility has also been described for repair of steroidal anti‐inflammatory agents in the immediate
a comminuted fourth carpal bone fracture associated perioperative period.
with carpal instability in an Arabian filly.65 This particu- Most horses with lag screw fixation of slab fractures
lar repair was also facilitated with CT d ocumentation. T undergo similar exercise and physical therapy protocols
plates or dynamic compression plates (DCPs) have been as osteochondral chip fragments. Initiation of walking
used in the past, with LCPs now offering advantages in exercise depends on the extent of the fracture and confi-
stability. dence in the repair, but often commences four to six
Pancarpal arthrodesis is indicated when there are frac- weeks after surgery. In the case of a collapsed or com-
tures and instability involving both proximal and distal minuted fracture, a cast is usually maintained on the
row of carpal bones. This technique has been described limb for four to six weeks (Figure 27.26).
using two broad DCP plates.6 More recently, the use of There have been two reports with follow‐up data for the
pancarpal arthrodesis using two LCPs for treatment of a treatment of routine third carpal bone slab fractures.33,52
comminuted ulnar carpal bone fracture associated with In one report the race records were obtained for 72
www.ajlobby.com
(A) (B)
(C) (D)
Figure 27.25 (A–C) Preoperative radiographs of comminuted fractures of distal row of carpal bones, and (D, E) postoperative view
after partial carpal arthrodesis using two broad locking compression plates. Preoperative views were taken on the surgery table
for improved clarity.
Thoroughbreds and 61 Standardbreds.62 However, these Standardbreds, all 38 horses who had raced before the
did not generally involve arthroscopic surgery and care fracture were able to race again. Prior racing starts were
should be taken in extrapolating results. Factors in addi- not related to treatment outcome in Thoroughbreds.
tion to the fracture characteristics or the treatment choice Convalescent time was not correlated with any variable
affected outcome.62 Females of both breeds were less (including treatment) or related to outcome. The percent-
likely to race after injury than males (46% versus 90%). In age of Standardbreds racing (77%) was significantly higher
www.ajlobby.com
(E)
than for Thoroughbreds (65%). Fracture characteristics

were an important determinant of outcome. None of
the Thoroughbreds treated by screw fixation with frag-
ment thickness >9 mm raced well. None of the four Figure 27.26 Use of a sleeve cast for postoperative management
Thoroughbreds with fragment thickness >7 mm raced of partial arthrodesis.
after fragment removal. Horses of both breeds treated by
fragment removal performed similarly to horses treated
by screw fixation, despite increased associated damage horses that did not race after recovery had significantly
and fracture displacement. Based on their findings, the larger fractures.39
authors felt that the optimal range of fragment thickness In the initial description of arthroscopic repair of third
for removal was <8 mm for Thoroughbreds and <14 mm carpal bone slab fractures in horses by Richardson,57
for Standardbreds.62 17 horses had follow‐up of six months or longer. Of
In another study of 31 Thoroughbred racehorses these, 10 returned to race successfully. One other horse
surgically treated for frontal slab fractures of the third was reported to be training soundly and two trained well,
carpal bone, 21 (67.7%) raced at least once after recov- but were retired because of other injuries. One horse was
ery from surgery.39 The mean convalescent time was unable to return to training because of an injury that had
9.5 months. Claiming value declined from a mean of occurred simultaneously with the slab fracture. Two
$13 900 to a mean of $6500 (n = 11; P < 0.05), based on horses did not recover well enough to train or race, and
two races before injury and on four races after recov- one horse was lost to follow‐up. Except for the horses
ery. The mean finish position was 5.8 ± 3.16 before requiring two screws for repair, the cosmetic appearance
injury and 5.8 ± 3.30 after recovery (n = 11). The authors of each carpus was reported to be good, with only a small
noted the more serious nature of carpal slab fractures swelling over the screw.57
(compared to osteochondral chip fractures) in that (i) Comminuted fractures can be salvaged if stability can
only 67.7% of the horses raced again compared to 86.0% be gained with internal fixation and postoperative com-
of Thoroughbreds with carpal chip fragments;45 and plications can be avoided. Pancarpal arthrodesis has
(ii) the performance level decreased by 50% as judged complications similar to fracture fixation of any long
by claiming value, whereas 65.9% of Thoroughbreds bone. Additionally, the author has had one horse with
with osteochondral chip fractures raced at or better pancarpal arthrodesis later fracture above the plates
than their previous performance level.45 Additionally, while galloping in pasture.
www.ajlobby.com
Accessory Carpal Bone the biomechanical forces associated with the ligamentous
Fractures attachments, together with normal movement of the
accessory carpal bone during carpal flexion, are involved.
Fractures of the accessory carpal bone are not common
when compared to other carpal bone fractures.1 The lim- Diagnosis
ited reports available, however, suggest that these fractures
occur most commonly in horses that race over fences, and Lameness associated with a fracture of the accessory car-
therefore are more frequently seen in the UK. A significant pal bone is usually acute in onset. There is often some
number are also seen in event horses.16 Vertical (frontal) swelling on the palmar aspect of the carpus and the horse
fractures occurring through the mid‐portion of the bone resents partial flexion. Diagnosis is by radiography. The
are the most common configuration, and may be single or lateromedial view will demonstrate most fractures, but a
slightly comminuted (Figure 27.27). Horizontally oriented full series should be taken to exclude other concurrent
fractures are much less common.13 In a series of 19 acces- problems. Dorsoproximal chip fragments of the acces-
sory carpal bone fractures reported by Barr et al.,4 17 were sory carpal bone may occur along with vertical fractures
vertical with 13 of these being comminuted, 1 was an avul- (Figure 27.28). Computed tomography may also be use-
sion fracture from the palmar or distal border of the bone, ful in comminuted fractures, where surgical removal of
and 1 was a comminuted fracture at the dorsal articular some or all of the fragments is contemplated.7
surface of the bone. The author has also seen small chip
fragments off the dorsoproximal aspect of the accessory
carpal bone which are located in the palmar pouch of the
Treatment
antebrachiocarpal joint. Chip fractures on the dorsoproximal or palmarodistal
Theories to explain the pathogenesis of vertical frac- aspect of the accessory carpal bone have been reported
tures in the accessory carpal bone include the bowstring to respond well to either conservative treatment or sur-
effect of the ulnaris lateralis, flexor carpi ulnaris, and digi- gical removal, with return to full athletic function.16
tal flexors on the accessory carpal bone when the horse Removal of some dorsoproximal fragments that involve
lands on a partially flexed leg, and also the accessory car- the antebrachiocarpal joint using arthroscopic technique
pal bone being caught in a “nutcracker” between the third is appropriate.42 Distal avulsion fragments are generally
metacarpus and the radius.55 It is logical to assume that treated conservatively. The author also recommends a
(A) (B)
Figure 27.27 (A) Radiographs of a minimally displaced vertical fracture of the accessory carpal bone in a three‐year‐old Thoroughbred. (B) The
fracture line distracts only along the proximal aspect during flexion. The horse went on to race. Source: Images courtesy Dr. Alan Nixon.
www.ajlobby.com
(A) (B)
(C) (D)
Figure 27.28 (A) Radiograph of a four‐year‐old‐Thoroughbred with a comminuted fracture of the accessory carpal bone of three months’
duration. A vertical nonarticular fracture (arrowheads) is developing a fibrous union, and a dorsoproximal fracture has separated in the
palmar pouch of the antebrachiocarpal joint (arrow). (B) Postoperative radiograph shows that the intraarticular fracture has been removed
to minimize the degenerative joint disease, and (C, D) tenoscopic images from the severely distended carpal sheath show that the
accessory carpal bone has excoriated the lateral edge of the deep digital flexor tendon (DDFT), resulting in chronic inflammation, adhesion
formation, and synovial hypertrophy. The tendon was debrided, the carpal canal opened by retinacular release, and the intruding fracture
edge smoothed. Source: Images courtesy Dr. Alan Nixon.
www.ajlobby.com
conservative approach to the treatment of vertical and Surgery

horizontal fractures. In the series of 19 accessory carpal
bone fractures described by Barr, all cases were treated The only cases of accessory carpal bone fracture that the
conservatively and, of the 11 cases followed up, all author considers appropriate for surgical treatment are
became sound and 6 returned to competition.4 In 6 cases avulsion chip fragments off the proximodorsal aspect of
radiographed between six months and three years after the accessory carpal bone. These cases are operated
the fracture occurred, none showed evidence of bony arthroscopically, with the horse in dorsal recum-
union. The usual outcome is a fibrous union, but clinical bency.14,42 Distention of the antebrachiocarpal joint
soundness will commonly result. There has been a results in visible distention of the palmar pouch, and the
report of a bony union in a horizontal fracture.13 arthroscope is inserted in the central portion of the
Although carpal canal syndrome has been reported as a pouch. If fragments can be recognized by visualization
common sequela to accessory carpal bone fracture,55 it and manipulation, they are removed (see Figure 27.28).
occurs relatively infrequently in the author’s experience. In some instances, avulsion fragments will be buried
If it does exist, it can be treated with a retinaculectomy. within soft tissue under the synovial membrane, and
More commonly, displaced frontal plane fractures of their removal is either difficult or impossible. Removal of
the accessory carpal bone can result in trauma to the proliferative synovial tissue often exposes the fracture
carpal sheath and contained digital flexor tendons (see fragment and allows retrieval using a rongeur. A case
Figure 27.28).47 In a recent description of nine frontal report also describes arthroscopically assisted arthrot-
plane fractures, eight communicated with the carpal omy to remove multiple comminuted fragments along
sheath, resulting in carpal tenosynovitis.47 Treatment the dorsal articulation of the accessory carpal bone with
consisted of removal of the torn deep digital flexor ten- the radius and ulnar carpal bone.7 OA was prevented,
don tissue and the intruding fracture fragments and and the horse was sound for its intended purpose.
sharp edges. Various surgical treatments have been
advocated for frontal plane fractures, including lag
screw fixation, bone grafting, and removal.17,58 Anecdotal
Postoperative Care
experience suggests that the majority of these cases end For conservative management of accessory carpal bone
up with a fibrous union. The use of ulnar neurectomy fractures, the horse is simply confined to a stall. Although
has been described, but there is no data to support that maintaining the horse in a standing position and the
it changes the overall success rate compared to conserv- use of external splinting has been described, the author
ative healing. Bony union is not necessary for return to would limit the treatment to support bandaging and
full athletic activity.16 confinement.
References
1 Adams, O.R. (1974). Lameness in Horses, 3e. 7 Bonilla, A.G. and Santschi, E.M. (2015). Comminuted
Philadelphia: Lea & Febiger. fracture of the accessory carpal bone removed via an
2 Auer, J.A., Taylor, J.R., Watkins, J.P. et al. (1990). Partial arthroscopic‐assisted arthrotomy. Can. Vet. J.
carpal arthrodesis in the horse. VCOT 3: 51–60. 56: 157–161.
3 Auer, J.A., Watkins, J.P., White, N.A. et al. (1986). Slab 8 Bramlage, L.R. (1983). Surgical diseases of the carpus.
fractures of the fourth and intermediate carpal bones in Vet. Clin. North Am. Large Anim. Pract. 5: 261–274.
five horses. J. Am. Vet. Med. Assoc. 188: 595–601. 9 Bramlage, L.R. (1988). A clinical perspective of lameness
4 Barr, A.R., Sinnott, J.A., and Denny, H.R. (1990). originating in the carpus. Equine Vet. J.(Suppl 6): 12–18.
Fractures of the accessory carpal bone in the horse. 10 Bueno, A.C., Galuppo, L.D., Taylor, K.T. et al. (2003).
Vet. Rec. 126: 432–434. A biomechanical comparison of headless tapered
5 Beinlich, C.P. and Nixon, A.J. (2005). Prevalence and variable pitch and AO cortical bone screws for fixation
response to surgical treatment of lateral palmar of a simulated slab fracture in equine third carpal
intercarpal ligament avulsion in horses: 37 cases bones. Vet. Surg. 32: 167–177.
(1990–2001). J. Am. Vet. Med. Assoc. 5: 760–766. 11 Carrier, T.K., Estberg, L., Stover, S.M. et al. (1998).
6 Bertone, A.L., Schneider, H.L., Turner, A.S., and Association between long periods without high‐speed
Shoemaker, R.S. (1989). Pancarpal arthrodesis for workouts and risk of complete humeral or pelvic fracture
treatment of carpal collapse in the adult horse. A report in Thoroughbred racehorses: 54 cases (1991–1994).
of two cases. Vet. Surg. 18: 353–359. J. Am. Vet. Med. Assoc. 212: 1582–1587.
www.ajlobby.com
12 Carpenter, R.S., Goodrich, L.R., Baxter, G.M. et al. 27 Gustafson, S.B., McIlwraith, C.W., and Jones, R.L.
(2008). Locking compression plates for pancarpal (1989). Comparison of the effect of polysulfated
arthrodesis in a Thoroughbred filly. Vet. Surg. glycosaminoglycans, corticosteroids and sodium
37: 508–514. hyaluronate in the potentiation of a subinfective dose of
13 Carson, D.M. (1990). The osseous repair of a horizontal Staphylococcus aureus in the midcarpal joint of horses.
fracture of the accessory carpal bone in a Am. J. Vet. Res. 50: 2014–2017.
Thoroughbred racehorse. Equine Vet. Educ. 2: 173–176. 28 Haussler, K.K. and King, M.R. (2015). Physical
14 Cheetham, J. and Nixon, A.J. (2006). Arthroscopic rehabilitation. In: Joint Disease in the Horse, 2e (ed.
approaches to the palmar aspect of the equine carpus. C.W. McIlwraith, D.D. Frisbie, C. Kawcak and R. van
Vet. Surg. 35: 227–231. Weeren), 243–269. Mosby/Elsevier.
15 Dabareiner, R.M., Sullins, K.E., and Bradley, W. (1993). 29 Hirsch, J.E., Galuppo, L.D., Graham, L.E. et al. (2007).
Removal of a fracture fragment from the palmar aspect Clinical evaluation of a titanium, headless variable‐
of the intermediate carpal bone in a horse. J. Am. Vet. pitch tapered cannulated compression screw for repair
Med. Assoc. 203: 553–554. of frontal plane slab fractures of the third carpal bone
16 Dyson, S.J. (1990). Fractures of the accessory carpal in Thoroughbred racehorses. Vet. Surg. 36: 178–184.
bone. Equine Vet. Educ. 2: 188–190. 30 Kawcak, C.E., McIlwraith, C.W., and Norrdin, R.W.
17 Easley, K.J. and Schneider, J.E. (1981). Evaluation of a (2000). Clinical effects of exercise on subchondral bone
surgical technique for repair of equine accessory carpal on carpo‐metacarpophalangeal joints in horses. Am. J.
bone fractures. J. Am. Vet. Med. Assoc. 178: 219–223. Vet. Res. 61: 1252–1258.
18 Fischer, A.T. and Stover, S.M. (1987). Sagittal fractures 31 Kawcak, C.E., McIlwraith, C.W., Norrdin, R.W. et al.
in the third carpal bone in horses: 12 cases. 1977–1985. (2001). The role of subchondral bone in joint disease: a
J. Am. Vet. Med. Assoc. 191: 106–108. review. Equine Vet. J. 33: 120–126.
19 Foerner, J.J. and McIlwraith, C.W. (1990). Orthopedic 32 King, M.R., Haussler, K.K., Kawcak, C.E. et al. (2017).
surgery in the racehorse. Vet. Clin. North Am. Large Biomechanical and histologic evaluation of the effects
Anim. Pract. 6: 147–177. of underwater treadmill exercise on horses with
20 Foland, J.W., McIlwraith, C.W., Trotter, G.W. et al. experimentally induced osteoarthritis of the middle
(1994). Effect of betamethasone and exercise on equine carpal joint. Am. J. Vet. Res. 78: 558–569.
carpal joints with osteochondral fragments. Vet. Surg. 33 Kraus, B.M., Ross, M.W., and Boston, R.C. (2005).
23: 369–376. Surgical and nonsurgical management of sagittal slab
21 Frisbie, D.D., Ghivizzani, S.C., Robbins, P.D. et al. fractures of the third carpal bone in racehorses: 32 cases
(2002). Treatment of experimental equine osteoarthritis (1991–2001). J. Am. Vet. Med. Assoc. 226: 945–950.
by an in vivo delivery of the equine interleukin‐1 34 Lang, H.M. and Nixon, A.J. (2015). Arthroscopic
receptor antagonist gene. Gene Ther. 9: 12–20. removal of discrete palmar carpal osteochondral
22 Frisbie, D.D., Kawcak, C.E., Baxter, G.M. et al. (1998). fragments in horses: 25 cases (1999–2013). J. Am. Vet.
Effects of 6‐α‐methylprednisolone acetate on an in vivo Med. Assoc. 246: 998–1004.
equine osteochondral exercise model. Am. J. Vet. Res. 35 Ley, C., Ekman, S., Elmané, A. et al. (2007).
59: 1619–1628. Interleukin‐6 and tumor necrosis factor in synovial
23 Frisbie, D.D., Kawcak, C.W., Trotter, G.W. et al. (1997). fluid from horses with carpal joint pathology. J. Vet.
Effects of triamcinolone acetonide on an in vivo Med. A 54: 346–351.
osteochondral fragment exercise model. Equine Vet. J. 36 Lindsay, W.A. and Horney, F.D. (1981). Equine carpal
29: 349–359. surgery: review of 89 cases and evaluation of return to
24 Frisbie, D.D., Kawcak, C.E., Werpy, N.M., and function. J. Am. Vet. Med. Assoc. 179: 682–685.
McIlwraith, C.W. (2009). Evaluation of polysulfated 37 Ljungvall, K. and Ronéus, B. (2011). Arthroscopic
glycosaminoglycan or sodium hyaluronan administered surgery of the middle carpal joint in trotting
intra‐articularly for treatment of horses with Standardbreds: findings and outcome. Vet. Comp.
experimentally induced osteoarthritis. Am. J. Vet. Res. Orthop. Traumatol. 24: 350–353.
70: 203–209. 38 Lucas, J.M., Ross, M.W., and Richardson, D.W. (1999).
25 Gertsen, K.E. and Dawson, H.A. (1976). Sagittal Post‐operative performance of racing Standardbreds
fracture of the third carpal bone in a horse. J. Am. Vet. treated arthroscopically for carpal chip fractures: 176
Med. Assoc. 169: 633–635. cases (1986–1993). Equine Vet. J. 31: 48–52.
26 Getman, L.M., Southwood, L.L., and Richardson, D.W. 39 Martin, G.S., Haynes, P.F., and McClure, J.R. (1988).
(2006). Palmar carpal osteochondral fragments in Effect of third carpal slab fracture and repair in racing
racehorses: 31 cases (1994–2004). J. Am. Vet. Med. performance in Thoroughbred horses: 31 cases
Assoc. 228: 1151–1558. (1977–1984). J. Am. Vet. Med. Assoc. 193: 107–110.
www.ajlobby.com
40 McIlwraith, C.W. (1992). Tearing of the medial palmar 56 Ramzan, P.H. and Palmer, L. (2011). Musculoskeletal
intercarpal ligament in the equine mid‐carpal joint. injuries in Thoroughbred racehorses: a study of three
Equine Vet. J. 24: 367–371. large training yards in Newmarket, UK (2005–2007).
41 McIlwraith, C.W. (2005). From arthroscopy to gene Vet. J. 187: 325–329.
therapy – 30 years of looking in joints. Milne Lecture. 57 Richardson, D.W. (1986). Technique for arthroscopic
In: Proceedings of the American Association of Equine repair of third carpal bone slab fractures in the horse.
Practitioners, vol. 51, 65–113. Lexington, KY: AAEP. J. Am. Vet. Med. Assoc. 188: 288–291.
42 McIlwraith, C.W., Nixon, A.J., and Wright, I.M. (2015). 58 Roberts, E.J. (1964). Some modern surgical operations
Diagnostic and Surgical Arthroscopy, 4e. Edinborough: applicable to the horse. Vet. Rec. 76: 75.
Mosby/Elsevier. 59 Rutherford, D.J., Bladon, B., and Rogers, C.W. (2007).
43 McIlwraith, C.W. and Turner, A.S. (1986). Assessing Outcome of lag‐screw treatment of incomplete
success of surgery. Equine Vet. J. 18: 165–166. fractures of the frontal plane of the radial facet of the
44 McIlwraith, C.W. and Vachon, A. (1988). Treatment third carpal bone in horses. N. Z. Vet. J. 55: 94–99.
of degenerative joint disease. Equine Vet. J.(Suppl 6): 60 Sarrafian, T.L., Case, J.T., Kinde, H. et al. (2012). Fatal
3–11. musculoskeletal injuries of Quarter Horse racehorses:
45 McIlwraith, C.W., Yovich, J.V., and Martin, G.S. (1987). 314 cases (1990–2007). J. Am. Vet. Med. Assoc. 241:
Arthroscopic surgery for the treatment of 935–942.
osteochondral chip fractures in the equine carpus. 61 Schneider, R.K., Bramlage, L.R., Gabel, A.A. et al.
J. Am. Vet. Med. Assoc. 191: 531–540. (1988). Incidence, location and classification of 371
46 Meagher, D.M. (1974). Joint surgery in the horse: selection third carpal bone fractures in 313 horses. Equine Vet.
of surgical cases and confirmation of the alternative. J.(Suppl 6): 33–42.
In: Proceedings of the American Association of Equine 62 Stephens, P.R., Richardson, D.W., and Spencer, P.A.
Practitioners, vol. 20, 81–88. Lexington, KY: AAEP. (1988). Slab fractures of the third carpal bone in
47 Minshall, G.J. and Wright, I.M. (2014). Frontal plane Standardbreds and Thoroughbreds. J. Am. Vet. Med.
fractures of the accessory carpal bone and implications Assoc. 193: 353–358.
for the carpal sheath of the digital flexor tendons. 63 Thrall, D.E., Lebel, J.L., and O’Brien, T.R. (1977). A five
Equine Vet. J. 46: 579–584. year survey of the incidence and location of equine
48 Murray, R.C., Gaughan, E.M., DeBowes, R.M. et al. carpal chip fractures. J. Am. Vet. Med. Assoc. 159:
(1998). Biomechanical comparison of the Herbert and 1366–1368.
AO cortical bone screws for compression of equine 64 Tidswell, H.K., Innes, J.F., Avery, N.C. et al. (2008).
third carpal bone dorsal plane slab osteotomy. Vet. High‐intensity exercise induces structural,
Surg. 27: 49–55. compositional and metabolic changes in cuboidal
49 Norrdin, R.W., Kawcak, C.E., Capwell, B.A. et al. bones – findings from an equine athlete model. Bone
(1998). Subchondral bone failure in an equine model of 43: 724–733.
overload arthrosis. Bone 22: 133–139. 65 Waselau, M., Bertone, A.L., and Green, E.M. (2006).
50 Palmer, S.E. (1983). Lag screw fixation of a sagittal Computed tomographic documentation of a
fracture of the third carpal bone in a horse. Vet. Surg. comminuted fourth carpal bone fracture associated
12: 54–57. with carpal instability treated by partial carpal
51 Palmer, S.E. (1986). Prevalence of carpal fractures in arthrodesis in an Arabian filly. Vet. Surg. 35: 618–625.
Thoroughbred and Standardbred racehorses. J. Am. 66 Wilke, M., Nixon, A.J., Malark, J. et al. (2001). Fractures
Vet. Med. Assoc. 188: 1171–1173. of the palmar aspect of the carpal bones in horses: 10
52 Park, R.D., Morgan, J.P., and O’Brien, T.R. (1970). Chip cases (1984–2000). J. Am. Vet. Med. Assoc. 219:
fractures in the carpus of the horse: a radiographic 801–804.
study of their incidence and location. J. Am. Vet. Med. 67 Wright, I.M. and Smith, M.R. (2011). The use of small
Assoc. 157: 1305–1311. (2.7 mm) screws for arthroscopically guided repair of
53 Phillips, T.J. and Wright, I.M. (1994). Observation on carpal chip fractures. Equine Vet. J. 43: 270–279.
the anatomy and pathology of the palmar intercarpal 68 Wyburn, R.S. and Goulden, D.E. (1974). Fractures of
ligaments of the middle carpal joints of Thoroughbred the equine carpus: report on 57 cases. N. Z. Vet. J.
racehorses. Equine Vet. J. 26: 486–491. 22: 133–142.
54 Pool, R.R. and Meagher, D.M. (1990). Pathologic 69 Yovich, J.V., Trotter, G.W., McIlwraith, C.W., and
findings and pathogenesis of racetrack injuries. Vet. Norrdin, R.W. (1987). Effects of polysulfated
Clin. North Am. Large Anim. Pract. 6: 1–30. glycosaminoglycans on chemical and physical defects
55 Radue, P. (1981). Carpal tunnel syndrome due to fracture in equine articular cartilage. Am. J. Vet. Res.
of the accessory carpal bone. Equine Pract. 3: 8–17. 48: 1407–1414.
www.ajlobby.com
515
28
Arthrodesis of the Carpus
Larry R. Bramlage and Alan J. Ruggles
Indications and General risks of the unfavorable biomechanics of carpal arthro

Considerations desis with a weakened skeleton. The end result is consid
erable risk of failure of the arthrodesis construct or the
Successful surgical arthrodesis of the carpus creates rigid involved long bones.
fixation of either the antebrachiocarpal joint, or the mid Recognition of the importance that the carpal joints
dle carpal/carpometacarpal joint (partial carpal arthro have in functional weight bearing creates the preference
desis), or the entire carpus (pancarpal arthrodesis) to for a partial rather than pancarpal arthrodesis whenever
provide pain‐free weight bearing. Indications for carpal possible. Horses undergoing partial carpal arthrodesis
arthrodesis include end‐stage degenerative arthritis, have a more rapid return to comfortable weight bearing,
destabilizing fracture, or intolerable angular deformity. reduced complications because of the improved biome
Carpal arthrodesis is a difficult procedure and carries chanics, and better long‐term outcomes compared to
significant morbidity risks. It should be reserved for horses with pancarpal arthrodesis.12 The remaining
horses with no alternate treatment options, and when intact joint can absorb loads and reduce biomechanical
fusion of a portion or the entire carpus is necessary for forces on the bone and implants during the postoperative
comfortable weight bearing. The procedure is intended period, while allowing some flexion of the carpus during
solely to create pasture soundness, with the exception of ambulation following successful fusion of the carpus.
some cases of carpometacarpal arthritis. In most cir
cumstances, it is a salvage procedure for horses that are
intended for breeding or retirement. Carpal Fractures
The carpal joints are responsible for a significant
amount of load dissipation during weight bearing. When Unstable nonreconstructable carpal fractures of single or
either the middle or antebrachiocarpal joints are fused, multiple carpal bones are an indication for carpal arthro
the demand for dissipation of forces is then exaggerated desis. Reconstruction of complex carpal fractures with lag
on the remaining structures.12 Total abolition of the car screws to allow axial weight bearing and restore joint
pal articulations by pancarpal arthrodesis requires com congruity is preferred over carpal arthrodesis. However,
plete neutralization of the nonaxial forces normally some complex carpal fractures are too comminuted and
absorbed by the carpus during the acute postoperative unstable to allow anatomic reconstruction sufficient
period and long term. These forces are very difficult to resist the biomechanical forces of weight bearing
to circumvent, with lever arms as long as the cannon (Figure 28.1). Comminuted fragments that are inaccessi
bone and the radius on each end of the fixation. It is ble and difficult or impossible to reconstruct with bone
this
biomechanical demand for stress neutralization screws require support with bone plates. The decision to
that makes the morbidity associated with pancarpal perform carpal arthrodesis is appropriate if the fracture
arthrodesis much higher than with other internal fixa damages the bone sufficiently that axial loading is impos
tion procedures. In addition, many of the horses who sible and axial alignment cannot be maintained after
require carpal arthrodesis are aged multi‐parturient reconstruction. The surgeon and the client should be pre
broodmares, who have some degree of osteopenia due to pared that carpal arthrodesis may be necessary prior to an
disuse and the demands of lactation. This combines the attempted reconstruction of a complex carpal fracture.

www.ajlobby.com
Foals occasionally have traumatic luxation of the

c arpometacarpal joint, with accompanying fracture of the
proximal aspect of the second, third, and/or fourth meta
carpal bones. Management in a sleeve cast is a possibility,
but carpal laxity, cast rub sores, and the development of
degenerative joint disease or angular deformity of the
contralateral limb are significant risks with nonsurgical
management. Stabilization of the carpus, either by carpo
metacarpal joint arthrodesis or plate f ixation of the proxi
mal splint bones, is generally a better choice (Figure 28.2).
In mature horses with such an injury, carpometacarpal or
partial distal carpal arthrodesis is usually a better option
than cast coaptation alone, due to the complications
associated with casting, such as prolonged healing times,
persistent lameness, cast sores and abnormal wear, and
the risk of contralateral limb laminitis.
Degenerative Osteoarthritis
In most instances, horses with severe degenerative
Figure 28.1 Comminuted unstable carpal fractures with collapse
in the dorsal plane in an adult. Involvement of both rows of carpal
arthritis of the carpus have previously had significant
bones in the fracture complex generally indicates the need for a carpal injury. It is generally best to deal with these
pancarpal arthrodesis. injuries at the time they occur, rather than later when the
(A) (B)
Figure 28.2 (A) 30‐day old Thoroughbred foal with proximal second metacarpal fracture and carpometacarpal subluxation.
(B) Stabilization of the carpometacarpal joint by plate fixation of the proximal aspect of the second metacarpal bone. Additional support
is provided by a sleeve cast. Arthrodesis of the carpometacarpal joint has been avoided.
www.ajlobby.com
(A) (B)
Figure 28.3 (A) 16‐year‐old Quarter Horse mare with carpal varus deformity secondary to degenerative joint disease. (B) Dorsopalmar
radiograph of carpus, with plan for collapsing wedge osteotomy of the antebrachiocarpal joint.
effects of the carpal injuries have led to severe degen

eration and angular deviation, and a partial or pancarpal
arthrodesis becomes a necessity to alleviate the pain.
Often there is an underestimation of the long‐term
effects of carpal injuries in horses retired for breeding.
In most cases of degenerative arthritis of the antebra
chiocarpal and middle carpal joints requiring a carpal
arthrodesis, there is an accompanying angular deformity
of the carpus, most often carpus varus. This deformity
is due to loss of cartilage on the medial aspect of the
joint and subsequent stretching of the lateral collateral
ligaments of the carpus (Figure 28.3). The problem is
exacerbated in broodmares due to increased weight
gain from pregnancy and ligamentous laxity, which
occurs as a consequence of hormonal changes during
parturition. In cases of degenerative arthritis of the
carpometacarpal joint, carpal angular deformities Figure 28.4 Wedged, cuffed glue on shoe with Advanced Cushion
Support® (Nanric, Lawrenceburg, KY, USA) sole support.
generally do not occur.2,10 However, lameness can be
profound, and response to medical treatment is poor;
11 of 19 horses had to be euthanized due to unrelenting
lameness in one study.10 the opposite foot is recommended before a decision for
In cases of deforming degenerative arthritis of the car carpal arthrodesis occurs, or a prognosis is given, in any
pus, the surgical procedure must remove the remaining longstanding carpal injury that may require arthrodesis.
articular cartilage, improve the axial or dorsal alignment Perioperative hoof care and shoeing should also be
of the limb, and provide fixation to allow long‐term pain‐ directed to the contralateral limb to minimize or treat
free weight bearing. The surgical correction should be laminitis (Figure 28.4). However, the best treatment for
undertaken before laminitis begins in the contralateral overload laminitis in the contralateral limb is the reestab
foot. Preoperative clinical and r adiographic assessment of lishment of pain‐free weight bearing in the injured limb.
www.ajlobby.com
Angular Deformities of the Carpus realignment during fixation. Improved limb alignment

will optimize implant function by promoting load sharing
Angular deformities severe enough to warrant correction by the implant–bone construct, and reduce soft tissue
and arthrodesis may result from collapsing carpal frac problems during coaptation.
tures or severe cartilage loss and ligamentous laxity in A preoperative plan based on radiographs is helpful in
adults, or from growth disparities or overload weight bear determining the best method of limb straightening. Care
ing secondary to a painful condition of the c ontralateral should be taken to minimize the amount of bone
limb in growing horses. Deformities can occur in both removed from the cuboidal bones during the osteotomy,
the sagittal and dorsal planes. In cases of fracture‐related which provides maximum screw purchase in the remain
or developmental angular deformities, an effort is made ing bones and preserves the stability provided by soft tis
to correct the malalignment during the arthrodesis pro sue structures. The transverse portion of the osteotomy
cedure by reconstruction of the fracture fragments or at the joint surface should be perpendicular to the long
with an osteotomy. In cases of deforming degenerative axis of the limb. If a wedge osteotomy is performed at the
arthritis, a less aggressive approach to limb straightening antebrachiocarpal joint, an effort is made to create slight
is often satisfactory if the ligamentous laxity secondary carpal flexion in the final construct (Figure 28.5). This
to the chronic arthritic condition can be negated with more effectively loads the cranially applied plates in
(A) (B)
(C) (D)
Figure 28.5 (A) Intraoperative view of antebrachiocarpal joint osteotomy (arrows) to correct carpal varus deformity. Lateral is to the top of
the image. (B) The osteotomy has been performed through the antebrachiocarpal joint and the wedge removed. (C) Application of a
4.5 mm broad dynamic compression plate on the dorsum of the carpus, using the tension device to load the plate and collapse the
osteotomy. A second plate was then applied. (D) Immediate postoperative appearance on mare from Figure 28.3 after closing wedge
osteotomy and carpal arthrodesis to correct carpal varus secondary to degenerative joint disease.
www.ajlobby.com
tension during the arthrodesis. Care should be taken to steopenia is usually present in instances of long‐term
o
avoid the accessory carpal bone when performing an lameness and decreased limb use.
osteotomy of the antebrachiocarpal joint. A determination of angular limb deformity and joint
laxity should be made on both the clinical examination
and by radiographic assessment, including stressed
Surgical Preparation views. Determination of the best surgical approach may
be influenced by the condition of the skin, the presence
of excessive bone formation, and the presence of skin
Preoperative Assessment ulcers or wounds. However, the most important factor is
Preoperative assessment of horses requiring carpal facilitation of the insertion of appropriate internal fixa
arthrodesis is vital to determine the complexity of the tion to stabilize the reconstructed carpus. Systemic
injury, select implants appropriate to the degree of insta health, pregnancy status, and number of previous foals
bility, and provide a preoperative prognosis. A series of should be considered. It is typical for mares in late gesta
high‐quality, properly positioned digital radiographs is tion to have worsening of their clinical signs. A decision
required for assessment of the carpal condition and to time the surgery shortly after parturition, rather than
planning of the necessary reconstruction or osteotomy. during gestation, is preferred, if possible.
Computed tomography, if available, is very helpful in A preoperative plan should be made and templates or
determining the severity of the condition, identifying measurements for osteotomy should be determined prior
occult fractures, and planning the appropriate recon to surgery. Checking implant inventory or ordering spe
struction with lag screws and plate application for partial cial implants prior to surgery is recommended if this
or pancarpal arthrodesis (Figure 28.6).13 In chronic cases, procedure is not routinely performed in the surgeon’s
assessment of the quality of bone, especially in the practice. Finally, the client should be informed of the risks
distal radius, must be made from radiographs. Disuse and potential complications inherent in this procedure.
(A) (B)
Figure 28.6 (A) Flexed lateral radiograph of a four‐year‐old Quarter Horse male with comminuted fracture of multiple carpal bones of the
proximal row. (B) Computed tomography transverse image of the proximal row of carpal bones of the same horse, showing destabilizing
fractures of the radial and intermediate carpal bones.
www.ajlobby.com
Implant Selection instability and collapse of the carpus (Figure 28.8).

Application of short DCP or locking compression plates
In all circumstances a combination of plates and screws (LCPs) is indicated when partial carpal arthrodesis of
will be used. In general, 5.5 mm cortex screws and broad relatively stable fractures or angular deformities is
4.5 mm dynamic compression plates (DCPs) are used planned. LCPs offer the advantage of a fixed angle of
(Figure 28.7). The dynamic condylar screw/plate sys the screw–plate construct, which prevents implant
tem (DCS) is very useful in cases where a buttress is loosening secondary to infection or motion of the
necessary to circumvent unstable carpal fractures or fracture fragments.5,6 For DCPs, the use of poly
instability in multiple planes. The authors now generally methlymethacrylate (PMMA; Simplex P®, Howmedica
prefer a single DCS plate for most unstable pancarpal Corporation, Mahwah, NJ, USA) impregnated with
arthrodesis procedures. The large diameter of the antimicrobial agents for plate luting can reduce stress
condylar screw–plate construct is effective in buttressing at the screw heads, improve bone–plate contact, and
(A) (B) Figure 28.7 (A) Lateral and (B) dorsopalmar

postoperative radiographs of horse from
Figure 28.6 after partial carpal arthrodesis of the
antebrachiocarpal joint with two broad 4.5 mm
dynamic compression plates and 5.5 mm screws.
(C) Clinical postoperative appearance after
antebrachiocarpal joint arthrodesis.
(C)
www.ajlobby.com
Surgical Technique
Approach
A straight to slightly curved incision is made, starting
proximally over the distal radius between the muscle bel
lies of the extensor carpi radialis and common digital
extensor muscle. The incision becomes transtendinous
through the carpal dorsal annular ligament and the com
mon digital extensor tendon, extending into the proxi
mal metacarpus (Figure 28.9). The length of the incision
varies depending on the implants used and whether a
partial or pancarpal arthrodesis is planned (Figure 28.10).
Two linear incisions, one on either side of the extensor
carpi radialis tendon, have been used by others,14 but
most carpal arthrodesis cases can be fused using a single
incision. The joint or joints to be fused are opened using
a straight vertical incision. Exostoses can be elevated
with the skin flap, or removed later if needed to facilitate
implant placement and wound closure. Care should be
taken to maintain the subcutaneous blood supply to the
skin flap by elevation with thick subcutaneous attach
ments. Variations in the approach are based on the con
formation of the limb, the presence of angular deformity,
and/or the fracture configuration (Figure 28.11). During
surgery the soft tissue should be lavaged with saline con
Figure 28.8 Radiographs several months after dynamic condylar taining antimicrobial agents to keep the tissues moist
screw (DCS) plating for carpal fracture and pancarpal arthrodesis and help prevent infection
in a Thoroughbred yearling. Note the placement of the DCS barrel
just proximal to the distal radial physis.
Osteotomy/Joint Debridement
increase resistance to cyclic fatigue, and should be After the affected joint or joints are opened, the a rticular
contemplated in most carpal arthrodesis procedures.9,11 cartilage is debrided using bone curettes, an oscillating
Plate luting is not indicated if locking plates are used,5,6 saw, or a combination of both. Removal of the articular
but PMMA beads or small cylinders containing anti cartilage is accomplished via osteotomy if correction of an
biotics placed adjacent to or between the plates helps angular deformity is needed (see Figure 28.9). Bone should
prevent or control infection of the arthrodesis. be removed from the distal radius to preserve the cuboidal
bones when possible, and should be removed with a
slightly caudally diverging osteotomy of the articular sur
Positioning and Draping
face to produce slight flexion of the fused carpus and
The horse is positioned in lateral recumbency with the thereby a tension surface dorsally after reconstruction.
affected limb uppermost for most carpal arthrodesis After debridement of the articular cartilage and cor
procedures. However, positioning the affected limb rection of the angular deformity, fixation is accom
down is occasionally necessary for better access to the plished by application of two bone plates. Plates are
medial surface of the carpus. The limb is aseptically typically applied dorsolaterally and dorsomedially, but
prepared for surgery from the fetlock to the proximal variations of these locations may occur, based on the
radius. The dorsal region of the carpus is also shaved injury and fixation requirements. Typically, two broad
over the length of the surgical approach. Liberal drap 4.5 mm DCPs or limited‐contact dynamic compression
ing is recommended to maintain adequate exposure of plates (LC‐DCPs) are applied. Locking plates have been
the limb to aid in visual realignment of the carpus. utilized more frequently in recent years and provide
Sterile adhesive drapes are recommended to reduce very stable fixation.5,6 In partial or pancarpal arthrode
exposure of the surgical field to the skin and to seal the sis, care should be taken to end the plates in the meta
area between the drapes and the skin. physis of the radius and/or the proximal third of the
www.ajlobby.com
(A) (B)
(C) (D)
(E) (F)
Figure 28.9 Illustration of the surgical approach and application of two locking compression plates (LCPs) for pancarpal arthrodesis.
(A) Skin incision over the dorsolateral aspect and flapped with hinge dorsomedially. (B) Transtendinous incision through common digital
extensor. (C) Osteotomy centered on the antebrachiocarpal joint for correction of an angular deformity. (D) Application of the first LCP
over the more comminuted region of the carpus. (E) Insertion of cortical and locking screws. An assistant stabilizes the osteotomized
carpus in alignment during initial implant insertion. Cortical screws are used to provide compression of the plate to the bones and across
the dorsal aspect of the carpus. Locking screws are then applied to enhance the rigidity of the repair. (F) Closure utilizes the common
digital extensor to cover one plate.
etacarpus, to avoid stress on the weakened diaphysis

m Spanning the entire length of the radius and meta
of the osteopenic limb. In pancarpal arthrodesis, the carpus is not recommended, and ending both plates in
benefit of having one mobile joint is lost and therefore the diaphysis of these bones, especially the radius,
more screw purchase in the radius is required, result should be avoided to prevent catastrophic failure of the
ing in at least one plate ending more proximally. osteopenic bone.
www.ajlobby.com
Plate Application
Prior to plate contouring, the osteotomy or fracture is
reduced. Any screws to be placed outside the plates are
inserted to assist maintenance of alignment prior to plate
fixation. The plate is carefully contoured to the appropri
ate site on the bone to maximize bone–plate interface
friction (see Figure 28.9). If the LCP plate system is used,
bone–plate contact is not required for function of the
plates, but careful contouring is nonetheless recom
mended to avoid difficulty in wound closure.5,6 Where the
Figure 28.10 Intraoperative view of approach for partial carpal antebrachiocarpal joint is to be fused, the plate should not
arthrodesis of the antebrachiocarpal joint. The needle (arrow) is engage more than the distal metaphysis of the radius.
used to identify the middle carpal joint. The incision is shortened Ending the plate more proximally in the bone increases
to end at the carpometacarpal joint. The edge of the longitudinally the risk of catastrophic failure of the radius. If a DCS/plate
divided tendon of the common digital extensor is evident
(arrow heads). system is to be used, the condylar screw is typically placed
in the distal radius immediately proximal to the remnant
of the physeal scar. Care is required when placing the
If the carpometacarpal joint is to be fused, the joint dynamic screw to ensure that it is placed in the center of
is not typically opened and the articular cartilage the bone and not solely in the cranial or caudal cortex.
is removed by transarticular drilling using a 3.2 mm The plate is positioned to allow maximal purchase
drill bit.2,13 The drill holes can then be packed with of screws in the cuboidal bones. Plates can encroach
autologous cancellous bone graft. Compression across onto remaining active carpal articulations, as hyperex
the joint can be accomplished with a bone plate. This tension does not occur in the carpus (Figure 28.12).
procedure is utilized for the alleviation of lameness, Screws near the joints can be angled to optimize purchase
rather than for the restoration of weight‐bearing in the bones. Placing two plates results in increased
stability. Given this, carpometacarpal arthrodesis is
potential for screw interference, and planning the
a much less challenging biomechanical problem, plate position to provide staggering of plate screws
compared to unstable injury of the more proximal
can avoid or minimize screw interference. This can be
carpal joints.12 difficult using fixed‐angle screws such as in the LCP
Figure 28.11 (A) Lateral and (B) (A) (B)

dorsopalmar preoperative radiographs
of a 12‐year‐old Quarter Horse mare with
a combination of distal medial radius
and comminuted radial carpal bone
fractures due to a gunshot wound.
www.ajlobby.com
(A) (B)
Figure 28.12 (A) Lateral and (B) dorsopalmar postoperative radiographs after partial carpal arthrodesis of the antebrachiocarpal joint
with 4.5 mm broad dynamic compression plates and 5.5 mm screws. The plates were placed at 90° and some of the screws in the medial
plate were placed in lag fashion due to the conformation of the fracture.
system, and using s everal nonlocked screws in the LCP with the foot and fetlock exposed is p referred in most
may be necessary, but should be minimized to enhance circumstances. Some authors advocate placing the
fixation rigidity. entire limb in a transfixation cast;14 however, strong
internal fixation accompanied by sleeve cast support
Closure has prevented early postoperative fracture in our hands.
Wound revision and resection of excessive soft tissue

or new bone formation should be performed prior to
commencing the closure. Placing resorbable or nonre Postoperative Management
sorbable antibiotic‐laden beads is recommended prior
to closure. The use of a closed suction drain (J‐Vac®, Postoperative cast coaptation is typically used for four
Ethicon, Summerville, NJ, USA) is at the surgeon’s pref weeks, with a cast change and suture removal per
erence, but is generally recommended in the presence formed standing two weeks after surgery. Longer coap
of bleeding tissues, excessive dead space, and where tation may be required in cases of fracture repair, but
there is the likelihood of seroma formation. The exit cast complications often limit long‐term coaptation.
for the drain should be sufficiently proximal to allow Broad‐spectrum systemic antimicrobial use varies from
removal of the drain without removal of the sleeve cast three to seven days, depending on the type of injury or
used for postoperative coaptation. Heavy fascial layers repair. Pain is alleviated by the use of nonsteroidal anti‐
are apposed with #1 or #2 polyglactin suture (Vicryl®, inflammatory drugs and opioid analgesics as needed
Ethicon) placed in a simple interrupted pattern. This (Fentanyl transdermal system, 75 mcg/h, Actavis South
can be followed by a continuous layer of the same suture Atlantic, Sunrise, FL, USA). Careful attention to the
to provide a tighter seal. The remaining layers are closed contralateral foot is necessary to prevent or treat lami
routinely. Stainless steel staples are typically used in nitis. Stall confinement for at least eight weeks is fol
the skin, except where excessive tension is present. lowed by hand walking with stall rest for an additional
Monofilament sutures placed in an interrupted or verti four weeks before any free exercise. The goal of carpal
cal mattress pattern can better resist tension at the skin arthrodesis is to allow eventual unrestricted pasture
edge. Sterile nonadherent dressings (Tegasorb®, 3M exercise. In the case of carpometacarpal arthrodesis, it
Company, St. Paul, MN, USA) are applied to the incision is possible to resume some athletic function typically
site and a sleeve or full limb cast is applied. A sleeve cast four to six months postoperatively.
www.ajlobby.com
Complications
Complications of carpal arthrodesis include infection,
implant loosening, cast ulcerations, catastrophic fracture
of the long bones at the ends of the plates, and laminitis
of the contralateral foot. Subclinical or clinical laminitis
may be present in the contralateral foot prior to surgery,
especially in longstanding cases of degenerative arthritis.
Pain associated with the arthrodesis procedure may exac
erbate this process and lead to an acute manifestation of
laminitis. Aggressive pain management and mechanical
support to the foot are helpful in reducing the risk of this
complication after carpal arthrodesis.
Results
There are no long‐term published case series of partial
or pancarpal arthrodesis in the horse. There are various
case reports in the literature and proceedings.1,3–7,11,13 A
single series reports good outcome for carpometacarpal Figure 28.13 Long‐term dorsopalmar radiograph several years
arthrodesis by joint forage for the treatment of carpo after successful pancarpal arthrodesis in a Thoroughbred yearling
metacarpal arthritis.2 Even so, complications can occur using a dynamic condylar screw plate. Same case as Figure 28.8.
The horse was a productive broodmare.
with forage of the carpometacarpal joint.8 The variation
in disease conditions of the carpus, presence of clinical
or subclinical laminitis, variations in bone mineral den than the results of cases requiring pancarpal arthrodesis.
sity of the radius and metacarpus, and the relatively small In general, prevention of degenerative arthritis of the
number of cases make comparison of cases difficult. In carpus and the inevitable secondary laminitis can be
the authors’ experience, overall prognosis for long‐term better achieved by carpal reconstruction or arthrodesis
pasture soundness is fair (Figures 28.12 and 28.13). Acute soon after the original carpal injury. Many cases with
cases with dense bone and no subclinical or clinical lami complex carpal fracture are best treated by early carpal
nitis provide the best outcome. Additionally, outcome arthrodesis, especially where stabilization and comfort
for cases treated with partial carpal arthrodesis is better cannot be accomplished by other means.
References
1 Auer, J.A., Taylor, J.R., Watkins, J.P. et al. (1990). Partial 5 Carpenter, R.S., Goodrich, L.R., Baxter, G.M. et al. (2008).
carpal arthrodesis in the horse. Vet. Comp. Orthop. Locking compression plates for pancarpal arthrodesis in
Traumatol. 3: 51. a Thoroughbred filly. Vet. Surg. 37: 508–514.
Barber, S., Paniozzi, L., and Lang, H. (2009).
2 Levine, D.G. and Richardson, D.W. (2007). Clinical use of
6
Osteoarthritis of the carpometacarpal joint (carpal the locking compression plate (LCP) in horses: a
spavin): treatment of 12 cases by arthrodesis. In: retrospective study of 31 cases (2004–2006). Equine Vet. J.
Proceedings of the American Association of Equine 39 (5): 401–406.
Practitioners, vol. 55, 67. Lexington, KY: AAEP. Lewis, R.D. (2004). Carpal arthrodesis: technique and
7
Barr, A.R., Hillyer, M.H., and Richardson, J.D. (1994).
3 prognosis. In: Proceedings of the Annual American
Partial carpal arthrodesis for multiple carpal fractures and College of Veterinary Surgeons Symposium, vol. 14,
subluxation in a pony. Equine Vet. Educ. 6 (5): 255–258. 94–97. Rockville, MD: ACVS.
Bertone, A.L., Schneiter, H.L., Turner, A.S., and
4 MacKay, A.V., Panizzi, L., Sparks, H.D., and Barber, S.M.
8
Shoemaker, R.S. (1989). Pancarpal arthrodesis for (2015). Second carpal bone slab fracture and subluxation of
treatment of carpal collapse in the adult horse. A report the middle carpal joint in a horse subsequent to arthrodesis
of two cases. Vet. Surg. 18 (5): 353–359. of the carpometacarpal joint. Vet. Surg. 44: 242–245.
www.ajlobby.com
9 Nunamaker, D.M., Richardson, D.W., and Butterweck, 12 Tulloch, P.J., Johnston, J.D., Barber, S.M. et al. (2015).
D.M. (1991). Mechanical and biological effects of plate Ex vivo evaluation of carpal flexion after partial carpal
luting. J. Orthop. Trauma. 5: 138–145. arthrodesis in horses. Vet. Surg. 44: 386–391.
10 Panizzi, L., Barber, S.M., Lang, H.M., and Carmalt, J.L. 13 Waselau, M., Bertone, A.L., and Green, E.M. (2006).
(2009). Carpometacarpal osteoarthritis in thirty‐three Computed tomographic documentation of a
horses. Vet. Surg. 38: 998–1005. comminuted fourth carpal bone fracture associated
1 Staller, G.S., Richardson, D.W., Nunamaker, D.M.,
1 with carpal instability treated by partial carpal
and Provost, M. (1995). Contact area and static arthrodesis in an Arabian filly. Vet. Surg. 35: 618–625.
pressure profile at the plate–bone interface in 4 Zubrod, C.J. and Schneider, R.K. (2005). Arthrodesis
1
the nonluted and luted bone plate. Vet. Surg. techniques in horses. Vet. Clin. North Am. Equine
24: 299–307. Pract. 21 (3): 691–711.
www.ajlobby.com
527
29
Fractures of the Radius
Joerg A. Auer
Introduction may not be able to detect the fracture in the acute case.15
The fracture lines, spiraling up the bone, may be visible
Fractures of the radius are encountered in horses of all only if the X‐ray beam is directed at the fissure through
types and ages. Foals, however, seem to fracture the the fracture plane. Diagnostic regional anesthesia is con-
radius more frequently than adults. The injury usually traindicated in such cases, because of the danger of
occurs acutely, either as a result of a kick by another allowing the animal to bear full weight on the limb and, in
horse,7,30 a fall during high‐speed exercise, or an abrupt so doing, induce a complete fracture. If an incomplete
stop after such activity.36 Immediately after the fracture, fracture is suspected but cannot be confirmed, the horse
the animal is non‐weight bearing on the involved limb. should be cross‐tied or placed in a sling (Figure 29.2) and
repeat radiographs performed after four to six days. New
radiographs usually allow the fracture lines to be recog-
Diagnosis nized and subsequent optimal treatment of the fracture
(Figure 29.3). Nuclear scintigraphy may be particularly
The diagnosis of a complete fracture is not difficult: the useful to diagnose incomplete stress fractures.15
limb is usually carried in a non‐weight‐bearing stance. In foals, fractures of the radius occur most frequently
Loading of the limb is impossible because of the instabil- as transverse or short oblique fractures in the mid‐dia-
ity and pain associated with movement. Swelling is usu- physeal region (Figure 29.4).36 Nevertheless, fractures of
ally present and crepitation may be elicited during the proximal or distal metaphyseal, physeal, epiphyseal,
careful manipulation of the fractured bone. The defini- or articular regions have also been described.24,26 Rarely,
tive diagnosis is made by radiography of the limb. Several fractures of the radius in foals are multifragmentary. The
views are usually necessary to evaluate the configuration distal metaphysis is involved most often in adult horses,
and extent of the fracture. In selected cases, stress views followed by the mid‐diaphyseal and proximal metaphy-
may help establish the diagnosis (Figure 29.1). The deci- seal regions.26 Radial fractures in adults are frequently
sion to treat the fracture or destroy the horse for humane multiple or comminuted because of the momentum of
reasons should only be made after careful study of good‐ the horses at the time of the fracture.
quality radiographs and after a thorough evaluation of
the entire horse. The treatment options, prognosis, and
costs should be discussed with the owner in detail, prior Preoperative Assessment
to making a decision for surgery.
Incomplete fractures of the radius are often a challenge There are few reports of successful repair of radius frac-
to diagnose. Most horses are acutely lame, but bear some tures in adult horses,1,4,5,14,16,19,24,32 and the prognosis in
weight on the injured limb. Minimal swelling may be pre- adults is generally unfavorable. However, the configura-
sent and the limb is usually stable. One of the few signs tion of the fracture is particularly important in determin-
evident during the physical examination may be a skin ing the possibility of repair. An ex vivo study mimicking
lesion from a kick by another horse.7,30 Also, the region kicking injuries on intact radii and tibiae revealed that
may be sensitive to pressure and palpation. Radiography 59% developed a complete fracture, 41% formed a fissure

www.ajlobby.com
(A) (B)
Figure 29.1 Craniocaudal radiographic stress view of a Salter–

Harris type I physeal fracture of the distal radius in a two‐month‐
old foal. The standard craniocaudal view did not clearly depict
the fracture. Figure 29.3 (A) Craniocaudal and (B) lateromedial radiographic
views of the radius of an adult horse with a two‐month history of
severe lameness of unknown origin in the forelimb. The
radiographs reveal considerable endosteal bone‐remodeling
activity and an oblique radiolucent line in the diaphysis (arrows),
representing an old nondisplaced spiral radial fracture in the
healing stage.
fracture, and, in 52% of the complete fractures, a butterfly

fracture was diagnosed.12 The radius is particularly
sensitive to side‐impact loads.22 If anatomic reduction of
the fracture(s) and solid bone‐to‐bone contact cannot be
achieved in an adult, especially in the caudal cortex, the
horse should be humanely destroyed. On the other hand,
the use of locking compression plates (LCPs) in general,
and the 5.5 mm LCP in particular, has provided the equine
surgeon with implants that ensure superior stability and
stiffness,10,31 and in so doing improve the prognosis. The
fracture configurations that are typical to foals are better
suited to internal fixation. Also, the lesser weight and the
weight‐to‐implant ratio favor open reduction and inter-
nal fixation (ORIF) of radius fractures in foals.
Minimal soft tissue coverage over the medial aspect
of the bone frequently predisposes to type I or type II
Figure 29.2 A horse with a fissure fracture is maintained in a
rescue sling. During the initial week the fractured bone was
open fractures, which reduces the prognosis further.
supported in a splint bandage extending up to the proximal end Nevertheless, reports of successful treatment of open
of the olecranon. fractures have appeared in the literature.1,2,16,17
www.ajlobby.com
(A) (B) use of a rescue sling, cross-tying, or external coaptation.

However, complete fractures of the radius often require
more reconstruction and rigid fixation, which includes
transfixation pinning, or most commonly, internal fixation.
The desire of the owners to treat the horse, the fracture
configuration and extent of soft tissue damage, and the
associated cost all influence which treatment is selected.
Incomplete stress fractures are usually managed by stall
rest for two months and limitation of movement through
cross‐tying to prevent the horse from lying down.16,27 If
available, the use of a rescue sling during this period is
encouraged (see Figure 29.2). Occasionally, splint band-
ages, extending to the top of the olecranon, are applied
during the immediate postinjury period. Applying
splints and bandages runs some risk of exacerbating an
incomplete fracture. Cross‐tying and nonsteroidal anti‐
inflammatory agents to control pain are generally the
most suitable treatment methods (Figure 29.6). Repeated
radiographs are used to determine when adequate
healing has developed to allow the horse to be removed
from the cross‐ties. Lameness decreases relatively rap-
idly with stall confinement, and pasture exercise must be
prevented for at least three months. Prior to starting
hand‐walking exercise, follow‐up radiographs should be
taken to determine the progress of fracture healing.
There are two reports in the literature where m
inimally
displaced radial fractures were successfully managed by
conservative treatment with and without Robert Jones
bandages.17,35 In one case of a minimally displaced radial
Figure 29.4 (A) Craniocaudal and (B) lateromedial radiographic fracture managed conservatively, a sequestrum formed,
views of mid‐diaphyseal fracture of the radius in a one‐day‐old which was managed by surgical removal three months
foal. One butterfly fragment is clearly visible. The mare stepped on after the fracture occurred. In another case, the initial
the limb during the post‐partum period. skin wound was opened and drained one week after the
fracture occurred. The wound was flushed several times
Correct preoperative management is important if internal and the bone went on to heal without any additional
fixation is to be attempted.11 Immobilization of the fracture complications.35
(Figure 29.5) and transport to a veterinary clinic equipped
for internal fixation should be expedited.11 If the animal is
shipped to a clinic in a cast or splint bandage, initial radio- External Coaptation/Transfixation Pinning
graphs should be taken through the external coaptation. Application of fiberglass casts, with or without transfixa-
Depending on the findings, the coaptation is subsequently tion pins, may be useful for cases where cost is a deter-
adjusted or changed, or the animal is taken immediately to rent to internal fixation in multifragment fractures of the
surgery. For additional information on first aid and transport distal third of the radius (Figure 29.7). However, frequent
of the equine fracture patient, review Chapter 6. cast changes may rapidly become more expensive than a
“state‐of‐the‐art” initial internal fixation. Insertion of
transfixation pins across the midportion of the radius,
Treatment and incorporation of the protruding pins into a walking
bar and full limb cast, has been used successfully in the
Successful management of incomplete or minimally horse.19 However, a long cast produces a long lever arm
displaced radial fractures can be achieved through con- and, with the transfixation pins in the bone near the
servative treatment, such as stall rest with or without the proximal end of the cast, torsional forces occurring during
www.ajlobby.com
(A) (B)
(C) (D)
Figure 29.5 Complete radius fracture in a middle‐aged horse (A) at presentation with poor stabilization, and (B) after application of a
caudally positioned polyvinylchloride (PVC) splint to the elbow and laterally positioned board to the shoulder. The fracture was
radiographed on presentation (C, D), and the horse euthanized due to the massive swelling and displaced distal diaphyseal fracture.
Source: Images courtesy Dr. Alan J. Nixon.
www.ajlobby.com
(A) (B) (C)
(D) (E)
Figure 29.6 Complete nondisplaced fracture in a 26‐year‐old Arabian horse treated by cross‐tying for four weeks. (A, B) At presentation
two weeks after injury, the craniocaudal and lateral radiographs reveal a complete minimally displaced fracture of the distal metaphyseal
region. (C) Recheck craniocaudal radiograph indicates that callus is beginning to form and the fracture is stable. (D, E) Radiographs
obtained four weeks after beginning cross‐tying show sufficient stable callus to discontinue cross-tying and allow free activity in the stall.
The horse was discharged three days later and healed completely. Source: Images courtesy Dr. Alan Nixon.
www.ajlobby.com
(A) (B)
(C)
Figure 29.7 (A) Craniocaudal (right) and lateromedial (left) radiographic views of a severely comminuted fracture of the distal radius in an
adult mare. The fracture is distracted prior to fiberglass cast application. (B) Follow‐up radiographs at two months reveal collapse of the
fractured bone. The proximal part of the fractured radius has been driven distally, interdigitating with the distal fragments, and distracting
them cranially in a frontal plane. This has resulted in an incongruency of the articular surface. (C) Follow‐up radiographs at 13 months after
the initial injury show the healed fracture. An angular deformity of the bone and severe osteoarthritic changes in the antebrachiocarpal
joint are present.
turning may lead to additional fractures. Additionally, evaluation and may represent a valuable improvement in
pin tract infections can loosen the pins, cause pain, the management of distal radial fractures.
develop into ring sequestra, and may even lead to patho- All transfixation techniques are carried out under
logic fractures. Nevertheless, this type of treatment is general anesthesia, and the reader is referred to the
recommended when other management modalities are respective portions of Chapters 9 and 13 for informa-
not an option. tion on the preparation of the patient and the surgery
A full limb tapered‐sleeve transfixation pin cast (TSTPC) site. Obviously, insertion of transfixation pins should be
withstood significantly higher forces than the traditional performed under aseptic conditions, while keeping heat
full limb transfixation pin cast (TPC) in an ex vivo single generation to a minimum during the preparation of the
load to failure study.9 This device deserves additional hole and pin insertion.
www.ajlobby.com
External Fixators portion is covered by musculature (brachialis and biceps

brachii muscle insertions) in addition to skin, subcuta-
The use of external fixation devices in the treatment of neous tissues, and periosteum.18 However, the approach
radial fractures is generally not encouraged; most of to this bone depends to a greater extent on fracture
these devices are not strong enough to support the loads configuration. Accepted principles of internal fixation of
placed on them. Additionally, the pins have to cross a oblique long bones in horses would indicate that the
relatively broad muscle layer on the lateral aspect of the plate should be placed over the distal tip of the oblique
limb, facilitating the development of pin tract infections. end of the proximal bone shaft, to more effectively pre-
One report of the successful application of such a device vent sliding of the fracture plane during axial weight
has appeared in the literature.37 bearing.2 Therefore, if the distal spike of the proximal
An external ring fixator was successfully applied in bone shaft were located medially, one plate would be
conjunction with a proximal radial osteotomy in an adult applied medially, necessitating a medial approach. This
donkey to correct an angular limb deformity.8 These may provide better fracture rigidity, but less soft tissue to
devices may be suitable for foals, but are not recom- cover the implants during wound closure.
mended in adult full‐sized horses. From a purely biomechanical perspective, the cranio-
An external fixator has been evaluated in vitro for lateral approach is generally preferred, dividing the tis-
repair of distal metaphyseal osteotomy models of radius sues between the extensor carpi radialis and the common
fractures.21 The mechanical characteristics of a solid digital extensor muscles (Figures 29.8).18 After sharply
sidebar external skeletal fixator were superior to a TPC transecting the intermuscular septum between these
and a more standard modular sidebar external skeletal muscles, blunt dissection is used to expose the radius.18
fixator. The solid sidebar external skeletal fixator was In displaced complete fractures, the fragments and the
stiffer and stronger than the TPC in both static and cyclic sharp edges of the bone are easily palpated, and care
axial loading. This type of external fixator may have a must be used to avoid perforation of surgical gloves;
role in distal metaphyseal fractures of the radius, double gloving is encouraged. Usually, a large hematoma
although no clinical application has been described. is present in the fracture region, which should be evacu-
ated as the radius is exposed. In selected non-displaced
Internal Fixation fractures, where stabilization can be provided by cortex
screws placed in lag fashion alone, without the need for
Preoperative preparation of the patient and anesthesia plate fixation, the bone is approached directly over the
follow the same guidelines as those described for the fracture to facilitate implant placement.38 In these cases,
treatment of other long bone fractures. Most patients are minimal lateral dissection is performed.
positioned in lateral recumbency on the surgery table, Wherever possible, the periosteum is left undisturbed
with the injured limb uppermost. In selected cases the along the entire length of the bone. This makes recon-
animal may be placed in dorsal recumbency, facilitating struction of a multifragment fracture more difficult,
fracture repair by two surgical teams working simultane- because the exact location and configuration of each
ously through two surgical approaches, and taking fragment cannot be visually assessed. However, fracture
advantage of an overhead hoist and the horse’s body healing is improved and sequestrum formation may be
weight to distract the fracture during reduction. reduced if there is any local infection. The soft tissues are
Perioperative broad‐spectrum antibiotics are adminis- bluntly separated from the periosteum to facilitate access
tered immediately prior to induction of anesthesia. In for plating of the lateral and cranial aspect of the bone.
prolonged procedures, it is advisable to repeat the antibi-
otic administration every two hours. Reduction
After adequately exposing the bone, reduction of the
Approach to the Bone fracture is achieved either by specific manipulations, or
Viewed from the lateral aspect, the radius has a curved by applying tension to the limb. In severely displaced
shape, with a cranial bowing of the diaphysis. This shape fractures, it is advisable to have an assistant, gloved and
of the bone results in a marked tension‐band side on the prepared for aseptic surgery, apply continuous tension
cranial and craniolateral aspect.27,29 The collagen fibers on the limb. This slowly elongates the contracted mus-
in the cranial cortex are oriented mainly in a longitudinal cles. Alternately, the large fragment distractor may be
direction, resulting in significantly higher ultimate ten- applied to the limb, or tension may be exerted with a
sile strength, compared to the caudal cortex, where the “calf puller” winch attached to a wall of the surgery suite.
collagen fibers are oriented more obliquely.23 On the If the horse has been positioned in dorsal recumbency,
medial aspect of the radius, only the most proximal the limb may be connected to a hoist on the ceiling,
www.ajlobby.com
(A)
Figure 29.9 The radial fracture is reduced and held in reduction with
the help of large pointed reduction forceps. In this configuration
(B) b cortical screws may be applied in lag fashion to stabilize the fracture.
the bone. Once the fragments are aligned, reduction is

a aintained by temporarily applying pointed reduction
m
forceps (Figure 29.9).
Stabilization
The fractured bone is stabilized through the application
of screws placed in lag fashion and plates. Positioning of
the plates is dictated by the fracture configuration. After
reduction, one or two cortex screws (3.5 or 4.5 mm) are
Figure 29.8 Craniolateral approach to the radius. (A) The bone is inserted across the fracture plane(s) using lag technique.
approached between the common digital extensor and the Care is taken to avoid the locations destined for the
extensor carpi radialis muscles. The periosteum (a) can be incised
if desired, elevated from the underlying bone, and reflected with
plates. If this is not possible, the screw can later be incor-
the help of four Hohmann retractors. The oblique diaphyseal porated into the plate or removed. Bone alignment must
fracture is easily recognizable. (B) Cross‐section of the anatomic be maintained during this exchange of the original screw
appearance in the diaphyseal region after the approach. The with another one 4 mm longer. Alternatively, 3.5 mm
periosteum and extensor carpi radialis muscle (b) are reflected cortex screws can be countersunk into the cortex of the
cranially and the rest of the muscles caudally, exposing the radius
along its cranial and lateral aspects.
radius so that the entire screw head is contained within
the bone. This allows the application of a plate directly
over the screw head. In any case, where interfragmentary
extending it gradually to the desired length. Toggling, by screws are applied for preliminary fracture fixation, care
tenting the two main fragments out of the incision to has to be taken to avoid contact of the plate screws with
engage the corresponding aspects of the bone before the initial interfragmentary screws. This is more difficult
slowly straightening the bone, may also reduce the frac- if locking‐head screws are applied in LCPs. Once the
ture. Toggling, however, cannot be accomplished in a fracture is reduced and stabilized with the screws, the
comminuted fracture. In such a case, the main fragments pointed reduction forceps may be removed.
are attached one by one, using cortical screws inserted In most radius fractures in adult horses, two plates are
in lag fashion, to slowly reconstruct the entire length of applied approximately 90° relative to each other. These
www.ajlobby.com
are frequently broad 5.5 mm LCPs, or one LCP and a and, using plate screw technique, a 4.5 or 5.5 mm cortex
dynamic condylar screw (DCS) plate or a broad dynamic screw inserted but not completely tightened. The second
compression plate (DCP). In rare cases, a single plate can plate screw is inserted near the other end of the plate,
be applied in a foal or very small horse. In one case report while maintaining the plate firmly pressed down onto
a cranial plate was successfully used, together with three the bone in the fracture region. This may be done by
surgical cerclage cables, over an oblique fracture in a manual assistance or with the help of a bone‐holding or
Peruvian Paso mare.5 Verbrugge clamp. The plate is pulled toward the fracture
site, placing the first screw in a loaded position within
Dynamic Compression Plate (DCP) and Locking the plate. The correct placement of the plate is confirmed
Compression Plate (LCP) Application and the second screw inserted in the loaded position,
The longest plates that will fit on the bone are selected, using the load guide and plate screw technique. The two
and contoured to the bone surface. Ideally, the cranial screws are subsequently tightened, bringing the fracture
plate should extend from metaphysis to metaphysis, under axial compression. Once compression is achieved,
spanning the entire bone. In foals, care is taken to avoid the reduction forceps can be removed. If necessary, one
engaging the physes and epiphyses, whenever possible additional screw on either side of the fracture line can be
(Figure 29.10). Slight overbending of the plate at the frac- inserted under load. However, prior to completely tight-
ture site is used to provide even compression across the ening these screws, the first screws have to be loosened
entire fracture cross-section. For double plating, the slightly to allow additional compression to be applied.
cranial plate is applied first and held in position by In adult horses, the lateral or medial plate is then
pointed reduction forceps, a push–pull device, or an contoured to fit the shape of the bone and secured
assistant. A plate hole near the end of the plate is selected using several screws inserted in neutral configuration
(Figure 29.11). In small foals, only the cranial plate is nec-
essary (see Figure 29.10). The cobra head DCP can be
useful for metaphyseal fractures in foals, where the
expanded end provides six screws to engage the short
metaphyseal bone end (Figure 29.12). The exceptions to
single plate fixation are metaphyseal and open fractures,
where two plates may be needed for additional stability.
Because of the cranial curvature of the radius, it is impos-
sible to apply a straight plate spanning the entire length
of the medial or lateral aspect of the bone. Either a some-
what shorter plate is selected and applied to the side of
the bone, or a full‐length plate is contoured by twisting
and applied medially or laterally over the distal aspect of
the radius and craniomedial or craniolateral in the proxi-
mal regions of the bone. There is a slightly curved LCP
available in a broad plate configuration (DePuy Synthes,
West Chester, PA, USA) that perfectly fits the lateral or
medial aspect of the radius, respectively (Figure 29.13).
Fracture of the radius through the proximal metaphysis
in adults or separation of the proximal physis in foals can
occur concurrently with ulnar fractures (Figure 29.14).
These mimic the devastating biomechanical derangement
evident in Monteggia fractures of the ulna, where there is
concurrent radiohumeral luxation. In adults, the limited
bone stock in the proximal radius can to some extent be
Figure 29.10 Craniocaudal and lateromedial radiographic views of compensated for by a long plate applied down the caudal
the mid‐diaphysis fracture shown in Figure 29.4. A broad 3.5 mm aspect of the ulna. Traction is required to realign the frac-
16‐hole locking compression plate was applied to the bone using tured radius. There is considerable advantage to dorsal
minimally invasive techniques through a distal incision. The screws recumbency and use of an overhead winch, which then
were inserted through stab incisions. The butterfly fragment was
utilizes the horse’s body weight to assist in reduction
removed because it had lost all periosteal attachments. Verification
of the plate location and screw length was achieved with the help (see Figure 29.14). Two incisions are required, one to apply
of fluoroscopy. The periosteum along the bone was intact and only a plate to the lateral or craniolateral aspect of the radius,
disrupted at the fracture site. and a separate incision for application of the plate to the
www.ajlobby.com
(A) caudal aspect of the ulna. The incisions should be sepa-

rated as far apart as possible and the deeper tissues left
attached to the skin to avoid skin necrosis between the
incisions. The ulna plate is frequently extended onto the
caudal aspect of the radius to provide additional fixation
(see Figure 29.14).
The plate screws should generally be inserted perpen-
dicular to the long axis of the bone. The second plate
should be positioned so that its holes are located between
plate holes of the cranial plate, to avoid contact between
the various screws.2,3 Inadvertent contact between the
drill bit or tap and a screw may result in breakage and
should be avoided. All the remaining screws in both
plates are subsequently inserted. Every screw crossing a
fracture plane is applied in lag technique. Once all the
screws are inserted in both plates, final tightening is per-
formed, alternating between the plates (see Figure 29.11).
(B)
Dynamic Condylar Screw Plate
Metaphyseal fractures of the radius are more difficult to
treat, because the small metaphyseal fragment provides
less bone stock to allow insertion of an adequate number
of implants (screws) for rigid internal fixation. In all such
cases, including foals, double plating is indicated. More
secure fixation may result from the use of the DCS
implant.1 This plate has the same width as the broad DCP,
but is 1 mm thicker and therefore stiffer (see Chapter 8).
The DCS plate is an ideal fixation device for large ani-
mals, partly because of its superior strength compared to
the broad DCP.1 The DCS plate is usually applied to the
lateral or medial aspect, because the craniocaudal width
of the proximal and distal aspect of the radius in a sagittal
plane may be insufficient to accept the smallest available
length of DCS lag screw, measuring 55 mm. Therefore,
this screw needs to be applied in the frontal or transverse
plane. All the instruments and implants needed for
insertion of the DCS lag screw are cannulated to allow
their application over the 2.5 mm guide pin which is
illustrated in Figure 9.6. The guide pin, manufactured
with a trocar point and associated threads, is inserted
through the DCS angled guide placed onto the surface of
the bone. It is vital that the angled drill guide is firmly
seated on the bone surface with all four pointed exten-
sions touching down on the bone. Tilting of the drill
guide would result in faulty angulation of the guide pin
Figure 29.11 Repair of a mid‐shaft fracture of the radius in an adult and subsequent misdirection of the 12.5 mm primary lag
horse. (A) Craniocaudal and oblique radiographic views of the oblique
mid‐shaft radial fracture. Preoperatively, the fracture was stabilized in
screw within the bone, leading to extensive contouring of
a cast with an additional lateral splint extending up to the shoulder. the plate, or exit of the threads of the lag screw on the
(B) The fracture was reduced and initially stabilized with three 3.5 mm cranial or caudal cortex of the metaphysis of the radius,
cortex screws as initial interfragmentary fixation, followed by a cranial which would weaken the repair. The hard equine bone
16‐hole dynamic hip screw plate modified by removal of the hip needs predrilling with a 2.0 or 2.5 mm drill bit inserted
screw barrel (DHS; the plate shaft of the DHS plate measuring
5.8 × 19 mm, the former fetlock arthrodesis plate) and a 17‐hole broad
through the same guide. The 2.5 mm guide pin of known
locking compression plate (LCP) applied laterally. The difference in the length is then inserted along the predrilled hole and
plate length despite the LCP being only one hole longer results from seated firmly in the opposite cortex. Correct placement
the longer combi hole in the LCP compared to the DHS holes. of the guide pin is the most difficult, time‐consuming,
www.ajlobby.com
(A) (B) (C)
(D) (E) (F)
Figure 29.12 A proximal diaphyseal fracture of the radius in a one‐day‐old foal repaired with a single cobra‐head dynamic compression
plate. (A, B) Preoperative radiographs reveal a short oblique fracture through the proximal diaphysis of the right radius. (C, D)
Postoperative radiographs obtained on Day 1 show the repair with a cobra‐head plate applied to the cranial aspect of the radius.
A combination of one 6.5 mm cancellous screw and five 5.5 mm cortex screws provides firm fixation in the proximal metaphysis.
Antibiotic‐laden polymethyl methacrylate (PMMA) beads are inserted lateral to the plate. (E, F) Radiographs obtained six weeks after the
repair show good stability and fracture healing of the radius and ulna. Source: Images courtesy Dr. Alan Nixon.
www.ajlobby.com
At the end of screw insertion, the horizontal bar of the

T‐handle must be aligned parallel to the long axis of the
bone and parallel to future plate location. Only in this
position is it possible to slide the plate barrel along the
T‐handle over the inserted screw shaft and into the bone.
Using the impactor and a mallet, the plate is seated firmly
over the DCS lag screw onto the bone surface. Any mala-
lignment between the plate and bone in that region is
Figure 29.13 A polyurethane model of an equine radius with an managed with plate luting.20 The two distal‐most plate
oblique diaphyseal fracture repaired with a cranially applied 16‐ holes in the DCS plate are round, preventing application
hole broad locking compression plate (LCP) and a laterally applied of axial compression, but allowing cortex or (rarely) can-
16‐hole broad curved LCP. Note that the lateral plate spans the
cellous screws to be inserted. All the remaining plate
entire lateral aspect of the bone, without torque contouring at the
proximal end into a craniolateral position. The curved plate fits the holes in the DCS plate are oriented to load only toward a
lateral aspect of the radius perfectly. fracture adjacent to the 12.5 mm lag screw end of the
plate. If needed, axial compression may be provided by
applying one or two 4.5 or 5.5 mm cortex screws in the
and important step of the entire procedure.1 It is impor- load position, or through the use of the tension device, at
tant to verify its correct placement with an image inten- the proximal end of the plate. Additionally, interfrag-
sifier or with intraoperative radiographs. The measuring mentary compression may be applied by inserting any
device is placed over the guide pin, allowing determina- screw crossing a fracture plane in lag fashion. The
tion of the correct length of the condylar screw needed. remaining screws in both plates are inserted and alter-
The triple reamer, which prepares the 8 mm diameter nately tightened. Again, care is taken to stagger the two
hole for the shaft of the DCS lag screw and the 12.5 mm plates to facilitate screw placement, and to prevent both
hole for the barrel of the DCS plate, and bevels the cortex plates ending at the same level of the bone in the diaphy-
for the barrel–plate junction, is assembled to the desired sis or metaphysis. Generally, one of the plates should
length and placed over the guide pin to contact the sur- span the entire length of the bone (in metaphyseal frac-
face of the bone. During the preparation of the hole, fre- tures). In diaphyseal and oblique fractures, both plates
quent flushing and cleansing of the triple reamer are together (additive) should span the entire length.
carried out to decrease friction and heat production. Plate luting has been advocated to increase the strength
This is especially important during the preparation of of internal fixation.20 The technique of plate luting was
these large defects in hard bone. To facilitate good con- described earlier (Chapter 9). It is still argued that filling
tact of the plate with bone, it may be necessary to remove of the oval plate holes around the screw heads supplies
sharp edges at the bone surface around the prepared hole the greatest portion of the increased stability of luting.34
with an osteotome. If necessary, additional reaming is The benefit of the DCP system, facilitating axial com-
performed. The desired length of the hole should be pression of the fracture by inserting selected screws in a
approximately 5 mm shorter than the length of the guide loaded position, is diminished postoperatively if minor
pin inserted into the bone, to ensure that the guide pin movement of the screw head develops relative to the
stays in position throughout the procedure. plate hole. However, by filling the plate holes around the
After reaming to the desired depth, the hole is tapped screw heads, the plate and screws are united more sol-
using the 12.5 mm tap, guided by the tap sleeve. The idly, supplying additional strength.
metric ruler engraved on the tap indicates the tapping
depth. After flushing of the prepared hole, the precon- Minimally Invasive Approaches
toured DCS plate is slid along the T‐handled introduc- The recent introduction of LCP technology has revolu-
tion device, followed by connection of the selected DCS tionized equine fracture management (see Chapters 8
lag screw to the introduction device. Insertion of the and 10). These implants have almost completely replaced
DCS lag screw is routine. The opposite sides of the screw DCPs. It is also possible to purchase DCS plates manu-
shaft are flat, fitting inside the complementarily shaped factured with combi holes to allow locking‐head screws
plate barrel, which prevents rotation of the screw once it to be inserted across these implants. Because of the
is inserted into the barrel. The plate barrel angle of 95° tapered tip at one end of the LCP, minimally invasive
should not be changed during plate contouring. It is also plate insertion is possible in nondisplaced or minimally
important that the metaphyseal cortex of the bone adja- displaced fractures not involving the articular surfaces
cent to the plate–barrel junction be intact for at least on either end (see Figure 29.10). The plate is contoured
4–5 cm, otherwise the stability of the 12.5 mm screw may with the help of a radiograph of the opposite healthy
be compromised. bone, and introduced through a small incision near the
www.ajlobby.com
(A) (B)
(C) (D) (E)
Figure 29.14 Combined fracture of the proximal radius and ulna shaft in an adult horse repaired with a reverse-machined cobra‐head
dynamic compression plate (DCP) on the radius and a standard 18-hole broad DCP on the ulna. (A, B) preoperative radiographs show a
proximal metaphyseal fracture of the radius and displaced fracture of the ulna shaft. (C) Positioning in dorsal recumbency allows
attachment of chains to the padded distal limb and use of an electric winch to provide axial distraction using the horse’s body weight to
reduce the fracture. (D, E) Repair using a reverse-machined cobra‐head plate over the lateral aspect of the radius combined with a long
DCP on the ulna. Source: Images courtesy Dr. Alan Nixon.
www.ajlobby.com
(A) (B) (A) (B)
Figure 29.15 An oblique radiographic view of a distal metaphyseal

fracture of the caudomedial aspect of the radius, repaired by
means of four 4.5 mm cortex screws applied in lag fashion. (A)
Immediate postoperative radiograph. (B) Follow‐up radiograph
2.5 months postoperatively, showing the healed fracture.
distal end of the radius. Supraperiosteal separation of the

tissues with the help of a tissue spreader facilitates plate
insertion. Once the plate is in the correct location, as Figure 29.16 Craniocaudal postoperative radiographic views of the
verified by palpation and fluoroscopy, the screws are distal radius of the same foal as in Figure 29.1. (A) Immediate
inserted, starting with the ones visibly accessible through postoperative view showing a four‐hole T‐plate applied to the
the small incision. Placing an identical plate over the one medial aspect of the bone, bridging the physis. Two short
cancellous plate screws were inserted in the epiphysis and three
inserted facilitates selecting the correct position for the
cortex screws in the metaphysis. The distal‐most cortex screw was
stab incisions over the combi holes. If two plates are subsequently exchanged for a short cancellous screw. (B) Four‐
applied using minimal invasive technique, it is advisable month follow‐up radiograph showing the healed fracture with the
only to use locking screws to minimize inadvertent screw implants still in place. The medial part of the physis is fused, while
contact and to reduce surgery time. Obviously, the plates the lateral was still open. Minimal varus deviation (overcorrection) is
present. The implants were left in place too long.
have to be placed so that the holes are staggered.
selected cases this cannot be avoided, especially if an

Lag Screw Stabilization
oblique fracture occurs in the metaphysis that involves
As previously mentioned, selected fractures of the distal
the physis or epiphysis. Should the application of screws
metaphysis may be managed with multiple cortex screws
in the physis be required, the screws should be removed
inserted using lag technique (Figure 29.15). The bone is
after two to three weeks. In doing so, the inherent growth
approached either through stab incisions, if the fragment
potential is only minimally impaired, and may be reacti-
is not displaced or only minimally displaced, or through
vated following screw removal. Obviously, potential
a straight incision.
damage to the germinal layers of the growth plate may
lead to the development of permanent deformities.25
Special Procedures in Foals Bridging of the distal growth plate may lead to greater
In young foals with a transverse mid‐diaphyseal fracture, growth disturbances than with the proximal physis,
usually only one plate is applied to the limb (see because of the greater growth potential in that region.
Figure 29.10). A prerequisite, however, is solid bone‐to‐ Physeal fractures often require bridging of the growth
bone contact of the caudal cortex after reduction of the plate if internal fixation is attempted (Figure 29.16).
fracture. The fracture is reduced and one or two cortex Exceptions include selected Salter–Harris type III or IV
screws are inserted in lag fashion across the fracture fractures, which may be amenable to simple screw fixa-
plane. The plate is contoured to fit the shape of the bone tion within the epiphysis.25 However, in one case of a
and applied using routine technique. Care is taken to Salter–Harris type III fracture described in the literature,
avoid placing screws across the physis. However, in a tension band across the physis was applied by a cerclage
www.ajlobby.com
wire in a figure‐eight configuration,13 to counteract the the proximal aspect with the help of some metallic sta-
tension created by the collateral ligament. A small bone ples. Once the horse is standing, the bandage is removed,
plate may be used instead of the cerclage wire. the surgery site washed with a mild antiseptic solution,
In long bone fractures (oblique or spiral) involving part and a sterile bandage applied with or without an addi-
of the growth plate, crossing of the physis by implants tional splint.
(plate, screw, wire) should be avoided if at all possible. If Perioperative antibiotics administered immediately
that is not possible, a minimal numbers of implants should prior to and during the surgery are continued for three to
bridge the physis, and they should be removed two to three five days.3,18 For additional information on antibiotic use,
weeks postoperatively. As mentioned previously, in meta- review Chapter 7.
physeal fractures double plating is indicated, even in foals. The animal is maintained in a box stall and the bandage
changed for the first time three to four days postopera-
Surgical Closure tively. Should fluid accumulation be noticed at the time
Once the implants are in place, the surgical region is thor- of bandage change, the region should be evaluated ultra-
oughly flushed and any bleeding vessels ligated. Insertion sonographically. Aspiration of the accumulated fluid
of a suction drain is discouraged. However, insertion of under aseptic conditions is encouraged to examine the
antibiotic‐impregnated collagen sponges (Syntacoll, Saal, quality of the fluid, taking into consideration that the ani-
Germany) or polymethylmethacrylate (PMMA) beads is mal is under the influence of antimicrobials. Any drains
often beneficial.28 These devices maintain a bacterial installed at the time of surgery should be removed at the
growth‐inhibiting concentration of antibiotics for several time of the first bandage change. Some type of bandage is
days (collagen sponge) or weeks (PMMA), and in so doing maintained for at least two weeks. After removal of the
reduce the incidence of postoperative infections. Closure skin sutures or staples 10–12 days postoperatively, a minimal
of the incision is performed in three to four layers. All lay- bandage may still be necessary. The horse may start to be
ers except the skin are closed using a simple continuous exercised at a walk four to six weeks postoperatively. Prior
pattern of #0 or #1 monofilament absorbable material. to turning the animal out on pasture, fracture healing
The layers include the intermuscular fascia, the antebra- should be assessed by radiographic evaluation—ideally
chial fascia, and the subcutaneous tissues. The skin is two months postoperatively. Fracture healing usually
closed using a simple interrupted pattern of a monofila- occurs within three to five months postoperatively.
ment nonabsorbable suture material. After closure of the
skin, a tight pressure bandage is applied over a nonadher-
ent pad placed over the incision site. The bandage extends Complications
from the foot to the elbow region.
Several complications may develop during the repair of
radius fractures. Poor surgical technique resulting in an
Postoperative Management implant, such as a screw, penetrating a joint may lead to
arthrosis, persistent pain, and decreased range of motion.
Most cases are recovered without a splint, so that the In foals, implants crossing the growth plate usually lead
carpus can flex. Once in the standing position, a splint to the development of an angular deformity (see
can be applied over the bandage if necessary.3 In foals Figure 29.16). Shortening of the bone, possibly resulting
with a distal physeal or metaphyseal fracture, the inter- in an abnormal gait pattern, may represent an additional
nal fixation is occasionally only marginally adequate, and complication. Physeal fractures usually result in consid-
some type of external coaptation should be used to sup- erable damage to the germinal layers of the physis. This
plement the fixation. External coaptation can be applied alone can lead to growth complications.25 Additionally,
prior to recovery, because foals can be assisted during screws placed through the radius of a young foal should
attempts to rise. Splint application is contraindicated in not penetrate the ulna, since with the ulna fixed to the
proximal metaphyseal or physeal fractures, since the radius, continued growth at the proximal aspect of the
external coaptation would end at the level of the fracture, radius results in subluxation and arthrosis of the elbow
resulting in additional leverage on the fixation. region.6,33 Prolonged severe lameness following fracture
If the animal is recovered in a pool, the skin sutures repair may result in overload laminitis of the opposite
are covered with fibrin adhesive or superglue, followed limb. Technical errors, such as applying plates which are
by application of an adhesive around the skin sutures. too short and do not span the entire length of the radius
Next an Ioban drape (3M Company, St. Paul, MN, USA) (Figures 29.17 and 29.18), or stop at the same level, may
is applied around the surgery site, followed by applica- lead to fractures during the recovery or postoperative
tion of an elastic adhesive tape (Copoly, Gräup, Bern, period. Breakdown of the fixation within a few days of
Switzerland). Occasionally the bandage is secured at fracture treatment (see Figure 29.17), or during recovery,
www.ajlobby.com
(A) (B)
Figure 29.17 Radiographs of a diaphyseal radial fracture in a foal treated with two bone plates. (A) A 10‐hole narrow dynamic compression
plate (DCP) was applied to the lateral aspect, and a 7‐hole broad DCP to the cranial aspect of the bone. Note that at least one plate should
have been longer to reach further distally into the metaphysis of the bone. (B) Refracture of the radius at the distal end of the lateral plate
18 days postoperatively. A longer plate would have prevented the refracture.
(A) (B) Figure 29.18 (A) Craniocaudal and (B) lateromedial radiographic
views of the radial fracture shown in Figure 29.11, 12 weeks
postoperatively. All the screws in the proximal fragment through the
cranial plate are broken, and the lateral plate eventually broke as a
result of the cyclic loading. In retrospect, the cranial plate was too
short to withstand the cyclic forces, and a longer plate might have
allowed additional screws to be placed proximally. The fracture was
subsequently replated with a dynamic condylar screw plate and a
locking compression plate.
www.ajlobby.com
is most frequently encountered. It is important to study as ideal as those in the mid‐diaphyseal region, leading to
the postoperative radiographs closely and to recognize a less satisfactory outcome.26,32,36
possible technical errors. Late implant failure due to cyclic In adult horses, a guarded to poor prognosis for heal-
fatigue of the screws or plates is common in adults ing and future soundness has to be given.3,32 The chances
(Figure 29.18), and every effort to use 5.5 mm screws, plates of an adult horse with a complete fracture of the radius
that span the entire shaft of the bone, plate luting when healing and becoming an athlete are quite poor. In adults,
using DCPs, use of the DCS plate, and at least one LCP the only fractures of the radius with a good prognosis for
optimizes the chance of radius fracture repair in adults. survival are the conservatively treated, minimally dis-
Finally, development of osteitis or osteomyelitis as a placed, incomplete fractures. In a recent retrospective
result of fracture treatment is of major concern. The vast study, 12 of 14 horses with incomplete fractures treated
majority of postoperative infections are iatrogenic in conservatively survived to discharge.32 For complete
nature, and eventually result in fixation breakdown, fol- fractures in adults, survival after surgical repair is rela-
lowed by humane destruction of the animal. Therefore, tively poor. In one study, 2 of 9 (22%) adult horses
during surgery, meticulous attention to the maintenance repaired by internal fixation survived.3 In another report
of aseptic technique and application of Halsted’s princi- of 47 cases, no adult horses with repaired radius frac-
ples of good surgical technique are vital.27 tures survived.26 In a more recent study, 8 of 13 surgically
managed adult horses (62%) were euthanized because
of surgical site infection and/or construct failure.32 A
Prognosis further 2 suffered catastrophic fixation failure during
anesthetic recovery, leaving only 3 of 13 (23%) repaired
Internal fixation of radius fractures is associated with radius fractures in adults to survive to discharge from the
various degrees of success. In foals with short oblique clinic. Of these 3 surviving horses, 2 were little more
or transverse fractures of the mid‐diaphyseal region, a than a year old at the time of surgery, and only 1 horse
relatively good prognosis can be given for future sound- was a mature adult. These aspects need to be carefully
ness and suitability for an athletic career.26,36 In a study explained to owners, prior to making the decision for
of radius fractures in 47 horses, 28 were repaired with surgery. However, the recent introduction of locking
internal fixation (22 foals and 6 adults), and 18 of the implants has led to some better results. A recent publica-
22 foals (82%) survived after surgical management.26 tion described use of the LCP alone or in combination in
No adults survived. Involvement of an articular surface 5 horses, of which 3 survived to be discharged from the
or the growth plate may jeopardize this prognosis. hospital.32 A comprehensive study of radius repair with
Additionally, stabilization of metaphyseal fractures is not locking plates has not yet been published.
References
1 Auer, J.A. (1988). Application of the dynamic condylar 7 Derungs, S., Fürst, A., Hässig, M., and Auer, J.A. (2004).
screw (DCS)–dynamic hip screw (DHS) implant system Frequency, consequences and clinical outcome of kick
in the horse. Vet. Comp. Orthop. Traumatol. 1: 18–25. injuries in horses: 256 cases (1992–2000). Wien.
2 Auer, J.A. (2018). Principles in fracture treatment. In: Equine Tierärztl. Monatsschr. 91: 114–119.
Surgery, 5e (ed. J.A. Auer, J.A. Stick, J.M. Kümmerle and 8 Eggleston, R.B., Mueller, P.O., Chambers, J.N., and
T. Prange), 1277–1314. St. Louis, Missouri: Elsevier Saunders. Bentley, A. (2000). Use of an external ring fixator for
3 Auer, J.A. and Watkins, J.P. (1987). Treatment of radial correction of an acquired angular limb deformity in a
fractures in adult horses: an analysis of 15 clinical cases. donkey. J. Am. Vet. Med. Assoc. 217: 1186–1190.
Equine Vet. J. 19: 103–110. Elce, Y.A., Southwood, L.L., Nutt, J.N., and Nunamaker,
9
4 Baxter, G.M., Moore, J.N., and Budsberg, S.C. (1991). D.M. (2006). Ex vivo comparison of a novel tapered‐
Repair of an open radial fracture in an adult horse. J. Am. sleeve and traditional full‐limb transfixation pin cast
Vet. Med. Assoc. 199: 364–367. for distal radial fracture stabilization in the horse. Vet.
5 Bolt, D.M. and Burba, D.J. (2003). Use of a dynamic Comp. Orthop. Traumatol. 19: 93–97.
compression plate and a cable cerclage system for repair 10 Florin, M., Arzdorf, M., Linke, B., and Auer, J.A.
of a fracture of the radius in a horse. J. Am. Vet. Med. (2005). Assessment of stiffness and strength of four
Assoc. 223: 89–92. different implants available for equine fracture
6 Clem, M.F., DeBowes, R.M., Douglass, J.P. et al. (1988). treatment: a study on a 20 degree oblique long bone
The effects of fixation of the ulna to the radius in young fracture model using a bone substitute. Vet. Surg. 34:
foals. Vet. Surg. 17: 338–345. 231–238.
www.ajlobby.com
11 Fürst, A. (2018). Emergency treatment and transport of 25 Rutherford, D.J., Textor, J., and Fretz, P.B. (2007).
equine fracture patients. In: Equine Surgery, 5e (ed. J.A. Surgical management and outcome of a type‐III
Auer, J.A. Stick, J.M. Kümmerle and T. Prange), Salter–Harris fracture of the frontal plane of the distal
1243–1255. St. Louis: Elsevier Saunders. radial physis in a foal. N. Z. Vet. J. 5: 248–252.
12 Fürst, A.E., Oswald, S., Jäggin, S. et al. (2008). Fracture 26 Saunders‐Shamis, M., Bramlage, L.R., and Gabel, A.A.
configurations of the equine radius and tibia after a (1986). Radius fractures in the horse: a retrospective
simulated kick. Vet. Comp. Orthop. Traumatol. 21: 49–58. study of 47 cases. Equine Vet. J. 18: 432–437.
13 Gaines, J.D. and Auer, J.A. (1982). Case report; 27 Schneider, R.K. (1990). Fractures of the radius. In:
treatment of a Salter–Harris type III epiphyseal fracture Current Practice of Equine Surgery (ed. N.A. White II
in a young horse. Compend. Contin. Educ. Pract. Vet. 5: and J.N. Moore), 646–652. Philadelphia: JB Lippincott
102–106. Company.
14 Levine, D.G. and Richardson, D.W. (2007). Clinical use 28 Schneider, R.K., Andrea, R., and Barnes, H.G. (1995).
of the locking compression plate (LCP) in horses: a Use of antibiotic‐impregnated polymethyl methacrylate
retrospective study of 31 cases (2004–2006). Equine for treatment of an open radial fracture in a horse.
Vet. J. 39: 401–406. J. Am. Vet. Med. Assoc. 207: 1454–1457.
15 Mackey, V.S., Trout, D.R., Meagher, D.M., and Hornof, 29 Schneider, R.K., Milne, D.W., Gabel, A.A. et al. (1982).
W.J. (1987). Stress fractures of the humerus, radius, and Multidirectional in vivo strain analysis of the equine
tibia in horses. Clinical features and radiographic and/ radius and tibia during loading with and without cast.
or scintigraphic appearance. Vet. Radiol. 28: 26–31. Am. J. Vet. Res. 43: 1541–1550.
16 Martin, B.B. and Reef, V.B. (1987). Conservative 30 Schroeder, O.E., Aceto, H.W., and Boyle, A.G. (2013).
treatment of a minimally displaced fracture of the A field study of kick injuries to the radius and tibia in
radius in a horse. J. Am. Vet. Med. Assoc. 191: 51 horses (2000–2010). Can. Vet. J. 54: 271–275.
847–848. 31 Sod, G.A., Mitchell, C.F., Hubert, J.D. et al. (2008).
17 Matthews, S., Dart, A.J., Dowling, B.A., and Hodgson, An in vitro biomechanical comparison of locking
D.R. (2002). Conservative management of minimally compression plate fixation and limited‐contact
displaced radial fractures in three horses. Aust. Vet. J. dynamic compression plate fixation of osteotomized
80: 44–47. equine third metacarpal bones. Vet. Surg. 37:
18 Milne, D.W. and Turner, A.S. (1979). Approaches to the 283–288.
radius. In: An Atlas of Surgical Approaches to the Bones 32 Stewart, S., Richardson, D., Boston, R., and Schaer, T.P.
of the Horse (ed. D.W. Milne and A.S. Turner), 98–107. (2015). Risk factors associated with survival to hospital
Philadelphia: WB Saunders Company. discharge of 54 horses with fractures of the radius. Vet.
19 Nemeth, F. and Back, W. (1991). The use of the walking Surg. 44: 1036–1041.
cast to repair fractures in horses and ponies. Equine 33 Stover, S.M. and Rick, M.C. (1985). Ulnar subluxation
Vet. J. 23: 32–36. following repair of a fractured radius in a foal. Vet. Surg.
20 Nunamaker, D.M., Richardson, D.W., and Butterweck, 14: 27–31.
D.M. (1991). Mechanical and biological effects of plate 34 Turner, A.S., Smith, F.W., Nunamaker, D.M. et al.
luting. J. Orthop. Trauma. 5: 138–145. (1991). Improved plate fixation of unstable fractures
21 Nutt, J.N., Southwood, L.L., Elce, Y.A., and Nunamaker, due to bone cement around the screw heads. Vet. Surg.
D.M. (2010). In vitro comparison of a novel external 20: 349.
fixator and traditional full‐limb transfixation pin cast in 35 van Veen, L. and de Greef, R.J. (2005). Conservative
horses. Vet. Surg. 39: 594–600. treatment of open incomplete radial fracture in an
22 Piskoty, G., Jäggin, S., Michel, S.A. et al. (2012). adult horse. Tijdschr. Diergeneeskd. 130: 375–377.
Resistance of equine tibiae and radii to side impact 36 Watkins, J.P. (2018). Radius and ulna. In: Equine
loads. Equine Vet. J. 44: 714–720. Surgery, 5e (ed. J.A. Auer, J.A. Stick, J.M. Kümmerle
23 Riggs, C.M., Vaughn, L.C., Evans, G.P. et al. (1993). and T. Prange), 1667–1689. St. Louis, Missouri:
Mechanical implications of collagen fibre orientation in Saunders Elsevier.
cortical bone of the equine radius. Anat. Embryol. 187: 37 Wisner, A.B. (1980). Full Kirshner splint repair of a
239–248. fractured radius in a foal. Vet. Med. Small Anim. Clin.
24 Rodgerson, D.H., Wilson, D.A., and Kramer, J. (2001). 75: 1045–1047.
Fracture repair of the distal portion of the radius by use 38 Zamos, D.T., Hunt, R.J., and Allen, D. Jr. (1994). Repair
of a condylar screw implant in an adult horse. J. Am. of fractures of the distal aspect of the radius in two
Vet. Med. Assoc. 15 (218): 1966–1969. horses. Vet. Surg. 23: 172–176.
www.ajlobby.com
545
30
Fractures of the Ulna
Alan J. Nixon1,2
1
2
Incidence Manipulation of the ulna is resented. Occasionally some

crepitus can be elicited, and rarely the fracture is sufficiently
The ulna is one of the more commonly fractured long recent to allow lateral‐medial displacement of the proximal
bones in the horse.10–12,18,19,21,27,37,41,44–46 Horses of any age ulna. When swelling is marked, fractures of the ulna need
and size can be affected. Most ulna fractures are the result to be differentiated from fractures of the distal humerus,
of external trauma from a kick or a sudden fall. External fractures of the proximal radius, and sepsis of the elbow
skin abrasions over the elbow can be seen on some horses, or its component bones. Fractures of the ulna can also
and occasionally the fracture is comminuted and p enetrates occur in combination with other injuries in foals, the most
the skin. In foals, the fractures often involve the apophy- frequent being disruption of the proximal growth plate of
seal attachment of the triceps muscle, and considerable the radius.36 Rarely, adults can develop radiohumeral
fracture fragment distraction occurs, with loss of the tri- luxation in combination with fracture of the ulna,2,26,43 or
ceps action. In older horses, loss of continuity in the triceps fracture of both the ulna and the radius.2,3,9,12,19,20
apparatus strain path still occurs; however, periarticular In foals, fracture and distraction of the olecranon
joint capsule, ligament, and tendon attachments reduce apophysis are frequent. Involvement of the body of the
the distance that fracture fragments are distracted. The olecranon, usually entering the elbow joint, predomi-
ulna is an integral component of the extensor mechanism nates in weanlings and yearlings. Adults sustain all types
of the elbow, but carries proportionally less direct weight of fracture configurations, depending on the type, loca-
in the stance phase than the radius and humerus.1,11,44 tion, and magnitude of impact.
Because of the ulna’s role in the tensile strain path, treat- The clinical signs and symptoms are strongly indica-
ment by tension band wires,28 or plates and screws,16,19 is tive of fractures of the ulna. The primary differential
often adequate to stabilize and compress fracture disrup- diagnosis is injury to the radial nerve, resulting in
tion. The outcome is generally good.10,18,19,41,42 identical loss of triceps muscle action.36,44 While most
injuries to the radial nerve do not have significant
swelling around the elbow, trauma to the humerus and
Diagnosis triceps region can result in swelling which gravitates
to the elbow, as well as radial nerve dysfunction.
Most horses demonstrate acute and severe lameness. Radiographs confirm the fracture, obviating the need
Swelling is frequently evident, and centers on the caudal for electrodiagnostics to assess radial nerve function.
elbow and triceps muscle mass. The extent of swelling and The configuration, complexity, and level of ulnar
lameness is generally an indicator of the magnitude of the fracture evident on radiographs dictate the optimal
original trauma and the complexity of the fracture. With treatment and associated prognosis.
disruption of the triceps attachment, the elbow is dropped, Ulnar fractures have been classified using various
and the carpus and fetlock flexed (Figure 30.1). Less com- anatomic schemes (Figure 30.2).10,12,44,46 Most can be
plex and more distal fractures do not disrupt the triceps differentiated into complete displaced or nondisplaced
strain path and these horses are usually less lame, with fractures, involving the epiphysis (types Ia and Ib), the
only moderate swelling and better elbow function.11,36,44 body of the olecranon (proximal to the level of the

www.ajlobby.com
mass (Figure 30.3).44 Some of these injuries result from

direct‐impact trauma; however, tensile overload from
sudden falls, bucking, and even galloping with the mare
can result in distraction of the insertion of the triceps
apparatus. In weanlings and yearlings, additional por-
tions of the metaphysis often fracture along with the epi-
physis (type Ib; Salter–Harris type II).11,12 These fractures
usually result from impact trauma (Figure 30.4).
Surgical Repair of Type Ia Apophyseal

Separation Fractures
Surgical repair of apophyseal separations is more diffi-
cult than for fractures involving more extensive portions
of the ulna. The apophysis is small and carries the entire
triceps load. As such, internal fixation is always indi-
cated, but not always successful. Attempts to reattach the
fragment with pins or screws and tension band wires are
well described in the literature.2,5,28,32,36 However, these
techniques weaken the epiphysis and it can disintegrate
around the implants, resulting in bony fragments of
insufficient size to reattach (Figure 30.5).
To overcome such catastrophic failure, the initial repair
should provide more widespread fixation. Single and
double hook plates (DePuy Synthes, West Chester, PA,
USA) have been used in the past, but are no longer avail-
able.34 An alternative is a markedly contoured 4.5 mm
narrow dynamic compression plate (DCP) to provide
counteracting fixation by wrapping over the epiphysis
from the caudal ulnar cortex (Figure 30.6). The tendinous
Figure 30.1 A two‐year‐old horse showing the characteristic
dropped elbow and flexed carpus stance following fracture of the insertion of the triceps is gently divided to allow the plate
olecranon and loss of triceps muscle action. to be seated onto the epiphyseal cortical bone. Cancellous
screws are used in the soft proximal bone in foals,
radiohumeral articulation; types II–IV), or fractures of although 5.5 or 4.5 mm cortical screws are adequate in
the shaft of the ulna distal to the level of the elbow joint older weanlings and for the distal plate fixation. The
(type V). Frequently, a fracture of the ulna will occur olecranon physis is completely bridged and often closes
distal to the level of the radiohumeral articulation and prematurely, owing to either the initial injury or the fixa-
angle proximally to enter the elbow joint. In adults, tion methods. Fracture healing is rapid, and most
type II and V fractures can develop comminution implants can be removed 8–10 weeks after the repair.
either at initial injury or later, to become type IV frac- Although implant removal in foals and weanlings is not
tures of the shaft of the ulna up to and including the essential, it is preferred, to allow transmission of the
olecranon as it forms its articulation with the humerus. normal biomechanical forces to the developing olecra-
non.6,11,36,44 Closure of the proximal ulnar physis in
horses has not been shown to have a deleterious effect on
the biomechanical function of the triceps lever arm.
Fracture Types
and Management
Surgical Repair of Type Ib Apophyseal/
Apophyseal and Epiphyseal Metaphyseal Fractures
The type Ib olecranon fracture in horses is a Salter–
Fractures (Type Ia and Ib) Harris type II fracture, which generally includes a cranial
Foals younger than three months old are predisposed to metaphyseal fragment extending into the elbow joint
separation of the tension physis (apophysis) of the olec- (see Figure 30.4). Less frequently, the metaphyseal frag-
ranon (type Ia), resulting in distraction of the triceps ment is shorter and does not include the anconeal pro-
attachment and bony epiphysis into the triceps muscle cess. The disruption to the triceps apparatus is clinically
www.ajlobby.com
Type Ia Type Ib Type II
Type III Type IV Type V
Figure 30.2 Classification scheme for ulna fractures in horses.
apparent, and fracture distraction, while not as marked risk of extending the glide hole beyond the fracture plane
as in type Ia fractures, still results in marked elbow joint and reducing or eliminating screw thread purchase in
incongruity, pain, and eventual degenerative joint dis- the metaphyseal fragment. A partially threaded 6.5 mm
ease. The metaphyseal fragment provides bone stock for cancellous screw can be used as a salvage screw, or can
a more secure plate fixation than that available in simple be applied as part of the planned fixation if appropriate‐
apophyseal separations. However, contouring the plate length cancellous screws are available (see Figure 30.6).
over the proximal olecranon is still necessary, and addi- The older age of these weanlings and yearlings also
tional purchase in the fracture fragment can be obtained provides more secure screw fixation in the dense bone.
by the tips of one or two plate screws placed from the The distal screws in the plate are angled toward the
caudal cortex and extending through the body of the radius, but should not penetrate the radial caudal cortex
olecranon. With care, these can be placed in lag fashion in growing foals (less than 12 months of age; Figure 30.7),
by overdrilling the caudal drill path to make a glide hole, or a functional bridging of the radius and ulna
but without radiographic control there is a considerable will occur.6,39 Plate removal is usually performed after
www.ajlobby.com
Figure 30.3 Radiograph of a two‐month‐old foal with a Salter–

Harris type I distraction fracture of the olecranon apophysis. Figure 30.5 Disintegration of the apophyseal portion of an
olecranon repair following pin and tension band wire fixation.
Figure 30.4 Radiograph of a Salter–Harris type II fracture of the Figure 30.6 Proximal olecranon fracture treated by a contoured
olecranon apophysis, with an extensive portion of attached plate placed over the olecranon tuber, axially dividing but
olecranon metaphysis with entry to the elbow joint. securing the triceps attachment.
www.ajlobby.com
fracture union has been confirmed radiographically.

However, if the ulna is bound to the radius in horses less
than 12 months of age, frequent radiographic assessment
is required to determine when bony healing has advanced
sufficiently that the plate and screws can be removed,
thereby preventing humero‐ulnar subluxation. If the frac-
ture has not healed adequately but elbow subluxation is
developing, only the bridging screws can be removed or
replaced by shorter screws engaging only the ulnar shaft.
Published guidelines suggest avoiding transfixation of the
radius to the ulna in repairs on horses younger than
7–12 months of age.6,39 Nevertheless, late‐maturing horse
breeds between 10 and 14 months of age, with screws
bridging the radius and the ulna, should also be radio-
graphed at regular intervals to avoid serious humero‐ulnar
subluxation. When client compliance is poor and sublux-
ation has developed, plate removal can still be useful, as
some spontaneous correction occurs (Figure 30.8).2,7,11,12,29
Degenerative joint disease is inevitable if the ulnar dis-
placement is marked; the anconeal process of the ulna
impacts and erodes the articular cartilage in the trochlea
of the humerus.6,40 Ulnar osteotomy has been described
to successfully treat elbow subluxation as a consequence
Figure 30.7 Plate fixation of the ulna in a 12‐month‐old horse, of radial‐ulnar synostosis after radius fracture repair in a
with all distal screws engaging only the ulnar shaft, to avoid one‐day‐old foal.24 A similar approach could be utilized
complications of bridging radius‐ulna screws. Source: Image
courtesy Dr. M. P. Brown.
after ulna fracture repair if removing the uniting hardware
was inadequate to correct the subluxation.
(A) (B) (C)
Figure 30.8 Radiographs of a type IV ulna fracture in a seven‐month‐old foal. (A) Preoperative lateromedial radiographs showing
multiple fracture lines entering the elbow joint. (B) Surgical repair with a narrow dynamic compression plate with 4.5 mm cortical
screws and 6.5 mm cancellous screws used to reduce the fracture. Several cortical screws engage the caudal aspect of the radius. (C)
Plate removal six weeks later after the fracture has healed allows the elbow incongruency (arrow) and tilting of the anconeal process
(arrowhead) to recover.
www.ajlobby.com
Fractures of the Anconeal Process radiographs. Removal by arthroscopic access is routine

Concurrent fracture of the anconeal process in immature (Figure 30.10). Arthroscopic removal of other pathology
and adult horses can occur with olecranon and ulna may then be necessary, particularly fractures or osteo-
shaft fractures.22,41 Involvement of the anconeus is often phytes along the cranial perimeter of the radius.
evident on preoperative radiographs, and needs to be
addressed during surgery by removal of the fragment Conservative Therapy of Type Ia and Ib
(Figure 30.9), or targeted lag screw fixation during the Fractures
reconstruction and stabilization using plate repair. Conservative treatment of these Salter–Harris type I
Dissection of the periarticular soft tissues along the lateral and II fractures in foals and weanlings is generally
aspect of the olecranon is used to allow digital palpation unsatisfactory. The fractures are often widely dis-
to help guide cortical or cancellous screws into the anco- tracted, with complete disruption of the triceps inser-
neal process. Rarely, a separate incision can be made over tions. Biomechanical continuity is rarely reestablished
the anconeal process to allow palpation and verification of and contracture deformity of the fractured limb devel-
screw insertion from the caudal aspect of the ulna. Where ops rapidly. Splinting of the limb, using caudally
the anconeus is comminuted or difficult to access, arthro- applied external coaptation, is not as successful as it is
scopic removal can be performed at the completion of the in yearlings and adults with minimally distracted frac-
olecranon plating procedure (see Figure 30.9). The tures. Salter–Harris type II fractures (ulnar type Ib)
removal of anconeal fractures accompanying type Ib frac- entering the elbow joint and not surgically reduced
tures of the olecranon has not had a detrimental effect on lead to varying degrees of degenerative joint disease
long‐term outcome.41 and persistent lameness. Overloading of the opposite
Anconeal fractures without fracture of other regions of forelimb also leads to angular deformity at the carpus
the olecranon have been reported sporadically.17 In and hyperextension of the fetlock. In heavy yearlings,
adults, fragmentation can be both a cause and a conse- there is the risk of laminitis and distal phalangeal rota-
quence of trauma to the elbow joint. Differentiating the tion. The complications of conservative therapy in
initiating traumatic event is often difficult. Lameness is immature horses are sufficiently extensive and life
frequently mild to moderate, compared to more substan- threatening that internal fixation is preferred in the
tial fractures of the ulna, and may require extensive vast majority of cases. Several studies in the literature
lameness examination including nuclear scintigraphy report success rates in the range of 30–33%, following
(Figure 30.10). Identification of the free fragment associ- conservative therapy of Salter–Harris type I and II
ated with the anconeal process can then be defined by olecranon fractures.11,35,46
(A) (B)
Hum
Anc
Figure 30.9 Anconeal fragmentation in an adult. (A) Intraoperative radiographs indicate a separated anconeal process (white arrows), and
an olecranon fragment as a result of incomplete drilling and tapping of the cranial cortex (arrowheads). (B) Arthroscopic removal of the
anconeal fragment (Anc) after separation along the fracture plane (arrows) using a caudoproximal approach to the elbow. Hum, humerus.
www.ajlobby.com
(A) (B)
L Elbow R Elbow
(C) (D) (E)
LHC
MHC
Figure 30.10 Anconeal fragmentation unrelated to more extensive ulnar fractures. (A) Preoperative radiograph showing the chronic
fragmentation of the anconeal process (white arrow) and osteophytes along the cranial aspect of the radius (black arrow). (B) Nuclear
scintigraphy confirms bone reaction at the site of the anconeal fracture. (C) Arthroscopic image showing irregular anconeal fragment
(white arrows). (D) Arthroscopic image in the cranial compartment of the elbow showing multiple osteophytes (arrows), which were
removed. LHC, lateral humeral condyle; MHC, medial humeral condyle. (E) Postoperative radiograph showing residual anconeus after
fracture fragment removal and smooth radius following osteophyte debridement.
Fractures of the Ulna Body (Type II–V fracture is better secured by the joint capsules and
humero‐ulnar ligaments (Figure 30.11).
Fractures) The complexity of the fracture and its level on the ulna
Closure of the proximal ulnar physis is not radiographi- dictate the appropriate treatment. Conservative therapy is
cally complete until 22 months; however, effective recommended only for minimally displaced fractures dis-
growth markedly slows between 15 and 18 months.15,39 tal to the level of the radiohumeral articulation (type V
The diminishing growth plate reduces the incidence of fractures).10,11,44,46 The radioulnar interosseus ligaments
fractures involving the physis (types Ia and Ib), while prevent appreciable fracture distraction, even when the
increasing the proportion of those that involve the center fracture line obviously opens into the joint. However, frac-
of the olecranon and ulna diaphysis (types II–V). ture nonunion can occur, and surgical repair is frequently
Fractures of the ulna in the adult enter the elbow joint indicated if radiographs indicate delayed or nonunion.23 In
more frequently than not and are usually complete and general, all intraarticular fractures of the olecranon should
moderately displaced.10–12,19,21,29,46 Fracture distraction be treated by internal fixation. The type of fixation depends
can occur due to the triceps tensile forces. Fracture sepa- on the size of the horse. Adults require tension band
ration is greater along the caudal cortex of the ulna, plating; foals and weanlings may be treated by combina-
largely because the cranial intraarticular portion of the tions of screws and wires, or tension band wires
www.ajlobby.com
extended to allow appropriate exposure of the fracture. If

a DCP or limited‐contact dynamic compression plate
(LC‐DCP) is being applied, the periosteum is divided
along the caudal ulnar shaft to provide a bony surface for
precise plate contact. Better plate contact may require
smoothing of the ulna in cases in which callus has
formed, but most cases are repaired early enough that
resection of part of the callus is not required.14,44
Application of a locking compression plate (LCP) can
generally be done with periosteum intact. Careful sepa-
ration of the fibers of the triceps attachment may be
required if the fracture is sufficiently proximal to war-
rant contouring the plate over the olecranon tuber.
Midline dissection and minimal abaxial reflection of the
triceps attachments provide a bed for a markedly con-
toured, narrow 4.5 mm LC‐DCP or DCP to be placed
over the proximal fragment (Figure 30.13). In adults,
most intraarticular fractures can be securely repaired
with minimal bending of the plate, and without extend-
ing the proximal portion of the plate over the olecranon
tuber (Figure 30.14).
Fracture reduction is usually accomplished without dif-
ficulty. Realignment of the fractured ulna in a lateral to
medial plane can be more challenging than simple align-
ment in a proximal to distal plane. Recognition of lateral
displacement or malalignment of the olecranon tuber
should be followed by correction and insertion of inde-
pendent cortical screws placed in lag fashion, or the use
of a laterally applied plate. In chronic nonunion fractures,
dissection of the fracture line may be required to remove
portions of the fibrous tissue preventing accurate apposi-
Figure 30.11 Distracted oblique intraarticular fracture of the
olecranon, showing greatest separation of the fracture line on the tion (Figure 30.14). Compression is always applied to the
caudal ulna surface, due to the triceps pull and fulcrum at the initial two screws in the plate, unless the fracture is exten-
articular surface. sively comminuted. Fragmented fractures are likely to
collapse with compression, and should be plated using
neutralization technique and with judicious use of single
alone.5,28,32,36 Heavier immature animals are better treated lag screws in other planes (Figure 30.15). For adults, use
with plating, rather than having the risk of wire failure and of 5.5 mm cortical screws is preferred over 4.5 mm screws.
the need for reoperation.16,44 In immature animals, 6.5 mm cancellous screws occa-
sionally provide better fixation in the soft bone of the
Surgical Technique olecranon, despite published reports of the biomechani-
The surgical approach to the ulna is straightforward and cally equivalent holding power of 6.5 mm cancellous and
has been well described in the literature.30,31,36,44 The 5.5 mm cortical screws in experimental studies per-
horse is positioned in lateral recumbency with the formed on the third metacarpal bones of foals.47
affected limb uppermost. A linear incision is made along Surgical repair of type IV fractures often requires addi-
the caudal midline of the antebrachium, with proximal tional independent cortical screws applied in lag fashion,
deviation craniolateral to the olecranon tuber, to avoid or insertion of plate screws in lag fashion. Fracture frag-
incising the skin directly over the point of the elbow ments forming the articular surface of the ulna must be
(Figure 30.12). The deep antebrachial fascia is incised optimally aligned to minimize osteoarthritis after repair.
and the plane between the ulnaris lateralis and ulnar Intraoperative radiography should be utilized during the
head of the deep digital flexor tendon is divided to expose reconstruction phase to allow better alignment of frac-
the caudal surface of the ulnar shaft. The division ture fragments (Figure 30.16). Use of partially threaded
between the muscles is more distinct distally, and can 6.5 mm cancellous lag screws can provide improvement
then be extended proximally. The plane of dissection is in fracture reduction and stabilization.
www.ajlobby.com
(A)
Humerus
(B)
Deep fascia Skin incision Radius
(C)
Ulnaris lateralis muscle
(D)
Fracture line Ulnar head of deep digital flexor muscle

(F)
Reflected ulnar head

of deep digital flexor
(E)
Divided triceps muscle insertion
Olecranon
Humeral head of deep digital flexor muscle
Figure 30.12 (A–F) Surgical approach for plate application to the ulna.
www.ajlobby.com
Figure 30.15 A plated repair of a simple but oblique fracture in

the sagittal plane. The overriding fragments were compressed by
Figure 30.13 A markedly contoured plate has been used to a single lag screw prior to plate application. Source: Image
secure a proximal ulna fracture in a 10‐year‐old broodmare. courtesy Dr. N. G. Ducharme.
Figure 30.14 A chronic nonunion fracture

(A) (B) in a four‐year‐old horse (A) six weeks after
initial injury. Note the comminuted
fragments forming the ulna (semilunar)
notch. (B) Postoperative radiograph
following surgical debridement and plate
application.
Fracture fixation using an LCP is now generally recom- fracture realignment and compression (Figure 30.17).
mended.18,19 Stability of the repair and resistance to Additional screws inserted into comminuted fragments
cyclic stress make the LCP a common choice. For mini- can be applied using lag screw technique. The remainder
mally comminuted fractures, the LCP has distinct advan- of the screws can be applied as locked screws, to add to
tages. Fracture realignment and initial LCP fixation with the fracture stability. Other than cost, there are few prac-
cortical screws applied through the combi holes provide tical reasons why an LCP should not be utilized for most
www.ajlobby.com
(A) (B)
(C) (D) (E)
Figure 30.16 Comminuted type IV fracture in a middle‐aged adult horse. (A, B) Preoperative radiographs show multiple fracture planes
entering the elbow joint, and lateromedial tilting (arrows indicate direction of displacement) of the proximal aspect of the ulna. (C) Initial
surgical reconstruction does not adequately establish the elbow congruency (arrow). (D) Replacement of the cortical screw with a
partially threaded 6.5 mm cancellous screw has drawn the displaced fragment back into the repair (arrow). (E) Radiograph obtained two
days after surgery indicates good fracture stability and articular surface alignment of the elbow.
ulna repairs. The distal aspect of the plate, however, The use of a tension device applied to the distal aspect of
must be positioned or spiraled to avoid screw penetra- an LC‐DCP or DCP provides considerably more fracture
tion of the lateral aspect of the radius, which can lead to compression than the plate screws alone.33,44 However, for
a catastrophic weakening of the metaphysis or diaphysis treatment of most ulna fractures, other than delayed or
of the radius (Figure 30.18).25 Given the narrow dimen- nonunion repairs, the tension device is unnecessary. Given
sion of the distal ulna shaft, it would be preferable to the lack of direct axial weight bearing placed on the ulna,
insert cortical screws in the distal aspect of the LCP, to use of the broad DCP, tension devices, and plate luting is
take advantage of the flexibility to orient screws more generally unnecessary. The broad 4.5 mm DCP is reserved
medially to penetrate the medullary cavity of the radius for large adults (heavier than 500 kg), and in most circum-
(Figure 30.19).19 stances the LCP is a better choice.
www.ajlobby.com
(A) (B)
Figure 30.17 Use of a locking compression plate (LCP) for type IV fracture reconstruction. (A) Preoperative radiograph indicating
comminuted fracture planes extending into the proximal caudal aspect of the olecranon. (B) Repair with a 9‐hole LCP. The sequence of
screw insertion is numbered. 1 = Initial cortical screw to attach the plate to the bone. 2 = A second cortical screw lagged through the
plate, but also with applied load to compress the fracture. 3 = A third cortical screw placed in lag fashion to compress an additional
fracture line. 4–9 = Locked screws to provide enhanced fracture stability. Note the antibiotic‐laden polymethylmethacrylate (PMMA)
cylinders located around the implant site (arrows).
Provided that fracture reduction is adequate and screw power.11,36,44 The ulnar shaft is markedly attenuated in
placement is secure, adult ulnar fractures can generally this region and the thick radial cortex improves screw
be expected to heal quickly. At least three screws proxi- holding power. Research studies indicate that growth of
mal and four distal to the fracture line provide ideal fixa- the proximal radial physis is slowing at 12 months of age,
tion. The screws must be angled away from the elbow even though perceptible growth does not cease until
joint, and where they are angled toward the joint for after 18 months.39 Nevertheless, on average the equine
fixation, intraoperative radiographic monitoring is radius will grow another 8 mm after the animal is
imperative. The surgical site must be draped to allow 12 months old, which necessitates plate removal in many
insertion of a digital receiver plate or standard radio- yearlings plated with screws that engage the radius. Mild
graphic cassette to allow lateromedial projections. disparity of the humerus and ulna can be tolerated in this
Imaging the proximal aspect of the olecranon may not age group, and some return to congruity occurs follow-
be possible in adults but the important elbow joint sur- ing implant removal (see Figure 30.8). In horses two
faces can be assessed. A craniocaudal radiograph toward years old or older, the ulna and radius can be united
the end of the procedure is also useful to assess ulna rea- without long‐term consequence to the elbow joint.
lignment, and to ensure that the distal screws in the plate The distal extremity of the ulna shaft is located over
repair are not angled excessively laterally. Overcontouring the lateral aspect of the radius. It is vital to apply the plate
of the plate should be avoided in the repair of intraar- in an orientation that will allow screw insertion directed
ticular fractures of the ulna, or the cranial (articular) toward the medullary cavity region of the radius.
surface of the ulna will be distracted (Figure 30.20). This Inadvertent screw insertion into the lateral cortex of the
distraction leads to joint incongruity, poor cartilage gap radius can be catastrophic (see Figure 30.18).25 This can
healing at the articular surface, and increased incidence be avoided by adequate dissection to provide good
of secondary degenerative joint disease, the latter being visualization of the plate over the distal aspect of the
one of the most important reasons for initially selecting radius, or by applying a twist to the distal aspect of
surgical repair. the plate to ensure that screws can be inserted toward
In adults, the distal plate screws are inserted into the the medullary cavity of the radius (see Figure 30.19). This
caudal cortex of the radius for additional holding becomes particularly important when applying an LCP
www.ajlobby.com
(A) (B) (C) (D)
(E)
Figure 30.18 Catastrophic failure associated with inadvertent penetration of the lateral cortex of the radius using locked screws.
(A) Lateral radiograph of the locking compression plate repair of a type IV fracture showing good fracture alignment and stable fixation.
(B) Craniocaudal radiograph showing potential complications with drill (black arrow) and screw (white arrow) insertion into the lateral
cortex of the radius. (C, D) Catastrophic breakdown of the radius through the distal screw holes. The horse was euthanized. (E) macerated
specimen of the ulna and radius showing the screw tract defined by the locked screw insertion into the lateral cortex. Source: Images
courtesy Dr. A. Fuerst.
with fixed‐angle locking screws. Application of cortical placed in a lateral to medial direction, and where there is
screws in the most distal combi holes in the LCP plate, to lateromedial displacement a second plate, could be
allow adequate targeting of the center of the radius, can required to assist in the reconstruction (Figure 30.21).
also be utilized to avoid this complication. Intraoperative Dissection of the soft tissues over the lateral aspect of the
radiographs in a craniocaudal plane can be used to ascer- ulna is required before insertion of a lateral plate. The
tain the position of the most distal screws in the plate. lateral plate may need to be applied prior to the caudal
However, by this time screw insertion into the lateral plate, particularly if there is considerable lateral to medial
cortex has done its damage. Intraoperative radiography malalignment, or the fracture has begun to heal with
during ulna plating is difficult at the best of times, and fibrous tissue resulting in a deviation of the ulna shaft.
lateral to medial radiographs do not reveal the danger of The lateral plate is generally shorter than the caudal
poorly directed screws. plate. Application of the lateral plate has to be planned to
Comminuted fractures (type IV) are reconstructed to avoid anticipated or existing screws in the caudally
reestablish the triceps strain path and to return the con- applied plate. Realigning the fracture and applying sev-
gruency of the articular surface. Additional lag screws eral screws in a lateral plate, followed by application of
www.ajlobby.com
(A) (B)
(C) (D) (E)
Figure 30.19 Comminuted type IV fracture of the ulna repaired with a locking compression plate (LCP) with distal spiral to ensure screw
insertion into the medullary cavity of the radius. (A, B) Radiographs indicate multiple fracture lines entering the elbow joint, with lateromedial
displacement of the olecranon. (C, D) Radiographs taken the day after surgery show application of an LCP with a distal spiral, resulting in locked
screws that have avoided the lateral cortex. On the craniocaudal X‐ray, the third most distal screw touches the endosteal surface of the lateral
cortex (arrow), but avoids cortical penetration. (E) Good healing of the fracture planes four months after surgery. The distal spiral of the plate is
still apparent.
the caudal plate before completing the lateral plate, gen- cranial lateral aspect of the radius is generally necessary
erally result in the most ideal fracture stabilization. (Figure 30.23). The incisions used for the implantation
Concurrent fractures of the ulna and radius can be of two plates need to be widely spaced, and the skin min-
particularly challenging (Figure 30.22).3,19 The mechani- imally reflected from the underlying fascia and muscles,
cal dysfunction resembles Monteggia fractures, where to avoid necrosis of the isthmus of skin between the
there has been ulna fracture and luxation of the radio- incisions (Figure 30.24).
humeral joint.20,43 However, successful repairs have Additional care is required when the fracture frag-
been described in the literature,3,19 and take advan- ments lacerate the skin, creating an open fracture.
tage of the easily accessible caudal aspects of the ulna Staged wound debridement and copious lavage are used
and extension distally onto the caudal aspects of prior to fracture reduction and fixation. Use of antibi-
the radius. An additional plate applied to the lateral or otic laden polymethylmethacrylate (PMMA) beads is
www.ajlobby.com
radiographic assessment is warranted to ensure that

bony union is progressing. Some may open up additional
fracture planes that push these cases toward a type IV
fracture and the need for plate repair (Figure 30.25).
Fractures that have displaced more than 2–3 mm and
also enter into the elbow joint can form a nonunion,
despite the persisting biomechanical integrity of the ulna
structure. These fractures can be surgically repaired,
with debridement of the fracture line and plate applica-
tion (Figure 30.26). Chronic cases will have formed a
pseudoarthrosis, with an extension to the caudal cul‐de‐
sac of the elbow joint, and the fracture line may contain
synovial fluid.
Extremely distal type V fractures of the ulna shaft gen-
erally do not require surgical fixation. The extensive inter-
osseous ligaments and bony fusion of the radius and ulna
limit the chance of fracture displacement. However, dis-
ruption of these attaching structures can allow significant
caudal displacement of the shaft of the ulna, and commu-
nication to the elbow joint (Figure 30.27). Surgical repair
is imperative to return function to the chronically disa-
Figure 30.20 Adult ulna fracture repaired with a narrow dynamic bled triceps apparatus. Exposure of the fracture line
compression plate, overcontoured and distracting the cranial frequently identifies a pseudoarthrosis, with communica-
(intraarticular) portion (arrowheads) of the fracture line.
tion to the elbow joint, and the consequence then is syno-
vial fluid occupying the space between the fracture ends.
always recommended (see Figure 30.17). Lavage of the Extensive debridement of the fracture line and plate appli-
elbow joint is also necessary when the fracture is intraar- cation are warranted. Extension of the plate onto the more
ticular. Once established, osteomyelitis of the ulna is dif- proximal regions of the olecranon may not be necessary
ficult to resolve. However, fracture healing generally (Figure 30.27); however, occult fracture lines may develop
progresses, provided that stabilization is maintained for later, or in some cases fracture through the plate screws,
8–10 weeks. Administration of antibiotics is continued leading to a recommendation for complete coverage of
on a long‐term basis to control infection while the the ulna shaft during implant stabilization.
fracture heals. Excessive wound swelling should be
As in adults, a small percentage of ulnar fractures in
addressed by ultrasonographic examination and careful weanlings and yearlings involve the distal olecranon or
aseptic skin preparation, followed by deep needle aspi- ulnar shaft. These fractures generally heal quickly and
ration of fluid pockets for culture and sensitivity. If without long‐term consequence.10–12,44,46 There have been
wound breakdown and discharge occur, culture and sporadic reports of massive fracture distraction following
sensitivity are indicated, followed by insertion of addi- distal ulnar fractures, with a fulcrum around the elbow
tional PMMA beads with appropriate antibiotics. joint.23 These fractures are clearly not candidates for con-
Following fracture union, the plate and screws are servative therapy and respond well to plate fixation.
removed if drainage persists. Generally, fixation failure Following plate fixation, the triceps tendon attachment
by screw loosening develops slowly in infected ulnar is repaired as necessary, the muscle bodies are reapposed,
repairs, and the results are not as devastating as sepsis in and the antebrachial fascia sutured with #1 or #2 synthetic
major axial long bone repairs. The major concern is to absorbable suture. The subcutis and skin are apposed
prevent chronic septic arthritis of the elbow. routinely, and a stent bandage is attached for compression
Minimally displaced fractures of the ulna in adults that of the wound and protection from surface contaminants.
occur distal to the level of the radiohumeral articulation Skin staples are avoided if the elbow is swollen. A suction
(type V), and angle proximally to enter the elbow joint, drain can be placed over the plate if desired; however, suc-
can be allowed to heal with conservative therapy such as tion drains rarely evacuate significant fluid at this site,
stall confinement or splinting. The inherent stability unless there was extensive muscle damage at the time of
provided by the annular ligament of the ulna, the elbow the original injury. An adhesive bandage tape ring can
joint capsule, and the radioulnar interosseous ligaments be applied and sutured to the skin proximal to the elbow,
prevents major distraction of the fracture ends. Repeated to provide a semipermanent attachment for a full limb
www.ajlobby.com
(A) (B) (C) (D)
(E) (F) (G)
(H) (I)
Figure 30.21 Double plate fixation of severely displaced type IV fracture. (A) Lateromedial radiograph indicates severe fracture
comminution, and (B) craniocaudal projection reveals significant axial malalignment of the fractured ulna (arrow). (C) Initial fracture
reduction and alignment were established with a lateral locking compression plate (LCP), followed by a larger LCP to provide the majority
of the stability. (D) Craniocaudal radiograph indicates spiraling of the distal aspect of the caudal LCP to avoid screw penetration of the
lateral cortex of the radius (arrows). (E, F) Different case showing oblique comminution and medial displacement of the proximal aspect of
the ulna. (G) Intraoperative image after placing a lateral dynamic compression plate (DCP) to stabilize the medial displacement, and (H)
after caudal plating to provide tension band stability. (I) Radiograph on Day 7 showing two plate fixation. The second most proximal screw
in the lateral four hole DCP was applied using lag technique to compress the oblique fracture.
www.ajlobby.com
Figure 30.22 Concurrent ulna and radius (A) (B)
fractures (A, B) with complete elbow luxation.
Repair would require fixation of both the
radius and the ulna. The small size of the
proximal radius fragment makes this more of
a Monteggia fracture. The horse was
euthanized.
(A) (B) (C)
Figure 30.23 Radius and ulna fractures in an adult with a larger proximal radius fragment. (A) Preoperative radiographs show severe
displacement of the radius in relation to the elbow joint. (B) Postoperative radiograph showing use of a cobra‐head dynamic compression
plate (DCP) on the radius and an 18‐hole DCP applied to the caudal aspect of the ulna and radius. (C) Normal weight‐bearing stance two
days after repair.
Figure 30.24 Wound‐healing complications (A) (B)

of the two long incisions for repair of both
radius and ulna fractures. (A, B) Seven days
after surgery, skin necrosis has started
adjacent to the ulnar incision. The horse
continued to use the limb normally.
www.ajlobby.com
bandage. Bandaging minimizes swelling at the surgical Postoperative Care

site, as well as minimizing distal limb edema. Coaptation
casting following ulnar repair is contraindicated because Recovery from anesthesia should be supervised, as is the
of the increased stress on the plated bone. case with any horse recovering from a long bone fracture
fixation. Head and tail ropes and assisted recovery are rec-
ommended. However, disruption of this repair is less likely
than it is with other repairs on more weight‐bearing bones.
(A) (B) Manual assistance is provided for most horses, and strug-
gling and premature attempts to stand are controlled by
the administration of xylazine, detomidine, or romifidine.
Perioperative antibiotics are maintained for 72 hours fol-
lowing aseptic repairs on simple fractures. Open fractures
require more extensive and protracted antibiotic regimens.
Of primary concern is the development of infection of the
internal fixation and recalcitrant septic arthritis of the
elbow. Any deterioration in use of the limb following repair
of an intraarticular ulnar fracture, particularly a fracture
that was originally open, should be regarded with suspi-
cion, and repeat radiographs of the repair, followed by
ultrasonographic examination and aspiration of fluid
pockets or centesis of the elbow joint, should be performed
to determine the origin of the increased lameness.
Figure 30.25 A type V ulna fracture, but one that has become Most horses show marked improvement immediately
comminuted five days after the initial diagnosis. (A) The original following fracture fixation. The reestablished triceps
fracture (white arrow) enters the elbow joint, but was minimally mechanism allows active weight bearing on the limb.
displaced and conservative therapy was initially elected. Follow‐
up radiographs revealed an additional fracture line (arrowheads) Analgesia with nonsteroidal anti‐inflammatory agents
that necessitated plate repair. (B) Application of a 10‐hole dynamic such as phenylbutazone (4.4–8.8 mg kg−1, orally) is usu-
compression plate provided good fracture stabilization. ally adequate. The dosage can be reduced in the first
(A) (B) (C)
Figure 30.26 Chronic nonunion of a distracted type V ulna fracture in a pony (A, B), eight weeks after the initial diagnosis. On the
craniocaudal projections, severe lateromedial tilting of the ulna has developed (arrowheads) as a consequence of the distracted fracture
(arrow). (C) Day 7 after stabilization with a locking compression plate using several cortical screws to initially reduce and compress the
fracture, followed by enhanced rigidity using several locked screws. Note the spiral in the distal aspect of the plate to orient the screws
into the radius.
www.ajlobby.com
Figure 30.27 Chronic nonunion and (A) (B)

complete separation of the ulna from the
radius due to disruption of the interosseous
ligaments. (A) Minimal healing has developed
eight weeks following fracture. (B) Stabilization
using a dynamic compression plate and
cortical screws. The four screws in the center
of the plate were applied in lag fashion, with
threads that only engaged the radius.
postoperative week and then eliminated, depending on of radiographic verification of screw length and direction, is
residual lameness. Comminuted fractures may necessi- vital to prevent inadequate fracture reduction, penetration
tate additional analgesia following surgery. of the elbow joint, union of the ulna and radius in young
Ulnar repairs in immature horses heal quickly, with horses, and inadvertent screw insertion into the lateral
apophyseal separations in foals often being united by six aspect of the radius in adult horses. Comminuted fractures
weeks. Increased exercise can be started at that stage, of the ulna represent the most challenging cases to recon-
and implants are removed three months after repair. struct the articular surface of the elbow. Intraoperative
Even though the proximal ulnar physis frequently closes radiographs should be utilized to verify fracture reduction
following screw and wire or plate and screw repair, at and appropriate screw length and position in the bone.
least along some of its width, the tendency has been to Screws that are too long can be replaced at surgery without
remove implants from foals younger than one year of long‐term consequence to the articular surface. Left in
age. Return of some active growth and redistribution of place, excoriation of the humeral condyles is inevitable.
forces within the bone add to the normal periosteal bone Contaminated fracture repair as a consequence of an
growth shaping the olecranon. Any screws spanning the open fracture adds the additional risk of infection of the
ulna and radius in foals younger than one year of age also fixation repair. Addition of PMMA beads laden with ami-
need to be removed, as previously discussed. kacin or gentamicin is routine in ulna fracture plating.
In mature adults, there are few specific indications for Contaminated wounds should be cultured at the conclu-
plate removal, although some plates are removed to sion of the surgical procedure, to provide some informa-
eliminate the chance of later complications.9–12,36,44 Clear tion as to the likely bacterial burden. Substitution of
indications for plate removal include drainage associated aminoglycosides with imipenem or tobramycin to the
with the plate, implant‐induced elbow incongruity, and PMMA may be warranted in extensively contaminated
loose or broken screws. Pain associated with the implant wounds. Incisional dehiscence may provide an opportu-
may become evident in athletes as the result of changes nity for microbial culture and sensitivity, but, impor-
in the biomechanical flexibility of the ulna or reaction of tantly, the insertion of additional PMMA beads containing
the soft tissues surrounding the plate. Increasingly, plates a more appropriate antibiotic. Regional intravenous per-
are being left in adults unless a problem emerges later. fusion is not possible in this more proximal location.
Late‐onset lameness localized to the upper limb also Intraosseous delivery of antibiotics to the elbow region
needs to be differentiated from elbow joint disease, has not been described. Typically, systemic intravenous
which may not be alleviated by plate removal. antibiotics with a combination of cephalosporins and
aminoglycosides is appropriate for the prevention and
treatment of infected ulna fracture repairs.
Complications Fracture through a screw tract in the radius represents
a catastrophic consequence to ulna fracture repair. This
Internal fixation of ulna fractures generally has a lower can occur even when appropriate screw angle in the dis-
complication rate compared to most long bone repairs. tal aspect of the ulna plate has avoided the lateral cortex
However, attention to appropriate screw insertion, and use of the radius. Recovery from anesthesia is the most
www.ajlobby.com
critical time for reinjury. Fracture through the radius While the prognosis for most ulna fractures is fair to
destabilizes the forelimb function, and a choice between good, the outlook after radius fractures should temper
euthanasia and internal fixation of the radius repair must the desire for a surgical attempt to salvage the horse’s life.
be made (Figure 30.28). The additional cost, trauma to
the patient of an extended anesthetic interval, and the
certainty of a more difficult subsequent recovery from
anesthesia influence the decision for radius repair after a Prognosis
postoperative fracture. In general, it may be better to
allow an adult horse several hours to recover from the Ulnar fractures in the horse generally carry a bet-
initial anesthetic before induction and repair of a new ter pro gnosis than other long bone frac-
fracture. The percentage of successful repairs of radius tures.1,4,7,8,10–13,18,19,21,29,36,38,41,42,44 Fractures in young
fractures in adults remains quite low (see Chapter 29). adults seem to be easier to securely repair by plate appli-
cation than those in the very young, in whom lack of
suitable bone stock in the fractured fragments leads to
(A) (B) occasional fixation failure and less than satisfactory
results. Comminuted fractures, especially those in which
the ulnar notch is shattered, are difficult to reconstruct
anatomically, and some degree of degenerative joint dis-
ease is the usual sequela. Nevertheless, this region of the
elbow joint surface is subject to less loading; and many
repairs heal satisfactorily, albeit somewhat slowly. Most
difficulty occurs with fractured portions of the anconeal
process of the ulna, and when these cannot be secured
they are better removed at the time of the initial
surgery.9,41,44
Surgical repair is recommended for most foals with
olecranon fractures. In the study of olecranon fractures
in 24 racebred foals by Janicek et al.,21 the fractured site
included most types of fracture (type I = 5; type II = 3;
(C) (D) type IV = 10; and type V = 6). Of the 24 foals, 22 were
repaired with a DCP, 1 with tension band wire, and 1
with a hook plate. Long‐term follow‐up was available on
22 horses with repaired fractures, and 16 of 22 (73%)
raced at least once.21 Other techniques such as tension
band wiring in combination with pins or screws have
also been successful in foals,28 with 18 of 22 cases healing
a spectrum of fractures, including types I–V.
Surgical repair of foals with type Ib fractures is always
recommended to optimize the chance of an athletic
career. In a study of 24 horses with type Ib fractures,41 20
were treated by plate fixation and the other 4 by euthana-
sia (2) or stall rest (2). Plate repair returned 11 of the 16
(69%) treated horses to complete fracture union and
intended function, and in long‐term follow‐up of 12 of
these 16 horses, 9 of the 12 (75%) were sound and per-
forming at an athletic level. Similar outcome has been
Figure 30.28 Radius fracture as a complication of recovery after
seen in other studies, including 21 of 25 horses surgically
routine ulna fracture repair with a dynamic compression plate repaired,10 where 16 of the 21 (76%) returned to full
(DCP). (A, B) Lateromedial and craniocaudal projections indicate function. Any implant stabilization technique is prefera-
good fracture reduction and no misdirected screws or drill tracts ble to conservative therapy for ulnar fractures of all
that might account for the fracture during assisted recovery. (C, D) types, except type V.46 Only 33% of 43 horses treated
Day 1 after repair of the fractures using a cobra‐head DCP on the
radius, and an 18‐hole DCP applied to the ulna and caudal aspect
conservatively were sound on follow‐up.46
of the radius. The six screws in the expanded portion of the Use of the locking plate system has been reported in
cobra‐head plate all engage the proximal fragment of the radius. two studies of ulnar fracture.18,19 Outcome was similar to
www.ajlobby.com
DCP application (13 of 18; 72% healed) in 18 horses with exacerbation, delayed return to work, and laminitis of
type II or IV fractures.18 In a more recent study of the opposite limb.
18 horses, an LCP was used to repair ulnar fractures in Foals younger than seven months of age must be radio-
15 horses (type Ib = 1; type II = 6; type IV = 3, and type graphed every four weeks following a repair where the
V = 5), or ulna and radius fracture (3 cases).19 Four horses plate screws bridge the ulna and the radius. Although this
had two LCPs applied. All were discharged from the technique is considered undesirable, occasionally the
clinic, and 15 of 18 (83%) went on to heal and enter their strength of the repair requires the addition of the radius to
intended use; 2 of the 3 that did not go on to athletic the screw fixation. Retarded relational movement of the
activity developed unrelated issues that precluded func- ulna in proportion to growth at the proximal radial phy-
tion. These data suggest that the LCP may be superior sis and articular‐epiphyseal cartilage results in humeroul-
for ulnar fracture repair. nar subluxation within eight weeks (see Figure 30.8).6,39
Type V fractures have a good prognosis for return to Removal of the bridging screws at that time will allow
function with plate fixation.42 In one report of 20 horses most of the incongruity to resolve. However, damage to
repaired with internal fixation, 85% returned to athletic the humeral articular surface develops quickly, and degen-
work.42 Additionally, the average time to return to com- erative joint disease can be prevented only by timely pro-
petition after plated repair was 9.5 months. Conservative gress checks and early implant removal. If fracture healing
treatment for minimally displaced fractures also can be is inadequate and elbow subluxation is progressing, selec-
useful, with 8 of 11 horses (73%) in a different study tive removal of the bridging screws should be considered,
considered sound.46 Interval to return to work is leaving only the screws that do not engage the radius.
delayed, however, with a mean time to work of Alternatively, the bridging screws should be replaced by
12 months.42 The decision for surgery should be dic- shorter cortical or cancellous screws. Refracture in horses,
tated by fracture displacement, severity of lameness and particularly yearlings, can occur following premature plate
susceptibility to laminitis, and economics. Conservative removal. Under these circumstances, replating is required,
treatment is less expensive, but carries risk of fracture with additional surgical and convalescence costs.
References
1 Alexander, J. and Rooney, J. (1972). The biomechanics, 8 Crawford, W. and Fretz, P. (1985). Long bone fractures
surgery and prognosis of equine fractures 1967–1971. in large animals: a retrospective study. Vet. Surg. 14:
In: Proceedings of the American Association of 295–302.
Equine Practitioners, vol. 18, 219–236. Lexington, KY: 9 Denny, H. (1976). The surgical treatment of fractures of
AAEP. the olecranon in the horse. Equine Vet. J. 8: 20–25.
2 Arnbjerg, J. (1969). Fracture of ulna in the horse: with 10 Denny, H., Barr, A., and Waterman, A. (1987). Surgical
case reports on three ponies. Nord. Vet. Med. 21: treatment of fractures of the olecranon in the horse: a
389–397. comparative review of 25 cases. Equine Vet. J. 19: 319–325.
3 Auer, J.A., Struchen, C.H., and Weidmann, C.H. (1996). 11 Donecker, J., Bramlage, L., and Gabel, A. (1984).
Surgical management of a foal with a humerus‐radius‐ Retrospective analysis of 29 fractures of the olecranon
ulna fracture. Equine Vet. J. 28: 416–420. process of the equine ulna. J. Am. Vet. Med. Assoc. 185:
4 Bramlage, L. (1983). The status of internal fixation of 183–189.
long bone fractures in the horse. In: Proceedings of the 12 Easley, K., Schneider, J., Guffy, M., and Boero, M.
American Association of Equine Practitioners, vol. 29, (1983). Equine ulnar fractures: a review of twenty five
119–123. Lexington, KY: AAEP. clinical cases. J. Equine Vet. Sci. 3: 5–12.
5 Brown, M. and Norrie, R. (1978). Surgical repair of 13 Embertson, R.M., Bramlage, L.R., and Gabel, A.A.
olecranon fractures in young horses. J. Equine Med. Surg. (1986). Physeal fractures in the horse II. Management
2: 545–550. and outcome. Vet. Surg. 15: 230–236.
6 Clem, M., DeBowes, R., Douglass, J. et al. (1988). The 14 Fretz, P. (1973). Fractured ulna in the horse. Can. Vet. J.
effects of fixation of the ulna to the radius in young foals. 14: 50–53.
Vet. Surg. 17: 338–345. 15 Getty, R. (1975). Sisson and Grossman’s The Anatomy of
7 Colahan, P. and Meagher, D. (1979). Repair of the Domestic Animals, 5e. Philadelphia: Saunders, W.B.
comminuted fractures of the proximal ulna and 16 Hanson, P.D., Hartwig, H., and Markel, M.D. (1997).
olecranon in young horses using tension band plating. Comparison of three methods of ulnar fixation in
Vet. Surg. 8: 105–111. horses. Vet. Surg. 26: 165–171.
www.ajlobby.com
17 Hardy, J., Marcoux, M., and Eisenberg, H. (1986). 32 Monin, T. (1978). Repair of physeal fractures of the
Osteochondrosis‐like lesion of the anconeal process in tuber olecranon in the horse, using a tension band
two horses. J. Am. Vet. Med. Assoc. 189: 802–803. method. J. Am. Vet. Med. Assoc. 172: 287–290.
18 Jackson, M., Kummer, M., Auer, J. et al. (2011). 33 Muller, M.E., Allgower, M., Schneider, R., and
Treatment of type 2 and 4 olecranon fractures with Willenegger, H. (1990). Manual of Internal Fixation,
locking compression plate osteosynthesis in horses: a 3e. New York: Springer‐Verlag.
prospective study (2002–2008). Vet. Comp. Orthop. 34 Murray, R.C., DeBowes, R.M., Gaughan, E.M., and
Traumatol. 24: 57–61. Bramlage, L.R. (1996). Application of a hook plate
19 Jacobs, C.C., Levine, D.G., and Richardson, D.W. for management of equine ulnar fractures. Vet. Surg.
(2017). Use of locking compression plates in ulnar 25: 207–212.
fractures of 18 horses. Vet. Surg. 46: 242–248. 35 Pettersson, V.H. (1981). Die konservative und chirurgische
20 Jalim, S.L., McKinnon, A.O., and Russell, T.M. (2009). versorgung der ulnafraktur. Prakt. Tierarzt. 62: 585–594.
Case report: repair of a type IV Monteggia fracture in a 36 Richardson, D.W. (1990). Ulnar fractures. In: Current
foal. Aust. Vet. J. 87: 463–466. Practice of Equine Surgery (ed. N.A. White and J.N.
21 Janicek, J.C., Rodgerson, D.H., Hunt, R.J. et al. (2006). Moore), 641–646. Philadelphia: J.B. Lippincott Company.
Racing prognosis of horses following surgically repaired 37 Scott, E. (1975). Tension‐band fixation of equine ulnar
olecranon fractures. Can. Vet. J. 47: 241–245. fractures using semitubular plates. In: Proceedings of
22 Jansson, N. (2008). Surgical treatment of an ulnar the American Association of Equine Practitioners, vol.
fracture complicated by anconeal process 21, 167–176. Lexington, KY: AAEP.
fragmentation. Comp. Equine 2008: 144–150. 38 Scott, E.A., Mattoon, J.S., Adams, J.G. et al. (1998).
23 Johnson, J.H. and Butler, H.C. (1971). The tension‐band Surgical repair of bilateral comminuted articular ulnar
principle in fixation of an equine ulnar fracture. Vet. fractures in a seven‐month‐old horse. J. Am. Vet. Med.
Med. 66: 552–556. Assoc. 212: 1380–1382.
24 Klopfenstein Bregger, M.D., Jackson, M.A., Kummer, 39 Smith, B., Auer, J., Taylor, T. et al. (1991). Use of
M. et al. (2012). Ulnar osteotomy for treatment of orthopedic markers for quantitative determination of
cubital subluxation, following locking compression proximal radial and ulnar growth in foals. Am. J. Vet.
plate osteosynthesis of a radius fracture in a foal. Res. 52: 1456–1460.
Equine Vet. Educ. 23: 455–461. 40 Stover, S.M. and Rick, M.C. (1985). Ulnar subluxation
25 Kuemmerle, J.M., Kuhn, K., Bryner, M., and Furst, A.E. following repair of a fractured radius in a foal. Vet. Surg.
(2013). Equine ulnar fracture repair with locking 14: 27–31.
compression plates can be associated with inadvertent 41 Swor, T.M., Watkins, J.P., Bahr, A., and Honnas, C.M.
penetration of the lateral cortex of the radius. Vet. Surg. (2003). Results of plate fixation of type 1b olecranon
42: 790–794. fractures in 24 horses. Equine Vet. J. 35: 670–675.
26 Levine, S. and Meagher, D. (1980). Repair of an ulnar 42 Swor, T.M., Watkins, J.R., Bahr, A. et al. (2006). Results
fracture with radial luxation in a horse. Vet. Surg. 9: of plate fixation of type 5 olecranon fractures in 20
58–60. horses. Equine Vet. J. 38: 30–34.
27 Lyall, M., Lyall, W., Traphagen, D., and Weaver, W. 43 Trostle, S.S., Peavey, C.L., King, D.S., and Hartmann,
(1971). Repair of a fractured equine ulna by F.A. (2001). Treatment of methicillin‐resistant
means of stainless steel bone plate. Auburn Vet. 27: Staphylococcus epidermidis infection following repair
29–31. of an ulnar fracture and humeroradial joint luxation in
28 Martin, F., Richardson, D.W., Nunamaker, D.M. et al. a horse. J. Am. Vet. Med. Assoc. 218: 554–559.
(1995). Use of tension band wires in horses with 44 Turner, A. (1983). Fractures of the olecranon. Vet. Clin.
fractures of the ulna: 22 cases (1980–1992). J. Am. Vet. North Am. Large Anim. Pract. 5: 275–283.
Med. Assoc. 207: 1085–1089. 45 von Salis, B. (1972). Internal fixation in the horse: Recent
29 McGill, C., Hilbert, B., and Jacobs, K. (1982). Internal advances and possible applications in private practice.
fixation of fractures of the ulna in the horse. Aust. Vet. In: Proceedings of the American Association of Equine
J. 58: 101–104. Practitioners, vol. 18, 193–218. Lexington, KY: AAEP.
30 Milne, D.W. and Turner, A.S. (1979). An Atlas of 46 Wilson, D. and Riedesel, E. (1985). Nonsurgical
Surgical Approaches to the Bones of the Horse, 1e. management of ulnar fractures in the horse: a
Philadelphia: Saunders, W.B. retrospective study of 43 cases. Vet. Surg. 14: 283–286.
31 Milne, D., Turner, A., and Gabel, A. (1976). Surgical 47 Yovich, J.V., Turner, A.S., and Smith, F.W. (1985).
approaches to certain long bones of the horse for Holding power of orthopedic screws in equine third
application of tension band plates. J. Am. Vet. Med. metacarpal and metatarsal bones Part 1. Foal bone. Vet.
Assoc. 168: 48–52. Surg. 14: 221–229.
www.ajlobby.com
567
31
Fractures of the Humerus
Alan J. Nixon1,2 and Jeffrey P. Watkins3
1
2
3
Incidence Diagnosis
Fractures of the humerus most commonly occur in foals Complete disruptive fractures of the humerus result in
and weanlings secondary to falls and other impact injuries, severe lameness, varying from marked to non‐weight‐
and in racing animals as either catastrophic failure during bearing. Nondisplaced fractures of the proximal or
race falls or failure as a result of accumulated stress and midshaft can lead to marked lameness that improves over
microfracture.7,20,22,33,38,43 The increasingly recognized 24 to 48 hours, leaving a persistent but often moderate
importance of stress fractures as a precursor to major (grade II to III) lameness. Fractures of the distal humeral
disruption of the humerus and other long bones may condyles and epicondylar regions are rare in horses, and
explain the apparent high incidence of these breaks during when they do occur the smaller fracture fragments can
race falls.9,17,19,20,22,30,33 In a recent study of Thoroughbred result in marked lameness of short duration, with later
racehorses in Hong Kong, the humerus accounted for lameness resulting from degenerative joint disease of the
almost 50% of the proximal limb fractures.25 A study of elbow.12,31 Rarely, the fracture can result in concurrent
fatal racehorse injuries in California indicated that 83% of sepsis of the elbow, which can confound the diagnosis.28
fatalities were due to musculoskeletal injuries.17 The fore- Complete humeral fractures usually result in crepitation
limbs were involved in 90% of the fatal fracture incidences, and increased motion on manipulation. Moderate to marked
with sesamoids, third metacarpus, and humerus being the swelling is apparent, the horse moves the limb to a limited
most frequently fractured bones, in order. Humeral stress extent, the elbow is dropped, the carpus and fetlock are fre-
fractures predispose to catastrophic fractures of the quently flexed (Figure 31.1), and there is evidence of
humerus.33 Thoroughbred and racing Quarter Horses are increased pain on attempts to manipulate the affected leg. In
mostly involved;30 however, the Standardbred can also heavily muscled horses, movement of the fractured bone
develop stress fracture of the humerus.19 Return from a ends may be reduced, resulting in less crepitation and
lay‐up from race training was strongly associated with a increased weight‐bearing capabilities. The presence of a
risk for catastrophic humeral fracture.9 Given the high fracture and its configuration are confirmed by radiography.
incidence of stress fractures, a cautious return to race Incomplete fractures and stress fractures resulting in
training after any lay‐up seems warranted. lameness can be particularly difficult to diagnose.21,22,33,38
In younger horses, simple biomechanical overloading Lameness and moderate swelling associated with incom-
results in bony disruption. The overall incidence of frac- plete fractures may be adequate to lead to a tentative diag-
tures of the humerus in nonracing horses is low com- nosis. However, stress fractures and nondisplaced
pared with that of other bones, because of the short, proximal fractures may require advanced diagnostic imag-
thick configuration of this bone and the surrounding ing by nuclear scintigraphy (Figure 31.2).21,30 Follow‐up
heavy musculature.22,38 Paddock falls, trapping the leg in radiographs occasionally reveal a small amount of c allus,
a fence or gate, and impact against a fixed object are the particularly along the caudal cortex of the humeral meta-
usual causes of fractures of the humerus. physis (Figure 31.3).

www.ajlobby.com
Figure 31.2 Nuclear scintigram of a three‐year‐old

Thoroughbred racehorse with lameness of four weeks’ duration
due to a nondisplaced proximal fracture of the humerus.
Radiographs obtained 10 days prior to this scintigram showed
no abnormality.
Figure 31.1 A five‐month‐old foal with a short, spiral midshaft
fracture of the humerus, resulting in marked swelling, dropped
elbow, and flexion of the carpus and fetlock.
Complete fractures of the diaphysis in foals, resulting

in a dropped elbow and carpal and fetlock flexion, need
to be differentiated from fractures of the ulna and radial
nerve paresis or paralysis. Radiography establishes any
ulnar involvement; however, diagnostic evaluation of
radial nerve damage is more difficult. Frequently, the
humeral fracture results in some radial nerve dysfunc-
tion, confounding the etiology of the clinical presenta-
tion. Preoperative assessment in these situations requires
electrodiagnostics, usually nerve conduction velocity
evaluation by spinal somatosensory‐evoked potential or
muscle‐evoked potential. There is no autonomous sen-
sory zone for the radial nerve, making peripheral skin
desensitization an unlikely indicator of solitary radial
nerve damage.6 More chronic fractures with secondary
radial nerve damage can be evaluated by electromyogra-
phy of the antebrachial extensor muscles after 14 days.
Return of complete function following concurrent nerve
injury is slow, and permanent residual deficits usually Figure 31.3 Radiograph of a two‐year‐old Thoroughbred
racehorse taken four weeks after sudden onset of lameness. A
remain following severe nerve compression. complete nondisplaced fracture has occurred. A small caudal
Radiography is used to confirm the fracture, define the cortical callus (arrow) has developed to stabilize the nondisplaced
configuration, and eliminate secondary problems such as proximal fracture.
www.ajlobby.com
fractures of the rib, ulna, or supraglenoid tubercle. A slightly humeral head fractures in adults. Horses with stress
oblique medial to lateral projection can be accomplished fractures can be managed with 60 days of stall confine-
with the horse standing, and usually provides the most ment, 60 days of pasture exercise, and repeat radiography
information, particularly if the animal will tolerate cranial to monitor healing before increased athletic activity.22,33
extension of the limb. Foals can often be sedated and Because of the inherent stability provided by the shoul-
restrained in lateral recumbency with the affected limb der girdle formed by the supraspinatus, infraspinatus,
down for medial to lateral projections. A cranial to caudal subscapular, deltoideus, and biceps tendinous insertions
view of the mid and distal humerus provides important and the periarticular capsules of the shoulder, it is
information on all mid‐diaphyseal and distal humeral uncommon for complete proximal humeral fractures to
fractures. Attempts to project the proximal humerus in a become displaced to any extent. Muscle mass and these
craniocaudal view are more difficult, but such projections supporting soft tissues provide adequate stability, reduc-
can provide useful information in adults. General anesthesia ing the need for internal fixation (Figure 31.4).
is necessary for improved craniocaudal projections, and When displacement is more than 2 cm, stability is
may also be necessary to obtain adequate images in painful poor, or a shorter convalescence is desired, internal
fracture cases in both foals and adults. fixation by lag screw fixation or plating is warranted
(Figure 31.5). Conservative treatment can have negative
consequences, particularly where the fracture separates
Fracture Types the intertuberal groove supporting the biceps brachii
and Management muscle (Figure 31.6). Some fractures of the greater tuber-
cle involve only the caudal eminence and can be success-
Humeral fractures can be classified as complete or fully treated by conservative therapy.30,35,42 Others are
incomplete and displaced or nondisplaced. Most more extensive or unstable, leading to more prominent
are complete and moderately displaced. Classified by lameness and the need for stabilization or removal.1,4,26,34
location, they include the following: In a retrospective study of 15 cases with fracture of the
greater tubercle, 10 needed surgery, which involved frag-
1) Proximal humeral head (epiphysis and metaphysis ment removal in 7, open reduction and internal fixation
in foals) in 2, and assessment without fragment removal in one
2) Greater tubercle case.26 Radiographic assessment using a cranioproximal
3) Deltoid tuberosity to craniodistal skyline projection was particularly valua-
4) Mid‐diaphysis ble in establishing the diagnosis and the extent of the
5) Distal metaphysis fracture in the greater tubercle (Figure 31.7). This
6) Distal condyle and epicondyle. information has been useful to decide on the need for
fragment removal or internal fixation (Figure 31.8).
Proximal Humerus and Greater
Surgical Technique
Tubercle Fractures The surgical approach to the proximal humerus is simi-
Proximal fractures can vary from incomplete stress frac- lar for the repair of humeral epiphyseal fractures in
tures in racing animals, to complete mildly displaced foals, proximal shaft fractures in adults, and greater
Figure 31.4 (A) Radiograph of a three‐year‐ (A) (B)

old Thoroughbred racehorse taken four weeks
after a sudden onset of lameness. A complete
nondisplaced fracture has occurred. (B)
Repeat radiographs obtained after 80 days in
a stall indicate that the fracture has healed.
www.ajlobby.com
(A) (B)
(C) (D)
Figure 31.5 Radiographs of a 14‐year‐old stallion at diagnosis, (A) showing a fracture of the greater tubercle with some displacement
(arrows) evident on the lateral projection, and (B) the craniomedial to caudolateral projection showing a more displaced fracture with
involvement of both lateral and middle tubercles. Surgery was declined, and at followup examination five months later (C, D) radiographs
revealed more severe displacement (arrows) with minimal callus formation. The horse remained lame.
tubercle reattachment in horses of all ages. With the of complete fractures of the proximal humerus is
horse positioned in lateral recumbency with the affected achieved by dynamic compression plate (DCP) fixation
limb uppermost, a limited craniolateral approach is on the craniolateral border of the humerus. A narrow
made to the humerus. A 10–15 cm skin incision is made 4.5 mm DCP is applied to the humerus, extending from
from the distal end of the scapula spine, parallel to the the cranial portion of the greater tubercle to the distal
cranial edge of the deltoid muscle, to expose a tissue end of the deltoid tuberosity (Figure 31.9). The sheath of
plane between the brachiocephalic muscle and the del- the biceps tendon should not be opened. Cortical screws
toid muscle border overlying the infraspinatus tendon are used to secure the plate to the humeral head and
attachment on the greater tubercle. Elevation and humeral shaft, similar to plate repair of deltoid tuberos-
retraction of portions of deltoid and brachiocephalic ity fractures described in the next section. Additional
muscles expose the lateral surfaces of the proximal dia- cortical or lag screws can also be utilized to add better
physis of the humerus. Manipulation of the humeral stabilization. Reliable intraoperative radiographs are
shaft is used to align the humeral head. Secure fixation difficult to obtain in the proximal humerus, and careful
www.ajlobby.com
(A) (B)
(C) (D)
Figure 31.6 Ultrasonographic examination of the horse in Figure 31.5, 5 months after the initial diagnosis and treatment by stall rest,
reveals collapse of the biceps brachii tendon into the fracture gap. (A) In the more proximal region, the fracture involves both middle and
lateral eminences of the greater tubercle, with more severe involvement of the lateral portion of the biceps brachii in the distal region of
the fracture (B, C). (D) The bicipital bursa was chronically inflamed, with tenosynovial masses and adhesions (arrow). Fx, fracture; FxGT,
fractured greater tubercle; LL, lateral lobe of the biceps brachii; ML, medial lobe of the biceps brachii.
(A) (B) (C)
Figure 31.7 Fractures of the greater tubercle can be best assessed by skyline radiographs. (A) The lateral projection identifies a fracture of
the greater tubercle, but poorly defines the extent of the fracture. (B) The craniomedial caudolateral projection indicates that the fracture
involved the lateral eminence of the greater tubercle. (C) A cranioproximal to craniodistal skyline projection indicates that only the lateral
portion of the lateral eminence is involved (arrows). Conservative therapy was effective in returning this horse to function. Source:
Radiographs courtesy Dr. Ryland Edwards.
www.ajlobby.com
(A) (B)
(C) (D)
Figure 31.8 Greater tubercle fracture in a standardbred yearling with chronic left forelimb lameness. (A) Lateral projections show only
bony callus (arrows). (B) However, the skyline projection readily identifies a fracture involving the lateral and a portion of the middle
eminence of the greater tubercle (arrows). (C) Transverse and (D) longitudinal ultrasonographic examination identifies the callus over the
middle eminence, and the echolucency (arrow heads) associated with tearing and granulation in the biceps brachii tendon.
measurement of screw length is required to avoid plate wires to counteract the pull of the supraspinatous and
screws exiting the caudal cortex of the humerus and infraspinatus tendons has also been utilized.26 Large
damaging vital neurovascular structures. distracted fractures of the greater tubercle may need
Extensive greater tubercle fractures may need to be to be secured using a DCP with several of the plate
rotated to be seated in the fracture bed.1 Digital manip- screws applied in lag fashion (Figure 31.11), much
ulation caudally is used to verify adequate reduction, like a complete fracture of the proximal aspect of the
and several 5.5 mm cortical or 6.5 mm cancellous screws humerus.
are inserted, using lag technique, through the greater On occasion, greater tubercle fractures can be reposi-
tubercle and proximocaudal portions of the humeral tioned manually, verified by radiography, and secured by
head.26 The screws should be angled distally to engage lag screws placed through stab incisions. The pull of the
the medial cortex of the humeral diaphysis (Figure 31.10). infraspinatus tendon results in greater tubercle displace-
The use of stainless‐steel washers beneath the screw ment in a proximal direction; however, these forces can
heads is recommended, and application of tension band usually be counteracted by screws alone. The majority of
www.ajlobby.com
Figure 31.9 Fracture of the proximal metaphysis of the humerus

repaired by lag screw fixation and application of a dynamic
compression plate. The plate is contoured to wrap over the Figure 31.10 Radiograph following lag screw repair of a displaced
proximal aspect of the greater tubercle. Source: Radiograph greater tubercle fracture in a two‐year‐old racehorse.
courtesy Dr. David Murphy.
Figure 31.11 Severely displaced greater (A) (B)

tubercle fracture involving lateral and middle
eminences in an adult. (A) Preoperative
craniomedial to caudolateral radiograph
indicates the extent of the fracture and the
need for stabilization. (B) Postoperative
radiograph showing application of a tension
band dynamic compression plate secured
with 5.5 mm cortical screws.
greater tubercle fractures are not massively displaced or when a chronic lameness is present.4,26 In one study
intraarticular, and can be managed conservatively by stall describing greater tubercle fracture in 15 horses, 11 cases
rest.26,42 Small chip fractures of the cranial portion of the returned to athletic use, including 9 of the 10 surgically
greater tubercle have also been described, and successful repaired horses.26 This included both of the horses that
management by fragment removal is recommended were repaired by lag screw fixation.
www.ajlobby.com
Deltoid Tuberosity Fractures the cranial approach to the entire diaphyseal shaft,32 and
similar to a published technique.11 A 10–12 cm skin inci-
Fractures specifically involving the deltoid tuberosity are sion is made over the craniolateral aspect of the humerus,
uncommon and generally involve direct impact injury to from the greater tubercle to the level of the mid‐humerus.
the lower region of the shoulder.11,13 More exposed The plane of dissection is continued deeper, dividing the
prominences, such as the supraglenoid or greater tuber- fibers of the brachiocephalic muscle to expose the del-
cles, are more frequently fractured. In one report involv- toid tuberosity. The deltoid tendon insertion is pre-
ing 19 cases, 18 had a wound on the craniolateral aspect served. Cortical (5.5 mm) or cancellous (6.5 mm) screws
of the proximal humerus, and all were believed to have are placed in lag fashion in a cranial to caudodistal direc-
been kicked by another horse.13 The degree of lameness tion, to secure the fracture fragment to the proximal
varied in the published report, with 6 of the 19 being humerus. The screws should engage the trans cortex, but
non‐weight bearing on admission, and the majority (10 the proximal screw must not penetrate the shoulder
of 19; 53%) being lame at a walk. Radiography is essential joint. Two or three screws are generally adequate.
to establish the diagnosis. The cranial 45° medial‐cau- Application of washers beneath the screw head may also
dolateral oblique projection has been described to con- be useful to prevent splitting and distraction of the frac-
sistently identify the fracture.13 In this study, the oblique tured portion of the deltoid tuberosity. Intraoperative
projection identified all fractures, while the standard radiography is recommended. In heavier animals, the
mediolateral view revealed the fracture in only 6 of 19 use of a narrow DCP to provide tension band plating
horses. Ultrasonography has also been useful in confirm- should be considered; however, it must be placed in a
ing the fracture, identifying comminution, and assisting spiral manner to avoid interference with the biceps ten-
in the decision for surgical removal of the fragment don in the intertuberal groove. Similarly, the plate is
rather than conservative therapy. Nuclear scintigraphy applied to the craniolateral aspect of the humerus,
may also be helpful, although not generally required. directly over the deltoid tuberosity and extending proxi-
Fractures of the deltoid tuberosity associated with open mally to end on the greater tubercle. Cortical screws,
wounds can often be treated by wound debridement and many placed in lag fashion, are inserted in a craniolateral
removal of bone fragments in the sedated horse. In a to caudomedial direction. Closure of the brachiocephalic
study of 19 horses, only 3 required general anesthesia for muscle, fascia, and subcutaneous tissues is routine.
treatment.13 Outcome has been good in published cases,
with 13 of 14 horses with follow‐up returning to their
previous use.13 Complications are rare and included
Middle and Distal Diaphyseal
sequestrum formation and sepsis of the shoulder joint, Fractures
both of which resolved with further treatment. The choice of treatment with complete displaced and
Most large fractures of the deltoid tuberosity also nondisplaced fractures depends on the age and size of
include portions of the greater tubercle, and surgical the horse, the degree of comminution, and the intended
repair is warranted to reattach the tendinous insertions use of the horse.3,7,18,22,27,32,36,37,43 There are few case
of the deltoid, brachiocephalic, supraspinatus, and occa- series describing repair of humeral fractures in
sionally infraspinatus muscles, and to reestablish cortical horses.10,32,41,43 Most diaphyseal fractures in horses and
continuity to the bicipital (intertuberal) groove.11 In the foals are short to long oblique spiral fractures, with some
largest published series, most deltoid tuberosity frac- fracture end overriding (Figure 31.12). Comminution is
tures were small, and none required internal fixation.13 usually more extensive with high‐energy fractures in
Involvement of the intertuberal groove was rare. A com- adults.20,22,27 The extensive muscle bulk attached to the
plete set of radiographs, including the cranial 45° lateral humerus results in considerable fracture overriding in
to caudomedial oblique and the cranioproximal to crani- oblique fractures (Figure 31.13).
odistal skyline, is important in defining involvement of Displaced fractures in adults are difficult to treat by
the bicipital bursa and shoulder joint, as well as involve- internal fixation and the principal decision has to be
ment of the greater tubercle or humeral diaphysis, which between euthanasia, extended stall rest, or an attempt at
may signal the need for open reduction and internal fixa- internal fixation. Generally, smaller adults, and younger
tion by lag screw technique or plating. horses less than a year of age, are better treated by open
reduction and double plating. Significant progress has
Surgical Technique also been made in the use of an intramedullary interlock-
Surgical repair can be accomplished by lag screw fixa- ing nail, supplemented by application of a cranial DCP.41
tion, using an approach to the cranial surface of the del- Fractures in foals weighing less than 150 kg may be
toid tuberosity and proximal diaphyseal shaft of the stabilized using internal fixation, with only a single

humerus. The surgical technique is a limited version of broad DCP placed on the cranial cortex (Figure 31.14).
www.ajlobby.com
Figure 31.13 Severely comminuted high‐energy fracture in an

adult with minimal chance of repair using either conservative or
surgical techniques.
Figure 31.12 Radiograph of a typical oblique spiral fracture of the
humerus found in foals and some adults. repaired. To put this in perspective, however, the surgical
repair included application of plates in only 5 of the 13
The oblique fractures frequently spiral from the proxi- surgical fixations. Numerous other methods of fracture
mocaudal cortex to the distocranial cortex, resulting in a stabilization were used, including stacked Steinmann
proximal fracture fragment that rests in the intercondy- pins (Zimmer Biomet, Warsaw, IN, USA), Rush pins,
lar region of the distal humeral fragment, preventing fur- Kuntschner intramedullary nails, lag screws, cerclage
ther overriding. Provided that the radial nerve is not wire, or combinations of several of these. Many of these
entrapped, some of these fractures in foals and adults are implants are now considered obsolete. Conservative
stabilized by the surrounding muscle mass and can heal therapy has also been described in a different publica-
in a relatively functional malunion. tion, where 7 of 10 horses treated nonsurgically healed
In the largest published case series, 17 of the 54 horses the fracture and were able to be ridden.43 The conclusion
with fractures of the humerus were treated conserva- from both these publications was that conservative
tively, and 9 of the 17 (53%) successfully healed the frac- therapy with stall rest was a viable alternative to surgical
ture.10 The mean age of horses treated with stall rest was fixation. Since that time, the cranial approach to the
2.2 years, suggesting that more mature horses may have a humerus, allowing application of longer plates, the intro-
better chance of stabilizing the fracture of the humerus, duction of the interlocking nail, and more recently the
due to the added musculature surrounding the humerus application of the locking compression plate (LCP) to
and the more stable temperament of adult horses. These double plate fixation, has allowed successful surgical
data for conservative therapy compare favorably to inter- repair rates nearing 60%.41 Internal fixation allows even
nal fixation, where only 3 of 13 horses were successfully better success in foals and yearlings.
www.ajlobby.com
DCP or LCP, and is probably the tension band side of this

bone, as it is in small animals. Additionally, a second
plate can be placed on the lateral surface of the bone,
immediately caudal to the prominence of the deltoid
tuberosity, providing rigidity for fracture stabilization in
more mature horses. Preoperative radiographs should be
used to develop a surgical plan for screw placement and
screw length (Figure 31.16).
The cranial surface of the entire shoulder and ante-
brachial region is prepared for surgery. The horse is
positioned in lateral recumbency with the fractured
limb uppermost and supported to be approximately
horizontal (Figure 31.17). The skin incision is made over
the cranial surface of the humerus, extending distally
from the cranial eminence of the greater tubercle to the
cranial border of the radius, over the extensor carpi
radialis muscle. The subcutaneous tissues are divided,
and the superficial branch of the cephalic vein is ligated
and severed. Proximally, the brachiocephalic muscle is
divided parallel to the fibers of its fleshy belly to expose
the deltoid tuberosity. Distally, the brachiocephalic
muscle can be divided from the brachial fascia and
retracted craniomedially. The attachments of the bra-
chiocephalic muscle are severed from the humeral crest.
If a second plate is to be applied laterally, the insertion
of the deltoid muscle is partially or completely severed
from the tuberosity. The biceps brachii on the cranial
surface of the humerus is easily separated and retracted
medially. The brachialis muscle in the musculospiral
groove of the humerus is isolated from the humerus,
Figure 31.14 Comminuted fracture in a 150 kg foal, stabilized
with a single 4.5 mm broad dynamic compression plate applied to
with care taken to avoid the radial nerve adjacent to the
the cranial aspect of the humerus. caudal border of the muscle. The brachialis muscle is
not divided. The origins of the extensor carpi radialis
muscle on the humerus are gently severed; this muscle
Short oblique and transverse fractures that override do is retracted laterally, and the biceps and brachialis
not stabilize well and should be treated by internal fixa- muscles are retracted medially (see Figure 31.17). Large
tion (Figure 31.15). Incomplete fractures of the midshaft self‐retaining retractors are placed. The radial nerve,
are generally treated conservatively with stall rest; exer- coursing with the deep surface of the extensor carpi
cise is increased only when follow‐up radiographs reveal radialis muscle, must be identified and preserved.
that callus formation has been well established. Mature Occasionally, the nerve is entrapped between the frac-
horses may take six to eight months before they can ture ends, and special care is required to retrieve the
return to work. Complete nondisplaced fractures in nerve without creating further crush injury. The bra-
adults are at risk for complete disruption, and the horse chialis muscle is alternately retracted craniomedially or
should be cross‐tied in a standing stall or fixed short on caudolaterally during the placement of implants.
a tie line to prevent the horse lying down for 30 days. The fracture is reduced and aligned using axial traction
applied by a femoral distractor attached to the greater
Surgical Techniques tubercle and distal humeral condyles, or obstetric chains
Open Reduction and Plate Fixation applied to the distal limb and attached to a winch. Fracture
The cranial approach to the humerus provides access to reduction is maintained by separate lag screws, cerclage
most regions of the humeral shaft22,32 and is recom- wires, or bone‐holding forceps, and the cranial 4.5 mm
mended over the lateral approach, which provides expo- broad DCP is contoured and applied (Figure 31.18). The
sure only to the irregular lateral border of the humerus LCP provides a more stable fixation and is preferred for
and the deltoid tuberosity.27,36,37 The flat, smooth, cranial most plate repairs of humeral fractures. Initial stabiliza-
surface of the humerus is ideal for placement of a broad tion using a push–pull device in either end of the cranially
www.ajlobby.com
(A) (B) (C) (D)
Figure 31.15 Comminuted displaced fracture of the humerus in a seven‐month‐old thoroughbred filly. (A) Mediolateral radiographs
indicate severe fracture overriding, and (B) the craniocaudal projection indicates no cortical contact and no ability to bear weight. (C, D)
Repair using two dynamic compression plates (DCPs), with a broad plate applied to the cranial aspect of the humerus and secured with
cortical screws and one 6.5 mm cancellous screw in the proximal metaphyseal region. A narrow DCP has also been applied to the lateral
aspect and secured with a combination of 4.5 mm cortical screws and one 6.5 mm cancellous screw. Note the considerable contouring
of the lateral plate required to fit the irregular lateral surface of the humerus. The distal two screws in the cranial plate are angled
distally to capture the medial epicondyle.
(A) (B)
80.4 mm
73.7 mm
63.2 mm
61.8 mm
48.6 mm
46.2 mm
45.2 mm
42.1 mm
0.0 mm 58.7 mm
53.4 mm
82.1 mm
41.8 mm
Figure 31.16 (A, B) Preoperative planning of screw length and ideal trajectory is important in repair of the humerus. Intraoperative
radiographs are difficult to obtain, and careful measurement and preoperative planning are required to avoid exit of the screws into the
caudal or medial musculature and neurovascular structures.
www.ajlobby.com
Incision
Deltoid muscle
Brachiocephalic muscle
Deltoid tuberosity
Cephalic vein
Extensor carpi radialis muscle

Biceps brachii muscle
Brachialis muscle
Deltoid muscle
Figure 31.17 Cranial approach to the humerus for diaphyseal and some distal humeral fractures. A broad 4.5 mm plate has been applied
to the cranial aspect of the humerus, and a second plate over the lateral surface.
applied LCP also assists in maintenance of fracture reduc- concavity to approximate the cranial metaphyseal and
tion during the initial application of the plate (see epicondylar region of the distal humerus. The distal
Figure 31.18). Where an LCP is being used, the initial screws are directed into the medial epicondyle of the cau-
screws are 5.5 mm cortical screws, to assist in compress- dodistal humerus, to avoid the olecranon fossa.
ing the plate onto the cranial surface of the humerus. Application of a locked screw in the distalmost hole of the
The distal extremity of the cranial plate needs a marked cranial LCP is possible (Figure 31.19), although use of a
www.ajlobby.com
Brachialis muscle Extensor carpi radialis muscle
Fracture
Deltoid tuberosity
Brachialis muscle
Deltoid muscle
Deltoid tuberosity
Extensor carpi radialis muscle

Radial nerve
Brachialis muscle
cortical screw allows better targeting of the medial epi- If the foal is heavier than 150 kg, a second plate is
condyle. Use of 5.5 mm cortical screws is recommended; applied on the lateral aspect of the humerus, immedi-
6.5 mm cancellous screws are also utilized in the soft met- ately caudal to the deltoid tuberosity (see Figures 31.18
aphyseal bone of the proximal humerus, where the trans and 31.19). This plate can be an LCP, or a narrow or
cortex is not engaged. broad 4.5 cm DCP, or a limited‐contact dynamic
www.ajlobby.com
(A) (B)
(C) (D)
Figure 31.18 Intraoperative images during fracture repair of a four‐month‐old Thoroughbred foal. (A) Initial reduction and stabilization are
provided by the large fracture reduction forceps, and a single 3.5 mm cortical screw applied in lag fashion. Distal is to the left. The fracture
line reduction is visible (arrows). (B) A broad locking compression plate (LCP) has been applied to the cranial aspect of the humerus and held
in place with a push–pull device. (C) The distal aspect of the LCP is markedly contoured, and a locking screw is being inserted to engage the
medial epicondyle. (D) Application of the lateral plate. A narrow LCP has been applied and is initially secured using 5.5 mm cortical screws.
Note the star‐drive screwdriver in the screws in the cranial plate to assist in staggering the plate screw placement. (E) The distal locking
screws need to be inserted through separate stab incisions through the lateral triceps musculature. Direct observation of the docking of the
locking drill guide and screws is possible over all but the most distal aspect of the lateral plate. Cortical screws may be used in the most
distal combi screw holes of the lateral plate if necessary; however, locking screws are generally preferred if they can be inserted.
c ompression plate (LC‐DCP), depending on the age and into the appropriate threaded portion of the combi hole.
size of the animal. The lateral plate is generally shorter To facilitate this, locked screws are often applied in the
than the cranial implant and is applied so that the screws central regions of the LCP, where the drill guide can be
alternate with those of the cranial plate (see Figure 31.19). visually aligned with the threaded portion of the plate
Insertion of the distal‐most screws in the lateral plate hole (see Figure 31.18). Direct visualization becomes
may require separate stab incisions in heavily muscled more difficult toward the ends of the LCP, due to the lim-
horses. Use of a laterally applied LCP introduces diffi- ited dissection available through the lateral approach to
culty in inserting the locked drill guides and locking head the humerus. This may not be as relevant in the cranial
screws through the extensive triceps musculature and plate, where there is generally a need to angle the screws
www.ajlobby.com
(A) (B) animals, the plates should extend as far distally on the
humerus as possible, without interfering with elbow
function (Figure 31.20).
Positive suction drains are placed over the cranial plate
and brought out through the pectoral region. Vacuum is
applied by commercial suction devices or a 60 ml syringe.
The brachiocephalic and deltoid muscles are reattached,
the extensor carpi radialis and brachialis muscles are
reapposed, and the brachial fascia, subcutaneous tissue,
and skin are sutured routinely. A stent is usually sutured
over the wound for protection, which is covered with an
adhesive drape for the first 24 hours following surgery
(Figure 31.21). Assisted recovery from anesthesia is man-
datory. Use of head and tail ropes, a recovery sling, tilt
table recovery, or pool recovery, where available, p
rovides
a better chance of the fixation surviving beyond recovery.
(C) (D) Open Reduction and Intramedullary Interlocking

Nail Fixation (Watkins)
Intramedullary fixation has occasionally been recom-
mended for fixation of humeral fractures in foals.7 This
recommendation has stemmed from the inability to effec-
tively stabilize the majority of oblique humeral fractures
using standard plate fixation applied via a lateral approach
to the humerus. The cranial approach improves screw
placement through the frontal‐plane obliquity of these
fractures, and success with this technique has been
reported.32 Success has also been reported using stacked
pin fixation.7 By filling the isthmus of the medulla to its
fullest extent with many intramedullary pins, frictional
forces between the intramedullary implants and the med-
ullary cortical bone of the proximal and distal fragments
are increased (see Chapter 9). Although stacked pin fixa-
tion provides significantly greater rotational stability than a
single intramedullary pin, the fixation functions primarily
as an internal splint, rather than providing rigid stability at
Figure 31.19 Double plating of a short diaphyseal fracture in a the fracture site. In human orthopedics, the shortcomings
310 kg foal. (A, B) Preoperative mediolateral and craniocaudal
radiographs indicate a long oblique comminuted fracture of the
of traditional intramedullary fixation for the management
diaphysis, with an additional longitudinal diaphyseal nondisplaced of complex fractures have, to a large extent, been overcome
fracture extending to the proximal physis. (C, D) Application of two with the use of interlocking designs. By interlocking the
locking compression plates (LCPs) for stable fixation of the fracture. major proximal and distal fracture segments, a static form
The cranial LCP has four 5.5 mm cortical screws applied across the of fixation is developed that resists collapse at the fracture
fracture in lag fashion. The proximal‐most screw had to be a cortical
screw to angle distally and avoid the proximal physis. The lateral
site and is rotationally stable. Furthermore, migration of
plate was secured with four 5.5 mm cortical screws in the the intramedullary implant is not possible when it is inter-
diaphyseal portion, to allow screw angling to avoid the fracture locked with the fractured long bone. Unfortunately, equine
line. The remaining screws were locked. application of the currently available human implants is
not possible because of inadequate dimensions and design.
in the ends of the plate to better engage the metaphyseal Furthermore, the interlocking nails used in humans rely on
regions of the humerus. specialized targeting devices and sophisticated imaging
Plate luting is always recommended where a DCP or techniques for interlocking the distal fragment, and this
LC‐DCP is being utilized. Luting is unnecessary for technology is not readily available or feasible for use in
an LCP. Alternate plate loosening and luting, using equine humeral fracture repair.
methylmethacrylate bone cement, is recommended for An intramedullary interlocking nail (IIN) has been
adult horses. Cancellous bone graft from the tuber designed for use in foals.39,40 The implant was originally
coxae or sternebrae is also usually indicated. In heavier intended for humeral fractures, but it has also found
www.ajlobby.com
(A) (B) (C)
Figure 31.20 Double plating in a 500 kg Warmblood yearling using two broad dynamic compression plates applied with 5.5 mm
screws, bone graft, plate luting, and with the distal screw engaging the medial epicondyle for added stability. (A) The short distal
metaphyseal portion dictates that maximal screw purchase will be required in the distal fragment. (B) Mediolateral radiograph
obtained at the completion of surgery showing the plate application and screw purchase in the medial epicondyle. (C) The oblique
fracture line evident in the craniocaudal postoperative radiographs was secured by angling the screws into the most distal and
medial aspect of the humerus.
(A) (B)
Figure 31.21 Postoperative bandaging in a Thoroughbred weanling repaired with two locking compression plates. (A) A stent
bandage has been secured with umbilical tape, and kept dry by an adhesive plastic drape. (B) A protective stretch reusable support is
then applied.
www.ajlobby.com
application for femoral fractures in foals. Extensive in completed by sharp and blunt dissection of the origin of
vitro and in vivo testing, particularly with respect to the the extensor carpi radialis muscle. The radial nerve should
fixation of humeral fractures, has been accomplished or be identified, and its continuity confirmed. There is little
is ongoing.39,40 The implant system has been previously hope for return to function if the nerve has been tran-
described (see Chapter 9). sected by the fracture fragments. The fascial attachments
A modified lateral approach to the humerus is favored of the radial nerve to the brachialis muscle are left intact
for most fractures.27 The cranial approach as previously and the two manipulated as a unit, using care to avoid
described may also be used, and is particularly useful if a additional trauma to the radial nerve.
plate is applied to the cranial surface of the humerus, to The fracture usually lies deep to the brachialis muscle,
supplement the fixation provided by the interlocking which is often traumatized by the fracture ends. On
nail.32 For the lateral approach, a straight incision is made, occasion, there will be nearly total disruption of the mus-
beginning approximately 4 cm proximal to the greater cle belly, secondary to laceration by sharp fracture frag-
tubercle and extending distally to the level of the caudal ments. Furthermore, the radial nerve may be transected,
aspect of the lateral epicondyle. The incision should lie hence the importance of identifying the intact nerve
directly over the deltoid tuberosity and cranial border of before proceeding with fracture repair. The fracture is
the lateral head of the triceps muscle. The brachiocephalic exposed by retraction of the isolated brachialis muscle.
muscle is incised along the same line in the proximal half Manipulation of the limb and retraction using wide‐blade
of the incision, to expose the craniolateral aspect of the hand‐held retractors will allow exposure of the medullary
greater tubercle and the proximal humeral metaphysis. canal of the distal fracture segment for retrograde ream-
The deltoid muscle insertion on the deltoid tuberosity is ing. The canal is reamed to a diameter of 13 mm.
incised, which exposes the proximal humeral metaphysis Normograde reaming of the proximal fracture seg-
and the proximal aspect of the brachialis muscle. Distally, ment requires access to the humeral fossa. The biceps
dissection between the lateral head of the triceps muscle brachii muscle is retracted medially, after its lateral
superficially and the extensor carpi radialis and brachialis fascial attachments are incised along the craniolateral
muscles allows identification of the distal humerus. aspect of the humerus. Blunt dissection through the
Caution must be exercised as the dissection approaches supraspinatus muscle provides access to the humeral
the caudal border of the brachialis muscle, where the fossa for reaming to a diameter of 13 mm. The fracture is
radial nerve and a venous plexus are located. Exposure of realigned, and a suitably sized interlocking nail is inserted
the cranial aspect of the distal humeral metaphysis is from the humeral fossa opening.
(A) (B) (C)
Figure 31.22 (A) Fractured right humerus in a 140 kg foal. A short oblique configuration with marked displacement and overriding is evident.
(B) Caudal to cranial radiograph taken intraoperatively, showing fracture stabilization with an intramedullary interlocking nail and two cerclage
wires. (C) Medial to lateral radiograph taken postoperatively after fracture stabilization with an interlocking nail and two cerclage wires.
www.ajlobby.com
Interlocking screw positions are determined by fracture

configuration. The external jig, attached to the proximal
end of the nail, is used to accurately drill the holes for
interlocking screw placement. If possible, three interlock-
ing screws are placed in each fracture segment, with mini-
mal distance separating the two screws on either side of
the fracture. If the fracture has significant obliquity, an
interlocking screw is positioned across the fracture in lag
fashion, or some form of cerclage is used (Figure 31.22).
Washers will prevent the heads of the interlocking screws
from penetrating the cortical bone. Care is taken to ensure
that all screws fully engage the opposite (trans) cortex.
Closure begins with reconstruction of the lateral fas-
cial attachments of the biceps muscle to the craniolateral
humerus, followed by closure of the deep fascia and
musculature over the humeral fossa. The insertion of
the deltoid muscle and the origin of the extensor carpi
radialis muscle are reattached, and the fascial planes are
reapposed. Postoperative drainage of the area is not rou-
tine. The incision is protected with a stent bandage,
which is covered with an adhesive drape for the first
24 hours following surgery.
Recovery from anesthesia is assisted. Postoperatively, Figure 31.23 Caudolateral‐craniomedial oblique radiograph of
the patient should be maintained on deep sand bedding the elbow of a horse, showing a 16 mm fracture of the lateral
to ensure secure footing, as well as provide support for condyle (arrow). A routine craniolateral arthroscopic approach
the contralateral foot. The affected limb should be was used for fragment removal.
uppermost as often as possible when the patient is
recumbent, to minimize the possibility of falling on the
repaired limb when the horse attempts to rise. Protected
weight bearing on the repaired limb is encouraged. separation of the medial humeral epicondyle has also
been described in a foal, which remained lame and was
Alternative Fixation Devices eventually euthanized.31 External trauma can result in
Less invasive methods for internal fixation may be appli- skin laceration and intraarticular fractures of the cranial
cable in transverse fractures of the humerus, particularly aspect of the lateral condyle within the elbow joint
in those with some interdigitation of the fracture ends and (Figure 31.23). Fragments from these types of fractures
in those without cortical defects created by comminution. can be removed by arthroscopic means and the contami-
These techniques include fixation with simple intramed- nation and sepsis from the wound treated appropri-
ullary pins, Rush pins, and various small nails.3,7,8,14,22,23,27 ately.29 More extensive fractures of the distal portions of
Intramedullary pins have little capacity to transmit axial the condyle and epicondyle often involve the medial por-
loads and fracture overriding and displacement occur. tion of the humerus, and may need lag screw repair using
Multiple pins reduce the capacity for overriding and rota- the open approaches described for access to the medial
tion, and judicious use of cerclage may also help.23 While regions of the elbow.5 A case report describes internal
normograde intramedullary pinning has achieved satis- fixation of a distal humeral Salter–Harris type II fracture
factory fracture union, the use of the interlocking nail using an ulnar osteotomy approach.2 A single seven‐hole
provides improved fracture stabilization.40 Additionally, broad LCP was used for stabilization of the humerus,
these fractures rarely lend themselves to stable intramed- and the ulnar osteotomy was subsequently repaired
ullary pinning because of their configuration, the pres- with an LCP applied in routine fashion. The fracture
ence of overriding, and the degree of comminution. healed with good cosmetic and functional outcome.
Salter–Harris type IV fractures of the distal humerus are
also rarely encountered (Figure 31.24) and are quite
destabilizing. Internal fixation and euthanasia are the
Distal Condylar and Epicondylar Fractures only two options.
Small fractures of the distal condyles and epicondylar Fractures of the medial or lateral epicondyles of the
region occasionally occur in adults. Apophyseal humerus are infrequently encountered. Most occur
www.ajlobby.com
shoe to the weight‐bearing foot may assist in preventing

(A) (B)
stress‐induced laminitis and third phalanx rotation.
Pentoxifylline with or without acetylpromazine is also
frequently used, in combination with cold therapy, espe-
cially when digital pulses are increased. The best lamini-
tis prevention remains effective pain control in the
fractured limb, which is achieved through rigid, stable
internal fixation, and accelerated bone healing through
preservation of blood supply and the use of bone grafts,
bovine morphogenetic protein, transforming growth
factor‐β, or other fracture‐enhancing biologicals (see
Chapters 11 and 12). Long‐term maintenance of horses
in partial buoyancy flotation tanks has also been
described.15,16,24
Preoperative antibiotics are continued for 7–10 days
after fracture repair, depending on the time of removal
of the suction drain, the type of fracture, the degree of
difficulty in reduction, and the results from culture
of organisms from drainage or wound fluids. Potassium
penicillin or a third‐generation cephalosporin, often
Figure 31.24 Salter–Harris type IV fracture of the distal humerus. combined with an aminoglycoside such as gen-
(A) The craniocaudal radiograph reveals significant fracture
displacement and destabilization of the medial elbow collateral
tamicin or amikacin, are the antibiotics of choice. If a
ligament. (B) The mediolateral projection shows severe caudal seroma develops, antibiotics may be continued beyond
displacement of the shaft of the humerus. Source: Radiographs the initial three days. If drainage from the incision
courtesy Dr. David Murphy. develops, ultrasonographic evaluation is advised,
allowing deep aspiration and bacterial culture to allow
the antibiotics to be changed to target isolated
organisms.
in foals and weanlings. These are non‐destabilizing Exercise is restricted to complete stall confinement
injuries, and most can be expected to heal with conserv- for 60–90 days. The degree of lameness, the age of the
ative therapy. Small fragments from the lateral or medial horse, and the radiographic appearance of the fracture
epicondyles may also be intraarticular, and can be arthro- are used to determine when increased exercise is
scopically removed from the elbow. warranted.
Implant removal is rare when the fracture is repaired
with single or double plates. The most common indi-
Postoperative Care cation for plate removal is chronic drainage associated
with the plates or the fracture. Where fracture union
Assisted recovery from anesthesia is important in foals is complete and drainage is absent, the plates should
and critical in adults following internal fixation of be left in situ. Most implants are extensively sur-
humeral fractures. In the few facilities with buoyancy rounded by bone, especially in foals, and the risks of
recovery systems, the chance of catastrophic implant removal outweigh those involved in leaving the plates
failure is reduced. Diaphyseal fractures in heavier ani- in place. In foals, if a screw in one of the plates engages
mals are at considerable risk. Tranquilization of the the proximal or distal humeral physis, it should be
horse using xylazine or romifidine is frequently needed removed immediately, and replaced by a shorter or
to prevent premature attempts to stand. Systemic anal- better‐directed screw. If the screw is left in place,
gesics such as detomidine, butorphanol, fentanyl, and shortening of the humerus will occur, depending on
morphine are occasionally used in combination with the age of the horse. Removal of only the offending
perioperative phenylbutazone. Manual assistance with screw is occasionally warranted four to six weeks after
three or four people and head and tail ropes is useful, and the initial repair.
firm footing for the horse is imperative. Intramedullary pins often migrate proximally and
Following recovery, many horses are considerably less should be trimmed to prevent laceration of the skin.22
lame, and can be allowed to ambulate around a box stall. When fracture healing is complete, pins that are acces-
Bandage support of the opposite forelimb assists the sus- sible are withdrawn. Fully enclosed intramedullary pins
pensory apparatus. Application of pads and a heart‐bar are left in situ.
www.ajlobby.com
Prognosis by application of two 5.5 mm LCPs spanning the entire

diaphysis, and applied to the cranial and lateral surfaces
Adult horses with stress fractures of the middle and (see Figure 31.19). Concurrent radial nerve neuropraxia is
proximal diaphysis generally heal with time, provided always a concern and remains a high priority in the preop-
that identification precedes major structural failure. erative decision for surgery. Sophisticated electrodiagnos-
Racehorses are removed from active work and stall tics are needed to determine the functional status of this
rested for 60–90 days, followed by small pasture confine- nerve and are rarely available in most fracture centers.
ment for an additional 30–60 days. Follow‐up radio- In foals and yearlings, the chances of a successful repair
graphs, and occasionally nuclear scintigraphy, are needed are quite high, except in those horses with radial nerve
to monitor healing. Most horses return to the previous damage. Double plating using the cranial approach for
level of performance. In one report of humeral stress LCP application is preferred, although the equine inter-
fracture in 39 thoroughbred racehorses, 30 of the 39 locking nails currently under development are a suitable
(77%) healed the fracture and returned to racing.30 It is alternative, particularly when combined with a single
worth noting that the humeral stress fracture recurred in cranially applied LCP or DCP.41 Conservative treatment
6 of these horses. of foals with displaced complete fractures is often com-
Complete diaphyseal disruption in adults still warrants plicated by contracture of the affected limb, and flexor
a guarded to poor prognosis. High‐energy falls result in breakdown and angular deformity of the overloaded
extensive comminution and a difficult reconstruction. opposite forelimb.7,8,22,36,43 Given the better results of
Lack of caudal cortical continuity results in implant failure internal fixation of humeral fractures in immature
and refracture. The best opportunity for the repair of horses, only incomplete fractures in foals are best treated
mildly comminuted and less complex fractures in adults is conservatively; all others need surgical repair.
References
1 Adams, R. and Turner, T. (1987). Internal fixation of a in thoroughbred racehorses: 54 cases (1991–1994).
greater tubercle fracture in an adolescent horse: a case J. Am. Vet. Med. Assoc. 212: 1582–1587.
report. J. Equine Vet. Sci. 7: 174–176. 10 Carter, B.G., Schneider, R.K., Hardy, J. et al. (1993).
2 Ahern, B.J. and Richardson, D.W. (2010). Distal humeral Assessment and treatment of equine humeral fractures:
Salter Harris (type II) fracture repair by an ulnar retrospective study of 54 cases (1972–1990). Equine
osteotomy approach in a horse. Vet. Surg. 39: 729–732. Vet. J. 25: 203–207.
3 Alexander, J. and Rooney, J. (1972). The biomechanics, 11 Dyson, S.J. and Greet, T.R.C. (1986). Repair of a
surgery and prognosis of equine fractures 1967–1971. fracture of the deltoid tuberosity of the humerus in a
In: Proceedings of the American Association of Equine pony. Equine Vet. J. 18: 230–232.
Practitioners, vol. 18, 219–236. Lexington, KY: AAEP. 12 Embertson, R.M., Bramlage, L.R., Herring, D.S., and
4 Allen, D. and White, N. (1984). Chip fracture of the greater Gabel, A.A. (1986). Physeal fractures in the horse:
tubercle of a horse. Compend. Contin. Educ. Vet. 6: 39–41. classification and incidence. Vet. Surg. 15: 223–229.
5 Bertone, A.L., McIlwraith, C.W., Powers, B.E. et al. 13 Fiske‐Jackson, A.R., Crawford, A.L., Archer, R.M. et al.
(1986). Subchondral osseous cystic lesions of the elbow (2010). Diagnosis, management, and outcome in 19
of horses: conservative versus surgical treatment. J. Am. horses with deltoid tuberosity fractures. Vet. Surg. 39:
Vet. Med. Assoc. 189: 540–546. 1005–1010.
6 Blythe, L.L. and Kitchell, R.L. (1982). Electrophysiologic 14 Foerner, J.F. (1977). The use of rush pins in long bone
studies of the thoracic limb of the horse. Am. J. Vet. Res. fractures. In: Proceedings of the American Association of
43: 1511–1524. Equine Practitioners, vol. 23, 223–227. Lexington, KY:
7 Bramlage, L. (1983). Long bone fractures. Vet. Clin. AAEP.
North Am. 5: 285–310. 15 Herthel, D.J., Hamer, E.J., and Martin, F. (1991). An
8 Bramlage, L. (1983). The status of internal fixation of equine orthopedic trauma center: a systematic
long bone fractures in the horse. In: Proceedings of the approach to long bone fracture management. In:
American Association of Equine Practitioners, vol. 29, Proceedings of the American Association of Equine
119–123. Lexington, KY: AAEP. Practitioners, vol. 37, 763–766. Lexington, KY: AAEP.
9 Carrier, T.K., Estberg, L., Stover, S.M. et al. (1998). 16 Hutchins, D., McClintock, S., and Brownlow, M. (1986).
Association between long periods without high‐speed Equine flotation tank design and technique. Equine
workouts and risk of complete humeral or pelvic fracture Vet. J. 18: 65–67.
www.ajlobby.com
17 Johnson, B.J., Stover, S.M., Daft, B.M. et al. (1994). 31 Pooley, A.L. and Slone, D.E. (1992). What is your
Causes of death in racehorses over a 2 year period. diagnosis? Bilateral Salter–Harris type‐II fracture of the
Equine Vet. J. 26: 327–330. medial epicondylar physis of each humerus. J. Am. Vet.
18 Kelman, D.A. (1980). Surgical repair of a spiral Med. Assoc. 200: 1139–1140.
fracture of a humerus in a foal. Aust. Vet. Pract. 32 Rakestraw, P.C., Nixon, A.J., Kaderly, R.E., and
10: 257–259. Ducharme, N.G. (1991). Cranial approach to the
19 Kraus, B.M., Ross, M.W., and Boswell, R.P. (2005). humerus for repair of fractures in horses and cattle.
Stress remodeling and stress fracture of the humerus in Vet. Surg. 20: 1–8.
four standardbred racehorses. Vet. Radiol. Ultrasound 33 Stover, S.M., Johnson, B.J., Daft, B.M. et al. (1992). An
46: 524–528. association between complete and incomplete stress
20 Krook, L. and Maylin, G. (1988). Fractures in fractures of the humerus in racehorses. Equine Vet. J.
thoroughbred race horses. Cornell Vet. 78: 7–133. 24: 260–263.
21 Mackey, V., Trout, D., Meagher, D., and Hornof, W. 34 Thomas, H.L. and Livesey, M.A. (1997). Internal
(1987). Stress fractures of the humerus, radius, and fixation of a greater tubercle fracture in an adult horse.
tibia in horses. Vet. Radiol. 28: 26–31. Aust. Vet. J. 75: 643–644.
22 Markel, M. (1990). Fractures of the humerus. In: 35 Tudor, R., Crosier, M., and Bowman, K.F. (2001).
Current Practice of Equine Surgery (ed. N. White and J. Radiographic diagnosis: fracture of the caudal aspect of
Moore), 652–657. Philadelphia: JB Lippincott. the greater tubercle of the humerus in a horse. Vet.
23 Markel, M.D., Nunamaker, D.M., Wheat, J.D., and Radiol. Ultrasound 42: 244–245.
Sams, A.E. (1988). In vitro comparison of three fixation 36 Turner, A.S. (1984). Fractures of the humerus.
methods for humeral fracture repair in adult horses. In: The Practice of Large Animal Surgery, 1e (ed. P.B.
Am. J. Vet. Res. 49: 586–593. Jennings), 798–800. Philadelphia: Saunders, W.B.
24 McClintock, S. and Hutchins, D. (1981). Some 37 Valdez, H., Morris, D., and Auer, J. (1979). Compression
preliminary comments on flotation tanks in the plating of long bone fractures in foals. Vet. Comp.
management of major skeletal injuries in the horse. Orthop. Traumatol. 1: 10–18.
Aust. Vet. Pract. 11: 256–257. 38 Watkins, J.P. (1991). Diseases of the musculoskeletal
25 McGlinchey, L., Hurley, M.J., Riggs, C.M., and system. Fractures of the humerus. In: Equine Medicine
Rosanowski, S.M. (2017). Description of the incidence, and Surgery, 4e (ed. P.T. Colahan, I.G. Mayhew, A.M.
clinical presentation and outcome of proximal limb and Merritt and J.N. Moore), 1450–1451. Goleta: American
pelvic fractures in Hong Kong racehorses during Veterinary Publications.
2003–2014. Equine Vet. J. 49 (6): 789–794. 39 Watkins, J.P. and Ashman, R.B. (1990). Intramedullary
26 Mez, J.C., Dabareiner, R.M., Cole, R.C., and Watkins, interlocking nail fixation in foals: effects on normal growth
J.P. (2007). Fractures of the greater tubercle of the and development of the humerus. Vet. Surg. 19: 80.
humerus in horses: 15 cases (1986–2004). J. Am. Vet. 40 Watkins, J.P. and Ashman, R.B. (1991). Intramedullary
Med. Assoc. 230: 1350–1355. interlocking nail fixation in transverse humeral
27 Milne, D.W. and Turner, A.S. (1979). An Atlas of fractures: an in‐vitro comparison with stacked pin
Surgical Approaches to the Bones of the Horse, 1e. fixation. In: Proceedings of the Veterinary Orthopedic
Philadelphia: Saunders, W.B. Society, vol. 18, 54. Parker, CO: VOS.
28 Mitchell, C. and Riley, C.B. (2002). Evaluation and 41 Watkins, J.P. and Glass, K. (2016). Intramedullary,
treatment of an adult quarter horse with an unusual interlocking nail and plate fixation of humeral
fracture of the humerus and septic arthritis. Can. Vet. J. fractures in fifteen horses less than one year of age
43: 120–122. (1999–2013). In: Proceedings of the ACVS Surgical
29 Nixon, A.J. (1990). Arthroscopic approaches and Summit, 9. Germantown, MD: ACVS.
intraarticular anatomy of the equine elbow. Vet. Surg. 42 Yovich, J. and Aanes, W. (1985). Fracture of the greater
19: 93–101. tubercle of the humerus in a filly. J. Am. Vet. Med.
30 O’Sullivan, C.B. and Lumsden, J.M. (2003). Stress Assoc. 187: 74–75.
fractures of the tibia and humerus in Thoroughbred 43 Zamos, D.T. and Parks, A.H. (1992). Comparison of surgical
racehorses: 99 cases (1992–2000). J. Am. Vet. Med. and nonsurgical treatment of humeral fractures in horses:
Assoc. 222: 491–498. 22 cases (1980–1989). J. Am. Vet. Med. Assoc. 201: 114–116.
www.ajlobby.com
588
32
Luxation of the Shoulder
Ashlee E. Watts1 and Alan J. Nixon2,3
1
2
3
Anatomic Considerations of supraglenoid fracture fragment removal suffered

shoulder luxation three weeks postoperatively. An
The shoulder is a diarthrodial joint consisting of the gle additional three luxations were treated from 1997 to
noid cavity of the scapula and the round humeral head. It 2008 (Table 32.1). Although still uncommon, shoulder
has the appearance of a ball and socket joint, able to move luxation appears to occur more commonly in ponies and
in numerous directions. Despite the rounded appearance miniature horses. This may be due to their shallower gle
of the humeral head, shoulder motion is largely confined noid cavities, decreased musculature, and increased
to flexion and extension in the sagittal plane. Unlike most incidence of shoulder joint dysplasia (Figure 32.1).3–5
joints in the body, the shoulder is not stabilized by collat
eral ligaments, and although the joint capsule is locally
strengthened by the so‐called glenohumeral ligaments Etiology
both medially and laterally, the shoulder is without true
pericapsular collateral ligament support. Instead, the Shoulder luxation is usually the result of trauma, and can
shoulder is braced by the joint capsule, glenohumeral liga develop with concurrent fracture of the glenoid,15,16,28 or
ments and supraspinatus muscles, infraspinatus muscles, as a standalone injury.6,11 Soft tissue injury occurs in all
and subscapularis and teres minor muscles, with their ten cases, with the structures injured depending on the
dinous insertions forming a surrounding “cuff” on all direction of luxation and inciting trauma.9,10,16,20
sides. These cuff t endons, particularly those of the infraspi Reported causes of shoulder luxation include forceful
natus and subscapularis muscles, stabilize the shoulder extraction of an entrapped limb in a pony,27 external
and allow function as a hinge joint.8,24,25 Additional stabi trauma after sliding into a fence post in a three‐year‐old
lizers of the shoulder include the biceps tendon of origin filly,16 during recovery from general anesthesia,19,28 sec
and the deltoideus muscles. Despite the lack of collateral ondary to widespread joint laxity in a neonatal foal,11 and
ligaments, shoulder luxation is a rare problem in horses. during paddock accidents.15 Other reported causes may
include falling with the shoulder flexed,20 and as a com
plication of supraglenoid tubercle fracture15,22 or follow
Prevalence ing removal of a large supraglenoid tubercle fracture.2,15
Luxation direction is dependent on the direction of
The abundance of musculature surrounding the joint on inciting trauma. Lateral or craniolateral luxation appears
all sides and the large humeral head, approximately two to be the most common,9,16,19,20,27,28 with a few cases of
times the surface of the glenoid cavity, are most likely medial luxation in the literature,11,23 and three cases of
responsible for the rarity of shoulder luxation in horses.24 cranial luxation.2,9,22
Over a 22‐year period (1976–1997), of 22,000 equine Injury to the suprascapular nerve and denervation of the
cases presented to Cornell’s equine hospital, only 6 supraspinatus and infraspinatus muscles (sweeney) may
were confirmed to have shoulder luxation,22 and a case result in intermittent lateral instability of the shoulder

www.ajlobby.com
Table 32.1 Cases of shoulder luxation available in the literature, as well as those unreported from our hospital (CUHA).
Signalment Luxation direction Concurrent injury Cause Repair Follow‐up Ref
27
11‐year‐old LF Lateral None reported Entrapped in a fence Unsuccessful (GA) attempt At 6 weeks, mild
pony gelding (Day 1) lameness at trot
Closed (GA) reduction
(Day 5)
16
3‐year‐old TB RF Lateral Lateral glenoid fragments on Fell and slid into a fence GA At 8 months,
filly radiographs at 2 weeks (not on post 2 weeks prior Closed reduction sound in light work with
originals) Arthroscopic debridement complete resolution of
Marked muscle atrophy atrophy
Torn joint capsule
28
14‐year‐old RF Craniolateral Fractured lesser tubercle and Uneventful recovery Attempted reduction with At 6 months, mild
mare (500 kg) lateral glenoid rim Marked from GA sedation lameness, no worse than
edema, hematoma over biceps Successful closed reduction prior to luxation
brachii under GA
15
1‐year‐old RF Luxation direction Supraglenoid tubercle fracture Occurred during group Removed supraglenoid At 1 year, mechanical
Arabian filly not reported turnout with other fracture and open reduction lameness at pasture
yearlings Reluxation at 8 days
Shoulder arthrodesis
11
4‐day‐old colt RF Medial No concurrent injury Multiple joint laxity Sedated, closed reduction, At 2 months, sound
Luxation occurred followed by Velpeau
during hospitalization bandage for 1 week
6
6‐year‐old LF Unknown due to No concurrent injury Attempted to jump a Closed reduction (GA) Developed supra/
pony mare single‐view radio‐ fence the previous day Reduction occurred during infraspinatus muscle
(240 kg) graph, suspected patient positioning atrophy.
lateral At 4 months sound,
atrophy improving,
periarticular new bone
20
5‐year‐old QH RF Lateral Severe degenerative changes Not reported 6‐week Euthanized NA
gelding Large excoriation on medial duration
humeral head
19
8‐year‐old LF Lateral None reported GA recovery Closed reduction (GA) Sound in light training
WB gelding at 4 months
As training intensified,
lameness recurred
2
Mature horse Cranial Supraglenoid tubercle fracture 6 weeks following Euthanized NA
supraglenoid fracture
removal
9
Adult pony RF Craniolateral None reported Pasture accident Closed reduction (GA) At 4 weeks, mild
mare (400 kg) lameness at trot
22
8‐year‐old LF Not available in Fractured scapula Pasture accident Euthanized NA
Arabian mare record
(Continued )
Chapter No.: 1 Title Name: <TITLENAME> 0004264545.INDD

0004264545.INDD 589
CSW
Comp. by: <USER> Date: 11 Sep 2019 Time: 03:38:05 PM Stage: <STAGE> WorkFlow:
www.ajlobby.com Page Number: 589
9/11/2019 3:38:05 PM
Table 32.1 (Continued )
Signalment Luxation direction Concurrent injury Cause Repair Follow‐up Ref

22
20‐day‐old LF Cranial Supraglenoid tubercle fracture Unknown trauma: Euthanized NA
STB colt possibly stepped on by
mare
22
1‐year‐old TB RF Medial Fractured supraglenoid Found at pasture Lag screw fixation of NA
colt tubercle supraglenoid tubercle and
open reduction Recurrent
luxation day 3 Euthanized
22
5‐month‐old LF Craniolateral Fractured supraglenoid Found at pasture 1 day Euthanized at surgery due NA
Paint colt tubercle Severe cartilage prior to presentation to severe cartilage and
damage to caudal humeral subchondral bone loss
head
22
1‐year‐old RF Cranial Fractured supraglenoid Unknown trauma, Euthanized. NA
Appaloosa tubercle and caudal humeral 4 days previously
colt head
23
6‐year‐old RF Medial luxation Osteoarthritis Possible shoulder joint Shoulder arthrodesis At 3 years, successful
Mini mare dysplasia broodmare
23
15‐year‐old LF Caudomedial Osteoarthritis Possible shoulder joint Shoulder arthrodesis At 2 years, using limb
Mini mare subluxation dysplasia
23
5‐year‐old LF Medial Osteoarthritis Possible shoulder joint Shoulder arthrodesis At 2 years, successful
Mini mare subluxation dysplasia broodmare
3‐year‐old RF Subluxation Osteoarthritis Unknown Biceps tendon transposition Unknown CUHA
Mini mare Lateral scapulohumeral
sutures
4‐month‐old RF Lateral Lateral glenoid fragmentation 2 weeks duration Attempted closed reduction Ankylosis 1 month CUHA
Mini filly Open reduction, biceps postop Functional limb
transposition, at pasture
scapulohumeral suture
5‐year‐old RF Medial Fracture of distomedial Hit by car 2 weeks prior Discharged without Unknown CUHA
Palomino glenoid treatment
mare
3‐year‐old LF Subluxation Osteoarthritis Shoulder joint dysplasia Discharged without Unknown CUHA
Mini mare Bilateral shoulder treatment
dysplasia
1‐year‐old RF Craniolateral, Supraglenoid fracture 3 weeks duration Removal of fracture NA CUHA
STB colt secondary to Pasture accident fragment Luxation occurred
fracture removal 3 weeks after fragment
removal Euthanized
1‐year‐old LF Cranial Supraglenoid fracture 5 days duration Pasture Euthanized NA CUHA
STB filly accident
CUHA, Cornell University Hospital for Animals; GA, general anesthesia; LF, left forelimb; NA, not applicable; QH, Quarter Horse; RF, right forelimb; STB, Standardbred; TB, Thoroughbred; WB,
Warmblood.
Chapter No.: 1 Title Name: <TITLENAME> 0004264545.INDD

0004264545.INDD 590
Comp. by: <USER> Date: 11 Sep 2019 Time: 03:38:05 PM Stage: <STAGE> WorkFlow:
www.ajlobby.com CSW Page Number: 590
9/11/2019 3:38:05 PM
Figure 32.1 (A) Caudal to cranial and (A) (B)

(B) right to left lateral radiographs of a
three‐year‐old Miniature Horse mare with
shoulder joint dysplasia and subluxation of
the left shoulder. Note the shallow glenoid
and flattened humeral head present in
both scapulohumeral joints. Lateral
scapulohumeral tension band suture or
shoulder joint arthrodesis was
recommended; however, therapy was not
pursued due to cost. R, right forelimb; L,
left forelimb.
uring weight bearing.7 Because the joint capsule and

d horses drag the limb and resent all limb manipulations.6,19
other supporting soft tissue structures are not generally Crepitus may be appreciable where there are concurrent
disrupted, these cases are not true luxations, but rather fractures.9 Because most shoulder luxations are lateral or
intermittent subluxation during axial weight bearing. craniolateral, the distal limb will most often be adducted
Historically, denervation was seen most c ommonly in pull with the elbow abducted.6,19 In addition to distal limb
ing horses, due to poorly fitted harness collars applying adduction, horses with lateral luxations will stand with
pressure to the suprascapular nerve as it passed over the their body inclined toward the contralateral limb and the
cranial edge of the scapula. With the decline in the use of affected limb pointed contralaterally,6,9,19 almost as if they
working horses, this condition is less frequent, and is now intend to cross their forelimbs. Swelling around the shoul
largely confined to horses that have suffered impact trauma der joint will vary with the structures injured, the nature
to the shoulder region. When the injury is due to impact of the injury, the duration since injury, and the direction of
trauma, acute lateral instability may be difficult to clinically luxation. A medial luxation will have a prominent lateral
differentiate from horses with true shoulder joint luxation glenoid rim, while a lateral luxation will have a prominent
and/or fracture. Realignment of the scapula and humerus, greater tubercle of the humerus and may have a caved‐in
by physical manipulation or spontaneous correction dur appearance to the triceps musculature (Figure 32.2).9,19,20,28
ing the non‐weight‐bearing phase of the stride, suggests The scapular spine is less prominent, with acute lateral
suprascapular nerve injury. Radiographs are occasionally luxations, and potentially more prominent once atrophy
required to differentiate a fracture or complete luxation of has occurred of the supra‐ and infraspinatus musculature
the shoulder region from denervation‐induced instability. in more chronic cases (Figure 32.3).9 Marked muscle atro
Additionally, reexamination 24–48 hours later, when phy may occur as soon as 10 days after suprascapular
the initial pain and swelling have subsided, may allow inter nerve injury7 and as soon as two weeks after shoulder
mittent lateral instability of the shoulder joint to be appre luxation and disuse.16 However, even after six weeks of
ciated, differentiating it from a luxation and/or fracture. shoulder luxation, one horse had only moderate supra‐
and infraspinatus muscle atrophy.20
Clinical Findings
Radiographs
The diagnosis of shoulder luxation is made based on phys
ical examination findings and can be confirmed with radi Orthogonal radiographs should be obtained to confirm
ographs. Horses have an acute, non‐weight‐bearing shoulder luxation, determine the direction of luxation,
forelimb lameness with shortening of the affected limb. and rule out concurrent fracture (Figure 32.4). Computed
Although the limb can be advanced to some degree, most tomography (CT) is very useful if the animal is small
www.ajlobby.com
(A) (B)
Figure 32.2 (A) Caudolateral and (B) frontal photographs of the shoulder region of a 14‐year‐old mare following craniolateral luxation of
the right scapulohumeral joint during a well‐coordinated recovery from general anesthesia. There is marked lateral displacement of the
greater tubercle of the humerus and a caved‐in appearance to the triceps musculature. Unsuccessful attempts were made at luxation
reduction under heavy sedation. The luxation was later manually reduced under general anesthesia, with assistance from an overhead
hoist. The mare was aided during the second recovery with a head and tail rope and recovered uneventfully. Source: Zilberstein et al.
2005.28 Reproduced with permission of BMJ.
enough. Radiographs of diagnostic quality can be obtained ossible to avoid secondary complications. However,
p
in the standing horse, although a machine capable of this procedure does not require immediate surgical
greater mAs than a standard portable unit is often attention at the time of presentation. If the patient is
required. The radiographic examination should include presented after hours, it is prudent to wait until the fol
the lateral and caudodorsal to cranioventral or oblique lowing day, when daytime staff are available and the
craniocaudal views. The humeral head will be displaced horse has had time to recover from shipping and accli
from the glenoid cavity and muscular contraction will mate to the hospital environment. Therapy while await
generally pull the humerus proximally. As in all joint luxa ing definitive treatment should consist of supportive
tions, the direction of luxation is described by the abnor care, anti‐inflammatory agents, wound care if indi
mal location of the distal component, the humeral head. cated, and stall confinement. Splinting and/or bandag
Radiographs should be examined for the presence of con ing are generally not useful. Significant delay in
current fracture, especially of the craniolateral rim of the presentation for diagnosis and repair can result in con
glenoid in chronic cases of lateral luxation, and of the siderable damage to the lateral glenoid rim of the scap
medial rim of the glenoid in medial luxations (Figures 32.5 ula, and to the cartilage and subchondral bone of the
and 32.6). Preexisting osteoarthritis or developmental medial humeral head in cases with lateral luxations (see
joint disease should be noted, as it will reduce the progno Figure 32.4).16,20
sis for function without lameness. At least orthogonal Closed reduction under general anesthesia has gener
projections should be obtained, since many luxations can ally been difficult but rewarding, although heavy sedation
be missed or misinterpreted as joint space narrowing on a may be adequate in the very young foal.11 For attempts at
lateral projection (see Figure 32.4). reduction when open or arthroscopic techniques may be
employed, the patient should be positioned in lateral
Surgical Repair recumbency. Central muscle‐relaxing agents may aid in
muscle relaxation and luxation reduction. If positive‐
pressure ventilation is available, neuromuscular blocking
Luxation Reduction and Surgery agents may also be employed to aid in reduction.27 To
Like most non‐weight‐bearing equine emergencies, further aid in muscle fatigue and luxation reduction, a
luxation reduction should be performed as soon as hobble on the distal limb can be used for limb traction.
www.ajlobby.com
experience and published literature suggest that when the

luxation is easily reduced, reluxation is more likely,15 and
surgical stabilization with a scapulohumeral tension band
may be necessary to maintain reduction.
Luxation reduction requires limb manipulation,
including limb traction with rotation and pressure on the
greater tubercle in a lateral luxation, and pressure on the
glenoid in a medial luxation. If traction and manipula
tion are not successful, slight limb flexion followed by
rotation and pressure on the shoulder may be useful.27
Several reports describe an audible pop or click when the
luxation is successfully reduced.6,19,28 In all cases, reduc
tion is apparent by a return to normal conformation
without a prominent humeral head in a lateral luxation,
or a prominent glenoid rim in a medial luxation, and the
ability to take the shoulder through a normal range of
motion. Radiographs should follow reduction to confirm
successful and complete reduction and check for the
presence of fractures, particularly of the lateral glenoid
rim. If the patient is positioned in lateral recumbency
and there is a suspicion of fractures on the craniocaudal
oblique view, the patient should be repositioned to the
other lateral for a medial to lateral radiograph to assist in
fracture verification.
Acute, simple luxations may not require arthro
scopic exploration. The published literature suggests
that for other cases, arthroscopy is advisable to main
tain the best possible prognosis.27 Either a craniolat
eral approach with the arthroscope inserted cranial to
the infraspinatus tendon or a lateral approach with
the arthroscope inserted immediately caudal to the
infraspinatus tendon can be used.17 The limb should
Figure 32.3 Caudal to cranial photograph of the left shoulder of be unsupported during arthroscopy, allowing some
a yearling Standardbred colt with craniolateral scapulohumeral distal limb adduction and widening of the lateral
luxation. There is marked lateral displacement of the greater aspect of the shoulder joint. The hobble and ropes for
tubercle of the humerus and moderate supra‐ and infraspinatus
muscle atrophy. The luxation was reduced and a supraglenoid
limb traction should be left in place for additional trac
tubercle fracture fragment was removed. The luxation recurred tion when exploring the medial aspect of the joint.
three weeks postoperatively and the colt was euthanized. Fibrous tissue and bony fragments should be removed,
accessible cartilage lesions debrided, and the joint lav
aged. Even with significant traction, examination of
the caudal and medial aspect of the shoulder joint is
difficult, especially in adult horses with an otherwise
This is accomplished best with the overhead hoist with normal joint. This is unfortunate, since much of the
the patient in dorsal recumbency,16,19,27,28 or a calf jack damage to the humeral head in lateral luxations is
with the patient in lateral recumbency.16 Despite two most likely to be located medially.20,27 Despite the
reports of simple reduction, one in a foal and another in a presence of articular cartilage damage at the medial
pony,6,11 luxation reduction is generally difficult, requir aspect of the humeral head, open reduction, which
ing up to 30 minutes of limb fatigue and limb manipula would allow more thorough joint exploration and
tion prior to successful reduction.16 This is especially true debridement, is not warranted.
if the luxation is chronic, allowing significant muscular
contraction and joint capsule fibrosis to occur. However,
unlike equine coxofemoral luxation, chronicity does not
prohibit successful closed reduction of the shoulder. In
Internal Fixation
smaller patients, or patients with multiple or large gle Internal fixation may be indicated when there is shoulder
noid fractures, reduction may be less difficult. Anecdotal luxation concurrent with supraglenoid tubercle fracture
www.ajlobby.com
(A) (B)
(C) (D)
Figure 32.4 Radiographic (A) left to right lateral and (B) caudal to cranial projections, and (C) frontal‐plane computed tomography (CT),
with (D) CT reconstruction images of a three‐year‐old alpaca with chronic (two weeks) lateral luxation of the right scapulohumeral joint
and a normal left scapulohumeral joint. Additionally, there is fracture of the acromion process and several small fragments of bone from
the lateral glenoid rim of the luxated shoulder. Orthogonal radiographs (A, B) allow confirmation of shoulder luxation and determination
of luxation direction. It should be noted that with only the left to right lateral view (A), the luxation could be misinterpreted as joint space
narrowing and it is impossible to know the luxation direction. The caudal to cranial view (B) demonstrates a lack of scapular glenoid over
the humeral head and confirms lateral luxation. CT reconstruction of both shoulders viewed from cranial to caudal (D) and CT frontal‐
plane images (C) of the right and left shoulder joints also demonstrate how fracture of the lateral glenoid rim and erosion of the cartilage
and subchondral bone on the medial humeral head can occur with chronic lateral luxation. R, right forelimb; L, left forelimb.
www.ajlobby.com
(Figures 32.6–32.8).15,22 Two case reports that describe stabilization of the supraglenoid tubercle fracture and
supraglenoid tubercle fracture concurrent with shoulder open luxation reduction, but the fracture fixation failed
luxation suggest that the outcome is generally poor. In the and the luxation recurred.22 Finally, large supraglenoid
first case, an immature horse was treated with supraglenoid tubercle fractures treated by fracture removal resulted in
tubercle fracture removal and open luxation reduction. shoulder joint luxation and euthanasia in two horses,
Luxation recurred by Day 8 postoperatively and was three and six weeks postoperatively.2 These case reports
followed by a second procedure for scapulohumeral
suggest that shoulder luxation concurrent with sup
arthrodesis.15 Another case was treated with lag screw raglenoid tubercle fracture, treated by either internal fix
ation of the fracture fragment or fragment removal,
requires additional shoulder fixation to prevent shoulder
reluxation.
(A) (B) Shoulder joint arthrodesis is reported in miniature
horses and horses of small stature and will certainly pre
vent reluxation. However, it is only a salvage technique
and has rarely been successful in a full‐sized horse.1,15,23
Difficulties that hinder successful scapulohumeral
arthrodesis in full‐sized horses include the inability to
utilize external coaptation to minimize cyclical stress on
the implants in a high‐motion joint, and the limited bone
for implant purchase in the scapula. With the recent
availability of locking compression plates (LCPs) this
obstacle may be overcome (see later example,
Figure 32.12), especially if the joint is chronically diseased
with a reduced range of motion.
In response to the increased incidence of reluxation in
large animal species other than horses, techniques have
been developed to maintain luxation stabilization follow
ing open reduction. Greater tubercle osteotomy for biceps
Figure 32.5 (A) Caudal to cranial and (B) left to right lateral
brachii transposition and capsular imbrication has been
radiographs of a five‐year‐old mare with medial luxation of the
right shoulder and fracture of the medial glenoid rim successful in maintaining luxation reduction. However,
(arrowheads). The horse was discharged for at‐home euthanasia the long‐term outcome has not been good, with persistent
due to the cost of treatment. lameness, severe osteoarthritis, and joint ankylosis ensuing
Figure 32.6 (A) Caudal to cranial and (B) (A) (B)

standing left to right lateral radiographs of
a one‐year‐old colt with cranial luxation of
the right shoulder and a large fracture of
the supraglenoid tubercle. The horse was
euthanized due to the cost of therapy and
reduced prognosis for full athletic
function.
www.ajlobby.com
(A) (B) Figure 32.7 (A) Caudal to cranial and (B)

right to left lateral radiographs of a five‐
month‐old Paint Horse colt with lateral
shoulder luxation and fracture of the
supraglenoid tubercle of the left shoulder.
Surgery for open luxation and fracture
reduction with internal fixation was
commenced; however, due to severe
osteochondral defects to the humeral
head, the colt was euthanized at surgery.
(Figure 32.9).13,22 A newer technique of scapulohumeral

tension band stabilization has been used successfully in
alpacas, goats, and a miniature steer, with maintenance of
luxation reduction, long‐term soundness, and a normal
range of motion.21,22,26 Application to luxation in horses
has not been described in the literature; however, the
technique seems applicable to horses. In two unpublished
cases of intermittent lateral instability causing shoulder
subluxation, a scapulohumeral tension band maintained
adequate shoulder joint alignment during full weight
bearing (D.W. Richardson, personal communication).
When recurrent luxation is possible, as in cases with con
comitant supraglenoid tubercle fracture or shoulder joint
dysplasia, scapulohumeral‐stabilizing suture techniques
may be superior, especially if athletic function is required.
Although it is impossible to speculate about the progno
sis for athletic function in horses with a scapulohumeral
tension band, if the technique is able to maintain reduc
tion, it is almost certainly better than the prognosis fol
lowing arthrodesis or biceps transposition.
Scapulohumeral Tension Band Technique

A scapulohumeral tension band should be used when
there is a risk for recurrent luxation or there is luxation
with a concurrent supraglenoid tubercle fracture.
Additionally, anecdotal reports suggest that it may also
be useful when there is intermittent, weight‐bearing lat
eral instability of the shoulder joint with dysplasia or
Figure 32.8 Right to left lateral radiograph of the left shoulder of Sweeny. The horse should be anesthetized and placed in
a yearling Standardbred filly. There is a large supraglenoid
tubercle fracture and cranial shoulder luxation. The injury
lateral recumbency with the affected limb uppermost. A
occurred while at pasture, five days prior to hospital presentation. craniolateral approach to the shoulder joint is used. A
The filly was euthanized due to the cost of therapy. 20 cm curvilinear skin incision is made, beginning at the
www.ajlobby.com
(A) (B)
(C) (D)
Figure 32.9 (A, B) Preoperative and (C, D) one month follow‐up radiographs of the right shoulder (R) of a four‐month‐old Miniature Horse
filly. On the preoperative films there is lateral luxation of the shoulder, with fragmentation of the lateral rim of the glenoid. Open reduction
was performed and stabilized via biceps tendon transposition with greater tubercle osteotomy (arrow), as well as a lateral scapulohumeral
tension band suture (*). Although the joint remains well aligned on the one month follow‐up films, there is marked osteoarthritis and joint
ankylosis. This case suggests that biceps transposition, while effective at maintaining joint reduction, does not allow for a functional
outcome long term. R, right forelimb; L, left forelimb.
www.ajlobby.com
(A) (B) Figure 32.10 Photographs of the left

shoulder region with craniolateral approach
suitable for lateral scapulohumeral tension
band suture for luxation reduction
stabilization or plate application for shoulder
arthrodesis. (A) The fascia along the scapular
spine (*) and the brachiocephalicus muscle
along its fibers (black arrows) have been
incised and retracted for identification of the
supraspinatus (SM) and infraspinatus
muscles (IM) and the insertion of the
infraspinatus tendon (IT) on the caudal
eminence of the greater tubercle of the
humerus (^). (B) After transection of the
insertion of the supraspinatus on the cranial
eminence of the greater tubercle (black
squares), the supraspinatus muscle can be
retracted dorsally for identification of the
suprascapular nerve (white arrows) coursing
around the cranial aspect of the scapular
neck, and the origin of the biceps tendon
(BT) on the supraglenoid tubercle of the
scapula.
middle of the scapula and following the scapular spine

distally, crossing the joint and continuing over the lateral
surface of the humerus to the midpoint of the shaft, at
the level of the deltoid tuberosity (Figure 32.10). The
deep brachial fascia is incised cranial to the deltoideus
muscle and caudal to or along the fibers of the brachioce
phalicus muscle, caudoventral to the scapular spine and
extending caudally and distally to the greater tubercle of
the humerus, allowing exposure of the lateral joint cap
sule and supra‐ and infraspinatus tendons (Figure 32.10).
The joint capsule is incised caudal to the infraspinatus
tendon and parallel to the humeral head, for examination
of the joint and debridement of fibrous tissue and carti
laginous or bony injury. Acute, simple luxations may not
require arthrotomy and joint exploration. Reduction is
performed after debridement. The joint should be exam
Figure 32.11 Left shoulder of a yearling Thoroughbred filly with
ined and lavaged once more, the lateral glenoid inspected, lateral scapulohumeral tension band suture using ultra‐high
and the joint capsule closed. Scapulohumeral tension molecular weight polyethylene cable for intermittent lateral instability
sutures using #5 Fiberwire® (Arthrex Vet Systems, Bonita of the shoulder. Dorsal is to the left and cranial is in the foreground.
Springs, FL, USA) suture or other ultra‐high molecular The suture has been placed in a figure‐eight pattern through bony
tunnels in the greater tubercle of the humerus and the scapular spine.
weight polyethylene cable are placed in a figure‐eight
The small arrow points to the distal aspect of the scapular spine. Large
pattern (Figure 32.11). Proximally, the suture is either arrows point to the caudoventral (black) and craniodorsal (white)
passed through a horizontal drill tract in the scapular aspects of the tunnel through the greater tubercle of the humerus,
spine or around a screw and washer in the scapular neck. between the insertions of the supraspinatus and infraspinatus
Distally, the suture is either passed through vertical drill tendons. Source: Image courtesy D.W. Richardson.
tracts in the greater tubercle or around two screws with
washers in the greater tubercle, between the insertions of tendon and the second cranial to the infraspinatus ten
the supraspinatus and infraspinatus muscles. If utilized, don. If drill tracts are utilized instead of screws, they are
screws are placed parallel to the joint surface, bicorti made with a 4.0 mm drill bit through an ample stock of
cally. Screw sizes should be appropriate for patient size; bone, between the insertions of the supraspinatus and
i.e., a 5.5 mm cortical bone screw in a full‐sized horse, a infraspinatus tendons, in an oblique caudoventral to
3.5 mm cortical bone screw in a small pony, or a cancel cranioproximal direction, parallel to the insertion of the
lous screw in a young foal. Two screws should be placed infraspinatus tendon (see Figure 32.11). This is not
in the greater tubercle, one caudal to the supraspinatus difficult to perform in the horse due to its large and
www.ajlobby.com
prominent greater tubercle. Tension band sutures are

tightened and tied in a figure‐eight pattern, while the
limb is maintained in extension with slight abduction. If
a large supraglenoid tubercle fragment was excised,
closed suction drainage and an implantable antibiotic
depot should be considered.2 The deep brachial fascia,
subcutaneous tissues, and skin are closed in separate lay
ers. An adhesive or stent bandage should be placed for
recovery from anesthesia.
Shoulder Arthrodesis
For shoulder joint arthrodesis, patients should be anes
thetized and positioned in lateral recumbency with the
affected limb uppermost. A 20–30 cm curvilinear inci
sion similar to that for scapulohumeral tension band
suture is made. The brachiocephalicus muscle should
be retracted cranially. The biceps tendon is transected
just distal to its origin on the supraglenoid tubercle, or
split longitudinally with the lateral half excised and
removed.15,23 The supraspinatus muscle is transected at
the level of its insertion on the greater tubercle of the
humerus, or an osteotomy of the greater tubercle can be
performed for dorsal reflection of the supraspinatus
muscle. Care is taken to avoid damage to the suprascap
ular nerve, as it courses around the cranial aspect of the
scapular neck by isolating it with small Penrose drains.
The Penrose drains are not intended to completely ele Figure 32.12 Medial to lateral radiograph 10 days after left
vate the suprascapular nerve from the surgical field, shoulder joint arthrodesis in a 175 pound three-year-old
but to serve as safe and obvious markers of its location. Miniature Horse gelding with shoulder joint dysplasia and
subluxation. The arthrodesis utilized an 11 hole 5.0 LCP, where the
The cranial aspect of the shoulder is the tension two central combi holes were left empty to allow transarticular
band side and is the ideal surface for plate application. lag screw fixation with 4.5 mm cortical bone screws through the
The intermediate tubercle of the humerus is removed adjacent holes. The proximal most screw is unicortical to reduce
with an oscillating saw or rongeurs to provide a flat sur the chance for a stress riser and postoperative scapular fracture.
face for the plate. The joint is incised and cartilage curet
ted. Two reports have described success with ostectomy
of the glenoid cavity and humeral head instead of carti in the horse describe application of the proximal aspect
lage removal when the plate was applied to the scapular of the plate to the scapula spine rather than the cranial
spine, as is done in small animal species,1,14,15 but this is surface of the scapula (similar to small animal tech
not necessary.23 Subchondral forage may be performed niques), after ostectomy of the glenoid cavity and
with a 2.5 mm drill bit on exposed articular surfaces. A humeral head.1,14,15 However, due to the increased vol
periosteal elevator is used to remove remaining soft tis ume of bone in the equine shoulder, plate application
sue attachments from the areas for plate attachment on may be more reliable when performed along the cranial,
both the scapula and humerus. tension band surface. Careful contouring of the LCP to
A 10‐ or 11‐hole, 4.5 mm narrow dynamic compres the 120° angle will still allow locking screw placement
sion plate (DCP) or 5.0 mm narrow LCP is bent to an (see Figures 32.12 and 32.13), but the use of transarticu
approximately 120° angle at its center point for applica lar lag screws through central combi holes in this angled
tion to the cranial surface of the scapula and humerus region may obviate this concern. Remaining holes are
(Figure 32.12). The proximal most hole should be a uni filled with 4.523 or 5.5 mm cortical bone screws for the
cortical locking screw, especially in smaller patients. DCP or 5.0 mm locking screws for the LCP. In smaller
This will minimize the chance for creation of a stress patients, the central holes are usually left unfilled, with
riser and postoperative scapular fracture. For larger transarticular lag screws placed through the adjacent
ponies or horses, a longer, broad plate applied cranially, holes (see Figure 32.12). In larger ponies and horses, a
or combination of a cranial narrow and additional broad short broad DCP or LCP can be applied over the lateral
plate applied to the lateral aspect of the shoulder, may aspect of the shoulder to provide additional stabiliza
be required (Figure 32.13). Two reports of arthrodesis tion (see Figure 32.13). Cancellous bone graft can be
www.ajlobby.com
(A) (B)
(C)
(D)
Figure 32.13 Double plate fixation for shoulder joint arthrodesis in a yearling with osteoarthritis secondary to severe OCD. (A) Severe
shoulder joint osteoarthritis. (B) Surgical exposure of the cranial aspect of the humerus and scapula to allow insertion of a narrow locking
compression plate (LCP) to the cranial intertuberal groove. The plate is contoured to the cranial surface of both humerus and scapula. Gr
Tub, greater tubercle. (C) Postoperative lateral radiograph showing application of a narrow LCP to the cranial aspect of the humerus and
scapula and a broad LCP to the lateral aspect of the humerus and scapula neck. (D) Oblique craniocaudal projection showing screw
insertion through both plates to form a stable shoulder fixation. Source: Images courtesy Dr. Jeffrey Watkins.
Recovery from General Anesthesia

placed within the joint prior to closure. If transected,
the biceps tendon should be reattached to its site of ori Regardless of surgical therapy, recovery from anesthesia
gin with #1 polydioxanone in a simple mattress or lock should be assisted, ideally in a pool recovery system.
ing‐loop pattern. If a greater tubercle osteotomy was Minimally, a head and tail rope should be used in conjunc
performed, it should be reattached with a 3.5 or 4.5 mm tion with appropriate sedation for a smooth and slow
cortical bone screw in lag fashion, otherwise the recovery. The patient should be positioned in the recovery
supraspinatus muscle and tendon of insertion can be stall with the affected limb uppermost. No splinting or
sutured. Antibiotic‐laden beads can be inserted around bandaging is indicated, other than an adhesive bandage or
the shoulder to minimize the incidence of implant stent to cover any surgical wounds. Although a Velpeau‐
infection. Each fascial layer and skin is closed sepa type sling has been used in large animals other than horses26
rately. An adhesive or stent bandage should be placed and a neonatal foal after luxation reduction,11 use of a non‐
over the incision for recovery. weight‐bearing sling is not appropriate in adult horses.
www.ajlobby.com
Postoperative Care atrophy was fully resolved by eight months. One pony

developed atrophy of the supra‐ and infraspinatus mus
For simple luxations treated by closed reduction with culature in the two months following closed reduction.
or without arthroscopic debridement, perioperative The atrophy did not seem to cause clinical problems, as
broad‐spectrum antibiotics are sufficient. If there is the luxation did not recur and there was no associated
extensive soft tissue swelling and injury, additional lameness or joint instability. By four months, no lame
antibiotic duration may be required. For cases that have ness was appreciable at the trot and the atrophy contin
supraglenoid tubercle fracture fragment removal or ued to improve.6
internal fixation, postoperative broad‐spectrum antibi
otics should be continued for a minimum of three to
five days. Intraarticular sodium hyaluronate or polysul Prognosis
fated glycosaminoglycans may be administered after
simple luxation reduction to reduce lameness and The prognosis for shoulder luxation appears to be rea
improve function,9 and it may be useful to repeat sonably good following appropriate treatment, unless
intraarticular injections in the postoperative period, at there is concurrent supraglenoid tubercle fracture.
two and six weeks. Closed reduction alone was successful without subse
Following luxation reduction, the horse should be quent lameness in one foal11 and one horse,19 and closed
markedly more comfortable and at least willing to reduction alone maintained reduction with only mild
bear weight on the limb within 24 hours.9,16,19,28 lameness in two ponies9,19,27 and one horse.28 Closed
Analgesics and anti‐inflammatory agents should be reduction followed by arthroscopic exploration and
administered as needed. Discharge from the hospital debridement maintained soundness in one horse
depends largely on the extent of the initial injury and despite the presence of intraarticular fractures and car
the treatment that followed. Simple luxations with tilage excoriations, which occurred in the two weeks of
closed reduction can be discharged within days, while luxation prior to treatment.16
luxation concurrent with multiple fractures, internal In contrast, two reports of shoulder luxation with
fixation, or supraglenoid fracture fragment removal concurrent supraglenoid tubercle fracture describe
should stay longer. Horses should be confined to stall poor success, with outcomes of delayed shoulder arthro
rest without hand walking for a minimum of 6 weeks desis15 or euthanasia.22 Shoulder joint arthrodesis
with closed reductions and 8–12 weeks with open has also been utilized when there was significant
techniques, to allow the periarticular structures to preexisting joint disease concomitant with shoulder

heal. After luxation repair, daily passive range of luxation.1,15,23 Although these cases had complications
motion physiotherapy should be employed.19 including implant breakage and/or implant‐related
Dependent on the degree of soft tissue, cartilaginous, infection, each did well long term: arthrodesis resulted
and bony injury, hand walking may begin around in a functional gait despite limb shortening in a 250 kg
6–12 weeks and light exercise around 3–6 months. yearling15 and lack of normal range of motion in four
Cases that have been treated with a scapulohumeral miniature horses.23
tension band suture should remain on stall rest with In summary, the prognosis after luxation repair
out hand walking for 10–12 weeks and should not appears to be good for long‐term soundness and return
return to exercise or turnout until 6 months postop to athletic function, especially if the joint is arthroscopi
eratively. Cases that have been treated with shoulder cally explored and debrided following luxation reduc
arthrodesis should be confined to a stall without tion, unless there is concurrent supraglenoid fracture, in
hand walking until there is radiographic evidence of which case the prognosis appears to be poor. Due to the
bony fusion and minimal lameness. Periarticular paucity of cases in the literature, it is impossible to judge
fibrosis is inevitable in all cases of shoulder luxation, the prognosis for return to full athletic function after
and exercises directed at maintaining and improving chronic shoulder luxation, although it is likely to be
joint mobility are crucial for long‐term soundness and decreased due to the reduced range of motion of the
athletic function. Acutely, this includes passive range shoulder.
of motion e xercises and in the long term therapeutic A good prognosis may be due to the rarity of reluxa
use of cavalettis may be beneficial. tion following reduction. Except in cases of concomitant
In addition to maintaining range of motion of the supraglenoid tubercle fracture, there are no reports of
shoulder joint, exercise is useful for the maintenance of recurrent luxation in horses or ponies. This is in con
shoulder strength and resolution of supra‐ and infraspi trast to small animal species12 and large animal species
natus muscle atrophy. One horse had marked atrophy other than horses,18,21,22 where reluxation is common.
of the supra‐ and infraspinatus musculature with shoul This may be due to the larger humeral head and greater
der luxation, two weeks after the inciting injury.16 This muscle mass of horses, as discussed previously.22,24
www.ajlobby.com
References
1 Arighi, M., Miller, C.R., and Pennock, P.W. (1987). 15 MacDonald, D.G., Bailey, J.V., and Fowler, J.D. (1995).
Arthrodesis of the scapulohumeral joint in a miniature Arthrodesis of the scapulohumeral joint in a horse.
horse. J. Am. Vet. Med. Assoc. 191: 713–714. Can. Vet. J. 36: 312–315.
2 Bleyaert, H.B., Sullins, K.E., and White, N.A. (1994). 16 Madison, J.B., Young, D., and Richardson, D. (1991).
Supraglenoid tubercle fracture in horses. Compend. Repair of shoulder luxation in a horse. J. Am. Vet. Med.
Contin. Educ. Pract. Vet. 16: 531–536. Assoc. 198: 455–456.
3 Boswell, J.C., Schramme, M.C., Wilson, A.M., and May, 17 McIlwraith, C.W., Nixon, A.J., and Wright, I.A. (2015).
S.A. (1999). Radiological study to evaluate suspected Shoulder. In: Diagnostic and Surgical Arthroscopy in
scapulohumeral joint dysplasia in shetland ponies. the Horse, 4e, 273–291. Elsevier.
Equine Vet. J. 31: 510–514. 18 Purohit, N.R., Choudhary, R.J., Chouhan, D.S. et al.
4 Clegg, P.D., Dyson, S.J., Summerhays, G.E., and (1985). Surgical repair of scapulohumeral luxation in
Schramme, M.C. (2001). Scapulohumeral osteoarthritis goats. Mod. Vet. Pract. 66: 758–759.
in 20 Shetland ponies, miniature horses and falabella 19 Rapp, H.J. and Weinreuter, S. (1996). Luxation of the
ponies. Vet. Rec. 148: 175–179. shoulder joint in a horse. A case report. Tierarztl. Prax.
5 Clegg, P.D. and May, S.A. (1995). Scapulohumeral 24: 41–43.
osteoarthritis in the Shetland pony (9 cases). In: 20 Rodgerson, D.H. and Hanson, R.R. (1997). What is your
Proceedings of the European College of Veterinary diagnosis? Subluxation of the right humerus with
Surgeons Annual Scientific Meeting, vol. 4, 290–291. secondary degenerative changes. J. Am. Vet. Med.
Zurich, Switzerland: ECVS. Assoc. 211: 701–702.
6 Colbourne, C.M., Yovich, J.V., and Bolton, J.R. 21 Rousseau, M., Anderson, D.E., Miesner, M.D. et al.
(1991). The diagnosis and successful treatment Retrospective study of scapulohumeral luxation in
of shoulder luxation in a pony. Aust. Equine Vet. South American camelids: 16 occurrences in 10
9: 100–102. alpacas and 1 llama (2003–2008). In: Proceedings
7 Devine, D.V., Jann, H.W., and Payton, M.E. (2006). Gait of the American College of Veterinary Surgeons
abnormalities caused by selective anesthesia of the Veterinary Symposium, vol. 2009, E44. Germantown,
suprascapular nerve in horses. Am. J. Vet. Res. 67: MD: ACVS.
834–836. 22 Semevolos, S.A., Nixon, A.J., Goodrich, L.R., and
8 Dyce, K.M., Sack, W.O., and Wensing, C.J.G. (1996). Ducharme, N.G. (1998). Shoulder joint luxation in large
The forelimb of the horse. In: Textbook of Veterinary animals: 14 cases (1976–1997). J. Am. Vet. Med. Assoc.
Anatomy, 2e (ed. K.M. Dyce, W.O. Sack and C.J.G. 213: 1608–1611.
Wensing), 573–610. Philadelphia: W.B. Saunders 23 Semevolos, S.A., Watkins, J.P., and Auer, J.A. (2003).
Company. Scapulohumeral arthrodesis in miniature horses.
9 Dyson, S. (1986). Shoulder lameness in horses: an Vet. Surg. 32: 416–420.
analysis of 58 suspected cases. Equine Vet. J. 18: 29–36. 24 Sisson, S. (1975). Syndesmology. In: Sisson and
10 Fortier, L.A. (2006). Shoulder. In: Equine Surgery, 3e Grossman’s The Anatomy of the Domestic Animals, 5e
(ed. J.A. Auer and J.A. Stick), 1280–1288. St. Louis, (ed. R. Getty), 354. Philadelphia: W.B. Saunders Co.
MO: Saunders Elsevier. 25 Vasseur, P.B., Moore, D., and Brown, S.A. (1982).
11 Hardy, J. and Marohn, M.A. (1989). What is your Stability of the canine shoulder joint: an in vitro
diagnosis? Scapulohumeral luxation. J. Am. Vet. Med. analysis. Am. J. Vet. Res. 43: 352–355.
Assoc. 195: 1773–1774. 26 Watts, A.E., Fortier, L.A., Nixon, A.J., and Ducharme,
12 Hohn, R.B., Rosen, H., Bohning, R.H. Jr., and N.G. (2008). A technique for internal fixation of
Brown, S.G. (1971). Surgical stabilization of recurrent scapulohumeral luxation using scapulohumeral tension
shoulder luxation. Vet. Clin. North Am. 1: 537–548. sutures in three alpacas and one miniature steer.
13 Howard, L.L. and Richardson, G.L. (2005). Vet. Surg. 37: 161–165.
Transposition of the biceps tendon to reduce lateral 27 Wilson, R.G. and Reynolds, W.T. (1984).
scapulohumeral luxation in three species of Scapulohumeral luxation with treatment by
nondomestic ruminant. J. Zoo. Wildl. Med. closed reduction in a horse. Aust. Vet. J. 61:
36: 290–294. 300–301.
14 Lesser, A.S. (2003). Arthrodesis. In: Textbook of Small 28 Zilberstein, L.F., Tnibar, A., Coudry, V. et al. (2005).
Animal Surgery, 3e (ed. D. Slatter), 2170–2171. Luxation of the shoulder joint in a horse recovering
Philadelphia, PA: Saunders. from general anaesthesia. Vet. Rec. 157: 748–749.
www.ajlobby.com
603
33
Fractures of the Scapula
Stephen B. Adams1 and Alan J. Nixon2,3
1
Department of Veterinary Clinical Sciences, School of Veterinary Medicine, Purdue University, Lynn Hall, West
Lafayette, IN, USA
2
3
Introduction Fractures of the supraglenoid tubercle are most common,

and often enter the glenoid cavity of the scapula.5,9 Scapular
Fractures of the scapula are not common in horses. The fractures may be caused by direct trauma such as a kick or
proximal location on the appendicular skeleton, close prox- the horse running into a fixed object. Fractures may also
imity to the chest, and relatively good muscle cover protect occur during falls in horses that are racing or jumping.10,22
the scapula from trauma.21 Data accumulated from 27 vet- Supraglenoid tubercle fractures may result from direct
erinary schools in North America (Veterinary Medical trauma in mature horses, avulsion injury in weanlings and
DataBases, http://www.vmdb.org) revealed that 193 horses yearlings, or develop following scapular notch resection for
were diagnosed with fractures of the scapula over an 18‐ release of the suprascapular nerve in horses with sweeney.19
year period (1991–2008). (Note that the VMDB does not Stress fractures of the scapula occur in racehorses and are
make any implicit or implied opinion on the subject of any located most frequently in the middle and distal third of
paper or study.) The 193 horses with scapular fractures the bone and in the suprascapular fossa.23–26 These frac-
were 1.03% of the 18 677 horses with all fractures and only tures often precede catastrophic fractures, which are usu-
0.06% of all horses admitted to these hospitals during the ally transverse through the distal end of the scapular spine
same time period. Scapular fractures occurred in all breeds and may be comminuted and extend into the glenoid cav-
and horses of all age. Fractures in intact and castrated male ity.26 Incidence data suggest a right forelimb predisposition
horses accounted for 66% of the scapular fractures. The to fracture, and a higher incidence in racing Quarter Horses
scapular fractures occurred in all ages of horses, with 14.4% than Thoroughbreds.23 Additionally, catastrophic scapular
occurring in horses less than 1 year old, 38.8% in horses fractures in racehorses were more likely to develop in
1–4 years of age, 23.3% in horses 5–10 years of age, and horses that had a delayed entry to race training and were
23.3% in horses over 10 years of age. In an earlier data anal- early in their high‐speed training program.24
ysis from the same database, 219 horses with scapular frac-
tures represented 1.068% of horses with all fractures, and
occurred in 0.123% of all equine patients admitted to the Clinical Signs and Diagnosis
hospitals from 1981 to 1990. Catastrophic scapular frac-
tures in Thoroughbred and Quarter Horse racehorses Supraglenoid Tubercle Fractures
accounted for 2% and 6%, respectively, of all musculoskel-
etal fatal injuries over the period from 1991 to 2006.22 Lameness following fracture of the supraglenoid tuber-
cle is acute in onset and initially severe. Horses may bear
weight on the affected limb, but they have trouble
E tiology extending the shoulder and the cranial phase of the
stride is shortened. Swelling is variable, and when it
Fractures of the scapula may occur in the body, neck, occurs may resolve quickly. Manipulation of the shoul-
supraglenoid tubercle, spine, or glenoid cavity.9,11,21 der causes pain, but crepitation is often not detected,

www.ajlobby.com
Figure 33.1 Fracture of the supraglenoid tubercle. Note the

articular involvement and displacement of the tubercle cranially
and ventrally.
possibly because the fractured supraglenoid tubercle

is pulled cranially and ventrally by the biceps and
coracobrachialis muscles distracting the fragment

from the parent bone. Severe lameness and swelling
from supraglenoid tubercle fractures often resolve
within 48–72 hours, making the clinician less likely to
suspect fracture as the diagnosis. Horses with fractures
of long duration may present with atrophy of the shoul-
der muscles and clinical signs can resemble suprascapu-
lar or radial nerve damage.9 There may be a firm,
nonpainful swelling over the point of the shoulder in
horses with chronic untreated fractures. Figure 33.2 Displaced mid‐body scapular fracture with severe
swelling and skin lacerations following an impact with a tree. The
Diagnosis of supraglenoid tubercle fractures is made by
horse was severely lame, and fracture stabilization was performed
history of trauma, clinical examination, improvement of three days after injury.
lameness with intraarticular anesthesia in acute f ractures,
and radiography. Diagnostic radiographs are usually pos- nerve damage.6 Nerve damage is hard to detect in a non‐
sible in the standing horse, because the supraglenoid weight‐bearing limb. Needle electromyography can be
tubercle is commonly displaced cranially and ventrally. helpful in assessing nerve damage, but must be done at
The tubercle may impinge on the articular cartilage of least seven days after injury.6 Large horses and horses in
the humerus. Supraglenoid tubercle fractures are usually severe pain may need to be anesthetized in order to
articular and may be simple or less commonly commi- get diagnostic‐quality radiographs. Digital radiography
nuted.9,17 The fracture occurs through the physis in should be utilized wherever possible. Radiographs must
young horses, or follows the line of the original physis in be high quality due to the thickness of the chest, and
older horses in which the physis has closed (Figure 33.1).9 overlapping ribs and vertebrae. Medial to lateral, ventro-
dorsal, and oblique cranial to caudal radiographic pro-
jections of the scapula will reveal most fractures.21
Fractures of the Neck or Body Nondisplaced fractures are often hard to detect radio-
These fractures are rare. Horses with fractures of the graphically. Nuclear scintigraphy may be vital in the
neck or body of the scapula are usually non‐weight bear- localization of the fracture (Figure 33.3). Ultrasound
ing on the affected limb after injury. Swelling of the entire examination of the scapula may reveal minimally dis-
shoulder region can be marked initially (Figure 33.2). placed fractures which cannot be detected with radiogra-
Palpation of the shoulder may induce pain. Crepitation phy (Figure 33.4).8 Lameness can vary from mild to severe
may be difficult to elicit due to the large muscle masses of in chronic cases, and pain is evident in both weight‐bear-
the shoulder and the marked swelling around the scap- ing and swinging phases of the stride.9 After resolution of
ula. Horses should be assessed for other injuries, such as swelling, muscle atrophy of the shoulder muscles may
rib fractures, intrathoracic trauma, and suprascapular become apparent within three weeks of injury.9
www.ajlobby.com
(see Figure 33.3) and the absence of improvement with

lower limb nerve blocks.25
Treatment
Supraglenoid Tubercle Fractures

Supraglenoid tubercle fractures can be treated by rest,
excision of the fractured tubercle, or internal fixation.
Rested horses may become pasture sound and useful for
breeding. Osteoarthritis of the scapulohumeral joint and
restriction of the cranial phase of the stride, due to
impingement of the tubercle on the humerus and to scar
tissue formation, often limit exercise. However, one
horse with minimal displacement of the fractured tuber-
cle and minimal joint involvement became sound for
athletic use following rest.18
Resection of the fractured supraglenoid tubercle has
been successful in returning three horses to athletic
use.5,18,27 Resection may be the best method of treatment
in horses with: 1) severely comminuted fractures; 2)
horses with fractures greater than seven days in duration
Figure 33.3 Nuclear scintigraphic image of horse with stress which are difficult to accurately reduce due to callus for-
fracture of the scapula neck. The increased radiopharmaceutical
mation, fibrosis, and remodeling; 3) very heavy horses in
uptake (arrow) at the junction of the body and neck confirm the
diagnosis. RF, right front. which internal fixation may be disrupted; and 4) horses
with small nonarticular fractures (Figure 33.5). Resection
of the fractured supraglenoid tubercle is an easier surgical
Stress Fractures procedure than internal fixation, and may be done if
Stress fractures cause acute onset of forelimb lameness intraoperative attempts at internal fixation are unsuccessful.
in racehorses. Lameness often improves with rest. The surgical approach for resection and internal fixation is
Clinical signs other than lameness are frequently absent, the same. Ideally, resection should be done before degen-
although some horses will have pain on palpation of erative changes develop in the joint. Resection eliminates
the scapula and resent upper limb abduction.25 The the mechanical interference to shoulder extension and
diagnosis is often confirmed with nuclear scintigraphy damage to the proximal humerus from the displaced
(A) (B) (C)
Figure 33.4 Fracture of the proximal region of the scapula body shown by ultrasonographic examination. (A) Day 2 ultrasonographic
appearance after acute onset of lameness. (B) Ultrasonographic appearance after four weeks showing active callus formation (arrows).
(C) Corresponding nuclear scintigraphic appearance. Source: Images courtesy Dr. Mary Beth Whitcomb.
www.ajlobby.com
using pins and cerclage wire.17 More recently, successful

repair with subsequent athletic soundness has been
achieved with lag screws alone;7 lag screws and tension
band wires;11 lag screws, tension band wires, and partial
tenotomy of the biceps brachii tendon;1 lag screw fixa-
tion with complete biceps brachii tenotomy;4 and appli-
cation of locking compression plates (LCPs).2,3,12,15
Current recommendations for treatment with internal
fixation are stabilization of the fracture with three
5.5 mm diameter cortical bone screws placed across the
fracture using lag technique, and a tension band wire
placed from the cranial scapula to the supraglenoid
tubercle. Two screws may be used in young foals. For
larger yearlings and adults, one or two LCPs may be an
effective alternative. Where screws and a tension band
wire are employed, partial or complete biceps tenotomy
should be considered in horses weighing more than
550 kg, to temporarily reduce distractive forces on the
supraglenoid tubercle and lessen the risk of failure of the
internal fixation.
Surgical Technique
Resection of the Supraglenoid Tubercle
Surgery to remove the fractured supraglenoid tubercle is
Figure 33.5 Small nonarticular fracture of the supraglenoid performed with the horse anesthetized and positioned
tubercle. Note the fracture bed on the scapula (arrowheads) and in lateral recumbency with the affected limb up.
the avulsed fragment retracted distally (arrow). Surgical removal Perioperative broad‐spectrum antibiotics should be
can return these horses to function. Source: Image courtesy administered and continued into the postoperative
Ryland Edwards. period. A 25 to 30 cm curvilinear skin incision is made
over the spine of the scapula and curves over the cranial
tubercle.17 Following resection, the biceps and coracobra- aspect of the greater tubercle of the humerus (Figure 33.6).
chialis tendons reattach to the scapula by fibrosis, thus The incision is continued distally to the deltoid tuberos-
reestablishing the horse’s ability to extend the shoulder ity. Fascia overlying the supraspinatus muscle is incised
joint over a period of time.17 Return to soundness requires and the brachiocephalicus muscle is identified. The fascia
three to six months of stall rest followed by restricted immediately adjacent to the caudodorsal aspect of the
exercise. The disadvantage to resection of articular frac- brachiocephalicus muscle is incised, leaving the muscle
tures of the supraglenoid tubercle is disruption of the intact, and the muscle is retracted cranially and ventrally.
joint surface with loss of part of the glenoid cavity, and the The supraspinatus muscle is incised in the direction of its
possibility of shoulder subluxation. fibers directly over the tubercle, and the muscle is split
Internal fixation of the fractured supraglenoid tubercle and separated with self‐retaining retractors. Care must
achieves reconstruction and restoration of the articular be taken to avoid damaging the suprascapular nerve and
surface and earlier return of function of the biceps brachii adjacent vessels. Alternatively, the supraspinatus muscle
and coracobrachialis muscles. Restoration of the articular overlying the fracture can be elevated from the scapula
surface to normal alignment is a major goal of articular and retracted cranially to expose the supraglenoid tuber-
fracture repair in horses intended for athletic use. Internal cle. Splitting the muscle is preferred, especially in large
fixation should be strongly considered when horses are horses or in horses with fractures of long standing that
intended for athletic use, the fracture is simple or mini- have developed fibrosis and callus. The fracture fragment
mally comminuted, the fracture involves one‐third or more and fissure are identified by palpation. To expose the
of the glenoid cavity, and reduction is possible.1,4,7,11 fracture fissure, any supraspinatus muscle and fibrous
Earlier attempts to stabilize fractured supraglenoid callus adhering to the tubercle are excised. Resection is
tubercles with internal fixation in horses were unsuc- performed by grasping the fragment with bone‐holding
cessful because of the strong distractive forces of the forceps and sharply dissecting around the fragment to
biceps brachii and inadequate hardware.17 One excep- detach the muscles, tendons, and joint capsule
tion was a successful repair in a three‐week‐old foal (Figure 33.7). Dissection can be difficult on the medial
www.ajlobby.com
side of the fractured fragment due to limited visualization

(A)
and mobility, and the surgeon should ensure that all dis-
section occurs immediately adjacent to the fracture frag-
ment. This can be done by keeping scissor blades and
scalpel blades against the fragment during excision.
Internal Fixation
The surgical approach to the fractured supraglenoid
Incision
tubercle used for resection is used for screw fixation
(see Figure 33.6). The fractured tubercle is identified
(B)
and reduced using the articular surface of the scapula as
Supraspinatus muscle the reference point. Clot, granulation tissue, and callus
may have to be removed from the fracture fissure. When
biceps brachii tenotomy is chosen as part of the proce-
dure, it is done at this point in time by sharp transection
of the tendon immediately adjacent to the tubercle with
a scalpel blade. To maintain fragment reduction while
inserting lag screws, a 1.25 mm diameter cerclage wire is
placed in a figure‐eight pattern between the supragle-
noid tubercle and the cranial edge of the scapula
(Figure 33.8). Small holes are drilled across the tubercle
and the c ranial edge of the scapula proximal to the frac-
ture for inserting the wire. The surgeon should identify
Supraglenoid tubercle
and avoid damage to the suprascapular nerve. Stab inci-
Figure 33.6 Surgical approach to the supraglenoid tubercle for sions can be made in the biceps brachii tendon for place-
internal fixation or excision of fractures. (A) The skin incision ment of screws when tenotomy is not performed. Partial
extends from the spine of the scapula over the point of the tenotomy of the biceps brachii is preferred. Three
shoulder to the level of the deltoid tuberosity. (B) After incision of
the skin and subcutaneous tissues, the brachiocephalicus muscle
5.5 mm diameter cortical screws should be placed across
is retracted cranioventrally and the supraspinatus muscle is split, the fracture as lag screws and should all diverge slightly
exposing the supraglenoid tubercle. to increase the strength of the fixation.11 These screws
(A) (B)
Figure 33.7 Surgical removal of supraglenoid tubercle in a displaced chronic fracture. (A) Preoperative radiographs show cranial and
ventral displacement of the fractured tubercle and minor involvement of the articular surface of the shoulder. (B) Radiograph taken nine
weeks postoperatively shows good reconstruction of the cranial glenoid rim of the shoulder joint. The horse went on to race. Source:
Images courtesy Dr. Alan J. Nixon.
www.ajlobby.com
direction for plate application, decreased risk of iatro-

genic damage to the suprascapular nerve, and plate
compression of the reduced fragment, which provides
expedited healing and better resistance to repair
disruption.2 Additionally, biceps tenotomy is avoided.
Specialized LCP implants such as the distal femoral
locking plate have also been utilized, although careful
overbending of the plate is required to avoid irritation
and dysfunction of the suprascapular nerve.12,13 The
study of bone density and anatomic arborization of the
suprascapular nerve suggests that transversely oriented
plates may be an advantage compared to application of
plates parallel to the scapula spine.13
Closure of the Wound
Following resection or internal fixation of the fracture,
copious lavage is performed. Drains increase the risk of
infection and are not recommended. The supraspinatus
Figure 33.8 Diagram of surgical repair of fracture of the muscle is closed with a simple continuous suture pattern
supraglenoid tubercle. A figure‐eight wire is placed to reduce the placed in the external fascia. The brachiocephalicus mus-
fracture and provide a tension band, and three 5.5 mm diameter cle and adjacent fascia, and the subcutaneous t issues, are
cortical screws are placed to secure the fracture using lag screw also closed with a simple continuous suture pattern.
technique. The figure‐eight wire could alternatively be placed
under the head of the proximal screw, using a washer to ensure it
Synthetic absorbable antibacterial suture materials such
remains in place. as polygalactin 910 (Vicryl® Plus, Ethicon, Somerville, NJ,
USA) or poliglecaprone (Monocryl® Plus, Ethicon) are
preferred for all deep layers. The skin is apposed with sur-
will be 80 mm or longer in adult horses (Figure 33.9). gical staples. Alternatively, any acceptable skin suture pat-
During fixation, the articular surface should be exam- tern using monofilament nonabsorbable suture material
ined visually and by palpation to ensure accurate reduc- may be used. Dead space and seroma formation following
tion and a well‐aligned articular surface. If for any fracture fragment removal, or biceps tenotomy and the
reason internal fixation is not accomplished, excision of implantation of screws and wires, may increase the risk of
the supraglenoid tubercle can be performed. infection. Following skin closure, an aminoglycoside anti-
Use of transversely applied LCPs has recently been microbial drug such as amikacin (Sicor Pharmaceuticals,
described.2,3,12,15 Advantages of the use of one or two LCP Irvine, CA, USA) can be injected directly into the wound
plates include easier access and drilling in a lateromedial adjacent to the shoulder joint as a prophylactic measure.
(A) (B) Figure 33.9 Repaired supraglenoid

tubercle fracture. (A) Preoperative
radiograph shows severe displacement of
the fractured tubercle. (B) Surgical
stabilization using a hemicerclage tension
band wire and three 5.5 mm cortical screws.
www.ajlobby.com
Postoperative Care For exposure of scapular neck fractures, the caudodorsal

The horse is recovered from anesthesia with tail and fascia adjacent to the brachiocephalicus muscle is incised
head rope assistance. Perioperative broad‐spectrum and the muscle is retracted cranially and ventrally. The
antibiotics should be continued for five days. Analgesics heavy fascia attaching the supraspinatus and infraspina-
are given as needed. Horses should be confined to a stall tus muscles to the spine of the scapula is incised; the
for eight weeks, followed by stall rest with hand walking muscles are elevated subperiosteally from the spine and
for a further four weeks. Restricted paddock exercise body of the scapula, and retracted to expose the fracture
can then be instituted for 8–12 weeks. Removal of the (Figure 33.10). The suprascapular nerve and adjacent
surgical implants is usually not required. vessels need to be identified, isolated, and protected. The
fracture is cleaned of debris and reduced.
Prognosis An appropriately sized bone plate is contoured and
The prognosis for athletic use is fair following internal applied to the side of the scapula at the junction of the body
fixation, providing that alignment of the articular surface and the spine. Narrow plates should be used to better fit in
is good, minimal joint surface has been damaged, and the angle between the spine and the body, which will allow
disruption of the repair does not occur. Fracture repair of maximal bone purchase by screws in the thicker scapular
supraglenoid tubercle fractures is not frequent, and bone adjacent to the spine (Figure 33.11).6 Narrow 4.5 mm
comparison of the outcome between horses with frac- dynamic compression plates (DCPs), limited‐contact
ture fragment resection and internal fixation in a single dynamic compression plates (LC‐DCPs), or LCPs can be
study has not been reported. The preference, however, selected for fracture repair. Narrow 3.5 mm DCPs, LC‐
for horses with reducible articular fractures intended for DCPs, or LCPs are sufficient in foals. In adult horses,
athletic use, is anatomic reduction and internal fixation. 8‐ to 10‐hole plates are generally the appropriate length.
Use of transversely applied LCPs resulted in successful Cancellous or locking bone screws of appropriate size
bony union in all four horses in a recent publication.2 and type are selected for each bone plate type.
Three of these four horses continued on to have athletic Bone plates have a slightly curved cross‐section, and
careers, including racing. Similarly, supraglenoid tuber- application of the plate to the scapula upside down to
cle fracture fixation with distal femoral locking plates in achieve better contact of the plate with the angle of the
three horses resulted in bony union, but the outcome scapula has been described.6,14 Although upside‐down
was complicated by supraspinatus and infraspinatus application can be considered for the DCP, the screw
muscle atrophy.12 heads do not fit into the screw holes on the back side of
the plate, thus weakening the fixation, and this technique
Fractures of the Neck or Body is generally not necessary. The LC‐DCP and LCP should
always be applied in the normal position. The LCP does
of the Scapula not require close application to the bone for secure fixa-
Fractures of the neck and body of the scapula can be tion, has superior construct strength in the soft thin
transverse, longitudinal, comminuted, or involve just the scapular bone compared to the other plates, is easy to
scapular spine. Fractures of the scapular body that are apply, and one plate may be sufficient for most horses.
nondisplaced or minimally displaced may heal in some The only disadvantage is the increased cost of the plate
horses following stall confinement.9 Six weeks or more and locking screws. When two plates are applied to the
may be required. Horses suitable for conservative ther- fractured scapula, the plates can be positioned at 90° to
apy should be able to bear weight on the affected limb. each other on each side of the spine (Figure 33.12). The
plates should be placed in a staggered position so that the
Transverse Fractures of the Neck or Body screws do not contact each other. Specifics of plate size,
Horses with transverse neck fractures or displaced screw type, and screw size depend on the size of the
unstable transverse body fractures are best treated with horse and the surgeon’s preference.
internal fixation. Successful repair of these fractures The wound is closed by apposing the fascia of the
using bone plates and screws has been reported.6,14,20 supraspinatus and infraspinatus muscles to the scapular
fascia, suturing the brachiocephalicus muscle to the
Surgical Technique adjacent fascia, and closing subcutaneous tissues and
Perioperative broad‐spectrum antibiotics should be skin, as described for the repair of supraglenoid tubercle
administered. Following induction of general anesthesia, fractures. Analgesics are used as needed to control
the horse is positioned in lateral recumbency with the severe pain. Implants rarely need to be removed follow-
affected limb up. The skin and fascia are incised just ing fracture healing. The prognosis for horses with
cranial to the spine of the scapula. The incision extends transverse neck or body fractures is fair in young horses
15 cm proximal and distal to the level of the fracture. and guarded in adults.
www.ajlobby.com
(A) (B)
(C) (D)
Figure 33.10 Double plating of a displaced mid‐body scapular fracture. Same case as Figure 33.2 (A) Preoperative craniocaudal
radiograph shows severe overriding of the scapula and minor comminution at the fracture line. (B) Surgical exposure of the fracture
shows severe displacement and overriding. (C) Realignment and application of the first narrow 4.5 mm dynamic compression plate (DCP).
(D) Application of the second DCP shows interdigitating plate screws, and contouring of the plates to fit the irregular scapula shape.
Source: Images courtesy Dr. Alan Nixon.
joint disease. A longitudinal fracture in one horse was

repaired with four 4.5 mm narrow DCPs positioned to
compress and stabilize the fracture at multiple sites.16
The surgical approach to longitudinal fractures is similar
to that described for transverse fractures. Comminuted
fractures of the neck or glenoid carry a grave prognosis
and euthanasia is a reasonable option.
Fractures of the Scapula Spine

Figure 33.11 Diagram of position of bone plates and screws for Closed fractures of the spine of the scapula often heal
repair of transverse neck or body fractures.
with rest alone and have a good prognosis. Diagnosis and
establishing an accurate prognosis can be difficult. In
smaller horses, computed tomography may be beneficial
Longitudinal Fractures (Figure 33.13). Open fractures can occasionally occur. If
Longitudinal fractures may occur in the scapular glenoid, sequestration of pieces of the scapular spine occurs, the
neck, or body, and may involve the joint.9 These fractures pieces should be removed surgically. This is performed by
are rare and may be difficult to visualize radiographically. incision directly over the sequestrum and the procedure
Nondisplaced fractures may heal with stall rest.9 However, often can be done on the standing sedated horse using
articular fractures should be repaired by internal fixation, local anesthesia. Prognosis following removal of the
when possible, to decrease the probability of degenerative sequestrum is good for athletic soundness.
www.ajlobby.com
(A) (B) (C)
Figure 33.12 Application of two locking compression plates (LCPs) for repair of a mid‐body transverse fracture of the scapula in
an adult. (A) Preoperative craniocaudal radiograph of the scapula shows fracture overriding of the short oblique midbody
fracture. (B, C) Postoperative radiographs showing application of two LCPs to provide rigid fixation. Source: Images courtesy
Dr. Ashlee Watts.
(A) (B) (C)
Figure 33.13 Longitudinal fracture of the scapular spine in a four‐month‐old foal. (A, B) Preoperative radiographs show a displaced
longitudinal fracture of the scapular spine. (C) Computed tomography indicates continued proximal attachment with moderate
displacement of the surface of the scapular spine. Conservative therapy was selected, and the foal returned to full function.
www.ajlobby.com
References
1 Adams, S.B. (1987). Surgical repair of a supraglenoid 16 Kidd, J.A., Lamas, L., and Henson, F.M.D. (2007).
tubercle fracture in a horse. J. Am. Vet. Med. Assoc. 191: Repair of a longitudinal scapular fracture in a horse.
332–334. Vet. Surg. 36: 378–381.
2 Ahearn, B.J., Bayliss, I.P.M., Zedler, S.T. et al. (2017). 17 Lietch, M. (1977). A review of treatment of tuber
Supraglenoid tubercle fracture repair with transverse scapulae fractures in the horse. J. Equine Med. Surg.
locking compression plates in 4 horses. Vet. Surg. 1: 234–240.
46: 507–514. 18 Pankowski, R.L., Grant, B.D., Sande, R., and Nickels,
3 Auer, J.A. and Furst, A.E. (2017). Fractures of the F.A. (1986). Fracture of the supraglenoid tubercle.
scapula. Equine Vet. Educ. 29: 184–195. Treatment and results in five horses. Vet. Surg. 15:
4 Blayaert, H.F. and Madison, J.B. (1999). Complete 33–39.
biceps brachii tenotomy to facilitate internal fixation of 19 Schneider, J.E., Adams, O.R., Easley, K.J. et al. (1985).
supraglenoid tubercle fractures in three horses. Vet. Scapular notch resection for suprascapular nerve
Surg. 28: 48–53. decompression in 12 horses. J. Am. Vet. Med. Assoc.
5 Blayaert, H.F., Sullins, K.E., and White, N.A. (1994). 187: 1019–1020.
Supraglenoid tubercle fractures in horses. Compend. 20 Shamis, L.D., Sanders‐Shamis, M., and Bramlage, L.R.
Equine Cont. Educ. Vet. 16: 531–537. (1989). Internal fixation of a transverse scapular neck
6 Bukowiecki, C.F., van Fe, R.T., and Schneiter, H.L. (1989). fracture in a filly. J. Am. Vet. Med. Assoc. 195:
Internal fixation of comminuted transverse scapular 1391–1392.
fracture in a foal. J. Am. Vet. Med. Assoc. 195: 781–783. 21 Stashak, T.S. (1987). Lameness. In: Adams’ Lameness in
7 Dart, A.J. and Snyder, J.R. (1992). Repair of a Horses (ed. T.S. Stashak), 691–692. Philadelphia: Lea
supraglenoid tuberosity fracture in a horse. J. Am. Vet. and Febiger.
Med. Assoc. 201: 95–96. 22 Stover, S.M. and Murray, A. (2008). The California
8 Davidson, E.J. and Martin, B.B. (2004). Stress fracture postmortem program: leading the way. Vet. Clin. North
of the scapula in two horses. Vet. Radiol. Ultrasound Am. Equine Pract. 24: 21–36.
45: 407–410. 23 Vallance, S.A., Case, J.T., Entwistle, R.C. et al. (2012).
9 Dyson, S. (1985). Sixteen fractures of the shoulder Characteristics of Thoroughbred and Quarter Horse
region in the horse. Equine Vet. J. 17: 104–110. racehorses that sustained a complete scapular fracture.
10 Dyson, S. (1986). Shoulder lameness in horses: an Equine Vet. J. 44: 425–431.
analysis of 58 suspected cases. Equine Vet. J. 18: 29–36. 24 Vallance, S.A., Entwistle, R.C., Hitchens, P.L. et al.
11 Fortier, L.A. (2006). Shoulder. In: Equine Surgery (ed. (2013). Case‐control study of high‐speed exercise
J.A. Auer and J.A. Stick), 1282–1285. Saunders Elsevier. history of Thoroughbred and Quarter Horse racehorses
12 Frei, S., Fürst, A.E., Sacks, M., and Bischofberger, A.S. that died related to a complete scapular fracture.
(2016). Fixation of supraglenoid tubercle fractures Equine Vet. J. 45: 284–292.
using distal femoral locking plates in three Warmblood 25 Vallance, S.A., Lumsden, J.M., and O’Sullivan, C.B.
horses. Vet. Comp. Orthop. Traumatol. 29: 246–252. (2007). Scapula stress fractures in eight Thoroughbred
13 Frei, S., Geyer, H., Hoey, S. et al. (2017). Evaluation of racehorses. In: Proceedings of the American Association
the optimal plate position for the fixation of of Equine Practitioners, vol. 53, 56–57. Lexington,
supraglenoid tubercle fractures in warmbloods. Vet. KY: AAEP.
Comp. Orthop. Traumatol. 30: 99–106. 26 Vallance, S.A., Spriet, M., and Stover, S.M. (2011).
14 Goble, D.O. and Brinker, W.O. (1977). Internal fixation Catastrophic scapular fractures in Californian
of the equine scapula: a case report. J. Equine Med. racehorses: pathology, morphometry and bone density.
Surg. 1: 341. Equine Vet. J. 43: 676–685.
15 Kamm, J.L., Quinn, G., and van Zwanenberg, D. (2017). 27 Wagner, P.C., Watrous, B.J., Shires, G.M., and Riebold,
Fixation of a complete scapular neck fracture in a foal T.W. (1985). Resection of the supraglenoid tubercle of
using two 3.5 mm locking compression plates. Equine the scapula in a colt. Compend. Cont. Educ. Pract. Vet.
Vet. Educ. 29: 180–182. 7: S36–S41.
www.ajlobby.com
613
34
Fractures and Luxations of the Hock
Alan J. Nixon1,2
1
2
Incidence the case of chronic trochlear ridge or central and third

tarsal bone fractures, to severe and non‐weight bearing
Fractures and luxations of the hock occur infrequently, and in the case of comminuted fractures of the talus or calca-
involve numerous sites and fracture configurations, making neus.10,15 Similarly, the degree of swelling reflects the extent
treatment and assessment of prognosis challenging. The of original trauma. Injuries to the tarsocrural articulation
hock is heavily invested by collateral and periarticular liga- and component bones are more noticeable owing to swelling
ments and the insertions of extensive muscles and ligaments, of the dorsomedial and dorsolateral synovial pouches, com-
including the cranial tibial and peroneus tertius muscles.40,41 pared with the tight capsules and extensive ligaments and
Because of these influences, fractures and luxations of the tendons investing the intertarsal and tarsometatarsal joints.
hock are not particularly common, and when they do occur Major disruption of the articulations that lead to insta-
involve significant trauma, which disrupts many of the sup- bility and luxation can be diagnosed by palpation alone.
port structures. External impact can account for fracture of Confirmation of the precise joint involved in the instabil-
the exposed portions of the tibial malleoli, trochlear ridges, ity requires radiography. Additionally, less obvious sub-
tuber calcaneus, and fourth tarsal bone. However, other luxations and most of the fractures require confirmation
forces, particularly rotatory twisting in an accident with or by radiography. Stressed views are integral to the diagno-
without the lower limb fixed, probably cause fractures of the sis of subluxations and occasionally assist in defining
body of the talus and distal portions of the tibia and luxation fractures of the talus, calcaneus, or distal tibial malleoli
of the various articulations of the hock. Accidents in which (Figure 34.1). Flexed lateral radiographs are important in
the distal limb is trapped in a hole, cattle grate, railway bridge, determining the extent of a fracture in the proximal
or entangled in a fence are often described in the history of trochlear ridges of the talus,33,36 and in stressing mini-
horses with luxations and major fractures of the tarsus. mally displaced fractures of the calcaneus. The os calcis
Most fractures and luxations of the hock are closed. The “skyline” projection is also critical in defining fractures of
one exception is fractures of the tuber calcaneus, which are portions of the trochlear ridges and, particularly, frac-
often open following external impact or the horse kicking tures of most areas of the calcaneus.8,14,16,33,38,39
out at walls, doors, fences, or machinery.14 Osteomyelitis, A preliminary diagnosis and confirmation of fractures
sequestration of fracture fragments, and chronic drainage of the central and third tarsal bones can be difficult.35,37
are common complications of this fracture. Additionally, Most fractures of these flat bones are not extensively dis-
disruption of the sustentaculum tali, infection of the tarsal placed and initially may not be evident on routine radio-
sheath and deep flexor tendon, and displacement of the graphs.19,35 Although some may eventually demineralize
superficial flexor tendon from the tuber calcaneus are pos- adequately along the fracture line, advanced imaging
sible sequelae to calcaneal fracture.31,34 such as nuclear scintigraphy is particularly helpful in
establishing a diagnosis (Figure 34.2).35 Regardless, a
Diagnosis complicating factor in many central and third tarsal frac-
tures is the presence of additional undetected fracture
The degree of lameness varies according to the extent of planes, which make the surgical treatment more difficult
structural damage. Lameness can be mild to moderate in and the prognosis less favorable.37 Multiple radiographic

www.ajlobby.com
(A) (B) Fractures of Specific

Tarsal Bones
Talus
Fractures of the talus vary from simple fragmentation of
small portions of the trochlear ridges to complete disrup-
tive comminuted fracture of the entire body of the talus.
The degree of comminution usually determines the sever-
ity of the lameness and the extent of associated swelling.
Trochlear Ridges of the Talus

The trochlear ridges are susceptible to external impact
trauma from direct kicks by other horses, polo mallet
injuries, or impact of the hock on rails, fences, walls, or
doors. The distal aspect of the lateral trochlear ridge
(LTR) and the proximal aspect of the medial trochlear
ridge (MTR) are most susceptible (Figure 34.4).10,15,21,33,3
6,38,43
However, fractures of the distal regions of the MTR
Figure 34.1 (A) Normal and (B) stressed radiographs showing also occur. Fractures of both trochlear ridges are more
subluxation of the tarsometatarsal joint. The horse was serious due to the loss of tarsocrural joint stability
successfully treated with a full limb cast for six weeks. afforded by the interdigitation of the trochlear ridges and
the distal tibia (Figure 34.5). Fractures that involve both
projections of these bones are important if surgical repair trochlear ridges can develop during severe twisting
is being considered. Ideally, three‐dimensional imaging movements of the affected limb with the hock partially
using standing magnetic resonance imaging (MRI) or flexed, which transfers the tibial contact region to the
standing robotic computed tomography (CT) should be distal areas of the talar trochlear ridges. Fractures of the
used to establish the fracture configuration (Figure 34.3). trochlear ridges need to be differentiated from osteo-
Additionally, use of CT under anesthesia immediately chondritis dissecans (OCD) fragments, particularly of the
prior to surgery allows for better assessment of the frac- LTR. The OCD fragments typically occur in weanlings
ture planes and more appropriate screw placement. and yearlings and lameness is rarely severe, compared
(A) (B) (C)
Figure 34.2 (A) Nuclear scintigram and subsequent (B) lateral and (C) dorsolateral to plantaromedial oblique radiographs of a horse with
a chronic hindlimb lameness. A minimally displaced central tarsal bone fracture is identified (arrow).
www.ajlobby.com
joint to allow examination of the LTR. An instrument

portal is made in the dorsolateral joint pouch after the
most appropriate site is determined by needle insertion.
Fractures of the LTR can usually be removed without dif-
ficulty. Extensive fractures may tend to be obscured, as
they rotate beneath the distal tibia articular surface when
the joint is flexed for arthroscope insertion. Placing both
the arthroscope and instrument portal in the dorsolat-
eral pouch will assist in complete examination. Large
fragments that consist of the distal one‐third to one‐half
of the entire LTR may be better reattached to the talus
(see Figure 34.5). Recessed 3.5 or 4.5 mm cortical bone
screws, or small cannulated screws, are suitable for
recently fractured extensive portions of the trochlear
ridge. Chronic fractures are more difficult to align accu-
rately, and most should be removed.
The dorsal and distal regions of the MTR protrude less
than the LTR and are fractured less frequently.
Nevertheless, when they do occur, MTR fractures tend
to be larger than LTR fractures. Lag screw fixation is
generally required. Arthroscopic guidance is used to
allow insertion of several recessed 3.5 mm cortical
screws. Arthroscope and instrument portals are made in
the dorsomedial joint pouch; the arthroscope enters
Figure 34.3 Standing low field strength MRI in a horse with a more proximally and medially, and the stab wounds for
two‐month history of severe hindlimb lameness. Transverse
screw placement are made at appropriate locations
T1‐weighted images identify a sagittal fracture of the central
tarsal bone. directly over the MTR. Radiographic control is recom-
mended in addition to arthroscopic visualization to
ensure adequate fracture reduction and screw place-
ment. Selection of the type of screw is dictated by avail-
with true fractures. The early literature on OCD often ability; however, 3.5 mm cortical screws have been
described these fragments as resulting from fracture satisfactory. Larger fracture fragments can be stabilized
rather than OCD. using 4.5 mm cortical screws.
Diagnosis of fractures of the trochlear ridge can usu- The distal regions of the trochlear ridges are not
ally be established using radiography. Multiple oblique directly weight bearing, and relatively large fragments
projections are often required, and unusual angles such can be removed. Similarly, reattached osteochondral
as the flexed proximolateral to distomedial view (see pieces heal relatively quickly with only one or two screws.
Figure 34.4) and skyline projections better highlight sur- The screwheads need to be recessed into subchondral
faces such as the proximal plantar aspect of the MTR. bone to avoid trauma to the tibial articular surface when
Comminuted and unusual fractures may necessitate the the tarsocrural joint is flexed.
use of CT or standing MRI to establish the fracture con- Fragments from the proximal plantar region of the
figuration and need for internal fixation. trochlear ridges can be removed arthroscopi-
cally.10,33,36,38 Arthroscopic approaches to this region
Treatment are described in the literature.23 Solitary fractures of
In most instances, surgical treatment is indicated to alle- the proximal region have always involved the MTR (see
viate the lameness and persisting effusion. Most small Figure 34.4). The LTR is well protected by the calca-
fragments can be removed by arthroscopy. However, for neus. Arthroscopic access is provided via the plantaro-
particularly large fragments, access can also be gained lateral joint pouch (Figure 34.6). The joint is distended
using limited arthrotomy.10,21,33,36,38 Fragmentation of and a spinal needle used to establish a portal in the
the distal and central regions of the trochlear ridges is more plantar aspects of the plantarolateral joint pouch.
visualized using standard arthroscopic techniques.23 This allows the arthroscope and instruments to more
Fractures of the LTR are visualized by an arthroscope easily traverse the prominent plantar extremities of
placed in the dorsomedial joint pouch and, with the hock the trochlear ridges. A 5 mm skin portal is made in
partially flexed, the arthroscope is advanced across the the plantar aspect of the plantarolateral pouch. The
www.ajlobby.com
(A) (B) (C)
(D) (E)
(H)
(F) (G)
Figure 34.4 Fracture of the proximal plantar aspect of the medial trochlear ridge in a Warmblood yearling. (A) A flexed proximal‐lateral to
distal‐medial projection identifies the fracture fragment (arrow). (B) Arthroscopic access allows visualization and separation of the
fracture; (C) dissection of capsular soft tissues; (D) removal of the fracture in pieces; (E) motorized debridement of the fracture bed; (F, G)
final assessment of soft tissues; and (H) intraoperative radiographs to verify fracture removal.
arthroscope is inserted and advanced from the lateral displace and may be partially embedded in the synovial
to the medial side, to allow examination of the talocal- lining, necessitating more dissection before removal.
caneal articulation, proximoplantar aspects of the Extensive fractures of the proximal plantar aspect of
LTR, caudal aspects of the intermediate ridge of the the MTR have significant synovial and joint capsule
tibia, and the MTR, in sequence. Flexion of the tar- attachment (Figure 34.7). Dissection of the soft tissues
socrural articulation increases the exposed area of the may require arthroscopic scissors, curved fixed‐blade
trochlear ridges. After localizing the fracture, a needle scalpels, periosteal elevators, and synovial resectors
is inserted through the plantaromedial joint pouch to (see Figure 34.4). Removal of the free fracture frag-
determine an appropriate site for instrument entry. ment may require forceps with aggressive teeth, includ-
Motorized synovial resectors are frequently used ini- ing insertion of Ochsner forceps or towel clamps.
tially to clear synovial proliferation and fibrin from the Rarely, large fractures will need to be divided using an
fracture line. For small fracture fragments of the osteotome, prior to removal in pieces. Debridement of
MTR, limited dissection of the synovial attachments the residual fracture bed is often required using a
and capsule will be required prior to insertion of ron- motorized bone bur to smooth the residual portion of
geurs and removal of the fragment. Some fragments the trochlear ridge.
www.ajlobby.com
Aftercare following fragment removal includes

8–10 weeks without vigorous exercise and starts with
several weeks of complete stall confinement. The rest
period generally increases for horses with extensive frac-
tures and fracture fragments that are reattached to the
talus. Radiographic monitoring is used in the latter case
to ensure adequate healing prior to increased exercise.
Implant removal is rarely possible or indicated in these
cases. The prognosis following fracture removal is good
to excellent if surgery is performed soon after injury and
the defect is less than 3 cm long. The horses with proxi-
mal trochlear ridge fragments in the author’s practice
and those described in the literature have returned to
active exercise. Fragmentation of the distal regions of the
trochlear ridges are less well described. However, the few
Standardbred racehorses treated in our clinic have
returned to racing following fragment removal. Fracture
fixation has been successful in two other horses, and a
third remained lame.
Plantar Fractures of the Talus

Fractures of the plantar regions of the talus are infre-
quent, and are often difficult to accurately diagnose.
Most are small, chronically rounded fragments associ-
Figure 34.5 Large fracture of the entire lateral trochlear ridge and ated with the plantar or plantaromedial surface of the
trochlear groove of the talus. Lag screw stabilization should be talus. The most frequent fracture is fragmentation of the
used for improved fracture reduction and fixation.
proximal tubercle of the talus (Figure 34.9).7,42 These
fragments are relatively rare, have been recognized as
incidental findings on prepurchase examination, are
more frequently seen in Warmbloods, and can affect one
or both hocks. They are best radiographically visualized
Some fractures of the MTR are sufficiently large that on lateral to medial and dorsomedial to plantarolateral
reattachment to the parent portion of the trochlear ridge oblique projections. A portion of the short medial col-
should be considered (see Figure 34.7). Insertion of one lateral ligament of the tarsocrural joint attaches to the
or several cortical screws, using the lag screw principle, proximal tubercle, and these probably represent chronic
can be accomplished with difficulty. Generally, the acute stable avulsion fractures of the insertion of this portion
angle required for drilling and screw insertion precludes of the collateral. Clinical symptoms are rare, potentially
accurate reduction, and fragment removal is required. due to the extraarticular nature of this fragment.
Accurate reduction and stabilization are even more dif- Consideration to additional diagnostic assessment using
ficult in chronic fractures of the MTR. ultrasonographic examination is warranted if effusion or
Combination fractures involving the proximal plantar lameness exists. The primary differential is fracture frag-
portion of the MTR and caudal portions of the distal mentation of the proximal plantar portion of the MTR
tibia can also develop (Figure 34.8). Most are associated (see Figure 34.4). Since fractures of the MTR are intraar-
with external trauma. Lameness and swelling can ini- ticular, they are generally symptomatic, including effu-
tially be severe, but quickly moderate. Radiographs show sion and mild lameness, compared to fractures of the
multiple fragments of bone in the plantar joint pouch of proximal tubercle, which are often asymptomatic inci-
the tarsocrural joint, and multiple radiographic projec- dental findings.
tions are required to define the sites of origin. Removal is Fractures of the plantar region of the talus unassoci-
required in most cases, and a dorsolateral arthroscope ated with the proximal tubercle can also occur. These
portal and dorsomedial instrument portal are utilized, as have involved the perimeter of the talus adjacent to the
described for fractures involving just the MTR. Outcome proximal plantar surface of the trochlear groove
has been good with a return to function in the few cases (Figure 34.10). These fragments appear to originate
treated at this clinic. along the plantar perimeter of the trochlear groove as
www.ajlobby.com
(A) (B) Figure 34.6 (A–C) Arthroscopic approach

to the plantar joint pouch of the
tarsocrural joint for retrieval of fracture
fragments from the trochlear ridge.
Fracture of
Rongeurs trochlear ridge
Arthroscope
Cranial view
(C)
Rongeurs
Medial view
Arthroscope
Craniolateral view
small synovial tissue‐covered intraarticular fractures, the fracture, and affected horses move with mild to mod-
rather than embedded fragments that have translocated erate lameness after the initial acute lameness dissipates
from elsewhere in the tarsocrural joint. Effusion and in 24–48 hours. A twisting fall may create some of these
lameness are generally mild, and surgical exploration fractures, but a race injury without an obvious accident
and fragment removal are only warranted if symptoms is also described in the literature.24 Immediate swelling
persist. Improvement in symptoms after surgery has of the tarsocrural joint is apparent and persists over time.
been rapid and the prognosis for this unusual fracture Arthrocentesis initially yields hemorrhagic synovial
appears excellent. fluid. Radiographs in the dorsoplantar projection usually
demonstrate the fracture, but additional views 10–20° in
Sagittal Fractures of Talus the dorsolateral‐plantaromedial oblique projection may
Sagittal fractures of the body of the talus occur rarely.24 define the fracture better.
These fractures displace minimally and are generally
most obvious radiographically on dorsoplantar projec- Treatment
tions (Figure 34.11). The integrity of the tarsocrural joint Sagittal and parasagittal fractures are amenable to lag
or the articular surfaces is not extensively disrupted by screw repair.24 Sagittal fractures divide the trochlear
www.ajlobby.com
(A) (B)
(C) (D)
(E) (F) (G)
Figure 34.7 An extensive chronic fracture of the proximal plantar aspect of the medial trochlear ridge (MTR). (A) A flexed proximal‐lateral to
distal‐medial oblique projection identifies the chronic fracture (arrows). (B) Skyline radiographic projection verifies a displaced medial
trochlear nonunion fracture (arrows). (C, D) Arthroscopic visualization, debridement, and alignment of the MTR fracture fragment (Fx). (E)
Needle insertion to show screw alignment in an attempt at lag screw fixation. (F) Fragment removal after fracture disintegration on lag screw
fixation. IRT, intermediate ridge of the tibia. (G) Postoperative radiograph showing residual MTR (arrows).
groove of the talus asymmetrically, creating a smaller experience, the preferred approach has been medially
medial fragment. Despite this configuration, a previous placed screws (see Figure 34.11). With the use of radio-
report describes easier access to the lateral region of the graphic control, and occasionally also arthroscopic visu-
talus for screw placement in a lateral to medial direction, alization of the articular surfaces, a 3.2 mm pilot drill is
using the distal end of the screw threads to draw the frag- placed through a stab incision on the medial surface of
ment onto the parent bone.24 In the author’s limited the talus, 2.5 cm proximal to the proximal intertarsal
www.ajlobby.com
(A) (B) (C)
(D) (E) (F) (G)
Figure 34.8 Combination fracture of the proximal plantar medial trochlear ridge (MTR) and caudal aspect of the distal intermediate ridge
of the tibia (IRT). (A) Lateral to medial radiograph shows a large displaced fracture fragment (arrow head) associated with the
proximoplantar region of the MTR. Additionally, the caudal portion of the distal IRT has multiple fractures (arrow). (B) A flexed lateral
oblique radiographic projection better demonstrates the MTR fracture fragment (arrowhead), but also shows several adjacent fractures of
the caudal portion of the distal IRT (arrow). The fracture bed on the MTR is indicated by a dotted line. (C) Skyline radiograph indicates that
the MTR fragment is embedded in the plantaromedial cul‐de‐sac (arrowhead) of the tarsocrural joint. (D) Arthroscopic view showing the
fracture fragment (Fx MTR) lodged in the synovial tissue of the plantaromedial cul‐de‐sac of the tarsocrural joint. The arthroscope has
been inserted through the plantarolateral pouch. The intrusions from the tarsal sheath (TS) and deep digital flexor tendon are shown on
the plantar surface. (E) The fracture fragment has been gripped in rongeurs for removal. (F) The arthroscope redirected more cranially then
allows assessment of the fracture fragments of the caudal perimeter of the distal IRT (Fx IRT). (G) Arthroscopic view, after removal of both
the MTR and IRT fractures, showing the debrided IRT and the MTR and lateral trochlear ridge (LTR).
joint. The stab entry should be through the medial col- dorsal in the body of the talus. The alignment of the pre-
lateral ligaments, parallel to the fibers, and slightly plan- vious screw is used as a guide as the second drill hole is
tar in the bony fossa for collateral attachment, to avoid made. Medial to lateral radiographs are again performed
the screw penetrating the dorsal articular surfaces. to ensure that the talocalcaneal joint has not been pene-
Medial to lateral radiographs and occasionally arthros- trated, and the screw is inserted as before. Both screws
copy are performed to establish that the drill is angled are fully tightened to compress the fracture (see
appropriately and has not entered the talocalcaneal Figure 34.11). Arthroscopy can be used to confirm com-
articulation or the dorsal region of the tarsocrural joint. pression and to ensure that no threads enter the tar-
Following completion of the 3.2 mm drilling, the medial socrural joint.
fracture fragment is overdrilled with a 4.5 mm drill, the The stab wounds are closed with monofilament suture,
cortex is lightly countersunk to avoid extensive damage and the limb bandaged for recovery. Box stall confine-
to the collateral ligaments, and the hole is measured and ment for 8–12 weeks is routine; however, radiographic
tapped for a 4.5 mm cortical screw. The initial screw is monitoring is used to determine when increased exercise
placed and lightly tightened. A second screw is placed is appropriate. Screw removal has not been necessary.
parallel and 2.5 cm proximal to the first and slightly more No evidence of degenerative arthritis developed.
www.ajlobby.com
(A) (B) (C)
Figure 34.9 Fracture of the proximal tubercle of the talus identified on prepurchase radiographs. The lateral to medial (A) and
dorsomedial to plantarolateral oblique (B) projections show the nondisplaced fracture (circle). (C) Lateral to medial projection of the
opposite normal limb. Source: Images courtesy Dr. Ryland Edwards.
(A) (B) (C)
(D) (E) (F)
Figure 34.10 Plantar chip fracture off the trochlear groove of the talus. (A, B) Dorsomedial to plantarolateral oblique and dorsoplantar
projections show the chip fracture associated with the proximal plantar edge of the trochlear groove (arrow). (C, D) Computed
tomography shows the fragment associated with the plantar nonarticular surface of the trochlear groove (arrow; circle). (E, F) Arthroscopic
views showing dissection of the fracture fragment (arrows) and fracture bed after fragment removal.
www.ajlobby.com
(A) (B)
Figure 34.11 (A) Sagittal fracture of the talus (arrowheads) in a four‐year‐old Standardbred racehorse. Minimal displacement has
occurred. (B) Compression of the fracture using three 4.5 mm cortical screws. The horse subsequently returned to competitive racing.
Similarly, one horse described in the literature had Calcaneus

healed by six months, based on radiographic examina-
tion, and raced nine months after surgery.24 Calcaneal fractures are always due to trauma. The prom-
Although sagittal fractures of the talus are uncommon, inence of the tuber calcaneus forming the point of the
the outcome after lag screw repair, using either the lat- hock makes it susceptible to external impact by kicks and
eral to medial or the medial to lateral application, appears falls, and also presents the most vulnerable portion of
to be good. There is no information on conservative the hock if the horse should kick out at a wall, door, or
treatment for this fracture. farm machinery (Figure 34.13).10,15 Falls and slipping on
wet or icy surfaces may also create sufficient Achilles’
tendon tension on the tuber calcaneus that the bone
Comminuted Fracture of the Talus fractures.31 Skin lacerations can accompany external
More severe trauma, including major twisting falls, kicks trauma or may result from the fracture fragments pene-
from other animals, and limb entrapments, can result in trating the skin from the interior.14,39 Chronic open frac-
comminuted fracture of the talus. The talus can fracture in tures may also have developed osteomyelitis of the
many configurations, and stability is extensively compro- calcaneus by the time of diagnosis, which compounds
mised (Figure 34.12). Nevertheless, the surrounding soft the treatment and increases the cost. Secondary compli-
tissue usually prevents major fragment distraction. cations can also include displacement of the superficial
Swelling and lameness are severe and remain constant. digital flexor (SDF) tendon from the tuber calcaneus, or
Crepitus on movement of the tarsocrural joint is occasion- sepsis of the tarsal sheath and deep digital flexor
ally elicited. Some comminuted fractures of the talus also tendon.31
involve the calcaneus, because of their anatomic proximity Fractures of the calcaneus can vary from chip fractures
and the extensive forces initiating these fractures. of various prominent regions of the tuber, more exten-
sive fractures of the calcaneal tuberosity, complete
Treatment displaced fractures of the shaft of the calcaneus, or com-
Most comminuted fractures of the talus are inoperable. minuted fractures of the entire body of the bone
Preoperative assessment must aim to seek an intact (Figure 34.14).4,9,10,14–16,31 The clinical signs reflect the
larger fragment onto which the smaller pieces can be severity of the bony derangement and possible second-
rebuilt. The goal of surgical treatment is to salvage the ary complications. Swelling and crepitus can be marked
horse’s life; return to soundness is not expected. However, with major bony fractures.9,31 Some fractures of the
most horses must be euthanized on humane grounds. medial border of the calcaneus and the pulley surface of
www.ajlobby.com
Figure 34.12 (A, B) Radiographs showing a (A) (B)

comminuted fracture of the talus in a
Thoroughbred stallion. The bone was too
fragmented for surgical reconstruction and
the horse was euthanized.
examination of most injuries of the calcaneus (see

Figure 34.14).8,14–16,39
Treatment
Small fractures that are not septic sometimes heal
spontaneously. Larger fragments of the calcaneal tuber
can be removed by direct surgical approaches.
Fractures on the medial surface of the calcaneus and
the sustentaculum talus are more difficult to treat sur-
gically. In cases in which the tarsal sheath is not
infected, the bony fragments have occasionally been
removed.10,15 Owing to the trauma induced by the
approach to the sustentaculum, some authors consider
that surgery is not warranted and a guarded prognosis
should be given.16 Undoubtedly, such is the situation in
sepsis of the tarsal sheath with osteomyelitis and bony
proliferation of the sustentaculum, although a com-
plete recovery is occasionally seen following surgical
debridement.39 More recent reports also indicate that
aggressive therapy can salvage horses for use, despite a
long convalescence.13
Fractures of the tuber calcis arising from a direct
Figure 34.13 Fractured calcaneus with sequestrum formation
(arrows) following traumatic laceration during a kicking episode. impact on a wall or a sharp object frequently involve
This sequestered fracture fragment was removed during calcaneal severe skin lacerations and penetration of the calcaneal
bursoscopy. bursa (Figure 34.15). Frequently, lacerations develop
without necessarily fracturing the calcaneus. Where
fractures do arise, debridement of the fracture fragment
and bony bed, and arthroscopic flushing of the calcaneal
the sustentaculum talus may be secondary to sepsis of bursa and infected SDF tendon, are indicated. Many of
the overlying soft tissues, and the clinical signs are largely these lacerations go on to have chronically infected
referable to those structures.39 The diagnosis and differ- calcaneal bursa and even osteomyelitis. Routine and

entiation of the fracture types can be made by radiogra- skyline radiographic projections are vital in determining
phy. The skyline projection is critical for complete the need for additional surgical debridement (see
www.ajlobby.com
(A) (B)
(C)
Figure 34.14 Comminuted calcaneal fracture with talocalcaneal subluxation in a newborn foal. (A) Lateromedial radiographic projection
shows multiple fractures of the distal aspect of the calcaneus (arrow), and subluxation of the calcaneus from the talus (double arrow).
(B) Skyline radiograph indicates a combination of calcaneal separation and rotation relative to the talus. L, lateral; M, medial. (C) Normal
opposite limb for comparison. Source: Images courtesy Dr. Ryland Edwards.
Figure 34.15). Three‐dimensional imaging with standing tarsal canal are usually indications for surgical repair.
or routine CT is occasionally required to determine the Internal fixation by tension band plating with additional
need for surgery and postoperative progress. lag screws is generally the procedure of choice.9,31
Major disruption of the shaft of the calcaneus occurs from For simple oblique fractures of the calcaneus, internal
a sudden fall or impact trauma.4,9,10,15,31 The loss of Achilles’ fixation using minimally invasive approaches and lag
tendon function, marked lameness, and constriction of the screw technique has been described in a foal.4
(A) (B) (C)
Figure 34.15 Osteomyelitis of the calcaneus following a traumatic kick wound. (A) Lateromedial radiograph showing soft tissue injury (white
arrows) and sequestrum formation on the plantar aspect of the calcaneal tuber (black arrow). (B) Skyline projection confirms the sequestrum
and involucrum (arrow). (C) Computed tomography after three months indicates persisting sequestrum and involucrum, with cloaca. New
bone formation is also developing on the medial and lateral aspects of the calcaneus. Source: Images courtesy Dr. Jon Cheetham.
www.ajlobby.com
Surgical Technique The plate should not be placed on the plantar midline
The horse is positioned in lateral recumbency with the if the plantarolateral surface is available. Persistent
affected limb supported uppermost. For most fractures, lameness and the need for plate removal have been

the plate can be applied along the plantarolateral surface described previously as complications due to the plate.9
of the calcaneus. A longitudinal skin incision is made Wound closure is routine, and the repair is supported by
parallel and immediately lateral to the SDF tendon. In a full limb cast for recovery and the initial two to
simple fractures, the tendon is left in situ, and the plate is three weeks. The cast should be removed with the horse
applied immediately lateral to it. If the fracture is par- standing rather than anesthetized.
ticularly comminuted, reconstruction by individual lag Removal of the implant as soon as union is evident on
screws is performed, followed by provision of primary radiographs minimizes the fibrosis of the calcaneal bursa
mechanical strength by a plate along the plantar aspect and SDF tendon and improves the long‐term mobility of
of the calcaneus. The lateral attachment of the SDF ten- the tarsocrural joint.31 The prognosis for soundness is
don is severed, the tendon reflected medially, and the guarded following plate fixation of calcaneal fractures.
plate applied directly in the calcaneal bursa and over the The horses described in the literature had residual stiff-
long plantar ligament more distally. The plate is attached ness of the tarsocrural joint, and none was completely
with 4.5 or 5.5 mm cortical screws. Application of a lock- sound.9,31
ing compression plate (LCP) provides better fixation, Comminuted calcaneal fractures that involve the
although the complex nature of many comminuted cal- body and sustentaculum, without disruption of the
caneal fractures necessitates application of numerous shaft of the calcaneus and the Achilles’ apparatus, are
cortical screws in the LCP construct. Compression is held in reasonable approximation by the periarticular
applied only if the fracture is oblique or transverse in ori- soft tissues (Figure 34.16A). Conservative treatment,
entation; otherwise it is applied as a neutralization plate. including extended periods of stall rest, is often ade-
A narrow dynamic compression plate (DCP) or LCP is quate to allow complete bony union without extensive
preferred for most horses, as it interferes less with the callus formation (Figure 34.16B). Some horses have
movement of the SDF tendon, which lies over the plate returned to being ridden, and the prognosis based on
when it is returned and reattached to its original position. several cases is fair.
(A) (B)
Figure 34.16 (A) Comminuted fracture of the calcaneus, with fractures of the body (arrowheads) and lateral articular portions (arrows). (B)
Radiograph obtained 12 months after injury. There has been minimal callus formation, and light riding is possible. Two years after injury,
the horse was sound and had returned to competitive polo.
www.ajlobby.com
Tibial Malleoli
Fractures of the malleoli are one of the more common
fractures of the hock. In a series of 13 hock fracture
cases, 5 involved the malleoli.15 Either the lateral or the
medial malleolus can be involved, although the lateral
malleolus is more commonly affected.15,46 Some frac-
tures are the result of external impact trauma, but many
are thought to result from avulsions of the short collat-
eral ligaments.10,15,41,46 Since the lateral or medial short
collateral ligaments are made up of many ligaments, sev-
eral fragments can be avulsed from the tibia at the time
of injury. Alternatively, one larger piece of the malleolus
can fracture. Rarely, the entire malleolus can fracture,
including the origin of the long collateral ligaments,
which can lead to tarsocrural joint instability. For the lat-
eral malleolus, the more cranial portion of the malleolus
is frequently fractured, leaving the caudal portion to
maintain joint stability.10,46 Since the short collateral liga-
ments are tensed during flexion, it is possible that the
avulsions occur because of increased torque or impact
on a partially flexed hock.41,46
Swelling is moderate to marked, with a sudden onset of
lameness. Direct pressure over the malleolus and flexion
of the hock elicit a painful response. The diagnosis is
confirmed by radiography, with the dorsoplantar projec-
tion providing the most information (Figure 34.17). A
slightly medial oblique dorsoplantar projection often
defines lateral malleoli fractures more distinctly. Because
of the residual short collateral ligament attachments, the Figure 34.17 Fracture of the lateral malleolus (arrow), defined by
a slightly oblique dorsoplantar projection of the hock. The fracture
fracture fragment tends to rotate caudodistally within
fragment has rotated due to the pull of the short lateral collateral
the fracture bed. Smaller fragments have previously been ligament, and is too small for reattachment. Arthroscopic removal
considered to be osteochondrosis of the lateral malleo- is necessary.
lus, although lateral malleolus fragmentation is rare in
growing horses, and should generally be considered to and collateral ligament tissue.23,28,32 Most lateral malleo-
have a traumatic origin.22,23 lus fractures destabilize only the short lateral collateral
ligament, and removal does not increase the risk of lat-
Treatment eral tarsocrural collateral ligament disruption and subse-
Small malleolar fragments are removed, and larger frag- quent subluxation. The primary decision with lateral
ments are reattached with one or two cortical screws malleolus fractures is a determination of whether the
applied in lag manner. Lateral malleolus fractures are fracture fragment is sufficiently extensive and relatively
often small, varying in size from 0.5 to 1 cm in proximal acute in onset to allow stabilization by lag screw fixation.
to distal length and from 1 to 2 cm in craniocaudal width. Small, chronic, and distracted lateral malleolus fractures
Most fragments that are less than 2 cm in craniocaudal should be removed. Where the majority of the lateral
width can be approached and removed arthroscopically malleolus is involved, the surrounding soft tissues main-
(Figure 34.18). More extensive lateral malleolus fractures tain the fracture fragment in relative proximity, and lag
can also be removed, particularly where they have split screw fixation is more appropriate (Figure 34.19). CT
into several fragments. Extensive lateral malleolus frac- can be useful if there is doubt about the size or integrity
ture fragment removal often results in an obvious com- of the lateral malleolus fracture.
munication from the dorsolateral to plantarolateral Arthroscopic removal of lateral malleolus fractures
compartments of the tarsocrural joint. is done with the horse positioned in dorsal recum-
For the approach, both the arthroscope and instru- bency. Lateral recumbency is only used when a large
ment portals are placed in the dorsolateral joint pouch, malleolus fracture is being repaired with screw fixa-
and the fragment is resected from the extensive synovial tion without arthroscopic assessment of the joint.
www.ajlobby.com
(A) (B)
(C) (D)
Figure 34.18 (A) Small lateral malleolar fracture fragment (arrow) suitable for arthroscopic removal. (B) Intraoperative radiograph
showing fracture bed after fragment removal. (C) Arthroscopic image of the lateral malleolus fracture with attached collateral ligament.
(D) Residual lateral malleolus of the tibia (LMT) after fracture removal, showing residual collateral ligament (CL) adjacent to the malleolus
and lateral trochlear ridge (LTR).
Often, there are small intraarticular fragments associ- and these soft tissues must be removed using sharp dis-
ated with a larger lateral malleolus fracture, and these section and motorized synovial resectors. The attached
will need arthroscopic removal. Good‐quality radio- short lateral collateral ligament fibers are then divided
graphs and the use of CT can be helpful in establishing using curved fixed blades, sharp periosteal elevators,
the need for arthroscopic assessment of the fracture. arthroscopic scissors, or electrosurgical dissection, fol-
Additionally, lag screw repair can be accomplished lowed by synovial resectors. Continued removal of any
with the horse in dorsal recumbency, provided that additional fracture fragments is accomplished until the
intraoperative radiographic or fluoroscopic monitor- entire fracture bed has been adequately debrided.
ing is available. Intraoperative radiographs or the use of fluoroscopy is
The arthroscope portal is placed slightly distal in the vital to confirm complete removal of the fracture frag-
dorsolateral pouch of the tarsocrural joint, to allow visu- ments. Careful examination of the more caudal extent of
alization of the lateral malleolus fragments and still leave the lateral malleolus is useful to ensure that no small
adequate space in the dorsolateral pouch for an instru- bone fragments have dislodged into the plantarolateral
ment portal directly cranial to the fractured malleolus. pouch of the tarsocrural joint. The long lateral collateral
The fractured fragments of the lateral malleolus are ligament often remains on the abaxial surface of the
often covered by synovial membrane and joint capsule, remaining lateral malleolus (see Figure 34.18).
www.ajlobby.com
(A) (B)
(C) (D)
(E) (F) (G)
Figure 34.19 Lag screw repair of a large lateral malleolar fracture. (A) Preoperative slightly oblique dorsoplantar radiograph showing the
slightly displaced fracture of the lateral malleolus (arrows). (B) Dorsomedial to plantarolateral oblique radiograph better defines the
cranial to caudal width of the fracture (arrows). (C, D) Preoperative computed tomography confirms that the entire lateral malleolus
(arrows) is detached and that lag screw fixation is indicated. (E) Preoperative planning is useful to define screw trajectory and length. (F, G)
Immediate postoperative radiographs showing fracture stabilization using two 3.5 mm cortical screws applied in lag fashion.
www.ajlobby.com
Lag screw fixation of lateral malleolus fractures is introduced to temporarily stabilize the fragment. Most
slightly easier with a horse in lateral recumbency. The fragments are too small to accommodate a 4.5 mm screw,
limb is supported with the fractured malleolus upper- and screws of smaller sizes are recommended to prevent
most. A preoperative surgical plan is useful to allow the fragment from splitting. One or two 3.5 mm cortical
selection of an appropriate diameter and length implant screws are generally appropriate. Precise angling of the
(see Figure 34.19). Inserting hypodermic needles at the screw is imperative to ensure that the tarsocrural articu-
appropriate entry point and angle for subsequent screw lation is not penetrated by the threads. Should the frag-
insertion is followed by radiographic confirmation. A ment split during surgery or in the recovery phase, all
5 mm stab incision can then be made at the appropriate fracture fragments should be removed, as described pre-
needle entry. Deeper blunt dissection to separate the fib- viously. Comminuted lateral malleolus fractures can also
ers of the lateral collateral ligament is necessary to probe repaired using a combination of removal of smaller
vide appropriate screw insertion on the most distal poorly aligned fragments, and screw fixation of larger
aspect of the lateral malleolus. The edges of the fracture fragments (Figure 34.20). Rarely, the entire lateral malle-
and the parent malleolus are located with needles, and olus is fractured and should be repaired with a minimum
the drill guide is placed on the extreme distal edge of the of two 3.5 or 4.5 mm cortical screws placed in lag screw
reduced fracture fragment. A Kirschner wire can be fashion.
(A) (B) (C)
(D) (E) (F)
Figure 34.20 Comminuted lateral malleolus fracture. (A) Dorsoplantar radiograph indicates a separated lateral malleolus fragment (large
arrow) and multiple comminuted smaller fragments (small arrows). (B) Dorsomedial to plantarolateral oblique projection indicates a
rotated free cranial portion of the lateral malleolus fracture (white arrows) and a minimally displaced fracture of the entire remaining
portion of the malleolus (black arrows). (C, D) Postoperative radiographs following removal of the cranial malleolus fragment and lag
screw fixation of the caudal portion of the malleolus. (E, F) Radiographs obtained eight months after surgery, showing the healed lateral
malleolus fracture, with the void associated with previously removed cranial fragment.
www.ajlobby.com
(A) (B) Figure 34.21 Medial malleolus fracture,

with distal avulsion of the fracture
fragment (A) due to tension from the short
medial collateral ligament. (B)
Postoperative radiograph following
arthroscopic fracture dissection and
removal.
Avulsion fragmentation of the medial malleolus occurs Medial malleolus fractures that involve the entire
less frequently than that of the lateral malleolus.15 medial extremity of the tibia destabilize the medial col-
However, medial malleolus fractures are often larger lateral ligament apparatus, and should be repaired by lag
than lateral malleolar avulsions, and often distract a con- screw fixation (Figure 34.24). These fractures are quite
siderable distance into the dorsomedial pouch of the tar- large and accept lag screws more readily than large lat-
socrural joint (Figure 34.21). Despite the larger size of eral malleolus fractures. The wider bone stock of the
the medial malleolus fractures, involvement of the long medial malleolus results in a lower incidence of fracture
collateral ligament is uncommon, and joint stability is and, when fractures do occur, a more secure repair. A
maintained. Arthroscopic removal is accomplished using direct approach to the malleolus is made, centered on
similar techniques to those used in removal of the lateral the fractured fragment, which is outlined with needles,
malleolus fractures. The horse is positioned in dorsal as described earlier. Given the larger size of medial
recumbency. Exposure of the fracture fragment and asso- malleolus fractures, two 4.5 or 5.5 mm screws are placed
ciated collateral ligament fibers is accomplished using an in lag screw fashion to compress the fracture line (see
arthroscope portal in the dorsomedial outpouching of Figure 34.24).
the tarsocrural joint, immediately medial to the saphenous Closure of the skin portals is routine, and a cast is not
vein. The fracture fragment can separate into several usually applied. Only in circumstances where there has
pieces, but most commonly remains as one large piece and been massive involvement of the short medial collateral
several smaller avulsion fractures. Extensive torn medial ligaments has the use of a temporary cast or splint been
short collateral ligament fibers cover the fragments, and necessary for recovery from anesthesia. Heavy bandag-
need to be removed to isolate the fracture fragment for ing is maintained for at least three weeks postoperatively.
removal (Figure 34.22). Curved fixed‐blade knives, radiof- The implants are not removed. Cosmetically, the affected
requency probes, biopsy suction punch, and motorized hock often remains slightly to moderately enlarged com-
resectors are all used to resect the medial malleolus frag- pared to the normal joint.
ments from the residual medial collateral ligament, and Results of arthroscopic removal of fractures of the lat-
allow removal of the extensive fragments in pieces. eral malleolus of the tibia have been described in several
Rarely, the distal tubercle of the talus, with its insertion case series.28,32 In a study of 13 cases, 12 involved racing
of the short collateral ligaments, is avulsed, rather than the Thoroughbreds, of which 10 went on to race.28 The
origin on the medial malleolus (Figure 34.23). Separation median time from surgery to return to racing was
of the avulsed t ubercle is limited by the heavy intertarsal 241 days. None of these fractures was repaired by
ligaments and joint capsule that overlie the distal tuber- stabilization with lag screw fixation. The overall progno-
cle, and most can be managed conservatively. Avulsion sis for return to athletic function was excellent. A more
and retraction of the fragment into the dorsomedial recent study reviewed the outcome after arthroscopic
pouch of the tarsocrural joint are very unusual. removal of lateral malleolus fractures in 26 horses.32 The
www.ajlobby.com
(A) (B) (C)
(D) (E) (F)
(G) (H) (I)
Figure 34.22 Entire medial malleolus fracture with continued collateral stability. (A, B) Dorsoplantar and dorsolateral‐plantaromedial
oblique radiographs showing avulsion fracture of the complete width of the malleolus with its attached origin of the short collateral
ligament. Arthroscopic images show (C) the fracture fragment with additional disrupted collateral ligament fibers; (D) dissection of the
fracture from the collateral ligament; (E) probing for residual fracture pieces; (F) trimming of the residual distal portion of the short
collateral ligament; and (G) the debrided fracture bed of the medial malleolus. (H, I) Postoperative dorsoplantar and lateral oblique
radiographs showing the residual medial malleolus.
www.ajlobby.com
fracture fragments only involved the short lateral collateral with minimal complications, and with the expectation of a
ligaments. All fragments were successfully removed using s uccessful return to athletic function. Moreover, the need
arthroscopic access and debridement. Of the 22 horses for arthrotomy for removal was unnecessary. Previous
with long‐term follow‐up, 18 returned to their previous studies using arthrotomy approaches have considered the
use. The authors concluded that arthroscopic removal was prognosis after fragment removal to be guarded to poor,
technically demanding, but was successful in all horses, with improvement following lag screw fixation of the frac-
ture fragment.10
Fractures of the Distal Tibia

Fractures of the distal tibia that enter the tarsocrural
joint can also involve more extensive portions of the tibia
than the lateral or medial malleoli. In adults, distal tibial
fractures can be part of more complex and comminuted
fractures destabilizing the tibial shaft. These fractures
are described in Chapter 35. Intraarticular fractures that
involve portions of the tibial epiphysis in foals are
uncommon. Salter–Harris types III and IV have been
seen. Some fractures involve combinations of Salter–
Harris types II and III (Figure 34.25). Radiographic
examination indicates the nature of the fracture, although
complex fractures are better defined by CT. Stabilization
of the primary fracture with combinations of cortical
screws placed in lag fashion, screws and wires, and exter-
nal coaptation may provide adequate fixation and rea-
lignment of the tibial articular surface for return to
function (see Figure 34.25). Most methods for the fixa-
tion of distal physeal fractures necessitate removal of the
implants for continued growth of the physis. In foals this
can frequently be accomplished six to eight weeks after
the primary repair.
Intraarticular fractures of the distal tibia in adults can
Figure 34.23 Avulsion fracture of the distal tubercle of the talus, involve the malleoli (described previously), the distal
associated with the insertion of the short medial collateral intermediate ridge, or larger portions of the intermedi-
ligament. The horse was managed conservatively. ate ridge and adjacent tibia. Fractures that involve
(A) (B) Figure 34.24 (A) Large medial malleolar

fracture in a 15‐year‐old Thoroughbred,
(B) repaired with two 5.5 mm cortical
screws placed in lag screw fashion. The
horse returned to athletic performance.
www.ajlobby.com
(A) (B) (C)
(D) (E)
Lat
Spin:
Calc Tilt: -
Y-shaped epiphyseal fr
Med
Figure 34.25 Complex distal tibial physeal fracture in a 42‐day‐old foal. (A) Dorsoplantar radiographs indicate a Salter–Harris type I
fracture (white arrow), type II with metaphyseal fragment (white arrowhead), and type III (black arrow), with extensive soft tissue swelling.
(B) Preoperative computed tomography (CT) confirms the radiographic findings of a complex Salter‐Harris type I, II, and III fracture
configuration. (C, D) Sagittal plane CT and a 3D reconstruction reveal the Y‐shaped Salter–Harris type III epiphyseal fragment. Calc,
calcaneus; Lat, lateral; Med, medial. (E) Repair using transphyseal cortical screw insertion and medially applied tension band wire. Source:
Images courtesy Dr. David Murphy.
cranial or caudal portions of the intermediate ridge can scopic access to the dorsal and plantar pouches of the
be difficult to differentiate from those attributed to tarsocrural joint is required for fragment removal.
osteochondrosis. Generally, the mature age of the horse Removal of dorsal fractures of the distal intermediate
and the involvement of the caudal extent of the distal ridge is done using dorsomedial arthroscopic access, as
intermediate ridge indicate a fracture rather than devel- described for the removal of intermediate‐ridge OCD
opmental disease (Figure 34.26). Removal using arthro- fragments.23 The instrument portal is located in the
www.ajlobby.com
(A) (B)
(C) (D)
Figure 34.26 Fracture fragmentation of the cranial and caudal aspects of the distal intermediate ridge of the tibia in a seven‐year‐old
horse. (A) Medial oblique radiograph showing fragmentation of the cranial aspect of the intermediate ridge (arrows) and a large fracture
of the caudal aspect of the intermediate ridge (circle). (B) Arthroscopic examination confirms multiple nonunion fragments on the cranial
aspect of the intermediate ridge (IRT). LTR, lateral trochlear ridge; MTR, medial trochlear ridge. (C) The caudal aspect of the distal
intermediate ridge (Caudal IRT) has also fractured (Fx IRT). TG, trochlear groove; TS, tarsal sheath. (D) Postoperative radiograph confirming
removal of the cranial and caudal fracture fragments.
dorsolateral pouch. True fractures of the cranial aspect are uncommon. Configuration can vary. These fractures
of the distal intermediate ridge are often larger and do not destabilize the tibial shaft, but involve extensive
have multiple components (see Figure 34.26). Access to portions of the tarsocrural articulation (Figure 34.27),
the plantar pouch of the tarsocrural joint for removal of and need to be repaired by cortical screw insertion to
fractures of the caudal portion of the distal intermedi- stabilize the fracture. Multiple radiographic projections
ate ridge generally uses the plantarolateral arthroscope are required to define the fracture configuration. Three‐
portal. The instrument portal is made in the plantaro- dimensional imaging using CT or MRI is also recom-
medial joint pouch. Fracture fragments are generally mended, particularly where multiple fractures are
large, and the skin portal may need to be enlarged for suspected on radiographic assessment. Arthroscopic
removal. examination is used to verify the fracture configuration
Fractures of the distal tibia that involve the intermedi- and allow debridement of smaller fracture fragments.
ate ridge and portions of the remaining tibial epiphysis Additionally, visual verification of fracture realignment
www.ajlobby.com
(B) (C)
(A)
(D) (E) (F)
Figure 34.27 Fracture of the craniolateral aspect of the distal tibia, entering the tarsocrural joint. (A) Lateral to medial radiograph
indicates multiple fracture lines (arrows) involving the distal tibia. (B) Dorsomedial to plantarolateral oblique radiograph confirms that the
fractures include both the lateral malleolus (LM) and distal intermediate ridge of the tibia (DIRT). (C) Arthroscopic examination using a
dorsolateral arthroscope portal allows removal of free fragments and visual assessment of fracture reduction. MM, medial malleolus; MTR,
medial trochlear ridge. (D) Fracture reduction and stabilization realign the fractured cranial aspect of the tibia with the parent bone
(arrows). (E, F) Postoperative radiographs 12 months after surgery showing the healed fracture after stabilization with two 5.5 mm cortical
screws applied in lag fashion. The horse returned to athletic function.
during repair is used to ensure better congruency of the particularly Standardbreds, but have also been seen in
distal tibial articular surface. Use of several 4.5 or 5.5 mm non‐race breeds.5,12,18,37 The central tarsal bone is
cortical screws placed in lag fashion is recommended to affected most frequently in some studies,45 and frac-
stabilize extensive fracture fragments (see Figure 34.27). tures generally involve the dorsomedial portion of this
Successful outcome after fracture alignment and stabili- bone.15,18,37 However, sagittal fractures of the central
zation has been evident in these fractures. tarsal bone are relatively common, and have been
described in the literature.29 The third tarsal bone was
fractured twice as frequently as the central tarsal bone
Central and Third Tarsal Bone in a study of 25 horses,27 and has a predisposition to
fracture on the dorsal and dorsolateral perimeter.10,19,37
Fractures Third tarsal bone fractures generally occur in the fron-
Slab fractures of the central or third tarsal bone are an tal plane. Fracture of the third tarsal bone has also been
uncommon injury. They generally occur in racehorses, associated with a wedge‐shaped conformational defect,
www.ajlobby.com
resulting in a narrowing of the bone near the dorsal fracture planes in central tarsal fractures make complete
perimeter.1 The high incidence of third tarsal bone assessment, accurate screw insertion, and a meaningful
involvement is also supported by a recent case series of prognosis difficult to offer.37 Ancillary procedures such as
17 Thoroughbred racehorses, where all had fractures of CT (see Figure 34.29) or standing MRI (see Figure 34.30)
the third tarsal bone repaired by lag screw fixation.2 may assist in defining the fracture planes, but treatment of
Conversely, the two case series of non‐racebred horses comminuted central tarsal fractures remains difficult.
involved only the central tarsal bone in six horses,12 and Four of six central tarsal fractures in one study were com-
another series involved only the central tarsal bone in minuted.37 More chronic fractures may have precipitated
four horses.18 secondary degenerative osteoarthritis (OA) by the time of
The fractures in racehorses occur during racing or diagnosis.
speed training, with acute onset of lameness referable to Given the unpredictable and often irregular or com-
the hock. The initial lameness diminishes to moderate or minuted nature of fractures of the central and third tarsal
mild in one to two weeks. Central tarsal bone fractures bones, a complete series of radiographs is important, and
usually result in effusion of the tarsocrural joint.37 Third most cases should be evaluated using three‐dimensional
tarsal fractures result in mild to moderate soft tissue swell- imaging such as CT before surgery, or after anesthesia on
ing over the dorsal aspect of the joint.3,19 Horses exhibit a the way to surgery, to determine the fracture configura-
marked response to the hock flexion test, react positively tion and develop a surgical plan to provide a better
to digital pressure directly over the fracture, and may chance of screw placement to adequately compress the
improve following intraarticular anesthesia of the tar- fracture planes (Figure 34.31).12 Standing robotic CT has
socrural and intertarsal joints. The diagnosis is established a distinct advantage in allowing accurate diagnosis before
by radiography, although acute fractures may not be read- anesthesia and repair. Alternatively, use of standing MRI
ily apparent on initial radiographs.10,35 Nuclear scintigra- provides satisfactory three‐dimensional images to
phy may be particularly beneficial in the early phases improve diagnostic accuracy and provide a plan for sur-
(Figure 34.28).35 The lateral to medial and dorsomedial‐ gery (see Figure 34.30).
plantarolateral oblique radiographic projections demon-
strate most fractures of the third tarsal bone Treatment
(Figure 34.29).37 However, the dorsolateral‐plantarome- Lag screw repair is indicated in most central and third
dial oblique and even the dorsoplantar or oblique dorso- tarsal slab fractures, provided that the fracture planes
plantar projections may show fractures of the central are known and OA has not developed.2,5,12,19,45 Results
tarsal bone more clearly, especially those in the sagittal of conservative therapy have traditionally been con-
plane (Figure 34.30).19 In non‐racehorses, oblique sagittal sidered to be quite poor.19,37 However, outcome in one
fractures of the central tarsal bone seem to be more com- study of 25 cases treated conservatively indicated that
mon, and are more clearly defined on the dorsomedial to 16 (64%) returned to athletic activity.27 Progressive
plantarolateral oblique projection.18 The immobility of the displacement of the fracture fragment, advanced OA,
intertarsal joints prevents dorsoproximal‐dorsodistal sky- and in some circumstances partial tarsal joint ankylo-
line views, which precludes the type of topographic assess- sis occur (see Figure 34.29). Stabilization by cortical
ment obtained in third carpal bone studies. The complex screw insertion may serve little purpose if the frac-
(A) (B) Figure 34.28 (A) Nuclear scintigraphic

study of the right hock of a horse with a
two‐week history of acute lameness, but
no localizing swelling in the limb. (B)
Radiographs confirmed a fracture (arrows)
of the central tarsal bone.
www.ajlobby.com
(A) (B)
(C) (D) (E)
Figure 34.29 Fracture of the third tarsal bone in a two‐year‐old Standardbred. (A, B) Lateral and dorsomedial to plantarolateral oblique
radiographs indicate a chronic fracture of the third tarsal bone (black arrow) associated with degeneration of the tarsometatarsal joint
(white arrow), and fracture displacement. Note the tapered appearance of the third tarsal bone. (C, D) Computed tomography indicates
the presence of two fractures in the third tarsal bone, the larger involving the dorsolateral aspect, and a second fracture along the dorsal
central region. The chronic nature of the fracture, the osteoarthritis in the tarsometatarsal joint, and the comminution of the proximal
surface of the bone at admission reduce the indications for surgical stabilization. L, lateral; M, medial. (E) Postoperative radiographs
obtained three months after repair using two 3.5 mm cortical screws indicate advancing osteoarthritis of the tarsometatarsal and distal
intertarsal joints, despite fracture union.
tures are comminuted or chronic, since joint ankylosis ermost to provide access to the dorsomedial aspect of
inevitably develops. If spontaneous fusion is complete, the tarsus. Conversely, the limb is generally positioned
some horses return to racing. However, many are uppermost for third tarsal fractures. Needles are placed
rested for more than a year and return, only to go lame to define the intertarsal and tarsometatarsal joints and
when fast work and racing commence.37 Given the the lateral and medial border of the fracture. Most dor-
improved results following lag screw fixation, these somedial slab fractures of the central tarsal are repaired
cases should be repaired as soon after diagnosis as using one 4.5 mm or two 3.5 mm cortical bone screws.
possible.2,5,12,19,45 The skin is incised longitudinally 2 cm over the previ-
ously defined fracture, usually directly over the proximal
Surgical Technique border of the cunean tendon (Figure 34.32). The fracture
Horses are positioned in lateral recumbency with the is further defined by needle insertion as necessary, and
fractured limb lowermost or uppermost depending on intraoperative radiography or fluoroscopy is used to con-
whether the fracture is medial or central. For most cen- firm needle placement. The fracture fragment is reduced
tral tarsal fractures, the affected limb is positioned low- against the parent bone, and a 2.5 or 3.2 mm pilot hole is
www.ajlobby.com
(A) (B) (C)
Figure 34.30 Central tarsal bone sagittal fracture in a six‐year‐old Warmblood. (A) Preoperative oblique dorsoplantar radiograph shows a
fracture (arrows) of the dorsal and plantar aspects of the central tarsal bone. (B, C) Standing MRI T1‐weighted images in transverse and
frontal planes reveal a displaced sagittal fracture of the central tarsal bone.
(A) (B)
Figure 34.31 (A) Transverse computed tomography image indicating the preoperative plan for cortical screw stabilization of a complex
central tarsal bone fracture. The fracture has a Y‐shape in the sagittal and oblique planes, dictating the need for two cortical screws
applied in lag fashion. (B) Immediate postoperative radiographs showing fracture plane compression using two 4.5 mm cortical screws.
Source: Images courtesy Dr. Ashlee Watts.
drilled through the slab and into the remainder of the 4.5 mm cortical screw placed in lag screw fashion in a
central tarsal bone (see Figure 34.32). Radiographic medial to lateral plane.29
monitoring is repeated to ensure that the drill angle and Fractures of the third tarsal bone more frequently involve
depth are satisfactory. The central and third tarsal bones the dorsolateral perimeter, and the affected limb is posi-
are not flat or particularly thick, and accurate drilling is tioned uppermost for better access.19 The skin is incised
difficult (Figure 34.33). The fracture fragment is over- 4–6 cm, parallel and lateral to the long digital extensor ten-
drilled with a 3.5 or 4.5 mm drill, and the surface p
repared don. The cranial tibial artery is avoided. The intertarsal and
for light countersinking. The pilot hole is tapped, and tarsometatarsal joints, and the fracture, are defined by nee-
the 3.5 or 4.5 mm screws are placed and tightened. dles. For most fractures, the center of the fracture slab is
Good fracture reduction should be evident radio- lateral to the long digital extensor tendon and directly
graphically, and new fracture planes should not have beneath the peroneus tertius tendon of insertion. The fibers
developed. If other fractures become obvious, they of the peroneus tertius tendon and the dorsal tarsal liga-
should be repaired by additional screws. A sagittal ment are separated, and a drill guide placed to allow drilling
fracture described in the literature was repaired with a of the 3.2 or 2.5 mm pilot hole. Radiographic or fluoroscopic
www.ajlobby.com
Cunean tendon
Skin incision
Tarsometatarsal
joint
Distal
intertarsal
Proximal joint
intertarsal
joint
Cunean tendon cut
Figure 34.32 Surgical approach and technique for placement of a lag screw in a slab fracture of the central tarsal bone.
control is used to check the drill angle and distance. If these started on hand‐walking exercise for an additional
are satisfactory, a single 4.5 mm cortical screw or two month. Most horses are not ready to return to work for
3.5 mm cortical screws are placed in a dorsoplantar plane six to eight months.
with the use of lag screw technique (Figure 34.34), and the
wound closed routinely. Radiographic confirmation of Outcome
screw placement is important. Lag screw repair has significantly improved the out-
A minimally invasive technique has been described, come in most studies, compared to conservative man-
using a stab incision to provide access for screw fixation of agement.2,12,18,19,45 In one report describing internal
fractures of the third tarsal bone.2 The exact position of fixation of third and central tarsal bone slab frac-
the incision between the long and lateral digital extensor tures in 20 horses, 18 were in Standardbreds, and the
tendons varies depending on preoperative information as central tarsal bone was involved in 12 cases and the
to the fracture position and width, and whether a single or third tarsal bone in 8;45 13 of 18 horses (72%) raced
two 3.5 mm screws are to be inserted. Most dorsolateral after repair. More recently, surgical repair of third tar-
fractures of the third tarsal bone can be repaired with a sal bone fractures in 17 Thoroughbred horses, using
single 3.5 mm cortical bone screw applied in lag fashion.2 minimally invasive techniques, returned 79% of the
Screw trajectory for repair of the third tarsal bone needs horses to racing.2 In non‐racehorses, surgical repair
to be angled slightly distally to remain in the center of this returned 5 of the 6 horses (83%) with central tarsal
slightly curved bone. Intraoperative radiography or fluor- bone fractures to athletic function.12 These results
oscopy is vital to confirm correct screw trajectory. compare favorably with the poor outcome previously
The limb is bandaged for recovery; casting is unneces- reported in the literature,15,37 and with the 64% return to
sary. Horses are confined to a stall for 8–10 weeks and function described in a group of race and non‐racebred
www.ajlobby.com
(A) (B)
(C) (E)
(D)
Figure 34.33 Lag screw stabilization of the central tarsal bone fracture shown in Figure 34.30. (A, B) Oblique dorsoplantar and lateromedial
radiographs obtained the day after surgery, showing the compression of the sagittal fracture (arrows) and the distal trajectory of the two
3.5 mm cortical screws to accommodate the curvature of the central tarsal bone. (C) The oblique dorsoplantar radiograph at eight weeks
postoperatively shows rapid fracture healing. (D, E) Radiographs obtained 18 months after surgical stabilization indicate complete fracture
union and minimal osteoarthritis of the proximal or distal intertarsal joints. The horse had returned to high‐level jumping.
horses treated conservatively.27 Early diagnosis and impact when the horse kicks and strikes a sharp object.
screw fixation before the development of intertarsal Many of these fractures also involve primary skin lacer-
and tarsometatarsal OA appear to improve the ations, with contamination and sepsis of the bone frag-
outcome. ments. Additionally, septic arthritis of the tarsometatarsal
and distal intertarsal joints is a potential sequela.
Primary fracture of the fourth tarsal bone without other
Fourth and Second–First Tarsal Bone injuries has also been described in one report.25 Solitary
fracture of the combined second and first tarsal bone is
Fractures extremely rare. The only involvement seems to be in
Fractures of the fourth tarsal bone are infrequent and catastrophic failure of the distal row of tarsal bones
generally involve combined injuries with the fourth associated with tarsometatarsal or proximal intertarsal
metatarsal bone. These injuries arise through external joint luxation.11,44
www.ajlobby.com
Figure 34.34 Frontal plane fracture of the (A) (B)

third tarsal bone in a four‐year‐old
Thoroughbred racehorse. (A, B) Preoperative
radiographs show a slightly displaced frontal
plane slab fracture of the third tarsal bone
(arrows). (C, D) Radiographs obtained
two months after fracture fixation using two
3.5 mm cortical screws applied in lag fashion
from dorsal to plantar. The horse competed
in multiple grade 1 stakes starting
seven months after surgical stabilization.
(C) (D)
Treatment Luxations of the Hock

Open fractures of the fourth tarsal and metatarsal bones
are treated by local debridement of bony fragments and Luxations of the hock result from major traumatic
devitalized soft tissues. Broad‐spectrum antibiotics are events, such as twisting falls or the trapping of a leg under
commenced after tissue and fluid samples have been col- or through doors or walls, and from fixed‐limb injuries
lected for culture. The tarsometatarsal and distal inter- associated with the lodging of a limb in a cattle grid, hole,
tarsal joints are lavaged with sterile lactated Ringer’s or bridge sleeper, or with trailering accidents.10,11,26,30,44
solution if the fracture opens the synovial lining. Fluid Occasionally, a luxation results when a horse violently
should egress from the fracture site. Most comminuted kicks a wall.26 The most frequently affected joints are the
fractures of the fourth metatarsal and tarsal bone are tarsometatarsal and proximal intertarsal articulations
allowed to heal open. Occasionally, fracture stabilization (see Figure 34.1). The fourth and, to some extent, the sec-
is required after the sepsis is controlled. One report of a ond and first tarsal bones support the integrity of the dis-
solitary nondisplaced fracture of the fourth tarsal bone tal intertarsal joint; luxation of this joint has not been
described bony union and return to soundness with con- reported. Furthermore, the biomechanical strength
servative therapy.25 afforded by the interdigitating bones of the tibia and
www.ajlobby.com
(A) (B)
Figure 34.35 Tarsocrural subluxation. (A) Dorsopalmar resting and (B) stressed radiographs showing complete medial collateral
disruption.
talus and their collateral ligaments make luxation of the tarsal and metatarsal bones.21,26 The resulting instabil-
tarsocrural joint quite uncommon.10,30 When the tar- ity frequently requires some form of internal fixation,
socrural joint does luxate, however, at least some of the and a coaptation cast is always applied to supplement
collateral ligaments are ruptured (Figure 34.35). the stabilization. Use of a transarticular lag screw and
Additionally, there is marked damage to the articular cast immobilization has been described for proximal
surfaces, and the soft tissue fibrosis and OA that form intertarsal joint stabilization,21 and a threaded
following successful reduction can be debilitating. Many Steinmann pin was used for tarsometatarsal joint stabi-
horses with tarsocrural luxation are euthanized without lization in a miniature foal.6 However, in subluxations
treatment because of the poor long‐term prognosis.21 in which collateral support is ruptured on one side only,
Tarsal luxation and subluxation result in marked to closed reduction and casting for six to eight weeks usu-
non‐weight‐bearing lameness and swelling. Crepitus can ally result in the return of stability and occasionally
often be elicited. The extent of concurrent tarsal fracture some capacity for light work.26 The horse is anesthe-
and the site of luxation are determined by radiography. tized prior to closed reduction surgery. Traction devices
Use of stressed radiographs to evaluate collateral liga- and manipulation, and occasionally muscle relaxants,
ment stability is vital (see Figures 34.1 and 34.35). may be required to realign the joints. In several cases of
Ultrasonography may add some information to the diag- major displacement, the luxation has been opened sur-
nosis and treatment plan; however, an unstable articula- gically to allow reduction, removal of fragmented tarsal
tion without fracture of the bony origin or insertion of bones, and cancellous bone grafting. In any case, internal
the collateral ligament leaves little doubt that the entire fixation is rarely required. Reduction of luxations
collateral apparatus is affected. with extensive collateral disruption, especially bilateral
Fracture/luxations are complex injuries that often tearing, may necessitate stabilization by cross‐screws
require internal fixation. Fracture of the proximal meta- or even plate application.21
tarsals with concurrent tarsometatarsal luxation is a dev- A full limb cast is applied to the reduced limb, and the
astating injury (Figure 34.36). Cast immobilization cast is changed at least once before it is removed six to
generally does not provide adequate stabilization and eight weeks after injury. In some cases in which collateral
healing (Figure 34.37), compared to simple tarsometatar- ligaments are thought to be still largely intact, the period
sal subluxation, where casting is the treatment of choice. of cast application can be reduced to four weeks.
Periarticular mineralization and fibrosis usually develop
around the distal hock joints following stabilization.
Treatment These joints frequently also ankylose.26 The convales-
Luxations of the tarsometatarsal and proximal intertar- cent time and delay in ankylosis of the affected joints are
sal joints often rupture some, but not all, of the sup- reduced by cartilage debridement and bone graft at the
porting collateral ligaments and fracture some of the time of reduction.10,26
www.ajlobby.com
(A) (B)
(C) (E) (F)
(D)
Figure 34.36 Tarsometatarsal luxation with concurrent second, third, and fourth metatarsal fracture. (A) Preoperative radiographs indicate
severe fracture/luxation and poor stability. (B) Preoperative planning for application of a plantarolateral plate. The plate screws incorporate
the calcaneus, fourth and central tarsal bones, and the third and fourth metatarsals. (C) A plantarolateral incision exposes the calcaneus and
metatarsals. The prominent proximal aspect of the fourth metatarsal is being removed to allow improved seating of the plate. (D) Application
of a locking compression plate, utilizing two cortical screws to compress the plate to the bone and provide dynamic compression to the
fixation, followed by locking‐head screws. (E, F) Lateral oblique and dorsoplantar radiographic projections showing good fracture and
luxation reduction and stabilization one day after surgery. The limb was additionally supported in a splint for three days postoperatively.
www.ajlobby.com
(A) (B) period. The initial plate fixation should utilize cortical
screws to allow compression of the LCP onto the planta-
rolateral surface of the bones (see Figure 34.36). The
remainder of the screws in an LCP can then be locked, to
enhance stability of the repair. Small horses and ponies
may be stabilized using an LC‐DCP; however, full‐sized
horses are better treated with an LCP.
An alternative approach includes the application of a
dorsal T‐shaped LCP or cobra‐head DCP. Both plates
provide the advantage of an expanded proximal end to
the implant, which allows numerous screws to be
inserted into the tarsal bones to provide rigid proximal
fixation (Figure 34.38). Standard LC‐DCP or DCP
implants applied to the dorsal surface of the tarsus and
third metatarsus generally do not provide sufficient fixa-
tion in the proximal bone stock.
For T-shaped LCP or cobra-head DCP application, the
skin incision is made on the dorsal midline, immediately
medial to the long digital extensor tendon, and extending
from the level of the proximal intertarsal joint to the
Figure 34.37 Tarsometatarsal luxation with concurrent metatarsal
fractures treated by cast fixation. (A) Radiograph on admission middle of the metatarsus. The soft tissues are exposed
showing subluxation of the tarsometatarsal joint with fractures of and the fibers of the insertion of the cranial tibial tendon
the second, third, and fourth metatarsal bones. (B) Delayed union and peroneus tertius ligament divided to provide
and exacerbated tarsal subluxation after two months of cast improved plate contact to the dorsal surfaces of the cen-
support.
tral and third tarsal bones. The proximal and distal inter-
tarsal joints are identified by needle insertion, and the
tarsometatarsal subluxation is generally obvious.
Luxation of the tarsometatarsal joint that involves Radiographic or fluoroscopic monitoring then provides
fracture of the proximal metatarsals is generally quite verification for the initial plate fixation. For the applica-
unstable and requires internal fixation (see Figure 34.36). tion of a cobra plate, cortical screws are applied in a
Internal fixation speeds the healing process, reducing diverging pattern to provide up to six screws that engage
costs and pain in the convalescent period. Stabilization the central, third, and fourth tarsal bones (see
with a plate and screws that incorporate the calcaneus Figure 34.38). Positioning the plate on the dorsomedial
and the proximal third and fourth metatarsus in the fixa- surface of the tarsus and third metatarsus allows screws
tion is preferred. to engage the fourth metatarsal bone, and these can be
applied using lag screw principle, to enhance compres-
Surgical Technique sion of the third and fourth metatarsal fractures. The
The horse is anesthetized and placed in lateral recum- remaining cortical screws are then applied in the distal
bency with the affected limb uppermost. A skin incision aspect of the plate.
extending from the proximal aspect of the calcaneus to Application of the T‐shaped LCP designed for stabili-
the junction of the upper and middle thirds of the meta- zation of proximal tibial physeal fractures (see Chapters
tarsus is made along the plantarolateral aspect of the 35 and 50) also provides additional proximal fixation for
hock. The soft tissues are separated, exposing the promi- stabilization of tarsometatarsal luxation with concurrent
nent proximal portion of the fourth metatarsus (see metatarsal fractures. The approach and plate position
Figure 34.36). This is smoothed flat with a curved oste- are similar to those described for insertion of a cobra‐
otome to allow improved seating of the bone plate onto head DCP. The fixed angle of the proximal locked screws
the calcaneus and fourth tarsal bone. Application of provides strong plate stability in the central, third, and
either a limited‐contact dynamic compression plate (LC‐ fourth tarsal bones. Initial fracture reduction and plate
DCP) or an LCP is appropriate. Given the irregular con- application are provided by a cortical screw inserted
tour of the palmarolateral aspect of the hock and using lag principle to reduce and compress the fracture
proximal metatarsus, an LCP is generally preferred. The in the proximal third and fourth metatarsi. An additional
increased cycles to failure of the LCP may also allow cortical screw may also be inserted using lag screw
reduced length of coaptation casting in the postoperative principle to provide additional compression across the
www.ajlobby.com
(A) (B) (C)
Figure 34.38 Displaced metatarsal fracture with tarsometatarsal subluxation treated by cobra‐head plate fixation. (A) Preoperative lateral
radiograph and (B, C) radiographs obtained three weeks after repair with a cobra‐head dynamic compression plate applied dorsally to
fuse the distal hock joints and the third metatarsal fracture.
fracture. The remaining screws, including the screws in pasture activity, including three that were used for light
the proximal T portion of the plate, are locked. riding.20 Application of an LCP to the plantarolateral
Wound closure of the plantarolateral or dorsal aspect of the hock in five horses, two with subluxation of
approach for stabilization of tarsometatarsal luxations the proximal intertarsal and three with tarsometatarsal
can be difficult, due to the cross‐sectional volume of a subluxation, salvaged all five horses for riding.17 However,
cobra‐head DCP or LCP. Soft tissue coverage of the plate while the two ponies were completely sound, the three
is vital, and strong fascial and subcutaneous continuous horses had minor residual lameness.17
suture patterns using #0 or #1 resorbable materials are Tarsocrural joint luxations are relatively easily reduced
recommended. Use of suture for skin closure rather than if the collateral ligaments on one side are disrupted (see
stainless‐steel staples is also recommended to resist inci- Figure 34.35); otherwise they can be quite challenging to
sional separation. treat. The luxation is toggled into reduction, and if radi-
For full‐sized horses, coaptation casting is recom- ography confirms normal positioning, a cast is applied to
mended for the recovery from anesthesia and the first one the limb up to the level of the stifle joint. If the collateral
to two weeks after surgery, depending on the implant used ligaments are still intact, reduction can require extensive
for primary stabilization of the fracture/subluxation. manipulation with the hock flexed. Regardless, if the
Smaller horses and ponies may be recovered in a splint luxation can be reduced, the limb is maintained in a cast
that extends to the proximal aspect of the calcaneus. for four to six weeks. Fibrosis of the hock always devel-
The outcome following plate fixation of distal tarsal ops, and enthesophyte formation and OA of the articula-
luxation and subluxation has been fair.17,20 Plantarolateral tions develop in most cases.21,30 The few horses described
plate fixation of five horses, three with subluxation of the in the literature, where follow‐up information was avail-
proximal intertarsal joint and two with tarsometatarsal able, have been salvaged as pasture‐sound horses, despite
subluxation, allowed four of the five to become sound for these joint changes.
www.ajlobby.com
References
1 Baird, D.H. and Pilsworth, R.C. (2001). Wedge‐shaped 15 Jakovljevic, S., Gibbs, C., and Yeats, J.J. (1982).
conformation of the dorsolateral aspect of the third Traumatic fractures of the equine hock: a report of 13
tarsal bone in the Thoroughbred racehorse is cases. Equine Vet. J. 14: 62–68.
associated with development of slab fractures in this 16 Jones, R.D. (1976). The diagnosis and treatment of
site. Equine Vet. J. 33: 617–620. avulsion fracture of the sustentaculum tali in a horse.
2 Barker, W.H. and Wright, I.M. (2017). Slab fractures Can. Vet. J. 17: 287–290.
of the third tarsal bone: minimally invasive repair 17 Keller, S.A., Furst, A.E., Kircher, P. et al. (2015). Locking
using a single 3.5 mm cortex screw placed in lag compression plate fixation of equine tarsal
fashion in 17 Thoroughbred racehorses. Equine Vet. J. subluxations. Vet. Surg. 44: 949–956.
49: 216–220. 18 Knuchell, J.A., Spriet, M., Galuppo, L.D., and Katzman,
3 Bolt, D.M., Hubert, J.D., and Williams, J. (2001). What S.A. (2016). Fracture of the central tarsal bone in
is your diagnosis? Minimal soft‐tissue swelling of the nonracehorses: four cases. Vet. Radiol. Ultrasound
tarsocrural and proximal intertarsal joints and a 57: 403–409.
minimally displaced oblique slab fracture of the 19 Lindsay, W.A., McMartin, R.B., and McClure, J.R.
third tarsal bone. J. Am. Vet. Med. Assoc. 218: (1982). Management of slab fractures of the third tarsal
1085–1086. bone in 5 horses. Equine Vet. J. 14: 55–58.
4 Bonilla, A.G. and Smith, K.J. (2012). Minimally invasive 20 McCormick, J.D. and Watkins, J. (2014). Plate fixation
repair of a calcaneus fracture in a Standardbred foal. for management of plantar instability of the distal
J. Am. Vet. Med. Assoc. 241: 1209–1213. tarsus/proximal metatarsus in 5 horses. Vet. Surg.
5 Chen, P., Vukicevic, S., Sampath, T.K., and Luyten, F.P. 43: 425–429.
(1993). Bovine articular chondrocytes do not undergo 21 McIlwraith, C.W. (1983). Surgery of the hock, stifle,
hypertrophy when cultured in the presence of serum and shoulder. Vet. Clin. North Am. 5: 350–354.
and osteogenic protein‐1. Biochem. Biophys. Res. 22 McIlwraith, C.W., Foerner, J.J., and Davis, D.M. (1991).
Commun. 197: 1253–1259. Osteochondritis dissecans of the tarsocrural joint:
6 Dowling, B.A., Dart, A.J., and Hodgson, D.R. (2000). results of treatment with arthroscopic surgery. Equine
Surgical treatment of tarsometatarsal joint luxation in a Vet. J. 23: 155–162.
miniature horse foal. Aust. Vet. J. 78: 683–684. 23 McIlwraith, C.W., Nixon, A.J., and Wright, I.M. (2015).
7 Espinosa, P., Lacourt, M., Alexander, K. et al. (2013). Diagnostic and Surgical Arthroscopy in the Horse, 4e.
Fragmentation of the proximal tubercle of the talus in Philadelphia: Mosby Elsevier.
horses: 9 cases (2004–2010). J. Am. Vet. Med. Assoc. 24 Meagher, D.M. and Mackey, V.S. (1990). Lag screw
242: 984–991. fixation of a sagittal fracture of the talus in the horse.
8 Farrow, C. (1963). Os calcis view. Calif. Vet. 1: 1–3. J. Equine Vet. Sci. 10: 108–112.
9 Ferguson, J.G. and Presnell, K.R. (1976). Tension band 25 Modransky, P., Welker, B., and Ryan, J. (1992).
plating of a fractured equine fibular tarsal bone. Can. Conservative management of fourth tarsal bone
Vet. J. 17: 314–317. fracture in a draft horse. J. Am. Vet. Med. Assoc. 201:
10 Foerner, J.J. (1992). Surgical treatment of selected 1040–1042.
conditions of the rear limb. In: Equine Surgery (ed. J.A. 26 Moll, H.D., Slone, D.E., Humburg, J.M., and Jagar, J.E.
Auer), 1060–1065. Philadelphia: W.B. Saunders. (1987). Traumatic tarsal luxation repaired without
11 Gross, D.R. (1964). Tarsal luxation and fracture in a internal fixation in three horses and three ponies.
pony. Mod. Vet. Prac.68–69. J. Am. Vet. Med. Assoc. 190: 297–300.
12 Gunst, S., Del, C.F., Furst, A.E., and Kuemmerle, J.M. 27 Murphey, E.D., Schneider, R.K., Adams, S.B. et al.
(2016). Central tarsal bone fractures in horses not used (2000). Long‐term outcome of horses with a slab
for racing: computed tomographic configuration and fracture of the central or third tarsal bone treated
long‐term outcome of lag screw fixation. Equine Vet. J. conservatively: 25 cases (1976–1993). J. Am. Vet. Med.
48: 585–589. Assoc. 216: 1949–1954.
13 Hand, D.R., Watkins, J.P., Honnas, C.M., and Kemper, 28 O’Neill, H.D. and Bladon, B.M. (2010). Arthroscopic
D. (2001). Osteomyelitis of the sustentaculum tali in removal of fractures of the lateral malleolus of the tibia
horses: 10 cases (1992–1998). J. Am. Vet. Med. Assoc. in the tarsocrural joint: a retrospective study of 13
219: 341–345. cases. Equine Vet. J. 42: 558–562.
14 Honnas, C.M., MacDonald, M.H., Penninck, D.G., and 29 Ramey, D.W. (1988). Use of lag screw fixation for repair
Pascoe, J.R. (1988). What is your diagnosis? J. Am. Vet. of a central tarsal bone fracture in a horse. J. Am. Vet.
Med. Assoc. 192: 1121–1122. Med. Assoc. 192: 1451–1452.
www.ajlobby.com
30 Reeves, M.J. and Trotter, G.W. (1991). Tarsocrural joint 39 Tulleners, E.P. and Reid, C.F. (1981). Osteomyelitis of
luxation in a horse. J. Am. Vet. Med. Assoc. 199: the sustentaculum talus in a pony. J. Am. Vet. Med.
1051–1053. Assoc. 178: 290–291.
31 Scott, E.A. (1983). Surgical repair of a dislocated 40 Updike, S.J. (1984). Anatomy of the tarsal tendons of
superficial digital flexor tendon and fractured fibular the equine tibialis cranialis and peroneus tertius
tarsal bone in a horse. J. Am. Vet. Med. Assoc. 183: muscles. Am. J. Vet. Res. 45: 1379–1382.
332–333. 41 Updike, S.J. (1984). Functional anatomy of the equine
32 Smith, M.R. and Wright, I.M. (2011). Arthroscopic tarsocrural collateral ligaments. Am. J. Vet. Res.
treatment of fractures of the lateral malleolus of the 45: 867–874.
tibia: 26 cases. Equine Vet. J. 43: 280–287. 42 Verwilghen, D.R., Bolen, G., Paindaveine, P., and
33 Specht, T.E. and Moran, A. (1990). What is your Busoni, V. (2010). What is your diagnosis? Bone
diagnosis? J. Am. Vet. Med. Assoc. 196: 1307–1308. fragment in hock joint. J. Am. Vet. Med. Assoc. 237:
34 Stashak, T.S. (1985). Lameness. In: Adams, Lameness in 29–30.
Horses, 4e (ed. T.S. Stashak), 748. Philadelphia: Lea & 43 Wheat, J.D. (1963). Fractures of the trochlea of
Febiger. the tibiotarsal bone in the horse. In: Proceedings of
3 5 Stover, S.M., Hornof, W.J., Richardson, G.L., and the Annual American Veterinary Medication
Meagher, D.M. (1986). Bone scintigraphy as an aid in Association Meeting, vol. 100, 86–87. Schaumburg, IL:
the diagnosis of occult distal tarsal bone trauma in AVMA.
three horses. J. Am. Vet. Med. Assoc. 188: 624–627. 44 Wheat, J.D. and Rhode, E.A. (1964). Luxation and
36 Sullins, K.E. and Stashak, T.S. (1983). An unusual fracture of the hock of the horse. J. Am. Vet. Med.
fracture of the tibiotarsal bone in a mare. J. Am. Vet. Assoc. 145: 341–344.
Med. Assoc. 182: 1395–1396. 45 Winberg, F.G. and Pettersson, H. (1999). Outcome and
37 Tulamo, R.M., Bramlage, L.R., and Gabel, A.A. (1983). racing performance after internal fixation of third and
Fractures of the central and third tarsal bones in horses. central tarsal bone slab fractures in horses. A review of
J. Am. Vet. Med. Assoc. 182: 1234–1238. 20 cases. Acta Vet. Scand. 40: 173–180.
38 Tulleners, E.P. and Reid, C.F. (1981). An unusual 46 Wright, I.M. (1992). Fractures of the lateral
fracture of the tarsus in two horses. J. Am. Vet. Med. malleolus of the tibia in 16 horses. Equine Vet. J.
Assoc. 178: 291–294. 24: 424–429.
www.ajlobby.com
648
35
Fractures of the Tibia
Jeffrey P. Watkins and Sarah N. Sampson
Incidence protect the soft tissues, cannot be overemphasized.

With proximal physeal fractures this is less important,
Fractures of the tibia are occasionally encountered in since bone fragments are usually smooth and rarely
equine practice. They occur as catastrophic injuries in result in an open injury.
foals and adults,6,8,13 as well as secondary to accumulated Catastrophic and unstable tibial fractures are readily
stress and microfracture in performing animals, most diagnosed on physical examination, particularly those of
commonly race horses. Although the incidence of tibial the tibial diaphysis. The clinical signs, in conjunction with a
fractures in horses is not well defined, one survey of long history of trauma such as a fall or kick injury, leave little
bone fractures presented to an academic referral hospital doubt as to the nature and location of the injury. Radiography
found the frequency to be low compared to other bones.3 confirms the diagnosis, but, more importantly, defines
the severity of bony disruption. Most diaphyseal fractures
in adults are characterized by extensive comminution, with
Diagnosis formation of multiple large and small fragments, leaving lit
tle hope for reconstructive efforts (Figure 35.1). Diaphyseal
Catastrophic tibial fractures are characterized by pera fractures in foals, however, are usually simple oblique or
cute onset of non‐weight‐bearing lameness. In cases of spiral configurations and are better candidates for surgical
diaphyseal fracture, the overlying soft tissues and skin on repair (Figure 35.2). Proximal physeal fractures in foals
the medial aspect of the limb are commonly disrupted by are characteristically Salter–Harris type II, with the meta
fracture fragments. Swelling of the soft tissues in this physeal fragment located laterally (Figure 35.3).
region is very prominent. Proximal physeal and tibial Fractures of the tibial tuberosity appear to be most
tuberosity fractures are accompanied by severe lame common in event horses, and develop during impact of
ness, but seldom have the same degree of soft tissue the stifle on fences.4 The differential diagnosis should
trauma as diaphyseal fractures, and are usually presented also include fracture of the patella or lateral trochlea of
with the overlying soft tissues and skin intact. the distal femur, as well as intraarticular ligamentous
Further evidence of a fracture includes instability and damage of the stifle. In non‐eventing horses, the most
deformity at the fracture site. With diaphyseal and proxi common cause of tibial tuberosity fracture is a direct
mal physeal fractures, there is valgus angulation of the kick injury.1,21 Tibial tuberosity fractures may be articular
limb distal to the fracture site due to the craniolateral or nonarticular and the fragment is often displaced
muscle mass overlying the tibia, which abducts the distal proximally. Horses with a fracture of the tibial tuberosity
limb when the bony column is disrupted. With abduc have an acute onset of severe lameness. Limited weight
tion, the fracture fragments are displaced medially and bearing with a marked decrease in the posterior phase
the sharp bone ends formed in diaphyseal fractures are of the stride may be noted. Local soft tissue swelling is
forced into the thin medial soft tissues, frequently pene usually evident, and there may be crepitance. Synovial
trating the skin. The importance of emergency coapta effusion is often present, and will always accompany
tion of the fractured limb, with support extending up the articular fractures. Periarticular soft tissue swelling may
lateral aspect of the thigh to prevent this abduction and partially obscure the synovial effusion. Radiography will

www.ajlobby.com
(A) (B) (A) (B)
Figure 35.2 (A) Craniocaudal and (B) lateromedial radiographs

Figure 35.1 (A) Craniocaudal and (B) lateromedial radiographs
depicting simple spiral diaphyseal fracture of the tibia in a foal.
depicting highly comminuted diaphyseal fracture of the tibia in
Double plate repair can be successful in most foals.
an adult horse. Attempts at repair are futile.
Figure 35.4 Lateromedial radiograph of tibial tuberosity avulsion

fracture in an adult horse. The fracture enters the femorotibial
joint proximally.
reveal the fracture, delineate the degree of displacement,

Figure 35.3 Caudocranial radiograph of Salter–Harris type II
fracture of the proximal tibial physis in a 10‐day‐old foal. The and determine whether the femorotibial joint is involved
metaphyseal fragment attached to the epiphysis is located (Figure 35.4). In young horses with minimally displaced
laterally. tibial tuberosity fractures, radiography of the contralateral
www.ajlobby.com
tibia may be required to allow a comparison to the to further localize the lameness with local and regional
fractured tibia to differentiate fracture lines from open anesthesia are unrewarding. Radiographic examination
physes. Union of the tibial tuberosity to the tibial meta with multiple high‐detail projections of the entire tibia
physis should be complete by 36–42 months of age.7 may be necessary to delineate the fracture (Figure 35.5).
Incomplete fractures of the tibial shaft are more diffi Spiral fractures are most common, with the fracture
cult to diagnose. Horses in race training, particularly commencing proximally in the lateral cortex and extend
Thoroughbreds two to four years of age, are at increased ing distally to the craniomedial cortex. In many cases
risk for incomplete tibial fracture. However, they can periosteal and/or endosteal reaction will be present as a
also occur in non‐racing performance horses. Horses result of a preexisting stress fracture. In cases which are
with incomplete fractures usually have acute onset of not detected by radiographic examination, nuclear scin
marked lameness. Localizing signs are minimal, and may tigraphy with 99mtechnetium methylene diphosphonate
include focal painful swelling along the tibial shaft. (99mTc‐MDP) will be diagnostic.
Hindlimb flexion tests and other manipulative proce Tibial stress fractures, which are secondary to accu
dures will usually accentuate the lameness, but attempts mulated stress and microfracture, are most frequently
reported in young Thoroughbreds in race training.10,14,15,17
The incidence of tibial and pelvic stress fractures may
(A) (B)
be increased by training and racing on synthetic track
surfaces.14 However, racing Quarter Horses and Stand
ardbreds can also be affected.16,20 In most instances the
disease is unilateral; however, one report described a
racing Quarter Horse affected bilaterally.16 History and
physical findings may be similar to those described
for incomplete tibial fracture. Lameness is generally
less severe and may resolve almost entirely with rest.
Radiographic examination will often identify periosteal
and/or endosteal reaction in a variety of locations along
the tibia, with the lateral cortex of the proximal tibial
metaphysis being involved most commonly (Figure 35.6).
However, a post‐mortem study found that complete
tibial fractures which could be attributed to preexisting
stress fractures in racing Thoroughbreds had evidence of
multiple tibial stress fractures in a number of different
locations.23 These included the nutrient foramen, the
distal aspect of the tibial crest, and a multitude of sites
throughout the tibial diaphysis. One study has shown
Figure 35.5 (A) Craniocaudal and (B) lateromedial radiographs that radiographic appearance is unreliable in assessing
depicting nondisplaced diaphyseal fracture of the tibia clinical severity or stage of lesion progression of stress
(arrowheads) in an adult horse. fractures, and confirmed that scintigraphy remains
(A) (B) Figure 35.6 (A) Caudal to cranial radiograph

demonstrating stress fracture (arrows) and
associated periosteal new bone formation
(arrowheads) of the proximal lateral tibia in a
racehorse. (B) Craniomedial to caudolateral
oblique projection demonstrates extension
of the periosteal new bone formation along
the caudolateral cortex (arrowheads) of the
proximal tibia associated with the stress
fracture.
www.ajlobby.com
In nearly all instances, a Salter–Harris type II fracture

is the resultant configuration. With lateral to medial
bending, fracture separation begins at the medial aspect
of the physis and courses laterally, through the zone of
proliferating chondrocytes within the physis. As the
separation approaches the lateral aspect of the tibia, the
fracture enters the metaphysis, forming the characteris
tic triangular metaphyseal bone fragment which remains
attached to the lateral physis and epiphysis. Although
injury to the germinal layers of the physis is reported to
be minimal following type II injuries in most species,
foals generally suffer significant physeal cartilage damage,
particularly older foals.6 With continued attempts to
bear weight on the affected limb, grinding of the unstable
metaphysis into the physis damages the physeal carti
lage, resulting in premature physeal closure following
fracture repair. However, neonatal foals seem to be less
predisposed to irreparable physeal damage, and in some
instances physeal growth potential can be preserved.25
Initial management of the injury includes minimizing
the foal’s activity to reduce the degree of damage to the
physis from attempted weight bearing. External coapta
tion to provide stability to the region prior to fracture
repair is often unrewarding, and may be detrimental.
Therefore, splinting for transportation and preoperative
assessment is not recommended.
Surgical treatment, using a variety of fixation tech
niques, has been the subject of multiple reports.12,24–27
Methods of fixation include the use of transverse pins
Figure 35.7 Scintigram of a two‐year‐old racing Thoroughbred in the configuration of a Charnley apparatus, cross‐pin
with a stress fracture in the mid‐diaphyseal region of the tibia.
fixation, lag screw fixation, and use of medial bone
Increased uptake is evident in the area of the stress fracture
(arrow),while the uptake in the proximal and distal physeal plates. These techniques have all been the subject of suc
regions is a normal finding. cessful case studies, and can be considered viable options
in management of these injuries.
the most diagnostically accurate technique.18 As with The authors have used cross‐pin fixation in neonatal foals
incomplete fractures, stress fractures which cannot be and medial bone plate fixation for all others.19,25,26 The
identified radiographically are best imaged using 99mTc‐ advantage of cross‐pin fixation in neonatal foals is the mini
MDP scintigraphy (Figure 35.7).14,15,18 mal need for specialized equipment and the limited amount
of surgical exposure necessary for fixation. Furthermore, in
cases where damage to the germinal layers of the physis is
minimal, longitudinal bone growth can resume with the
cross‐pins in situ. The major disadvantage of cross‐pin
Fracture Types and Management
fixation is inferior strength when compared to plate fixa
tion. In foals other than neonates, this becomes the primary
Proximal Physeal Fractures reason for advocating plate fixation. An additional advan
Fractures of the proximal tibial physis are one of the tage of plate fixation in larger foals is the use of the fixation
more common physeal fractures that occur in foals.6 appliance as an aid in reduction of the fracture.
The configuration of the fracture implicates lateral to
medial bending as the primary force responsible for the Surgical Technique
injury. This may occur secondary to a recumbent foal Cross‐pin fixation of type II physeal fractures in neonates
attempting to stand with the uppermost limb entrapped requires surgical access to both the medial and lateral
under a stationary object, or when the mare steps on aspects of the stifle region. The foal is prepared for asep
the recumbent foal’s uppermost hindlimb. A kick or tic surgery in dorsal recumbency. After draping, the foal
other blunt trauma to the lateral aspect of the stifle is repositioned in dorsolateral recumbency with the
could also cause this injury. affected limb down, to allow access to the medial aspect
www.ajlobby.com
of the stifle region. A straight 6–10 cm skin incision is tibial physis (Figure 35.8). Where necessary, supplemen
made, centered over the palpable defect in the medial tal fixation can be provided cranially by a third cross‐pin
aspect of the proximal tibial physis, immediately cranial placed through the tibial tuberosity to engage the caudal
to the medial collateral ligament. After exposing the phy cortex. However, care should be used to avoid excessive
seal separation, debris is removed from the fracture site fixation across the physis, as physeal growth may be dis
and the fracture is realigned by manipulating the distal rupted. In cases where cross‐pin fixation is utilized, it is
limb. If adequate realignment is not initially possible by possible to preserve growth potential, especially if preop
manual manipulation, plate fixation rather than cross‐ erative physeal damage is limited.
pinning is used for stabilization. If alignment can be Physeal fractures in older foals are stabilized by medial
achieved, a 1/8 or 5/32 in. Steinmann pin is driven through plate application (Figure 35.9). In these cases, fracture
the medial aspect of the tibial epiphysis, cranial to the reduction by manipulating the distal limb is more dif
collateral ligament, and across the physis and on into the ficult and the bone plate provides better leverage to rea
metaphysis and lateral diaphyseal region. The pin should lign the fracture. In addition, fixation with one or two
engage, but not exit, the lateral metaphyseal/diaphyseal transphyseal bone plates is substantially stronger than
cortex. An effort is made to direct the pin quite distal to fixation with cross‐pins. Lastly, the germinal layers of
the metaphyseal fracture fragment. With the pin seated, the physis are damaged during attempts at weight bear
the proximal portion of the pin is bent distally, taking care ing following the injury, and the likelihood of premature
to avoid fracturing the epiphysis. The limb is repositioned physeal closure is quite high. Therefore, transphyseal
to allow lateral access, and the process of pin placement is fixation with a bone plate may serve to reduce the poten
repeated through the lateral epiphysis into the medial tial for residual angular deformity of the proximal tibia.26
metaphysis/diaphysis. The pin is inserted caudal to the The affected limb is positioned in lateral decubitus to
long digital extensor muscle as it courses distally across allow medial plate fixation. A medial approach as already
the stifle joint. Additional stabilization is provided by described is utilized; however, the incision must extend
cancellous screws or 5.5 mm cortical screws placed in lag further distally. Deep dissection to expose the epiphysis
manner through the lateral metaphyseal fragment. These and metaphysis is also necessary for plate fixation.
screws are inserted distal and parallel to the proximal Both curvilinear and straight incisions have been used
successfully. Once the fracture is exposed and debris
removed, the plate is contoured to the proximal meta
physis and epiphysis, so that the portion of the plate
overlying the epiphysis will assist fracture reduction as
the epiphyseal screws are tightened. This is helpful in
larger foals, where anatomic reduction is difficult to
maintain during plate application due to the smooth
nature of the fracture fragments, and the collapse with
loss of bone at the lateral junction of the physeal and
metaphyseal fracture lines in the parent tibia. The con
toured plate is initially secured to the metaphysis near
the distal end of the plate. The proper location of the
epiphyseal hole(s) is then determined and, using radio
graphic control, the screw hole is drilled parallel to the
femorotibial joint. Manipulation of the distal limb with
simultaneous tightening of the epiphyseal screw(s)
brings the fracture into reduction and maintains align
ment at the fracture site. A single T‐plate or two dynamic
compression plates (DCPs) have been preferred in the
past, which allowed epiphyseal purchase with at least two
screws. A tibial buttress plate has also been effectively
utilized for repair of proximal tibial epiphyseal fractures
(Figure 35.10). This plate has regular 4.5 mm DCP plate
stock and an expanded curved proximal end to accom
modate several cortex screws angled in diverging direc
Figure 35.8 Caudal to cranial radiograph taken intraoperatively of
type II physeal fracture in a 10‐day‐old foal. Fracture stability has tions into the tibial epiphysis. The proximal curvature of
been achieved with medial and lateral cross‐pins and lag screw the tibial buttress plate dictates the need for specific
fixation of the metaphyseal fragment. plates for left or right tibia. The DCP or tibial buttress
www.ajlobby.com
(A) (B)
(C)
Figure 35.9 Salter–Harris type II fracture of the proximal tibial physis in a two‐month‐old Quarter Horse foal. (A) Lateromedial
radiographic view depicts marked caudal displacement of the distal tibia. (B) Medial plate fixation demonstrates the use of a T‐plate with
cancellous screws in the proximal tibial epiphysis, as well as cancellous lag screws in the lateral metaphyseal fragment. Note the presence
of a cranial to caudal cross‐pin and suction drain. (C) Two‐month follow‐up radiographs of healed fracture.
www.ajlobby.com
(A) (B)
(C) (D) (E)
Figure 35.10 Repair of a proximal tibial epiphyseal fracture using a tibial buttress plate in a four‐week‐old foal. (A) Preoperative radiograph
showing Salter–Harris type II fracture. (B) Intraoperative view showing fracture reduction and temporary fixation. (C) Intraoperative view
showing tibial buttress plate applied with a mix of cortex and cancellous screws. (D, E) Postoperative radiographs showing reduction and
stabilization. The most proximal 6.5 mm screw was cranial in the tibial plateau on other images, avoiding the lateral femorotibial joint and
meniscus. Source: Images courtesy Dr. Alan Nixon.
plate should be of sufficient length to place four or more

(A) (B)
screws distal to the physis. In foals over 250–300 kg, two
narrow DCPs placed side by side are recommended.19
Standard DCPs and the tibial buttress plate are signifi
cantly stronger than the original T‐plate and, although
the plate is stressed primarily in tension, the added
strength of fixation is required in larger foals (Figure 35.11).
Once the epiphyseal screws are secure, the remaining
screws immediately distal to the physis are placed.
These screws should be placed in lag fashion through
the plate and across the proximal tibial metaphysis, to
engage in the fractured lateral portion of the metaphysis.
In most Salter–Harris type II physeal fractures of the
proximal tibia, one or two screws can be positioned in
this manner. However, in some instances, the lateral
metaphyseal fragment will be of insufficient size to be
incorporated into the fixation. Figure 35.11 Repair of type II fracture of the proximal tibial physis
A new locking‐head 4.5 mm narrow locking compres shown in Figure 35.3, using two narrow 4.5 mm dynamic compression
sion plate (LCP) T‐plate (DePuy Synthes, West Chester, plates. Craniocaudal radiographs (A) immediately postoperatively and
PA, USA) has been developed which allows three locking (B) four months postoperatively showing healed fracture.
www.ajlobby.com
screws to be inserted into the tibial epiphysis through the of time, a return to previous performance is possible.1,4
stacked combi holes in the proximal T portion of the Displaced or articular fractures can be reduced and
plate (see Chapter 50). This provides rigid stabilization stabilized by open reduction and internal fixation.4,21
of the tibial epiphysis, while the shaft of the LCP has
standard combi holes that accept cortex screws or locked Surgical Technique
screws (Figure 35.12). The distal shaft of the LCP T‐plate The horse is positioned in lateral recumbency with the
is manufactured in 4‐, 6‐, 8‐, and 10‐hole lengths, pro affected limb uppermost. In some cases dorsal recum
viding different sizes to accommodate varying configu bency may be preferred. The fracture is approached via
rations of the proximal fracture and increased‐sized a straight or slightly curvilinear incision centered over
foals. The locking‐head plate provides the advantages of the fracture site. The fragment is reduced and fixation
a locked screw–plate construct, thicker plate stock than is accomplished using the tension band principle
previous T‐plates, and improved cyclic resistance to (Figure 35.13). Sharp dissection of a portion of the patel
failure. lar tendon insertion may be necessary to prepare the
area for plate fixation. A small femorotibial arthrotomy is
necessary to ensure reduction of articular fractures.
Tibial Tuberosity Fractures Fracture fixation using 5.5 mm cortical bone screws
Nondisplaced tibial tuberosity fractures have been reported inserted in lag fashion through a DCP or a combination
to heal satisfactorily with stall confinement and cross‐ of cortical and locking screws in an LCP provides the
tying to prevent recumbency. Careful monitoring of the most secure fixation. The fracture fragment can be
fracture is necessary to identify displacement if it occurs. weakened by an excessive number of screws placed in
Although healing is likely to require a protracted period longitudinal alignment, predisposing to a sagittal frac
ture through the screw holes.21 Therefore, the number of
screws inserted through a narrow plate should be lim
ited, or in fractures with a large fragment a broad plate
should be used (Figure 35.14). A technique for plate
bending and twisting has been described using a 7‐hole
4.5 mm narrow DCP, but reports of the use of this tech
nique in live animals are not available at this time.5
Figure 35.13 Lag screw and tension band plate fixation of the
Figure 35.12 The 4.5 mm locking compression T‐plate suitable for tibial tuberosity avulsion fracture depicted in Figure 35.4. Source:
repair of proximal tibial physeal fractures in foals. Image courtesy Dr. J Auer.
www.ajlobby.com
(A) (B) (C)
Figure 35.14 Large distracted intraarticular tibial crest fracture in a nine‐year‐old Thoroughbred. (A) Preoperative lateromedial radiograph
showing effects of tension from the patellar ligament insertions on the fractured tibial crest. (B, C) Repair of the fracture using three
6.5 mm partially threaded lag screws, and supplemented with two broad 4.5 mm locking compression plates attached with a combination
of cortical screws and locked screws. Source: Images courtesy Dr. Alan J. Nixon.
(A) (B) (C)
Figure 35.15 Smaller nonarticular tibial crest fracture in a 13‐year‐old Warmblood repaired using tension band screws and wire.
(A) preoperative lateromedial radiographs showing the tibial crest fracture (arrows). (B, C) Lateromedial and craniocaudal radiographs
seven days after repair using 5.5 and 4.5 mm screws, washers, and tension band wires. Note that the screws have already deformed,
indicating marginal stability. Healing was uneventful. Source: Images courtesy Dr. Alan J. Nixon.
Diaphyseal Tibial Fractures

For small fracture fragments, adequate stability can be
achieved with lag screws and tension band wiring to the Adults
parent tibia (Figure 35.15). It is advisable to use washers In all but rare instances, diaphyseal fractures of the adult
under the screw heads to prevent wire displacement, tibia are high‐energy, catastrophic injuries characterized
and multiple wires to reduce the risk of wire breakage. by extensive comminution. These injuries occur secondary
Tuberosity fractures resulting in fragments of insuffi to external trauma from a fall or kick, as well as internal
cient size to accept fixation appliances may be removed.4 trauma during performance activities. Fractures due to
www.ajlobby.com
internal trauma have been reported secondary to preexist midshaft fractures of the tibia, external coaptation may be
ing stress fracture, as well as incomplete fracture, in race required to support the plate fixation. In small‐stature
horses. However, catastrophic tibial fractures can occur adults, the cast can extend onto the stifle.
in horses engaged in performance activities other than
racing, and these appear to have resulted from internal Foals
forces without gross evidence of preexisting bone disease. Fractures of the tibial diaphysis are less likely to be com
Catastrophic tibial fractures in adults are often highly minuted in foals than in adults, and frequently have either
comminuted as well as open. The degree of comminu an oblique or spiral configuration (see Figure 35.2). This
tion is usually so severe that the possibility of a satisfac configuration, in conjunction with the diaphyseal location,
tory reconstruction of the bone is minimal. Fixation is makes fracture fixation feasible in many instances.28
often further compromised by the distal diaphyseal/ However, significant soft tissue damage, especially per
metaphyseal location of the fracture, precluding ade foration of the overlying skin, reduces the potential for
quate implant purchase in the parent bone distal to the successful repair.
fracture site. Furthermore, the fractures are often open
and contaminated. For these reasons, open reduction and Surgical Technique
internal fixation are seldom attempted. Rarely, an adult Diaphyseal fractures are best stabilized by double plate
will present with a tibial fracture which is a candidate for fixation.19,28 Positioning of the foal for fracture repair is at
internal fixation.2 In these cases, plate fixation is consid the discretion of the surgeon. The author prefers to posi
ered the treatment of choice, and the plates are applied as tion the foal with the affected limb uppermost, regardless
described in the following section for complete diaphy of whether a medial or lateral plate will be applied.
seal fractures in foals (Figure 35.16). Use of implants However, others prefer to place the affected limb down
which increase the strength of fixation, such as the LCP when a medial plate is to be utilized, while some surgeons
or the dynamic condylar screw (DCS) plate, which also prefer to position the horse in dorsal recumbency to pro
provides for increased purchase in the epiphysis nearest vide better access to both sides of the limb, and also to
the fracture, should be considered in adult horses. Repair utilize an overhead hoist to help distract and realign the
of more comminuted tibial fractures in adults can only be fracture fragments. The fracture is approached via a cra
accomplished in small breeds of horse such as ponies and nial curvilinear skin incision located over the cranial tibial
miniature horses (Figure 35.17). Even then, for distal and muscle.2 The skin flap is based either medial or lateral
(A) (B) (C) (D)
Figure 35.16 Long oblique fracture of the distal tibia in an adult miniature horse, which was open medially (type II open injury). (A) Lateromedial
and (B) craniocaudal radiographic projections demonstrate proximity of fracture to tarsocrural joint. (C) Lateromedial and (D) craniocaudal
projections demonstrate double plate fixation with the use of a 4.5 mm broad dynamic compression plate (DCP) contoured to the distal cranial
aspect of the tibia, extending proximally to the craniolateral aspect of the tibia, and affixed with 5.5 mm cortical bone screws. A 4.5 mm narrow
DCP was applied laterally to avoid the medial soft tissue injury secondary to the open nature of fracture. Numerous plate screws were placed
across the fracture in lag screw fashion and the cranial plate was luted. Healing proceeded without complication.
www.ajlobby.com
(A) (B) (C) (D)
Figure 35.17 Extensively comminuted tibial fracture in an adult miniature horse repaired using two broad dynamic compression plates
(DCPs). Preoperative (A) craniocaudal and (B) lateromedial radiographs show multiple spiral fractures throughout the diaphysis, a large
butterfly fragment, and extension of the fracture into the tarsocrural joint. (C, D) Radiographs at three months show repair using
craniomedially and craniolaterally applied DCPs. A cast was also applied for the first three weeks. The fracture healed uneventfully.
depending on the intended plate position. A plane of dis

section beneath the deep crural fascia is extended medi (A) (B)
ally to the tibia. Subperiosteal dissection and retraction
allow exposure of the fracture for debridement and reduc
tion. Temporary stabilization of the reduced fracture is
provided by bone-holding forceps, or preferably one or
two screws placed in lag fashion across the fracture.
Temporary fixation screws are positioned to avoid inter
ference with plate application. If this is not possible,
3.5 mm screws are utilized through glide holes which have
been countersunk sufficiently to recess the screw head in
the tibial cortex. A broad LCP or DCP is contoured for
application from the cranial aspect of the distal tibia to the
craniolateral aspect of the proximal tibia. A second plate is
positioned either medial or lateral, depending on fracture
configuration. If the foal is positioned with the fractured
limb uppermost, and the surgeon elects to apply the sec
ond plate medially, the limb is flexed and externally rotated
for medial access. Medial plate positioning provides easier
access due to the lack of overlying musculature.
Additionally, a lateral plate is difficult to apply due to the
overlying soft tissues, and a longer exposure may be
needed for insertion of the proximal and distal screws. Figure 35.18 Double plate fixation of the spiral tibial fracture of
the foal shown in Figure 35.2. (A) Craniocaudal and (B)
The stability of fixation is maximized by the insertion of lateromedial radiographs show the 4.5 mm broad dynamic
screws that cross the fracture line in lag fashion, by the use compression plate (DCP) contoured to extend from the distal
of 5.5 mm bone screws, and by the application of plates cranial to the proximal craniolateral aspect of the tibia, spanning
that are of sufficient length to span the distance between the distance between the proximal and distal physes. A 4.5 mm
the proximal and distal physes (Figure 35.18). Furthermore, narrow DCP was applied medially. Note the 5.5 mm screws
throughout the majority of the medial plate and at the proximal
luting of one or both plates is advocated to increase the and distal ends of the cranial plate. A number of plate screws were
stability and fatigue life of the fixation. In larger foals and used in lag fashion and the cranial plate was luted to increase
adults, the use of the LCP implant system is strongly stability. Healing was uncomplicated.
www.ajlobby.com
recommended due to the additional fixation stability Minimally invasive application of an LCP can be
afforded by the locked screws (Figure 35.19). Where the tilized for minimally displaced fractures in young foals
u
LCP is unavailable, stronger implants such as the DCS (Figure 35.20). One plate can be contoured and conven
plate are recommended to maximize the strength and iently applied to the medial aspect of the tibia through a
stability of the bone–implant unit. proximal or distal stab wound. A proximal entry is preferred
(A) (B) (C)
Figure 35.19 Use of two locking compression plates (LCPs) to stabilize a long spiral midshaft fracture of the tibia in a five‐month‐old foal.
(A) Preoperative radiographs show multiple fracture lines propagating from the proximal metaphysis to the distal midshaft. (B)
Craniocaudal radiograph 10 days after minimally invasive application of two LCPs with several cortical screws in each to compress the
plate against the bone, followed by the insertion of locking screws. (C) Lateromedial radiograph 10 days after repair shows that cortical
screws have been used in the ends of both plates to allow angulation of the screw to avoid the physis. Additionally, three cortical screws
in the center of the cranial plate have been applied using lag technique. Callus formation has begun on the caudal aspect of the fracture
(arrow). Source: Images courtesy Dr. Alan J. Nixon.
(A) (B) (C)
Figure 35.20 Minimally invasive application of two locking compression plates (LCPs) for the nondisplaced tibial fracture in the five‐
month old foal depicted in Figure 35.19. (A) Foal is positioned in dorsal recumbency to assist in access to the tibia. A broad LCP is
contoured to the shape of the medial aspect of the tibia, and (B) the plate holder and two threaded drill guides are used to form a handle.
(C) The plate is inserted through a proximally located stab wound over the medial aspect of the tibia. Stab wounds are then used to insert
multiple locking screws. The cranial/craniolateral plate was then inserted using a distally located stab wound over the cranial aspect of the
tibia. Source: Images courtesy Dr. Alan J. Nixon.
www.ajlobby.com
when the foal is in dorsal recumbency. Radiographic or

fluoroscopic monitoring is important to avoid screw
insertion into the proximal or distal physis. Stab wounds
are made over the combi holes in the LCP to allow inser
tion of one or two cortex screws, followed by insertion of
locking screws in the remaining plate holes. Minimally
invasive application of a second LCP to the craniolateral
side of the tibia is required in all but the youngest foals;
however, insertion of locking screws to the craniolater
ally applied plate is cumbersome due to the overlying
musculature and need to avoid neurovascular structures.
Alternatively, a single LCP and use of coaptation casting
for 14–21 days may be sufficient in small foals.
Incomplete Tibial Fractures

Incomplete fractures of the tibial diaphysis present a
management dilemma. These fractures can progress to
complete catastrophic disruption of the bone and over
lying soft tissues (Figure 35.21).9 Although plate fixation
would decrease this possibility, the risk of surgical com
plications is high and precludes internal fixation as the
initial course of therapy. The incidence of fracture disrup
tion is less than 50%, and most incomplete tibial frac
tures are managed conservatively.19 Stall confinement,
with the horse cross‐tied or placed in a sling to pre
vent recumbency, is recommended to reduce the risk of
fracture disruption. Frequent radiographic monitoring is
recommended to identify progression of the fracture. If
progression occurs, then plate fixation is warranted.
Figure 35.21 Craniocaudal radiograph depicting dehiscence of
Stress Fractures a nondisplaced diaphyseal fracture of the tibia in the horse
shown in Figure 35.5. Displacement followed 25 days of strict
Horses with tibial stress fracture should be withdrawn stall confinement combined with cross‐tying to prevent the
from training and allowed rest until the fracture under horse from lying down.
goes complete remodeling and is fully healed. Recent
evidence suggests that complete tibial fracture is likely if over a nonadherent bandage placed over the wounds.
training and racing continue.22,23 The prevalence of pre The skin is cleaned and dried to optimize adherence of
existing tibial stress fractures in horses euthanized at the bandage and provide a seal capable of preventing
California racetracks because of complete tibial fracture environmental contamination of the surgical sites. Alter
emphasizes the importance of identifying affected horses natively, a stent bandage can be sutured over the incision
early and removing them from training to prevent cata to apply focal pressure and minimize contamination.
strophic injury. Four to six months of rest are recom In addition, a well‐padded pressure bandage is applied,
mended, with a return to training being contingent on extending proximally from the distal limb, to cover the
follow‐up evaluation revealing radiographic healing and inner bandage and aid in protection, and to minimize
inactivity of the periosteal response. If available, scinti postoperative soft tissue swelling.
graphic examination with 99mTc‐MDP is performed to Recovery from anesthesia is assisted in all instances.
determine whether the bony response is quiescent. The foal is positioned in the recovery stall with the
affected limb uppermost and assisted to its feet.
Following recovery, the foal is confined to a stall with
Postoperative Care nonslip flooring for two to three months. It is impor
tant that the foal be assisted to rise as needed during
The proximal location of the skin incision following the postoperative period. Although most foals will
physeal fracture repair makes postoperative bandaging learn to lay with the affected limb uppermost, occa
difficult. However, elastic adhesive tape can be applied sionally they will position the fractured limb down. It
www.ajlobby.com
is particularly important to assist the foal to stand is also recommended, particularly in foals intended for
when this occurs. performance activities. Implants have been left in situ in
Physeal fractures stabilized by cross‐pin fixation are foals that were not intended for performance activities.
monitored carefully for evidence of pin migration, which Implant removal is ideally staged. There is an increased
could adversely affect stability at the fracture site or per risk of refracture when implants are removed simultane
forate the overlying skin and predispose to ascending ously. The foal is then assisted during recovery from
infection. Healing of the physis occurs in approximately anesthesia and immediately postoperatively, and con
half the time required for healing of the metaphyseal fined to a stall for an additional four to six weeks.
fracture. Therefore, when the metaphyseal fracture line Adults with tibial fractures, whether a tibial tuberosity
appears radiographically healed, it can be assumed that fracture or diaphyseal fracture, are managed similarly to
the physeal fracture is healed and the implants can be foals during recovery and the postoperative period.
removed. Cross‐pins which have become incorporated However, once the horse is returned to its stall, it is
into the growing tibia are left in situ. However, if the advisable to use cross‐ties in an effort to prevent lateral
proximal ends of the cross‐pins extend beyond the epi recumbency in the immediate postoperative period.
physis, they are identified and removed via stab inci This reduces the risk of catastrophic failure of the fixa
sions. Implant removal will prevent impingement on soft tion secondary to forces generated on standing.
tissue structures, as well as allow unrestrained physeal
growth. In cases with residual valgus deformity at the
physis after healing of a plated metaphyseal fracture, the Prognosis
plate may be left in place to continue to retard growth at
the medial physis, allowing continued lateral physeal Salter–Harris type II fractures of the proximal tibial
growth to correct the deformity. Once the limb is physis have been successfully treated using many tech
straight, or when growth at the physis has stopped, the niques. Most achieved adequate stability to allow healing
implants are removed. Although plates have been left in of the fracture, and residual lameness was not a frequent
situ, it is recommended that they be removed from foals complication.12,24–27 Reports of potential discrepancy in
intended for performance activities, because of their limb length or angular deformity due to transphyseal cal
close proximity to the medial femorotibial joint and lus formation are rare. In small foals which are stabilized
medial collateral ligament. Impingement on these struc by cross‐pins, physeal growth may continue without
tures could cause lameness. noticeable consequence.25 However, if physeal damage is
Postoperative care following repair of complete tibial severe and fixation across the physis is restrictive, as with
fractures in foals is similar to that described for physeal transphyseal lag screws or plating, the tibia may not
fracture. A sterile nonadherent bandage over the skin achieve its maximal length or angular limb deformity
incision, with an overlying pressure bandage, is main may develop. Minor limb length discrepancy as a conse
tained until the skin sutures or staples are removed. quence of disturbed longitudinal growth of the proximal
Although not routine, a closed suction drain placed prior tibial physis is not likely to be of major consequence, as
to wound closure may be used to evacuate fluids accu the degree of angulation in the hock, stifle, and hip joints
mulating within the surgical site. Use of these drains is at can be adjusted to compensate for slight discrepancy in
the discretion of the surgeon. However, when severe soft tibial length between the limbs. Valgus angulation, how
tissue trauma accompanies the fracture, postoperative ever, cannot be compensated, and if severe may cause
seroma formation is likely. If drains are inserted, meticu problems with ambulation. Fortunately, in cases where
lous care of the drain is essential to reduce the potential physeal damage results in transphyseal callus formation,
for ascending infection. This includes maintaining a the damage is usually widespread and includes the central
closed system with negative suction present at all times. portion of the physis.6 Physiodesis in these instances
The duration of suction drainage will vary among sur results in cessation of growth centrally rather than periph
geons and with the type of fracture. Most are removed erally, reducing the likelihood of angular deformity.
24–36 hours following surgery, or when a substantial Results of fixation following tibial tuberosity fractures
reduction in effluent is noted. The likelihood of ascend are reportedly good, provided that the fracture fragment
ing infection along the drain increases substantially after can be fixed to the parent tibia without unduly weakening
24 hours, even if negative suction can be maintained. it. In cases where the fragment is weakened, longitudinal
For foals with repaired complete tibial fractures, recov fracture through the screw holes may develop
ery from anesthesia and assistance to stand during the (Figure 35.22).21 However, when stable fixation has been
early postoperative period are similar to physeal fracture maintained, full restoration of athletic ability has been
cases. Confinement to a stall with nonslip flooring for achieved.4 In a recent report, 80% of horses with nonar
the duration of fracture healing is indicated. Implant ticular tibial tuberosity fractures, including two horses
removal following healing of complete fractures in foals with moderate displacement of the tibial tuberosity, were
www.ajlobby.com
(A) (B) Figure 35.22 (A) Intraoperative and (B)

immediate postoperative radiographs of a
14‐year‐old Thoroughbred mare with
complete fracture of the tibia after 4.5 mm
narrow dynamic compression plate repair
of an avulsion fracture of the tibial
tuberosity. The fracture has developed
along the line of the screws. Source:
Images courtesy Dr. Alan J. Nixon.
able to return to use after conservative treatment.1 understanding of the biomechanical and biologic princi
In this study, concurrent soft tissue injury associated ples of tibial fracture fixation in adults expands, and
with the fracture was shown to have a negative impact on more clinics utilize the LCP system, more reports of suc
return to performance. cessful repair of these fractures will emerge.
Foals that undergo fixation of diaphyseal fractures Incomplete tibial fractures, which do not propagate to
have a good prognosis for survival with a reasonable out become complete fractures, have a good prognosis for the
look for athletic soundness.28 Osteomyelitis and loss of horse returning to its intended use.11 However, a signifi
stable fixation are the most serious complications and cant number of affected horses will develop complete
are more likely with short oblique and comminuted frac diaphyseal fractures within the first month following the
tures. Open fractures and those accompanied by severe injury.19 The prognosis then becomes quite poor.
soft tissue damage are also at increased risk for compli Tibial stress fractures that are diagnosed early and
cations and failure of fixation. appropriately treated have an excellent prognosis for
Successful repair of complete diaphyseal tibial fractures return to complete function.17,20 Following an appropri
in adult horses is rare.2 Fracture configuration, location, ate period of rest, horses can be expected to return to
soft tissue damage, and perforation of the skin usually racing. Further, it appears that recurrence of the injury
necessitate humane destruction of the horse. Even when is uncommon.17 However, if the fracture is not identified
the fracture is favorable for fixation, the potential for early and the horse removed from the stress of training
catastrophic failure of the bone–implant construct dur and racing, progression to complete diaphyseal fracture
ing recovery from anesthesia is high. Hopefully, as our is possible.22,23
References
1 Arnold, C.E., Schaer, T.P., Baird, D.L., and Martin, B.B. 4 Dyson, S.J. (1994). Stifle trauma in the event horse.
(2003). Conservative management of 17 horses with Equine Vet. Educ. 6: 234–240.
nonarticular fractures of the tibial tuberosity. Equine 5 Eliashar, E., Smith, R.K.W., Schramme, M.C., and Pead,
Vet. J. 35: 202–206. M.J. (2000). Preoperative bending and twisting of a
Bramlage, L.R. and Hanes, G.E. (1982). Internal fixation
2 dynamic compression plate for the repair of tibial
of a tibial fracture in an adult horse. J. Am. Vet. Med. tuberosity fracture in the horse. Equine Vet. J. 32:
Assoc. 180: 1090–1094. 447–448.
Crawford, W.H. and Fretz, P.B. (1985). Long bone
3 6 Embertson, R.M., Bramlage, L.R., and Gabel, A.A.
fractures in large animals: a retrospective study. Vet. (1986). Physeal fractures in the horse II: management
Surg. 14: 295–302. and outcome. Vet. Surg. 15: 230–236.
www.ajlobby.com
7 Getty, R. (1975). Sisson and Grossman’s The Anatomy of grading system to equine tibial stress fractures: 42
Domestic Animals, 5e. Philadelphia: Saunders, W.B. cases. Equine Vet. J. 35: 382–388.
8 Glass, K. and Watts, A.E. (2017). Diagnosis and 19 Richardson, D.W. (1990). Fractures of the tibia. In:
treatment considerations for non‐physeal long bone Current Practice of Equine Surgery (ed. N.A. White and
fractures in the foal. Vet. Clin. North Am. Equine Pract. J.N. Moore), 660–665. Philadelphia: Lippincott, J.B.
33: 431–438. 20 Ruggles, A., Moore, R.M., Bertone, A.L. et al. (1994).
9 Haynes, P.F., Watter, J.W., McClure, R.J., and French, D. Tibial stress fractures in 13 racing Standardbreds. Vet.
(1980). Incomplete tibial fractures in three horses. J. Surg. 23: 416.
Am. Vet. Med. Assoc. 177: 1143–1145. 21 Smith, B.L., Auer, J.A., and Watkins, J.P. (1990). Surgical
10 Johnson, B.J., Stover, S.M., Daft, B.M. et al. (1994). repair of tibial tuberosity avulsion fractures in four
Causes of death in racehorses over a 2 year period. horses. Vet. Surg. 19: 117–121.
Equine Vet. J. 26: 327–330. 22 Stover, S.M. (1994). Stress fractures of the humerus and
11 Johnson, P.J., Allhands, R.V., Baker, G.J. et al. (1988). tibia in racehorses. In: Proceedings of the Annual
Incomplete linear tibial fractures in two horses. J. Am. Surgical Forum of the ACVS, vol. 22, 160–163.
Vet. Med. Assoc. 192: 522–524. Germantown, MD: ACVS.
12 Juzwiak, J.A. and Milton, J.L. (1985). Closed reduction 23 Stover, S.M., Ardans, A.A., Deryck, H.R. et al. (1993).
and blind cross‐pinning for repair of a proximal tibial Patterns of stress fractures associated with complete
fracture in a foal. J. Am. Vet. Med. Assoc. 187: 743–745. bone fractures in racehorses. In: Proceedings of the
13 Levine, D.G. and Aitken, M.R. (2017). Physeal fractures American Association of Equine Practitioners, vol. 39,
in foals. Vet. Clin. North Am. Equine Pract. 33: 131. Lexington, KY: AAEP.
417–430. 24 Wagner, P.C., DeBowes, R.M., Grant, B.D. et al. (1984).
14 MacKinnon, M.C., Bonder, D., Boston, R.C., and Ross, Cancellous bone screws for repair of proximal growth
M.W. (2015). Analysis of stress fractures associated plate fractures of the tibia in foals. J. Am. Vet. Med.
with lameness in Thoroughbred flat racehorses training Assoc. 184: 688–691.
on different track surfaces undergoing nuclear 25 Watkins, J.P., Auer, J.A., and Taylor, T.S. (1985).
scintigraphic examination. Equine Vet. J. 47: 296–301. Crosspin fixation of fractures of the proximal tibia in
15 O’Sullivan, C.B. and Lumsden, J.M. (2003). Stress three foals. Vet. Surg. 14: 153–159.
fractures in the tibia and humerus in Thoroughbred 26 White, N.A., Blackwell, R.B., and Hoffman, P.E. (1982).
racehorses: 99 cases (1992–2000). J. Am. Vet. Med. Use of a bone plate for repair of proximal physeal
Assoc. 222: 491–498. fractures of the tibia in two foals. J. Am. Vet. Med.
16 Peloso, J.G., Watkins, J.P., Keele, S.R., and Morris, E.L. Assoc. 181: 252–254.
(1993). Bilateral stress fractures of the tibia in a racing 27 White, N.A. and Wheat, J.D. (1975). An expansion and
American Quarter Horse. J. Am. Vet. Med. Assoc. 203: compression technique for reducing and stabilizing
801–805. proximal epiphyseal fractures of the tibia in foals. J. Am.
17 Pilsworth, R.C. and Webbon, P.M. (1988). The use of Vet. Med. Assoc. 167: 733–738.
radionuclide bone scanning in the diagnosis of tibial 28 Young, D.R., Richardson, D.W., Nunamaker, D.M. et al.
stress fractures in the horse: a review of five cases. (1989). Use of dynamic compression plates for
Equine Vet. J.(Suppl. 6): 60–65. treatment of tibial diaphyseal fractures in foals: Nine
18 Ramzan, P.H.L., Newton, J.R., Shepherd, M.C., and cases (1980–1987). J. Am. Vet. Med. Assoc. 194:
Head, M.J. (2003). The application of a scintigraphic 1755–1760.
www.ajlobby.com
664
36
Fractures of the Stifle
Alan J. Nixon1,2
1
2
Incidence frequently evident, including soft tissue edema and

fibrosis, and effusion in the affected joint. The degree of
Fractures involving the bones forming the stifle are uncom- lameness generally is dictated by the size and location of
mon. The femoropatellar and femorotibial joints forming the fracture. Swelling and lameness associated with frac-
the stifle are well invested by periarticular ligaments and tures of the patella and the tibial crest, and the cruciate
heavy fascia. However, there are several surfaces that are insertions, are often severe; horses frequently only toe
prone to external impact, including the patella, tibial crest, touch in the acute phase. Signs of external trauma are
and lateral trochlear ridge (LTR). Internal stabilizing struc- frequently observed, with skin abrasions over the cranial
tures such as the cruciate ligaments and ligamentous attach- aspect of the patella or tibial crest. Palpation of a frac-
ments of the menisci both represent sites of internal tured patella is resented, and several days of medical
avulsion fracture that can destabilize the femorotibial therapy using nonsteroidal anti‐inflammatory agents
apparatus and result in severe lameness and osteoarthritis. and rest from active work may be required before a more
The most frequent fractures of the stifle include the definitive diagnosis can be obtained by palpation.
medial intercondylar eminence of the tibia, fractures Examination of the dense fascia over the cranial aspect
of the tibial crest, and fractures of the patella.3,10,11,27,31 of the patella is vital in fractures that involve the majority
Intraarticular shear fractures involving portions of the of the width or length of the patella.15 Fracture distrac-
medial or lateral femoral condyle (LFC) are also encoun- tion leads to a fracture gap, which can be palpated in the
tered in the course of lameness evaluation when the dense cranial fascia over the patella (Figure 36.1), and
problem is isolated to the femorotibial joints. Many internal fixation is often required. Minimally distracted
become chronic rounded intraarticular osteochondral fractures do not disrupt the cranial fascia and the stabil-
free bodies. Isolated fractures of the trochlear ridges are ity and quadriceps strain path are maintained, lessening
also seen sporadically,24 and fractures of the femoral the need for surgical stabilization. Even with careful pal-
condyles that involve portions of the entire epiphysis can pation, radiography may be the only definitive mecha-
be part of a more significant destabilizing fracture of the nism for diagnosis. Ultrasonography is useful to define
distal femur. Lastly, fractures of the origin or insertion the width of the fracture gap, but more importantly to
of the cruciate ligaments or meniscal attachments are identify other lesions such as patella desmitis and rup-
encountered infrequently, and need to be differentiated ture of the femorotibial collateral ligaments. Fracture of
from less significant fractures of the intercondylar notch the medial aspect of the patella has been recognized as a
of the femur or caudal aspect of the tibia.12,29 concurrent injury to avulsion of the femoral origin of the
lateral collateral ligament of the femorotibial joint.22
Intraarticular fractures involving the femoral trochlear
Diagnosis ridges and femoral condyles initially result in moderate
to severe lameness, depending on the extent of articular
Fractures involving the femoropatellar and femorotibial surface involvement of the trochlear ridges or condyles.
joints forming the stifle often present with a history The trochlear ridges are not heavily weighted, compared
of acute lameness that has moderated. Swelling is to the femoral condyles, and fractures involving either

www.ajlobby.com
the LTR or medial trochlear ridge (MTR) can often smaller intraarticular fractures such as those that involve
mimic osteochondritis dissecans (OCD). Concurrent the tibial eminences, or small portions of the femoral
chip fracture of the perimeter of the patella may exacer- condyle, require local joint blocks to confirm the origin
bate the lameness (Figure 36.2). of the lameness.
The medial intercondylar eminence is the most frequent Radiography is required to establish a diagnosis.
site for fracture in the femorotibial joints (Figure 36.3).31 Caudocranial and lateromedial projections are a mini-
Clinical signs can commence with acute lameness and mum. The caudolateral to craniomedial oblique projec-
medial femorotibial joint effusion, which later moder- tion, flexed lateromedial, and flexed lateromedial oblique
ates, leaving a mild lameness and persisting effusion, views often add to the information on fracture location,
depending on the extent of cruciate or meniscal attach- extent, and treatment options. A flexed cranioproximal‐
ment. Intraarticular anesthesia may be required to con- craniodistal (skyline) projection of the patella is essential
firm the site of involvement in subacute and chronic to establish a diagnosis of a fractured patella and develop
cases. The more destabilizing fractures such as those a treatment plan (see Figure 36.1). This may require
that involve the patella, tibial crest, extensive portions of
the cruciate insertion, and fracture of the caudal aspects
of the femoral condyles often result in significant swell-
ing, pain on direct palpation, and significant reaction on
joint flexion. These fractures can be diagnosed without
the need for intra articular anesthesia. Conversely,
Figure 36.1 Dorsoproximal to dorsodistal skyline radiograph of a Figure 36.2 Combination patella fractures (black arrows) and
mid‐sagittal patella fracture. The fracture was repaired by insertion fracture of the distal aspect of the lateral trochlear ridge (white
of multiple screws. Source: Images courtesy Dr. Alan Ruggles. arrows) as a result of direct trauma to the cranial aspect of the stifle.
Figure 36.3 (A) Caudocranial and (A) (B)

(B) lateromedial radiographs showing
chronic fracture of the medial tubercle of
the intercondylar eminence of the tibia
(arrow). LFC, lateral femoral condyle; MFC,
medial femoral condyle.
www.ajlobby.com
heavy sedation, since the view is obtained with the stifle lateral patellar ligaments. Assessment of the stability
partially flexed. The image is best obtained with the and congruency of the fractured LTR dictates whether
digital receiver distal to the stifle, and with the tibia removal or stabilization using lag screw fixation is war-
parallel to the ground. The X‐ray beam is then angled at ranted. Most chronic fractures of the LTR have a fibrous
45° to the ground and receiver to highlight the patella union and can be further stabilized by insertion of corti-
and trochlear ridges in the flexed stifle. The skyline cal screws using lag screw principle. Arthroscopic visu-
projection can also define small fractures of the trochlear alization of the fracture and needle insertion to guide
ridges better than routine views. Use of three‐dimensional subsequent screw placement allow the insertion of sev-
imaging such as computed tomography (CT) or CT eral 3.5 mm cortical screws. The screw heads need to be
arthrography is also helpful in some cases involving recessed beneath the cartilage surface to prevent exco-
fracture of the femoral condyles.7,26,32 riation of the patella during flexion of the stifle. Large
trochlear fractures may need to be accessed using
arthrotomy, which allows debridement of the fracture
Fractures of the Distal Femur line and manual stabilization while the screws are
inserted (see Figure 36.4). Intraoperative monitoring is
Femoral Trochlear Ridges vital to verify fracture reduction and screw position.
Arthroscopic removal of chronic fractures of the
Fractures of the trochlear ridges are relatively uncom- LTR can be tedious due to the large size of the fracture
mon, due to the protected position of the trochlear ridges fragment (Figure 36.6). Stabilization is generally pre-
relative to the patella and cranial aspect of the tibia. ferred. Where fracture alignment cannot be reestab-
External impact of the stifle against a fixed object such as lished, or the cartilage surface over the fractured
a door latch or the rails of a jump, or a kick from another fragment has degenerated, removal may be necessary.
horse, are frequent causes of fracture. The location in An 8–10 mm instrument portal is developed over the
relation to the support surface for the patella and the lateral femoropatellar joint pouch using a 3 in. spinal
extent of trochlear ridge involvement influence clinical needle to define the most appropriate instrument entry
symptoms and the treatment approach. Fractures of the point. The fracture fragment fibrous union is divided
proximal portions of the trochlear ridges are rare. The using periosteal elevators or an osteotome, and the soft
distal aspect of the LTR is the most commonly affected tissue attachments dissected with serrated arthroscopic
location.24 Chip fracture of the trochlear ridges have scalpels, arthroscopic scissors, or motorized resectors.
been described in three horses, two involving the LTR Removal of the fractured portion of the trochlear ridge
and one occurring on the MTR, all occurring as a result generally requires division of the fragment into several
of direct trauma.24 Concurrent fracture of the LTR and pieces to allow extraction through the instrument por-
portions of the patella can also develop from the same tal. Use of heavy arthroscopic toothed forceps or
cranial impact trauma (see Figure 36.2). Fractures can Ochsner forceps may be required to adequately grip the
involve the lateral perimeter of the LTR and extend over fracture fragments for extraction. Debridement of the
to the common site of origin of the long digital extensor fibrous tissue in the base of the fracture bed is then
tendon and peroneus tertius (Figure 36.4). done to improve cartilage healing in the original defect.
Small fractures can be removed arthroscopically Closure when large fragments have been removed may
(Figure 36.5).24 More extensive fractures of the LTR, need several sutures in the capsule tissues.
particularly those involving the proximal aspect, can
be stabilized by internal fixation (see Figure 36.4). This Outcome
reduces the propensity for patella subluxation due to the Removal of chip fractures of the LTR or MTR returned all
loss of LTR support. three horses to athletic function in one series.24 There are
no published case series to establish a prognosis following
Surgical Technique fracture removal or fixation of large fractures of the LTR.
The entry site for the arthroscope is defined by the posi- Retaining large fracture fragments of the LTR minimizes
tion of the trochlear ridge fracture. Distal LTR fractures the potential for lateral subluxation of the patella. Surgical
can be visualized using an arthroscope entry in the cra- removal of the existing fracture fragment may destabilize
niomedial joint pouch, placing the arthroscope medial patella support, and tracking should be assessed intraop-
to the middle patellar ligament. Flexion of the femoro- eratively to determine the impact of fragment removal.
patellar joint provides better visualization of the distal Anecdotal experience indicates that fracture stabilization
regions of the LTR. Fractures of the middle and proxi- of lateral sagittal fractures of the LTR can return horses to
mal regions of the LTR can be visualized using the athletic function. The author has no experience in frac-
standard arthroscope entry between the middle and ture stabilization of the MTR.
www.ajlobby.com
(A) (B)
(C) (D)
Figure 36.4 Fracture of the lateral trochlear ridge and origin of the peroneus tertius/long digital extensor tendon. (A) Lateromedial and
(B) caudocranial radiographs show fracture avulsion of the lateral trochlear ridge (arrows). (C) Intraoperative photograph shows fracture
line (black arrow) and multiple sites for screw insertion (white arrows), including drilled and countersunk holes, with one screw inserted.
(D) Postoperative lateromedial radiograph shows multiple lag screw insertion to stabilize the lateral trochlear ridge fracture. Screw heads
are recessed below the articular cartilage.
(A) (B) (C)
Figure 36.5 Combination fracture of the lateral trochlear ridge and patella (same case as Figure 36.2). (A) Comminuted fracture of the
distal aspect of the lateral trochlear ridge (arrow). (B) Arthroscopic image showing the displaced fracture (arrows) on the distal‐most
aspect of the trochlear ridge. (C) Approach for removal of the proximal patella fracture in the same joint. Pat, patella; TG, trochlear groove.
www.ajlobby.com
(A) (B)
(C) (D)
Figure 36.6 Extensive lateral trochlear ridge fracture of the femur. (A) Radiograph showing displaced extensive fracture (arrow) of the
lateral trochlear ridge (LTR) of the femur. (B) Separating the osteochondral chronic nonunion fracture of the LTR. Pat, patella. (C) Dissection
of the soft tissue nonunion attaching the fracture (Fx) of the LTR. (D) Residual fracture bed showing remaining LTR and tracking of the
patella. Subluxation has developed.
Femoral Condyles may involve portions of the origin of the cranial cruciate
Fractures of the femoral condyles can vary from small ligament (CrCL) on the axial side of the LFC. Others can
osteochondral fractures (Figure 36.7) to larger shear originate on the axial borders of either the lateral or
fractures that involve the entire caudal aspect of the medial condyle more cranial to the cranial cruciate ori-
medial femoral condyle (MFC) or LFC (Figure 36.8).8 gin. These fractures can stabilize in the septum between
Both are unusual. Acute osteochondral fractures that the lateral and medial femorotibial joints. However, per-
involve central weight‐bearing portions of the femoral sisting lameness often necessitates fragment removal.
condyles result in transitory acute lameness, followed Concurrent involvement of the medial tubercle of the
by chronic mild to moderate lameness and persisting intercondylar eminence has also been seen. Encroachment
effusion of the femorotibial and femoropatellar joints. of the fracture fragment on the CrCL and separation of
Fractures predominantly affect the MFC. Separation of portions of the cruciate insertion through fracture of the
the fractured fragment and translocation to the caudal medial tubercle of the intercondylar eminence can be a
cul‐de‐sac of the medial femorotibial joint is common consequence of chronic fracture in the intercondylar
(see Figure 36.7). Fragments may then continue to notch. Differentiation of these fragments from complete
enlarge over months to years, to become substantial avulsion fracture of the origin or insertion of the CrCL is
rounded osteochondral fragments that no longer resem- important, since involvement of the cruciate ligament
ble the site of origin (see Figure 36.7). Arthroscopic caries a poor prognosis, due to the ongoing instability
removal is required for return to athletic function. after fracture fragment removal (Figure 36.10).12
Fracture of the LFC or MFC are occasionally seen in the Slab fractures of the caudal aspect of the femoral condyles
region of the intercondylar notch (Figure 36.9). Some can result from impact trauma with the stifle partially
www.ajlobby.com
(A) (B)
(C) (D)
Figure 36.7 Chronic displaced fracture of the medial femoral condyle. (A) Oblique radiograph showing a large rounded chronic
osteochondral fragment (arrow) in the caudal cul‐de‐sac of the medial femorotibial joint. (B) Arthroscope and instrument entry to the
caudal aspect of the medial femorotibial joint, showing arthroscope positioning immediately cranial to the saphenous vein, and
instrument (arrow) to retrieve the fracture fragment. (C) Fracture fragment in forceps for extraction. (D) Retrieved 2 cm fragment from the
caudal aspect of the medial femorotibial joint.
flexed. Falls during jumping events may lead to shear or late‐stage chronic osteomyelitis (Figure 36.11).
fracture. The medial condyle is predisposed (see Fragment removal can be attempted in chronic nonun-
Figure 36.8).8 The fractures are commonly too large to ion fractures in immature horses, using a caudomedial
remove, and an attempt at reduction and internal fixa- approach to the caudal cul‐de‐sac of the medial femo-
tion should be made. Treated conservatively, most large rotibial joint.
fractures of the caudal aspect of the medial condyle
develop a fibrous nonunion. However, this can allow Surgical Technique
return to comfortable nonathletic paddock exercise. Osteochondral fractures are frequently chronic and have
Smaller fractures of the caudal aspect of the MFC detached from the LFC or MFC. The original fracture site
can develop in foals and weanlings. These frequently has often partially healed, and should be debrided fol-
are chronic at the time of diagnosis, and need to be lowed by arthroscopic removal of the osteochondral
differentiated from caudal femoral osteochondrosis fragment. Some fragments translocate to the intercondylar
www.ajlobby.com
(A) (B)
Figure 36.8 Shear fracture of the medial femoral condyle. (A) Lateromedial and (B) oblique radiograph showing unstable nonunion of
the caudal aspect of the medial femoral condyle. Surgical reattachment using multiple 4.0 mm cannulated cancellous screws was
recommended.
(A) (B) (C)
(D) (E) (F)
Figure 36.9 Intercondylar notch fractures of the femur. (A) Caudocranial radiograph showing avulsion fracture of the origin of the cranial
cruciate ligament (CrCL; arrows). LFC, lateral femoral condyle; MFC, medial femoral condyle. (B) Lateromedial radiograph showing avulsion
fracture of the CrCL on the femoral condyle (FCFx) and tibial tubercle fracture (TTFx). (C) Arthroscopic image showing multiple fracture
beds (arrows) on the intercondylar notch (FemICN), producing intrusion onto the CrCL. (D) Exposure of the avulsion fracture (Fx) of the
CrCL, on the axial aspect of the LFC forming the FemICN. (E) Retrieval of the chronic osteochondral fragment (Fx) attached to the CrCL.
(F) Debrided cruciate origin and FemICN.
www.ajlobby.com
(A) (B)
Fx
MFC CrCL LFC

LFC
MFC T
CLMM
Figure 36.10 (A) Complete avulsion of the origin of the cranial cruciate ligament (CrCL; arrows) on the lateral femoral condyle (LFC). MFC,
medical femoral condyle. (B) Necropsy image shows the avulsion fracture (Fx) of the CrCL on the LFC. CLMM, caudal ligament of the
medial meniscus; T, medial tubercle of the intercondylar eminence.
proliferative synovial tissue and fibrous tissue that has

formed around the osteochondral fracture fragment.
Exchange of arthroscope and instrument portals is
required to adequately examine and debride the inter-
condylar notch region, particularly when fractures
involve the axial perimeter of the LFC (see Figure 36.9).
Concurrent fracture of the medial tubercle of the inter-
condylar eminence can also be examined and removed
during removal of the femoral fracture fragment.
Many osteochondral fractures from the MFC need to
be retrieved from the caudal compartment of the medial
femorotibial joint. Here they can grow into substantial
rounded fragments (see Figure 36.7). Arthroscopic
approaches to the caudal cul‐de‐sac of the medial femo-
rotibial joint have been described.35 The arthroscope por-
tal is made immediately cranial to the saphenous vein,
level with the proximal plane of the tibial plateau. The
arthroscope is then inserted in a cranial and lateral direc-
tion to penetrate the caudal cul‐de‐sac of the medial fem-
orotibial joint. An instrument portal is developed using a
Figure 36.11 Chronic displaced fracture of the caudal aspect of spinal needle to guide the position and direction to ade-
the medial femoral condyle in a thoroughbred weanling. quately target the osteochondral fragment in the caudal
cul‐de‐sac. Swelling from fluid leakage around both
instrument and arthroscope portals develops rapidly and
notch adjacent to the medial intercondylar eminence of can be extensive. The fracture fragment is identified, sep-
the tibia, and can be readily removed using standard arated from any attachments, and removed with a large
approaches (see Figure 36.9). A craniolateral approach to rongeur or grasping forceps. Large fragments may need
the medial femorotibial joint is made, with the arthro- to be removed using Ochsner forceps. A careful search
scope portal lateral to the lateral patellar ligament. The for smaller additional fragments is required. Some frag-
femorotibial joint is flexed to 90°. A cranial portal for ments may also attach to the synovial tissue on the proxi-
instrument entry to the cranial compartment of the medial mal aspect of the MFC (Figure 36.12). A more proximal
femorotibial joint is made using spinal needle guidance. instrument entry is required to target this region. Closure
Motorized shavers are generally required to reduce the is routine, using nonabsorbable sutures in the skin.
www.ajlobby.com
(A) (B) (C)
Figure 36.12 Chronic displaced osteochondral fracture of the medial femoral condyle (MFC). (A) Oblique radiograph showing fragment
attached to the proximal aspect of the MFC (arrow). (B, C) Arthroscopic images showing identification of the fracture fragment proximal to
the MFC (arrow), and retrieval using rongeurs.
Removal of caudal femoral osteochondral fragmen- Outcome

tation in foals and weanlings involves a similar Review of 20 foals with caudal osteochondral fragmen-
approach, with the arthroscope positioned cranial to tation indicated that most had severe lameness and 11
the saphenous vein, but 3–5 cm proximal to the line of were euthanized on admission.16 Of the remaining 9, 4
the tibial plateau.16 An instrument portal is developed were operated on, and 2 of the 4 recovered to perform
using spinal needle placement to verify position and athletically. The other 2 were euthanized at surgery.
direction. Dissection of the caudal femoral condyle Of the 5 treated conservatively, 3 were sound after
fragment from peripheral synovial and capsule attach- one year, while 2 remained lame; 2 of the 3 that recov-
ments is done using curved serrated blades, biopsy ered were considered septic at admission and yet still
rongeurs, and motorized resectors (Figure 36.13). improved.
Most fragments are too large to remove in one piece, There are no published case series describing outcome
and need to be split or removed using a motorized bur. after fracture removal or fixation of the caudal aspect of
Dissection can be tedious. The residual bony bed can the MFC. Anecdotal information suggests that adequate
be grafted with bone marrow aspirate concentrate or reduction and fracture fixation can be associated with a
stem cells, depending on the extent of the fragment return to active competitive events.
and age of the weanling. Removal of the fracture frag-
ment in foals has allowed some to go on to complete
athletic activity, including racing. Previous descrip- Fracture of the Distal Femoral
tions suggest that some of these are a consequence of
sepsis, and the outlook is poor.16
Epiphysis
Internal fixation may be required in adults and Distal femoral fractures in foals occur as Salter–Harris
arthroscopic visualization utilizes the caudal entry to the type IV fractures (Figure 36.14), or occasionally type II or
medial femorotibial joint. Assessment of the fractured III fractures. Rarely, comminution results in a combina-
portion of the caudal aspect of the MFC is followed by tion of Salter–Harris fracture types (Figure 36.15). Most
debridement of small fracture fragments and unhealed occur as a result of paddock injuries, presumably with
cartilage surfaces. Stabilization of the fractured portion lateral bending or torque applied during exercise.
of the MFC requires the insertion of instruments and Lameness is severe, with the limb generally not bearing
implants from the caudal aspect of the thigh. This can be weight. Swelling can be moderate to severe, depending
technically challenging, and guide‐pin systems such as on the length and distraction of the fracture. The periar-
the 4.0 or 7.3 mm cannulated screw system have been ticular soft tissues stabilize most Salter–Harris type IV
used by the author. The instrument entry is caudal and fractures to lessen fracture distraction and allow a return
deep to the saphenous vein, coursing proximally through to limited weight bearing within several days of the frac-
the caudomedial aspect of the thigh. Cannulated screw ture. Type IV fractures develop in a sagittal plane, most
systems using the small 4.0 mm cannulated screw are entering the intercondylar notch of the femur (see
preferred for fixation of acute fractures of the caudal Figure 36.14). The Salter–Harris type III fracture can
aspect of the MFC. develop in the same plane, and displace only minimally.4
www.ajlobby.com
(A) (B)
(C) (D)
(E) (F)
Figure 36.13 Extensive chronic fracture of the medial femoral condyle (MFC) in a Thoroughbred weanling. (A, B) Radiographs show
chronic nonunion fracture (arrows) of the entire caudal aspect of the MFC. (C) Arthroscopic image showing the proximal aspect of the
fracture (Fx) of the MFC extending down to the medial meniscus (MM). (D) Debridement of the osteochondral fracture using a motorized
resector. (E) Retrieval of residual osteochondral fragments using rongeurs. (F) Debrided medial femoral condyle (MFC Fx Bed).
www.ajlobby.com
(A) (B) Figure 36.14 Salter‐Harris type IV fracture of
the distal femur. (A) Preoperative radiograph
showing fracture commencing in the medial
aspect of the intercondylar notch and
extending proximally through the femoral
physis and into the distal metaphysis. (B)
Caudocranial radiograph 60 days after
reduction and stabilization using two 7.0 mm
cannulated screws with washers beneath the
screw heads.
(A) (B)
(C) (D)
Figure 36.15 Combination Salter–Harris type III and IV fracture of the distal femur of a Thoroughbred foal. (A) Caudocranial radiograph
showing multiple type III fractures of the medial and lateral femoral condyles, extending into the physis and including a complete
metaphyseal fracture (arrow) constituting an irregular Salter–Harris type IV fracture. (B) Lateromedial radiograph showing minor caudal
comminution of the fracture (arrow). (C) Caudocranial radiograph at 40 days showing stabilization of the fractures using a combination of
5.5 mm cortical and 6.5 mm cancellous screws placed from both medial to lateral and lateral to medial, including several with washers
beneath the screw heads. (D) Lateromedial radiograph 40 days postoperatively, showing fracture stabilization using multiple lag screws.
Source: Images courtesy Dr. Paddy Todhunter.
www.ajlobby.com
Salter–Harris type II fractures are significantly more intercondylar notch to engage the opposite side of the
destabilizing, and interrupt the strain path of the femoral femoral epiphysis. Washers should be included beneath
shaft. These fractures do not primarily involve the stifle the screw head to avoid the screw sinking through
joint, and are described in more detail in Chapter 37. the soft cortex of the femoral epiphysis in foals.
Radiography is required to establish the diagnosis Intraoperative radiography or fluoroscopy is vital to
and determine the need for surgical stabilization. verify fracture reduction and alignment, and to ensure
Caudocranial and lateromedial projections are usually that the screw path enters proximal to the intercondylar
adequate to identify the fracture. Further oblique views notch of the femur and is in the center of the craniocau-
may also indicate fracture comminution, or involvement dal width of the femoral epiphysis. Multiple screws can
of additional regions of the condyles or trochlear ridges. be placed, including several in the femoral metaphysis
Computed tomography may be required in complex for Salter–Harris type IV fractures. Screws should not
fracture configurations, but most are relatively linear bridge the distal femoral physis during repair of Salter–
sagittal fractures. Harris type III or IV fractures. More comminuted
Internal fixation of Salter–Harris type III and IV frac- fractures of the distal femoral epiphysis may separate
tures is required to improve the likelihood of an athletic the distal femoral epiphysis into a lateral and medial
career. Distracted sagittal plane fractures often do not portion, or include portions of the distal femoral
involve the articular surface of the femoral condyles, but metaphysis (see Figure 36.15). Lag screw fixation from
do propagate into the femoropatellar joint, with an both lateral and medial directions may be useful to
oblique fracture of the trochlear groove and parts of the ensure adequate stabilization of the femoral condyles in
trochlear ridge. Damage to the cartilage surface of the a Salter–Harris type III injury, and provides similar
patella is likely for distracted femoral fractures that are stability in type IV fractures (see Figure 36.15).
not stabilized by screw fixation. Application of bone plates is not generally indicated
for type III or IV fractures, provided that stability can be
Surgical Technique achieved using lag screws. Use of a dynamic condylar
The foal is positioned in either dorsal or lateral recum- screw (DCS) plate in a two‐year‐old adult horse has been
bency (with the affected limb uppermost), depending described to treat a type III fracture,4 although the utility
on the surgeon’s preference and the potential need to of the large 12.5 mm locking screw in the DCS system
insert screws from both a lateral and a medial direction. could easily have been replaced by multiple individual
Dorsal recumbency allows improved access to both cortical or cancellous screws, as described here. Salter–
sides of the femur, and makes intraoperative radiogra- Harris type II fractures need stabilization with a laterally
phy or fluoroscopy easier. Fracture fixation generally applied bone plate (see Chapter 37).
uses cortical screws applied in lag fashion, although par- Assisted recovery from anesthesia is mandatory. Most
tially threaded cancellous screws have also been used to cases occur in foals, and many are small enough that they
provide compression of type III and IV fractures (see can be manually assisted to their feet in the recovery box.
Figures 36.14 and 36.15). Screws are inserted from Complete stall rest is indicated for six weeks following
either the lateral or medial aspect of the femoral condyle surgery, depending on follow‐up radiographs. Implant
through stab incisions, and directed proximal to the removal is not necessary.
(A) (B)
Figure 36.16 (A, B) Extensive combination fractures of the lateral femoral condyle (LFC) and trochlear ridge (LTR), with displacement and
destabilization of the patella. The horse was euthanized. MFC, medial femoral condyle.
www.ajlobby.com
Comminuted fractures of the femoral condyles in been described for larger fractures.34 The majority of
adults are devastating injuries that are generally not medial tubercle fractures are chronic, with rounded frac-
repairable (Figure 36.16). Extensive fracture fragment ture edges, and removal is the treatment of choice.
displacement and articular disruption limit likely success
using reduction and lag screw repair. Surgical Technique
Arthroscopic access using a standard craniolateral
approach to the medial femorotibial joint is used.21
Fractures Instrument entry to the cranial pouch of the medial
of the Proximal Tibia femorotibial joint is defined by preplacing a spinal nee-
dle to ensure a direct approach to the fractured tubercle.
A motorized resector is used to remove synovial prolif-
Fractured Intercondylar Eminence eration around the base of the fractured tubercle. Any
Intraarticular fracture of the medial tubercle of the inter- cranial cruciate or cranial ligament of the medial
condylar eminence of the tibia is the most common frac- meniscus fiber insertions are also carefully dissected
ture of the stifle joint.31,34 These were originally considered away from the fracture fragment. A fibrous union is
to be avulsion injuries of the insertion of the CrCL.5,25,29 common in chronic cases, which provides inadequate
However, most medial tubercle fractures involve minimal stability, but also makes removal more difficult.
portions of the cruciate insertion,34 although a recent Separation of the fibrous union with a periosteal eleva-
report indicated some cranial cruciate fiber attachment tor or curved serrated blade is required (see Figure 36.18).
in the majority of horses.31 The pathogenesis of these The fracture fragment is then gripped in a large rongeur,
fractures may involve transient lateromedial instability rotated until free, and withdrawn from the joint.
and stress on the femorotibial joints during athletic activ- Enlargement of the skin incision for instrument access
ity, resulting in shear forces being applied to the promi- is frequently required to allow exit of the fracture frag-
nent medial tubercle of the intercondylar eminence of the ment. Debridement of the fracture bed with a motorized
tibia. The lateral tubercle is shorter and rarely involved. bur is used to remove sharp edges.
These tubercle fractures are relatively small and non‐ For large fractures of the medial tubercle, lag screw
destabilizing, and clinical symptoms include mild to fixation may be preferred.34 Most large fractures are
moderate lameness, effusion of the medial femorotibial also chronic, which complicates the decision for lag
joint, and a positive response to stifle flexion tests. screw stabilization rather than fracture removal.
Caudocranial radiographs usually identify the fracture Internal fixation may lessen the disruption of the sur-
(Figure 36.17), although flexed lateromedial projections rounding soft tissues, including the cranial cruciate and
may improve information on the size and distraction of cranial ligament of the medial meniscus fiber inser-
the fracture (Figure 36.18), which is useful to guide the tions. Arthroscopic visualization can be used to guide
surgical choice of removal versus internal fixation with screw insertion. The stifle needs to be flexed to at least
screw insertion. Most fractures involve just the medial 90°, and a suitable proximal entry point established
tubercle of the intercondylar eminence and respond using a 3 in. spinal needle as a guide. A 3.5 mm cortical
favorably to fracture fragment removal.14,31 Stabilization screw is then inserted using lag screw principle.
by insertion of a cortical screw in lag fashion has also The screw is placed on the cranial lateral portion of the
(A) (B) Figure 36.17 Fractures of the medial

tubercle of the intercondylar eminence of
the tibia (arrows), with the caudocranial
radiograph (A) showing moderate
displacement and the lateromedial
radiograph (B) indicating multiple
fragments.
www.ajlobby.com
(A) (B)
(C) (D)
Figure 36.18 Fracture of the lateral aspect (arrows) of the medial tubercle of the intercondylar eminence evident on caudocranial
radiograph (A), and flexed lateral (B) showing the distracted fracture fragment associated with insertion of fibers of the cranial cruciate
and cranial ligament of the medial meniscus. (C, D) Arthroscopic images showing fragmentation of the medial tubercle of the tibia
(Fx Med Tubercle) and dissection of the fragment from the adjacent cranial cruciate ligament.
medial tubercle, to avoid irritation of the femur by the with only 2 horses having damage to more than 50% of
screw head. The countersink is applied just sufficiently the cross‐sectional area of the cruciate. The cranial liga-
to allow congruous screw head seating, and should not ment of the medial meniscus was damaged in 11 of the
penetrate far into the tubercle, which may weaken the 21 horses. Additionally, 14 horses had articular cartilage
repair. Screw removal should not be necessary. erosion on the MFC. Despite these changes, 75% of the
horses that had arthroscopic removal of the fractured
Outcome medial tubercle of the intercondylar eminence returned
A recent report describes outcome after arthroscopic to function.
removal of the medial tubercle of the intercondylar
eminence in 21 horses.31 Follow‐up information was
available for 20 cases, of which 15 were sound and had
Fracture of the Tibial Crest
returned to the previous use. The remaining horses did The proximal aspect of the tibia is exposed to direct
not return to athletic activity, and all had severe changes trauma from a kick injury or impact from a fixed object
in the articular soft tissue structures, including articular such as the rails of a jump. Some fractures may also
cartilage, the CrCL, and the cranial ligament of the represent avulsion injuries from the tensile stretch of
medial meniscus; 2 of these horses had to be euthanized. the patella ligaments (Figure 36.19). Fracture size can
Contrary to previous literature, the CrCL was concur- vary, and small fractures of the tibial crest can be man-
rently damaged in 15 of the 21 horses. The extent of aged conservatively (Figure 36.20).3 More extensive
cruciate rupture varied, being less than 25% in 9 horses, fractures that involve the majority of the insertion of the
www.ajlobby.com
(A) (B) Figure 36.19 Avulsion fracture of the

entire tibial crest insertion of the patella
ligaments. (A, B) Radiographs show the
proximally distracted patella and tibial
crest fragment (arrow) and fracture bed on
the tibia (arrowheads). Complete
destabilization of the quadriceps strain
path has disabled the stifle extension and
locking capabilities. Stabilization of the
fracture was declined and the horse was
euthanized.
Avulsion Fractures of the Caudal

Cruciate Insertion
The caudal cruciate insertion on the caudal axial aspect
of the proximal tibia is an extraarticular, long, and exten-
sive insertion point. However, avulsion fragments can
retract into the caudal compartment of the medial
femorotibial joint (Figure 36.21). The popliteal artery is
immediately adjacent, and is at risk of tearing during the
fracture or during fracture fragment removal. Clinical
signs of caudal cruciate avulsion vary, with acute
lameness moderating to mild lameness with persisting
effusion in the femorotibial joint. The fracture can often
be identified on caudocranial and lateromedial radio-
graphic projections.30 The primary differential diagno-
sis is mineralization of the caudal horn of the meniscus
and intraarticular fractures of the tibia or femur that
have migrated into the caudal cul‐de‐sac of the joint.
Repositioning and internal fixation of the caudal cruciate
avulsion have not been described. Access would be quite
difficult. Conservative treatment of complete avulsion
fractures of the caudal cruciate ligament has not resulted
Figure 36.20 Nonarticular chronic fracture of the tibial crest
(arrow). Surgical removal is unnecessary. in return to function.
patellar ligaments or propagate into the femorotibial Patellar Fractures

joints need surgical stabilization (see Figures 35.14 and
35.15 in Chapter 35).36 The patella is the largest sesamoid in the body and is an
Depending on the fracture fragment size, internal integral component of the quadriceps apparatus, result-
fixation can be accomplished using multiple cortical ing in extension and stabilization of the stifle joint. The
screws inserted using lag screw principle, or, for larger quadriceps muscle bundle includes the rectus femoris,
fragments, a single or paired plate application. Detailed vastus medialis, vastus intermedius, and vastus lateralis,
information on fracture configuration and appropriate and all insert on the proximal aspect of the patella.
repair methods is provided in Chapter 35. The strain path for the quadriceps apparatus is extended
www.ajlobby.com
(A) (B)
(C)
Figure 36.21 Caudal cruciate ligament avulsion from the insertion on the caudal cortex of the tibia. (A, B) Caudocranial and lateromedial
radiographs show that the avulsion fragment (arrows) has reflected proximally into the caudal cul‐de‐sac of the medial femorotibial joint.
(C) Necropsy specimen showing the caudal cruciate avulsion with bony fragment and adjacent popliteal artery. CaCL, caudal cruciate
ligament; LFC, lateral femoral condyle; MFC, medial femoral condyle; PopA, popliteal artery. Source: Images courtesy Dr. Greg Staller.
to the tibial tuberosity by the lateral, middle, and medial prominent MTR, which is more exposed to the initial
patellar ligaments. impact and tends to form a prominence that cleaves
Patella fractures are usually the consequence of direct off the medial perimeter of the patella. More extensive
trauma such as a kick from another horse, or impact sagittal fractures may result from a similar mechanism
from hitting a rail during jumping events.10,11,19,22,28 (see Figure 36.1), while transverse fractures result
The most common fracture associated with direct from significant tension in the quadriceps apparatus
impact is cleavage of the medial perimeter of the patella in combination with direct impact with the stifle
(Figure 36.22).10,11,18 This may be the consequence of the partially flexed.
www.ajlobby.com
(A) (B)
(C) (D)
Figure 36.22 (A) Skyline radiograph showing fracture of the medial aspect of the patella. (B) Location and path of screw insertion have
been established using preplaced needles and skyline radiograph. Insertion angle provides cranial reduction of the fracture fragment to
improve the caudal articular surface alignment. (C, D) Cortical screw insertion has been used to reduce and stabilize the medial fracture of
the patella. Source: Images courtesy Dr. Norm Ducharme.
Chip fractures of the medial, lateral, or proximal aspect be used to establish the need for fracture stabilization.
of the patella represent intraarticular fragmentation that For complete fractures of the patella with an intact fascia
can have a detrimental effect on femoropatellar cartilage and minimal displacement on radiographs, conservative
and joint function (Figure 36.23).19 Most chip fractures measures such as stall rest and pain control with non-
should be removed using arthroscopic access. Stability steroidal anti‐inflammatory agents may be adequate.
can be maintained through the residual attachment of Distraction and a palpable fracture gap indicate the need
the heavy fascia along the cranial perimeter of the patella. for fracture reduction and lag screw fixation.
Dissection and fracture removal from the fascia can be
tedious. Some fractures are sufficiently large that an
arthrotomy may be necessary.6,27
Chip Fractures of the Patella
Complete patellar fractures may be managed conserv- Most chip fractures of the patellar are due to external
atively if there has been minimal separation along the impact. The acute lameness often rapidly improves, leaving
fracture plane.15 Careful palpation and radiography can only moderate lameness and concurrent femoropatellar
www.ajlobby.com
(A) (B)
(C) (D)
Figure 36.23 Chip fracture of the proximal medial aspect of the patella. (A) Flexed lateromedial radiograph showing proximal fracture
of the patella (arrow). (B) Skyline radiograph indicates that the proximal fracture is on the medial aspect of the patella (arrows).
(C) Arthroscopic view showing displaced chip fracture of the proximal medial aspect of the patella (arrows), with a spinal needle insertion
into the suprapatellar pouch to dictate pathway for instrument entry. (D) Fracture removal using rongeurs.
joint effusion. Marked response to stifle flexion persists. MTR or LTR is occasionally encountered. An instrument
Additionally, pain on direct palpation of the patella and portal over the craniomedial aspect of the femoropatel-
peripatellar soft tissue swelling are common early symp- lar joint is defined by first preplacing a spinal needle to
toms. Radiographs are required to definitively confirm give appropriate access to the fracture fragment. The
involvement of the patella, and should always include a fracture has dense ligamentous and fibrocartilaginous
flexed lateral and skyline projection. Most chip fractures attachments, and dissection from these often requires
involve the medial aspect of the patella.11,19,27 A report sharp elevators, a serrated banana blade, radiofrequency
has been published of three cases of medial patellar frac- probe, or fixed‐blade scalpels. Motorized equipment,
ture with concurrent femorotibial joint lateral collateral including soft tissue resectors and bone burs, are often
ligament avulsion.22 required to smooth the fracture bed and detached soft
tissues.
Surgical Technique Fractures of the proximal aspect of the patella are the
Arthroscopic confirmation of the fracture and fragment most difficult to access (see Figure 36.23).6 Positioning
removal are always indicated when the fragment has dis- the arthroscope portal midway between the tibial crest
tracted (see Figure 36.23). The arthroscope portal for and the apex of the patella generally allows insertion of
access to the medial aspect of the patella is made lateral the arthroscope beneath the underside of the patella,
or medial to the middle patellar ligament, depending on to visualize the fracture fragment along the proximal
the proximal distal location and size of the fracture of the perimeter of the patella (see Figure 36.23). Most proxi-
medial patella perimeter. Concurrent damage to the mal fractures are on the proximal‐medial aspect of the
www.ajlobby.com
patella. Removal often requires an instrument portal into

the proximal joint pouch through the quadriceps muscle
insertion, or preferably through the proximolateral cul‐
de‐sac of the femoropatellar joint via the lateral fascial
attachments just caudal to the lateral perimeter of the
patella.20 This provides a more direct approach to the
proximal aspect of the patella, with less muscle thickness
and less chance of inadvertently dropping a fragment in
the fascia or quadriceps musculature. This portal has
also been described as optimal for arthroscopic entry to
examine the proximal aspects of the patella and troch-
lear ridges.33 An additional portal can then be made into
the suprapatellar pouch to allow dissection and removal
of proximal fractures of the patella. The author prefers
to use a distal arthroscope entry, midway between the
patellar apex and tibial crest, and the proximolateral
instrument portal for fragment removal. The arthroscope
can be transiently placed into the suprapatellar portal to
verify complete fragment removal if the standard arthro-
scope entry does not provide complete visualization of
the fracture bed. This minimizes suprapatellar entries
through the fascia and lateral patellofemoral ligament,
which have a propensity to develop fibrous nodules
which take months to resolve and cause cosmetic con- Figure 36.24 Fracture fragmentation of the distal apex of the
cern for the sale of the horse. patella evident on a lateromedial radiograph (arrows). Surgical
removal was recommended. Source: Image courtesy Dr. Greg Staller.
Outcome desmotomy.13,20 Fragmentation can develop without

Prognosis after removal of chip fractures of the patella is
previous patellar ligament desmotomy (Figure 36.24).
good. Up to one‐third of the patella has been removed
Mild to moderate lameness is common, and synovial
with a successful outcome.19 A retrospective study has
effusion can generally be palpated. Lateromedial and
been published of 5 horses treated by arthroscopic
flexed lateromedial radiographs often confirm fragmen-
removal of chip fractures, 4 on the medial aspect and 1 on
tation of the distal apex of the patella. The lesion size and
the lateral aspect.19 All horses recovered and reentered
shape can vary from discrete fragmentation to spur for-
performance at the same or a higher level of competition.
mation or lysis of the apex. The incidence has declined,
Concurrent involvement of the lateral femorotibial joint
since fewer horses with upward fixation of the patella are
collateral ligament complicates the outcome.22 Removal
treated by medial patella desmotomy.
of a distracted medial patellar fragment did not resolve
Treatment is by arthroscopic debridement. The arthro-
the lameness in 1 case, while 2 of the 3 horses, both with
scope portal is made between the lateral and middle
small nondistracted patellar fractures, were treated con-
patellar ligaments, 4 cm proximal to the tibial crest. An
servatively and both recovered. A study of 15 horses with
instrument portal is developed lateral to the lateral patel-
fracture of the medial aspect of the patella indicated that
lar ligament, guided by needle insertion to access the dis-
the predominant cause of fracture was striking a rail
tal aspect of the patella.21 The fragmentation on the apex
when jumping (12) or being kicked (2);11 2 of the horses
of the patella is exposed by the removal of soft tissue
had concurrent fracture of the LTR. Arthrotomy and
proliferation using synovial resectors, and the bone and
removal of the fracture fragment in 12 of the 15 horses
degenerative cartilage removed with rongeurs. The bony
allowed 10 (83%) to return to athletic work.
bed is smoothed with curettes and motorized resectors. In
a series of 12 horses, 8 returned to performance.20
Distal Osteochondral Patellar
Fragmentation Destabilized Fractures of the Patella
Fragmentation of the distal aspect of the patella may rep- Fractures that involve the full width of the patella result
resent a degenerative change rather than a fracture. It in severe lameness, extensive peripatellar swelling, pain on
has been recognized as a consequence of medial patellar palpation, and considerable effusion of the femoropatellar
www.ajlobby.com
joint. In the acute phase, the horse frequently only lameness indicates the need for additional radiographs
touches the toe to the ground and will not fully extend to determine whether the fracture has further distracted,
and lock the patella and stifle. Sagittal fractures are more indicating the need for surgical repair. Stall rest for a
frequent than transverse fractures. Most sagittal frac- minimum of eight weeks is required, and radiographic
tures involve the central third of the patella. A cranio- reevaluation should be used to establish fracture sta-
proximal to craniodistal skyline radiographic projection bility. However, most sagittal fractures of the patella
readily identifies the sagittal fracture and defines the that are managed conservatively heal by fibrous union.
degree of separation (Figure 36.25). Transverse frac- A radiographic gap frequently persists, despite the func-
tures are rare, and often develop in a horizontal plane tional fibrous union. Other clinical symptoms such as
through the middle of the patella.2 These fractures diminished lameness and femoropatellar joint effusion
often distract and are readily visible on lateromedial may be useful to determine transition to light exercise
and flexed lateromedial views (Figure 36.26). Function such as controlled walking. Stable transverse and com-
of the quadriceps apparatus is diminished, and in the minuted fractures of the patella often coalesce into a
acute stages the horse is reluctant to fully extend the bony union capable of sustaining athletic activity.
stifle. Surgical repair by interfragmentary compression
is indicated for both sagittal and transverse fractures Surgical Technique
when a fracture gap can be palpated or fracture separa- Internal fixation of unstable and distracted patellar frac-
tion is evident on radiographs. tures is indicated.1,9 The horse is positioned in dorsal
Stable patellar fractures without fracture plane separa- recumbency to allow access to the lateral and medial
tion or malalignment on radiographs can be managed aspects of the patella and stifle. This also facilitates intra-
conservatively (Figure 36.27). Pain control and complete operative radiography or fluoroscopy. The fractured
stall confinement are indicated. Any sudden increase in limb is fully extended and the tension on the quadriceps
(A) (B) (C)
(D) (E)
Figure 36.25 Parasagittal fracture of the patella. (A, B) Skyline and caudal oblique radiographs showing displaced medial patellar fracture
(black arrows), with minor comminution (white arrow). (C) Arthroscopic image showing the patellar fracture line entering over the medial
trochlear ridge. (D, E) Skyline and lateromedial radiographs showing cortical screw insertion using lag screw principle, to reduce and
stabilize the sagittal fracture. Both screws have washers beneath the screw head to prevent screw head sinking into the soft bone. Source:
Images courtesy Dr. Ashlee Watts.
www.ajlobby.com
(A) (B) (C)
Figure 36.26 Transverse fracture of the patella. (A) Lateromedial radiograph showing a horizontal (transverse) fracture through the
mid‐body of the patella. (B) Fracture reduction and stabilization using multiple screws inserted from a distal to proximal direction. (C) Final
stabilization using multiple partially threaded 6.5 mm cancellous screws placed from a distal to proximal orientation. A spiked washer or a
stainless steel washer have been used beneath two of the three screw heads to prevent sinking into the cortex.
(A) (B)
Figure 36.27 Nondisplaced transverse and sagittal fractures of the patella. (A) Lateromedial radiograph indicates stable comminuted fractures of
the patella, with maintenance of the quadriceps strain path. (B) Skyline radiograph indicates moderate separation of the lateral and medial portions
of the sagittal fracture. The horse was treated with eight weeks of stall rest, and the fracture healed. Source: Images courtesy Dr. Marta Prades.
apparatus reduced by elevation of the foot using a forceps. Further disruption of the heavy fascia over
hoist or ropes, secured to rings placed high on the wall the cranial aspect of the patella should be minimized.
adjacent to the end of the surgery table. Most displaced Arthroscopic verification of the caudal alignment of the
patella fractures require open reduction and internal patella is useful to establish a congruous articular sur-
fixation. Rarely, arthroscopically assisted reduction and face to the patella. A small femoropatellar arthrotomy
stabilization using stab wounds for screw insertion can can also be used to establish joint articular surface con-
be used (see Figure 36.25). This allows accurate align- gruency if arthroscopy is not feasible. If the fascia is
ment of the fracture lines through the patella. divided for better access to the fracture, predrilling the
For the open approach, a 15 cm curvilinear incision is glide hole can be done more accurately (Figure 36.28A).
made over the cranial aspect of the patella, with the After reduction of sagittal fractures, two to four 4.5 or
hinge placed opposite to the anticipated screw insertion 5.5 mm cortical screws are inserted in a lateral to medial
aspect (Figure 36.28). This allows exposure of the frac- plane, or medial to lateral plane, using lag screw prin-
ture, and stabilization using a large pointed reduction ciple (Figure 36.29). Washers beneath the screw heads
www.ajlobby.com
(A) (B)
Figure 36.28 (A) Surgical approach for repair of a sagittal fracture using a curvilinear incision over the cranial aspect of the patella, with
the horse in dorsal recumbency. The fascia has been divided in this case (arrowheads), exposing the widely distracted fracture and
allowing debridement of the trochlear cartilage and overdrilling the glide holes. Two pins have been inserted in the existing glide holes
(arrows). (B) Lateral aspect of the patella after reduction and insertion of all four screws, each with washers to provide compression of the
sagittal fracture. Source: Images courtesy Dr. Dean Richardson.
(A) (B)
(C) (D)
Figure 36.29 Displaced mid‐sagittal fracture of the patella (same case as Figure 36.1). (A) Lateromedial radiograph identifies widely
separated fracture fragments of the patella. (B) Horse has been positioned in lateral recumbency and a cranial incision used to allow
debridement and application of a large reduction forceps to the fracture. (C, D) Postoperative radiographs show lag screws placed from a
lateral to medial direction to repair the widely distracted fracture line in the patella. Source: Images courtesy Dr. Alan Ruggles.
www.ajlobby.com
(A) (B) Figure 36.30 Displaced comminuted

fracture of the patella needing reduction
and internal fixation. (A) Lateromedial
radiograph indicates a transverse fracture
(arrows) and a sagittal fracture
(arrowheads), which was defined on a
skyline radiograph. (B) Postoperative
radiograph showing reduction of the
transverse fracture using a 4.5 mm cortical
screw and a hemicerclage wire. The
sagittal fracture was repaired with a
5.5 mm cortical screw. Source: Images
courtesy Dr. Dean Richardson.
may be needed to prevent the head sinking into the fashion is used to stabilize the sagittal fracture, as previ-
patella and diminishing fracture compression (see ously described, while the transverse fracture is repaired
Figure 36.28B). using distal‐ to proximal‐oriented cortical or cancellous
Transverse fractures should be reduced and stabilized screws and/or cerclage wire. Most complex fractures of
using a large pointed reduction forceps.2 Application of the patella need open reduction and internal fixation.
two reduction forceps is often required to counteract the This provides a clearer understanding of the fracture
tension in the quadriceps strain path. Cortical screws are planes and accurate screw placement.
inserted in a distal to proximal direction, again using lag
screw principles (see Figure 36.26). A tension band wire Outcome
can often add to the stability, provided that the wire is The prognosis for return to athletic function with minimally
passed through drill holes in the patella or washers are displaced sagittal, transverse, or comminuted complete
used beneath the screw head. fractures of the patella is good with conservative ther-
Comminuted fractures frequently result in sagittal and apy.10,15 There are no retrospective studies describing the
transverse fractures. Where these fracture planes have results of patellar fractures following internal fixation.
become displaced or distracted, they may need realign- Individual case reports and anecdotal evidence support
ment and stabilization in both planes (Figure 36.30). the use of lag screw repair for distracted sagittal and
A combination of lateral to medial screws inserted in lag transverse fractures.17
References
1 Aldrete, A.V. and Meagher, D.M. (1981). Lag screw at the tibial insertion of the cranial cruciate ligament.
fixation of a patellar fracture in a horse. Vet. Surg. 10: J. Am. Vet. Med. Assoc. 227: 883–884.
143–148. 6 Colbern, G.T. and Moore, J.N. (1984). Surgical
2 Anderson, B.H., Turner, T.A., and Johnson, G.R. (1996). management of proximal articular fracture of the
What is your diagnosis? Fracture of the distal third of the patella in a horse. J. Am. Vet. Med. Assoc. 185:
patella in a horse. J. Am. Vet. Med. Assoc. 209: 1847–1848. 543–545.
3 Arnold, C.E., Schaer, T.P., Baird, D.L., and Martin, B.B. 7 Crijns, C.P., Gielen, I.M., van Bree, H.J., and Bergman,
(2003). Conservative management of 17 horses with E.H. (2010). The use of CT and CT arthrography in
nonarticular fractures of the tibial tuberosity. Equine diagnosing equine stifle injury in a Rheinlander gelding.
Vet. J. 35: 202–206. Equine Vet. J. 42: 367–371.
4 Byron, C.R., Stick, J.A., Brown, J.A., and Lugo, J. (2002). 8 Dabareiner, R.M. and Sullins, K.E. (1993). Fracture of the
Use of a condylar screw plate for repair of a Salter‐Harris caudal medial femoral condyle in a horse. Equine Vet. J.
type‐III fracture of the femur in a 2‐year‐old horse. J. 25: 75–77.
Am. Vet. Med. Assoc. 221: 1292–1295. 9 DeBowes, R.M., Grant, B.D., Chalman, J.A., and
5 Campos, A.G., Froes, T.R., Tararunas, A.C. et al. (2005). Rantanen, N.W. (1980). Fractured patella in a horse.
What is your diagnosis? Intra‐articular avulsion fracture Equine Prac. 2: 49–53.
www.ajlobby.com
10 Dik, K.J. and Nemeth, F. (1983). Traumatic patella 24 Montesso, F. and Wright, I.M. (1995). Removal of chip
fractures in the horse. Equine Vet. J. 15: 244–247. fractures of the femoral trochlear ridges of three horses
11 Dyson, S., Wright, I., Kold, S., and Vatistas, N. (1992). by arthroscopy. Vet. Rec. 137: 94–96.
Clinical and radiographic features, treatment and 25 Mueller, P.O., Allen, D., Watson, E., and Hay, C. (1994).
outcome in 15 horses with fracture of the medial aspect Arthroscopic removal of a fragment from an
of the patella. Equine Vet. J. 24: 264–268. intercondylar eminence fracture of the tibia in a
12 Edwards, R.B. and Nixon, A.J. (1996). Avulsion of the two‐year‐old horse. J. Am. Vet. Med. Assoc. 204:
cranial cruciate ligament insertion in a horse. Equine 1793–1795.
Vet. J. 28: 334–336. 26 Nelson, B.B., Kawcak, C.E., Goodrich, L.R. et al. (2016).
13 Gibson, K.T., McIlwraith, C.W., Park, R.D., and Comparison between computed tomographic
Norrdin, R.W. (1989). Production of patellar lesions by arthrography, radiography, ultrasonography, and
medial patellar desmotomy in normal horses. Vet. Surg. arthroscopy for the diagnosis of femorotibial joint
18: 466–471. disease in Western performance horses. Vet. Radiol.
14 Grzybowski, M., Brehm, W., Werren, C., and Tessier, C. Ultrasound 57: 387–402.
(2008). Successful treatment of a medial intercondylar 27 Pankowski, R.I. and White, K.K. (1985). Fractures of
eminence fracture in a stallion by arthroscopic removal. the patella in horses. Compend. Contin. Educ. Pract.
Vet. Rec. 162: 756–758. Vet. 7: s566–s573.
15 Hance, S.R. and Bramlage, L.R. (1995). Fractures of the 28 Parks, A.H. and Wyn‐Jones, G. (1988). Traumatic
femur and patella. In: Equine Fracture Repair, 1e (ed. injuries of the patella in five horses. Equine Vet. J. 20:
A.J. Nixon), 284–293. Philadelphia: WB Saunders. 25–28.
16 Hance, S.R., Schneider, R.K., Embertson, R.M. et al. 29 Prades, M., Grant, B.D., Turner, T.A. et al. (1989).
(1993). Lesions of the caudal aspect of the femoral Injuries to the cranial cruciate ligament and associated
condyles in foals: 20 cases (1980–1990). J. Am. Vet. structures: summary of clinical, radiographic,
Med. Assoc. 202: 637–646. arthroscopic and pathological findings from 10 horses.
17 Hunt, R.J., Baxter, G.M., and Zamos, D.T. (1992). Equine Vet. J. 21: 354–357.
Tension‐band wiring and lag screw fixation of a 30 Rose, P.L., Graham, J.P., Moore, I., and Riley, C.B.
transverse, comminuted fracture of a patella in a horse. (2001). Imaging diagnosis‐caudal cruciate ligament
J. Am. Vet. Med. Assoc. 200: 819–820. avulsion in a horse. Vet. Radiol. Ultrasound 42:
18 Janicek, J.C. and Witte, S. (2005). What is your 414–416.
diagnosis? Medial sagittal patella fracture. J. Am. Vet. 31 Rubio‐Martinez, L.M., Redding, W.R., Bladon, B. et al.
Med. Assoc. 227: 381–382. (2018). Fracture of the medial intercondylar eminence
19 Marble, G.P. and Sullins, K.E. (2000). Arthroscopic of the tibia in horses treated by arthroscopic fragment
removal of patellar fracture fragments in horses: five removal (21 horses). Equine Vet. J. 50: 60–64.
cases (1989–1998). J. Am. Vet. Med. Assoc. 216: 32 Vekens, E.V., Bergman, E.H., Vanderperren, K. et al.
1799–1801. (2011). Computed tomographic anatomy of the equine
20 McIlwraith, C.W. (1990). Osteochondral fragmentation stifle joint. Am. J. Vet. Res. 72: 512–521.
of the distal aspect of the patella in horses. Equine Vet. J. 33 Vinardell, T., David, F., and Morisset, S. (2008).
22: 157–163. Arthroscopic surgical approach and intra‐articular
21 McIlwraith, C.W., Nixon, A.J., and Wright, I.M. (2015). anatomy of the equine suprapatellar pouch. Vet. Surg.
Diagnostic and Surgical Arthroscopy in the Horse, 4e. 37: 350–356.
175–242. Philadelphia: Mosby/Elsevier. 34 Walmsley, J.P. (1997). Fracture of the intercondylar
22 McLellan, J., Plevin, S., and Taylor, E. (2012). eminence of the tibia treated by arthroscopic internal
Concurrent patellar fracture and lateral collateral fixation. Equine Vet. J. 29: 148–150.
ligament avulsion as a result of trauma in three horses. 35 Watts, A.E. and Nixon, A.J. (2006). Comparison of
J. Am. Vet. Med. Assoc. 240: 1218–1222. arthroscopic approaches and accessible anatomic
23 Mc Nally, T.P., Slone, D.E., Lynch, T.M., and Hughes, structures during arthroscopy of the caudal pouches of
F.E. (2011). Use of a suprapatellar pouch portal and equine femorotibial joints. Vet. Surg. 35: 219–226.
laparoscopic cannula for removal of debris or loose 36 Wright, I.M., Montesso, F., and Kidd, L.J. (1995).
fragments following arthroscopy of the femoropatellar Surgical treatment of fractures of the tibial tuberosity
joint of 168 horses (245 joints). Vet. Surg. 40: 886–890. in 6 adult horses. Equine Vet. J. 27: 96–102.
www.ajlobby.com
688
37
Fractures of the Femur
Alan J. Nixon1,2, Larry R. Bramlage3, and Steven R. Hance4
1
2
3
4
Equine Sales and Radiographic Consultant, Oklahoma City, OK, USA
iaphyseal and Distal Physeal

D eral, with the opposite limb abducted. A caudal to cranial
Fractures projection should also be taken of the femoral shaft, but is
most useful for evaluation of fractures of the distal epiphy-
Femur fractures are common in foals.8–10,12,16 Pathologic sis and metaphysis. Visualization of the proximal diaphy-
surveys report that one‐quarter of the foals with long bone sis and physis is very difficult with a caudal to cranial
fractures have diaphyseal fractures of the femur.6 Femur projection, but obliques of the proximal limb are useful in
fractures also occur in adult horses. However, because of determining the fracture configuration.
the increased body size and severely comminuted config- The most common diaphyseal fracture configuration is
uration of these fractures, this chapter will focus predomi- a comminuted fracture with a large spiral component
nantly on femur fractures in younger horses. (Figure 37.1). However, short oblique and transverse frac-
tures can occur.10 Fractures usually involve greater than
two‐thirds of the diaphysis, because the equine femur is
Diagnosis relatively short. Open fractures are uncommon due to the
Clinical signs of diaphyseal and distal physeal fractures extensive musculature surrounding the femur. The most
include severe hematoma and edema, and the resulting common configuration for a distal physeal fracture is a
swelling in the thigh region. In some proximal and distal Salter–Harris type II, where the fracture extends along the
physeal fractures the fracture is minimally displaced and physis and exits through the metaphysis (Figure 37.2).10,16
there is limited swelling. A non‐weight‐bearing lameness Other types of physeal fractures include Salter–Harris
is usually present, and in displaced diaphyseal fractures type IV (Figure 37.3), in which the fracture propagates
the limb is rotationally unstable. The distance from the sagittally from the intercondylar notch, or alternatively
greater trochanter to the patella is frequently shortened separates obliquely through the trochlear ridges parallel to
due to the pull of the quadriceps muscles resulting in over- the tibial plateau, before continuing proximally to cross
riding of the fracture fragments. This can give the appear- the physis and exit through the caudal aspect of the meta-
ance of upward fixation of the patella. Crepitance is usually physis (see later 37.12). There have also been two reports
elicited on manipulation of the limb. Less common clini- of Salter–Harris type III fractures, which commenced in
cal signs include decreased temperature of the distal limb the intercondylar notch and exited on the lateral or medial
and a weak pulse in the greater metatarsal artery due to aspect of the physis, resulting in minimal displacement of
compromise of the vasculature surrounding the femur.23 the affected condyle.4,10 Examples of type III fractures and
Definitive diagnosis of a femoral fracture is made radio- subsequent repair are also described in Chapter 36.
graphically. This can be best accomplished with the foal The direct traumatic event resulting in the fracture is
anesthetized or under heavy sedation. The foal is placed in rarely observed. However, when it is, the fracture usually
lateral recumbency with the affected limb down. The radi- occurs as the result of a fall with the limb in adduction or
ographic receiver plate is placed under the affected limb from an external blow. The primary force in the devel-
and the radiographic beam is directed from medial to lat- opment of femur fractures is probably torsional and the

www.ajlobby.com
Figure 37.1 (A) Lateral and (B) caudocranial (A) (B)

radiographs showing a long oblique,
comminuted, overridden diaphyseal fracture
of the femur in a five‐month‐old foal.
Figure 37.2 Distal physeal Salter–Harris type II fracture. There is

considerable displacement with a caudal metaphyseal fragment.
Figure 37.3 Distal physeal Salter–Harris type IV fracture.
comminution is the result of the large energy dissipated is prepared for aseptic surgery. A large plastic adhesive
at the time of fracture. drape is applied, and a large stockinette applied to the
distal limb up to the tibial crest. The entire sterile area is
Surgical Repair then quadrant draped using impervious drape materials.
The distal limb should be protected with padding if ten-
Preparation and Draping sion is to be applied with mechanical devices to apply
Horses are placed in lateral recumbency with the affected traction to the fracture. Axial traction can be used to
limb up. The hair is clipped from the dorsal midline, advantage in oblique fractures when combined with a
extending cranially to include the tuber coxa, and distally large reduction forceps to maintain whatever extension
to approximately 10 cm below the stifle. The skin is is gained by the sequential application of traction.
shaved over the lateral aspect of the femur, and this area However, fracture malalignment commonly develops
www.ajlobby.com
with axial traction due to the asymmetric pull of the fracture ends back into position. Fracture reduction is
reciprocal apparatus. maintained by self‐retaining bone‐holding forceps while
lag screws are placed across the fracture whenever pos-
sible. Screws used to maintain reduction should be posi-
Surgical Approach tioned to avoid interference with subsequent plate
A linear skin incision is made from the greater trochanter placement. A broad dynamic compression plate (DCP),
to the lateral aspect of the stifle. The tensor fascia lata is broad 5.5 mm locking compression plate (LCP), or
incised and the vastus lateralis and biceps femoris mus- dynamic condylar screw (DCS) plate is positioned on the
cles are bluntly separated and retracted (Figure 37.4). lateral surface of the femur, to span from the greater tro-
Large hinged self‐retaining retractors are inserted. The chanter to the supracondylar fossa or lateral epicondyle.
retractor can be maintained in the musculature during The lateral plate is applied first, with several 5.5 mm
extensive manipulation by using sharp towel clamps to screws loaded to apply compression to the fracture. In
secure the shaft of the retractor to the skin (see very young foals, 6.5 mm partially or fully threaded can-
Figure 37.4). This exposes the tendinous insertion of the cellous screws can be applied in the metaphyseal regions
superficial gluteal muscle on the third trochanter, which for additional holding power. Screws are placed in all
is transected to provide adequate exposure of the proxi- plate holes and inserted through the plate using lag tech-
mal femur. Sufficient tendon should be left attached to nique whenever possible, to provide interfragmentary
the bone for reapproximation of the tendon at closure. compression of an oblique fracture.
The insertion of the biceps femoris muscle on the lateral In diaphyseal fractures, a broad DCP or broad LCP
patellar ligament is partially incised to provide the neces- should also be placed 90° to the lateral plate, on the cranial
sary exposure of the femur for distal fracture repair. The surface under the rectus femoris.10,31 In heavy or more
fracture hematoma and any devitalized tissue should be mature foals, a dynamic hip screw (DHS) plate can be
removed. used for the cranial plate, especially for distal diaphyseal
fractures. This can complement a laterally applied DCS
Reduction and Plate Fixation plate for maximum stability. A single DCP, combined with
Fracture reduction is accomplished by manual traction cerclage wire and lag screws, was used to successfully
combined with temporary bone clamp fixation across an repair a diaphyseal fracture in a 60 kg neonate.3 However,
oblique fracture, or tenting and interdigitating the most femoral fracture cases are heavier than the foal in
fragments out through the incision before toggling the that report, and two plates are always indicated.
The cranial plate is applied as a neutralization or com-
pression plate, and lag screws are inserted across the
fracture whenever possible (Figure 37.5). The applica-
tion of plates at a 90° angle provides maximum stability
and neutralizes the bending forces at the fracture site.
Implant selection is important. The pullout strength of
5.5 mm cortical screws is significantly greater than
4.5 mm screws in foal diaphyseal bone,34 and should
always be used when additional stability is needed. The
6.5 mm cancellous screw has increased holding power in
the metaphyseal and diaphyseal regions of the femur in
foal bone.14 However, there are no advantages to the use
of the 7.3 mm cannulated cancellous screw compared to
the 6.5 mm solid‐core cancellous screw in the femoral
diaphyseal or metaphyseal bone in the foal.
For most diaphyseal fractures in foals, the LCP is pre-
ferred over the DCP or limited‐contact dynamic com-
pression plate (LC‐DCP) for at least the lateral plate, and
Figure 37.4 Initial exposure for a mid‐diaphyseal femoral fracture. often for both lateral and cranial plates (Figure 37.6).9,17
A wide sterile field has been established, including an adhesive Holding power and cycles to failure are improved with
drape over the entire lateral upper hindlimb from dorsal midline the LCP. Additionally, plate luting is not required. The
to stifle. The distal limb has been enclosed using a sterile
sequence of plate application is the same for the LCP,
stockinette and impervious drape with padding. The biceps
femoris and quadriceps muscle group are separated using large with the lateral plate being applied before the cranial
hinged Beckmann self‐retaining retractors, further secured with plate. With the fracture adequately reduced and stabi-
penetrating towel clamps (arrows). lized with clamps or independent lag screws, the lateral
www.ajlobby.com
Figure 37.5 Repair of a mid‐diaphyseal (A) (B)

femoral fracture in a four‐month‐old
foal with two dynamic compression
plates (DCPs). (A) Preoperative medial to
lateral radiograph showing a long
oblique, comminuted overridden mid‐
diaphyseal fracture of the femur. (B)
Radiographs two weeks after the repair
show application of two broad DCPs to
the lateral and cranial aspect of the
femur, utilizing a combination of
cortical and fully threaded cancellous
screws in both plates, and adding
additional stabilization by cancellous
screws penetrating the femoral neck.
(C) Radiograph at seven weeks showing
good fracture healing with caudal callus
formation and continued growth of the
distal femoral physis. (D) Appearance of
the foal five days postoperatively,
including use of two suction drains to
evacuate the dead space common to
closure of most femoral fracture repairs.
(C) (D)
LCP is contoured and applied with a push–pull device at metaphysis is required to avoid the physis, a 5.5 mm cor-
either end. A 5.5 mm cortical screw is then applied near tical screw is used to allow flexibility in the screw inser-
the proximal and distal ends of the LCP to compress the tion angle.
plate to the bone. After removal of the push–pull device, Application of a second LCP to the cranial aspect of
additional cortical screws are applied using the lag screw the femur follows initial stabilization of the femoral frac-
principle, if they can compress oblique portions of the ture using the lateral plate. Not all screws should be
diaphyseal fracture. Otherwise, locking screws are applied in the lateral LCP before the cranial plate is
inserted in the LCP combi holes, taking care that the inserted beneath the rectus femoris and compressed
most distal plate screw does not penetrate the distal fem- onto the bone using several 5.5 mm cortical screws. The
oral physis. If angulation of the distal plate screw into the push–pull device cannot be utilized for the cranial plate
www.ajlobby.com
(A) (B) Figure 37.6 Repair of a mid‐diaphyseal

short oblique, comminuted fracture of the
femur using two broad locking
compression plates (LCPs) in a five‐month‐
old foal. (A) Radiograph showing the
irregular, spiral comminuted fracture of
the midshaft of the femur. (B)
Postoperative radiograph five days after
repair, showing application of the LCPs
using cortical screws in the extremities of
each plate to allow further purchase of the
plate screws in the proximal and distal
metaphyseal bone. Additionally,
antibiotic‐laden bone cement beads are
evident caudal to the lateral plate, and
two positive suction drains are installed in
the distal aspect of the surgical wound.
due to the overlying quadriceps musculature. If lag screw can generally be visualized as they enter the cranial LCP
application through the cranial plate can be established combi holes, to ensure that they engage the appropriate
to compress an oblique fracture, the near cortex is over- portion of the combi hole and, importantly, that the
drilled prior to insertion of a 5.5 mm cortical screw into locking drill guide is threaded perpendicular to the plate.
the tapped pilot hole. The thick quadriceps musculature Additional locking screws are then inserted in the lateral
can only be adequately retracted near the center of the plate. Eventually, all plate holes should be filled with a
diaphyseal region to allow screw insertion into the cra- screw.
nial plate. In the more distal and proximal regions, stab
incisions through the quadriceps musculature are used Wound Closure
to allow drill guides or the stacked locking drill guides to Inserting antibiotic‐laden polymethylmethacrylate
be inserted and secured into the plate (Figure 37.7). The (PMMA) beads alongside the plates provides local anti-
drill guides and subsequent cortical or locking screws biotic delivery for several weeks postoperatively
(Figure 37.8). A continuous suction drain should be
placed deep in the incision and exteriorized through a
separate portal toward the proximal or distal end of the
Figure 37.7 Application of the cranial locking compression plate

in a mid‐diaphyseal femoral fracture. The lateral plate has been
secured with several screws in the proximal and distal combi
holes. The cranial plate is positioned and secured with two cortical
screws. Application of locking screws in the proximal and distal
aspects of the cranial plate often requires separate penetrations Figure 37.8 Double locking compression plate application to the
through the quadriceps musculature, as shown. Vastus L, vastus lateral and cranial aspect of the femur, followed by insertion of
lateralis. antibiotic‐laden polymethylmethacrylate (PMMA) beads.
www.ajlobby.com
iaphyseal fracture repair.26 The major disadvantage of

d
intramedullary techniques in foals is that approximately
75% of femur fractures are comminuted, most are
oblique, and, since intramedullary pins cannot protect
against axial forces and compression, the fractured bone
tends to collapse. A single case report describes success-
ful use of intramedullary pinning for a fractured femur in
a foal.29 Comparative experimental studies also suggest
that a single intramedullary pin has advantages over
multiple pins or Küntscher nails.30 Intramedullary nails
provide additional axial support when compared to
intramedullary pins. However, most studies and clinical
data suggest that intramedullary nails are not as strong
as double plating as a means of internal fixation, and will
frequently result in a nonunion. Interlocking nails cir-
cumvent many of these disadvantages, but in vitro stud-
ies suggest that even interlocking nails are inferior to
double plating.22 In vivo studies using a transverse oste-
otomy femoral fracture model in foals indicated that the
Figure 37.9 Postoperative appearance on Day 5 following mid‐ intramedullary interlocking nail had adequate strength
diaphyseal femoral fracture repair using two locking compression to maintain stability and allow healing in all of the ani-
plates. The wound is protected with a laparotomy sponge, secured
mals examined over a six‐month healing period.20
using umbilical tape tie‐overs through preplaced loop sutures.
Two positive suction drains are instilled in the distal aspect of the Without significant technical or mechanical advantages
wound and the suction syringes are protected by bandaging. to the intramedullary interlocking nail, continued use
of double plating, particularly two LCPs, seems
appropriate.
incision. Suction drains can also be placed in the more
superficial tissue planes in an attempt to prevent seroma
formation. However, seroma formation is much more Distal Metaphyseal and Physeal Fractures
common in the deeper layers. Two suction drains can be Increased distal exposure is frequently necessary to pro-
used for larger foals (Figure 37.9). The drain is sutured in vide adequate reduction and stabilization of distal meta-
position and maintained postoperatively until drainage physeal or physeal fractures. This is accomplished by
has substantially decreased, which is usually in three to partially transecting the biceps femoris insertion from
four days. Transected tendinous insertions are apposed the lateral patellar ligament. In distal physeal fractures, a
and sutured. The intermuscular septum between the DCS plate, condylar buttress plate, tibial buttress plate,
vastus lateralis muscle and the biceps femoris, and the or cobra‐head plate is used.4,15,21 Only a lateral bone
incisions in the tensor fascia lata, subcutaneous tissue, plate is necessary, with the plate positioned over the lat-
and skin, are all closed in routine fashion, and a stent eral epicondyle and screws placed into the epiphysis of
bandage sutured over the incision to prevent contamina- the femur (Figure 37.10). Tibial buttress plates are
tion in the postoperative period (see Figure 37.9). designed for left or right tibia, and application to the dis-
tal femur requires use of a plate manufactured for the
Postoperative Care opposite limb. Additional independent lag screws can be
Patients should receive preoperative broad‐spectrum inserted to secure the metaphyseal fragment of the frac-
antibiotics and tetanus prophylaxis. If the intraoperative tured bone.16 Rarely, the metaphyseal portion of the
period exceeds two hours, it may be necessary to admin- Salter–Harris type II fracture is located medially, and the
ister additional systemic antibiotics during surgery. plate should be positioned medially. A plate that spans
Antibiotics are continued in the postoperative period for the distal femoral physis in a foal needs to be removed as
at least 24 hours after removal of the suction drain. All soon as adequate fracture healing develops, to avoid
foals receive a nonsteroidal anti‐inflammatory drug for angular limb deformity. The use of a cancellous bone
control of inflammation at the fracture site. graft is rarely necessary, because fracture repair is lim-
ited to foals, the fracture commonly involves a portion of
Other Fixation Methods the metaphysis, and the soft tissue surrounding the frac-
In calves, intramedullary pins and cerclage wires ture usually provides a favorable blood supply to the
have been used as an alternative to plate fixation for fracture site.
www.ajlobby.com
(A) (B) (C) (D)
Figure 37.10 Severely displaced Salter–Harris type II fracture of the distal femur in an eight‐week‐old foal. (A, B) Lateromedial and
caudocranial radiographs show a severely malaligned physeal fracture, with a caudomedial metaphyseal fragment. The fracture was
highly unstable, necessitating internal fixation. (C, D) Radiographs eight weeks after repair using a tibial buttress plate, showing good
fracture healing.
Conservative Management Conservative management of distal physeal fractures,

Conservative management of diaphyseal fractures by however, can result in a satisfactory outcome if the frac-
stall confinement can result in fracture healing.19 ture has only minimal displacement and is stable
However, the affected limb is usually shorter and rota- (Figures 37.12 and 37.13).10 These foals should be con-
tionally deformed (Figure 37.11). Additionally, most of fined to a stall for three months, followed by restricted
these foals will develop serious varus angular limb exercise in a confined area. The use of nonsteroidal anti‐
deformity in the opposite limb, because of the prolonged inflammatory drugs to control inflammation and pain
non‐weight‐bearing lameness in the affected limb. should be included.
(A) (B)
Figure 37.11 (A) Radiograph of femur five months post‐fracture, which has healed with conservative management. There is massive
callus formation along the diaphysis of the fractured bone. The fracture has healed with the fragment in an overriding position, resulting
in a shortened diaphysis. (B) Photograph of the foal, showing considerable shortening of the affected limb. The heel is not touching the
ground, even though the tarsus is in extension. This foal had serious gait abnormalities.
www.ajlobby.com
weeks of surgery. This callus formation is most prominent

on the caudal cortex at the site of the linea aspera and
muscle insertions on the femur. Three months after sur-
gery, the fracture line is usually no longer discernible. In
foals where successful fracture healing occurs, approxi-
mately 80% will have no long‐term evidence of the frac-
ture and are able to perform at their intended use. Surgical
removal of the implants is rarely required, and as the horse
matures the implants become engulfed by the cortex of
the bone. Implants that become infected or span a physis
may require removal to resolve the infection or preserve
any additional longitudinal growth of the bone.
Prognosis
Success of treatment in diaphyseal fractures is related to
the age and size of the horse, with the majority of foals
Figure 37.12 Salter–Harris type IV fracture of the femur with an with successful outcomes being less than three months
oblique frontal plane orientation, commencing from the cranial of age.10 In foals greater than three months of age, it is
epiphyseal region of the trochlear ridges, and propagating
beneficial to use LCPs or the DCS plate, which is a more
proximally and caudally to exit on the caudal metaphyseal cortex.
This foal was managed conservatively and raced as an adult. rigid implant than the standard broad DCP (Figure 37.14).
Successful treatment also depends on the integrity of the
caudal cortex. A bone deficit of any size results in a loss
of the buttressing effect of the intact cortex and predis-
poses to implant failure.
Except for very young foals or small breeds, the prog-
nosis for distal physeal fractures is more guarded than
for foals with diaphyseal fractures, due to the limited
bone available on the distal fragment for implant pur-
chase. Implant failure and loss of fracture reduction are
relatively common sequelae. However, newer implants
such as the condylar buttress plate,21 the cobra‐head
plate,15 the DCS plate, or the human distal femoral LCP
(see Chapter 50) all allow increased purchase in the dis-
tal fracture fragment, which compensates for the prob-
lems of limited bone stock to provide stability. The
advantage of using the condylar buttress plate, tibial but-
tress plate, or cobra‐head plate is that none requires the
use of instrumentation other than the standard AO/ASIF
bone‐plating equipment. However, because of their large
distal flaring, flexibility of positioning and screw place-
ment are more limited. The DCS system, on the other
hand, requires the use of specific instrumentation, but
affords increased positioning flexibility. The DCS plate
also is a more rigid implant, being 5.4 mm thick com-
Figure 37.13 Salter–Harris type II fracture with a lateral
metaphyseal fragment. This foal was managed conservatively and
pared to the 5.0 mm condylar buttress plate. The cobra‐
was able to perform as a reining horse as an adult. head plate has a thickness of 6.0 mm, but because of the
expanded head, it can be difficult to contour.
Outcome
Complications
Approximately 50% of foals with diaphyseal fractures
repaired by internal fixation with double plating develop The most frequently encountered complication with sur-
full bony union.10 Radiographically, extensive periosteal gical repair of femur fractures is the development of a
and endosteal callus is present in all cases within five seroma. Seroma formation often adds to the difficulty of
www.ajlobby.com
(A) (B)
Figure 37.14 (A, B) Radiographs of a four‐month‐old foal in which a dynamic condylar screw plate was utilized on the lateral cortex of the
femur to provide additional stability to the fixation. A standard DCP was applied on the cranial cortex.
maintaining the integrity of the skin and deep incisions. seroma or infection.17 Adhesions between the fracture
Positive suction drainage is essential, despite the risks of and quadriceps muscles have been observed as a compli-
contamination. Additionally, suture closure of the skin cation in dogs, but have not been reported in horses.
using a combination of vertical mattress sutures to pro- However, if a diaphyseal fracture is managed conserva-
vide incisional strength, with interrupted sutures at the tively by stall confinement, this complication is more
skin edge, lessens the chance of seroma‐induced dehis- likely to develop because of the substantial callus forma-
cence. Moreover, closure of the subcutaneous layer is tion and absence of quadriceps mobility.
performed with heavy resorbable suture such as #1 Vascular insult may also occur in association with
monocryl placed in a closely spaced continuous pattern femur fractures.23 Ischemia and vascular thrombosis
to firmly appose the soft tissues. If the closure is compro- can develop, as well as hemorrhage and exsanguination
mised, this directly adds to the likelihood of infection, from excessive bleeding from the open medullary
which is the most common complication related to fail- cavity.
ure (Figure 37.15). Implant loosening can also be
observed, especially with distal physeal fractures.
Although anatomic reconstruction is necessary to Proximal Physeal and
allow the bone to support the horse’s weight without Subtrochanteric Fractures
pain, minor instability can be overcome in femoral dia-
physeal fractures in foals through their capacity to form Diagnosis
callus. The large muscle cover and callus formation can
aid in stabilizing the fracture repair. The soft tissue pro- Femoral Capital Physeal Fractures
vides both protection and a superior blood flow to the Proximal femoral physeal fractures are fairly common in
healing fracture. However, infection or major instability foals, historically accounting for 16% of physeal fractures
will prevent healing in most femur fractures, in spite of in the horse.8 The incidence of femoral capital physeal
the superior blood supply (see Figure 37.15). Introduction fractures has declined since these early reports.16
of the LCP has provided better stability and improved The history usually involves the foal flipping over back-
the chances of a successful bony union in the face of ward and falling on its side, or severe abduction of both
www.ajlobby.com
Figure 37.15 Consequences of seroma and infection. (A) (A) (B)

Preoperative radiograph showing short oblique, overridden
comminuted fracture of the diaphyseal region of the femur in
a six‐month‐old foal. (B, C) Lateral and caudocranial
radiographs 3 weeks after surgery show good reduction and
stable fixation. However, a seroma developed 10 days after
surgery, leading to wound dehiscence. A Penrose drain can be
identified in the seroma to facilitate drainage. (D)
Postoperative radiograph at four months showing the fracture
site osteomyelitis, implant breakdown, and an unstable
fixation. The horse was euthanized.
(C) (D)
pelvic limbs. There is commonly an acute onset of non‐ develops instead of femoral capital physis fracture.1
weight‐bearing lameness. Crepitus is frequently elicited Fractures of the acetabular rim can also occur, as well as
by manipulation of the distal limb while palpating the separation of the greater trochanter. The epiphysis (fem-
coxofemoral region. The crepitus may also be palpated oral head) may even be subluxated or luxated from the
as low as the stifle region. There may be some pelvic acetabulum. Early diagnosis is a critical concern, as
asymmetry, with the tuber coxae appearing lower on the motion at the fracture site rapidly crushes the interdigi-
affected limb. External rotation of the limb is common tations of the physis, which makes subsequent fracture
due to the continued pull of the gluteal muscles on the reduction difficult. Additionally, complete physeal sepa-
greater trochanter. Muscular atrophy may be observed if ration and coxofemoral luxation may result in avascular
the fracture is chronic. necrosis of the femoral head. Subsequent surgery gener-
Proximal femoral physeal fractures are difficult to ally fails at 10–14 days due to implant loosening.
diagnose clinically; definitive diagnosis requires radio-
graphic evaluation. The foal is anesthetized and a ven-
trodorsal and slightly oblique ventrodorsal projection of Femoral Neck and Subtrochanteric
the pelvis used to evaluate the coxofemoral joint and Fractures
proximal physis (Figure 37.16). Concomitant injury to In more mature horses, subtrochanteric or femoral neck
the coxofemoral joint is frequent. The fracture can fractures remote to the physeal scar can occur
extend through the epiphysis or involve a portion of the (Figure 37.17). Medial to lateral radiographs with the
metaphysis adjacent to the growth plate. Less frequently, affected limb down show the proximal femur best.
apophyseal avulsion fracture of the greater trochanter Subtrochanteric fractures develop in more mature
www.ajlobby.com
(A) (B)
Figure 37.16 (A) Radiograph of a displaced proximal physeal fracture of the femur in a foal. (B) Two 6.5 mm cancellous screws were used
to repair the proximal physeal fracture. The remaining screws and tension band wires were used to reattach the greater trochanter to the
femur after fracture reduction.
horses, where the previously susceptible physis has subtrochanteric and femoral neck region (see
united. Fractures in this region are rare, with most abnor- Figure 37.17). Fractures that involve the femoral meta-
mal mechanical stresses leading to hip luxation or sub- physis immediately distal to the greater trochanter can
luxation, or fracture of the acetabulum and ilium. be similarly stabilized with reverse‐machined cobra‐
Initiating injury is usually impact onto the lateral aspect head plates that better match the contour of the femoral
of the hip or severe abductory forces from slipping on shaft as it extends up onto the greater trochanter
slick surfaces. With additional torque, most femoral frac- (Figure 37.18). The expanded end of a cobra‐head plate
tures involve the mid‐diaphysis in a spiral fracture rather allows as many as six screws to engage in the proximal
than the proximal femur, which tends to fracture in a femur, including femoral neck, femoral head, and greater
short oblique or slightly comminuted transverse config- trochanter. Newer LCP plate styles such as the human
uration. Lameness is immediate and profound. Crepitus distal femoral condylar plate and human 4.5 mm LCP
is consistently palpable in the acute stages. proximal femur plate may be suitable alternatives,
Diagnosis is equally difficult in adults as it is in foals, depending on the size of the proximal femoral fracture
with the need for radiography under anesthesia to defini- segment.
tively establish the diagnosis. Radiographs obtained
standing using an oblique ventrodorsal projection18 may
identify the fracture adequately to develop a plan for sur- Surgical Repair – Femoral Capital
gical repair or conservative treatment. Ultrasonography Physeal Fracture
can also readily identify disruption to the bony cortices
of the proximal femur. Additionally, ultrasound can add Surgical Approach
information on the integrity of the acetabulum and cox- The foal is positioned in lateral recumbency with the
ofemoral joint effusion. Detailed radiographic evaluation affected limb uppermost. An incision is made starting
requires general anesthesia, which can often be inte- cranial and midway between the greater trochanter and
grated into the presurgical preparation, depending on the wing of the ilium, and extending caudally, proximal
the size and age of the horse. Careful assessment of the to the greater trochanter, to curve distally along the cra-
proximal femur and evaluation of the acetabulum and nial plane of the biceps femoris muscle. The subcutane-
adjacent regions of the ilium and ischium are required to ous tissue is incised, leaving the tough dorsal fascia of the
get an accurate diagnosis and develop the surgical plan. area attached to the skin until the greater trochanter is
Repair requires plate stabilization rather than simple encountered. The tendinous insertion of the superficial
lag screws. Specialized plates such as the cobra‐head gluteal muscle on the third trochanter is transected, tak-
plate allow multiple screws to be inserted into the short ing care to leave adequate tendon attached to the bone
www.ajlobby.com
(A) (B)
(C) (E)
(D)
Figure 37.17 Femoral neck fracture in a young adult Quarter Horse repaired using a cobra‐head plate. (A) Preoperative oblique
ventrodorsal radiograph shows a comminuted fracture of the femoral neck and head. (B) Femoral shaft exposure after greater trochanter
(GT) osteotomy (arrows), allowing visualization and stabilization of the fractured femoral neck and head during plate and screw insertion.
(C) Application of a cobra‐head dynamic compression plate to the proximal shaft of the femur, showing insertion of cancellous screws into
the femoral subtrochanteric region extending up into the femoral neck and head. (D) Intraoperative radiograph showing multiple fully
threaded 6.5 mm cancellous screws engaging the proximal femoral shaft, femoral neck, and femoral head. The greater trochanteric
osteotomy has been reattached using additional independent cancellous screws. The plate shaft is secured using cortical screws. (E)
Postoperative appearance on Day 3, showing incision protection using a rolled hand towel, and positive suction drainage using a J‐VACTM
(Ethicon, Somerville, NJ, USA) vacuum device.
www.ajlobby.com
(A) shaft of the femur is usually displaced cranially and proxi-

mally to the femoral head, and must be retracted distally
and replaced in line with the acetabulum and femoral
head. Manipulation and reduction of the femur are greatly
facilitated by a large bone clamp positioned across the
proximal femur in the area of the femoral neck. This
allows distal retraction of the femur away from the ace-
tabulum, for visual assessment of the rotational and cra-
nial to caudal maneuvers necessary for fracture reduction.
The femur is difficult to distract from the acetabulum, as
the accessory ligament remains attached to the metaphy-
(B) seal aspect of the femur. Therefore, reduction of the frac-
ture is monitored by palpation.
Reduction and Fixation
Before the fracture is reduced, a finger is inserted into
the fracture line to identify the optimal location for the
implant to pass across the fracture and into the epiphy-
sis. This is best accomplished by carefully drilling a hole
until the drill bit can be palpated as it exits the metaphy-
Figure 37.18 Subtrochanteric oblique femoral Y-shaped fracture sis. The proximal or capital physis in a foal is small and
repaired with a reverse‐milled cobra‐head dynamic compression optimal purchase is critical. Implants available for frac-
plate. (A) Intraoperative views showing application of the
expanded end of the plate to the proximal femur and greater ture fixation include cannulated or partially threaded
trochanter (GT). The fracture line (arrows) is reduced and stabilized cancellous screws. Because of the nature of the biome-
by plate screws, including two placed in lag fashion. (B) chanical loading of the coxofemoral joint, pins have his-
Craniocaudal radiograph obtained immediately after surgery, torically been considered adequate, because the femoral
showing insertion of multiple cortical and cancellous screws into epiphysis tends to impact upon the femoral neck.32
the proximal femur, and additional cortical and cancellous screws
placed in the femoral shaft to reduce the oblique Y-shaped However, a 6.5 mm cancellous bone screw with 16 mm of
fracture (arrows). thread provides immediate compression and should be
considered the implant of choice. Successful repair has
also been reported using fully threaded 6.5 mm cancel-
for reapproximation of the tendon at closure. The inser- lous screws.25
tion of the middle gluteal muscle is isolated by digitally A 3.2 mm drill bit is used to drill the thread hole through
dissecting beneath it in a cranial to caudal direction the lateral femur up the femoral neck and into the center
around the trochanter, which protrudes proximal to the of the femoral metaphysis. The fracture is then reduced
femoral head. A trochanteric osteotomy is performed and the epiphysis drilled. To prevent penetration of the
transversely and often slightly obliquely from a distolat- articular surface, a finger is placed into the joint at the
eral to proximomedial position (see Figure 37.17). location of the expected exit. Drilling and tapping this ini-
Adequate bone must be left with the insertion of tial hole while maintaining fracture reduction are diffi-
the middle gluteal muscle to allow for internal fixation cult. Loss of reduction makes it difficult to reposition and
of the osteotomy. Predrilling holes for lag screw repair of relocate the 3.2 mm hole. Leaving the initial drill bit in
the osteotomy helps in accurate positioning of the greater place to maintain reduction, while drilling and inserting a
trochanter after the definitive femoral head repair. second cancellous screw, is the most effective method
Modification of these drill holes may be necessary if the for establishing fixation without losing the reduction.
screws used in the primary repair cross through the pre- The guide pins in the 7.3 mm cannulated screw system
placed holes. Trochanteric osteotomy allows the middle achieve the same temporary fixation.
gluteal muscle to be retracted proximally and medially, Prior to tapping the hole, a depth gauge is used to deter-
exposing the proximal aspect of the femur and the femo- mine the appropriate‐length screw and a 4.0 mm drill bit
ral head. More extensive dissection of this region is lim- is used to expand and form a glide hole in the cortical
ited, because the sciatic nerve lies immediately caudal to bone of the lateral cortex. It is not necessary to enlarge
the acetabulum and cannot be mobilized. this hole through the entire metaphysis. The cancellous
The coxofemoral joint can be visualized at this point tap will not easily pass through the lateral cortex, but will
and the joint capsule will normally be torn. However, if it readily penetrate the metaphyseal bone along the path of
is not, it can be incised to allow access to the joint. The the 3.2 mm drill. The hole depth is determined from the
www.ajlobby.com
millimeter gradations on the tap, allowing the surgeon to imal femoral epiphysis (femoral head) measuring 32 mm,
anticipate when the articular surface is being approached, and only adds an additional 8 mm by 12 months of age.13
as well as to confirm the length of screw that will be nec-
essary. The cancellous tap is used to tap the hole within
the epiphysis until it nears the surface of the articular car- Surgical Repair – Subtrochanteric
tilage. The 6.5 mm cancellous screw is only available in Fractures
gradations of 5 mm in length, so a screw length slightly
shorter than the joint surface is used. Two or three screws Fractures of the proximal femur in more mature horses
can be inserted. Two screws are adequate to maintain require less exposure of the hip and more access to the
reduction and fixation if the fracture is not chronic with shaft of the femur to allow plate application. The surgical
eburnated interdigitations (see Figure 37.16). A case approach already described for repair of a slipped femoral
report also describes a combination of a partially threaded capital physis is modified to expose less of the gluteal mus-
6.5 mm cancellous screw and a Steinmann pin to success- culature and attachments, and more of the greater tro-
fully repair a femoral neck fracture.5 When the fixation chanter and proximal half of the femoral diaphysis. The
has been accomplished, a suction drain is placed deep horse is placed in lateral recumbency with the affected
within the site. The greater trochanter is reattached to the limb uppermost. A curvilinear incision is made from a
proximal femur using multiple lag screws with washers or point 5 cm proximal to the palpable greater trochanter,
optional tension band wires. When wires are used, the curving along the caudal surface of the trochanter, and
distal attachment is passed through the third trochanter extending distally parallel to the femoral shaft for 15 cm.
and the lateral aspect of the femur. Occasionally, the head Exposure of the greater trochanter and the proximal
of a screw securing the fracture is available for wire aspect of the femoral diaphysis and metaphysis is similar
attachment. The insertion of the superficial gluteal ten- to the approach for femoral capital physeal repair. The
don to the third trochanter is reestablished by sutures. surrounding musculature generally maintains proximal
The subcutaneous tissue and skin are then closed and a femoral fractures in reasonable alignment. Selection and
stent bandage is sutured to the skin. contouring of an appropriate plate are then performed.
An alternative method for the fixation of proximal Application of the cobra‐head plate is ideal for these frac-
physeal fractures of the femur is the use of a 135° DHS tures (see Figures 37.17 and 37.18). Use of standard 4.5 or
system.12,13 However, the associated hip screw is very 5.5 mm cortical screws makes the application technique
large relative to the foal’s physis and femoral head, mak- familiar. However, the plate is no longer manufactured
ing precise placement critical.13 In addition, the femoral and available stock is limited. An LCP with an expanded
head and neck are not in a plane directly perpendicular proximal end, such as the 4.5 mm LCP proximal femur
to the flat surface of the lateral cortex of the femur, but plate, may be a suitable alternative. Implant cost is an
are positioned craniomedially to the flat lateral cortex issue. The LCP femur plate has fixed‐angle locking stacked
and diaphysis of the femur. Therefore, if the DHS plate is combi holes that allow locking screws to be inserted into
set flush with the diaphysis of the femur, the hip screw the femoral neck to provide significant stability. The shaft
will pass medially in a plane perpendicular to the lateral can then be positioned along the femoral diaphysis to pro-
surface of the bone and exit caudally to the femoral head. vide further locking screw stabilization.
If the DHS plate is to be used successfully the plate must Application of a cobra‐head plate or standard DCP
be tilted, not making full contact with the bone, and commences with the insertion of cortical screws that are
thereby angling the lag screw more cranially.13 In addi- angled into the femoral neck and greater trochanter (see
tion, a single screw does not provide rotational stability. Figure 37.17). The fracture is then further reduced and
Cannulated 7.0 or 7.3 mm screws have also been additional screws inserted into the distal aspects of the
described for use in bulls.33 The advantage to this implant plate to engage the femoral shaft. Compression can be
is that a guide wire is used to maintain reduction while applied if the subtrochanteric fracture is relatively trans-
the cannulated 4.5 mm drill bit, tap, and screw are placed verse. However, most fractures are moderately commi-
over this guide wire, decreasing the likelihood of mala- nuted and neutralization plating is generally utilized. A
lignment while changing drill bits and taps. Any type of second plate is not needed. A suction drain and antibi-
lag screw is preferred to pins, because it allows immedi- otic‐laden cement beads are placed adjacent to the plate
ate compression and more stable fixation. Multiple before the superficial gluteal is reattached to the third
intramedullary pins seem to be satisfactory only in trochanter. The drain needs to be exteriorized through
calves.11 Pins may be desirable to prevent the potential the skin cranially to the incision to avoid inadvertent
arrest of growth potential in the proximal physis. injury to the sciatic nerve (see Figure 37.17).
However, this is of less importance than loss of stability, The horse is maintained on antibiotics for at least
since a foal that is three to four months of age has a prox- 24 hours after the removal of the suction drain. Nonsteroidal
www.ajlobby.com
anti‐inflammatory agents are administered to control useful for arthritic joint replacement in small ponies, but
inflammation and pain. External support is rarely possi- not indicated in fracture cases.28 In a larger series of 25
ble. Plate removal is not necessary. foals with slipped femoral capital physis, the age ranged
from 11 days to 12 months (mean age 5 months).12 Of the
Complications 25 foals, 21 were euthanized without repair. Surgical sta-
bilization was performed in 3 foals; 2 had multiple
Complications with proximal physeal fractures are fre- intramedullary pins placed and both failed, leading to
quent and include fixation failure, postoperative infec- euthanasia within two weeks of surgery. The third horse
tion, and degenerative arthritis of the coxofemoral joint. was repaired with the DHS plate system, and this horse
Degenerative arthritis can develop as a sequela to the was sound one year later. A subsequent study of the DHS
articular cartilage damage that occurs at the time of implant systems in cadavers identified the 135° DHS
the fracture or at surgery, or because of the chronicity of plate as the most suitable angle for foals, and the subse-
the injury. Degenerative arthritis can also result from quent in vivo study in three foals with an osteotomized
necrosis of the capital epiphysis. If adequate fixation is femoral neck model resulted in femoral neck healing, but
achieved, the foal will begin to use the limb several hours femoral shortening that varied from 4 to 27 mm.13
after surgery. If an unstable fixation develops, degenera- Embertson et al.8 reported on femoral capital physeal
tive arthritis is unavoidable and a comfortable life for the fracture as part of a larger physeal incidence study.
foal is unlikely. Proximal femoral physeal fracture occurred in 11 foals,
out of a total of 70 foals with physeal fractures. Treatment
for these 11 foals included 5 euthanized on admission, 4
Outcome treated conservatively by stall confinement, and 2 which
Results of femoral capital physeal repair have been pub- were repaired by internal fixation.7 Both horses treated
lished in several small case series.5,7,12,25,32 Turner et al.32 by internal fixation survived, with 1 being sound. This
reported successful repair of femoral capital physeal compares favorably with the 4 horses treated by stall
fractures using multiple intramedullary pins in one foal, confinement, where only 1 horse survived.7
and femoral head resection in two others. Femoral head There are no reports of repair of proximal femur frac-
resection has been shown to be an acceptable alternative ture in mature horses. Limited experience by one of the
to stabilization only in ponies and miniature horses up to authors (Nixon) suggests that the horse can be salvaged
100 kg.27 A feasibility study also examined total hip for riding (Figure 37.19). Apophyseal separation of the
replacement in three ponies, and concluded that it was greater trochanter in foals occurred in 3 out of 70 foals
(B)
(A)
Figure 37.19 Adult subtrochanteric femoral fracture repaired with cobra‐head plate (same case as Figure 37.17). (A) Follow‐up radiograph
seven months after repair, showing the cobra‐head plate positioning and multiple screws inserted to stabilize the femoral neck and head.
Four independent screws have been used to reattach the greater trochanter. The fracture has healed, and the periarticular comminution
smoothed. (B) The appearance of the horse and upper hindlimb musculature seven months after surgery. The horse was sound for
competition.
www.ajlobby.com
with physeal fracture in one study.8 One foal was man- few localizing signs, although exacerbation of the lame-
aged by stall confinement and another by internal fixa- ness with upper limb flexion has been evident. The frac-
tion.7 None of these foals survived. ture is often chronic by the time the diagnosis is
established. The diagnosis is generally made by nuclear
scintigraphic evidence of increased radionucleotide
Greater Trochanter Fractures uptake in the proximal femur (Figure 37.20).
Confirmation is then established by radiography or
The greater trochanter of the femur can be fractured as ultrasonographic examination or both (Figure 37.21).
an isolated fracture or as part of a complex of fractures Treatment by rest from athletic endeavors resolves the
of the femoral head/neck or proximal femoral shaft.7,8,10 lameness over time. A fibrous union usually restabilizes
Apophyseal fracture from excessive pull of the gluteal the tendinous attachment disrupted in the original
musculature has been described in a foal.1 In adults, injury. Chronically lame horses may respond to ultra-
fracture of the greater trochanter can be a cause of lame- sound‐guided injection of platelet‐rich plasma (PRP) or
ness that originates in the upper hindlimb. There are steroids (see Figure 37.21).
Figure 37.20 Nuclear scintigraphic exam (A) (B)

in a 14‐year‐old Thoroughbred with an
11‐month history of chronic unresolved
right hind lameness. (A, B) Increased
radionucleotide uptake over the cranial
portion (arrow) of the greater trochanter
of the right femur (Cran Gr Tr). The caudal
portion of the greater trochanter (Caud Gr
Tr) and third trochanter (3rd Tr) are
normal. Source: Images courtesy Dr. Norm
Ducharme.
(A) (B)
Figure 37.21 Same horse as Figure 37.20, with confirmation of the right greater trochanter fracture by (A) radiographs showing a fracture
(arrow) of a portion of the cranial protuberance of the greater trochanter of the right femur; and (B) ultrasonographic confirmation and
steroid injection (arrows identify needle). Fx, fracture; Gr Troch, greater trochanter.
www.ajlobby.com
Third Trochanter Fractures of a fracture affecting the third trochanter. Radiographic

and ultrasonographic examinations confirmed the frac-
Isolated fractures of the third trochanter of the femur ture.2,24 Follow‐up examination in the eight‐horse study
have been described as a cause of acute lameness in two revealed that all fractures healed by the development of
reports, one involving eight horses,2 and a more recent a fibrous union, with the fragment in a persistently cra-
study of 20 cases.24 A single fracture fragment was nially displaced position.2 Lameness resolved with non-
identified in 7 of the 8 horses.2 The fractured trochanter surgical treatment in all horses. The prognosis was not
consisted of multiple fragments in 1 horse. Nuclear as favorable in the larger study,24 with only 6 of 12 with
scintigraphic examination for hindlimb lameness was available follow‐up returning to work, despite rest for
the primary diagnostic modality used in identification 8–18 months.
References
1 Beccati, F., Pepe, M., Nannarone, S. et al. (2012). 12 Hunt, D.A., Snyder, J.R., Morgan, J.P., and Pascoe, J.R.
Apophyseal avulsion fracture of the greater trochanter (1990). Femoral capital physeal fractures in 25 foals.
of the femur in a Thoroughbred filly. Vet. Comp. Vet. Surg. 19: 41–49.
Orthop. Traumatol. 25: 342–347. 13 Hunt, D.A., Snyder, J.R., Morgan, J.P. et al. (1990).
2 Bertoni, L., Seignour, M., de Mira, M.C. et al. (2013). Evaluation of an interfragmentary compression system
Fractures of the third trochanter in horses: 8 cases for the repair of equine femoral capital physeal
(2000–2012). J. Am. Vet. Med. Assoc. 243: 261–266. fractures. Vet. Surg. 19: 107–116.
3 Boulton, C.H. and Dallman, M.J. (1983). Equine femoral 14 Johnson, N.L., Galuppo, L.D., Stover, S.M., and Taylor,
fracture repair: a case report. Equine Vet. Sci. 3: 60–64. K.T. (2004). An in vitro biomechanical comparison of
4 Byron, C.R., Stick, J.A., Brown, J.A., and Lugo, J. (2002). the insertion variables and pullout mechanical
Use of a condylar screw plate for repair of a Salter‐ properties of AO 6.5‐mm standard cancellous and
Harris type‐III fracture of the femur in a 2‐year‐old 7.3‐mm self‐tapping, cannulated bone screws in foal
horse. J. Am. Vet. Med. Assoc. 221: 1292–1295. femoral bone. Vet. Surg. 33: 681–690.
5 Denny, H.R., Watkins, P.E., and Waterman, A. (1983). 15 Kirker‐Head, C.A. and Fackelman, G.E. (1989). Use of
Fracture of the femoral neck in a Shetland pony. Equine the cobra head bone plate for distal long bone fractures
Vet. J. 15: 283–284. in large animal: a report of four cases. Vet. Surg. 18:
6 Dwyer R, Powell D. Results of post examinations of 227–234.
foals less than six months of age submitted to the 16 Levine, D.G. and Aitken, M.R. (2017). Physeal fractures
livestock disease diagnostic center, Lexington, in foals. Vet. Clin. North Am. Equine Pract. 33:
Kentucky in 1987 and 1989. Lloyd’s Foal Disease 417–430.
Project. University of Kentucky, Sciences, Gluck Equine 17 Levine, D.G. and Richardson, D.W. (2007). Clinical use
Research Center. Lexington, KY, 1989. of the locking compression plate (LCP) in horses: a
7 Embertson, R.M., Bramlage, L.R., and Gabel, A.A. retrospective study of 31 cases (2004–2006). Equine
(1986). Physeal fractures in the horse: II. Management Vet. J. 39: 401–406.
and outcome. Vet. Surg. 15: 230–236. 18 May, S.A., Patterson, L.J., Peacock, P.J., and Edwards,
8 Embertson, R.M., Bramlage, L.R., Herring, D.S., and G.B. (1991). Radiographic technique for the pelvis in
Gabel, A.A. (1986). Physeal fractures in the horse: I. the standing horse. Equine Vet. J. 23: 312–314.
Classification and incidence. Vet. Surg. 15: 223–229. 19 McCann, M.E. and Hunt, R.J. (1993). Conservative
9 Glass, K. and Watts, A.E. (2017). Diagnosis and management of femoral diaphyseal fractures in four
treatment considerations for non‐physeal long bone foals. Cornell Vet. 83: 125–132.
fractures in the foal. Vet. Clin. North Am. Equine Pract. 20 McClure, S.R., Watkins, J.P., and Ashman, R.B. (1998).
33: 431–438. In vivo evaluation of intramedullary interlocking nail
10 Hance, S.R., Bramlage, L.R., Schneider, R.K., and fixation of transverse femoral osteotomies in foals. Vet.
Embertson, R.M. (1992). Retrospective study of 38 Surg. 27: 29–36.
cases of femur fractures in horses less than one year of 21 Orsini, J.A., Buonanno, A.M., Richardson, D.W., and
age. Equine Vet. J. 24: 357–363. Nunamaker, D.N. (1990). Condylar buttress plate
11 Hull, B.L., Koenig, G.J., and Monke, D.R. (1990). fixation of femoral fracture in a colt. J. Am. Vet. Med.
Treatment of slipped capital femoral epiphysis in cattle: Assoc. 197: 1184–1186.
11 cases (1974–1988). J. Am. Vet. Med. Assoc. 197: 22 Radcliffe, R.M., Lopez, M.J., Turner, T.A. et al. (2001).
1509–1512. An in vitro biomechanical comparison of interlocking
www.ajlobby.com
nail constructs and double plating for fixation of 28 Squire, K.R.E., Fessler, J.F., Toombs, J.P. et al. (1996).
diaphyseal femur fractures in immature horses. Vet. Total hip replacement in three ponies – a feasibility
Surg. 30: 179–190. study. Vet. Comp. Orthop. Traumatol. 9: 4–9.
23 Rose, P.L., Watkins, J.P., and Auer, J.A. (1984). Femoral 29 Stick, J.A. and Derksen, F.J. (1980). Intramedullary
fracture repair complicated by vascular injury in a foal. pinning of a fractured femur in a foal. J. Am. Vet. Med.
J. Am. Vet. Med. Assoc. 185: 795–797. Assoc. 176: 627–629.
24 Shields, G.E., Whitcomb, M.B., Vaughan, B., and 30 Taneja, A.K., Singh, J., Behl, S.M., and Singh, A.P.
Wisner, E.R. (2015). Abnormal findings of the femoral (1986). Repair techniques for femoral fractures in
third trochanter in 20 horses. Vet. Radiol. Ultrasound horses. Equine Pract. 8: 35–40.
56: 466–473. 31 Turner, A.S. (1977). Surgical repair of a fractured femur
25 Smyth, G.B. and Taylor, E.G. (1992). Stabilization of a in a foal: a case report. J. Equine Med. Surg. 1: 180–185.
proximal femoral physeal fracture in a filly by use of 32 Turner, A.S., Milne, D.W., Hohn, R.B., and Rouse, G.P.
cancellous bone screws. J. Am. Vet. Med. Assoc. 201: (1979). Surgical repair of fractured capital femoral epiphysis
895–898. in three foals. J. Am. Vet. Med. Assoc. 175: 1198–1202.
26 St‐Jean, G., DeBowes, R.M., Hull, B.L., and 33 Wilson, D.G., Crawford, W.H., Stone, W.C., and
Constable, P.D. (1992). Intramedullary pinning of Frampton, J.W. (1991). Fixation of femoral capital
femoral diaphyseal fractures in neonatal calves: 12 physeal fractures with 7.0 mm cannulated screws in five
cases (1980–1990). J. Am. Vet. Med. Assoc. 200: bulls. Vet. Surg. 20: 240–244.
1372–1376. 34 Yovich, J.V., Turner, A.S., and Smith, F.W. (1985).
27 Squire, K.R.E., Fessler, J.F., Toombs, J.P. et al. (1991). Holding power of orthopedic screws in equine third
Femoral head ostectomy in horses and capital. Vet. metacarpal and metatarsal bones: Part 1. Foal bone.
Surg. 20: 453–458. Vet. Surg. 14: 221–229.
www.ajlobby.com
706
38
Luxation and Subluxation
of the Coxofemoral Joint
Alan J. Nixon1,2 and Norm G. Ducharme1,2
1
2
Introduction Diagnosis
Coxofemoral luxation is relatively rare in horses due to Clinical signs of coxofemoral luxation include a short-
the strength of the soft tissues surrounding and within ened limb on the affected side; this is best evaluated by
this joint.4,5,8,15,16,23,25,27,29 The ligament of the head of the comparing the height of the points of the hocks. The
femur and the accessory ligament, which are attached to limb (toe and stifle) usually is rotated outward, with
the femoral head, provide primary stability. In addition, the point of the toe angling out at a 45° angle. In cranio‐
the acetabulum is surrounded by a fibrocartilaginous cot- dorsal luxations, the greater trochanter area is very
yloid ligament, which decreases the possibility of luxa- prominent in the affected limb. Miniature horses also
tion. Finally, the heavy musculature contributes to the frequently have concurrent upward fixation of the patella.
stability of this joint.8 Luxations are usually secondary to Rectal examination is usually unrewarding (except to
trauma, are generally unilateral, and most commonly rule out pelvic fracture), although crepitus or clunking
occur in the cranio‐dorsal direction. Luxations are more might be felt on examination. Radiography, particularly a
frequently diagnosed in foals and miniature horses and
ponies.8,16,20,22,25 Luxation as a complication of recovery
from anesthesia after application of a full hindlimb cast
has also been described.27 Additionally, coxofemoral lux-
ation after a long anesthesia with an extended difficult
recovery has been reported.23 Subluxation can also
develop as a more chronic complication of injury to the
acetabulum or ligament of the head of the femur.
In horses an exact cause for subluxation can be difficult
to discern. Good‐quality radiographs obtained under
anesthesia can sometimes provide a tentative cause for
joint instability, but most require computed tomography
(CT), magnetic resonance imaging (MRI), or even hip
arthroscopy to establish a diagnosis.18 The acetabular
labrum or cotyloid ligament can be injured, cartilage on
the head of the femur or acetabulum eroded, or the liga-
ment of the head of the femur partially or completely
torn. Additionally, small acetabular fractures can lead
to subluxation and osteoarthritis. Regardless of the
cause, joint laxity, mild to moderate lameness, and poor
response to treatment are common. In small ponies and
miniature horses, an MRI or CT may add preoperative Figure 38.1 Luxated left hip in a 17‐year‐old 280 kg miniature horse.
information and improve the treatment plan. Lateral radiographic projection confirmed a cranio‐dorsal luxation.

www.ajlobby.com
(A) (B)
(C) (D)
Figure 38.2 Standing digital ventrodorsal radiography of the pelvis and hip. (A, B) Position of the generator and receiver plate. (C) Oblique
ventrodorsal radiographic projection showing subluxation and early osteoarthritis of the right hip with remodeling and osteophytes of
the femoral head (white arrows), and osteophytes on the cranial margin of the acetabulum (black arrow). Arthroscopic assessment of the
hip joint, particularly the ligament of the head of the femur, is warranted. (D) Normal hip joint radiographs obtained in the standing
position. Images obtained with MinXray portable generator at 80 KvP and 2 seconds exposure. Source: Images reproduced with
permission from McIlwraith et al. 2015.18
v entrodorsal view, is the best modality to confirm the ultrasonographic techniques that are appropriate for
diagnosis (Figure 38.1), and rules out pelvic fractures and both field and hospital examinations and give comparable
slipped physis of the femoral head, which are the two diagnostic accuracy when compared to standing radiog-
main differentials. A standing radiographic technique raphy. In this technique, the positions of the femoral
(Figure 38.2), has been reported, which generally pro- head in relation to the dorsal rim of the a cetabulum can
vides only a tentative diagnosis that will require confir- be observed in transverse section using a low‐frequency
mation using better‐quality radiographs obtained under (2.5–5 MHz) curvilinear probe. A dynamic study with
anesthesia.1,9,17 Most recently, several reports4,9,24 describe the animal non‐weight bearing and weight bearing can
www.ajlobby.com
identify the femoral head movement in relation to Treatment

the acetabulum. Ultrasound‐guided arthrocentesis may
also be useful in the diagnostic workup of subluxation Two manifestations of hip disruption have been recog-
cases.6,32 nized, with very different treatments. A milder form of
For foals, and small and miniature horses, MRI or instability causing subluxation is usually associated
CT may be possible.28,31 This is generally unnecessary with an acetabulum fracture involving the dorsal rim,
for diagnosis and staging of complete luxations. avulsion fracture of the ligament of the head of the femur,
However, CT is especially useful for detecting addi- or partial or complete rupture of the ligament of the head
tional fractures or erosion of the femoral head and of the femur. These cases have a poor prognosis, as they
acetabulum that may limit the prognosis or complicate generally progress to degenerative joint disease, despite
surgical repair (Figure 38.3).28 The size and weight of conservative treatment consisting of prolonged box stall
the horse limit which cases can be examined by CT. rest (four to six months) and pain management with
Most ponies up to 200 kg can be accommodated in nonsteroidal anti‐inflammatory drugs.3,4,12,21 In light
modern CT gantries. Large‐bore mobile CT units for of this, arthroscopic examination and surgical removal of
standing and anesthetized CT studies are becoming the acetabular fracture fragments, or debridement of
increasingly available. Three‐dimensional imaging fibers of a partially frayed ligament of the head of the
using CT or MRI should be done if there is any ambi- femur, should be considered in these horses.19
guity in the routine radiographs (Figure 38.4). MRI A second and more acute instability of the coxofem-
may establish the cause of subluxation, particularly if it oral joint is complete luxation, usually cranio‐dorsal
is due to soft tissue injury, small acetabular fractures, in direction. For these horses, management includes
or fractures of the medial aspect of the femoral head closed reduction, or open reduction with surgical
associated with avulsion of the ligament of the head of stabilization.2,5,8,13,16,20,27,29
the femur (Figure 38.5).21 The size limitation of most Closed reduction can be achieved by hoisting the hind
available high field strength MRI units limits this end of the horse by the luxated hindlimb (or by other
modality to horses less than 100 kg. This can be cir- means of applied traction), combined with external
cumvented in open‐format low field strength units, rotation and adduction of the limb. This is followed by
although coil placement and duration of the study can internal rotation, as traction is released, in order to com-
be concerns. plete the reduction.5,16,20 Closed reduction is difficult,
(A) (B)
Figure 38.3 Combination of coxofemoral luxation and femoral head fracture in a 70 kg Haflinger foal. (A) Ventrodorsal radiograph
indicates luxation of the right hip, with multiple fractures of the femoral head still within the joint (white arrows), or displaced along the
shaft of the ilium (black arrow). (B) Computed tomography and 3D reconstruction better defines the femoral head fracture fragments in
the acetabulum (white arrow) or displaced cranial to the hip joint (black arrows). The femoral head was severely damaged. The horse was
euthanized without repair due to the expected mature body weight of 480 kg.
www.ajlobby.com
(A)
(C)
(B)
Figure 38.4 Cranio‐dorsal coxofemoral luxation in a 120 kg miniature horse. (A) Oblique ventrodorsal radiographs indicate right
coxofemoral luxation with suspicious fragmentation of the femoral head or acetabulum. (B, C) Computed tomography confirms a
cranio‐dorsal luxation, but the femoral head and acetabulum are not fractured. Reduction and stabilization were performed.
and when it is successful, the reduction often fails within coxofemoral joint, and femoral head excision. However,
a few days.2,8,16,27,29 This is probably due to a portion of for small horses, an additional option may be total
the joint capsule or the fibrocartilaginous cotyloid liga- hip arthroplasty, which has recently been reported in
ment becoming caught in the acetabulum, preventing the horse.11,26,30
proper reduction. Although transarticular pinning and
DeVita pins have been attempted, none has been suc- Surgery
cessful.16,27 Application of a transarticular toggle pin
combined with synthetic capsule reconstruction and Open Reduction
transposition of the greater trochanter was successful The horse is placed in lateral recumbency under general
in one case report.8 Two surgical treatments should anesthesia. Prior to surgical preparation, the horse is
be considered: open reduction with stabilization of the secured to the table by placing ropes between the
www.ajlobby.com
clots are removed from the acetabulum and the area lav-
aged with a sterile polyionic solution. Depending on the
duration of the luxation, fibrous tissue might be present
and its removal from the acetabulum is essential.
The femoral head is then located and exposed prior to
reduction. In most acute cases, there is little gross carti-
lage damage (Figure 38.8). If extensive cartilage eburna-
tion of the femoral head is present, then femoral head
and neck excision should be considered, particularly in
small ponies and miniature horses.25 If not, traction is
then applied and the luxation reduced. For reduction of
all coxofemoral luxations, the line of traction should be
in a direction opposite to the luxation. In addition, trac-
tion should be applied with the limb in a normal or
slightly abducted position. In craniodorsal luxation,
during traction an assistant should externally rotate the
limb to allow the femoral head to clear the dorsal rim of
the acetabulum. Care must be taken that the fibrocarti-
lage on the dorsal rim of the acetabulum is not trapped
between the femoral head and the acetabulum, or relux-
ation will occur. Closure of the coxofemoral joint cap-
Figure 38.5 Magnetic resonance imaging of a Morgan 280 kg sule is difficult and offers no gain in stability. Therefore,
yearling found acutely lame at pasture. Transverse short tau to prevent reluxation in the early postoperative period,
inversion recovery (STIR) image showing a nondisplaced fracture heavy sutures are placed between the greater trochanter
of the cranial aspect of the acetabulum (arrow). of the femur and the acetabulum. These can be heavy #5
USP (7 metric) ultra‐high molecular weight polyethyl-
forelimbs and across the sternum, and around the pelvis ene suture with a braided polyester jacket (FiberWire®
between the hindlimbs (Figure 38.6). Marked traction is polyblend sutures, Arthrex, Naples, FL, USA) attached
required for reduction of the luxation, which is not pos- to the acetabulum using screw‐in bone anchors
sible if the horse is not properly secured to the surgical (Arthrex), and secured to the trochanter by either 3.5 mm
table. In addition, a heavy cotton bandage is placed on drill holes or two 4.5 mm cortical screws with spiked or
the distal aspect of the limb, where obstetric chains will stainless‐steel washers to ensure that the suture loops
be placed to apply traction. After the surgical site is pre- do not dislodge (see Figure 38.8). The size of the bone
pared aseptically, a large adhesive plastic barrier drape is anchors in bigger ponies and use in the soft pelvic bone
applied, quadrant draping is secured to provide a large of younger horses can be a concern. Anchor pullout or
sterile field, and a sterile thick impervious drape is placed severance of the FiberWire at the junction with the
over the padded distal limb. Obstetric chains are then anchor and subsequent relaxation have both been seen
placed on the limb and connected to the traction device. (Figure 38.9). A more secure fixation utilizes two 4.5 or
A craniolateral approach to the coxofemoral joint is 5.5 mm screws placed in the greater trochanter and two
used. A curvilinear skin incision is made, centered over or three 4.5 or 5.5 mm screws placed in the dorsal ace-
the greater trochanter (Figure 38.7). The cranial edge of tabular rim (Figure 38.10). No. 5 USP polyblend suture
the biceps femoris muscle and the caudal borders of the (FiberWire) strands are used to provide reinforcement
superficial gluteal muscle and tensor fascia lata are against dorsal and external rotation forces in the post-
divided at their intermuscular junction and retracted to operative period. The sutures do not protect against
expose the greater trochanter of the femur. The ventral abductory forces and therefore are of little use in ventral
border of the middle gluteal muscle is retracted dorsally coxofemoral luxation. To prevent the sutures from slip-
(see Figure 38.7). This dorsal retraction may need to be ping off the screw head, a polyacetal resin spike washer
enhanced by partially incising the middle gluteal tendon is used (see Figure 38.8).
of insertion from its attachment to the greater trochanter. A description of successful repair following capsule
The femoral attachment of the vastus lateralis muscle is reconstruction using cortical anchor screws with an eyed
partially elevated and retracted cranially and ventrally. head placed in the acetabulum and femoral neck and
After partially reflecting the deep gluteal muscle at its bridged by FiberWire has also been described.13 This
attachment on the cranial portion of the greater tro- obviates the need for washers. The sutures are placed
chanter, the acetabulum is exposed. Fibrin and blood taut, with the stifle joint in normal standing angulation
www.ajlobby.com
Figure 38.6 Positioning of a miniature (A)

horse for right hip open reduction and
stabilization. (A) Padding and ropes have
been used to secure the horse’s torso on
the surgery table. (B) A wide sterile field
and draping of the entire hindlimb allow
open reduction assisted by axial traction
provided by a winch attached to calving
chains.
(B)
but with a slight internal rotation of the limb. Tunneling Femoral Head Ostectomy/Total Hip
the FiberWire sutures through the greater trochanter Arthroplasty
and securing to several screws placed in the acetabulum When severe damage involving the coxofemoral joint is
can also fail by suture pullout from the greater trochanter present, when reluxation occurs, or if the luxation can-
(Figure 38.11). Replacing the luxation and the addition of not be reduced because of its duration, femoral head
several screws in the trochanter generally provides per- ostectomy should be considered.7,10,14,15,22,25,29 Ostectomy
sisting stability. In larger ponies and some horses, rein- is quite acceptable for small horses, but rarely provides a
forcement of the FiberWire with stainless‐steel wire stable pseudoarthrosis in horses heavier than 300 kg.25
loops between the acetabular and greater trochanter A craniolateral approach as already described can be
screws may be advisable. These wires always cycle and used, although a dorsal approach with osteotomy of the
break, but if reluxation can be prevented for several greater trochanter gives much better exposure.25,29 It
weeks, the persisting FiberWire and fibrous tissue gener- must be mentioned that the strength of the fixation of
ally prevent reluxation. If further luxation develops, fem- the greater trochanter after osteotomy is unknown in
oral head ostectomy is recommended (Figure 38.12). animals over 200 kg. There are reports that such fixation
Suction drains are optional and routine closure follows. is secure in bulls of up to 700 kg, using cannulated screws
www.ajlobby.com
(A) (B)
Incision Biceps
femoris muscle
Middle gluteal muscle
(C)
Superficial
gluteal muscle
Lateral vastus muscle
Greater trochanter
Middle gluteal muscle
(D)
Superficial
gluteal muscle
Biceps
femoris muscle
Femoral head
(E)
Greater trochanter
Figure 38.7 (A–E) Craniolateral surgical approach to the coxofemoral joint for reduction and stabilization of luxations.
(W. Crawford, personal communication). The skin made. Alternatively, cannulated screws could be used.
incision and its extension to the superficial gluteal Inserting the screws three or four turns into the bone
muscle are identical to those described for open reduc- (to visibly enlarge the hole) prior to the osteotomy facilitates
tion. The greater trochanter is drilled and tapped for identification of the holes at closure.25 Gigli wires are
two 6.5 mm cancellous screws before the osteotomy is used to perform the osteotomy, which allows reflection
www.ajlobby.com
(A) (B)
(C) (D)
Figure 38.8 Open surgical reduction and capsular stabilization in a miniature horse (same case as Figure 38.4). (A) Oblique lateral
radiograph indicates dorsal coxofemoral luxation. (B) Exposure of the femoral head. (C) Stabilization after reduction, utilizing two cortical
screws with washers inserted in the greater trochanter to secure multiple FiberWire strands inserted in the acetabulum using swaged‐on
suture anchors. (D) Postoperative oblique lateral radiograph showing implant positioning.
(A) (B)
Figure 38.9 Technical errors in stabilization of coxofemoral luxation. (A) Failure to apply spiked or metal washers has allowed one of the
wire loops to dislodge (arrow). Additionally, the wire loop was not applied as a figure‐eight, which likely predisposed to the wire dislodging
from beneath the screw head. (B) Reluxation five days after stabilization shown in Figure 38.8. The FiberWire sutures had broken at the
junction to the suture anchor. Reduction and further stabilization were applied using three cortical screws in the acetabulum.
www.ajlobby.com
(A) (B)
(C) (D)
Figure 38.10 Cranio‐dorsal luxation in a 270 kg miniature horse. (A) Ventrodorsal radiograph shows cranial displacement of the femoral
head. (B) Spiked washer on a 5.5 mm cortical screw for insertion into the acetabulum. (C) Reduction and insertion of the first cortical screw
(#1) in the acetabulum to anchor FiberWire sutures inserted through drill holes in the greater trochanter. Acet, acetabulum. (D) Two
5.5 mm cortical screws with spiked washers (#1, #2) have been inserted and partially tightened prior to passage of the FiberWire suture in
a figure of 8 pattern around the screws and through the greater trochanter (GT).
(A) (B)
Figure 38.11 Repair of a cranio‐dorsal luxation in a 10‐year‐old 290 kg miniature horse. Closed reduction under anesthesia and application of
an Ehmer sling successfully maintained coxofemoral stability until the sling broke three days after reduction. (A) Radiograph obtained five days
after open reduction and stabilization using FiberWire inserted through drill holes in the greater trochanter and attached to two 4.5 mm
cortical screws in the acetabulum. The coxofemoral joint has reluxated. (B) Second repair showing two 4.5 mm cortical screws with spiked
washers placed in the greater trochanter to secure multiple strands of FiberWire to the two original acetabular screws, supplemented with a
third screw more caudal to the original screws. The original FiberWires had torn through the soft bone of the greater trochanter.
www.ajlobby.com
Coxofemoral Arthroscopy
Subluxation of the hip joint can be due to several desta-
bilizing lesions, including partial or complete rupture
of the ligament of the head of the femur, fractures of the
cranial or caudal perimeter of the acetabulum, cartilage
erosion or osteochondral fragmentation of the femoral
head, and damage to the acetabular labrum or cotyloid
ligament. An accurate diagnosis needs CT or MRI,
followed by a decision for conservative therapy or
arthroscopic examination.
Arthroscopy of the hip joint in foals and horses up to
400 kg is readily accomplished using standard arthro-
scopic equipment.18,19 Larger horses may require a
longer arthroscope.18 The horse is operated in lateral
recumbency with the affected limb uppermost. The
entire limb is draped and the leg supported to maintain
neutral positioning. Distal limb padding should be applied
in case traction is required to separate the femoral head
Figure 38.12 Breakdown of stainless‐steel wires used for from the acetabulum. A 6 or 8 in. spinal needle or the
stabilization after coxofemoral reduction. Two screws with
washers were applied to the greater trochanter, and three screws stylet from a 6 in. intravenous catheter is used to predis-
with metal washers in the acetabulum. A combination of tend the hip joint. The standard arthroscopic portal is
FiberWire and stainless‐steel wires may be more appropriate. palpable 2 cm proximal and between the cranial and cau-
Stainless‐steel wire cycles and breaks over several weeks, and the dal portions of the greater trochanter.18 The arthroscope
FiberWire may then provide sustained stability. is inserted in a cranial and distal direction to follow the
path of the femoral neck, penetrating the midportion of
the joint, which allows access to both cranial and caudal
of the attachment of the middle and deep gluteal regions of the joint cavity. Instrument portals are defined
muscles. Good exposure of the coxofemoral joint is by preplacing a 6 in. spinal needle or the 6 in. stylet from
obtained by this approach. For treatment by femoral an intravenous catheter to appropriately target the lesion.
head ostectomy, the femoral neck is transected as For most cartilage erosions, osteochondral fragmenta-
close to the shaft of the femur as possible with an oscil- tion, and ligament of the head of the femur lesions, an
lating saw (Figure 38.13). In addition, the dorsal rim of instrument portal cranial to the arthroscope portal is
the acetabulum should be rounded with rongeurs and appropriate.
curettes.25 The femur generally remains proximally Most lesions affecting the hip joint can only be visual-
displaced compared to its original location relative to ized after distraction of the femoral head from the ace-
the acetabulum. Complete smoothing of the femoral tabulum, followed by deeper insertion of the arthroscope
neck and shaft is essential during ostectomy to prevent to view the central weight‐bearing portion of the femoral
persisting lameness from rubbing of the femur against head and adjacent acetabulum. With axial traction, the
the acetabulum (Figure 38.14). arthroscope can be further inserted to view the ligament
For treatment using total hip arthroplasty,11 after the of the head of the femur. Fraying and tearing of the liga-
femoral neck is removed and the acetabulum explored, ment causing subluxation and osteoarthrosis are rela-
graduated reamers are used to create an acetabular cavity. tively common findings during diagnostic arthroscopy of
In the only report of this treatment in horses, an outside the hip joints, particularly in small‐breed horses, but also
diameter 64 mm acetabular shell was used and implanted in larger‐breed animals (Figure 38.15). Partial tears of the
at the orientation of a 45° lateral opening and 20° retro- ligament of the head of the femur can be debrided using
version.11 The shell is secured with titanium screws. synovial resectors, and many of these cases have made a
The femoral canal is then prepared with graduated complete recovery. Complete rupture of this ligament
reamers and an appropriate‐size stem and femoral head does occur, and the outlook even with debridement is
(in the only report in a horse, 24 and 36 mm, respec- guarded to poor. Concurrent tearing of the accessory
tively, were used) placed in 20° anteversion. ligament has not been encountered or reported.
The greater trochanter is replaced in its correct ana- Avulsion injury to the femoral insertion of the ligament
tomic position and secured using cancellous screws and to the head of the femur is rare. These can be readily iden-
figure‐eight wire in a tension band principle. Closure is tified on arthroscopy (Figure 38.16).21 Osteochondral
similar to that described for open hip reduction. fragments may be visible in the region of the fovea of the
www.ajlobby.com
(A) (B)
(C) (D)
(E) (F)
Figure 38.13 Chronic luxation in a seven‐year‐old 170 kg miniature horse treated by femoral head excision. (A, B) Radiographs showing
the cranio‐dorsal coxofemoral luxation at presentation 11 weeks after injury. The oblique lateral projection shows a defect in the femoral
head (arrow). (C) Exposure of the femoral head and neck, showing eroded cartilage on the femoral head, and oblique osteotomy of the
femoral neck (arrowheads). (D) Residual femoral shaft (arrows) after removing the femoral neck and head, and smoothing of the edges.
Acet, acetabulum (E, F) Postoperative radiographs obtained three days after excision.
www.ajlobby.com
(A) (B) (C)
Figure 38.14 Postoperative oblique lateral radiograph after femoral head excision to treat a failed stabilization. (A) Return of severe
lameness 10 days after excision shows prominent dorsal position of the femoral shaft in relation to the acetabulum. (B) Computed
tomography confirms the proximal positioning of the femoral shaft in relation to the acetabulum (arrow), and gluteal bulging as a
consequence of the position of the femur. (C) Three‐dimensional reconstruction shows rubbing of the lesser trochanter and femoral
osteotomy in the acetabulum. Continued lameness led to euthanasia of the horse.
(A) (B) (C)
(D) (E) (F) (G)
Figure 38.15 Coxofemoral joint subluxation due to partial tearing of the ligament of the head of the femur in a 410 kg horse. Recalcitrant
lameness was evident, which resolved with intraarticular anesthesia. (A) Ventrodorsal radiograph obtained under anesthesia is normal.
(B) Coxofemoral arthroscopy using a 25 cm arthroscope and long instruments. 1 = long Ferris Smith rongeurs, 23 cm with 4 × 10 mm cup;
2 = long probe; 3 = long egress cannula, 8 mm × 30 cm; 4 = small probe extended using a hemostat; 5 = 25 cm blunt obturator for
arthroscope sleeve insertion. (C) Debriding torn portion of ligament of the head of the femur. (D) Distraction of the femoral head allows
visualization of the torn portion of the ligament of the head of the femur (Torn Proper L), and an intact accessory ligament (Accessory L).
(E) Removal of the torn ligament fibers using a long rongeur. (F) Acetabular fossa after debridement of the ligament of the head of the
femur. (G) Horse 48 hours after arthroscopy. A TegadermTM (3M Healthcare, St. Paul, MN, USA) bandage protects the surgical incisions.
femoral head or in the adjacent acetabular fossa. Utilization and remodeling of both femoral and acetabular surfaces
of CT or MRI may provide additional diagnostic infor- limit the likelihood of a recovery for functional activity.
mation, although the definitive diagnosis will require The general prognosis is largely similar to complete tearing
arthroscopic verification. The secondary osteoarthritis of the ligament of the head of the femur. Debridement of
www.ajlobby.com
(A)
(B) (C) (D)
Figure 38.16 Avulsion of the femoral insertion of the ligament of the head of the femur in 565 kg Warmblood. (A) Preoperative ventrodorsal
radiographs identify proliferation of the acetabular bone around the origin of the ligament (black arrows), a cyst in the acetabulum (open
arrow), and an osteochondral fragment over the femoral head (white arrow). Early osteoarthritis is evident with osteophytes along the
femoral neck (arrow heads) (B) Arthroscopic examination verifies new bone proliferation in the acetabulum (black arrows), and an avulsion
fragment of the ligament of the head of the femur on the femoral head (Avulsion Proper L). (C) The cartilage surrounding the acetabular
fossa and avulsed fragment on the femoral head are fibrillated. (D) The cranial aspect of the acetabulum has a secondary subchondral cyst,
correlating with preoperative radiographs. Fem head, femoral head; Proper L, ligament of the head of the femur.
visible avulsion pieces is advisable to the point that the Fracture fragmentation of the cranial or caudal perim-
diagnosis of either partial or complete involvement eter of the acetabulum is readily identified on arthro-
allows a decision on recovery from anesthesia or eutha- scopic examination. If the fracture is small, separation
nasia on the surgery table. using an osteotome can allow removal using long rongeurs
Degeneration and loss of the cotyloid ligament can (Figure 38.18). Further smoothing of the acetabular frac-
lead to chronic lameness and early osteoarthritis of the ture bed is then accomplished using long curettes or a
hip joint (Figure 38.17). This syndrome is poorly motorized bur. There are few synovial resector blades or
described in the veterinary literature. Arthroscopic arthroscopic burrs longer than the standard 6 in. instru-
examination is required to establish the diagnosis, given ments used in routine arthroscopy. For removal and
the insensitivity of CT and even MRI for periacetabular debridement of cartilage and bone lesions in the hip
soft tissue imaging. Arthroscopic examination and joint of full‐sized horses, long rongeurs (Ferris Smith
debridement of the torn acetabular labral tissues with 4 × 10 mm cup × 23 cm shaft rongeurs, #404‐7929, Sontec
biopsy rongeurs or motorized resectors are the treat- Instruments, Centennial, CO, USA) may be the only
ment of choice. Outcome in the few cases identified available instrument. A long 8 mm diameter and 30 cm
would suggest that the degree of concurrent cartilage long egress cannula (#SC94‐0321, Sontec Instruments)
erosion dictates whether the horse is capable of a return with obturator, designed for the suprapatellar pouch of
to athletic activity. the stifle, is also useful for flushing debris from the joint.
www.ajlobby.com
(A) (B) (C)
Figure 38.17 Coxofemoral subluxation and early osteoarthritis as a result of tearing of the acetabular labrum (cotyloid ligament) in a
full‐sized horse. (A) Preoperative ventrodorsal radiograph obtained under anesthesia identifies irregularities of the femoral head (short
arrow) and new bone formation in the fovea of the femoral head (long arrow). (B) Arthroscopic examination shows tearing and a void in
the acetabular labrum (arrows), and cartilage irregularity and fibrillation of the cranial surface of the femoral head. (C) Central positioning
of the arthroscope shows severe degeneration of the acetabular labrum (arrows) and extensive cartilage fibrillation.
(A) (B)
Caudal
acetabular
fracture Caudal
acetabular
fracture
Acetabulum
Figure 38.18 Coxofemoral subluxation associated with a fracture of the caudal acetabular rim. (A) Arthroscopic assessment shows a
chronic fracture line along the caudal perimeter of the acetabulum, with protruding fibrinous and fibrous granulation. (B) An osteotome is
being used to separate the chronic fracture fragment for removal.
Nondisplaced and stable fractures of the cranial or subside, arthroscopic exploration of the affected hip
caudal perimeter of the acetabulum may heal spontane- may be warranted.
ously with little residual osteoarthritis (Figure 38.19).
Accurate evaluation using CT or MRI is required to
establish fracture displacement or additional evidence Postoperative Care
of osteoarthritis. Stable fractures, particularly in young
horses, may improve sufficiently to allow the horse to Ponies or foals undergoing surgical repair of hip luxation
return to athletic activity. Intraarticular medication by stabilization or femoral head ostectomy should be con-
with hyaluronic acid or platelet‐rich plasma (PRP) may fined to a box stall with deep bedding for eight weeks after
both improve the chances of fracture healing without surgery. In horses and large ponies, cross‐tying for two to
secondary osteoarthritis. Where lameness is slow to three weeks should be considered after luxation repair.13
www.ajlobby.com
(A) (B) (C)
(D) (E) (F)
Figure 38.19 Coxofemoral subluxation associated with acute nondisplaced fracture of the cranial perimeter of the acetabulum. (A, B)
Preoperative standing ventrodorsal radiographs show irregularity of the femoral head (arrowheads) and a small callus formed along the
cranial perimeter of the acetabulum (arrow). (C) Magnetic resonance imaging with a short tau inversion recovery (STIR) sequence
obtained in a sagittal plane showing an incomplete nondisplaced fracture of the cranial perimeter of the acetabulum (arrow). Joint
effusion is present in the cranial and caudal cul‐de‐sacs of the coxofemoral joint. (D) The fracture is verified (arrow) on the STIR sequence
obtained in a frontal plane, indicating a lateral component to the acetabular fracture. (E) A more medial sagittal STIR sequence slice
identifies minor cartilage and subchondral bone irregularities in the center of the acetabulum (arrows), an intact accessory ligament, and
a normal femoral head. GT, greater trochanter. (F) Synoviocentesis indicated uniformly bloody joint fluid, which was aspirated and 20 mg
hyaluronic acid injected. The weanling made a complete recovery.
An Ehmer sling has been used on several cases, but most articulation, and can be started on limited walking
reluxate.5,16,27 Physiotherapy with repeated flexion and exercise two weeks after surgery. Nondisplaced or
extension of the hip is useful to establish a pseudoar- mildly displaced fractures of the acetabulum should be
throsis after femoral head excision. Permanent upward restricted to stall rest for six to eight weeks, while the
fixation of the patella is a frequent complication.2,5 Medial fracture heals. Repeat injection of the affected hip with
patella desmotomy is often curative, provided that stifle hyaluronic acid or PRP may be warranted.
joint arthrofibrosis is not extreme. If a closed suction drain
has been placed, it should be removed after one to two
days. Routine prophylactic antibiotic therapy is recom- Prognosis
mended in all cases because of the severe complications of
surgical site infections. Nonsteroidal anti‐inflammatory Without reduction, horses with a complete luxation will
agents are administered as needed. remain lame and frequently suffer from breakdown in
Ponies and horses having arthroscopic examination the contralateral limb. The smaller the horse or pony, the
of the hip joint do not generally have a destabilized better the long‐term survival. With successful reduction
www.ajlobby.com
there is a chance for some degree of athletic activity. stabilizing structures. Complete rupture of the ligament
Femoral head excision is a salvage procedure only, and is of the head of the femur is generally serious and pre-
successful in approximately 50% of operated patients.10,25 cludes a comfortable retirement. Debridement of partial
There are few published reports of successful hip joint rupture of ligament of the head of the femur can allow
replacement in the horse.11,26 horses to return to ridden activity.
For horses with subluxation, the prognosis is
frequently determined by the extent of damage to the
References
1 Barrett, E.L., Talbot, A.M., Driver, A.J. et al. (2006). A luxation and upward fixation of the patella. Can. Vet. J.
technique for pelvic radiography in the standing horse. 58: 498–502.
Equine Vet. J. 38: 266–270. 15 Mackay‐Smith, M.P. (1964). Management of fracture
2 Bennett, D., Campbell, J.R., and Rawlinson, J.R. (1977). and luxation of the femoral head in two ponies. J. Am.
Coxofemoral luxation complicated by upward fixation Vet. Med. Assoc. 145: 248–251.
of the patella in the pony. Equine Vet. J. 9: 192–194. 16 Malark, J.A., Nixon, A.J., Haughland, M.A., and Brown,
3 Bergfeld, W.A. III (1978). Coxitis in a horse. J. Am. Vet. M.P. (1992). Equine coxofemoral luxations: 17 cases
Med. Assoc. 172: 273–274. (1975–1990). Cornell Vet. 82: 79–90.
4 Brenner, S. and Whitcomb, M.B. (2009). 17 May, S.A., Patterson, L.J., Peacock, P.J., and Edwards,
Ultrasonographic diagnosis of coxofemoral subluxation G.B. (1991). Radiographic technique for the pelvis in
in horses. Vet. Radiol. Ultrasound 50: 423–428. the standing horse. Equine Vet. J. 23: 312–314.
5 Clegg, P.D. and Butson, R.J. (1996). Treatment of a 18 McIlwraith, C.W., Nixon, A.J., and Wright, I.M. (2015).
coxofemoral luxation secondary to upward fixation of Diagnostic and Surgical Arthroscopy in the Horse, 4e.
the patella in a Shetland pony. Vet. Rec. 138: 134–137. 308–315. Philadelphia: Mosby Elsevier.
6 David, F., Rougier, M., Alexander, K., and Morisset, S. 19 Nixon, A.J. (1994). Diagnostic and operative
(2007). Ultrasound‐guided coxofemoral arthrocentesis arthroscopy of the coxofemoral joint in horses. Vet.
in horses. Equine Vet. J. 39: 79–83. Surg. 23: 377–385.
7 Field, J.R., McLaughlin, R., and Davies, M. (1992). 20 Nyack, B., Willard, M., Scott, J., and Padmore, C.
Surgical repair of coxofemoral luxation in a miniature (1982). Non‐surgical repair of coxofemoral luxation in a
horse. Can. Vet. J. 33: 404–405. Quarter Horse filly. Equine Pract. (USA) 4: 11–14.
8 Garcia‐Lopez, J.M., Boudrieau, R.J., and Provost, P.J. 21 O’Brien, T., Koch, C., and Livesey, M.A. (2012). What is
(2001). Surgical repair of coxofemoral luxation in a your diagnosis? Avulsion fracture of the insertion of the
horse. J. Am. Vet. Med. Assoc. 219: 1254–1258. round ligament of the head of the femur. J. Am. Vet.
9 Geburek, F., Rotting, A.K., and Stadler, P.M. (2009). Med. Assoc. 240: 1059–1060.
Comparison of the diagnostic value of ultrasonography 22 Platt, D., Wright, I.M., and Houlton, J.E. (1990).
and standing radiography for pelvic‐femoral disorders Treatment of chronic coxofemoral luxation in a
in horses. Vet. Surg. 38: 310–317. Shetland pony by excision arthroplasty of the femoral
10 Gracia Calvo, L.A., Martin‐Cuervo, M., Pena, E. et al. head: a case report. Br. Vet. J. 146: 374–379.
(2011). Femoral head excision after coxofemoral 23 Portier, K. and Walsh, C.M. (2006). Coxofemoral
luxation in an Arab filly: four years follow‐up. Equine luxation in a horse during recovery from general
Vet. Educ. 23: 346–352. anaesthesia. Vet. Rec. 159: 84–85.
11 Huggons, N., Andrea, R., Grant, B., and Duncan, C. 24 Rottensteiner, U., Palm, F., and Kofler, J. (2012).
(2010). Total hip arthroplasty in the horse: overview, Ultrasonographic evaluation of the coxofemoral joint
technical considerations and case report. Equine Vet. region in young foals. Vet. J. 191: 193–198.
Educ. 22: 547–553. 25 Squire, K.R., Fessler, J.F., Toombs, J.P. et al. (1991).
12 Jogi, P. and Norberg, I. (1962). Malformation of the hip Femoral head ostectomy in horses and cattle. Vet. Surg.
joint in a standard‐bred horse. Vet. Rec. 74: 421–422. 20: 453–458.
13 Kuemmerle, J.M. and Furst, A.E. (2011). Treatment of a 26 Squire, K.R.E., Fessler, J.F., Toombs, J.P. et al. (1996).
coxofemoral luxation in a pony using a prosthetic Total hip replacement in three ponies – a feasibility
capsule technique. Vet. Surg. 40: 631–635. study. Vet. Comp. Orthop. Traumtol. 9: 4–9.
14 Ludwig, E.K. and Byron, C.R. (2017). Femoral head 27 Trotter, G.W., Auer, J.A., Arden, W., and Parks, A.
ostectomy and medial patellar ligament desmotomy to (1986). Coxofemoral luxation in two foals wearing
treat a pregnant miniature horse with coxofemoral joint hindlimb casts. J. Am. Vet. Med. Assoc. 189: 560–561.
www.ajlobby.com
28 Trump, M., Kircher, P.R., and Furst, A. (2011). The use 31 Whitcomb, M.B., Doval, J., and Peters, J. (2011). The
of computed tomography in the diagnosis of pelvic use of computed tomographic three‐dimensional
fractures involving the acetabulum in two fillies. reconstructions to develop instructional models for
Vet. Comp. Orthop. Traumatol. 24: 68–71. equine pelvic ultrasonography. Vet. Radiol. Ultrasound
29 von Deitz O, Nagel E, Holdhaus W, Litzke L‐F. 52: 542–547.
Femurluxation beim Pony. 1986; 778–781. 2 Whitcomb, M.B., Vaughan, B., Katzman, S., and
3
30 von Recum, A.F., Parchinski, T.J., Lunceford, E.M. Hersman, J. (2016). Ultrasound‐guided injections in
et al. (1980). Experimental coxofemoral horses with cranio‐ventral distension of the
replacement hemiarthroplasty in the pony. coxofemoral joint capsule: feasibility for a cranioventral
Vet. Surg. 9: 116–120. approach. Vet. Radiol. Ultrasound 57: 199–206.
www.ajlobby.com
723
39
Fractures of the Pelvis
Norm G. Ducharme1,2 and Alan J. Nixon1,2
1
2
Introduction pelvic fracture,22 while others indicated evidence of

chronic morphological anomalies.9,11,29 Indeed, Hesse and
Pelvic fractures are infrequent occurrences in horses, with Verheyen11 reported, in a retrospective case‐control study
a reported prevalence ranging from 0.5% to 4.4% of all of horses which subsequently were diagnosed with pelvic
fractures presented.3,13,22 In post‐mortem examination of or hindlimb fracture, that affected horses were 11.1 times
36 Thoroughbred racehorses that died of vertebral or pel- more likely to show pelvic bone asymmetry, 4.7 times
vic injuries in California, 28% of the horses had pelvic more likely to display muscle atrophy of the hindquarters,
stress fractures.9 To put this injury in perspective, pelvic and 6.6 times more likely to have spasm or tenderness on
fracture and third metacarpal fracture have been reported palpation of the gluteal muscles prior to injury than the
to be the most prevalent fractures in National Hunt race- control group of horses which did not develop fracture.
horses.6 This compares to Thoroughbred racehorses in This suggests that early identification of these clinical
flat training/racing, where pelvic fracture is diagnosed, abnormalities could reduce the incidence of pelvic frac-
but less frequently than tibial stress fracture, proximal ture during race training/racing.9
phalanx fracture, or carpal fracture.20 The higher rate of
pelvic fracture in National Hunt horses compared to flat
racing may be related to the incidence of falls or jumps in Diagnosis
the former, which leads to predisposing factors.6 Most
studies have not shown any age or sex predilection,6,20,22,29 Horses with pelvic fractures generally present with unilat-
although in two studies female horses (<4 years) were eral or bilateral severe hindlimb lameness; rarely, the horse
reported to be predisposed to pelvic fractures.4,22 Tarsus is unable to stand. In contrast, horses with fractures of mus-
valgus conformation and increased coxal angle have been cle origin tubercles such as the tuber coxae have mild to
reported as predisposing factors.30 Trauma such as strik- moderate lameness.28 Visual inspection of the pelvis may
ing a stall door or a starting gate and falls are the most reveal a deviation or tipping of the pelvis toward the side of
common cause of pelvic fracture; in these cases the frac- the fracture. External swelling is absent unless the tuber
ture is apparently a result of a single high‐impact force coxae or the ilium is fractured; in these cases a painful swell-
beyond the bone strength. However, a percentage of young ing is appreciated ventral to the level of the tuber coxae. In
horses appear to suffer pelvic fractures without an acute addition, horses with tuber coxae fracture can show guard-
trauma, which is seen during stressful activities such as ing muscle response or spasm on palpation in the area of
racing or race training;6,20,22,29 presumably this is a result the tuber sacrale.18,25 In horses with pelvic fractures, crepi-
of accumulated bone microdamage induced by repetitive tus can sometimes be detected by palpation of the greater
loading, leading to disturbance in remodeling and finally trochanter, rocking the horse from side to side, or during
frank stress fracture.2,11,21,23 A third hypothesis not entirely manipulation of the affected hindlimb and hemipelvis.
separate from acute injury or repeated stress injury is that Clinical diagnosis of pelvic fracture is obtained by rectal
of a preexisting incomplete fracture from an acute episode detection of crepitus or abnormal protrusion into the pel-
that then displaces during strenuous activity. Some reports vic canal. Palpation is easiest at the cranial aspect of the
indicated the absence of lameness prior to occurrence of pubis, the medial limits of the acetabulum, and the caudal

www.ajlobby.com
aspect of the ilial shaft, where little soft tissue c overage is the more scatter that the muscle mass induces, and the
present. If no abnormality is detected, an assistant can more difficult the image is to accurately interpret. The
push the horse from side to side and/or pick up the affected standing ventrodorsal projection (see Figure 38.2 in
limb and move the limb in a rotary movement. In tractable Chapter 38) and several different lateral projections
patients, the horse can be walked during rectal examina- allow examination of the pelvic bones and acetabulum.
tion. Rectal detection of pelvic asymmetry or crepitus is a Oblique lateral projections separate the two ilia, acetab-
reliable indicator of fracture, but in one study was noted in ulae, and ischia to provide better definition of either side
less than 30% of the horses with pelvic fracture,22 and in of the pelvis (Figure 39.2). Radiography under general
another study was only detected in horses examined anesthesia will provide more precise characterization of
within 48 hours of the injury.14 the fracture, which in turn provides a more complete
The diagnosis can be confirmed by scintigraphy, treatment plan and prognosis. Indeed, the need for radi-
standing radiography, radiography with the animal ography under general anesthesia is arguable, since in
under general anesthesia, and/or ultrasound examina- two studies there was no correlation between the bone
tion.1,8,9,12,15,24,25 The sensitivity of the diagnosis using fracture and survival.14,22 In addition, there is a risk of
scintigraphy has been estimated at 94%.24 The actual further injury and even death from exsanguination sec-
sensitivity of standing radiography and ultrasound has ondary to iliac artery rupture during recovery.22,26 Since
not been reported. It seems preferable to avoid general the survival rate with medical treatment ranges from
anesthesia if standing radiographs are adequate to 50% to 77%, radiographs under general anesthesia are
establish a diagnosis (Figure 39.1). The larger the horse, not recommended in horses where salvage is a satisfac-
tory outcome. A combination of standing radiography
complemented by standing ultrasonography also pro-
vides a more accurate diagnosis (Figure 39.3), which
becomes increasingly relevant in large horses where
radiography is more difficult.
In cases where athletic performance is the only accept-
able outcome, radiographs under general anesthesia may
be justifiable. Radiographs provide a definitive diagnosis,
and horses with displaced acetabular fractures are
unlikely to return to any type of athletic activity
Figure 39.1 Standing ventrodorsal radiographic view of the pelvis

of a three‐year‐old Arabian filly with a comminuted and displaced Figure 39.2 Standing oblique lateral radiograph of the pelvis
acetabular fracture. Multiple fracture fragments are evident in the shows both hip joints and both shafts of the ilium. The hip joint
cranial and caudal aspects of the acetabulum (arrows). There is closest to the radiographic receiver plate (in this case the right
little hope for returning to soundness, and euthanasia is indicated. hip) is smaller than the opposite hip.
www.ajlobby.com
(Figure 39.4). On the contrary, a horse with an ilial shaft anesthesia (Figure 39.5).27 The increasing availability of
fracture without acetabulum involvement would have a large‐bore CT units for standing and recumbent CT
better prognosis. Ideally lateral, oblique lateral, and vari- studies has allowed a more precise assessment of frac-
ous ventrodorsal views should be obtained.22 Computed ture configuration, treatment options, and correlation to
tomography (CT) has been found to be more sensitive later athletic performance. Additionally, it provides bony
than radiography, and can add vital information when information that can better inform subsequent ultra-
the acetabulum and immediate periarticular tissues are sound examination.31
questionably damaged on radiographs obtained under The ilial wing is the most commonly involved site
for pelvic fracture in Thoroughbred racehorses
(Figure 39.6).10,16,19,21,29 In a study of 31 horses with frac-
tures of the pelvis reported by Hennessy et al.,10 22
involved just a single fracture site and 9 had fractures in
two places. For the 22 horses with only a single fracture,
the ilial wing was most commonly affected (12), followed
by the ischium (7), ilial shaft (2), and acetabulum (1). When
two sites were fractured, the most prevalent combina-
tion was bilateral ilial wings (3) and unilateral ilial wing
and shaft (3). The acetabulum was fractured in only 4 of
the 31 horses. These distribution numbers for fractures
of the pelvis are similar to a previous study by Jeffcott,13
where the ilium was fractured in 17 of 50 pelvic fractures
(34%), and the ischium was involved in 11 (22%). The
remaining fractures were equally distributed among the
pubis, the sacrum, and the acetabulum.
The tuber coxae is the most prominent portion of the
pelvis and is therefore susceptible to external impact
trauma (Figure 39.7).5 Dabareiner and Cole5 described
Figure 39.3 Ultrasonographic examination of the ilium shows fractures of the tuber coxae in 29 horses, all of which
marked fracture displacement in the proximal shaft of the ilium. had a traumatic event leading to the fracture. Of the
Figure 39.4 General anesthesia for radiography allows better detail of fractures of the pelvis and acetabulum. Multiple displaced fractures
of the left ischium and pubis (white arrows) with concurrent fractures of the ilium (black arrows) result in a destabilized acetabulum.
www.ajlobby.com
29 horses, 24 had palpable and visual asymmetry between at the trot. These horses highlighted the reliability of
the affected and unaffected tuber coxae. The majority radiographic confirmation using a dorsomedial‐ventro-
of these horses had an unusual hindlimb gait, with lateral 50° oblique projection.
the hindlimbs tracking to one side of the forelimbs. Scintigraphy has been used as an alternative to general
Additionally, the horses were more lame at the walk than anesthesia and radiography for the detection of pelvic frac-
tures.6,8,12,18,19 Both probe scintigraphy and conventional
scintigraphy have the advantage of confirming a diagnosis
of fracture without the risk of general anesthesia.
Unfortunately, these two techniques only localize the bone
where the fracture is located, and not the degree of com-
minution. Follow‐up ultrasonographic examination pro-
vides more structural information,7 and the combination
of standing scintigraphy and standing ultrasonographic
examination is often adequate to define a treatment path
(Figure 39.8).10 Standing radiographs can occasionally add
additional information on the progress of healing and rela-
tive alignment of the fractured ilial shaft or tuber coxae.
Fractures of the pubis and shaft of the ischium can be
part of multiple fractures that involve the acetabulum,
but on occasion can be isolated, with involvement of the
ischium caudal to the acetabulum (Figure 39.9). The
muscles of the pelvic floor and the origins of attached
hindlimb musculature generally maintain displaced frac-
tures of the caudal aspect of the pelvis in reasonable
alignment. Healing generally progresses rapidly, with
few long‐term consequences.
In non‐racing horses, scintigraphy has frequently
identified fractures of the tuber ischii and tuber coxae as
Figure 39.5 Computed tomography three dimensional a cause of hindlimb lameness (Figure 39.10).5,8 Follow‐up
reconstruction in a foal allows identification of multiple fractures
of the femoral head (arrows), fractures of the acetabular dorsal rim radiography often confirmed mildly to moderately dis-
and adjacent ischium (arrowheads), and luxation of the femoral placed fractures of either tuberosity. Healing at both sites
head from the acetabulum. was generally inevitable, with a return to full function.
Figure 39.6 Standing ultrasonographic examination of the shaft of the ilium in a four‐year‐old Thoroughbred racehorse identifies a
displaced fracture of the expanded cranial flat‐wing portion of the right ilium. The left ilium is included for comparison. The fracture
healed with stall confinement and the horse returned to racing.
www.ajlobby.com
(A)
(B)
DORSAL DORSAL
R CAUDOCRANIALO
VENTRAL
VENTRAL (C)
Figure 39.7 Left tuber coxae fracture in an eight‐year‐old Polo pony that developed acute lameness after a game. (A) Nuclear scintigraphy
allowed screening of the pelvis to identify the fracture. Dorsal (left) and both right and left oblique examination (right) reveals increased
radionucleotide uptake in the left tuber coxae. (B) Craniocaudal radiographic projections of left and right tuber coxae show a moderately
displaced, mildly comminuted fracture of the left tuber coxae. (C) Dorsoventral oblique skyline projections of the left and right tuber
coxae show the displaced fracture of the left tuber coxae (arrowheads). The fracture healed without complication and the horse returned
to riding.
Treatment arthroscopic removal of comminuted portions that are

intraarticular, femoral head excision in small horses and
Currently, there are no published surgical treatments for ponies, and hip replacement in small horses with chronic
pelvic fractures in horses, with the exception of debride- fracture‐induced osteoarthritis.
ment and removal of secondary septic osteitis of frac- Arthroscopic examination of the hip and retrieval of
tured tuber coxae.5 Treatment consists of confinement intraarticular comminution are described in Chapter 38.
to a box stall with excellent footing for four to six months. A lateral arthroscopic approach to the hip is made and an
Nonsteroidal anti‐inflammatory agents are administered instrument portal established either cranial or caudal to
as needed, usually for the first month. The surrounding the arthroscope entry, depending on fracture fragment
musculature and associated blood supply keep most location. The fragment is elevated with a thin osteotome
nonarticular fractures aligned and capable of rapid for- and removed with a long rongeur (see Figure 38.18 in
mation of stabilizing callus. For Thoroughbred race- Chapter 38).
horses with nonarticular pelvic fractures, fracture Similarly, discussion of the limitations and rather
displacement of the ilium or ischium had no bearing on mediocre results to date with hip replacement in small
the return to race.10 Horses with fracture involving the ponies and miniature horses is described in Chapters 37
acetabulum did not return to race, and 50% were eutha- and 38. Availability of large acetabular and femoral head
nized because of unremitting pain and debility. Surgical prostheses limits application to small horses.12 Femoral
repair of ilial fractures that extend into the acetabulum head ostectomy has similar size constraints, with ponies
includes internal fixation of major fracture planes, doing better afterward if they weighed less than 100 kg.
www.ajlobby.com
(A)
(B)
(C)
Figure 39.8 Fractured right wing of the ilium of five weeks’ duration in a Warmblood
weanling. (A) Scintigraphy identifies moderately increased radionucleotide uptake
(arrow) in the right ilium compared to the left. (B) Ultrasonography of the right and
left wings of the ilium verifies a displaced fracture of the right ilium. (C) Standing
lateral radiography verified the fracture displacement (arrowheads), and identified
healing callus forming ventral to the fracture line. The right tuber coxae healed in a
ventrally displaced position.
Internal fixation of select ilial and acetabular frac- potential broodmare may be indication for internal
tures is possible. For ilial fractures, indications for fixation. Minimally displaced acetabular fractures may
stabilization include unstable multiple fractures of the heal adequately to provide a good quality of life.
shaft that are either bilateral, or unilateral but protrude However, some impact injuries drive the femoral
axially and risk rupture of the internal iliac artery head through the acetabulum, and an attempt at recon-
(Figure 39.11). Additionally, multiple fractures that struction may be indicated to salvage the horse for
displace axially and compromise the pelvic canal in a comfortable retirement.
www.ajlobby.com
Unstable fractures of both ilial shafts immediately cra- to the greater trochanter and extends distally, to track
nial to the acetabulum are quite debilitating. Stabilization the femoral shaft for 5–10 cm, depending on whether
of one ilial shaft may be adequate to salvage the horse. exposure of the acetabulum is planned. For exposure of
Similarly, in foals, displaced fractures of the cranial only the ilial shaft, the superficial gluteal muscle is tran-
region of the ilial shaft create significant lameness and sected near its insertion and retracted proximally. The
raise the threat of varus breakdown of the opposite limb. middle gluteal musculotendinous junction and insertion
The approach to the shaft of the ilium uses a modifica- are identified by blunt dissection near the cranial line of
tion of the craniolateral approach to the hip for luxation attachment to the greater trochanter. The ventral border
repair. A curvilinear skin incision is made, commencing of the muscle is then defined by tracking cranially from
15 cm cranial to the palpable greater trochanter on a line the tendon of insertion, to allow the middle gluteal mus-
connecting the trochanter with the cranio‐dorsal promi- cle belly to be retracted dorsally. The muscle becomes
nence of the tuber coxae. For exposure of the caudal more invested onto the shaft of the ilium as the dissec-
region of the shaft of the ilium, the incision curves caudal tion is extended cranially. The tensor fascia lata is
detached from the femur and retracted cranially and
ventrally. The cranial femoral neurovascular structures
are deep in the junction between tensor fascia lata and
middle gluteal muscle, and should be avoided. The frac-
ture hematoma provides some muscle stripping and a
plane to isolate and expose the fracture. The dissection is
deep and muscle bleeding can be profuse. The fracture is
exposed only enough to place one or two short 4.5 mm
locking compression plates (LCPs) on the dorsolateral
surfaces of the ilium. The cranial portion of the plate can
be tunneled under the muscle using an Ochsner or blunt
elevator to form a path near the bone surface. Drilling
through the trans cortex of the ilial shaft must be done
with extreme care to avoid puncturing the iliac arteries
or penetrating the pelvic canal contents, including the
rectum. Several cortical screws are placed to draw the
fractured ends toward the plate and the remaining plate
holes are filled with locking‐head screws. Visualization
Figure 39.9 Standing oblique lateral radiographs of an 11‐year‐old of the ilium is difficult and manipulating the fracture into
Warmblood with a two‐week history of severe lameness reveals a
fracture of the shaft of the left ischium (arrows) immediately alignment can be obscured by muscle. Intraoperative
caudal to the acetabulum. FH, femoral head; GT, greater radiographic or fluoroscopic monitoring is rarely possi-
trochanter. ble unless the horse is very small.
Dor Pelvis
(A) (B) (C)
Figure 39.10 Fracture of the right tuber ischium of a six‐year‐old Thoroughbred with a two‐month history of right hindlimb lameness.
(A) Nuclear scintigraphy identifies increased radionucleotide uptake (arrow) in the right ischium. (B) Ultrasonographic examination
confirms a displaced fracture of the ischium. (C) Standing oblique dorsoventral radiographs confirm a fracture of the right ischium,
compared to the left. The horse recovered with rest alone to allow riding.
www.ajlobby.com
(A) (B)
Figure 39.11 Fracture of the left ilium in a foal. Radiographs obtained in ventrodorsal (A) and oblique lateral (B) projections indicate a
severely displaced fracture of the cranial portion of the shaft of the ilium (arrows). Source: Images courtesy Dr. Dean Richardson.
Fracture of the more cranial region of the shaft of the of the shaft of the ilium is exposed as necessary to allow
ilium requires a more cranial approach, which still allows seating of a plate. The hip joint capsule should be incised
dorsal elevation of the middle gluteal musculature to expose the femoral head for removal of small commi-
(Figure 39.12). A 15 cm curvilinear skin incision is made, nuted pieces and provide visual verification of the articu-
extending caudally from the palpable caudoventral lar plane of the acetabulum. A narrow limited‐contact
aspect of the tube coxae on a line connecting the tuber dynamic compression plate (LC‐DCP) is then contoured
coxae with the greater trochanter of the femur. The mus- to the ilial shaft and up onto the acetabulum. Short
culature is elevated off the dorsolateral shaft of the ilium 5.5 mm cortical or 6.5 mm cancellous screws are used to
and retracted dorsally. This exposes the fracture in the stabilize the fracture. Drilling the trans cortex should be
ilial shaft. Where possible, application of two plates to done carefully, to avoid penetrating the joint or the pelvic
this region is recommended. Use of LCPs also provides canal contents. Realigning the articular surface of the
better holding power in the soft bone of the pelvis. The acetabulum can be facilitated by inserting a round‐edged
plates are inserted from the cranial exposure of the shaft Freer or Adson elevator (Sontec Instruments, Centennial,
of the ilium and tunneled caudally beneath the middle CO, USA) into the joint to manipulate the unstable
gluteal musculature (see Figure 39.12). A lateral LCP is pieces. Screws that are shorter than the measured dis-
applied initially and secured with several cortical screws. tance on the direct measuring device should be used to
The remaining LCP combi holes are filled with locking‐ avoid penetration of the pelvic canal. The greater tro-
head screws. A second LCP is contoured to the shape of chanter is then reattached as previously described, and
the dorsal surface of the ilium and applied with locking‐ the muscle planes apposed. A suction drain should be
head screws. The shape of the ilial shaft requires a con- placed and antibiotic‐laden beads inserted.
cave contour with additional twisting of the plate. Fractures of the cranial flat surfaces of the ilium near
Insertion of the LCP drill guides requires separate stab the sacroiliac junction and those involving the tuber
incisions, with separation of the overlying musculature coxae, as well as the tuber ischia of the ischium, do not
for appropriate threading of the guide into the LCP require stabilization (see Figure 39.8). Chronic drainage
combi hole (see Figure 39.12). from an infected tuber coxae fracture may need surgical
Ilial fractures that extend onto the acetabulum require debridement or removal of infected fragments.5 In one
trochanteric osteotomy to expose the acetabulum. The description of 29 cases with fracture of the tuber coxae,5
approach is illustrated in Figure 38.7 in Chapter 38 and is only 2 needed surgical treatment, which consisted of
described in the literature.17 The fracture planes are incision and debridement of the fractured fragments
identified by limited removal of periosteum, and as much under sedation.
www.ajlobby.com
(A) (B)
(C) (D)
(E) (F)
Figure 39.12 Stabilization of the ilial fracture shown in Figure 39.11, using two locking compression plates. (A) Exposure of the ilial shaft.
(B) Application of two contoured plates, one on the lateral and one on the dorsal surface of the ilium. (C) The dorsal plate has been
contoured and twisted, and the locking screws in the caudal portion of the plate are inserted through separate stab incisions.
(D) Appearance of the repaired shaft of the ilium after both plates have been inserted. (E, F) Postoperative oblique ventrodorsal and
lateral radiographs show realignment of the ilium and stable fixation. Source: Case detail and images courtesy Dr. Dean Richardson.
www.ajlobby.com
Prognosis was good.14,22 A retrospective study of 100 horses with

pelvic fractures reported positive return to function in
Medical treatment for all types of pelvic fractures has 77% of horses.22 Importantly, the fracture site including
resulted in a 50–70% salvage rate.3,10,13,14,22 The progno- the presence of an acetabular fracture was not statistically
sis for athletic performance is good with fractures of the related to the prognosis. This seems counterintuitive,
tuber coxae.5 Otherwise, the prognosis varies depending given the importance of articular c ongruency for long‐
on whether the acetabulum is involved; approximately term function of the hip joint. Various subsets of these
50% of horses with nonarticular pelvic fractures will be outcome data after acetabular fracture suggest a more
capable of athletic activity, while only (20%) of horses serious negative impact.22 Of 10 horses with fracture of
with articular fracture will be capable of athletic perfor- the ilium and acetabulum, 8 were destroyed at diagnosis
mance.13 Displaced and nondisplaced fractures of the or sometime afterward. Additionally, 7 of 13 horses with
ilium healed adequately to allow similar percentages of combination fracture of the ischium, pubis, and acetabu-
horses to return to racing.10 These data are skewed to lum were also destroyed at the time of diagnosis or soon
some extent by elimination of four horses with displaced afterward. Lastly, both of the horses with solitary central
fractures that had to be destroyed on humane grounds. acetabular fracture were destroyed.22
All four of these horses had fractures at two sites in the Little and Hilbert14 analyzed outcome in 19 horses
pelvis, including two with unilateral fracture of the ace- with pelvic fracture, 7 of which were destroyed at the
tabulum and ilium. Additionally, horses that recovered time of diagnosis. One case was lost to follow‐up, and
from displaced fractures raced fewer times in the two of the remaining 11 horses with long‐term informa-
years after injury. tion, 7 survived (64%). However, only 4 of the 11
Fractures involving only the tuber coxae of the ilium (36%) were free of lameness and being ridden.
have a good prognosis for complete recovery.5 Dabareiner Acetabular involvement was evident in 11 of the 19
and Cox reported that 27 of 29 horses (93%) with tuber horses, and 6 of the 11 (55%) were destroyed due to
coxae fracture returned to athletic use.5 All but 2 of these lameness. A further 2 of the 11 (18%) were lame at
horses were treated by extended stall rest and pain con- pasture or with exercise, and only 2 horses were
trol. Local debridement under sedation was used for sound and performing. Outcome after acetabular
2 horses and both recovered. fracture was unknown in the last horse. Given this,
In a study of proximal limb and pelvic fractures in acetabular involvement only allowed 2 of 10 horses to
Thoroughbred racehorses, 10 of 129 fractures involved return to work, and 8 of 10 (80%) were destroyed or
the pelvis.16 Of these 10 horses, 6 returned to racing with remained lame. Both this study and the series by
conservative therapy. The median interval until first race Rutkowski and Richardson22 indicate that fracture of
after injury was 210 days, and horses raced a median the acetabulum is a negative prognostic indicator for
number of 16 times after recovery.16 These data are con- both survival and pain‐free existence. Outcome after
sistent with two previous studies, both indicating that the surgical repair of the acetabulum has not been
prognosis for returning to function after a pelvic fracture described, but some form of repair is clearly needed.
References
1 Barrett, E.L., Talbot, A.M., Driver, A.J. et al. (2006). A 5 Dabareiner, R.M. and Cole, R.C. (2009). Fractures of the
technique for pelvic radiography in the standing horse. tuber coxa of the ilium in horses: 29 cases (1996–2007).
Equine Vet. J. 38: 266–270. J. Am. Vet. Med. Assoc. 234: 1303–1307.
Bennell, K.L., Malcolm, S.A., Wark, J.D., and Brukner,
2 Ely, E.R., Avella, C.S., Price, J.S. et al. (2009). Descriptive
6
P.D. (1996). Models for the pathogenesis of stress epidemiology of fracture, tendon and suspensory
fractures in athletes. Br. J. Sports Med. 30: 200–204. ligament injuries in National Hunt racehorses in
British Equine Veterinary Association (1965). Survey of
3 training. Equine Vet. J. 41: 372–378.
equine disease: 1962–63. Vet. Rec. 77: 528–538. Geburek, F., Rötting, A.K., and Stadler, P.M. (2009).
7
Carrier, T.K., Estberg, L., Stover, S.M. et al. (1998).
4 Comparison of the diagnostic value of ultrasonography
Association between long periods without high‐speed and standing radiography for pelvic‐femoral disorders in
workouts and risk of complete humeral or pelvic horses. Vet. Surg. 38: 310–317.
fracture in thoroughbred racehorses: 54 cases (1991– Geissbühler, U., Busato, A., and Ueltschi, G. (1998).
8
1994). J. Am. Vet. Med. Assoc. 15 (212): 1582–1587. Abnormal bone scan findings of the equine ischial
www.ajlobby.com
tuberosity and third trochanter. Vet. Radiol. Ultrasound 22 Rutkowski, J.A. and Richardson, D.W. (1989). A
39: 572–577. retrospective study of 100 pelvic fractures in horses.
9 Haussler, K.K. and Stover, S.M. (1998). Stress fractures Equine Vet. J. 21: 256–259.
of the vertebral lamina and pelvis in Thoroughbred 23 Schaffler, M.B. (2001). Bone fatigue and remodeling in
racehorses. Equine Vet. J. 30: 374–381. the development of stress fractures. In: Musculoskeletal
10 Hennessy, S.E., Muurlink, M.A., Anderson, G.A. et al. Fatigue and Stress Fractures (ed. D.B. Burr and C.
(2013). Effect of displaced versus non‐displaced Milgrom), 161–182. Boca Raton: CRC Press.
pelvic fractures on long‐term racing performance 24 Scheidegger, E., Geissbühlerl, U., Doherr, M.G., and
in 31 Thoroughbred racehorses. Aust. Vet. J. 91: 246–250. Lang, J. (2006). Technetium‐99m‐HDP uptake
11 Hesse, K.L. and Verheyen, K.L. (2010). Associations characteristics in equine fractures: a retrospective
between physiotherapy findings and subsequent study. Schweiz. Arch. Tierheilkd. 148: 569–575.
diagnosis of pelvic or hindlimb fracture in racing 25 Shepherd, M.C., Pilsworth, R.C., Hopes, R., and Steven,
Thoroughbreds. Equine Vet. J. 42: 234–239. W.N. (1994). Clinical signs, diagnosis, management and
12 Huggons, N., Andrea, R., Grant, B., and Duncan, C. outcome of complete and incomplete fracture to the
(2010). Total hip arthroplasty in the horse: overview, ilium: a review of 20 cases. In: Proceedings of the
technical considerations and a case report. Equine Vet. American Association of Equine Practitioners, vol. 40,
Educ. 22: 547–553. 177–180. Lexington, KY: AAEP.
13 Jeffcott, L.B. (1982). Pelvic lameness in the horse. 26 Sweeney, C.R. and Hodge, T.G. (1983). Sudden death
Equine Pract. 4: 21–47. in a horse following fracture of the acetabulum and
14 Little, C. and Hilbert, B. (1987). Pelvic fracture in horses: iliac artery laceration. J. Am. Vet. Med. Assoc. 182:
19 cases. J. Am. Vet. Med. Assoc. 190: 1203–1206. 712–713.
15 May, S.A., Patterson, L.J., Peacock, P.J. et al. (1991). 27 Trump, M., Kircher, P.R., and Fürst, A. (2011). The use
Radiographic technique for the pelvis in the standing of computed tomography in the diagnosis of pelvic
horse. Equine Vet. J. 23: 312–314. fractures involving the acetabulum in two fillies.
16 McGlinchey, L., Hurley, M.J., Riggs, C.M., and Vet. Comp. Orthop. Traumatol. 24: 68–71.
Rosanowski, S.M. (2017). Description of the incidence, 28 Vaughan, J.T. (1965). Analysis of lameness in pelvic
clinical presentation and outcome of proximal limb and limbs and selected cases. In: Proceedings of the
pelvic fractures in Hong Kong racehorses during American Association of Equine Practitioners, vol. 11,
2003–2014. Equine Vet. J. 49: 789–794. 223–241. Lexington, KY: AAEP.
17 Milne, D.W. and Turner, A.S. (1979). An Atlas of 29 Verheyen, K.L., Newton, J.R., Price, J.S., and Wood, J.L.
Surgical Approaches to Bones of the Horse, 160–165. (2006). A case‐control study of factors associated with
Philadelphia: WB Saunders. pelvic and tibial stress fractures in Thoroughbred
18 Pilsworth, R.C. (1992). Can a pelvic fracture in a horse racehorses in training in the UK. Prev. Vet. Med. 74:
be detected by probe scintigraphy? Vet. Rec. 131: 21–35.
123–125. 30 Weller, R., Pfau, T., Verheyen, K. et al. (2006). The
19 Pilsworth, R.C., Shepherd, M.C., Herinckx, B.M., and effect of conformation on orthopaedic health and
Holmes, M.A. (1994). Fracture of the wing of the ilium, performance in a cohort of National Hunt racehorses:
adjacent to the sacroiliac joint, in Thoroughbred preliminary results. Equine Vet. J. 38: 622–627.
racehorses. Equine Vet. J. 26: 94–99. 31 Whitcomb, M.B., Doval, J., and Peters, J. (2011). The
20 Ramzan, P.H. and Palmer, L. (2011). Musculoskeletal use of computed tomographic three‐dimensional
injuries in Thoroughbred racehorses: a study of three reconstructions to develop instructional models for
large training yards in Newmarket, UK (2005–2007). equine pelvic ultrasonography. Vet. Radiol. Ultrasound
Vet. J. 187: 325–329. 52: 542–547.
21 Riggs, C.M. (2002). Fractures – a preventable hazard of
racing Thoroughbreds? Vet. J. 163: 19–29.
www.ajlobby.com
734
40
Fractures of the Vertebrae
Alan J. Nixon1,2
1
2
Introduction additional 10 horses had lumbar vertebrae fractures.

Similarly, a necropsy survey of 4319 horses in France indi-
Vertebral fractures are relatively common, particularly in cated that 543 horses had neurologic disease, of which 187
young horses, where explosive athletic activity or training (34.4%) were due to vertebral or skull trauma.21
incidents can lead to combinations of cervical physeal The causes of spinal trauma vary largely according to the
disruption and subluxation, and racehorses which often age of the horse. Young, excitable animals often injure the
develop thoracolumbar fracture, all of which frequently immature cervical vertebrae by rearing and falling, pulling
result in spinal cord compression. Fractures most fre- back during training episodes and falling, or colliding with
quently involve the cervical and thoracolumbar vertebrae. objects during play.23 Adults are more commonly injured in
Racehorses have a relatively high frequency of vertebral high‐speed paddock or race accidents, which frequently
fractures, particularly steeplechase horses. In a series of result in catastrophic fracture displacement. Because of this
125 adult racehorses euthanized in the UK after cata- variation in etiology and energy of the fracture, foals and
strophic fractures, vertebral fractures were present in yearlings are more commonly presented for fracture stabi-
29 horses, 14 involving the cervical vertebrae and 15 the lization. Adults are frequently recumbent after fractures of
thoracolumbar vertebrae.57 Generally, lower‐energy the cervical and thoracolumbar spine, and few attempts
fractures are less likely to involve significant spinal cord have been made to surgically repair these injuries.
compression. A multicenter international study of sudden
death in 268 Thoroughbred racehorses in the USA, Cervical Vertebrae
Australia, Japan, and Hong Kong indicated that 11 of 268
(4.1%) of horses died due to cervical fracture.24 In another Fractures of the cervical vertebrae occur predominantly
series of 53 catastrophic fractures in Thoroughbred race- in immature horses and represent a challenging surgical
horses that ran on New York tracks, only 1 involved the repair. Falls, haltering accidents, and hyperflexion and
vertebral column.20 A California racetrack fatality analysis extension injuries are commonly described in the history
also recorded a lower incidence of vertebral fractures, with of most of these fractures.8,31,40,51,60 Occasionally, a high‐
3 fractures of the cervical vertebrae out of a total of 192 speed impact with a fixed object causes fracture of the
axial and appendicular breakdown injuries.18 These figures axis or atlas. The cervical vertebrae are more accessible
probably reflect the greater popularity of hurdle and stee- than other bones in the axial skeleton and are fractured
plechase events in the UK compared with other countries. more frequently in foals than in adults; both of these
Trauma to the central nervous system (CNS) is fre- characteristics improve the chances of a surgical repair.
quently diagnosed in horses presented for neurologic dis-
ease. In a retrospective study of 450 horses in Australia Fractures of the Cranial Cervical Vertebrae
presented with signs of neurologic deficit, 119 were found
to have CNS trauma.55 Vertebral fracture was identified in Atlanto‐occipital Fracture
60 of the 119 cases (50.4%). The cervical vertebrae were Fractures of the occipital condyles and cranial articulation
most frequently involved (33 cases; 55%), while 10 horses with the atlas are uncommon, and generally occur in foals
(30%) had fracture of the thoracic vertebrae and an and weanlings. Symptoms develop suddenly and include

www.ajlobby.com
severe neck pain, head tilt, reluctance to lift the head or turn anesthesia, generally provides better information as to
the head to the side, and rarely spinal cord compression and the affected portion of the atlanto‐occipital junction,
ataxia. Many result from an unwitnessed incident in the the most appropriate treatment including the need for
paddock or in a stall. Swelling around the cranial aspect of surgery, and the necessity for external support after
the atlas, and an asymmetry of left and right wings of the recovery (see Figure 40.1). Surgical repair of damage to
atlas and the space between the paracondylar process of the the occipital condyles or atlanto‐occipital joint is rare.
base of the skull and the wing of the atlas, are common. Most cases are treated by splinting of the atlanto‐
The diagnosis relies on standing radiographs, including occipital junction, using a ventral padded fiberglass
lateral, oblique, and ventrodorsal projections (Figure 40.1). splint to maintain head and neck alignment while the
Precise imaging of this area is difficult and computed affected occipital condyle or atlanto‐occipital articula-
tomography (CT), either standing or under general tion stabilizes.
(A) (B)
(C) (D)
Figure 40.1 Fracture of the occipital condyle in a three‐month‐old Thoroughbred foal. (A) Lateral radiograph showing multiple bony
irregularities (arrows) of the occipital condyle. (B) Oblique lateral radiographs indicate that the fracture (arrow) predominantly
involves the right occipital condyle. (C) Computed tomography (CT) indicates multiple crush injury of the right occipital condyle.
(D) Reprocessing the CT for soft tissue indicates significant hemorrhage within the Atlas (arrows), displacing the spinal cord (SC)
dorsally and to the left. The foal was managed in a head and neck splint to maintain alignment, and healed despite initial reduced
mobility of the atlanto‐occipital joint.
www.ajlobby.com
Fracture of the Atlas Myelography is necessary to definitively assess the

The atlas and adjacent portions of the occiput or axis compression and the dynamics of the atlantoaxial region
occasionally fracture. The atlantal arches, including during flexion and extension. Most horses with pro-
portions or all of one of the atlantal wings, are most liferative fracture callus experience some relief of the
commonly involved. Many fractures do not result in compression during atlantoaxial flexion, while extension
clinical ataxia, although neck pain and stiffness are com- often exacerbates the problem. A ventrodorsal myelo-
mon. These fractures are often difficult to assess on graphic projection also defines the asymmetry of the
standing lateral radiographs, and attempts at oblique lesion, which may be important for surgical planning.
and ventrodorsal projections should be made to ade- Decompression of fracture callus is provided by dorsal
quately assess the fracture. The dorsal symphysis of the laminectomy of the caudal half to two‐thirds of the atlas
atlas should not be confused with a fracture. The atlantal dorsal arch (see Figure 40.3).34 The surgical procedure is
arches, including portions or all of one of the atlantal the same as that described later for atlantoaxial sub-
wings, are occasionally fractured. Pain and crepitation luxation. Dissection through the atlantoaxial ligament is
can often be elicited by manipulation. Few horses with often difficult because of fibrous scar development. The
these fractures show neurologic deficits in the acute thickened lamina is burred routinely, with care taken not
stage, largely because of the spacious vertebral canal at to traumatize the spinal cord, which can be compressed
this level (Figure 40.2). Late onset of clinical ataxia fol- firmly against these dorsal structures.
lowing injury to the atlantoaxial region has been attrib- Following removal of the lamina and dorsal atlantoaxial
uted to callus formation within the vertebral canal scar, the protruding callus can be examined. Unless there
(Figure 40.3). Radiographs often show new bone for- is extensive dorsolateral bone formation, no attempt to
mation in the region of the ventral arch of the atlas and bur the callus is required. The dorsal laminectomy pro-
around the articulation of the dens with the atlas. vides adequate relief to the spinal cord. Fat harvested
Combined with thickening of the dorsal arch of the atlas from the edges of the nuchal crest is placed in the lami-
and dorsal displacement of the dens within the vertebral nectomy defect, and the nuchal ligament is apposed with
canal of the atlas, many of these changes result in static #2 synthetic absorbable suture. A drain can be placed, but
compression of the spinal cord, which can only be is rarely productive or necessary at this location.
relieved by laminectomy of the dorsal arch of the atlas Most horses recover from anesthesia without increased
(see Figure 40.3). Disruption and mineralization of the ataxia. Improvement in neurologic signs commences
longitudinal ligaments of the dens are possibly involved. within several weeks, and return to full activity has been
Stiffness of this region is common, and reluctance or described in several cases and should be expected within
inability of the horse to bend the neck laterally is frequently 14 months.34 Remodeling of the residual callus can also
reported. Palpable swellings, commonly lateralized, are occur over time, further improving the diameter of
also often evident in chronic cases. the vertebral canal. Continued neck stiffness caused by
(B)
(A)
Figure 40.2 Fracture of the atlas in an adult horse with upper neck stiffness but no neurologic deficit. (A) Lateral radiograph identifies
non‐destabilizing fractures (arrows) in the lateral arches of the atlas. (B) Oblique radiograph indicates that the fracture extends to the
cranial foramen of the atlas (arrows).
www.ajlobby.com
(A)
(B) (C)
Figure 40.3 Chronic fracture of the atlas with secondary spinal cord compression in a two‐year‐old Quarter Horse. The horse was injured
during a training incident as a yearling. (A) Lateral myelographic image shows multiple bony densities in the ventral arch of the atlas
(white arrows), massive thickening of the dorsal arch of the atlas, and compression of the spinal cord (arrowheads). (B) Intraoperative view
shows laminectomy of the caudal two‐thirds of the dorsal lamina of the atlas. (C) Completed laminectomy prior to insertion of nuchal fat.
fibrosis and callus around the articulation of the dens

with the atlas will remain. Surgical fusion of the atlan-
toaxial junction, with the use of the ventral approach
described, usually exacerbates the stiffness, and laminec-
tomy is generally preferred in these cases.
Atlantoaxial Subluxation
Primary idiopathic atlantoaxial subluxation has been
described.34 The lesion is characterized by spinal cord
compression during extension (Figure 40.4), which dif-
ferentiates it from the syndrome of the same name in
humans and dogs. Horses with atlantoaxial subluxation
are young, generally 1.5–3.5 years of age. Most have an
insidious onset of clinical signs, and often a chronic Figure 40.4 Myelogram of an idiopathic atlantoaxial subluxation,
history of problems. Trauma is described in the early shown with the horse’s neck extended. The vertebral canal is
history, frequently preceding signs of ataxia by months narrowed between the dorsal arch of the atlas and the dens of the
or years. Neurologic deficiencies are generally symmet- axis. Compression is alleviated by flexion. Source: Reproduced with
permission from Nixon and Stashak 1988.34
ric and moderate to severe (grades 2–3 on a scale of 4).
Palpable swellings are not common, but a vertical tilting
of the atlantal wings may be detected. Plain radiographs Definitive diagnosis requires myelography, at which
obtained with the horse standing demonstrate a mala- time compression during extension and relief during
lignment with overextension of the atlas relative to the flexion are evident (see Figure 40.4). Aggressive exten-
axis, caused by a vertical tilting of the atlas. The bony sion with the horse under general anesthesia should be
structure of the atlas frequently appears normal. avoided in these cases.
www.ajlobby.com
Most horses are presented after the degree of ataxia has laminectomy (see Figure 40.5), leaving 1–1.5 cm of the
worsened, but none are reported to have been recum- dorsal arch cranially. The dural sac bulges into the lami-
bent. Medical therapy is generally unnecessary because of nectomy defect, but durotomy is unnecessary. A 5 mm
the chronic nature of the compression. Surgical decom- thick autogenous fat graft is harvested from the adjacent
pression is required for recovery of performance. nuchal fat and placed in the bony defect to prevent a
laminectomy scar. The semispinalis and rectus muscles
Surgical Technique are reapposed with #1 synthetic absorbable suture mate-
Horses are positioned in left lateral recumbency with the rial in a continuous pattern. The nuchal ligament and
neck flexed (Figure 40.5). A 25 cm midline skin incision subcutaneous tissues are closed with #2 absorbable
is made, extending caudally from the occipital protuber- suture, and the skin closed with #0 monofilament nylon,
ance. The nuchal fat is divided, and the funicular portion in simple continuous patterns. A stent is secured over
of the nuchal ligament is incised on the midline and the wound for protection.
retracted laterally. The semispinalis capitis muscles and Recovery from anesthesia is often supervised, and
rectus capitis dorsalis muscles are divided on the midline manual assistance is provided as necessary. Improvement
and reflected from the bone using periosteal elevators. in the neurologic deficits is slow; however, two of the
Hinged self‐retaining retractors are placed to maintain four horses described in the literature recovered com-
exposure of the dorsal arch of the atlas. The dorsal atlan- pletely, and one was improved but had low‐grade pro-
toaxial ligament and the interspinous ligament are par- prioceptive deficiencies.34 The long‐term prognosis
tially separated from their attachments to the dorsal arch appears to be improved by surgery.
of the atlas. A high‐speed bur is then used to form a Trauma and destabilization of the ligaments of the
channel outlining the lamina for removal. The caudal dens within the atlas can allow dorsal displacement and
portion of the lamina is removed in an oval‐shaped potential compression between the dens and the dorsal
Neck restraint
(A) Sternal stabilization (B)
Halter rope Skin incision
(C) Laminectomy
defect
Figure 40.5 (A–C) Dorsal laminectomy of the atlas for relief of compression in atlantoaxial subluxation and postfracture callus cases.
Source: Adapted with permission from Nixon and Stashak 1988.34
www.ajlobby.com
arch of the atlas. The dens is stabilized to the atlas and cartilage loss and osteoarthritis of the articulation of the
occiput only by the paired longitudinal ligaments of the dens with the atlas. Compression of the spinal cord can
dens, compared to the multiple stabilizing ligaments develop, but this is unusual. Most horses have pain on
seen in dogs and humans.11 Chronic effects of ligamen- lateral bending of the upper neck. Improvement in
tous damage include new bone formation around the clinical symptoms can occur with periods of splint stabi-
base of the dens, increased distance between the ventral lization of the neck and head (Figure 40.7). If spinal cord
arch of the atlas and the dens, and a decreased distance compression develops, a dynamic study under anesthesia,
between the dens and the dorsal arch of the atlas often including a myelogram, defines the best approach
(Figure 40.6). Chronic changes can be seen on radiographs. to therapy. This generally means dorsal laminectomy,
Trauma to the atlantoaxial junction can also lead to provided there is adequate fibrosis and stability of the
(A) (B)
Figure 40.6 Acute trauma to the atlantoaxial junction in a yearling with disruption of the soft tissues stabilizing the dens. (A) Lateral
radiograph shows dorsal displacement of the dens (black arrow), narrowing of the sagittal diameter between the dens and the dorsal arch
of the atlas (white double arrows), and secondary mineralization of the soft tissues at the base of the atlantoaxial joint (white arrows).
(B) Standing ventrodorsal radiograph indicates crush injury to the right articulation of the atlantoaxial joint (arrows). The horse recovered
normal upper neck function after neck splinting for four weeks.
(A) (B)
Figure 40.7 (A) Fiberglass splint for bracing of the upper cervical spine. (B) Custom bivalved neck splint for long‐term stabilization of the
upper cervical spine. Same case as Figure 40.6.
www.ajlobby.com
atlantoaxial junction. If the articulation is unstable, then the first and second cervical vertebrae (Figure 40.9). The
ventral stabilization would be a more appropriate surgical atlantoaxial junction is extended and transarticular
treatment. screws inserted from the abaxial region of the axis, cau-
Congenital atlantoaxial subluxation with compression dal to the articular surface on each side, and angled to
of the spinal cord during flexion of the atlantoaxial junc- diverge dorsorostrally to engage the lateral arch of the
tion, similar to the syndrome in dogs, is rare in horses. atlas. Preplacing a Kirschner wire can also stabilize the
Abnormality of the stability of the dens within the atlas junction during subsequent screw insertion. One or two
allows dorsal displacement of the dens during flexion cortical screws are applied on either side of the atlanto-
(Figure 40.8). Hypoplasia of the dens does not appear to axial junction. This is then further stabilized by the
be a factor in the horse, although a single case report of application of screws and wires incorporated into bone
hypoplasia in a foal exists in the literature.41 Treatment cement, or in larger foals by the use of small plates. For
by ventral stabilization of the atlantoaxial junction, the screw and wiring technique, short cortical screws
employing similar methods to those used in the dog, are partially inserted on the ventral midline of the axis,
have been utilized in the horse. and similar screws placed across the ventral arch of the
A ventral midline approach, with retraction of the tra- atlas (see Figure 40.9). The screws are connected using
chea and larynx to the left, exposes the ventral aspects of large‐gauge wire placed beneath the screw heads. The
(A)
(B) (C)
Figure 40.8 Congenital atlantoaxial subluxation in a miniature foal. (A) Lateral radiograph shows severe atlantoaxial subluxation on
flexion, with dorsal protrusion of the odontoid process (OP) of the axis (C2). (B) Preoperative computed tomography (CT) in the flexed
position shows marked cranial and dorsal displacement of the axis within the atlantal vertebral canal. (C) Extended CT shows partial
reduction and retraction of the axis. Fusion in extension would reduce spinal cord compression.
www.ajlobby.com
(D)
(A)
(B)
(E)
(C)
Figure 40.9 Ventral fusion of the atlantoaxial joint to stabilize congenital atlantoaxial subluxation. Same case as Figure 40.8. (A) Ventral
access and elevation of the musculature have exposed the ventral crest of the axis and the ventral tubercle and arch of the atlas.
(B) Titanium screws and wire are used to stabilize the atlantoaxial junction in extension. Titanium screws have already been inserted
abaxially to compress the articulation of the atlantoaxial joint. (C) Polymethylmethacrylate (PMMA) has been formed around the
protruding screws and wire, including the abaxial independent screws and Kirschner wires used to stabilize the atlantoaxial joint.
(D) Postoperative sagittal computed tomography (CT) shows portions of the screws in both axis and atlas incorporated in the PMMA,
and the significant space between the odontoid process (OP) and the dorsal arch of the atlas. (E) Three‐dimensional CT shows the
independent screws and Kirschner wires inserted on the lateral margins of the atlantoaxial joint, and the stabilizing titanium screws and
wires in the bone cement bridge. Source: Images courtesy Dr. Alan Nixon and Dr. Curtis Dewey.
www.ajlobby.com
(A) (B)
Figure 40.10 Stabilizing neck splint after atlantoaxial fusion. Same case as Figure 40.9. (A) Fiberglass splint enclosed with orthopedic felt
is contoured to the head and neck in the extended position. (B) After the fiberglass has cured, the splint is secured using soft bandage
material. A nasogastric feeding tube is in place.
screw and wire combination is consolidated by the head, stiffness and splinting of the neck, and occasionally
application of polymethylmethacrylate (PMMA) bone altered head carriage. Acute cases may have swelling
cement. In larger foals, two polyvinilidine or stainless‐ over the lateral surfaces of the atlas, and crepitation can
steel plates are applied on either side of the midline, rarely be elicited. Careful palpation may detect malalign-
rather than the screw and wire technique described for ment and ventral displacement of the axis relative to
miniature foals. The screws in the rostral region of the the wings of the atlas. The space between the dorsal
plate are angled to engage the lateral vertebral arches of spine of the axis and the atlas becomes palpably shorter.
the atlas. Use of a locking compression plate (LCP) for Neurologic deficits are rare. Definitive diagnosis is by
this application is hampered by the need for this critical radiography (Figure 40.11). The ventrally displaced
screw insertion angle. The limited‐contact dynamic odontoid process is captured by the ventral tubercle
compression plate (LC‐DCP) is preferred, although the of the atlas and the ventral atlantoaxial ligament (see
flexibility of polyvinilidine (LubraTM, Lubra Co., Fort Figure 40.11), limiting the extent of the luxation to a
Collins, CO, USA) plates limits screw pullout during stable position with the odontoid process abutting the
vertebral flexion. ventral tubercle. When a complete luxation develops,
Postoperative splinting is also recommended. Use with the dens located ventral to the ventral tubercle and
of a padded fiberglass splint material (4 and 6 in. arch of the atlas (Figure 40.12), cord compression is
Ortho‐Glass® Splint Roll, BSN Medical, Charlotte, NC, severe and can lead to sudden death.
USA) provides a rigid, replaceable support to limit Many horses are presented with subacute or chronic
flexion of the head and neck (Figure 40.10). It sets after luxation, and replacement of the luxated dens is impos-
activation by water and can be secured to the ventral sible. Acute injuries can be repaired by manipulation
aspect of the jaw and neck using regular bandage materi- with the horse under general anesthesia.12,14 The
als. The splint can be removed and reset with padding stretched or disrupted ligaments of the dens can ade-
as necessary. Placing a nasogastric feeding tube may quately stabilize the articulation following reduction, but
also be advisable for very young foals in the early post- replacing the dens in the atlantal foramen can be very
operative period. difficult. Rostral tension on the head, followed by flexion
of the involved atlantoaxial junction with lateral rotation
Atlantoaxial Luxation and a twisting torque on the head, is occasionally suc-
Complete luxation of the atlantoaxial articulation, with cessful (Figure 40.13). The torso needs to be secured to
ventral displacement of the odontoid process of the axis, the surgery table, followed by rostral stretching of the
is uncommon. Luxation generally occurs in adults, while head to fatigue the longitudinal ligaments of the dens
foals frequently luxate the atlantoaxial junction by frac- and any surrounding fibrous tissue. The atlantoaxial
turing the dens. Disruption of the paired longitudinal axial junction is then maximally flexed and the head
ligaments of the apex of the dens has to occur for major additionally twisted to reposition the odontoid process
luxation to develop. These injuries are traumatic in origin, dorsal to the ventral arch of the atlas. Radiographic
and the immediate clinical signs include extension of the verification is necessary. There are no descriptions of
www.ajlobby.com
(A) (B)
Figure 40.11 Acute atlantoaxial subluxation in a six‐year‐old Quarter Horse returning from pasture with acute neck pain and stiffness.
(A) Standing lateral radiograph indicates that the dens has displaced ventral to the ventral arch of the atlas. (B) A normal cervical vertebral
specimen showing the prominent ventral tubercle (VT) of the atlas, which captures the dens in a luxated position (arrow).
applying a full cast extending from the level of the rostral

perimeter of the facial crest and extending caudally to
the mid‐ or lower mid‐cervical region. A large stocki-
nette is applied over the head and neck, followed by a
ring of thick orthopedic felt for the rostral and caudal
end points of the cast. The eyelids are temporarily closed
with tape during this application. A thick layer of cast
padding is applied over the entire cast region, and 4 or 5
in. fiberglass tape is then applied to fully enclose the
head and neck from the level of the mid‐mandible to
the mid‐cervical region. The atlantoaxial junction should
be positioned in neutral to slight flexion during cast
application to help maintain the reduction. When the
cast has cured, a cast cutter is used to remove the dorsal
half of the cast over the head and extending to immedi-
ately caudal to the ears. The stockinette is opened to
allow retrieval of the ears and to provide separate holes
for the eyes (see Figure 40.14). The rostral aspect of the
cast is then secured to the head using elastic tape. The
dorsal half of the cast over the neck can be removed
three to five days after recovery from anesthesia, and
Figure 40.12 Severe atlantoaxial laxation with complete elastic tape used to secure what then becomes a ventral
separation of the axis attachments to the atlas. The horse was splint of the head and neck. Padding should be main-
quadriplegic and euthanized. tained between the splint and the head and neck, par-
ticularly over the caudal angle of the mandible.
surgical reduction of a luxated dens, although this should The prognosis for horses with atlantoaxial luxation is
be possible using a ventral approach to the atlantoaxial reasonably good, but is based on a limited number of
junction. cases. Reduction of atlantoaxial luxation generally only
Splinting after repair of an atlantoaxial luxation is succeeds in the acute cases. Chronic luxations are
important (Figure 40.14). Some existing ligamentous extremely difficult to reduce, and most horses can func-
injury or damage to the longitudinal ligaments of tion quite adequately in a stable luxated position.
the dens during replacement should be anticipated. Limited lateral mobility of the upper head and neck may
The horse should be recovered with the splint in place. be the only visible clinical signs of the luxation. Indeed,
For adult horses, the most secure splint can be formed by complete luxations are occasionally found as incidental
www.ajlobby.com
(A) (B)
(C) (D)
(E) (F)
(G)
www.ajlobby.com
(A) (B)
Figure 40.14 Fiberglass cast used for upper cervical vertebral stabilization. (A) The cast remains as a full encircling cast around the proximal and
mid‐cervical regions for recovery. (B) The dorsal half of the cast is removed three to five days later, leaving a ventral splint secured with tape.
findings on radiographs or at necropsy. Horses with

complete luxations have some stiffness of the cranial
neck, but few if any neurologic deficits. Although head
carriage is occasionally tilted, the horse’s return to rid-
ing activity can be expected.
Fractures of the Axis
Fracture of the Dens
Most fractures of this region in foals involve disruption
of the physis of the dens, resulting in separation of the
odontoid process.1,27,35,47 The tension within the
nuchal ligament results in ventral luxation of the axis
relative to the fractured odontoid process, which often Figure 40.15 Fracture of the dens of the axis with ventral
remains firmly attached to the ventral arch of the atlas displacement and subluxation of the atlantoaxial junction in a
(Figure 40.15). The predisposition for fracture of the foal. The spinal cord can move lateral to the fractured dens,
atlantoaxial junction may in part be due to the pressure lessening the severity of the neurologic deficit.
of the poll strap of halters and bridles, which focuses on
the atlantoaxial junction if a young horse pulls back.23 lateral bending all place considerable stress on this phy-
Additionally, the flexibility of this region and lack of a sis, particularly during falls and accidents.
fibrous intervertebral disk, place considerable stress on the The degree of neurologic deficit varies according to
single tapered prominence of the dens or odontoid process the degree of dens displacement. However, the vertebral
and its integral physes. Hyperflexion, hyperextension, and canal is spacious at this level, and allows the fractured
Figure 40.13 Steps in reduction and stabilization of an acute atlantoaxial luxation. Same case as Figure 40.11. (A) The horse is secured to a
stable platform. (B) Ropes are applied to the head and axial traction provided with a mechanical device to stretch the atlantoaxial region.
(C) Intraoperative radiograph shows the dens beginning to withdraw from the ventral tubercle of the atlas (arrow). (D) A rope is applied to the
throat latch to stabilize the upper cervical spine during marked flexion of the atlantoaxial joint. The head is simultaneously torqued laterally
to assist in relocation of the dens within the atlantal foramen. (E) Intraoperative radiographs were used to verify repositioning of the dens.
Note the small truncation of the rostral aspect of the odontoid process. (F) Intraoperative ventrodorsal radiograph identifies a small fracture
(arrow) associated with the reduction. (G) Follow‐up nine weeks after atlantoaxial reduction showing normal atlantoaxial articulation and
regrowth of the odontoid process after the shear fracture. The horse was maintained in a ventral neck splint for eight weeks.
www.ajlobby.com
dens to displace the cord laterally, lessening the spinal Antibiotics are useful prior to and following surgical
cord impact. Nevertheless, if cord damage is severe, decompression or stabilization, and may prevent cystitis
death can occur immediately. Most foals exhibit some and pneumonia in incapacitated horses not undergoing
clinical ataxia and paresis or paralysis. Many eventually surgery.
become recumbent and are unable to raise the head and Many horses with a fractured odontoid process and
neck. Sensory deficits along the lateral cervical area major atlantoaxial malalignment have a deteriorating
are marked, and occasionally crepitus can be elicited clinical course, and surgical intervention is warranted.
by manipulation. Swelling is moderate, and some axial Late consequences of fracture luxation or subluxation of
malalignment is common. The diagnosis is confirmed by the atlantoaxial region can also occur, and recurrence of
radiography. Analysis of cerebrospinal fluid or myelogra- neurologic signs in an improved horse can signal callus
phy is rarely necessary in acute cases, but myelography or soft tissue compression of the cord and the need for
may be useful later to detect encroaching callus or to surgery.
demonstrate atlantoaxial instability.
Some fractures of the axis stabilize and do not directly Surgical Therapy
affect the spinal cord, producing minimal or no neuro- Careful manipulation, with the horse under general
logic deficit. Although such an injury can result in neck anesthesia, can reduce some fracture luxations of the
stiffness, ataxia and paresis may resolve completely. Some atlantoaxial junction. Manipulation and alignment prior
adult horses present with neck stiffness as a consequence to application of a cast on the neck of foals have been
of complete atlantoaxial fusion resulting from trauma as a useful in treating fractures of other parts of the neck,
weanling or yearling.56 Conversely, some asymptomatic but stabilization of the atlantoaxial junction seems less
fractures can eventually cause spinal cord compression satisfactory.46
from subsequent callus. Surgical repairs of fracture luxations of the dens have
been described. Pins have been used successfully to
Medical Therapy stabilize a fractured dens with luxation of the axis in a
For most horses, immediate medical therapy is indicated foal.35 More recently, a ventral approach for dens removal
to reduce soft tissue swelling and mitigate spinal cord and atlantoaxial fusion has been described.27,31 Ventral
compression. Administration of anti‐inflammatory agents, decompression, alignment, and use of screws or plates
analgesics, and osmotic diuretics is routine following the and screws provide decompression and stabilization.
initial mechanical insult. In peracute stages, dexametha- The ventral approach for atlantoaxial fusion is made
sone at 0.1–0.2 mg kg−1 body weight is given intravenously. with the foal in dorsal recumbency. The skin is incised
The benefits of corticosteroids for treating subacute on the ventral midline, from the level of the caudal limit
injury are debatable and generally minimal. Excessive of the axis to the level of the cricoid cartilage of the
doses or extended courses of dexamethasone adminis- larynx. The insertions of the omohyoid and sternothyro-
tration can induce laminitis, and may impact on bone hyoid muscles are split and separated. Blunt dissection
and soft tissue healing if surgery is elected. Dimethyl on the left side of the larynx, trachea, and esophagus
sulfoxide (DMSO) is administered slowly at 1 g kg−1 in a allows retraction of these structures to the right and gen-
10% solution in intravenous fluids. Repeat doses up to tle retraction of the left carotid artery, vagosympathetic
four times at 24‐hour intervals may provide supplemen- trunk, and left recurrent laryngeal nerve bundles to the
tal benefits. Hyperosmolar diuretics, such as mannitol left side. The longus colli muscles are split on the midline
given intravenously as a 20% solution at 0.25–1 mg kg−1, and dissected from the ventral crest of the axis and ven-
have also occasionally been used, but rarely result in tral tubercle of the atlas with the use of periosteal eleva-
improved clinical status. The analgesic and anti‐inflam- tors (Cobb Periosteal Elevator, Orthopedic Equipment
matory actions of phenylbutazone or firocoxib (Equioxx, Co., Bourbon, IN, USA). Some reports have described
Merial, Duluth, GA, USA) are often useful, particularly removal of the fractured portion of the dens
in the days following termination of aggressive corticos- (Figure 40.16),27,31 but it can be left in place, the atlanto-
teroid and DMSO therapy. Additional pain relief can be axial alignment reestablished, and the fracture stabilized.
derived from morphine, butorphanol, or butorphanol/ Removal of the fractured dens requires the burring of
detomidine combinations. Supplementary intravenous portions of the ventral arch of the atlas, in addition to
fluid therapy is indicated for recumbent animals, as is the severing the longitudinal ligaments that secure the dens
administration of antibiotics and the occasional use of to the atlas (see Figure 40.16). Exposure of the dural sac
sedatives such as acepromazine, diazepam, or detomidine. after removal of the dens confirms decompression and
Gastroprotectants such as omeprazole should be admin- allows better appreciation of the atlantoaxial alignment.
istered to horses receiving corticosteroid and/or non- A durotomy is rarely necessary. Stabilization is initially
steroidal anti‐inflammatories. accomplished by removing cartilage from the articular
www.ajlobby.com
(A) (B)
(C) (E)
(D)
Figure 40.16 Ventral decompression and stabilization for repair of atlantoaxial subluxation secondary to a fractured dens (Fx dens) in a
100 kg foal. Same case as Figure 40.15. (A) Ventral exposure of the atlas and axis allows decompression by ventral atlantal laminectomy,
removal of the dens, and stabilization of the atlantoaxial articulation with plates and screws. (B) The dens is split to facilitate removal from
the atlantal foramen. (C) Semirigid stabilization was provided by 6.5 mm cancellous screws securing two Lubra plates. Independent screws
were also inserted in lag fashion on the lateral articular surface of the atlantoaxial joint. (D, E) Postoperative lateral and ventrodorsal
radiographs obtained through a neck cast showing screw position for independent dorsal articular screws (DAS) placed across the
atlantoaxial articulation in a diverging ventral to dorsal direction, and plate screws (PS) used to secure the Lubra plates.
www.ajlobby.com
surfaces of the atlantoaxial junction and inserting The cranial portion of the neck has a reduced range of
6.5 mm cancellous screws across the articulation (see lateral motion following atlantoaxial fusion. Mobility of
Figure 40.16). For accurate screw placement, the 3.2 mm the atlanto‐occipital joint remains, but lateral bending is
drill bit should penetrate the axis 1 cm lateral to the reduced. For most foals this is minimally debilitating.
ventral crest and immediately caudal to the rim of the The implants are left in place unless loosening and lysis
cranial articular facet of the axis. The drill is angled 45° develop. There are very few cases in the literature to
dorsocranially using the atlantal fossa as the limit to the adequately provide a prognosis following the ventral
abaxial angle of the drill. This placement ensures that the approach for atlantoaxial fusion.27,31 However, the prog-
drill penetrates the lateral vertebral arches of the atlas, nosis would appear to be improved by surgery, particu-
without risk of damage to the spinal cord axially or the larly since surgery is reserved for foals with deteriorating
vertebral arteries and first cervical nerves abaxially. clinical signs. From the limited information available,
Intraoperative radiographs can be useful in ensuring surgery should be performed before recumbency ensues.
correct placement of the drill. A 6.5 mm cancellous If the foal is presented recumbent, the prognosis is poor.
screw of suitable length is then inserted. The second Trauma to the spinal cord and thrombosis of the basilar
screw is placed on the opposite side of the ventral crest of artery are occasional complications of dens fracture.
the axis, and both screws are tightened. A bone graft is Atlantoaxial fusion is generally preferable to dorsal
placed in the articulation. decompression, since the instability of the fracture is
Additional fixation can be provided by attaching immediately corrected. One report describes the use of a
polyvinilidine plates or stainless‐steel LC‐DCPs to the small laminectomy to provide decompression of fibrous
ventral surfaces of the atlas and axis with the use of addi- tissue and dens pressure following fracture of the axis
tional cancellous screws (see Figure 40.16). Intraoperative and possibly the ventral atlantal arch.47 Instability per-
radiographs are used to ensure correct screw placement. sisted, and the foal was found dead 14 days after surgery.
In one report, a pair of dynamic compression plates Laminectomy does have a place, however, in the man-
(DCPs) was applied to provide more rigid stabilization agement of stenosis due to fracture callus formation and
than a pair of lag screws.27 Closure of the longus colli is the compression associated with primary atlantoaxial
accomplished with #1 synthetic absorbable suture, and a subluxation.34
suction drain is placed between the muscles and the
larynx and trachea. Closure of the remaining soft tissues
is routine. Fractures of the Cranial Articulation of the Axis
Postoperative care following atlantoaxial fusion Trauma to the cranial articulation of the axis, not
includes a padded fiberglass neck brace, formed to the involving fracture of the dens, can also occur. Fractures
contour of the ventral neck and flared to accommodate generally involve either left or right articular surfaces of
the caudal perimeter of each mandible. The brace is the axis in the atlantoaxial diarthrodial articulation
attached with adhesive bandage, as previously described. with the atlas. This joint consists of a smooth, contiguous
The suction drain is emptied as needed and removed articulation spanning the ventral and lateral aspects
after one to two days. If the foal is recumbent after sur- of the axis, and a smooth but relatively incongruous
gery, intensive nursing care will be required. Waterbeds surface with the adjacent atlas that allows rotation and
or heated water pads assist in preventing pressure sores lateral bending through the atlantoaxial intervertebral
and maintaining body temperature. Intravenous fluid junction. Lateral bending and impact forces have the
therapy is required and, if the foal is reluctant to suckle, propensity to damage either left or right articular sur-
a nasogastric tube can be maintained for alimentation. faces of the axis. Clinical signs include a head tilt, often
Repeat doses of DMSO and occasionally corticosteroids combined with lateral deviation (Figure 40.17), guard-
are often helpful. Antibiotics are used for three to ing of the upper neck, swelling over the lateral surface
four days, or at least until the suction drain is removed. of the axis, a stiff neck with a splinted appearance,
Flunixin or firocoxib are used to control edema and pain. and extreme pain on manipulation. Plain radiography,
More potent analgesics are rarely necessary. Diazepam including oblique lateral projections, often suggests an
or acepromazine is used as necessary to control the foal’s irregularity of the atlantoaxial joint surfaces, although a
struggling, but its use should be short term. ventrodorsal projection is required to better determine
The foal should be assisted in standing and nursing involvement of the left or right articular surfaces of the
as soon as possible. If recumbency persists beyond axis (see Figure 40.17). More precise information is
the first three days, the prognosis declines markedly. provided by CT examination (Figure 40.18). Most inju-
Ideally, surgery should be performed before the foal is ries to the cranial articular facets of the axis tend to be
unable to stand. This timing improves the chances of crush injuries, with fragmentation of the subchondral
a successful repair. bone and damage to the cartilage surface. These injuries
www.ajlobby.com
(A) (B)
(C)
Figure 40.17 Traumatic crush injury to the right cranial articular surface of the axis in a seven‐month‐old Thoroughbred weanling.
(A) Head tilt associated with collapse and shortening of the right articular surface of the axis. (B) Oblique lateral radiograph showing
comminuted fracture fragments (arrow) along the ventrolateral aspect of the cranial articular surface of the axis. (C) Oblique ventrodorsal
radiograph confirms unilateral right‐sided involvement (circle).
(A) (B) (C)
Figure 40.18 Computed tomography (CT) of the horse in Figure 40.17 provides information on the fracture configuration and extent of involvement
of the articular surface of the axis. (A) Transverse CT slices show a right‐sided fragmentation of the articular surface of the axis, without fracture of the
atlas. (B) Three‐dimensional reconstruction shows right‐sided fracture fragmentation and collapse, and suggests that splinting with axial extension of
the right articulation may allow appropriate healing. (C) Ventral fiberglass splint in place for recovery from anesthesia.
www.ajlobby.com
resemble lateralized injury to the occipital condyles displace laterally (Figure 40.19). For simple transverse
in the atlanto‐occipital articulation; both generally fractures, with mild to moderate displacement and few if
involve only one side of the articulation and do not any spinal cord symptoms, confinement to limited stall
destabilize the cervical vertebra to the extent that spinal exercise, external neck splinting, and pain control can
cord compression develops. often allow complete bony union of the fracture. Four of
Treatment includes pain control and external splinting, five horses in one study healed completely and returned
particularly in foals, to allow healing of the affected to athletic activity.58,59 Unusual bending forces can result
articular surface, combined with restriction to stall rest. in complete fracture of the cranial aspect of the axis
Application of a ventral splint using fiberglass layers with dorsal displacement of the remaining portion of
folded and contoured to the ventral mandible and upper the vertebra (Figure 40.20). Some of these fractures have
neck can provide pain relief and axial alignment to lessen
the long‐term head tilt or lateral deviation associated
with the unilateral collapse of the atlantoaxial articulation
(see Figure 40.18).
Fractures of the Axis Body

Surgical treatment of axis fractures, other than those
involving the dens, is rarely necessary. The axis is rein-
forced by the large dorsal spinous process and wide
vertebral body, and is rarely disrupted. Nevertheless,
complete fracture through the cranial to mid‐portion of
the body of the axis can have serious consequences, due
to the relatively confined nature of the vertebral canal
through the axis. Trauma associated with lateral bending
falls or impact into fixed objects can result in fractures of
the axis with variable bony disruption. Clinical signs are
similar to other fractures of the upper cervical vertebra,
including splinting and guarding of the neck, localized Figure 40.20 Massively displaced fracture of the cranial midbody
swelling, and variable degrees of ataxia. Radiographs are of the axis of a six‐year‐old Quarter Horse. Lateral radiograph
indicates fracture of the axis with severe dorsal displacement of
used to establish the diagnosis. Fractures of the cranial the body of the axis in relation to the cranial fracture fragment,
aspect of the axis tend to propagate transversely through which still articulates with the atlas. Stabilization was performed
the body of the axis and enter the vertebral canal near the with application of several lag screws and a dynamic compression
cranial foramen, to destabilize the axis, which can then plate. Source: Images courtesy Dr. Tim Eastman.
(A) (B)
Figure 40.19 Fracture of the cranial midbody of the axis. (A) Lateral radiograph shows a mildly displaced fracture (arrowheads) of the
cranial midbody of the axis, with a step in the floor of the spinal canal (arrow). (B) Ventrodorsal projection confirms minimal lateromedial
displacement of the fracture (arrows), and conservative treatment by stall rest allowed complete healing.
www.ajlobby.com
Figure 40.22 Fracture of the caudal articular facets and dorsal

Figure 40.21 Comminuted, displaced, unstable fracture of the
spine of the axis. Lateral radiograph shows multiple fracture lines
cranial half of the axis of a 17‐month‐old Thoroughbred colt.
(arrows) separating the dorsal spinous process and attached
Lateral radiograph indicates multiple fracture fragments, severe
articular facets of the caudal aspect of the axis. The horse
malalignment of the axis and atlas, and inadequate bone to allow
recovered with stall rest confinement for eight weeks.
internal fixation. The horse was euthanized.
sufficient bone stock in the cranial fractured portion of

the axis that internal fixation can be effective in realign-
ing the vertebral canal.45 Most fractures can be repaired
by internal fixation applied to the ventro-lateral aspects
of the axis. A case report describes chronic distraction of
the dorsal aspect of a complete transverse fracture of the
axis, which was successfully repaired by application of a
DCP to the axis dorsal spine.15 Conservative treatment is
most appropriate where the fracture involves the ventral
body of the axis without disruption of the vertebral canal,
although lag screw fixation for a case with persisting
neurologic deficits has also been described.2 High‐
energy fractures can be more comminuted, with disrup-
tion of the vertebral canal and severe spinal cord injury
(Figure 40.21). Comminution limits the chance for
Figure 40.23 Kyphotic C2–3 articulation in a three‐year‐old
effective stabilization by internal fixation, which is exac- Thoroughbred gelding. There were minimal neurologic deficits.
erbated by the frequent occurrence of severe neurologic Lateral radiograph indicating a shortened vertebral body of the
deficits at the time of admission. axis (arrow), resulting in asymmetry of the length of the vertebral
Fracture of the dorsal spine of the axis, including body and dorsal spine of the axis, with secondary kyphotic
involvement of the caudal articular facets, results in a deformity of the C2–3 junction. There was little change in the
C2–3 angle on standing flexed or extended radiographs.
relatively stable fracture configuration due to the sig-
nificant stabilizing effect of the remaining dorsal spine
of the axis (Figure 40.22). Conservative therapy gener- spine may be evident externally as a yearling develops;
ally provides complete bony union, with improvement in however, the lack of any clinical symptoms limits the
neck mobility and reduced ataxia. likely detection by radiography until the horse is an adult.
Diagnosis is usually made as the horse matures and the
Kyphosis of the C2–C3 Articulation lesion worsens, leading to investigation using standing
Congenital and acquired kyphotic angulation of the lateral radiographs. The vertebral body of the axis is con-
C2–C3 junction is encountered with reasonable frequency siderably shortened, resulting in a kyphotic deviation
(Figure 40.23). It is generally not apparent whether this is across the C2–C3 junction (see Figure 40.23). The spinal
a congenital or acquired malformation due to the late cord may not necessarily be compressed, despite the
diagnosis. A mild kyphotic curvature to the upper cervical severe flexion abnormality. However, if the angle is too
www.ajlobby.com
severe, the spinal cord becomes stretched across the jumping horses can shatter the vertebrae, resulting in
pinnacle of the cranial aspect of C3 and long tract signs devastating neurologic damage.57 The articulations of
develop. the cervical vertebrae are strengthened by the fibrous
Surgical repair is rarely successful. Attempts to dissect intervertebral disk, which leaves the bony pedicle sup-
the intervertebral disc and surrounding soft tissues rarely port to the articular facets, and the physes in immature
succeed in allowing extension of the C2–C3 junction. horses, as the weakest points of the spine (Figure 40.24).
The inherent shortening of the caudal aspect of the axis Tearing of the synovial joint capsules can also develop,
body is the primary lesion. The adjacent intervertebral which allows lateral bending and subluxation.43 The
disc and the shortened ventral bony column of the caudal physis of the cervical vertebrae remains radio-
second and third cervical vertebrae result in the flexion graphically obvious for up to four years, particularly the
abnormality. For horses with clinical symptoms, some ventral extremity of this physis. Functionally, however,
improvement may follow extensive dissection of the the cranial and caudal physes of the vertebrae generally
soft tissues in and around the intervertebral disc, separate during fracture luxations only in horses up to
realignment by forcible extension, and fusion of the two years of age. Hyperextension injuries can separate
intervertebral space by application of a perforated one or both facets by fracture through the pedicles, and
stainless‐steel cylinder or bone plates to stabilize
tension on the vertebral bodies separates all or part of
symptoms. Successful realignment of the second and the caudal epiphysis of the affected intervertebral junc-
third cervical vertebrae has not been described to date, tion (Figure 40.25). In severe hyperextension injury, the
but some value may rest in the prevention of addi- entire dorsal shelf of the vertebra is sheared, which
tional flexion at this junction. results from fracture through the lateral arches of the
vertebral canal (Figure 40.26).30 With persisting tension
from the nuchal ligament, the fracture configuration
Fractures of the Mid and Caudal remains hyperextended. Higher‐energy fractures can
shatter one or more vertebrae, with resulting major
Cervical Vertebrae
instability and spinal cord injury.
Hyperflexion, hyperextension, and lateral bending Neurologic deficits can vary, despite obvious bony
injuries all can cause fractures of the third through sixth disruption. Minimal spinal cord compression can occur,
cervical vertebrae. In one study, the third and fourth cervi- which may allow gradual spontaneous bone healing
cal vertebrae were most frequently involved.57 Bending (see Figure 40.25).30 Fractures involving the abaxial
forces associated with high‐speed paddock falls, forward portion of the caudal cervical vertebra can also result in
somersault accidents, or impact injuries into fixed objects prominent peripheral nerve signs in addition to the long
can all fracture portions of the cervical vertebrae.26,44 tract deficits.22 More comminuted fractures often
The degree of comminution is generally related to the severely traumatize the cord, resulting in quadriplegia.
energy of the accident. Some race falls or injuries in The lateral cervical region is swollen, and some palpable
(A) (B)
Figure 40.24 Combination fracture of the cranial physis of C3 and tearing of the joint capsules of the dorsal articular facets in an 18‐
month‐old Quarter Horse. (A) Lateral radiograph reveals a physeal fracture separation of the cranial physis of the third cervical vertebra,
exacerbated by tearing and distraction of the dorsal articular facet joint capsules (arrow), resulting in severe angulation at the C2–C3
junction. Neurological deficits were initially moderate, but deteriorated over 24 hours and the horse was euthanized. (B) Necropsy
examination shows the unstable vertebral body due to complete separation of the cranial physis.
www.ajlobby.com
(A)
(B) (C)
Figure 40.25 Severe fracture with luxation at C4–C5 but preserved neurologic function. (A) Acute bilateral fracture of the dorsal articular
processes through the supporting vertebral pedicles of C4 and distraction fracture of the caudal epiphysis of C4. Vertebral
malalignment is prominent, but neurologic deficits were minimal. (B) Radiograph obtained following three months of stall rest.
Stabilizing callus has formed to unite the C4–C5 articulation. (C) Bony union eventually developed at 18 months with marked
malalignment. No neurologic deficits remained.
(A) (B)
Figure 40.26 Severe comminuted fracture of C5–C6 with vertebral hyperextension in a five‐month‐old Thoroughbred foal. The foal was
quadriplegic with deep pain. (A) The foal is recumbent and the marked hyperextension of the mid‐cervical vertebra is apparent. (B) Lateral
radiograph shows multiple fractures of the fifth cervical vertebra resulting from a “deroofing” hyperextension injury. The entire dorsal
lamina and pedicles are cleaved from the vertebral body, and tension fractures of the vertebral end plate are evident. The foal was
euthanized.
www.ajlobby.com
and obvious deviation of the vertebral column can often Severely disrupted vertebrae are difficult to stabilize
be detected. Definitive diagnosis requires radiography, by plates and screws, and a neck cast provides an alter-
and occasionally a myelogram is necessary to differentiate native.46 When malalignment has developed and the
sites of compression in multiple fractures. A common vertebral bodies remain intact, internal fixation is a useful
sequela to healed hyperextension fractures in juvenile option. Older yearlings and adults have more dense bone,
horses is a domino‐effect instability in adjacent cervical which also adds to the stability of plate screws.
articulations. Although the fracture derangement heals, Chronic fractures with adequate stability from the
the development or return of ataxia is an indication that healing callus are often associated with little or no signs of
adjacent vertebral instability has developed.30 A myelo- spinal cord dysfunction, but may create chronic peripheral
gram will differentiate the problem areas. Fracture of one nerve root symptoms (neck stiffness, regions of dermal
pedicle of a vertebra can result in short‐term neurologic
deficits that return in six to eight weeks because of callus
formation. Radiographs of the affected vertebrae often
initially show no abnormality. Oblique lateral and standing
ventrodorsal projections should be used to assist in
detecting these fractures (Figures 40.27 and 40.28).
Treatment
Medical management of the acute neurologic problem is
often warranted. Severe deficits and persisting recum-
bency following treatment are poor signs, and euthanasia
is generally necessary. In ambulatory animals with stable
or improving neurologic deficits, continued stall con-
finement is advisable. Formation of a stabilizing callus
can occur even though the alignment of the vertebrae on Figure 40.27 Unilateral facet fracture through the cranial
vertebral pedicle of C6 in a 16‐month‐old Belgian draft horse
radiographs is abnormal (see Figure 40.25). Deteriorating with progressive ataxia. Lateral radiograph shows the fracture
neurologic deficits are a clear indication for surgical line through the cranial pedicle of C6 (white arrows), with an
stabilization. Availability of adequate bone in the vertebral additional fracture of the cranial vertebral body of C6 which
bodies for implant fixation is an obvious necessity. has displaced dorsally (black arrows).
(B) Figure 40.28 Marked lateral torticollis of

(A) the neck of the horse in Figure 40.27
under general anesthesia for ventrodorsal
radiographs and surgery. Radiographs
show a fracture of the right pedicle with
overriding and secondary concave
curvature (arrows). The fracture and
associated torticollis were realigned by
ventral vertebral plating.
www.ajlobby.com
anesthesia or sweating, and muscle atrophy) due to com- tebrae and applied as a neutralization plate with the
pression of the cervical nerves exiting the lateral foramena. use of fully threaded 6.5 mm cancellous screws (see
In these horses, treatment with gabapentin at 5–10 mg kg−1 Figure 40.29). The screws should just start to engage the
given orally every eight hours may be helpful. Slightly dorsal cortex of the vertebral body. This requires extreme
better results are evident in some horses treated with care in drilling, measuring, and screw length selection.
pregabalin at 2–4 mg kg−1 given orally three times daily. Penetrating the ventral sinuses within the vertebral canal
Recalcitrant pain associated with fracture callus or osteo- should be avoided if possible, but bleeding will cease
arthritis of the facet joints is best treated by intervertebral with screw placement if the ventral surface of a sinus is
fusion after the original fracture is well stabilized. opened. Intraoperative radiographs are essential to eval-
uate final screw placement. The plate can extend to the
Ventral Plating caudal limit of the caudally affected vertebra, but should
Application of a plate to the ventral aspect of the verte- not interfere with the normal flexion of the articulation
brae violates the principle of plating the tension side of cranial to the repair. This may result in fracture of the
a bone. As a result, flexion of the neck predisposes the ventral crest, due to impact on the plate during flexion
fixation to failure by causing screw distraction from the (see Figure 40.29).
bone. However, the dorsal surfaces of the bone are more The necessity for partial discectomy during fracture sta-
difficult to access, contain less bone stock, and frequently bilization is not well established. The surgical procedure
have bony disruptions. As a result, ventral plating is still can be expedited by applying a long contoured plate to sta-
the best option. bilize the affected two vertebral segments, without a dis-
The ventral approach to the cervical vertebrae has cectomy and intervertebral fusion implant (Figure 40.30).45
been extensively described in the literature.7,13,32,60,61 Use of fully threaded 6.5 mm cancellous screws provides
Adequate exposure of the fractured vertebrae is impor- significant stabilizing fixation in the soft vertebral bone.
tant for secure plate fixation. The ventral crest of each Comparison of pullout strength of 5.5 mm cortical screws
vertebra is removed with a curved osteotome to provide compared to 6.5 mm cancellous screws in metaphyseal
a flat surface for midline plate application. To enhance bone has no bearing in the softer vertebral bone. However,
bony union across the intervertebral disk, the vertebrae application of a locking compression plate (LCP) may be
are aligned and two‐thirds of the disk is removed by drill- appropriate.39,45 Research studies suggest that improved
ing, with the use of techniques described for routine holding power and bending strength can be achieved
intervertebral fusion (Figure 40.29).32 A perforated stain- using the locking plate system compared to the kerf‐cut
less‐steel cylinder packed with cancellous bone is inserted cylinder alone.37,38 However, for fracture fixation there are
to provide initial stability. A broad DCP or LC‐DCP is
then contoured to the undulations of the affected ver-
Figure 40.30 Ventral plate fixation to repair a comminuted

Figure 40.29 Ventral stabilization of C5–C6 to repair the fracture fracture of C4 in a 12‐year‐old broodmare. A contoured broad
evident in Figures 40.27 and 40.28. Standing lateral radiograph 4.5 mm dynamic compression plate has been applied using fully
one year after repair by partial intervertebral discectomy, threaded 6.5 mm cancellous screws. The original vertebral body
intervertebral fusion using a stainless‐steel implant, and dynamic fracture (white arrows) is aligned, although the extension into the
compression plate application with multiple 6.5 mm fully lateral vertebral arch (black arrowheads) is still partially visible. The
threaded cancellous screws to stabilize the fracture. The cranial alignment of the vertebral canal is good. Angulation of the screws
aspect of the plate has irritated the C4–C5 intervertebral disc in the cranial and caudal ends of the plate provides maximum
(arrow), but the horse was asymptomatic. purchase in the soft vertebral bone.
www.ajlobby.com
no comparative studies comparing LCP fixation to DCP canal, making orientation relative to the dural sac
application utilizing 6.5 mm cancellous screws. Clinical uncertain. Careful burring exposes the encroaching
application of an LCP for cervical vertebral fracture repair bony callus and soft tissues. A diamond bur is used to
has been described in the axis and mid‐cervical vertebra.45 trim back the obstructing callus (see Figure 40.31).
Closure of the repair is routine, and a suction drain is Massive excavation of bone in the lateral portions of the
always placed to evacuate serum accumulation between canal should be avoided, as this significantly weakens the
the longus colli muscles and trachea. Assisted recovery bony support to the articular process and can result in
is mandatory. External splinting is not generally used. pedicle refracture.
Antibiotics are maintained for several days postopera- Following callus reduction, a 5 mm thick nuchal fat
tively while the drain is in place. Continued nonsteroidal graft is placed over and down the affected side of the
anti‐inflammatory agents such as phenylbutazone dural sac. The multifidus muscles are reapposed over the
are required for pain relief. The degree of ataxia after fat, and a suction drain placed. Suturing of the remaining
surgery is usually similar to that before surgery. If the tissues is as described in the literature.32,33
neurologic status is worse, additional doses of dexameth- A long‐term response to decompression has been
asone (0.2 mg kg−1 intravenously) and DMSO (1 g kg−1) seen in the few horses operated on by the author. One
are indicated to improve neural function. Stabilization of horse suffered a refracture through the original verte-
signs should occur within 48 hours. If the neurologic bral pedicle fracture, but eventually stabilized with
deficits remain, repeat radiographs are warranted to grade 1 neurologic deficits. Overall, the poor prognosis
evaluate the stability of the fixation and to assist in the of encroaching callus warrants consideration for surgical
detection of other previously unrecognized fractures. callus reduction. Alternatively, fracture union could be
Gradual improvement in ataxia and paresis should be expedited by ventral intervertebral fusion, which should
expected. Complete recovery can take 16–18 months. allow bony remodeling and reduction of callus mass,
Residual deficits may remain, depending on alignment similar to the effect of intervertebral fusion on the bony
following repair, the severity of the deficits initially, and proliferation seen with degenerative joint disease of the
the amount of intrusive callus that forms. Plate removal articular facets.13
has not been performed.
Dorsal Laminectomy Fractures of the Pedicle or Facets

Minimally displaced pedicle fractures should be treated of the Cervical Vertebrae
by stall confinement if the neurologic condition is not Simple fracture of one or both articular facets or the
deteriorating. Stabilizing callus forms around the pedicle attached vertebral pedicle is relatively common in
within 90 days and can eventually lead to union of the horses of all ages. The diagnosis can be difficult to con-
original fracture. However, it can also lead to callus firm by radiography in the initial period following injury
intrusion into the vertebral canal or lateral foramen, (Figure 40.32). Clinical symptoms frequently arise after
both of which are causes of late sequelae such as ataxia or a fall or an unwitnessed incident in the paddock or stall.
nerve root signature and lameness (Figure 40.31) Under Swelling is minimal; however, guarding and stiffness in
these circumstances surgical intervention may be the neck are common, and reluctance to bend the neck
warranted. Delay in treating fracture callus cases has not laterally is profound. Lateral and oblique radiographs
been rewarding. Final bony union usually yields exuberant obtained in the standing position often indicate a subtle
callus which engulfs the articular facets, resulting in fracture of the cranial pedicle area of an affected
degenerative joint disease and f urther compression of the intervertebral junction.48,63 CT provides more detailed
spinal cord by osteophytes and synovial structures. information, and should always be considered if there
Decompression by dorsal laminectomy may help some is uncertainty as to the presence of a fracture or the
of these cases. Laminectomy in horses has been described extent of vertebral arch, pedicle, or facet involvement
previously and is a physically demanding procedure.32,33 (Figure 40.33).
Positioning the horse in lateral recumbency and experi- Treatment choices with cervical vertebral pedicle or
ence with the techniques are important for success. The facet fractures include conservative management and
dorsal midline approach is used to expose the dorsal later intervertebral fusion or decompression if a fracture
lamina at the affected site. The soft tissue and exuberant callus intrudes on the spinal canal, or, if ataxia is appar-
joint capsule are excised from the articular facets. ent or worsening, immediate surgical fusion to provide
Initially, a 2 cm portion of lamina is removed from the stabilization and regression of the associated callus.26,48
cranially affected vertebra. A high‐speed bur is used to An initial conservative approach is reasonable. However,
channel the perimeter of the lamina to be removed. The encroaching callus rapidly compresses the spinal cord in
bone is often very dense and encroaches on the spinal the mid and caudal cervical vertebrae. Intervertebral
www.ajlobby.com
(A) (B)
(C)
Figure 40.31 Chronic fracture callus and spinal cord compression from a right C5–C6 pedicle and facet fracture in a three‐year‐old
Tennessee walking horse. (A) Lateral myelographic projection shows severe narrowing of dorsal and ventral contrast columns at the
C5–C6 junction, massive dorsal proliferation of bone in the C5–C6 facet joints, and expansion of the sagittal diameter of the spinal cord
through the affected region. (B) Ventrodorsal myelographic projection shows fracture callus intrusion (arrows) and compression of the
spinal cord on the right side. (C) Dorsal laminectomy has been performed to remove the caudal third of the C5 lamina at the C5–C6
articulation. A diamond bur has been used to remove fracture callus from the right articular facet and pedicle region (black arrows). The
dorsal lamina and dorsal spinous process (DSP) of C6 are intact. A ventral interbody fusion was performed three weeks later to fuse the
C5–C6 junction and lessen the chance of fracture callus regrowth.
(A) (B)
Figure 40.32 A comminuted pedicle and vertebral body fracture of C6–C7 in a 12‐month‐old horse treated by ventral interbody fusion.
The horse had a six‐week history of neck pain and moderate ataxia after an acute onset. (A) Lateral radiograph shows extensive new
bone formation and osteoarthritis of the facet joints and separate fractures of the cranial portion of the body of C7. (B) Left ventral to right
dorsal oblique radiograph shows a discrete fracture line through the left pedicle and facet of C7 (arrows), and a defect in the cranial
aspect of the body of C7 (arrowheads).
www.ajlobby.com
(A) (B) Figure 40.33 Computed tomography (CT)

of the C6–C7 fracture in the horse in
Figure 40.32. CT slices through the center
of the C6–C7 articulation (A), and on the
caudal perimeter of the C6–C7 articulation
(B), confirm fractures of both the caudal
facet of C6 and the cranial facet of C7. The
fracture callus extends down the left
ventral aspect to obliterate the left lateral
intervertebral foramen.
(A) (B)
Figure 40.34 Treatment of the horse in Figures 40.32 and 40.33 by ventral intervertebral fusion using a threaded kerf‐cut stainless‐steel
implant to arthrodese the C6–C7 intervertebral junction. (A) Postoperative lateral radiograph 18 days after repair. (B) Lateral radiograph
13 months after surgery. The fractures are no longer visible, and the lateral intervertebral foramen has opened. New bone has formed in
the vertebral bodies of C6 and C7 dorsal and ventral to the implant. Vertebral alignment is good and minimal callus is evident in the
vertebral canal. The horse was asymptomatic.
fusion using a threaded kerf‐cut cylinder provides lesion; the osteomyelitis lesion is generally worse than
immediate stabilization of the affected intervertebral expected (see Figure 40.35). Treatment includes sam-
junction (Figure 40.34), and ultimately induces fusion of pling of the affected region using CT‐guided JamshidiTM
the vertebral body and affected vertebral arch, pedicle, (Becton, Dickinson & Company, Franklin Lakes, NJ,
or facet fracture. USA) needle aspiration and culture, followed by
local antibiotic delivery, either as liquid or slow‐release
Pathologic Fractures of the Cervical Vertebrae polymer‐based antibiotic therapy. Resolution of the
Hematogenous bacterial localization to the cervical clinical symptoms often precedes improvement on
vertebral epiphyses has been seen as a complication radiographs.
of bacteremia in foals (Figure 40.35). Involvement of Penetrating wounds resulting in fracture of the transverse
the intervertebral disc is common, and osteomyelitis process of the vertebral body have also been described.52
involving both the adjacent vertebrae frequently devel- Local surgical debridement of the wound and removal
ops, weakening the structure of the affected cervical of the fractured portion of the transverse process may
vertebra. CT is useful to establish the extent of the be adequate to resolve the infection.
www.ajlobby.com
Figure 40.35 Hematogenous discitis/ (A) (B)

osteomyelitis of the C4–C5 junction in a
five‐month‐old Thoroughbred foal. (A)
Lateral radiograph shows radiolucency
of C4 and C5 (arrow), with erosion of
both endplates and deterioration of the
dorsal region of the intervertebral disc.
(B) Progressive expansion of the lytic
lesion over three weeks prompted
computed tomography‐guided
aspiration and injection of antibiotics in
a resorbable bone cement.
Thoracolumbar Vertebrae
Thoracolumbar vertebral fractures are more common in
adults than foals. In one study in adult horses, 22 of 65
(34%) vertebral or skull fractures involved the thora-
columbar spine.17 The most commonly affected verte-
brae were T12 and L5. Falls and other traumatic episodes
are usually involved and result in burst fractures in adults,
generally with catastrophic results. The small size of the
vertebral canal relative to the spinal cord results in neuro-
logic deficits, despite relatively minor bony disruption.
One of the more common fractures in adults involves
the dorsal spinous processes of the withers. A horse that
rears over backward can traumatize either the withers Figure 40.36 Acute fractures of multiple dorsal spinous processes
of the thoracic vertebrae following a traumatic injury to the withers.
or the poll region. When the withers is affected, several
dorsal spinous processes can fracture and displace laterally
(Figure 40.36). The vertebral canal is often unaffected, lumbar fractures occurred at L5–L6, particularly in
and clinical signs are limited to pain and swelling of the Quarter Horses (87%). In foals, fracture separation of the
withers. Medical treatment aimed at controlling pain physes and associated facet joints can result in complete
and tissue swelling is usually adequate. Surgical inter- thoracic vertebral disruptions (Figure 40.37). These
vention is not necessary. Eventual bony union develops horses are immediately paraplegic and are often eutha-
and the horses can return to work with a good prognosis. nized.3,42 Electric shock resulted in fracture of T11 in
Some residual pain and deformity of the withers may one foal.9
require the use of a different saddle. Although forelimb extensor rigidity associated with
High‐speed falls, steeplechase races, jumping events, the Schiff–Sherrington syndrome is not frequently
and polo collisions all have led to fracture of the thora- encountered in horses, there are two recorded episodes
columbar spine in adults.8,17,18,20,29,57,60 Some predisposing in the literature associated with severe thoracolumbar
conditions such as intervertebral disk damage, chronic vertebral fractures.4,49 Most other cases of thoracic
ligamentous strain, and spondylitic lesions have been vertebral fracture show immediate and variable degrees
described.17 Additionally, stress fractures have been of paraparesis or paraplegia.9,25,29,36 Additionally, lower
identified in over 50% of Thoroughbred racehorses motor neuron symptoms such as loss of withdrawal
with subsequent catastrophic vertebral fractures.16 In a and patellar reflexes in the hindlimbs may result from
22‐year review of fatal lumbar vertebral fractures in damage to the spinal cord segments L4–S5.8,10,40 In the
California Thoroughbred and Quarter Horses, lumbar adult, this corresponds to fractures of L4 through to and
vertebral fractures occurred in 38 Quarter Horses and including the first sacral vertebra. Cranial to L4, fracture
represented the third most common musculoskeletal disruption can release hindlimb reflexes from upper
cause of death.5 In Thoroughbreds, 29 horses had fatal motor neuron control, resulting in normal or hyperac-
lumbar fractures over the 22‐year study period. Most tive reflexes.10,40 Paradoxical lower motor signs in the
www.ajlobby.com
Myelography or CT myelography is used to determine

the craniocaudal extent of the spinal cord swelling and
probable length of decompression needed (Figure 40.39).
If surgery is an option, medical therapy, including
dexamethasone, DMSO, and broad‐spectrum antibiotics,
is commenced prior to the induction of anesthesia.
Expeditious decompression and stabilization will improve
the functional outcome.
For lumbar dorsal laminectomy, foals are carefully
positioned in sternal recumbency with the sternum
Figure 40.37 Acute traumatically induced fracture luxation of the and pubis well padded (Figure 40.40). A dorsal midline
T16–T17 junction in a foal. The foal was paraplegic. approach is made over the dorsal spinous processes. The
incision should span at least four vertebrae cranial and
hindlimbs in a foal with an L1 fracture were thought to four caudal to the affected vertebra, to allow spinal plate
be the result of “spinal shock” or deficiency of blood flow application. The longissimus and multifidus muscles
to the more caudal segments of the lumbar spinal cord.25 are separated on the midline and dissected from the
Foals also occasionally develop pathologic fractures dorsal spinous processes. Malalignment of the spinous
secondary to osteomyelitis of the thoracic vertebrae. processes is usually a good indicator of the fracture site
Rhodococcus equi is the usual organism and can seed the (Figure 40.41). In less displaced cases, intraoperative
thoracic vertebrae by hematogenous or local spread.50 radiographs will be needed. Loose dorsal laminae with
Fracture collapse with severe spinal cord attenuation is evi- attached dorsal spinous process can be removed to
dent on radiographs (Figure 40.38). Many foals have a known
history of rhodococcal pneumonia with sudden onset of
paraparesis or paraplegia. Treatment is usually ineffective.
Treatment
There is one report describing surgical treatment of a
thoracolumbar fracture in a foal.36 Most other foals
described were paraplegic, without evidence of deep pain
recognition, and were subsequently euthanized.4,9,25,49 If
pain recognition is evident or there is some persisting
voluntary motor activity in the hindlimbs, surgical stabili- Figure 40.39 Myelogram of a compression fracture of the L1
zation may be indicated in foals. There are no reports of vertebra. Compression is severe, although malalignment at the
successful thoracolumbar fracture repair in adults. thoracolumbar junction is not prominent.
(A) (B)
Figure 40.38 (A) Pathologic collapse of the T8 vertebral body with extrusion of the bone dorsally and ventrally, with resulting
malalignment. (B) Myelogram demonstrating complete subdural blockage of flow of contrast material because of T8 fracture.
Rhodococcus spp. was cultured from the bone at necropsy.
www.ajlobby.com
Figure 40.40 Horse in sternal

recumbency for thoracolumbar
laminectomy. The fracture malalignment
at the thoracolumbar junction is apparent.
(A) (B)
(C) (D)
Figure 40.41 Intraoperative view following dorsal exposure of the thoracolumbar junction, showing (A) malalignment of T18–L1 and a
mobile dorsal spinous process and attached lamina of L1. (B) The caudally oriented dorsal spines of the thoracic vertebra necessitated
removing a portion of the dorsal spine of T18, the dorsal lamina of L1 was removed by lifting on the dorsal spinous process and
discarding, and a small portion of the dorsal spinous process of L2 has been removed. The bulging dura mater is evident (arrows). (C) For
unstable articulations, threaded Steinmann pins are inserted into the vertebral bodies from an abaxial to converging axial direction,
polyvinilidine (Lubra) plates are inserted on either side of the dorsal spinous processes and secured using bolts or 4.5 mm cortical screws
with nuts. A polymethylmethacrylate (PMMA) bone cement ring is then used to incorporate the dorsal ends of the interbody pins and
Lubra plate. (D) For inherently stable thoracolumbar fractures, Lubra plates alone may be adequate to provide postoperative stabilization.
The laminectomy defect is visible, covered by white Gelfoam® (Pharmacia and Upjohn, Kalamazoo, MI, USA) beneath the Lubra plates.
www.ajlobby.com
commence the decompression. If nothing feels loose, the

spinous process of the affected vertebra, as shown on
radiographs, is removed with rongeurs, and a high‐speed
bur used to channel the perimeter of the dorsal lamina.
Following removal of the lamina, the dural sac and spinal
cord are examined for hemorrhagic areas and contu-
sions. Bulging of the dural sac into the laminectomy
defect usually develops. In severe trauma cases, assess-
ment of the spinal cord by durotomy is recommended.
Even if the dura mater is intact, the thoracolumbar spinal
cord can still be seriously disrupted at the fracture site
(Figure 40.42). These horses should be euthanized Figure 40.43 Radiograph showing the configuration of
intraoperatively. Steinmann pins and methylmethacrylate bone cement fixation for
a thoracolumbar fracture stabilization of the case in Figure 40.39.
If the spinal cord is intact, stabilization of the verte-
A pair of polyvinilidine (Lubra) plates have been applied to the
brae by pins and methylmethacrylate, in combination dorsal spinous processes and are secured with bolts. Note the
with polyvinilidine dorsal spinous process plating, is improved alignment compared to the preoperative myelogram,
indicated (see Figure 40.41). Steinmann pins are placed, despite the crushed L1.
two into the vertebral body of the caudally adjacent
vertebra and two into the cranial portion of the fractured
vertebra. If the fracture has collapsed the majority of the manipulated into anatomic alignment, and a pair of
vertebral body, the cranially adjacent vertebra can be polyvinilidine (Lubra) plastic plates is applied to the
pinned. Pins measuring 3/16 in. are inserted with power dorsal spinous processes. Final rigidity is provided by
equipment, but with considerable care. The caudal pair connecting the Steinmann pins with cold‐cure PMMA,
of pins are inserted caudal to the articular processes and which is formed into a circle that overlaps the Lubra
lateral to the vertebral canal. They are angled ventrocau- plates (see Figure 40.41C). Fixation should then be com-
dally at 30° off the vertical line and angled toward the pletely rigid, and the pins can be cut on the dorsal surface
midline at 20° off the vertical line, to converge in the of the hardened cement. The bone cement is lavaged dur-
middle of the vertebral body (Figure 40.43). The pins ing polymerization to dissipate any heat generated dur-
should barely exit the ventral portion of the vertebrae. ing this process. Where the thoracic or lumbar fracture
Laceration of the aorta or the vena cava, or both, is pos- has not extensively collapsed, Lubra plates alone may be
sible. The cranial pins are applied in a similar fashion, sufficient to provide stability after decompression (see
with the use of a cranioventral converging‐pin technique. Figure 40.41D).
With the Steinmann pins in place, the vertebrae are The epaxial muscles are apposed over and around the
Lubra plates and bone cement conglomerate. In younger
foals, only the subcutaneous tissues and skin can be
apposed over the implants. The incision is protected by
a stent bandage. Drains are usually unnecessary at this
location.
Intensive nursing care is needed in the postoperative
period. In foals that regain ambulation and whose frac-
tures develop a bony union, the implants need to be
removed three to six months after insertion. In young
foals, considerable growth will occur in the vertebral
body length, and the Lubra plates will retard this devel-
opment, resulting in lordosis. Return of growth potential
develops after plate removal. Although it is usually
unnecessary, the pins and cement are removed at the
time of plate removal.
The prognosis for foals with thoracolumbar fractures is
generally grave. Surgery improves the outcome for the
Figure 40.42 Exploration of foal with severe neurologic few horses that are sufficiently mobile to warrant inter-
deficits but deep pain should include a durotomy and
investigation of the spinal cord. Here a remnant of the spinal
vention. One case report describes a one‐month‐old foal
cord is evident beneath a hemostat. The horse was euthanized that survived after conservative treatment for a thoracic
on the surgery table. vertebral fracture during a paddock accident.19 The
www.ajlobby.com
Figure 40.44 Computed tomographic (CT) (A) (B)

myelography may provide information on
the cause of compression where thoracic
radiographs are normal. (A) Transverse CT
through T5 shows a normal spinal cord
and subdural space. (B) CT myelography at
T6 shows an epidural space‐occupying
lesion (arrows) compressing the spinal
cord to the side. The cord is reduced in
diameter and subdural space is
compressed. Epidural empyema was
suspected. Laminectomy or
hemilaminectomy at T6 is indicated.
horse had a debilitating kyphosis as a two‐year‐old. Sacrum and Caudal Vertebrae

Overall, most foals with thoracolumbar vertebral fractures
are euthanized at the time of diagnosis. Fractures of the sacrum and caudal (coccygeal) verte-
Compression associated with spinal sepsis secondary brae result from hard impact following the horse falling
to bacteremia or extension from thoracic abscessation backward, sitting down suddenly, or backing into a
can result in epidural empyema and spinal cord com- wall.6,31,60,62 The cranial sacrum is protected by the
pression. Radiographs are often normal, except for adja- broader dimension of the sacrum at this level and the
cent pulmonary consolidation, and CT or CT myelogram tuber sacrale of the pelvis, which prevent sacral fracture
is often required to establish the diagnosis (Figure 40.44). but may lead to sacroiliac subluxation and chronic lame-
For small horses and foals, MRI can also be particularly ness. The tail head region is more dependent, and
helpful in establishing the diagnosis. Surgical decom- impact injury puts considerable stress on the long lever
pression by dorsal hemilaminectomy or laminectomy arm of the caudal aspect of the sacrum and the first two
provides access for decompression and local delivery of caudal vertebrae.54
depot forms of antibiotics. The sacrum in most horses contains five conjoined
The horse is positioned in dorsal recumbency as sacral vertebrae, and in adults these function as one unit.
previously described. Radiographic markers such as
In foals, however, the sacral vertebrae, including the
hypodermic needles are used to provide preliminary individual physes, are separate, and some independent
identification of the appropriate site for decompression. motion is possible. As the horse matures, the epiphyses
Fluoroscopic examination or intraoperative digital of the sacral vertebrae fuse, often preceding closure of
radiography is important to monitor the site and extent the adjacent physes. The stress of an injury to the tail
of decompression. The dorsal spinal processes of the base is, therefore, concentrated on the caudal portion of
affected and adjacent vertebrae are exposed (Figure 40.45). the sacrum in an adult, but may affect individual sacral
The dorsal spinal process of the vertebra to be decom- vertebrae in a foal. As a result, the range of clinical signs
pressed is removed with heavy rongeurs. A portion or is greater in foals. The sacrum contains the S4, S5,
the entire dorsal spinous process of adjacent vertebrae and caudal cord segments in the caudal aspect.53 More
may also need to be removed, particularly for the importantly, it contains the termination of the cauda
thoracic vertebrae, where the dorsal spinous processes equina complex of peripheral nerves, including the
are markedly angled caudally. The laminectomy or major lumbar and sacral nerves contributing to the
hemilaminectomy, depending on lesion laterality, is sciatic and gluteal nerves.
then done using a high‐speed bur. Evacuation of The clinical signs include pain and swelling over the
epidural empyema is performed to fully decompress croup and tail head. Pain on manipulation of the tail
the spinal cord. Residual antibiotic delivery is provided base is exacerbated by direct pressure on the fractured
by bone cement beads laden with antibiotics. Use of vertebrae. Neurologic deficits include variable degrees
suction drains is optional. Postoperative splinting of of loss of tail and anal sphincter tone, fecal retention,
the thoracic and lumbar spine after laminectomy is paresthesia or hyperesthesia of the perineum, and, with
generally unnecessary, provided that the vertebral body fractures that involve more cranial structures toward
structure is still intact. the first sacral vertebra, hindlimb sensory and motor
www.ajlobby.com
(A) (B)
(C)
Figure 40.45 Dorsal T6 hemilaminectomy of the foal in Figure 40.44. (A) Exposure of the dorsal spinous processes of the thoracic vertebra.
The abaxial musculature has been dissected and retracted, and intraoperative radiographs are used to identify the target vertebra for
laminectomy. (B) The dorsal spinous process of T6 and part of T5 have been removed and the dorsal lamina of T6 exposed for
laminectomy (arrows). (C) Postoperative radiograph indicating the site of hemilaminectomy (black arrows) and the residual cranial portion
of the T6 lamina (white arrows).
deficits.53,54 Chronic cases often show gluteal muscle CT myelography (Figure 40.46).50 Occasionally an epi-
atrophy. Fracture of the caudal (coccygeal) vertebrae in durogram provides diagnostic information on fracture
the free portion of the tail results in flaccid paralysis of compression of the sacrocaudal and first caudal vertebrae.
the tail distal to the injury. Overall loss of tail function For small horses and foals, MRI may also be feasible.
depends on the actual fracture level.10,54 Caudal vertebral venography has sometimes been used
A tentative diagnosis is made from the clinical signs to assist in the evaluation of compression in the caudal
and rectal examination and is confirmed by radiography. vertebrae, but rarely provides additional localizing
Imaging of this area becomes more difficult in adults, information. Electromyography is useful to define the
requiring powerful radiology equipment. The mass of extent of denervation injury in chronic cases. Myelography
the ilia and the overlying gluteal musculature result in provides information on the extent of the compression
reduced clarity of image. Additional information on frac- and is an important guide in planning any surgical stabi-
tures of the sacrum is often obtained by myelography or lization or decompression (see Figure 40.46).
www.ajlobby.com
horse is positioned in left lateral recumbency, and the

dorsal region of the caudal lumbar and sacral vertebrae
are prepared for surgery. A midline skin incision is
centered over the affected sacral vertebrae. The epaxial
musculature is dissected from the dorsal spinous pro-
cesses to expose the malalignment. Instability may be
evident in acute cases. In chronic cases, realignment of
the sacrum is usually not possible, and decompression
by laminectomy is used to expose and decompress the
cauda equina (Figure 40.47). More recent injuries can be
aligned for stabilization. A laminectomy is performed if
there is a possibility of hemorrhage or fibrosis within the
Figure 40.46 Myelographic examination of a foal with a burst vertebral canal. In one foal with a burst fracture of the
fracture of the second sacral vertebra and ventral displacement of sacrum, the affected vertebral body was decompressed
a portion of the vertebral body (arrow). Dorsal and ventral by laminectomy and then plated to reestablish vertebral
compression of the sacral and caudal cord segments at the level congruity. The laminectomy defect is usually narrow,
of S2 has developed.
and a fat graft is unnecessary. Stabilization is safely
obtained by application of a pair of polyvinilidine spinal
Treatment plates to fix two dorsal spinous processes cranial and
Scant information is available in the literature concern- two caudal to the fractured vertebra (see Figure 40.47).
ing the treatment of sacral fractures. Laminectomy was In younger foals, some manipulation is required to seat
used to decompress chronic displacement and callus the plates between the sacral tubers. Suction drains are
following fracture of the fifth sacral vertebra in a placed, and closure of the soft tissues is routine.
horse.6 Another horse with a fracture of the third sacral Intraoperative radiographs are obtained to assess verte-
vertebra was euthanized.62 Surgical decompression bral alignment.
followed by stabilization using a bone plate or a Lubra The administration of antibiotics and nonsteroidal
plate has been used in fractures of the fourth and fifth anti‐inflammatory agents is continued for several days
sacral vertebrae in cows.28 There are no other reports after surgery. Horses with fractures of the first or second
of definitive surgical repair in horses. An alternative in sacral vertebrae may have difficulty in standing, and dex-
cases with recalcitrant paresthesia of the tail head is amethasone and DMSO are useful to diminish spinal
amputation of the tail. cord and nerve root edema and signal‐conduction block.
Decompression by dorsal laminectomy and stabili- Removal of long Lubra plates is required in foals within
zation by Lubra plate or DCP application has been several months of repair. Active growth from the physes
used by the author for fracture of the sacrum. The of the caudal lumbar and sacral vertebrae will result in
(A) (B)
Figure 40.47 Stabilization of S2 fracture in Figure 40.46 with polyvinilidine plates following dorsal laminectomy for decompression of the
termination of the spinal cord and cauda equina. (A) Postoperative week four radiograph showing alignment of the sacral vertebrae and
healing of the body of the second sacral vertebra. The original fracture fragment is still visible, but becoming incorporated in callus. (B)
Radiographs at three months show continued healing, but the sacrum is becoming displaced with the continued growth of the physes of
the lumbar and sacral vertebrae. The plate was removed and the foal went on to a complete recovery.
www.ajlobby.com
lordosis of the lumbosacral region within 12 weeks of Fractures of the tail head without complete displace-
repair in foals (see Figure 40.47). ment may be candidates for stabilization (Figure 40.49).
The prognosis for sacral fractures is improved by It should be recognized that these cases are also the
surgery, and decompression should be an option, even better type to treat conservatively. Consideration of a
in chronic cases. Acute cases will need stabilization better tail head conformation and reduced hyperesthesia
following decompression, and Lubra plates or DCPs are may enter into the decision for surgery The dorsal
satisfactory. If adequate bone stock is available, a DCP midline approach is utilized. Paired dorsolateral caudal
can be applied to the lateral aspects of the sacral verte- arteries and paired ventrolateral caudal arteries, together
brae, with the plate screws into the lateral arches of the with the middle caudal artery along the ventral midline,
sacral vertebrae. The DCP is particularly useful nearer provide blood to the tail. Dissection of a fracture of the
the sacrocaudal junction, where nerves exiting the sacral
foramina do not interfere with plate seating. However,
Lubra plates are safer and easier to apply to cranial and
mid‐sacral fractures.
Fractures of the sacrocaudal junction or caudal verte-
bra can be difficult to stabilize.53,54 Conservative treat-
ment of fractures of the first or second caudal vertebra in
12 horses has been described.54 Follow‐up was only
available for 3 of these horses, 2 of which had improved
function of the tail despite continued conformational
defects, and the third had no improvement by 11 months
post‐injury. Completely displaced fractures generally
sever or irreparably stretch the caudal nerves, and tail
function is never restored (Figure 40.48). Tail amputa-
tion is appropriate. The primary indication for tail ampu-
tation is to improve the elimination of fecal balls from
the perineal region. If the tail does not obstruct the pas-
sage of manure, the paralyzed tail may have little impact
on geldings and stallions. Mares may encounter urine
Figure 40.48 Sacrocaudal fracture associated with rearing over
scald. Use of tail ropes may apply axial tension sufficient backward and landing on the tail head. The tail was totally
to dislocate the tail. Skeletal repair may not restore func- paralyzed; however, passage of the neuroma was unobstructed
tion if the nerves are stretched or disrupted. and no treatment was instituted.
(A) (B)
Figure 40.49 Displaced fracture of the first caudal vertebra (C1) as a result of an impact injury. (A) Normally positioned tail shows the
ventrally displaced caudal portion of the fractured caudal vertebra. (B) Extension of the tail partially realigns the fractured vertebra. This
mobility led to surgical stabilization using sublamina wires.
www.ajlobby.com
sacrocaudal junction must avoid the dorsolateral arteries, The literature contains too few cases of sacral or caudal
although hemorrhage can be surprisingly profuse regard- vertebral fractures with follow‐up information to provide
less. Repair of the sacrocaudal or first caudal vertebra sound guidelines for treatment or expected outcome.
can be accomplished using sublaminar wires. The dorsal A case report of a seven‐year‐old Thoroughbred treated
approach provides access for wiring of the affected verte- conservatively for a sacrocaudal fracture/luxation indi-
bra by placing several stainless‐steel wires, carefully cated bony union in a displaced alignment, but improved
inserted beneath the dorsal lamina and looped back to clinical signs.53 A larger series of 12 horses with fractures
tie and provide decompression by realignment of the of the first or second caudal vertebra treated conserva-
caudal vertebra. The dorsal lamina becomes too thin to tively has been described.54 Outcome data was only avail-
hold wire after C2, but a small plate could conceivably able for 3 horses, 2 of which had improved function of the
be applied to the ventroabaxial surface of the caudal tail, but persisting malalignment of the tail head confor-
vertebra. However, fractures distal to C2 are rare due to mation. Certainly surgical options are available and should
the mobility of the tail. be considered, even in chronic cases.
References
1 Baker, G.J. (1970). Comminuted fracture of the axis. 11 Forterre, F., Stoffel, M.H., Koch, C. et al. (2017).
Equine Vet. J. 2: 37–38. Comparative anatomy and biomechanical properties of
2 Barnes, H.G., Tucker, R.L., Grant, B.D. et al. (1995). Lag atlantoaxial ligaments in equine, bovine, and canine
screw stabilization of a cervical vertebral fracture by cadaveric specimens. Vet. Comp. Orthop. Traumatol.
use of computed tomography in a horse. J. Am. Vet. 30: 219–222.
Med. Assoc. 206: 221–223. 12 Funk, K.A. and Erickson, E.D. (1968). A case of
3 Carson‐Dunkerley, S.A., Beard, D.M., and Williams, atlanto‐axial subluxation in a horse. Can. Vet. J. 9:
M.A. (1997). What is your diagnosis? Comminution of 120–123.
T2 and luxation of T2 and T3. J. Am. Vet. Med. Assoc. 13 Grant, B.D., Hoskinson, J.J., Barbee, D.D. et al. (1985).
211: 545–546. Ventral stabilization for decompression of caudal
4 Chiapetta, J.R., Baker, J.C., and Feeney, D.A. (1985). cervical spinal cord compression in the horse. In:
Vertebral fracture, extensor hypertonia of thoracic Proceedings of the American Association of Equine
limbs, and paralysis of pelvic limbs (Schiff–Sherrington Practitioners, vol. 31, 75–90. Lexington, KY: AAEP.
syndrome) in an Arabian foal. J. Am. Vet. Med. Assoc. 14 Guffy, M.M., Coffman, J.R., and Strafuss, A.C. (1969).
186: 387–388. Atlantoaxial luxation in a foal. J. Am. Vet. Med. Assoc.
5 Collar, E.M., Zavodovskaya, R., Spriet, M. et al. (2015). 155: 754–757.
Caudal lumbar vertebral fractures in California Quarter 15 Gygax, D., Furst, A., Picek, S., and Kummer, M. (2011).
Horse and Thoroughbred racehorses. Equine Vet. J. 47: Internal fixation of a fractured axis in an adult horse.
573–579. Vet. Surg. 40: 636–640.
6 Collatos, C., Allen, D., Chambers, J., and Henry, M. 16 Haussler, K.K. and Stover, S.M. (1998). Stress fractures
(1991). Surgical treatment of sacral fracture in a horse. of the vertebral lamina and pelvis in thoroughbred
J. Am. Vet. Med. Assoc. 198: 877–879. racehorses. Equine Vet. J. 30: 374–381.
7 DeBowes, R.M. (1990). Cervical vertebral interbody 17 Jeffcott, L.B. and Whitwell, K.E. (1976). Fractures of the
fusion for management of instability and thoracolumbar spine of the horse. In: Proceedings of the
malformations. In: Current Practice of Equine Surgery American Association of Equine Practitioners, vol. 22,
(ed. N.A. White and J.N. Moore), 181–187. 91–102. Lexington, KY: AAEP.
Philadelphia: Lippincott, J.B. 18 Johnson, B. (1992). A look at racetrack breakdowns
8 DeBowes, R.M. and Gift, L. (1992). Trauma of the brain and deaths. The Thoroughbred of California Sept.:
and spinal cord. In: Current Therapy in Equine 50–54.
Medicine, 3e (ed. N.E. Robinson), 535–539. 19 Kothstein, T., Rashmir‐Raven, A.M., Thomas, M.W.,
Philadelphia: WB Saunders Co. and Brashier, M.K. (2000). Radiographic diagnosis:
9 DeBowes, R.M., Wagner, P.C., Gavin, P.R., and Roden, thoracic spinal fracture resulting in kyphosis in a horse.
P.H. (1981). Vertebral compression fracture in a foal Vet. Radiol. Ultrasound 41: 44–45.
following electric shock. Vet. Comp. Orthop. 20 Krook, L. and Maylin, G. (1988). Fractures in
Traumatol. 2: 14–19. thoroughbred race horses. Cornell Vet. 78: 7–133.
10 DeLahunta, A. (1983). Veterinary Neuroanatomy and 21 Laugier, C., Tapprest, J., Foucher, N., and Sevin, C.
Clinical Neurology, 2e. Philadelphia: WB Saunders Co. (2009). A necropsy survey of neurologic diseases in
www.ajlobby.com
4,319 horses examined in Normandy (France) from cervical vertebrae. Vet. Comp. Orthop. Traumatol.
1986 to 2006. J. Equine Vet. Sci. 29: 561–568. 22: 371–379.
22 Lopez, M.J., Nordberg, C., and Trostle, S. (1997). 39 Reardon, R.J., Bailey, R., Walmsley, J.P. et al. (2010). An
Fracture of the 7th cervical and 1st thoracic vertebrae in vitro biomechanical comparison of a locking
presenting as radial nerve paralysis in a horse. Can. Vet. compression plate fixation and kerf cut cylinder
J. 38: 112. fixation for ventral arthrodesis of the fourth and the
23 Lundvall, R.L. (1969). Ataxia of colts as a result of fifth equine cervical vertebrae. Vet. Surg. 39: 980–990.
injuries. Norden News Summer: 6–10. 38 Reardon, R., Kummer, M., and Lischer, C. (2009).
24 Lyle, C.H., Uzal, F.A., McGorum, B.C. et al. (2011). Ventral locking compression plate for treatment of
Sudden death in racing Thoroughbred horses: an cervical stenotic myelopathy in a 3‐month‐old
international multicentre study of post mortem Warmblood foal. Vet. Surg. 38: 537–542.
findings. Equine Vet. J. 43: 324–331. 40 Reed, S.M. (1983). Spinal cord trauma. In: Current
25 Mason, B.J.E. (1971). A case of spinal cord compression Therapy in Equine Medicine, 2e (ed. N.E. Robinson),
causing paraplegia of a foal. Equine Vet. J. 3: 155–157. 355–359. Philadelphia: W.B. Saunders.
26 McConnico, R.S., Rashmir, A.M., and Douglass, J.P. 41 Rendano, V.T. and Quick, C.B. (1978). Equine
(1989). What is your diagnosis? Fracture of the sixth radiology – the cervical spine. Mod. Vet. Pract.
cervical vertebra. J. Am. Vet. Med. Assoc. 194: 59: 921–927.
1477–1478. 42 Rhoads, W.S. and Cox, J.H. (1997). What is your
27 McCoy, D.J., Shires, P.K., and Beadle, R. (1984). Ventral diagnosis? Compression fracture of the 12th thoracic
approach for stabilization of atlantoaxial subluxation vertebra. J. Am. Vet. Med. Assoc. 210: 755–756.
secondary to odontoid fracture in a foal. J. Am. Vet. 43 Robinson, P.A. and Currall, J.H.S. (1981). Surgical
Med. Assoc. 5: 545–549. repair of a cervical fracture/dislocation in a mature
28 McDuffee, L.A., Ducharme, N.G., and Ward, J.L. horse. New Zealand Vet. J. 29: 28.
(1993). Repair of sacral fracture in two dairy cattle. 44 Rosenbruch, M., Denecke, R., and Hertsch, B. (1982).
J. Am. Vet. Med. Assoc. 202: 1126–1128. Fracture of the 6th cervical vertebra in a breeding
29 Moyer, W.A. and Rooney, J.R. (1971). Vertebral fracture stallion. Dtsch. Tierartl. Wochenschr. 89: 261–312.
in a horse. J. Am. Vet. Med. Assoc. 159: 1022–1024. 45 Rossignol, F., Brandenberger, O., and Mespoulhes‐
30 Muno, J., Samii, V., Gallatin, L. et al. (2009). Cervical Riviere, C. (2016). Internal fixation of cervical fractures
vertebral fracture in a thoroughbred filly with minimal in three horses. Vet. Surg. 45: 104–109.
neurological dysfunction. Equine Vet. Educ. 21: 46 Schneider, J.E. (1981). Immobilization of cervical
527–531. vertebral fractures. In: Proceedings of the American
31 Nixon, A.J. (1987). Vertebral fractures. In: Adams’ Association of Equine Practitioners, vol. 27, 253–256.
Lameness in Horses, 4e (ed. T.S. Stashak), 779–784. Lexington, KY: AAEP.
Philadelphia: Williams & Wilkins. 47 Slone, D.E., Bergfeld, W.A., and Walker, T.L. (1979).
32 Nixon, A.J. (1991). Surgical management of equine Surgical decompression for traumatic atlantoaxial
cervical vertebral malformation. Prog. Vet. Neurol. subluxation in a weanling filly. J. Am. Vet. Med. Assoc.
2: 183–195. 174: 1234–1236.
33 Nixon, A.J. and Stashak, T.S. (1983). Dorsal 48 Smyth, G.B. (1993). Use of ventral cervical stabilization
laminectomy in the horse I. Review of the literature for treatment of a suspected articular facet fracture in a
and description of a new procedure. Vet. Surg. 12: horse. J. Am. Vet. Med. Assoc. 202: 771–772.
172–176. 49 Stanek, V.C. and Reicher, R. (1987). Schiff–Sherrington
34 Nixon, A.J. and Stashak, T.S. (1988). Laminectomy for Syndrom nach Luxationsfraktur des 12. Brustwirbels
relief of atlantoaxial subluxation in four horses. J. Am. bei einer Stute. Wien. Tierarztl. Monatsschr. 74:
Vet. Med. Assoc. 193: 677–682. 98–100.
35 Owen, R. and Maxie, L.L. (1978). Repair of fractured 50 Stewart, A.J., Salazar, P., Waldridge, B.M. et al. (2007).
dens of the axis in a foal. J. Am. Vet. Med. Assoc. 173: Computed tomographic diagnosis of a pathological
854–856. fracture due to rhodococcal osteomyelitis and spinal
36 Rashmir‐Raven, A., DeBowes, R., Hudson, L. et al. abscess in a foal. Equine Vet. Educ. 19: 231–235.
(1991). Vertebral fracture and paraplegia in a foal. Prog. 51 Stewart, R.H. (1987). Central nervous system trauma.
Vet. Neurol. 2: 197–202. Vet. Clin. North. Am. 3: 371–377.
37 Reardon, R., Bailey, R., Walmsley, J. et al. (2009). A pilot 52 Sysel, A.M., Moll, H.D., Carrig, C.B., and Newton, T.J.
in vitro biomechanical comparison of locking (1998). What is your diagnosis? Oblique fracture of the
compression plate fixation and kerf‐cut cylinder caudal half of the transverse process of the fourth
fixation for ventral fusion of fourth and fifth equine cervical vertebra. J. Am. Vet. Med. Assoc. 213: 607–608.
www.ajlobby.com
53 Taylor, S.L., Murray, R., Donovan, T., and Scott, C. 59 Vos, N.J., Pollock, P.J., Harty, M. et al. (2008). Fractures
(2002). Conservative management of a sacrococcygeal of the cervical vertebral odontoid in four horses and
fracture/luxation in a horse. Equine Vet. Educ. 14: 63–68. one pony. Vet. Rec. 162: 116–119.
54 Tutko, J.M., Sellon, D.C., Burns, G.A. et al. (2002). 60 Wagner, P.C. (1992). Surgical treatment of traumatic
Cranial coccygeal vertebral fractures in horses: 12 disease of the spinal column. In: Equine Surgery (ed.
cases. Equine Vet. Educ. 14: 197–200. J.A. Auer), 1093–1098. Philadelphia: W.B. Saunders.
55 Tyler, C.M., Davis, R.E., Begg, A.P. et al. (1993). A 61 Wagner, P.C., Bagby, G.W., Grant, B.D. et al. (1979).
survey of neurological diseases in horses. Aust. Vet. J. Surgical stabilization of the equine cervical spine. Vet.
70: 445–449. Surg. 8: 7–12.
56 Vatistas, N., Lee, M., and Snyder, J. (1993). What is your 62 Wagner, P.C., Long, G.G., Chatburn, C.C., and Grant,
diagnosis? Congenital fusion of vertebrae C1 and C2. J. B.D. (1977). Traumatic injury of the cauda equina in
Am. Vet. Med. Assoc. 203: 47–48. the horse: a case report. J. Equine Med. Surg. 1:
57 Vaughan, L.C. and BJE, M. (1973). A Clinico‐ 282–285.
Pathological Study of Racing Accidents in Horses. 63 Withers, J.M., Voûte, L.C., and Lischer, C.J. (2009).
Dorking: Bartholomew Press. Multi‐modality diagnostic imaging of a cervical
58 Vos, N. (2008). Conservative treatment of a articular process fracture in a Thoroughbred horse
comminuted cervical fracture in a racehorse. Ir. Vet. J. including a novel C‐Arm imaging technique. Equine
61: 244–247. Vet. Educ. 21: 540–545.
www.ajlobby.com
770
41
Fractures of the Head
Anton E. Fuerst and Joerg A. Auer
Overview hard palate; and the nasal process. Ventrally, the visceral
cranium consists of the palatal bone, the vomer and
Anatomic Considerations pterygoid bone, and caudally the ethmoid bone.
The mandible consists of the incisive part, interalveolar
The description and understanding of head fractures are rim, molar part, mandibular ramus, condylar process, and
aided by a good working knowledge of the anatomy of the coronoid process. The anatomic terminology describing
skull. The following summary should help the reader under- the mandible is not uniform. In this chapter, the tooth‐
stand the basic anatomy of the skull, but an anatomic text- bearing part of the mandible is referred to as the body or
book should be consulted for more detailed information.1 corpus (historically termed the horizontal ramus), and the
The bones of the head consist of the skull, mandible, and remaining vertical part as the ramus of the mandible (pre-
hyoid bones (Figures 41.1 and 41.2).32 The skull is broadly viously termed the vertical ramus). The horse has two
divided into the cerebral cranium or neurocranium, which mandibles, left and right, and the two mandibles are fused
forms a solid shell around the brain, and the visceral cra- to form an intermandibular suture line via a synchondrosis,
nium or splanchnocranium, which forms the basis for the which ossifies during the second year of life.
face. In contrast to humans, in the horse the visceral cra- The hyoid bone is located in the intermandibular space,
nium is much larger than the cerebral cranium and lies ros- where it is well protected between the two mandibular rami.
tral to, rather than below, the cerebral cranium. The bones
of the skull are usually flat and have a compact external and
internal lamina separated by a cancellous/spongy layer.
The cerebral cranium (neurocranium or calvarium) is
Introduction
divided into the roof and base of the skull, and consists of Fractures of the head, particularly of the mandible, are
the following parts: the dorsally situated frontal bone, common in horses.1 In a recent review of fractures caused
interparietal bone, and parietal bone; the laterally located by a kick from another horse, fractures involving the head
temporal bone (composed of the petrous part and tym- comprised 12% of all incidents and were the second most
panic part, which contains the inner and middle ear, and common such incident after splint bone fractures.23 The
the squamous part, with the zygomatic process); the ven- main causes were a kick from another horse, collision with
trally situated sphenoid bone, and the basilar part of the a solid object, or falls during which the horse’s head hit a
occipital bone, as well as the rostrally located occipital hard surface. The paucity of soft tissue makes the head
bone caudal to this, and the ethmoid bone. especially susceptible to fractures. Injuries to the head
The bones of the visceral cranium form, among others, range from small lesions, which may only be apparent as
the ocular, nasal, and oral cavities. The visceral cranium small indentations in the bone, to severe multifragment
consists of the frontal bone and nasal bone dorsally, and fractures with secondary involvement of vital structures
the lacrymal bone, zygomatic bone, incisive bone, and such as teeth, sinuses, eyes, nerves, or major blood vessels
maxilla laterally. The incisive bone consists of the alveo- (Figure 41.3). The extent and type of these secondary
lar part, which contains the alveoli of the upper incisors; lesions are usually the most important prognostic factors.
the palatine process, which forms the rostral part of the A common type of head fracture involves the rostral parts

www.ajlobby.com
a surprising fact considering that 80% of head fractures are

open. In the study by Hug (2009), 90% of horses with head
fractures were discharged following successful treatment
and only 10% had to be euthanized.23 Head fractures are
commonly missed or their significance is underestimated.
Computed tomography (CT) is a very useful diagnostic
procedure that is often indicated for the assessment of com-
plicated head fractures.2,4,26 In the horse, CT has had the
greatest impact in the management of diseases involving
the head, particularly fractures. Frequently head fractures
are much more dramatic on CT images than on radiographs
or what one would expect after external inspection.
Figure 41.1 Lateral schematic representation of the bones of the

skull. Legend to the various bones of the skull: 1, Incisive bone; 2, Clinical Signs
Nasal bone; 3, Frontal bone; 4, Maxilla; 5, Lacrimal bone; 6,
Zygomatic bone; 7, Interparietal bone; 8, Parietal bone; 9,
The clinical signs of head fractures are numerous and
Temporal bone; 10, Petrous and tympanic parts of temporal bone; depend on the location of the lesions. In addition to pain
11, Sphenoid bone; 12, Occipital bone; 13, Ethmoid bone; 14, during palpation of the affected head region, there may be
Palatine bone; 15, Vomer; 16, Pterygoid bone; 17, Mandible; 17a, hemorrhage from the ocular, nasal, or oral cavities, regard-
Incisive part; 17b, Interalveolar part; 17c, Molar part; 17d, Ramus less of whether the neighboring soft tissues are affected.
of the mandible; 17e, Condylar process; 17f, Coronoid process.
Occasionally emphysema may be palpated. Horses with
head fractures often have an abnormal general demeanor,
loss of appetite, drooling, and/or a foul odor from the
mouth. Fractures that involve the c erebral cranium usually
lead to neurologic deficits such as d epression, seizures,
head tilt, ataxia or vestibular syndrome. A fracture should
be suspected when there is asymmetry of the skull.
Clinical Examination
Figure 41.2 Ventral schematic representation of the bones of the
skull. The legend is the same as in Figure 41.1. A comprehensive assessment of a head fracture requires
a thorough clinical examination. Of critical interest is
whether the fracture involves soft tissue structures,
particularly the brain, but also the eyes or cranial
nerves. The clinical examination should be supple-
mented by endoscopy, ultrasonography, radiography,
and CT, if available. Depending on whether the central
nervous system (CNS) is involved, the patient is allo-
cated to one of two groups, which have very different
prognoses and require different treatment. If the nerv-
ous system is not affected, the demeanor and general
condition and appetite are usually normal and there are
no cranial nerve deficits. This is usually the case with
trauma to the rostral part of the visceral skull. The risk
of injury to the CNS increases considerably with trauma
Figure 41.3 Schematic representation of typical sites and fracture and fractures located further caudally, and in these
configurations of the equine skull. cases the immediate application of emergency meas-
ures is critical for a favorable outcome. The primary
of the visceral skull, including the alveoli of the incisors, concern that must be addressed initially is the risk of
when a horse firmly bites an object and suddenly with- cerebral edema, which is minimized by the immediate
draws its head while the teeth remain lodged. administration of dimethyl sulfoxide (DMSO), corti-
Most head fractures occur in the stall or on pasture in costeroids, mannitol, nonsteroidal anti‐inflammatory
the presence of other horses. Many head fractures are drugs, and intravenous fluids (for additional informa-
treated surgically and generally the prognosis is very good; tion see Chapter 42).
www.ajlobby.com
Examination of the oral cavity must be performed with because the bone is very thin and soft. Special small‐
care to prevent exacerbation of a fracture. A mouth gag is sized interlocking implants are available to effectively
usually inserted only on the contralateral side of the frac- manage selected fractures. Administration of antibiotics
ture. A minimum of two radiographic views must be taken is almost always recommended, because most fractures
in horses suspected of having a fracture. Additional views are open.
including oblique and intraoral radiographs are recom- Based on their location, skull fractures can be divided
mended when a fracture is diagnosed. However, the diag- into fractures of the cerebral cranium, visceral cranium,
nostic value of skull radiographs is limited, and many mandible, and hyoid bone. With normal occlusion, the
fractures cannot be definitively diagnosed, especially aspects of the bones of the maxilla and mandible that
those of the cerebral cranium. CT has become the diag- undergo traction are those inside the oral cavity. For this
nostic imaging method of choice for diagnosing equine reason, intraoral implants provide better stability than
skull fractures, and should be used in difficult cases.2,4,26 those placed on the ventral aspect of the mandible.
As for any fracture, preoperative preparation is essen-
tial: the surgical approach must be carefully planned, and
Treatment and Prognosis all required equipment must be available. Surgeons must
In the majority of horses with skull fractures, treatment have a wide variety of instruments at their disposal for
is successful and the prognosis is good.12 This applies not the repair of skull fractures. Special materials such as a
only to open fractures, but also to severely displaced U‐frame must be bent and drilled beforehand. The oral
fractures. The reasons for this include a good blood sup- cavity is thoroughly cleaned and rinsed. Fractures of the
ply to the head despite a paucity of soft tissue cover; a rostral mandible or the incisive bone, with or without
relatively small mechanical load to the bones of the head; involvement of the incisors, can be repaired in the stand-
jagged edges of fracture fragments, which often occur ing horse using sedation and local anesthesia. General
and allow stable fixation; the availability of instruments anesthesia is required for the treatment of complicated
and implants similar to those used in human craniomax- fractures, and nasal intubation is of great advantage in
illofacial (CMF) surgery; and the large cheek teeth, which rendering an unobstructed view to the oral cavity. The
provide a means of stabilization for certain fractures horse should be fitted with good head protection for the
(Figure 41.4). Fractures of the temporomandibular joint induction of anesthesia. Whenever possible the patient
(TMJ) or cerebral cranium, as well as old, infected, and should be assisted during recovery. A thorough knowl-
extensive fractures, have a guarded prognosis. Skull frac- edge of the anatomy of the head is a prerequisite for the
tures generally heal very quickly and implants do not treatment of head fractures, because many vital struc-
need to remain in place for a long time. Fractures involv- tures such as nerves, blood vessels, teeth, and salivary
ing the incisor teeth usually heal in approximately ducts may be in close proximity to the surgical approach.
8 weeks and those of other regions take 12 weeks, after The following structures must be protected during
which time the implants can be removed. surgery: the parotid duct, facial artery and vein, palatine
Cerclage wire is frequently used for repair of skull frac- artery, and infraorbital and mental nerves.
tures, because it is inexpensive and has a broad range of For most mandibular and maxillary fractures, the horse
applications (see Figure 41.4).21,31 The use of standard is placed in dorsal recumbency, because this allows access
plates and screws is limited for the repair of skull fractures, to both sides of the head. For all other fractures, the posi-
tion of the horse depends on the location of the fracture.
The teeth are often involved in fractures and this presents
a special problem, especially when the alveoli of the inci-
sors or cheek teeth are involved. Fractures of the body of
the tooth are rare, whereas the connective tissue attach-
ment (periodontal ligament) is frequently affected. In gen-
eral, loosened teeth associated with the fracture must not
be extracted. In many instances, teeth have a stabilizing
function and their removal may induce instability and
exacerbate the bone damage. However, the teeth involved
are often shortened by rasping, to prevent contact with
their counterparts in the maxilla or mandible and to
reduce the stress on the fracture line. If fistulas involving
teeth develop at a later stage, appropriate treatment can be
Figure 41.4 Overview of methods of fixation of various fractures carried out after the fracture has healed. Many dental
of the equine skull. disorders resolve spontaneously. Because head fractures
www.ajlobby.com
are often missed or underestimated, osteitis/osteomyelitis mature horses, they are removed only in cases of infection.
may develop in the affected region following inadequate Complications may be encountered during healing of a
conservative treatment. This may lead to a so‐called head fracture, but they can usually be managed success-
chronic fracture, but although many of these are infected, fully. Implant failures are rare, because the mechanical
treatment consisting of thorough cleansing of the wound stress on plates, screws, and cerclage wires in the head
and extensive curettage and flushing to remove all infected region is considerably less than in a long bone. Broken cer-
bone fragments is usually successful. clage wires are simply replaced if still needed, or removed.
Because bandages of the head are generally not fea- In most open fractures, infection of the bone is inevitable,
sible for extended periods of time, the surgical site and the development of osteitis/osteomyelitis and seques-
should be covered with a protective stent bandage. trum formation is therefore common. Sequestra require
Intraoral implants should be cleaned several times careful removal, curettage, and rinsing with generous
daily for the first few days. After this time, rinsing the amounts of an antiseptic solution, such as chlorhexidine,
mouth with water from a hose once a day is usually and aggressive and prolonged broad‐spectrum antibiotic
sufficient. The design of the box stall must be such treatment. Dental fistulas are common after fractures that
that the patient can move around, lay down, and rise involve teeth and require specific treatment, which could
safely without the danger of hitting its head on a pro- involve endodontic procedures or extraction.
truding object, particularly when an external fixator
has been applied. Sutures should be examined and
wounds and fistulas cleaned and rinsed daily. Adequate Fractures of the Calvarium
drainage must be ensured to allow open wounds to (Cerebral Skull)
heal from the inside. Open wounds and fistulas nor-
mally take a long time to heal completely, but they can Introduction
easily be treated by the owner and an extended period
of hospitalization is rarely necessary. Nonsteroidal Fractures of the calvarium or cerebral skull are divided
anti‐inflammatory drugs are given for a short time, into fractures of the roof and those of the base of the skull.
but antibiotics are needed for extended periods, often In the horse, fractures of the base of the skull are uncom-
several weeks, because of wound contamination and mon. Fractures of the cerebral skull are often associated
infection. Wounds that fail to heal must be reexam- with intracranial hemorrhage and edema, which lead to
ined and any sequestra present removed. neurologic deficits defined by the cerebral areas involved.
The postoperative workload of the horse depends on This underlines the importance of a neurologic examina-
the type of fracture, its treatment, and the progress of tion when presented with a patient with a skull fracture.
healing. External fixators and intraoral implants must be
removed after the fracture has healed, and this can usually
be accomplished under sedation alone. There is often
Causes
localized infection around the pins of an external fixator, Head trauma results from collision with immovable
but this resolves quickly once the pins are removed. In objects, kicks from other horses, or from falls during
growing horses, all implants are removed, whereas in which the head sustains a forceful impact (Figure 41.5),
(A) (B)
Figure 41.5 (A) Computed tomography (CT) image of a compression fracture of the parietal bone of a mature horse, which resulted in
immediate death after impact. (B) Transverse CT image of a fractured parietal bone of a mature horse, which died immediately.
www.ajlobby.com
and most are accompanied by soft tissue injuries. fractures were detected by radiography alone.15
Although bone injuries are common in head trauma, Pneumocephalus can be secondary to fracture of the
injuries to the CNS are relatively rare, with the exception sinus or calvarium, and can resolve without serious
of horses that rear over backward and hit their head on a consequences unless the brain parenchyma or brainstem
hard surface during their fall. The prognosis is particu- are involved (Figure 41.6).14 Endoscopic examination
larly poor when the base of the occipital bone is affected of the upper airway serves to identify neurologic defi-
(basioccipital fracture).2,4,15 cits involving the larynx and pharynx, and to diagnose
injuries to the hyoid bone, or the source of hemorrhage
into the guttural pouch. Cytologic analysis of the cere-
Examination brospinal fluid may provide a lead in obscure cases or
In addition to clinical and radiographic examination, help confirm a tentative diagnosis. A final diagnosis is
CT is an important and often indispensable diagnostic often not possible, especially when diagnostic modali-
procedure for the assessment of the entire extent of a ties such as CT or MRI are limited; however, a diagnosis
fracture.2,18,26 The severity of a head fracture is fre- may be reached on the basis of the patient’s response
quently underestimated in cases where CT was not to treatment. After the initial examination, follow‐up
used (see Figure 41.5). A recent study of skull fractures examinations should be carried out at regular intervals
in the horse revealed that only about half of all to monitor the progress of the healing phase.16
(A) (B)
(C) (D)
Figure 41.6 (A) Foal with severe laceration and frontal bone fracture after being kicked in the head by the mare. The foal was blind but
ambulatory. (B) Three‐dimensional computed tomography (CT) reconstruction showing fracture of the frontal bone extending to the
temporal and parietal bones. (C) Sagittal CT slice showing frontal and cribriform plate fracture, with impacted bone in the frontal cortex
and extensive pneumocephalus. (D) Corresponding transverse CT slice showing fracture of the frontal bone and portions of the cribriform
plate in the frontal cortex with adjacent gas. Source: Images courtesy Dr. Alan J. Nixon.
www.ajlobby.com
Clinical Signs
Injury to the CNS after a head fracture commonly
results in changes in behavior and demeanor, such as
depression, apathy, stupor, or coma (Figures 41.7 and
41.8). Other common signs are muscle spasms, opis-
thotonus, vestibular dysfunction, and specific cranial
nerve deficits. The latter are most easily diagnosed
when they involve the eyes. Affected horses may have
nystagmus with the fast phase directed away from the
lesion, strabismus, bilateral mydriatic unresponsive
pupils, bilateral miosis, or anisocoria. These manifesta-
tions usually indicate severe head trauma and a guarded
prognosis. Fractures of the base of the skull may be
associated with brainstem lesions (Figure 41.9), and can Figure 41.8 Transverse computed tomography (CT) image of
lead to changes in heart and respiratory rates. Other the foal in Figure 41.7, showing the fractured petrous temporal
possible accompanying signs are hemorrhage into the bone (arrows).
external ear canal and leakage of cerebrospinal fluid
from the ears and nares. The severity of the clinical
signs generally is closely correlated with the severity of
the lesions in the CNS, although the absence of
neurologic signs does not rule out CNS involvement.
Following severe head trauma, affected horses may go
down or die acutely.
Figure 41.9 Transverse computed tomography (CT) image of a

fractured basisphenoid bone in a mature horse.
Treatment
The immediate implementation of aggressive treatment
in a horse with an injury to the CNS is critical for a
favorable outcome, especially in a recumbent patient;
prolonged periods of recumbency are a significant indi-
cator of a poor prognosis. A recumbent patient is lifted,
preferably with a rescue sling designed for this purpose.17
However, if the horse is unable to support its own weight,
it is placed back in lateral recumbency. Circulatory shock
therapy is aimed at hemostasis and stabilization of respi-
ration and the circulatory system. Intravenous fluids
prevent a drop in blood pressure. Recumbent patients
are placed on soft bedding and rolled to the other side
every four to six hours to prevent muscle necrosis and
damage to peripheral nerves. Protective headgear is
Figure 41.7 Foal with a head tilt attributable to a fractured left applied to prevent soft tissue injuries. The patient’s
petrous temporal bone. respiratory, cardiovascular, and intestinal function, and
www.ajlobby.com
the passing of manure and urine, are monitored Surgical Treatment

continuously. Surgical intervention for trauma of the cerebral skull
The primary goal of drug therapy is the prevention should be restricted to those cases in which a real benefit
and treatment of cerebral edema and the associated can be expected from fracture reduction or intracranial
increased intracranial pressure.16 Dexamethasone decompression. These include meningeal injuries, frac-
(0.05–0.1 mg kg−1, intravenously, once a day) should be tures leading to injuries of the surface of the CNS, or cases
administered at the very start of treatment; clinical that are not yet recumbent but with progressing neuro-
improvement can be expected within 12–24 hours if logic signs despite aggressive treatment. Fragments of the
the disorder present is amenable to this treatment. paracondylar process may be removed surgically.28
Mannitol (1 mg kg−1, intravenously, four times a day)
may be given to relieve cerebral edema and reduce Prognosis
intracranial pressure; clinical improvement typically
occurs within a few hours. Hydration must be moni- The prognosis for a cerebral skull fracture depends
tored carefully during this treatment, and mannitol is mainly on the extent of the lesion. Furthermore, patients
contraindicated in cases with intracranial hemorrhage. that respond poorly or not at all to the initial treatment
Because of its anti‐inflammatory effect, DMSO is used generally have a guarded prognosis, as do horses with a
by many clinicians to treat CNS diseases. Although fractured skull base, and those that have been down for
there are currently no formulations of mannitol or more than four hours.4 Interestingly, a recent study
DMSO that are approved for the horse, the latter drug revealed that the prognosis for horses with cerebral skull
is used at our clinic at a dose of 1 g kg−1, intravenously, fractures is generally better than is commonly assumed;
once a day for three days, followed by the same amount approximately 62% of horses diagnosed with a fracture of
administered every other day for three further treat- the cerebral skull were healed at the time of discharge.15
ments. A 20% solution is used, administered slowly
(over hours) to reduce the risk of hemolysis. As for Fractures of the Facial Bones
mannitol, hydration must be monitored carefully
because of its diuretic effect. If necessary, intravenous
fluids can be administered at the same time.
Introduction
Nonsteroidal anti‐inflammatory drugs are given at rec- This subchapter deals with fractures of the facial skull,
ommended dosages to combat inflammation of the excluding fractures of the rostral part of the incisive
CNS. Broad‐spectrum antibiotics are indicated in con- bone. Fractures of the facial skull must be examined
firmed or suspected open fractures (e.g., hemorrhage thoroughly for the possible involvement of adjacent
from ears or nares); trimethoprim‐sulfonamide drugs structures such as the oral and nasal cavities, sinuses, the
(30 mg kg−1, orally, twice a day) appear useful, because orbit, eyes, and adnexa, as well as the cerebrum and
at least some sulfonamides can reach therapeutic levels other parts of the nervous system.1 Most trauma to the
in the cerebrospinal fluid. Diazepam and phenobarbital facial region includes large depression fractures with
may be used to treat muscle spasms and seizures.15 multiple large or smaller bone fragments that are pushed
(A) (B)
Figure 41.10 (A) A severe head injury with multiple fractures of the maxilla and exposure of the maxillary sinus in a horse that was kicked
by another horse. (B) The same horse five months after surgical repair of the fracture.
www.ajlobby.com
Figure 41.11 (A) Head trauma involving the left

(A) (B)
frontal and nasal bones with exposure of the nasal
cavity. (B) Close‐up view of the injury. (C) Head of
the horse 10 years after the injury. (D) Post-mortem
preparation of the skull of the horse 14 years after
the injury, when the horse was euthanized because
of lameness. Note the multiple cerclage wires used
in the repair.
(C) (D)
into the sinus, nasal cavity, or orbit by an external force

Treatment
(Figures 41.10 and 41.11). Like most head fractures in the
horse, facial fractures are usually open, and frequently Surgical exploration of a complicated skull fracture is
large sections of skin are separated from the bone. strongly recommended, because it allows evaluation of
Fractures of the nasal bone are commonly associated the full extent of the damage.1 The severity of most facial
with the separation of large portions of soft tissue from fractures is difficult to assess with a clinical examination
the bone, whereas soft tissue involvement is less com- alone, and even with radiographic and ultrasonographic
mon in fractures of the frontal and maxillary bones.12 As examinations it is frequently not possible to gauge the
with fractures of other parts of the skull, the extent of extent of injury. Surgical treatment is indicated in most
involvement of the facial skull is often underestimated open fractures, whereas small closed depression frac-
without a thorough radiographic or CT examination, tures with minimal displacement may be amenable to
and surgeons are frequently surprised by the actual conservative treatment. Conservative treatment carries
extent of the traumatic insult encountered during CT a much greater risk of wound infection or other compli-
and/or surgery. The prognosis for facial skull fractures, cations such as chronic or mycotic sinusitis, sequestrum
even large ones, is usually very good, because of the formation, delayed wound healing, deformation of the
abundant vascular supply to the region and the low phys- skull, narrowing of the nasal passages, or head shaking.
ical load that most bones encounter during mastication Surgical intervention should be performed as soon as
(see Figures 41.10 and 41.11). possible once the patient is stable and has received
www.ajlobby.com
nonsteroidal anti‐inflammatory drugs and antibiotics. together; they are freed and any blood clots are care-
Smaller bone fragments that commonly accompany fully removed.
larger ones often render exact repositioning difficult.
Although wound healing is generally good in the head Reduction
region, soft tissues must be handled gently, and an After wound debridement has been achieved and the
attempt should be made to maintain periosteal attach- trauma assessed, the fracture is reduced using one of sev-
ment to the bones and complete soft tissue cover. A vari- eral methods. Repositioning hooks can be made easily by
ety of special instruments for repositioning and fixation bending 2.0 or 2.6 mm Kirschner wire. These hooks are
of skull bones have been developed for humans, and introduced into bone fragments or intact bone through
several of them, including extraction instruments and predrilled 3 mm holes (Figure 41.12) and, by applying
rosettes (FlapFix, DePuy Synthes, West Chester, PA, careful and controlled traction to the hook, the frag-
USA), are useful in equine surgery.1 ments are retracted into their normal anatomic position.
Usually several holes are drilled so that the traction force
is evenly distributed. Alternatively, periosteal elevators
Surgical Procedures or Langenbeck retractors can be effectively applied for
Surgical Approach, Fracture Assessment, and Fracture
fracture reduction.1,35 In addition, a specially designed
Management
reduction instrument (Figure 41.13), manufactured in
Surgery is undertaken with the horse under general
two sizes (2.4 and 3.5 mm), has recently become availa-
anesthesia, or rarely in standing patients using seda-
ble. It consists of a horizontal cross‐handle, connected to
tion and local analgesia. Soft tissue injuries are treated
a tap‐like rod that is twisted into the bone fragment. Of
by applying standard principles. The wound edges are
all the various instruments that are available, these are
debrided and the wound rinsed liberally. Sinuses that
the best for use in the horse. Depending on the size of the
have been exposed by the injury are also rinsed. For
fragment, a 1.8 or 2.4 mm drill hole is prepared and the
closed fractures, a curved incision of the skin is made,
instrument inserted into the bone fragment. Occasionally,
starting at the center of the fracture and then extended
it is necessary to trim the bone fragments to facilitate
beyond the visible edges of the fracture. Once the skin
correct anatomic repositioning and fracture reduction.
is incised and the wound debrided and rinsed, the
skin is retracted and the fracture assessed. Care must
Fixation
be exercised during preparation of the fracture site to
preserve the connection between the periosteum and Minimal internal fixation. Bone fragments with jagged
the underlying bone. Small loose bone fragments that edges that can be wedged into other fragments are
are not connected to the periosteum are removed. often reduced and stabilized without additional fixa-
Depression fractures typically have multiple frag- tion, provided that the fracture appears stable after
ments that are displaced inward and firmly wedged reduction (Figure 41.14).12,33,35
Figure 41.12 (A) Fracture of the left frontal

(A) (B) and nasal bones with multiple bone
fragments in a Warmblood gelding. (B) The
fracture was reduced and the fragments
repositioned using Steinmann pins that were
introduced into small drill holes. The
depression fracture was reduced by applying
traction to the bent Steinman pins, and
reduction was maintained solely via
interdigitation of the jagged edges of the
bone fragments; no implants were used for
fixation.
www.ajlobby.com
(A)
(B) (C) (D)
(E)
Figure 41.13 Fracture of the frontal and nasal bones and maxilla in a horse that was kicked by another horse. (A) Presurgical laterolateral
radiographic view. (B) Intraoperative view of the fracture. (C) Reduction of bone fragments using traction devices. (D) Fixation using
titanium rosettes. (E) Postsurgical laterolateral radiograph.
www.ajlobby.com
(A) (B)
Figure 41.14 (A) Fracture of the nasal and incisive bones in a horse that was kicked by another horse. (B) View of the fracture after
reduction, which was achieved without internal or external fixation.
Fixation using polydioxanone. Head fractures may be

repaired using #2 polydioxanone sutures, which have (A)
several advantages: no additional implants are
required, and the suture material cuts only minimally
into the bone, retains its tensile strength for approxi-
mately 56 days, and is usually absorbed by 182 days,
which eliminates the need for suture removal.33
Fixation using cerclage wire. Skull fractures may be
repaired using 1 or 1.2 mm (20‐ or 18‐gauge) cerclage
wire once they are reduced and properly aligned.12
Holes approximately 2 mm in diameter are drilled into
the bone fragments. Great care should be used when
tightening cerclage wires, because the bones of the (B)
facial skull are usually thin and easily cut by the wire
(Figures 41.15 and 41.16).
Fixation using rosettes. The advantage of this method
(FlapFix; see Chapter 50) is that the titanium rosettes
provide a large contact area with the bone fragments,
which minimizes the iatrogenic bone damage poten-
tially occurring during fracture reduction (see
Figures 41.13 and 41.16). However, an even bone sur-
face is a prerequisite for stable application of the
rosettes.
Fixation using plates. Large fractures are amenable to
repair using suitable plates.8,13 At the present time,
locking plates are favored by most surgeons, because
they allow very stable fixation. Plates like the 3.5 lock- Figure 41.15 (A) Fixation of a fracture of the frontal bone using
ing compression plate (LCP) reconstruction plates or cerclage wire. (B) Schematic representation of the reduction
the 2.4‐mm UniLock (DePuy Synthes) system are use- (arrow) and fixation of the frontal bone using cerclage wire.
ful implants (Figure 41.17). Most fixation methods
using plates require only a few short screws of
8–14 mm length.
primary wound closure is not always possible, particu-
larly in fractures associated with extensive loss of bone,
Skin Closure soft tissue, and skin damage. Many of these fractures
The skin overlying the fracture should be sutured and wounds heal surprisingly well via second intention
whenever possible, and the use of distant relief inci- and have a satisfactory functional and cosmetic outcome.
sions usually facilitates primary skin closure. However, Depending on the degree of contamination, a flush tube
www.ajlobby.com
facial skull, orbital fractures are often characterized by

multiple fragments of various sizes, which must be
reduced to their normal position cautiously using trac-
tion. Either 2.7 or 3.5 mm reconstruction plates are suit-
able for fixation, because they are easily adapted to the
shape of the bones.1 The prognosis with prompt medical
and surgical therapy of orbital fractures is favorable.19
Fractures of the Jaw
Introduction
This section deals with fractures of the mandible and the
incisive bone of the maxilla. Mandibular fractures are
the most common head fracture in the horse. The rostral
Figure 41.16 Fixation of a fractured maxilla using cerclage wire
and rosettes. parts of the mandible are more prone to fracture than the
caudal parts.12 The clinical manifestations as well as
treatment options for mandibular fractures vary consid-
may be inserted into an injured sinus to facilitate flush-
erably, depending on whether the incisor region, the
ing during follow‐up treatment. Drains may also be
interdental space (diastema), the body (horizontal
required if dead space occurs between bone and skin.
ramus), the ramus (vertical ramus), or even the temporo-
mandibular joint (TMJ) is affected. Rostral fractures are
Follow‐up Treatment
the least stable fractures, because the cheek teeth and
A head bandage and padded head protection are applied
muscles, which provide some stability, are lacking in this
to the patient during recovery from anesthesia.
region. Incisive bone and mandibular fractures often
Depending on the healing progress, nonsteroidal anti‐
open into the oral cavity, because fracture fragments are
inflammatory drugs and antibiotics are given for three to
typically sharp and there is very little soft tissue covering
five days, or longer if required. In most cases implants do
the bones. Therefore, many of these fracture sites are
not need to be removed, provided that wound healing is
contaminated and infection is a common sequel. If den-
normal and no persistent draining tracts develop.
tal alveoli are involved, loss of one or more teeth can
occur, either immediately during the traumatic event or
Orbital Fractures later as a result of infection.
The orbit is prone to fracture because of its exposed

location on the head. These fractures present a special Clinical Signs
challenge because, in addition to the bony eye socket,
associated structures such as the globe or neighboring Clinical signs of fractures of the mandible and incisive
parts of the brain may be involved (Figure 41.18). For this bone vary with their location and include dysphagia,
reason, orbital fractures must be thoroughly examined. excessive salivation, abnormal head contour, halitosis,
Most orbital fractures require surgical intervention to malocclusion, crepitation, and oral hemorrhage. Severe
restore correct anatomic relationships, particularly with fractures may also affect the demeanor and general con-
respect to the globe and its nervous and vascular sup- dition of the horse. In older fractures, a foul‐smelling,
plies. With fractures of the inner wall of the orbit, the fetid odor may be noted.
globe may be displaced into the maxillary sinus.7 When
this occurs, repositioning of the globe may be achieved
Etiology
nonsurgically, but a surgical approach is usually recom-
mended. The outer parts of the orbit consist of solid Like other head fractures, those of the jaw are commonly
bone and are therefore amenable to fixation with surgical caused by blunt trauma such as a kick from another
plates, whereas the deeper parts are thin and do not usu- horse, a fall, or collision with a solid object. Rostral frac-
ally allow repair using implants (Figure 41.19). The fron- tures can occur when a horse bites onto vertical metal
tal, temporal, and zygomatic bones are commonly bars in the stall: the horse bites the bar with its head in
involved in orbital fractures and are typically displaced a slightly horizontal position and then suddenly pulls
inwardly. Similar to fractures of other parts of the back after positioning its head vertically. Because of the
www.ajlobby.com
(A)
(B) (C)
Figure 41.17 (A) Radiographic view of a large fracture of the facial skull involving nasal and frontal bone. (B) Intraoperative view of the
fracture, showing numerous depression fractures of nasal, frontal, maxillary, and lacrimal bones. (C) Fixation of the fracture using several
locking plates.
relatively large total width of the lower incisors, they tomographic examination is extremely helpful and is
become wedged between the bars, resulting in alveolar strongly recommended.
fractures with rostral dislocation of the incisors.
Interestingly, these fractures often cause little pain, and if
the dislocation is minimal, may be missed and left to heal Treatment
without treatment.12 Such fractures are more common
in nervous or curious young horses. General Considerations
The surgical fixation technique depends on the severity
and localization of the fracture, as well as the age and
Examination weight of the patient. Because most jaw fractures are unsta-
A thorough clinical examination of the oral cavity and ble and distracted, conservative treatment alone without
radiographic examination of the fracture are carried out surgical fixation is rarely successful and should there-
to develop a treatment plan. In complicated cases or fore not be attempted. General anesthesia with the horse
when involvement of the TMJ is suspected, a computed in dorsal recumbency is suitable for most situations,1
www.ajlobby.com
side of the bone. This can be associated with considera-

ble mechanical stress on the implant, sometimes leading
to implant failure (see later Figure 41.39). As a general
rule, teeth are left in place because they provide support,
improve fixation, and increase stability. Even loose or
fractured teeth should not be removed until later in the
course of treatment, when the fractures have healed.
Wound Management
All fracture wounds are carefully cleaned and rinsed.
This involves trimming the soft tissue wound edges with
a scalpel if necessary, and debridement of the bones
with a sharp spoon curette, accompanied by rinsing with
0.05% chlorhexidine solution to remove all debris. Drains
Figure 41.18 Orbital fracture in a horse. are an important consideration, because jaw fractures
commonly open into the oral cavity and are therefore
prone to infection. A drain allows the removal of wound
although less invasive procedures such as intraoral wire secretions, but also therapeutic flushing of the wound.
fixation of rostral fractures involving the incisors are com- Healing complications, including infection, sequestrum
monly carried out in the standing, sedated horse. Alveolar formation, implant failure, and fistulas, are common and
and infraorbital nerve blocks (Figure 41.20) provide in one study had an incidence of 27%.21 However, the
regional anesthesia for these cases.31,34 majority of these complications respond to treatment
and have a favorable outcome.
Surgical Planning and Preparation
As with other head fractures, the full extent of the lesion Follow‐up
may only become apparent during surgery, and therefore During the postsurgical period, the horse is confined to
the surgical team should be prepared for all eventualities. stall rest and fed soft fiber feed stuff; firm feed such as hay
This includes preparation for intraoperative imaging, cubes, apples, or carrots should be avoided. Antibiotics
orthopedic reduction, and stabilization, as well as dental and anti‐inflammatory drugs are given for three to five
procedures. The head region involved is generously clipped days, or longer if required, especially in open fractures.
and surgically prepared, and the mouth is rinsed liberally. If Intraoral cerclage and tension wires are cleaned twice
manipulations inside the mouth are required, nasotracheal daily for a few days, then once daily until removed.
intubation is recommended. The mouth is held open using
an appropriate mouth gag that does not put any pressure
on the fracture site; wedges made from hard rubber or Surgical Techniques
plastic placed between the cheek teeth not involved in the
fracture work well for this purpose. In complicated cases Intraoral Wire Fixation
requiring intraoperative imaging, the horse should be The majority of rostral fractures are amenable to wire
positioned to facilitate radiographic access; fluoroscopy fixation. For this procedure, the wire loops are first
is particularly useful in these cases (Figure 41.21). placed at the predetermined locations, then tightened
Required surgical equipment includes instruments for by hand and finally tightened using pliers or needle driv-
orthopedic procedures and wire fixation, a drill with spe- ers. This must be completed in an even fashion, alter-
cial bits for dental drilling, various surgical plates and nating between multiple loops, and with careful
screws, as well as arthroscopy or other rigid endoscopy monitoring of the fracture site to avoid displacement
equipment for intraoral examination.1 Grinding tools are after reduction. After the wires are tightened, the
often required to lower the chewing surface of the inci- twisted ends are shortened and bent flat so that they do
sor teeth to decrease pressure on the fracture site during not irritate or injure the gingiva. The mouth is closed
chewing while the fracture is healing. Dental extractors manually to assess reduction of the fracture and occlu-
should also be available. Since the tension side of the sion of the teeth. Correct reduction of the fracture can
mandible and maxilla is in the mouth, implants should also be verified by applying reduction forceps to the
ideally be placed intraorally;1 however, with the excep- upper and lower jaw (Figure 41.22). If the reduced frac-
tion of tension band wires and intraoral splints, this is ture collapses during final tightening of the wire or if the
not usually feasible.24 As a result, and for practical fracture remains unstable, other fixation methods such
reasons, implants are often applied to the compressed as plates should be used. Cerclage or hemicerclage wire
www.ajlobby.com
(A)
(B) (D)
(C)
Figure 41.19 (A) Computed tomography (CT) slice showing multiple fractures of the left orbit, with dislocation of the globe medially and
ventrally. (B) Reconstructed CT image of the fracture. (C) Postsurgical radiographic view after reconstruction with multiple small plates.
(D) The horse two months after the injury.
without incorporating the incisor teeth may also be immediately adjacent to the fracture may not be very
used for fixation of the mandibular symphysis or in frac- stable, and therefore at least two teeth should be engaged
tures of the interdental space. In one study, 90% of all on either side of the fracture. The wire should always be
rostral fractures that involved incisors could be fixed tight and care must be taken that it is not weakened by
using cerclage wire.21 repeated bending during insertion. A sharp end can be
created by cutting the wire at an angle, which facilitates
Wire Placement penetration of the gingiva. Alternatively, a 2 mm (14‐
In the horse, 1.2 mm (18‐gauge) orthopedic stainless‐ gauge) hypodermic needle can be used to penetrate the
steel wire is most commonly used for cerclage.22 The tissue and allow passage of the wire (Figure 41.23A), or
teeth that are not involved in the fracture serve as small holes (2.0 or 2.5 mm diameter) may be prepared
anchors and are engaged by the wire.30 The teeth using a Steinmann pin or a small drill bit.21,31 A drill is
www.ajlobby.com
usually required for passing a wire between the incisors,

and almost always for placing the wire between cheek
teeth.
Wire Fixation of the Incisors

For rostral fractures that result in loosening of the inci-
sors, an interdental continuous wire loop splint origi-
nally described by Obwegeser in 1952 can be used
(Figure 41.23).6 It allows the application of uniform ten-
sion between all the teeth that are engaged in the splint.1
Wire placement is shown in Figure 41.23B: one end of
the wire is guided back and forth between all incisors to
form small loops in front of the incisor teeth, starting on
one side of the arcade. The other end of the wire is then
threaded through the loops, followed by tightening of
the wire ends. Subsequently, each wire loop previously
created in front of the incisor teeth is tightened in a uni-
form fashion. There are many other ways to place the
wire loops for optimal accommodation and compression
of the fracture. Simple loops must overlap to ensure that
teeth are not pulled apart,30 and figure‐eight loops can
be used to increase stability (Figure 41.23C). Wires
should not be placed through a fracture line. Numerous
Figure 41.20 Nerve blocks in the head region. 1, Infraorbital nerve variations of wire placement are possible in the upper
block at the maxillary foramen; 2, Infraorbital nerve block at the jaw and, unlike the lower jaw, wire can also be placed
infraorbital foramen; 3, Inferior alveolar nerve block at the mandibular across the palate from one side to the other.
foramen; 4, Inferior alveolar nerve block at the mental foramen.
Figure 41.21 Fluoroscopic monitoring of

the placement of plates and screws during
surgery.
www.ajlobby.com
Figure 41.22 Reduction of jaw fractures

using reduction forceps to check
preliminary alignment during placement
of cerclage wires.
(A) (B) (C)
Figure 41.23 (A) Insertion of an 18‐gauge wire using 14‐gauge (2 mm) needles. (B) Interdental continuous wire loop technique described
by Obwegeser. (C) Figure‐eight wire loop engaging the canine tooth.
Anchoring the Wire associated with screw loosening, fistulation, and subse-

Depending on the fracture and the degree of stability quent loss of tension. Cheek teeth provide very good sta-
required for fixation, wires are anchored around the bility for tension wires, with the wire usually placed
canine tooth or cheek teeth. If the canine teeth are used between the 06 and 07 teeth (the second and third pre-
for anchoring, a notch is filed into the tooth at its base to molars; Figure 41.24B). To achieve this, the skin on the cheek
prevent the wire from slipping off. Alternatively, a screw is clipped, surgically prepared, and a short arthroscopy
can be placed into the mandible for anchoring sleeve with a trocar or obturator is advanced through
(Figure 41.24A), but this carries a high risk of infection the cheek and into the mouth via a stab incision.1 This
www.ajlobby.com
(A) (B) (C)
Figure 41.24 (A) Anchoring the wire loop using a screw. (B) Drilling a hole between teeth 406 and 407 for insertion of wire. (C) Wire across
the interdental space is twisted together to increase compression of the fracture site.
technique minimizes hemorrhage, which can be a prob- compression plates (DCPs) can be used, but LCPs are
lem when the tissue is cut with a scalpel. A long 3.2 mm presently preferred, because they provide better stability.25
drill bit is then introduced through a protective drill In areas with only one cortex and a predominance of
guide and a hole is prepared between the two cheek spongy bone, locking-head screws provide good stability.
teeth. Once the wire has been placed to form a loop, it Depending on the size of the horse, narrow 3.5 or 4.5
can be twisted together in the interdental space to LCPs are used. Biomechanical studies have shown that
increase tension (Figure 41.24C). The correct position- intraoral wire fixation combined with a plate provides
ing of the wire in the oral cavity can be confirmed optimal stability.29 Plates applied ventrolaterally or ven-
endoscopically. tromedially, on the other hand, appear to be less satis-
factory (Figure 41.27). Severely comminuted fractures
Fixation Using Screws and/or Plates involving the body and ramus of the mandibles may
Many fractures of the body or the ramus of the mandi- require plate fixation and cerclage wire or additional
ble can be fixed using screws and plates (Figures 41.25– external fixator application.9,24 Many simple fractures
41.27). In selected cases, interfragmentary screws are of the ramus of the mandible heal without surgery, due
applied to provide compression at the fracture site. As to the stabilizing effect of the masseter muscle. Where
mentioned earlier, screws are also used to anchor wire the fracture overrides or overtly interferes with masti-
fixations. Although the oral side of the mandible and cation, stabilization with a narrow limited‐contact
maxilla is the tension surface, plates are frequently dynamic compression plate (LC‐DCP) applied to the
applied on the ventral compressed side of the mandible, caudolateral side of the ramus may be warranted (see
where the thick cortex provides a stable fixation Figure 41.26A). Complex fractures of the ramus can be
(Figure 41.25).24 The horse is placed in dorsal recum- repaired with a caudally applied compression plate such
bency, and the fracture site is prepared and freed from as the LC‐DCP or LCP, which frequently is contoured
soft tissue axially and abaxially. Blood vessels and sali- to extend onto the ventral surface of the body of the
vary ducts are preserved and protected during surgery mandible (Figure 41.26B). Where further stabilization
using Penrose drains. The fracture is stabilized using is required, plates can be applied to both the caudal and
reduction forceps and the plate is applied. Dynamic lateral surfaces.
www.ajlobby.com
(B)
(A)
Figure 41.25 (A) Intraoperative view of a comminuted fracture of the mandibular body with a medial free fragment. (B) A limited‐contact
dynamic compression plate has been applied to the ventral aspect of the mandible. Note that the smaller fragment has been secured
using an independently placed screw.
(A) (B)
Figure 41.26 Schematic representation of plate repair of fractures of the ramus of the mandible. (A) Lateral plate application of a
horizontal fracture of the ramus using limited elevation of the masseter muscle. (B) Repair of a comminuted fracture of the ramus of the
mandible, with a caudally applied plate extending ventrally onto the body of the mandible.
Fixation Using a U‐Splint or U‐Shaped interdental space that might collapse when the wires
Splint are tightened. The implants are molded and fixed to the
Metal splints can easily be bent into a U‐shape and jaw in several spots using wire loops (Figure 41.29), in
attached to the buccal aspect of the incisors and cheek an attempt to prevent collapse of the fracture.10,11 First,
teeth using wire sutures (Figure 41.28). However, attach- 2 mm holes are drilled between the teeth and across the
ment of the splint to the caudal cheek teeth is very diffi- bone in selected locations. The polymethylmeth-
cult, time consuming, and presents a major limitation of acrylate (PMMA) compound is then mixed and molded
this technique. to the area to be reinforced at a thickness of 6–8 mm.
Acrylic implants that are too thick impair chewing.
In the lower jaw, the mold should have a U‐shape so
Fixation Using Polymethylmethacrylate that the frenulum of the tongue is not restricted,
Compounds whereas in the upper jaw the acrylic can be applied
Methylmethacrylate implants are used to reinforce directly over the hard palate. Cold‐curing acrylic is
comminuted jaw fractures, particularly those in the used to prevent thermal tissue damage. Wires are
www.ajlobby.com
(A) (B)
(C) (D)
Figure 41.27 (A) Typical mandibular fracture. (B) Fixation of fracture using cerclage wire from incisors to first cheek tooth; this is often
insufficient for complete fracture reduction. (C) Fixation of fracture using cerclage wire and locking compression plate. (D) Alternative
placement of the plate laterally on the mandible.
Figure 41.29 Schematic representation of a

polymethylmethacrylate intraoral splint secured and anchored
Figure 41.28 Schematic representation of the placement of a with several wire loops and the incisor to cheek tooth tension
U‐splint. band wire.
www.ajlobby.com
subsequently threaded through the holes in the jaw and

pushed through the soft acrylic. Once the acrylic is
hardened, the wire loops can be solidly tightened. This
technique has the advantage of being inexpensive and
minimally invasive, while providing good stabilization
at the tension surface of the fracture site. Disadvantages
are the relatively difficult and time‐consuming applica-
tion of the material and its limited strength.
Fixation Using Intramedullary Pins

The stability obtained with intramedullary pins is lim-
ited and this technique is now rarely used in horses.
Fixation Using External Fixators

External fixators can be used to stabilize fractures of the
body or horizontal ramus of the mandible (Figure 41.30).
The Kirschner–Ehmer (KE) apparatus is most commonly
used as a type I or II fixator.5,12 A type I fixator engages the
two cortices of one mandibular body and a type II fixator
engages both mandibles. Positive‐profile threaded pins
have higher strength and better pin–bone interface stabil-
ity; pins with a diameter of approximately 4 mm are used
in the horse. Holes for the pins are predrilled and care
must be taken to cool the drill bits to prevent thermal tis-
sue damage. If feasible, two pins are used on either side of
the fracture.5 Crossbars should be used to increase the
strength of the fixation. All pins as well as external bars
are shortened and padded to prevent them from getting
caught on objects in the horse’s environment. The
implants are placed remote to the fracture site, and access Figure 41.30 Schematic representation of the use of an external
fixator in a mandibular fracture.
is readily maintained for local wound treatment, both fea-
tures representing major advantages of external fixation.5
Fixation Using a Pinless Fixator

This technique provides quick and minimally invasive fixa- injuries. Dental alveoli are generally involved in these
tion of mandibular fractures in the horse.20,27 It is indicated fractures, but the teeth themselves are rarely fractured.21
in fractures in which extensive infection precludes the Considerable force may be required to place the teeth
immediate use of plates and other implants.1,20 The pinless back into their normal position (Figure 41.32). These
fixator uses clamps that function similarly to a type I exter- fractures are quite amenable to wire fixation and the
nal fixator, but without penetrating the bone (Figure 41.31). canine or second premolar tooth is usually selected as
This technique has the advantages of providing a reduced the back anchor (Figure 41.33). In foals, the wire loop
risk of dental damage and osteomyelitis, allowing minimally should extend across the symphysis to prevent it from
invasive application, ensuring long‐term maintenance of splitting, even in fractures involving only one side of the
the clamping force, and enabling repeated use of the clamps. mandible. The wire fixation may be applied in the
sedated standing patient or under general anesthesia
with the horse in lateral or dorsal recumbency. The wires
Examples of Jaw Fractures are removed six to eight weeks later, when healing
should be complete.31 In foals, wire removal is often
Body of the Incisive Bone Involving the Alveolar done earlier, because healing is very rapid and there is a
and Incisive Parts of the Mandible risk of abnormal skeletal or dental development if the
Horses with fractures of these bones commonly have wire is left in place too long. Compression screws or
only mild clinical signs. A diagnosis can usually be made hemicerclage wire fixation, in addition to encircling wire
based on clinical examination. Radiographic and endo- fixations, are mainly indicated in symphyseal fractures in
scopic examination may be undertaken to rule out additional foals.
www.ajlobby.com
(A) (B)
Figure 41.31 (A) Schematic representation of pinless fixator on a mandibular fracture. (B) Schematic representation of pinless fixator clamp.
(A) (B)
(C) (D)
Figure 41.32 (A) Recent fracture of the incisive part of the mandible. (B) Cerclage wires engaging the canine teeth. (C) Overlapping wire
cerclages. (D) Different case with healed fracture eight weeks later.
www.ajlobby.com
(A) (B)
(C) (D)
Figure 41.33 (A) Fracture of the incisive bone. (B) Fixation with tension wires spanning from the first cheek teeth to form overlapping
continuous interdental wires, as described by Obwegeser. (C) Rostral view showing fixation of the fractured incisive bone using two
interdental continuous wire loops. (D) Incisor reduction using motorized rasp.
Interdental Space of the Incisive Bone

and type vary greatly. These fractures may be unilateral
and Maxilla
or bilateral, and the fragments are often severely dislo-
Wire fixation is also well suited for most fractures in this
cated and highly mobile. Surgery under general anes-
part of the upper jaw (Figure 41.34). The fragments are
thesia provides the best chance for optimal reduction
reduced to their anatomically correct position and a sta-
and stable fixation. Dorsal recumbency and nasal intu-
ble fixation is obtained by multiple cerclage wires, each
bation allow good access to the oral cavity during sur-
running from the upper incisors to anchor back to the
gery. A combination of intraoral wire fixation and a
first and second cheek teeth on either arcade. The vari-
wire cerclage that runs along the ventral aspect of the
ous wires are tightened gradually and evenly to prevent
mandible can be useful in bilateral fractures of the ros-
dislocation of the fragments. To prevent fracture dis-
tral part of the mandible (Figure 41.35). In unilateral
placement along oblique fracture planes, it may be nec-
fractures, intraoral wire fixation alone may produce
essary to feed the wires through drill holes prepared
sufficient stability, but care must be taken to prevent
through the bone on either side of the fracture plane.
dislocation of the fragments during tightening of the
wire. Another option is the placement of an additional
Interdental Space of the Mandible wire under the mucosa along and ventral to the frac-
Fractures of the mandibular interdental space (previ- tured mandible, to obtain added stability. Very unstable
ously diastema) are very common and their location and bilateral mandibular fractures require fixation with
www.ajlobby.com
(A) (B)
(C) (D)
Figure 41.34 (A) Fracture of the incisive bone and maxilla (arrows) caused by the use of a mouth gag/speculum. (B) Fixation of fracture
using two cerclage wires spanning from cheek teeth to incisors. (C) Fracture of the incisive bone and maxilla caused by a kick from
another horse. (D) Fixation of fracture using two cerclage wires.
(A) (B)
(C)
Figure 41.35 (A) Radiograph of a fracture of the interdental space of the mandible. (B) Fixation using a U‐splint and intraoral wire cerclage
does not provide sufficient stability. (C) Fracture is stable after the addition of a wire fixation along the ventral aspect of the mandibular body.
www.ajlobby.com
(A) (B)
Figure 41.36 (A) Radiograph of a displaced fracture of the interdental space of the mandible (arrows). (B) Fixation of fracture using a
locking compression plate and intraoral cerclage wire. The fracture reduction and alignment are well maintained (arrows).
one or two plates, in addition to intraoral wire fixation

that engages the premolars (Figure 41.36). Teeth that
are involved in the fracture are not removed because (A)
this would decrease the stability of the fracture; endo-
dontic treatment of damaged teeth can be undertaken
during correction of the fracture or at a later date
(Figure 41.37).
Horizontal Body of the Mandible

These are usually unilateral fractures with mild disloca-
tion of the fragments. Conservative treatment is indi-
cated when the ventral region of the bone is not involved
in the fracture, but is also possible in other closed frac- (B)
tures that are only mildly displaced. Open and distracted
fractures require surgical treatment, and fixation using
plates and screws is the treatment of choice. The ventral
margin of the mandible is very strong and accommodates
multiple screws (Figures 41.37 and 41.38). Dental roots
are occasionally damaged by the screws, but this rarely
has negative effects. Cyclic loading during chewing can
lead to implant failure (Figure 41.39). External or pinless
fixators are useful for the treatment of infected fractures
(Figure 41.40);20 a minimum of two clamps should be
applied on either side of the fracture. The pinless fixator (C)
is removed after six to eight weeks. Alternatively, intraoral
splints or tension-band wires may be used to treat frac-
tures of the mandibular body (Figure 41.41).
Vertical Ramus of the Mandible

Fractures of the vertical ramus of the mandible are rare.
Transverse fractures with minimal displacement are
treated conservatively, whereas unstable fractures and
those with more severe displacement require surgical
Figure 41.37 (A) Mandibular fracture in a foal (arrows). (B)
treatment. Severe displaced fractures may occur when a Radiograph of the fixation using a narrow 4.5 locking compression
horse has its head wedged between two solid objects and plate. (C) Radiograph of the fracture six weeks after surgery
withdraws forcefully (see earlier Figure 41.19). Fractures showing progressive healing.
www.ajlobby.com
(A) (C)
(B)
Figure 41.38 (A) Reconstructed computed tomography (CT) showing multiple mandibular fractures (arrows), including an oblique
fracture through the interalveolar part of the body of the mandible (arrows oriented left) and multiple fractures of the mandibular ramus
and mandibular angle. (B) Fixation of the rostral part of the fracture using a narrow 4.5 locking compression plate (LCP) and two cerclage
wires. (C) Fixation of the caudal part of the fracture using two narrow 4.5 LCPs.
(A) (B)
(E)
Figure 41.39 (A) Radiograph of a fractured molar portion of the mandibular body in an old horse. Multiple fracture planes are evident. (B)
Radiograph of the fracture fixation using a narrow 4.5 locking compression plate (LCP), multiple hemicerclage wires, and a twisted tension
band wire from incisors to the first two cheek teeth. (C) Radiograph of the fracture fixation showing the broken tension band wire (arrow),
which was removed. (D) Later radiograph of the fracture fixation, showing a break in the plate through a screw hole (arrow) associated
with loss of the dorsal stabilizing effect of the tension band wire. (E) Radiograph after the second fracture fixation using a new LCP and
additional tension band wire cerclages dorsal to the mandible and between screws inserted into the middle of the mandibular body.
www.ajlobby.com
(A) (C)
(B)
Figure 41.40 (A) Fixation of an open and infected mandibular fracture using a pinless fixator. (B) Appearance 10 days after application of
the pinless fixator. (C) Seven weeks after fixator application.
(A) (B)
(C) (D)
Figure 41.41 (A) Radiograph of a three‐week‐old oblique mandibular fracture in a pony, involving the roots of several premolar cheek
teeth. (B) Radiograph of fracture fixation using wire cerclage. (C) Radiograph taken two months after surgery showing good healing of
fracture. (D) Radiograph after endodontic treatment of the pulps of 306, 307, and 308 (arrows).
www.ajlobby.com
(A) (B)
(C)
(D)
(E)
(F)
Figure 41.42 (A) Lock‐jaw associated with bilateral temporomandibular joint (TMJ) luxation. (B) Reconstructed 3D computed
tomography (CT) shows multiple fractures of the inner aspect of the orbit (1), fractured coronoid process (2), temporomandibular luxation
with cranial displacement of the mandibular condyle (3), and rostral displacement of the entire mandible (4). (C) CT of the isolated
mandible shows bilateral coronoid process fractures (large arrows) and multiple smaller articular fractures of the mandibular condyles
(arrow). (D) Oblique ventrodorsal CT shows the bilateral temporomandibular luxation (arrows). (E) Reduction required a Swales mouth
gag inserted between the molars (white arrow), and closing compression applied with a cattle hip lifter (black arrows). Rotatory torque
was also applied to the mandible to free the mandibular condyles from the orbital socket. (F) Normal occlusion after TMJ reduction.
www.ajlobby.com
that involve the TMJ are usually associated with severe cannot be forcibly closed, which is a hallmark of bilateral
clinical signs. Plating the ventral and caudal aspect of the TMJ luxation. Repair under general anesthesia requires a
vertical ramus can be difficult, because access for drilling mouth gag inserted between the caudal molars to act as
and screw placement is limited by the parotid area and a fulcrum, followed by closing pressure on the cranial
the wing of the atlas (see Figure 41.38). The complicated mandible and maxilla. Rotation of the mandible assists in
access to the TMJ renders surgical procedures in this freeing the mandibular condyles from their trapped
region difficult; fragments of the coronoid process can position between the zygomatic arch and frontal bone
be removed,12 and in other cases condylectomy may be forming the inner surface of the orbit. Blindness can
indicated.3 occur from injury to the optic nerve or globe during the
TMJ luxation is rare. Bilateral luxation results in a fracture luxation. Temporohyoid luxation and fracture
fixed open mouth (Figure 41.42). The coronoid process can also occur. Damage to the mandibular condyle sur-
of the mandible has to fracture to allow the mandibular face can lead to late‐onset joint pain. The mouth is taped
condyles to luxate rostrally and dorsally. The condylar shut for several weeks after reduction, and the horse
surface of the mandible then becomes trapped inside the fed by stomach tube for several days until it can learn
zygomatic arch, creating a fixed open mouth by fulcrum to eat wet gruels. The prognosis for complete recovery
on the sixth cheek tooth (see Figure 41.42). The mouth is guarded.
References
1 Auer, J.A. (2006). Craniomaxillofacial disorders. In: 11 Dart, A.J. and Pascoe, R.R. (1987). Treatment of a
Equine Surgery, 3e (ed. J.A. Auer and J.A. Stick), bilateral mandibular fracture in a mare using an
1341–1362. St. Louis: Saunders Elsevier. intraoral acrylic splint. Aust. Vet. J. 64: 382–384.
2 Avella, C.S. and Perkins, J.D. (2011). Computed 12 DeBowes, R.M. (1996). Fractures of the mandible and
tomography in the investigation of trauma to the maxilla. In: Equine Fracture Repair (ed. A.J. Nixon),
ventral cranium. Equine Vet. Educ. 23: 333–338. 313–322. Philadelphia: W.B. Saunders.
3 Barber, S.M., Doige, C.E., and Humphreys, S.G. (1985). 13 Dowling, B.A., Dart, A.J., and Trope, G. (2001). Surgical
Mandibular condylectomy. Technique and results in repair of skull fractures in four horses using cuttable
normal horses. Vet. Surg. 14: 79–86. bone plates. Aust. Vet. J. 79: 324–327.
4 Beccati, F., Angeli, G., Secco, L. et al. (2011). 14 Dunkel, B., Corley, K.T., Johnson, A.L. et al. (2013).
Comminuted basilar skull fracture in a colt: use of Pneumocephalus in five horses. Equine Vet. J. 45:
computed tomography to aid the diagnosis. Equine Vet. 367–371.
Educ. 23: 327–331. 15 Feary, D.J., Magdesian, K.G., Aleman, M.A., and
5 Belsito, K.A. and Fischer, A.T. (2001). External skeletal Rhodes, D.M. (2007). Traumatic brain injury in horses:
fixation in the management of equine mandibular 34 cases (1994–2004). J. Am. Vet. Med. Assoc. 231:
fractures: 16 cases (1988–1998). Equine Vet. J. 33: 259–266.
176–183. 16 Feige, K., Fürst, A., Kaser‐Hotz, B. et al. (2000).
6 Bindler, D., Theiss, J., Kummerle, J., and Furst, A. Traumatic injury to the central nervous system in
(2017). Obwegeser cerclage technique for the treatment horses: occurrence, diagnosis and outcome. Equine Vet.
of jaw fractures in horses: a retrospective study on 46 Educ. 12: 220–224.
cases (1987–2010). Pferdeheilkunde 33: 52–58. 17 Fürst, A., Keller, R., Kummer, M., and Bettschart‐
7 Blogg, J.R., Stanley, R.G., and Phillip, C.J. (1990). Skull Wolfensberger, R. (2008). Evaluation of a new full‐body
and orbital blow‐out fractures in a horse. Equine Vet. J. animal rescue and transportation sling in horses: 181
10 (Sept Suppl.): 5–7. horses (1998–2006). J. Vet. Emergency Crit. Care 18:
8 Burba, D.J. and Collier, M.A. (1991). T‐plate repair of 619–625.
fracture of the nasal bones in a horse. J. Am. Vet. Med. 18 Gardelle, O., Feige, K., Geissbuhler, U. et al. (1999).
Assoc. 199: 909–912. Possibilities for computer tomography of the equine
9 Caldwell, F.J. and Davis, H.A. (2012). Surgical head based on two cases with a fracture of the base of
reconstruction of a severely comminuted mandibular the skull. Schweiz. Arch. Tierheilkd. 41: 267–272.
fracture in a horse. Equine Vet. Educ. 24: 217–221. 19 Gerding, J.C., Clode, A., Gilger, B.C., and Montgomery,
10 Colahan, P.T. and Pascoe, J.R. (1983). Stabilization of K.W. (2014). Equine orbital fractures: a review of 18 cases
equine and bovine mandibular and maxillary fractures, (2006–2013). Vet. Ophthalmol. 17 (Suppl 1): 97–106.
using an acrylic splint. J. Am. Vet. Med. Assoc. 182: 20 Haralambus, R.M., Werren, C., Brehm, W., and Tessier,
1117–1119. C. (2010). Use of a pinless external fixator for unilateral
www.ajlobby.com
mandibular fracture repair in nine equids. Vet. Surg. 39: 27 Lischer, C., Fluri, E., Kaser‐Hotz, B. et al. (1997). Pinless
761–764. external fixation of mandible fractures in cattle. Vet.
21 Henninger, R.W., Beard, W.L., Schneider, R.K. et al. Surg. 26: 14–19.
(1999). Fractures of the rostral portion of the mandible 28 Lischer, C.J., Walliser, U., Witzmann, P. et al. (2005).
and maxilla in horses: 89 cases (1979–1997). J. Am. Vet. Fracture of the paracondylar process in four horses:
Med. Assoc. 214: 1648–1652. advantages of CT imaging. Equine Vet. J. 37: 483–487.
22 Hertsch, B. and Wissdorf, H. (1990). Die chirurgische 29 Peavey, C.L., Edwards, R.B. 3rd, Escarcega, A.J. et al.
Behandlung von Unterkieferfrakturen beim Pferd mit (2003). Fixation technique influences the monotonic
Cerclage oder dem Fixateur externe. Pferdeheilkunde properties of equine mandibular fracture constructs.
6: 55–61. Vet. Surg. 32: 350–358.
23 Hug S: Ursache von Frakturen bei den Pferden, die an 30 Piacenza, C. and Böhm, D. (1985). Zur Fraktur des Kiefers
die Pferdeklinik der Vetsuisse‐Fakultät überwiesen beim Pferd unter besonderer Berücksichtigung der
wurden: Bedeutung der Schlagverletzung als Ursache Schneidezähne. Berl. Münch. Tierärztl. Wschr. 98: 181–186.
für Frakturen. Departement für Pferde, Vetsuisse‐ 31 Ramzan, P.H. (2008). Management of rostral
Fakultät Universität Zürich, 2009. mandibular fractures in the young horse. Equine Vet.
24 Kuemmerle, J.M. (2012). Mandibular fractures in Educ. 20: 107–112.
horses. Equine Vet. Educ. 24: 222–224. 32 Salomon, F.V., Geyer, H., and Gille, U. (2005). Anatomie
25 Kuemmerle, J.M., Kummer, M., Auer, J. et al. (2009). für die Tiermedizin. Stuttgart: Enke Verlag.
Locking compression plate osteosynthesis of 33 Schaaf, K.L., Kannegieter, N.J., and Lovell, D.K. (2008).
complicated mandibular fractures in six horses. Vet. Management of equine skull fractures using fixation
Comp. Orthop. Traumatol. 22: 54–58. with polydioxanone sutures. Aust. Vet. J. 86: 481–485.
26 Lacombe, V.A., Sogaro‐Robinson, C., and Reed, S.M. 34 Tremaine, W.H. (1998). Management of equine
(2010). Diagnostic utility of computed tomography mandibular injuries. Equine Vet. Educ. 10: 146–154.
imaging in equine intracranial conditions. Equine Vet. J. 35 Turner, A.S. (1979). Surgical management of depression
42: 393–399. fractures of the equine skull. Vet. Surg. 8: 29–33.
www.ajlobby.com
800
42
Medical Aspects of Traumatic Brain Injury
in Horses
Stephen M. Reed
Introduction often has an acute onset, although the bony changes

observed on radiographs and endoscopy appear more
Trauma to the nervous system may involve the brain, long standing.
spinal cord, or peripheral nerves.3,4,10,16,17,20 Traumatic In some horses, traumatic brain injury may occur
injury has been reported to account for up to 22% of without a fracture. In fact, some of the most severe inju-
equine central nervous system (CNS) disorders in one ries to the brain occur when the injury is contained
study.4 Traumatic brain injury is a common cause of within the closed calvarium.10 Clinical signs often
death or disability in horses, especially young horses. observed following traumatic brain injury include an
Management of brain injury can be difficult because of altered level of consciousness (stupor to coma), abnor-
primary damage to the bony structures of the skull or the mal behavior, cranial nerve deficits, and open skull frac-
nervous tissue, and the secondary complications such tures.3,4,10 Types of brain injuries include concussion,
as bacterial meningitis and septic arthritis. In addition, contusion, laceration, and hemorrhage. These injuries
much of the neurologic damage does not occur at the describe symptoms that progress from least to most
time of impact, but may develop over the ensuing hours severe.3,4,10,16,18,23 Concussion is associated with a brief
to days. Intensive care for severe head injury is aimed at loss of consciousness, but does not result in permanent
control of increased intracranial pressure; in humans brain damage and has a favorable prognosis. A contusion
this treatment often utilizes five specific interventions indicates a distinct area of swollen brain tissue along
including hyperventilation, mannitol, cerebrospinal with vascular damage. Cerebral lacerations are often
fluid (CSF) drainage, barbiturates, and corticosteroids.19 caused by sudden acceleration or deceleration injuries or
In horses, techniques such as hyperventilation and CSF by a projectile object penetrating the skull, and indicate
drainage may be b eneficial, but are rarely used in man- structural damage to the nervous tissue.3,4,10,12,16,18,23
agement of head trauma, because the procedures are Hemorrhage within the brain parenchyma or within a
difficult and the n
ecessary equipment is often not closed calvarium can lead to very serious and debilitating
available. consequences as a result of direct injury to the brain,
Head trauma is more common in foals and young secondary swelling, or brain herniation. Following trau-
horses, in part because of the inquisitive nature of young matic head injury, damage to the brain may be focal or
animals, and because the bony calvarium is much thin- diffuse, and can sometimes lead to death as a result of
ner, providing less protection. Clinical signs are dependent either primary or secondary damage to vital brain
on the location and extent of brain damage, as well as the structures as well as hemorrhage or infection. Following
amount and severity of secondary damage to the brain traumatic head injury, trauma to the brain occurs as a
and surrounding tissues. Common types of head injuries result of the brain being thrown about within the calva-
that horses sustain are fractures of the calvarium, basis- rium, and may result from forces near the site of the
phenoid, basioccipital, and temporohyoid bones. These trauma (coup) as well as opposite (contrecoup) the site
injuries occur as a result of falling, flipping over back- of impact.10
ward, running into an immovable object, and being hit In horses with traumatic brain injury and concurrent
by a projectile. Damage to the temporohyoid apparatus hypovolemic shock, autoregulatory mechanisms will be

www.ajlobby.com
activated to protect the ischemic sensitive neurons of the brain has a high metabolic rate and high oxygen demand,
brain and spinal cord by maintaining adequate blood with very minimal energy stores. Given this, it is subject
flow. Cerebral perfusion above 12 ml (mg min−1)−1 is ade- to very rapid deterioration when there is a loss of oxygen
quate to prevent damage to neuronal cells.2,9,14 While and glucose; even modest hypotension can convert a
changes in cerebral perfusion pressure between 50 and reversible brain injury into one in which ischemic brain
150 mm Hg do not cause significant changes in cerebral damage is irreversible.1,2,13 Therefore, initial aggressive
blood flow, perfusion pressures below 50 mm Hg often treatment to combat systemic hypotension, maintain
result in ischemic necrosis.1,5,7 cerebral perfusion pressure, and provide a continuous
In humans, the effectiveness of interventions used in supply of energy to maintain membrane potentials and
the intensive management of severe head injuries has electrochemical gradients is important for normal syn-
been reviewed.2,11,19,24 Because much of the damage fol- aptic transmission.2
lowing traumatic brain injury is a result of the secondary The supply of energy for the brain is produced by
insults which lead to a reduction in cerebral perfusion, oxidation of glucose. When the supply of energy is

treatment is often directed toward stopping this reduc- disrupted, regardless of the reason, neuronal function
tion in cerebral blood flow. Secondary brain injury may will be altered within minutes.21 The brain also requires
occur as a result of systemic hypotension and hypox- a nearly constant supply of oxygen. Lack of oxygen due to
emia. In a review of outcomes following traumatic brain either hypoxemia or ischemia may lead to increased gly-
injury in humans, hypoxemia was associated with colysis, decreased neurotransmitter production,
increased morbidity and mortality, and appeared to be a increased lactate concentration, lowered adenosine
more common finding than systemic hypotension.2,24 In triphosphate (ATP) and energy production, and finally
these studies, restoration of blood pressure as rapidly as permanent damage to neurons. If cerebral blood flow
possible by use of hypertonic saline was associated with can be quickly and adequately restored, many of the
better outcome. clinical signs might be reversed.2
The performance of a neurologic examination on a
horse with head trauma can be challenging, and may
require the use of sedation, especially if the animal is Assessment
attempting to stand but is not fully aware of its sur-
roundings or lacks coordination as a result of its injury. A complete and careful physical examination is impor-
Use of drugs such as xylazine, chloral hydrate, diazepam, tant to help identify injuries to other body systems.
midazolam, phenobarbital, and acepromazine is indi- Horses with head trauma sometimes suffer fractures of
cated.6,10,12,15 Loss of strength and coordination is the axial or the appendicular skeleton, and could also
especially problematic when damage to the cerebellar have a serious injury of the chest or abdominal cavity.
or vestibular regions of the brain and brainstem have Careful monitoring of heart and respiratory rates, as well
occurred. Evaluation of the level of consciousness, along as measurement of blood pressure, should be a routine
with assessment of the cranial nerves, can help with the part of the examination. Fluid therapy, usually with nor-
neuroanatomic localization of a brain injury. Much of mal saline or sometimes hypertonic saline, along with
the primary brain damage is caused by increased intrac- careful monitoring of clinical signs is important.3,10,11
ranial pressure, and therefore interventions to reduce In humans, the use of dextrose in water or hypotonic
increased intracranial pressure are essential and need solutions may have a deleterious effect on the recovery
to be performed as soon as possible following injury. from head trauma.21
Secondary changes are a result of a cascade of patho- The neurologic examination should be performed
physiologic events that evolve over time, leading to the without sedation whenever possible, although many
release of excitatory neurotransmitters and ischemia. horses with head injury are either in too much pain or
The excess concentration of neurotransmitters leads to too dangerous to examine without sedation. Important
instability of ion channel receptors on brain cells that features of the examination include assessment of the
may not have been damaged, resulting in a massive influx horse’s level of consciousness, head posture, coordina-
of calcium ions into the cells, which triggers apoptotic tion, behavior, and cranial nerve function. Following
pathways and eventual cell death.2,10,11 traumatic brain injury, the horse’s level of consciousness,
Regardless of the cause, primary brain injury may ini- mental alertness, and behavior can change rapidly.
tially appear modest, but later appear more severe. This Therefore, the pattern of respiration and heart rate, along
secondary brain damage due to ongoing cerebral hypoxia, with pupil size and function, should be closely observed.
systemic hypercapnia, hypotension, and hyperthermia, Monitoring of changes in response to treatment can be
or occasionally hemorrhage, ischemia, and infection, helpful to determine whether a life‐threatening brain-
further adds to the metabolic demands of the brain. The stem lesion is present.
www.ajlobby.com
All parts of the neurologic examination are impor- Initial management should include adequate sedation,
tant. However, following traumatic brain injury, in a intubation in order to provide ventilation, maintenance of
recumbent horse the pupil size, symmetry, and response fluid balance with 0.9% saline, muscle relaxants as needed,
to light directed into the eye are especially important, anticonvulsant therapy, mannitol at 0.25 mg kg−1 intrave-
and may help with rapid assessment regarding the nously or dimethyl sulfoxide (DMSO) at 1 g kg−1 as a 10%
horse’s condition. A change in pupil size from bilateral solution, glucocorticoids, nonsteroidal anti‐inflamma-
constriction to bilateral dilation with no response to tory agents, and barbiturates. Use of supplemental
light directed into either eye is an indication of a very oxygen combined with hyperventilation will provide
serious brain condition and the need for prompt therapy. transient reduction of brain swelling. Hypothermia has
If the brainstem, especially the region of the midbrain, been shown to have positive sparing effects in damaged
is injured, the horse will often show signs of depression brain tissue.
or even coma, along with loss of normal pupillary light Initial therapy is dependent on the signs demonstrated
responses and sometimes asymmetric pupil size. If the by the horse at the time of the first examination. In
injury affects the region of the medulla oblongata, signs horses that are aware and cognizant, initiating treat-
may include strabismus, a head tilt, and ipsilateral ment might be delayed until after further diagnostic
weakness, and if the horse is able to walk it will often testing, such as radiographs or computed tomography
be circling. If the horse is able to stand, it is important (CT). In horses that are presented recumbent with
to evaluate its ability to walk. If the horse is recum- obvious signs of recent trauma and/or an altered level
bent and unable to rise, the spinal reflexes should be of consciousness, aggressive treatment and potentially
examined. even surgical intervention to evacuate cerebral hemor-
rhage may be indicated.
DMSO (Domoso®, Diamond Labs, Des Moines, IA,
Treatment USA) at a dose of 0.9–1.0 g kg−1 as a 10% solution intrave-
nously is one possible treatment.3,8,16,18,22,23 Its proposed
Management of traumatic brain injury in horses is diffi- mechanism of action is to reduce the formation of ara-
cult because of the size of the animal, as well as how chidonic acid metabolites such as thromboxanes and
quickly changes in its neurologic status might occur. In prostaglandins, resulting in stabilization of membrane
addition, some beneficial treatments do not lend them- phospholipids, in addition to its effect as a scavenger of
selves to ambulatory practice. Treatment of traumatic free radicals.8
brain injury may be further complicated by a need to Barbiturates may have a protective effect against
treat injuries to other body systems. As well as emer- ischemia following brain injury, by lowering cerebral
gency management of the acute brain injury, it is equally metabolism and by retarding peroxidation of lipids
or sometimes more important to slow down or prevent within brain cell membranes. Although an exact dose
the secondary changes, which result in continuing and frequency are not worked out in horses, phenobarbi-
encephalopathic processes that can sometimes lead to tal at a dose of 5–10 mg kg−1 intravenously given to effect
death or permanent disability of the horse. may be useful. However, it is important to remember
These secondary changes are often a result of hypoten- that whenever these drugs are administered to the horse,
sion, hypoxia, hypercapnia, and fever following the origi- there will be systemic hypotension in at least 25% of
nal injury. Regardless of the cause of the head trauma, patients, according to the human literature.19
prompt attention to alleviating further damage by care- Surgical decompression is controversial, although
ful assessment and treatment is important. Most head with the ability to evaluate horses using CT scan and/or
injuries occur away from a referral center and therefore magnetic resonance imaging (MRI), surgical interven-
will need to be monitored, at least for a time, by the tion may become more routine. Rapid decompression
attending veterinarian and the owner. The most impor- by surgical intervention is most appropriate when dete-
tant diagnostic tool available to the attending veterinar- rioration continues despite aggressive medical therapy.
ian is the neurologic examination. Careful monitoring Surgical intervention should be considered to either
implies frequent or continuous evaluation, along with evacuate a hematoma or to allow swelling of the brain to
swift alterations in therapy when changes in neurologic occur unimpeded. All treatment plans should include
status are detected. At the same time as carefully moni- the use of broad‐spectrum antimicrobial agents, seda-
toring the neurologic status of the patient, the veterinar- tives, and a mechanism for long‐term feeding. The
ian may also monitor selected biochemical changes in horse’s intestinal tract should be functioning normally.
the blood or CSF. In blood, the arterial blood gas ten- Therefore, the use of an indwelling nasogastric tube may
sions may be of help to determine the need for either be quite helpful and is especially indicated for foals,
controlled or assisted ventilation. which have very limited energy reserves.
www.ajlobby.com
References
1 Bayir, H., Clark, R.S., and Kochanek, P.M. (2003). Promising 14 Mobbs, R.J., Stoodley, M.A., and Fuller, J. (2002). Effect
strategies to minimize secondary brain injury after head of cervical hard collar on intracranial pressure after
trauma. Crit. Care Med. 31 (Suppl. 1): S112–S117. head injury. ANZ J. Surg. 72: 389–391.
2 Bullock, M.R. and Povlishock, J.T. (2007). Guidelines 15 Moore, R.M. and Trims, C.M. (1992). Effect of xylazine
for the management of severe traumatic brain injury. on cerebrospinal fluid pressure in conscious horses.
Editor’s commentary. J. Neurotrauma 24 (Suppl. 1): Am. J. Vet. Res. 53: 1558–1561.
2p preceding S1. 16 Reed, S.M. (1987). Intracranial trauma. In: Current
3 Feary, D.J., Magdesian, K.G., Aleman, M.A., and Therapy in Equine Medicine, 2e (ed. N.E. Robinson).
Rhodes, D.M. (2007). Traumatic brain injury in horses: Philadelphia: W.B. Saunders.
34 cases (1994–2004). J. Am. Vet. Med. Assoc. 231: 17 Reed, S.M. (1993). Management of head trauma in
259–266. horses. Compend. Contin. Educ. Pract. Vet. 15:
4 Feige, K., Fürst, A., Kaser‐Hotz, B., and Ossent, P. 270–273.
(2000). Traumatic injury to the central nervous system 18 Reed, S.M. (1994). Medical and surgical emergencies of
in horses: occurrence, diagnosis and outcome. Equine the nervous system of horses: diagnosis, treatment and
Vet. Educ. 12: 220–224. sequelae. Vet. Clin. North Am. Equine Pract. 10:
5 Finnie, J.W. and Blumbergs, P.C. (2002). Traumatic 703–715.
brain injury. Vet. Pathol. 39: 679–689. 19 Roberts, I., Schierhout, G., and Alderson, P. (1998).
6 Furr, M. and Reed, S. (eds.) (2008). Equine Neurology. Absence of evidence for the effectiveness of five
Ames, IA: Wiley Blackwell. interventions routinely used in the intensive care
7 Hardman, J.M. and Manoukian, A. (2002). Pathology of management of severe head injury: a systematic review.
head trauma. Neuroimaging Clin. N. Am. 12: 175–187. J. Neurol. Neurosurg. Psychiatry 65: 729–733.
8 Jacob, S.W. and de la Torre, J.C. (2009). Pharmacology 20 Rush‐Moore, B. (1997). Central nervous system
of dimethyl sulfoxide in cardiac and CNS damage. trauma. In: Current Therapy in Equine Medicine, 3e
Pharmacol. Rep. 61: 225–235. (ed. N.E. Robinson). Philadelphia: WB Saunders.
9 Leker, R.R., Shohami, E., and Constantini, S. (2002). 21 Schwartz, G. and Fehlings, M.G. (2002). Secondary
Experimental models of head trauma. Acta Neurochir. injury mechanisms of spinal cord trauma: a novel
83 (Suppl.): 49–54. therapeutic approach for the management of secondary
10 MacKay, R.J. (2004). Brain injury after head trauma: pathophysiology with the sodium channel blocker.
pathophysiology, diagnosis and treatment. Vet. Clin. Prog. Brain Res. 137: 177–190.
North Am. Equine Pract. 20: 199–216. 22 Shi, R., Qiao, X., Emerson, N., and Malcolm, A. (2001).
11 Margulies, S. and Hicks, R. (2009). Combination Dimethyl sulfoxide enhances CNS neuronal plasma
therapies for traumatic brain injury: prospective membrane resealing after injury in low temperature or
considerations. J. Neurotrauma 26: 925–939. low calcium. J. Neurocytol. 30: 829–839.
12 Mayhew, I.G. (2008). Coma and altered states of 23 Stewart, R.H. (1987). Central nervous system trauma.
consciousness. In: Large Animal Neurology, 2e. Oxford: Vet. Clin. North Am. Equine Pract. 3: 371–377.
Wiley Blackwell. 24 Tawfeeq, N., Halawani, M.M., Al‐Faridi, K. et al.
13 Mazzola, C.A. and Andelson, P.D. (2002). Critical care (2009). Traumatic brain injury: neuroprotective
management of head trauma in children. Crit. Care anaesthetic techniques, an update. Injury 40 (Suppl. 4):
Med. 30 (Suppl. 11): S393–S401. S75–S81.
www.ajlobby.com
805
Part III
Postoperative Aspects of Fracture Repair
www.ajlobby.com
807
43
Systems for Recovery from Anesthesia
John B. Madison
Ocala Equine Hospital, Ocala, FL, USA
Overview wall padding. Depending on the layout of the hospital, it

is not essential that the recovery stalls be square, since
Smooth recovery from general anesthesia is the final horses can be positioned for recovery to take advantage
crucial step in the successful repair of equine fractures. of the longest axis of the stall. The walls should be cov-
Most surgeons who routinely repair complicated equine ered with sufficient soft padding to diminish the impact
fractures have suffered the disappointment of having a of a stumbling horse. The padding must be adequately
robust repair destroyed in a matter of minutes by a rough secured to the walls to ensure that the horse cannot get a
recovery from anesthesia. Anesthetic recovery of horses head or limb caught between the padding and the wall.
can be complicated by early attempts to rise with potential The padding should extend up the wall approximately
catastrophic injuries when an unsteady horse stumbles, 7½ ft (2.3 m) from the floor. This allows firmly anchored
falls, or crashes into the wall. There is no right or wrong wall rings to be placed just above the wall padding.
way to recover a horse from anesthesia. The experience
of the surgeon, and the type and demeanor of the patient
Flooring
(e.g., young racehorse vs. older sport horse or broodmare),
and the expected degree of comfort of the patient postop- Choice of recovery stall flooring is important. There cur-
eratively, all play important roles in the choice of recovery rently is no perfect recovery stall flooring material, but
methods. While systems to recover fracture patients there are several good products available. The floor should
from anesthesia vary, there are some guidelines that provide good traction when wet, yet be smooth enough to
should be adhered to in order to maximize success. allow one or two people to reposition a horse that gets
trapped in a corner or cast against a wall. Floors that are
too tacky make it extremely difficult to move a down horse
Recovery Room Design that, for example, has gotten its head caught in a corner of
the stall. All materials used in the recovery stall should be
able to be cleaned and disinfected after each case. The ideal
Dimensions floor should be soft enough to cushion a falling horse and
While recovery on turf has the advantage of excellent prevent injury. Thick recovery stall mattresses that can be
footing, most hospitals that are performing equine frac- removed or placed against a wall are also useful to maxi-
ture repair will have indoor recovery systems. The ideal mize the comfort of the recumbent horse and therefore
recovery stall should be of adequate size to allow person- encourage it to remain in lateral recumbency until it is
nel to safely assist horses in recovery, but not so large ready to stand. A rapidly inflating–deflating air pillow has
that there is room for a horse to develop significant the advantage of a deep, soft‐contoured cushion that
momentum before running into a recovery stall wall. For encourages a horse to remain recumbent until fully alert
most light horse breeds, recovery stalls that are square and then deflates to allow firm footing when it finally rises.4
and 10–11 ft (3–3.4 m) along each wall work best. If large A comparison of air pillow and conventional padded
Warmbloods or draft horses are frequently anesthetized, flooring in 409 horses indicated a significantly longer rest
the recovery box wall length is better extended to 12–13 ft period before attempting to stand and less failed attempts
(3.7–4 m). These dimensions allow for 4 in. (10 cm) thick to regain footing after the air cushion was deflated.4

www.ajlobby.com
808 Part III Postoperative Aspects of Fracture Repair
Doors shoulder and to directly gauge a horse’s response to

assistance, so they can increase or decrease rope tension
The recovery stall must have at least one wide doorway accordingly. However, danger to personnel is clearly
for ingress and egress of patients and clinic personnel. greater, and the merits of having assistants in the box
All doors must close securely and latches must be able to rather than working ropes from outside vary by case and
withstand the forces generated by the impact of an unsta- the recovery box setup.
ble horse. While crash bars are a commonly used method A locking system to fix the tail rope using a Grigri®
to secure access doors, they can be difficult to engage (Petzl Distribution, Crolles, France) rock‐climbing pul-
quickly in the event that the doors must be closed and ley, coupled with a head rope that is vectored via pulleys
secured rapidly. A system of hardened steel pins at the to a similar position outside the box, allows one person
top and bottom of the door, engaged by a latch handle, to assist a horse to stand from a safe location.3,9 This sys-
provides a quick way to secure the door, and these can be tem uses a “legs away from the wall” approach, and the
reinforced with a crash bar if desired. head rope tension can prevent a horse rolling up into
sternal recumbency and attempting to stand prema-
Monitoring turely. It requires a larger recovery stall, with at least one
wall being 14 ft (4.3 m), to take advantage of the fixed tail
The recovery stall should have at least one small open rope “pulling” the horse up. In smaller recovery stalls,
window through which the horse can be watched and the horse impacts the corner in front of it before the tail
heard. This window should be in a position such that rope develops lift. Other block‐and‐tackle systems are
oxygen lines and ropes can be run through the door if also useful to develop more mechanical advantage in
needed. A mirror or video camera should be placed in applying tail rope tension, but tend to be slow to respond
the stall to allow the horse to be seen if it is lying against to changing situations, given the length of rope travel
the door with the window. An oxygen supply, emergency required to change the working length of the tail rope in
drugs, and a ventilation demand valve should be availa- 2:1 or 4:1 block‐and‐tackle pulley systems.
ble near the stall. Some method should also be available Some practices use self‐tailing winches from sail boat
to lift a down horse, should it become necessary to assist equipment vendors to provide better control of the head
a horse that is unable to rise during recovery. and tail ropes (Figure 43.1). These need to be mounted
on a wall in the corner of the recovery box, and have a
guide pulley on either side of the winch to prevent the
Head and Tail Rope Recovery rope slipping off the drum of the winch. They provide
little mechanical advantage compared to a block and
Head and tail rope systems vary, particularly regarding tackle, but any rope gained as the horse moves can be
whether the horse is recovered with its feet toward or locked and only released if the handler slackens the rope
away from the wall. A secure wall‐mounted ring or they control from the winch. Compared to block‐and‐
bracket is required in every corner. These are generally tackle systems, rapid tension can be applied to the head
around 8 ft (2.5 m) above floor level. With the “limbs and tail ropes by the 1:1 tensioning of the winch.
toward the wall” technique, the head and tail ropes are Ultimately, the choice of system for rope recovery
secured through the rings in the corners of the closest depends on the experience and background of the indi-
wall. This way, the ropes assist the horse to swing into viduals, and the shape and setup of the stall. A coordi-
sternal recumbency. Alternatively, with the limbs facing nated team is generally the most efficient and important
away from the wall (back line close to the wall), the head aspect of rope recovery. The decision on whether to pro-
rope can be used to prevent the horse swinging up into vide manual assistance with head and/or tail ropes to a
sternal position and attempting to stand prematurely. In recovering horse should be based on the type of
either system, the majority of the horse’s support is patient, the type of fracture, and the surgeon’s experi-
derived from the tail rope. A horse cannot be lifted by ence. Certainly, long bone fracture repairs and horses
head and tail ropes alone; ropes are only capable of main- that are not particularly fit should be assisted during
taining and steadying a horse as it rises from the recum- recovery. However, in young athletic horses with simple
bent position. The ropes need to be long enough to go fractures, it is the author’s opinion that they are best left
through the corner rings and outside the recovery stall, to recover on their own. The stimulation of having hos-
either through windows or over the doors. The choice pital personnel in the recovery stall, along with head and
for the team to remain in the recovery box and work both tail ropes, encourages many horses to rise before they are
head and tail ropes and assist at the shoulder varies with ready. These horses are better managed by placing them
surgeon and the type of horse or injury. Many surgeons on a soft, deep pad with the lights dimmed in the recov-
prefer being able to add some stabilizing support at the ery stall, and allowing them to lie undisturbed in lateral
www.ajlobby.com
(A) (B)
Figure 43.1 (A) Rope recovery system using self‐tailing sailing winches to control head and tail rope tension. (B) Close‐up of winch shows
how tension on the rope held by personnel prevents loosening of the end attached to the horse.
recumbency until they are able to rise with one attempt.

If these horses are comfortable and not disturbed, they
will frequently have to be stimulated to rise after suffi-
cient time has passed, and often stand with one smooth
attempt and are ready to return to their stall within
minutes.
Tilt Table Recovery

A tilt table has been found by some groups to be a useful
system for recovering horses believed to be at increased
risk of injury during anesthetic recovery, particularly
those having high‐risk orthopedic‐related procedures. In
a review of tilt table use for 54 anesthetic recoveries in 36
horses, only 1 horse (1.9%) had complete failure of the
internal fixation during recovery and was euthanized.1
Six (11%) of the horses failed to adapt to the tilt table
system, which necessitated transfer to a conventional Figure 43.2 Horse recovering in Anderson sling. It is helpful to have
recovery room. Complications without important con- the option to walk the horse while still in the sling with the hoist on
sequences for clinical outcome (skin abrasions, myositis, a monorail. Forelimb function generally returns first and the ability
cast breakage, partial implant failure) occurred in eight to walk the horse encourages return of hind limb function and
(15%) of the recoveries. The authors concluded that a tilt allows accurate assessment of when it is safe to remove the sling.
table recovery system was associated with minimal inci-
dence of serious complications.1 Potential disadvantages padded recovery stall. The anesthetized horse is placed
of the system were the number of personnel required, in the sling while on the surgery table and the sling
the longer recovery time, and the need for a specialized further adjusted in the recovery box. After extubation
table. and during the initial attempt to stand, a hoist is used to
suspend the horse just above ground level until it is
conscious and capable of full weight bearing (Figure 43.2).
Anderson Sling Recovery In the author’s experience the head support on the
Anderson sling is potentially dangerous to people assist-
The Anderson Sling recovery system is another mecha- ing with the recovery process and it should be removed.
nism to recover horses that are at increased risk for A dental stand provides easy to use support for the head
injury associated with adverse events during recovery until the horse is awake enough to no longer need
from general anesthesia.7 The sling is used in a regular support. In the author’s practice the plane of anesthesia
www.ajlobby.com
is lightened at the end of surgery and, other than a single with the patient in a sling and the horse is moved to the
dose of xylazine (50 mg/450 kg) administered prior to operating theater using the sling. Following the comple-
hoisting the horse off the surgery table, no other sedation tion of surgery, the horse is lifted in the sling and placed
is given during recovery to minimize time in the sling. In in a custom‐designed rubber raft, which is then lowered
one report of 32 assisted recoveries in 24 horses, 31 into the heated pool. When the horse appears to be
recoveries were considered successful.7 No complica- awake enough to stand, a blindfold is applied, both horse
tions associated with the sling or recovery system pro- and raft are lifted out of the pool, the raft dropped on the
tocol occurred. One horse was intolerant of the sling’s pool apron, and the blindfolded horse moved in the sling
support and was reanesthetized and recovered success- to the recovery stall. Head and tail ropes are passed
fully using head and tail ropes. through wall rings and the horse lowered to the recovery
stall floor, where it should be ready to stand on its own.
The major advantage of the raft recovery system over
the lift recovery system is that the surgical site is not
Medication for Recovery immersed in water.6 The major disadvantage of the raft
system is that the anesthesia personnel do not know with
Adequate postoperative analgesia is an important com-
certainty whether the horse can stand on its own until it
ponent of ensuring smooth recovery from anesthesia.
has been moved out of the pool and into the recovery stall.
While the majority of minor procedures are treated with
With experience, however, the ability to predict when a
a nonsteroidal anti‐inflammatory drug (NSAID) preop-
horse is ready to stand improves. Other disadvantages of
eratively, procedures in which considerable postoper-
the raft recovery system are the cost of manufacture of the
ative discomfort is anticipated benefit from a more
one‐of‐a‐kind raft, and the number of personnel (7) it
aggressive pain management strategy. In the author’s
takes to recover a horse using this system.6
opinion, local anesthetic blocks should be considered
The lift recovery system was originally designed by
only for procedures of the distal limb (fetlock or below).
Dr. Doug Herthel and installed at Alamo Pintado Equine
More proximal regional nerve blocks may result in some
Medical Center (Los Olivos, CA, USA).2 Other lift recov-
loss of normal proprioception and subsequent difficulty
ery system pools have since been installed at Ocala
in rising. Potentially fragile long bone fracture repairs
Equine Hospital (Ocala, FL, USA); Washington State
should not be blocked by local perineural anesthesia to
University (Pullman, WA, USA); the Helen Woodward
eliminate pain sensation, due to the risk of overloading
Clinic (San Diego, CA, USA); and the University of
the limb during recovery. Morphine, administered either
Zurich in Switzerland. All employ a smaller pool (most
parenterally or via an epidural catheter, provides excel-
are 12 ft/3.7 m long, 4 ft/1.2 m wide, and 8 ft/2.4 m deep)
lent postoperative analgesia for painful fracture repairs
and a perforated metal grate floor with hydraulic lift.
(see Chapter 7), allowing the horse to rest comfortably
Using this system, anesthesia is again induced in a sling
in the recovery stall until it is ready to stand. Analgesic
and the horse is moved in the sling to the operating
medications should ideally be administered either pre-
room. At the completion of surgery, a light waterproof
operatively or while the horse is still under anesthesia,
bandage is applied to the surgery site. This consists of
to provide analgesia before the onset of pain.
coating the incisions with cyanoacrylate glue, placing an
adhesive plastic drape around the limb, and wrapping
the limb with MicrofoamTM tape (3M Company, St. Paul,
Pool Recovery Systems MN, USA). No padded bandages are applied. The horse
is then moved to the heated pool in the sling, and the
In an effort to improve the anesthetic recovery of sling used to maintain the horse at the appropriate depth
patients with major fracture repairs, several clinics have to stabilize it in the pool. A small raft is used to support
installed pool recovery systems. The patient recovers in the horse’s head out of the water. Minimal lift is required
a warm‐water pool (about 100 °F), which allows the on the sling to maintain the horse’s backline level with
horse to paddle and struggle against the resistance of the the surface of the water, because of the natural buoyancy
water without injuring itself or disrupting the fracture of the horse. Head and tail ropes are placed through wall
repair. There are two types of pool recovery systems in rings to keep the horse centered in the pool. When the
use: the raft recovery system and the lift recovery system horse appears to be awake enough to stand, the pool
(Figures 43.3 and 43.4). floor (a stainless‐steel hydraulic lift table) is raised until
The only raft recovery system in use was devised by Dr. the horse’s feet contact the floor. If the horse is not able
Jacques Jenny and was installed at the C. Malon Kline to stand squarely on the floor, it is lowered again and the
Center at New Bolton Center (Kennett Square, PA, USA) horse given more time to recover. Once the horse is able
in the early 1970s. In this system, anesthesia is induced to stand squarely on all four limbs, a blindfold is applied,
www.ajlobby.com
(A) (B)
(C) (D)
(E) (F)
Figure 43.3 Lift pool recovery sequence. (A) Anesthesia is induced in a sling and the horse is positioned on the surgery table.
(B) Following the completion of surgery, the horse is placed in the warm‐water recovery pool. A light waterproof bandage covers the
surgical site (left hindlimb). (C) The horse’s head is supported by a small raft and the sling helps maintain the horse level with the surface
of the pool. (D) Once the horse begins to recover from anesthesia, the pool floor is raised to determine whether the horse can stand
squarely on all four limbs. (E) Once the horse is able to stand on all limbs, the pool floor and sling are quickly raised, bringing the pool
floor level with the pool apron. (F) With the horse standing out of the pool, the bandage is changed to a standard padded bandage and
the sling is removed. The horse is then ready to return to its stall.
www.ajlobby.com
(A) (B)
(C) (D)
(E) (F)
Figure 43.4 Raft pool recovery sequence. (A) Anesthesia is induced in a sling, as with the lift pool recovery. (B) Following the completion
of surgery, the horse is placed in a specially designed raft and the horse and raft are lowered into the warm‐water recovery pool. (C) Once
the horse is sufficiently recovered to stand, the raft and horse are removed from the pool. (D) The raft is dropped on the pool apron and
the horse hoisted out of the raft. (E) The horse is moved in the sling to the recovery stall. (F) Head and tail ropes are placed through rings
in the recovery stall wall and the horse is lowered to the recovery stall floor.
www.ajlobby.com
and floor and sling are quickly elevated until the floor is needed for recovery, even when the patient is coming
level with the pool apron. With the tail rope and blind- from a nearby farm. It is essential that the water be
fold removed but the sling still in place for support, the warmed to at least body temperature in both systems, or
bandage is removed, the surgical site dried, and a new the recovery from anesthesia will be greatly prolonged.
padded sterile bandage is applied. Once the bandage has Pool recovery systems have largely eliminated the
been changed, the sling is removed, and the horse walked catastrophic injuries that can occur during standard

back to its stall. assisted‐recovery techniques. Pool recoveries, however,
The major advantage of the lift recovery system is that are not foolproof. Mechanical failures and errors in
the horse’s ability to stand can be assessed while the horse human judgment can still occur and can result in serious
is still in the pool, and repeated attempts to raise the floor injury to the recovering horse. In one report, 10 of 60
can be made before the final decision to remove the horse horses recovered in a lift pool system developed
from the pool. The major disadvantage of this system is pulmonary edema.5 This was thought to be due to the
that the surgical site is immersed in water under a “water- effects of increased hydrostatic pressure on the thorax
proof” bandage. In the author’s hospital, the inability to during immersion in water. We have not had a similar
truly waterproof the surgery site has not appeared to result incidence of postrecovery pulmonary edema, with only
in any increase in wound infections in pool recovered one mild case of pulmonary edema in our pool recovery
horses over those recovered using standard recovery stall caseload, which quickly responded to a single dose of
methods. The lift recovery system is not as labor intensive furosemide. In a retrospective study of raft pool recover-
as the raft system, but it still requires at least four people ies, 9 of 337 horses recovered in the pool were euthanized
to get a horse out of the pool. after being moved to the recovery stall due to complete or
Both systems require a substantial initial capital invest- partial failure of the fracture fixation.6 In the author’s
ment and both systems have recurring maintenance hospital, pool recoveries are used primarily for long bone
costs. The pool at the author’s hospital is emptied fractures, although the pool is also used for recovery after
between cases, which obviates the need to keep the pool other procedures (cervical stabilization, pelvic fractures,
filter and heater running continuously. These pools hold and weak or neurologic horses that are having difficulty
less water than the raft recovery pool at New Bolton with a standard recovery stall recovery).8 Occasionally
Center, so they can be rapidly filled and heated. Fill times owners request a pool recovery for their horse, and their
are approximately 20 minutes, with another 2 hours wishes are generally accommodated when medically fea-
required to heat the water to about 100 °F (38 °C). This sible. The majority of cases in our hospital, however, are
allows the pool to be filled and heated long before it is still recovered using standard recovery stall methods.
References
1 Elmas, C.R., Cruz, A.M., and Kerr, C.L. (2007). Tilt table anesthetic recovery in a hydropool. Am. J. Vet. Res. 62:
recovery of horses after orthopedic surgery: fifty‐four 1903–1910.
cases (1994–2005). Vet. Surg. 36: 252–258. 6 Sullivan, E.K., Klein, L.V., Richardson, D.W. et al. (2002).
2 Herthel, D.J. (1996). Systems for recovery from Use of a pool‐raft system for recovery of horses from
anesthesia. In: Equine Fracture Repair (ed. A.J. Nixon), general anesthesia: 393 horses (1984–2000). J. Am. Vet.
339–342. Philadelphia: Saunders. Med. Assoc. 221: 1014–1018.
3 Niimura del Barrio, M.C., David, F., Hughes, J.M.L. et al. 7 Taylor, E.L., Galuppo, L.D., Steffey, E.P. et al. (2005).
(2018). A retrospective report (2003–2013) of the Use of the Anderson Sling suspension system for
complications associated with the use of a one‐man recovery of horses from general anesthesia. Vet. Surg.
(head and tail) rope recovery system in horses following 34: 559–564.
general anaesthesia. Irish Vet. J. 71: 6. 8 Tidwell, S.A., Schneider, R.K., Ragle, C.A. et al. (2002).
4 Ray‐Miller, W.M., Hodgson, D.S., McMurphy, R.M., and Use of a hydro‐pool system to recover horses after
Chapman, P.L. (2006). Comparison of recoveries from general anesthesia: 60 cases. Vet. Surg. 31: 455–461.
anesthesia of horses placed on a rapidly inflating‐ 9 Wilderjans, H. (2004). Advances in assisted recovery
deflating air pillow or the floor of a padded stall. J. Am. from anaesthesia in horses with fractures. In:
Vet. Med. Assoc. 229: 711–716. Proceedings of the European Society of Veterinary
5 Richter, M.C., Bayly, W.M., Keegan, R.D. et al. (2001). Orthopaedics and Traumatology Congress, vol. 12,
Cardiopulmonary function in horses during 201–202. Munich: ESVOT.
www.ajlobby.com
814
44
Postanesthetic Myopathy
Manuel Martin‐Flores and Robin D. Gleed
Introduction Longer duration of anesthesia seems to increase the

chance of myopathy.14 Animals undergoing certain
Postanesthetic myopathy is a common, serious compli- orthopedic procedures (e.g., repair of condylar fracture)
cation of general anesthesia of horses. It can occur in ani- may be at greater risk than others undergoing proce-
mals which are ostensibly in excellent condition for dures such as celiotomy for relief of colic.14 Other factors
anesthesia, in well‐equipped hospitals where all standard which may increase the risk for postanesthetic myopathy
precautions are observed, and after an anesthetic episode include a history of recent racing in fit horses14 and
which was without apparent complication. Its incidence intraoperative hypoxemia. However, the study by Franci
may be quite variable and depends on several factors, but et al.7 showed that the incidence of postanesthetic myo-
has recently been reported to be as high as 2.3%, when pathy/neuropathy was at least as high in horses anesthe-
signs of myopathy and/or neuropathy combined were tized for magnetic resonance imaging (MRI) compared
evaluated at a referral facility.7 In contrast, Richey et al. with those anesthetized for various surgeries (2.3% vs.
(1990), reported an incidence of 6.4%, also at a referral 0.98%, not statistically different). Additionally, anesthesia
institution, which suggests current anesthetic techniques for the MRI group was shorter than that in the surgery
may have led to a decline in the incidence of myopathy.34 group, but horses in the MRI group were heavier than
The condition may be severe enough to require euthana- those in the surgery group. This emphasizes that the
sia on humane or economic grounds. A large‐scale study, etiology of myopathy may be multifactorial.7
evaluating over 8000 anesthetic episodes, found the inci- Increasing pain after recovery from anesthesia is typical
dence of myopathy to be ~0.8%, but with a fatality rate of of the condition. Pain causes distress and increased sym-
~15% for that subpopulation.13 pathetic tone, characterized by excitement, tachycardia,
Several different causes of postanesthetic lameness tachypnea, and sweating. Affected muscle groups are swol-
have been reported, including myopathy, peripheral neu- len, tense, and painful on palpation. Muscle fasciculation
ropathy, spinal degeneration, and metabolic abnormali- may be observed. Usually muscles which were in contact
ties. Of these, myopathy is the most commonly diagnosed. with the operating table are affected, but occasionally other
Peripheral neuropathy may occur in conjunction with muscles are involved. If the animal was positioned in lateral
postanesthetic myopathy, but has also been recognized recumbency, the affected muscles may include the triceps,
independently.6 supraspinatus, infraspinatus, pectoral, brachiocephalic, del-
toid, intercostal, or masseter muscles.23 In horses that were
in dorsal recumbency, the longissimus dorsi and gluteal
Clinical Presentation muscles are often affected,23 as are the rear limb adductor
muscles (adductor, pectineus, and gracilis muscles).4
Affected horses have impairment ranging from minor Triceps myopathy is the most commonly recognized
lameness, through incoordination, to complete inability form of postanesthetic myopathy in horses anesthetized
to stand. The condition is often obvious during recovery in lateral recumbency. Affected limbs bear little weight,
from anesthesia, but may not become apparent until sev- and the elbow is dropped. Most animals with this condi-
eral hours thereafter. Larger, well‐muscled horses are more tion are distressed and appear to be in extreme pain.
likely to develop the condition than smaller animals.14 Some have little or no apparent pain, and in these patients

www.ajlobby.com
it is assumed that peripheral neurologic damage to enzyme concentration in the plasma and myoglobinuria.
either the brachial plexus or radial nerve is also involved. A thorough physical, neurologic, and biochemical exami-
Occasionally, complete brachial or radial nerve paralysis nation is necessary for accurate diagnosis in all lame or
alone causes a nonpainful lameness, with dropped elbow incoordinate animals where myopathy cannot be localized.
and characteristic limb advancement by “flipping” of the
whole brachium.23
Animals with adductor myopathy may have difficulty Pathologic Appearance
standing.4 They adopt a base wide, crouched posture,
with the hindquarters lower than the forequarters. The Affected muscles are acutely congested and hemorrhagic.
stifle, hock, and fetlock tend to be flexed and the animal Histologically there are usually masses of red cells dis-
bears its weight on the toes of the hindlimb.4 Femoral or secting between muscle bundles and fibers (Figure 44.1).
sciatic nerve paralysis may cause a similar posture, but is There may be areas of edema. The long‐term conse-
not associated with pain.6 Animals with myopathy of the quences of myopathy largely depend on the extent of
longissimus dorsi and gluteal muscle groups appear to damage. The muscle cell consists of a long, multinucleate
experience severe back pain and are reluctant to walk. myofiber contained within a tough basal lamina.12 Many
Loss of muscle cell integrity causes myoglobinemia and satellite cells are also contained within the basal lamina.
myoglobinuria. The latter may give the urine a port wine The spectrum of degeneration observed in muscle has
color when myopathy is extensive. In one study of animals been divided into four levels.12 The first level is character-
with myopathy, serum creatinine kinase (CK) activity ized by disruption of myofibrils and sarcoplasma, but
increased rapidly after recovery from anesthesia, and six intact sarcolemma, myonuclei, satellite cells, and basal
hours after anesthesia exceeded 9000 IU l−1.21 In the same lamina. The second level involves disruption of the myo-
study, aspartate transaminase (AST) activity increased nuclei, but leaves satellite cells and the basal lamina intact
more slowly and plateaued 24–48 hours after anesthesia at (Figures 44.2 and 44.3). The third level involves loss of
values in excess of 900 IU l−1. It should be noted that ani- satellite cells. In fourth‐level degeneration, connective
mals recovering from anesthesia, and exhibiting no signs tissue and capillaries are also lost.12
of myopathy, had modest increases in these two enzymes.21 Muscle has extensive powers of regeneration
Surgical intervention may exacerbate the release of these (Figures 44.2 and 44.3). Satellite cells are part of the mye-
enzymes. Ordinarily, maximal CK and AST levels should loblast cell line and retain the ability for mitotic division
exceed 3000 and 400 IU l−1, respectively, in order to sup- and incorporation into myofibers. Hence, extensive
port a diagnosis of myopathy. damage may occur to a muscle fiber, but regeneration
Most cases of myopathy recover in 24–48 hours, but should be complete if satellite cells are present. First‐ and
some may take up to 2 weeks for complete recovery. second‐level degeneration are usually associated with
Occasionally animals must be euthanized because they complete recovery, because satellite cells are still present
are unable to support their own weight, even after pro- within the basal lamina. Because myofibers are relatively
longed treatment including hoisting in a sling.
Myopathy may be difficult to distinguish from spinal
cord diseases, which have been reported in horses after
anesthesia and surgery. These include thrombo‐embolic
ischemic myelopathy,39 hemorrhagic myelopathy,2,44
myelomalacia,38 and traumatic fracture/luxation.
Hyperkalemic periodic paralysis may also be confused
with postanesthetic myopathy, particularly as muscle
injury itself may cause hyperkalemia.35 Muscle weakness
associated with nutritional myopathy (white muscle dis-
ease) should also appear on a list of possible differential
diagnoses, especially in horses coming from areas with
selenium deficiency. Equine polysaccharide storage
disease is seen in many draft horses and also has been
reported in other breeds. It may cause muscle weakness
that can be confused with postanesthetic myopathy
Figure 44.1 Biopsy from the long head of the triceps muscle
when it is noticed during recovery from anesthesia.
taken six hours after recovery from anesthesia (125×, H&E stain).
Prolonged recumbency caused by polysaccharide stor- The muscle was swollen, painful to the touch, and appeared dark
age disease may even initiate the usual clinical and bio- and congested on fasciotomy. Note the red blood cells dissecting
chemical signs of myopathy, including increasing muscle between apparently normal muscle cells.
www.ajlobby.com
Etiology
It has been postulated that the earliest lesion in muscle
“crush syndrome” in humans is pressure‐stretch myo-
pathy.26 This mechanism may be applicable to anes-
thetic myopathy. It suggests that deformation (stretch)
of cell membranes by external compression permits
increased cellular influx of sodium, chloride, water,
and calcium, down their electrochemical gradients.26
Simultaneously, the energy available to cationic extru-
sion pumps may be reduced by ischemic hypoxia caused
by vascular compression. The muscle cells swell and
the concentration of sarcoplasmic and mitochondrial
calcium increases as these pumps are overwhelmed.
Figure 44.2 Longitudinal section of triceps muscle from a horse The increased calcium, in turn, leads to activation of
which was euthanized 10 days after anesthesia (125×, H&E stain). autolytic processes and further interference with cellular
The limb was not weight bearing at this time. Note the two narrower respiration and homeostasis.26
myotubes in the middle of the field. These contain centralized The closing pressure for muscle capillaries is approxi-
satellite cells in more basophilic‐staining cytosol. This is characteristic
of second‐level degeneration. The two cells either side are apparently
mately 30 mmHg and sustained pressure greater than this
normal, with peripheral nuclei and less basophilic staining. leads to ischemic neuromuscular damage.10 Pressure val-
ues in excess of this have been reported in the dependent
(weight‐bearing) muscles of anesthetized horses.19,20,24,43
Muscle perfusion decreases during anesthesia,42 is lower
in the muscle of dependent limbs compared to uppermost
limbs,37 and dependent, compressed muscles become
progressively more acidic.24 These observations are con-
sistent with muscular ischemia during anesthesia of the
horse. Although poor perfusion secondary to hypotension
is a very likely cause of myopathy, increased intracompart-
mental muscle pressure (ICMP) may contribute.29
During ischemia, energy stores are depleted by reduced
ability to generate adenosine triphosphate (ATP) and the
continuing demand of the mechanisms responsible for
cellular homeostasis.26 Although this ischemia may be
damaging in itself, the important damage to muscle is
probably initiated during reperfusion (reoxygenation)
Figure 44.3 Cross‐section of triceps muscle from the patient after ischemia.17,36
described in Figure 44.2 (125×, H&E stain). There are narrow, During compressive ischemia, anaerobic metabolism
basophilic‐staining myotubes with internal nuclei interspersed
between apparently normal muscle cells.
produces hydrogen ions, which are exchanged for
sodium ions; hence, there is an increase in cellular
sodium. On reperfusion, the sodium–calcium exchange
long, damage to them is often confined to a part of their mechanism is probably reactivated, with sodium being
length (“segmental” degeneration). If this is the case, and exchanged for calcium, resulting in further accumulation
the basal lamina is intact, reconstruction of the fiber is of intracellular calcium.26 Overloading with calcium
often complete. impairs many aspects of cell function. Mitochondrial
Ordinarily, more than six hours of ischemia is necessary inhibition by calcium causes reduced respiration and
to produce irreversible muscle damage, i.e., extensive loss ATP production, sufficient in itself to hasten cell death.
of both myonuclei and satellite cells.12 Irreversible dam- Certain protease enzymes are also activated by increased
age, however, may occur after much less than six hours of cytosolic calcium; in consequence, reperfusion of muscle
anesthesia, suggesting that ischemia during the period is associated with irreversible calcium‐dependent prote-
of anesthesia is not the sole factor involved in the etiology olytic conversion of xanthine dehydrogenase to xanthine
of this condition. If large amounts of muscle are damaged, oxidase.22 In most other tissues, conversion of xanthine
then repair by fibrosis may lead to ischemic contracture dehydrogenase to xanthine oxidase occurs during
and varying degrees of functional impairment. hypoxia and reperfusion is not a necessary precursor of
www.ajlobby.com
22
the conversion. On reperfusion, hypoxanthine which Prevention
accumulates during ischemia is oxidized by molecular
oxygen, producing oxygen free radicals.22 This reaction Careful attention to positioning of the horse during
is catalyzed by xanthine oxidase and produces a burst anesthesia prevents many instances of myopathy. In lat-
of superoxide radicals and the formation of hydrogen eral recumbency, supporting the upper limb in a hori-
peroxide. The free radicals usually associated with zontal position and advancing the lower (weight‐bearing)
ischemia and reperfusion injury include superoxide limb cranially produce the lowest pressure in the triceps
anion, hydroxyl radical, and iron–oxygen complexes muscles of the lower limb.43 This limb arrangement
(ferryl [FeIVO]2+ and perferryl [FeIVO2]2+ ions).36 In reduces triceps myopathy. The edge of the operating
horses with postanesthetic myopathy, a decrease in table should not be under the brachium or shoulder, as
plasma antiperferryl activity has been observed during the weight of the distal leg in this position acts as a lever,
the period when reperfusion occurs, consistent with compressing the proximal limb. Support applied to the
iron–oxygen complex proliferation.36 Oxygen free radi- lateral hindquarters and thighs of horses in dorsal
cals attack the unsaturated bonds of free fatty acids in the recumbency prevents maximal abduction of the hind
phospholipid bilayer of cell membranes.26 Lipid peroxi- legs; this is thought to reduce the chance of adductor
dation causes structural and functional alterations in the myopathy and/or neuropathy.
cell membranes and leads to cell swelling, interstitial Padding is of critical importance in minimizing pos-
edema, and ultimately to cell death.15 tanesthetic myopathy. It should distribute the weight of
Increased cell calcium during reperfusion may also an animal evenly over as large an area as possible. In the
activate phospholipase A2, which results in the produc- future, it may be possible to design padding systems
tion of lysophospholipids, leukotrienes, and prostaglan- which safely spare the muscle groups at special risk. In
dins, all of which injure muscle cells.26 Prostaglandin one study of horses in lateral recumbency, a water
biosynthesis also results in superoxide anion and hydroxyl mattress produced the least dramatic increase in triceps
radical production. Polymorphonuclear leukocytes accu- muscle pressure.20 This was followed, in order of decreas-
mulate in postischemic muscle, and may be observed ing usefulness, by an air dunnage bag, a concrete floor,
adhered to the capillary walls in histologic specimens. and a 10 cm thick foam mattress. In another study, 10 cm
Such leukocytes may produce enzymes and oxygen radi- thick foam was found to be superior to no padding.43 A
cals in a “respiratory burst,” which promotes the produc- major disadvantage of the commonly available open‐cell
tion of other potent cytotoxic oxidants.16 foam mattress is that if the shell (usually made from
Compartment syndrome is caused by disturbed circu- vinyl) is perforated, subsequent washing causes the
lation to muscles and nerves in closed osseofascial com- mattress to become waterlogged, reducing its ability to
partments, and is characterized by sustained increase in distribute weight. Closed‐cell foam mattresses are more
interstitial fluid pressure within those compartments.43 water resistant and maintain weight‐distributing proper-
Much research on the etiology of postanesthetic myo- ties. Research to identify the best materials for operating
pathy has focused on compartment syndrome. It is sur- table surfaces and recovery room floors is ongoing.
mised that capillary leakage and cellular edema are Careful attention to anesthetic technique is vital in
initiated during ischemia due to external compression.27 preventing myopathy. Systemic arterial hypotension
The swelling and pressure increase produced by these induced by halothane causes myopathy.9,21 This suggests
processes are sufficient to occlude venous egress from that minimizing the depth of anesthesia and maintaining
the compartment, even after external compression is adequate blood pressure will reduce the possibility of
released.27 Hence, compartment syndrome is self‐ myopathy. The available experimental data do not distin-
sustaining. Whether compartment syndrome is a neces- guish between the effects of minimizing the concentra-
sary component in all postanesthetic myopathies is tion of inhaled anesthetics and maintaining adequate
unclear. It seems unlikely to be a part of myopathy where blood pressure. Anecdotal evidence strongly suggests,
there is no clear anatomic osseofascial compartment. however, that maintaining mean systemic arterial pres-
Increased pressure, however, has been recorded 24 and sure in excess of 80 mmHg reduces the incidence of pos-
48 hours after anesthesia in the muscles of a horse with tanesthetic myopathy, regardless of anesthetic dose. To
postanesthetic myopathy of the triceps group.25 this end, many surgical facilities monitor blood pressure
Compression and reperfusion of muscle clearly play an by catheterization of an appropriate artery or with a cuff‐
important role in most cases of postanesthetic myopa- type indirect measurement device (e.g., Dinamap 8300,
thy. Nevertheless, direct compression cannot explain Critikon, Tampa, FL, USA). Ideally, mean systemic blood
cases in which myopathy develops bilaterally, or unilat- pressure should be kept above 80 mmHg, and pressure
erally in the upper limb, after anesthesia in lateral below 70 mmHg should be treated by minimizing depth
recumbency.14 of anesthesia and intravenous fluid administration
www.ajlobby.com
(e.g., >10 ml/kg/hr of lactated Ringers). In fact, mean choosing anesthetic protocols which produce quiet,
arterial pressure lower than 70 mmHg was associated unhurried recovery from anesthesia may prevent sudden
with an increased risk of postanesthetic myopathy in one reperfusion of muscle after anesthesia. Premedication
study using halothane as the anesthetic agent.29 with suitable drugs (e.g., xylazine or acepromazine)
The choice of inhalational agent may also play a role in encourages quiet recovery. In orthopedic patients where
the development of postanesthetic myopathy. Evidence postoperative pain is likely to cause excitement, small
indicates that isoflurane maintains perfusion better than doses of an analgesic (e.g., detomidine 10–20 μg kg−1,
halothane, even during hypotensive states. When halo- intramuscularly) given in the recovery room may pre-
thane is used for anesthesia, a decrease in arterial blood vent premature motor activity without unduly delaying
pressure can be accompanied by an increase in femoral recovery.
vascular resistance, which may impede perfusion to the The almost certain involvement of reperfusion injury
limb.33 Left ventricular systolic function and blood flow in postanesthetic myopathy would suggest that prophy-
to the limbs were maintained better with isoflurane than lactic use of free radical antagonists might be useful. The
with halothane at equipotent concentrations.31 In addi- relatively low incidence of postanesthetic myopathy, the
tion to preserving better ventricular systolic function, inability to accurately predict those horses likely to get
lower femoral vascular resistance was seen when isoflu- the condition, the high cost of many of the drugs, and
rane was used, likely contributing to the superior perfu- insufficient data concerning their efficacy and safety in
sion of the muscle in the limbs. horses mitigate against such a recommendation at this
Dobutamine is probably the most appropriate sympa- time. Nevertheless, the author has used dimethyl sulfox-
thomimetic for increasing cardiac output and perfusion ide (DMSO) as a prophylactic free radical scavenger in
pressure in anesthetized horses; its β‐agonist properties several draft horses where prolonged anesthesia was
provide a degree of vasodilation that reduces vascular anticipated. Pretreatment with vitamin E and selenium
resistance and promotes blood flow. Approximately has yet to be evaluated, but may prove useful in prevent-
1.7 μg/kg/min is a suitable initial rate of infusion,5 ing postanesthetic myopathy.
although doses as low as 0.5 μg/kg/min have been shown A link between anesthetic myopathy and malignant
to enhance blood flow in association with a decrease in hyperthermia has been postulated on the basis of an in
femoral vascular resistance.30 This rate should be vitro contracture test.41 Dantrolene is a specific treatment
adjusted to maintain adequate blood pressure. Solution for malignant hyperthermia. However, there is no evi-
concentration is usually 0.1 mg of dobutamine per ml of dence that dantrolene is effective for preventing or treat-
0.9% saline. Overdosage with dobutamine is character- ing postanesthetic myopathy. Dantrolene has been used in
ized by cardiac tachydysrhythmias and, because of its horses that subsequently were afflicted with myopathy
short half‐life, can usually be treated by simply reducing and others where prolonged recumbency after anesthesia
the rate of drug infusion. Ephedrine has also been shown required euthanasia.40 Dantrolene should not be used to
to increase muscle perfusion.18 Its longer duration and try to prevent postanesthetic myopathy, because it has not
ability to cause dysrhythmias may make it a less attrac- been shown to be either safe or efficacious.
tive alternative to dobutamine. Phenylephrine, a short‐
acting α1‐agonist, produces vasoconstriction, and readily
elevates arterial blood pressure. However, this increase
in blood pressure results from an elevated systemic vas- Treatment
cular resistance. Therefore, although an effective treat-
ment for hypotension, phenylephrine typically results in Animals with obvious signs of postanesthetic myopathy
a decreased cardiac output (due to an increase in after- should be treated promptly. Therapy including the
load) and decreased muscle perfusion. When given at free radical scavenger DMSO (1 g kg−1, 10–20% solution
1 μg/kg/min to anesthetized horses, phenylephrine in 5% dextrose, intravenously), on the grounds that
resulted in a reduction in femoral blood flow and an reperfusion generates free radicals during the short

increase in femoral vascular resistance.32 Although no period after perfusion is reestablished, should be
particular anesthetic protocol has been definitely impli- considered.1,23,25
cated in the etiology of myopathy, avoiding large doses of Other substances which modify reperfusion injury in
any drug known to produce hypotension or hypoperfu- muscle include superoxide dismutase (a superoxide
sion of muscle is critical in reducing the chance of myo- anion scavenger), catalase (a peroxidase), mannitol (a
pathy occurring. hydroxyl free radical scavenger), and allopurinol (a xan-
Minimizing the duration of anesthesia reduces the thine oxidase inhibitor).26 Presently, none of these sub-
chance of myopathy.14 However, slow return of blood stances has been evaluated for this purpose in horses and
flow may minimize reperfusion injury in muscle.17 Thus, their future role is speculative.
www.ajlobby.com
Cellular accumulation of calcium seems to be a critical recumbency, is quite satisfactory. Sternal recumbency is
component of ischemic and reperfusion muscle damage. preferred because of the enhanced oxygenation in this
Conventional calcium entry blockers that act at calcium posture.8 Larger horses are more likely to exacerbate
slow channels do not appear to provide protection from pressure problems in the recovery room, therefore larger
reperfusion injury.26 On the other hand, the potassium‐ horses require hoisting more frequently, despite the fact
sparing diuretics amiloride and benzamil have been that hoisting them is more difficult. Splinting of the fore-
shown experimentally to inhibit sodium–calcium leg may help patients with triceps myopathy/neuropathy.
exchange during reperfusion, and at least provide partial Hobbling of the hind legs in cases of adductor myopathy/
protection from reperfusion injury.3,28 Any clinical appli- neuropathy reduces the risk of overabduction.
cation of these drugs, however, will require simultaneous Circulatory failure is a potential complication of severe
fluid administration to prevent volume depletion sec- myopathy. Humans with extensive muscle degeneration
ondary to diuresis.26 can sequester a volume similar to their entire extracel-
Additional therapy is supportive and symptomatic.23 lular fluid volume in affected muscle.26 Extrapolation
Analgesics, sedatives, and/or tranquilizers should be suggests that a 500 kg horse might lose nearly 80 l to this
used to minimize the patient’s distress. Xylazine (0.1– site. This is likely to cause severe hypovolemia, which
0.3 mg kg−1, intravenously) and detomidine (10– may be complicated by sequestration of red cells and
20 μg kg−1, intravenously) produce both sedation and plasma protein. Careful monitoring of blood volume,
analgesia. Detomidine may be preferable because of its acid‐base status, packed cell volume, and plasma protein
longer duration. Acepromazine (0.04 mg kg−1, intrave- concentration should be instituted in cases of severe
nously) appears to ease the distress of animals with pos- myopathy. Hypovolemia and other blood deficiencies
tanesthetic myopathy;25 whether this is due to should be treated accordingly.
vasodilation in the muscle, tranquilization, or some Renal failure has been associated with myopathy
other effect is not known. (Figure 44.4). This may be secondary to hypovolemia,
Glucocorticosteroids (e.g., dexamethasone sodium which can cause renal ischemia by activation of vasocon-
phosphate, 0.05–0.10 mg kg−1, intravenously) may be strictor hormones.26 Tubular obstruction by myoglobin
used to reduce inflammation and to inhibit cyclooxyge- or uric acid crystals may also play a part in the etiology of
nase‐mediated prostaglandin synthesis, a process which renal failure.26 It may be caused by a direct nephrotoxic
produces free radicals.11 Nonsteroidal anti‐inflamma- effect of myoglobin or products of its decomposition,
tory drugs such as phenylbutazone (5 mg kg−1, intrave- such as ferrihemate.26 In the first 24 hours after the onset
nously) or flunixin meglumine (1 mg kg−1, intravenously) of myopathy, serum creatinine concentration and blood
are also useful,23 but the possibility of causing or exacer- urea nitrogen usually increase. Continuing increase after
bating nephrotoxicity should be minimized by ensuring
adequate blood volume (see later in the chapter).
Once the central nervous system effects of anesthesia
have dissipated, it is usual to try to assist recumbent
horses in their efforts to stand. Pulling up on a tail rope,
occasionally via a wall ring, is the first assistance usually
given to myopathic horses. This may be supplemented
by a similar arrangement supporting the head. Assisting
these animals minimizes the opportunity for further
compressive muscle damage during recumbency.
Animals which stand unaided or with minimal tail and
head support have a good prognosis for recovery. When
support of the tail and head is inadequate, and if facilities
are available, then hoisting in a sling is the next alterna-
tive. Ideally, horses in a sling should be able to support
themselves once standing. Animals with extensive mus-
cle and/or nerve damage may not be able to support Figure 44.4 Section of kidney from the patient described in
themselves and require intermittent hoisting to prevent Figure 44.2 (125×, H&E stain). The horse had no clinical signs of
compressive damage continuing in the recovery room. renal disease at the time of euthanasia. Note the loss of cell detail,
pycnotic nuclei, and debris in the tubule that is located below and
Prolonged use of a poorly fitting sling may in itself cause
to the right of center. The tubule above is lined by plump cells in
significant muscle compression. The decision of when to mild disarray, indicative of tubular epithelial degeneration,
hoist is empiric. Leaving horses in well‐padded recovery although ongoing tubular epithelial damage is still present, as
stalls for 4–6 hours, especially if they are in sternal evidenced by nuclear pycnosis.
www.ajlobby.com
24 hours is consistent with renal compromise. Extensive eventually to fibrosis and contracture. Specific treatment
discussion of therapy for renal compromise is beyond involves prompt surgical decompression of afflicted
the scope of this chapter. Nevertheless, fluid therapy is compartments by fasciotomy. This can usually be accom-
an essential component of prophylaxis and treatment for plished with the aid of sedation and local anesthesia.
renal compromise. Hence, all but the mildest cases of
myopathy should receive fluid support.
If compartment syndrome is suspected, it is probably
wise to measure intramuscular pressure. Tissue pressure Conclusion
may be measured with a transducer designed for blood
pressure measurement and zeroed at the level of the Attention to positioning and padding of anesthetized
muscle. The transducer should be attached to either a horses, along with careful avoidance of systemic hypo-
Teflon catheter43 or a specially designed wick catheter tension, has greatly reduced the incidence of serious
implanted in the body of the muscle.19 Normal muscle postanesthetic myopathy. Nevertheless, postanesthetic
pressure is 0–14 mmHg.25 Sustained intramuscular myopathy still occurs with sufficient frequency to war-
pressure in excess of 45 mmHg is probably diagnostic of rant a chapter in a book such as this, and when it does
compartment syndrome. Compartment syndrome, if occur it often has serious humane and economic
unrelieved, may lead to ischemic muscle necrosis, and consequences.
Acknowledgments
The author gratefully acknowledges the helpful com-
ments of Dr. Beth A. Valentine and Dr. Paula F. Moon.
References
1 Appell, L.H., Blythe, L.L., Lassen, E.D., and Craig, A.M. 9 Grandy, J.L., Steffey, E.P., Hodgson, D.S., and Woliner,
(1992). Adverse effects of rapid intravenous DMSO M.J. (1987). Arterial hypotension and the development
administration in horses. J. Equine Vet. Sci. 12: 215–218. of postanesthetic myopathy in halothane‐anesthetized
2 Brearley, J.C., Jones, R.S., and Kelly, D.F. (1986). Spinal horses. Am. J. Vet. Res. 48: 192–197.
cord degeneration following general anaesthesia in a 10 Hargens, A.R., Akeson, W.H., Mubarak, S.J. et al.
Shire horse. Equine Vet. J. 18: 222–224. (1978). Fluid balance within the canine anterolateral
3 Dennis, S.C., Coetzee, W.A., Cragoe, E.J., and Opie, L.H. compartment and its relationship to compartment
(1990). Effects of proton buffering and amiloride syndromes. J. Bone Jt. Surg. 60‐A: 499–505.
derivatives on reperfusion arrhythmias in isolated rat 11 Haynes, R.C. (1990). Adrenocorticotrophic hormone;
hearts: possible evidence for an arrhythmogenic role of adrenocortical steroids and their synthetic analogues;
Na‐H exchange. Circ. Res. 66: 1156–1159. inhibitors of the synthesis and actions of adrenocortical
4 Dodman, N.H., Williams, R., Court, M.H., and Norman, hormones. In: The Pharmacological Basis of
W.M. (1988). Postanesthetic hind limb adductor myopathy Therapeutics, 8e (ed. A.G. Gilman, T.W. Rall, A.S. Nies
in five horses. J. Am. Vet. Med. Assoc. 193: 83–86. and P. Taylor), 1431–1462. New York: Pergamon.
5 Donaldson, L.L. (1988). Retrospective assessment of 12 Hulland, T.J. (1992). Muscle and tendon. In: Pathology
dobutamine therapy for hypotension in anesthetized of Domestic Animals, 4e (ed. K.V.F. Jubb, P.C. Kennedy
horses. Vet. Surg. 17: 53–57. and N. Palmer), 183–264. San Diego: Harcourt Brace
6 Dyson, S., Taylor, P., and Whitwell, K. (1988). Femoral Jovanovitch.
nerve paralysis after general anaesthesia. Equine Vet. J. 13 Johnston, G.M., Eastment, J.K., Taylor, P.M., and Wood,
20: 376–380. J.L. (2004). Is isoflurane safer than halothane in equine
7 Franci, P., Leece, E.A., and Brearley, J.C. (2006). Post anaesthesia? Results from a prospective multicenter
anesthetic myopathy/neuropathy in horses undergoing randomized controlled trial. Equine Vet. J. 36: 64–71.
magnetic resonance imaging compared to horses 14 Klein, L. (1978). A review of 50 cases of post‐operative
undergoing surgery. Equine Vet. J. 38: 497–501. myopathy in the horse—intrinsic and management
8 Gleed, R.D. and Dobson, A. (1988). Improvement in factors affecting risk. In: Proceedings of the American
arterial oxygen tension with change in posture in Association of Equine Practitioners, vol. 24, 89–94.
anaesthetized horses. Res. Vet. Sci. 44: 255–259. Lexington, KY: AAEP.
www.ajlobby.com
15 Korthuis, R.J., Granger, D.N., Townsley, M.I., and dysfunction and damage in rat myocardium after
Taylor, A.E. (1985). The role of oxygen‐derived free calcium depletion and repletion. Am. J. Physiol. Heart
radicals in ischemia‐induced increases in canine Circ. Physiol. 258: H17–H23.
skeletal muscle vascular permeability. Circ. Res. 29 Raisis, A.L. (2005). Skeletal muscle blood flow in
57: 599–609. anaesthetized horses. Part II: effects of anesthetics
16 Korthuis, R.J., Grisham, M.B., and Granger, D.N. and vasoactive agents. Vet. Anaesth. Analg.
(1988). Leukocyte depletion attenuates vascular injury 32: 331–337.
in postischemic skeletal muscle. Am. J. Physiol. Heart 30 Raisis, A.L., Young, L.E., Blissitt, K.J. et al. (2000). Effect
Circ. Physiol. 254: H823–H827. of a 30‐minute infusion of dobutamine hydrochloride
17 Korthuis, R.J., Smith, J.K., and Carden, D.L. (1989). on hind limb blood flow and hemodynamics in
Hypoxic reperfusion attenuates postischemic halothane‐anesthetized horses. Am. J. Vet. Res.
microvascular injury. Am. J. Physiol. Heart Circ. Physiol. 61: 1282–1288.
256: H315–H319. 31 Raisis, A.L., Young, L.E., Blissitt, K.J. et al. (2000). A
18 Lee, Y.L., Clarke, K.W., Alibhai, H.I., and Song, D.Y. comparison of the haemodynamic effects of 1.2 MAC
(2002). The effects of ephedrine on intramuscular isoflurane and halothane anaesthesia in horses
blood flow and other cardiopulmonary parameters in premedicated with romifidine and induced with
halothane‐anesthetized ponies. Vet. Anaesth. Analg. ketamine. Equine Vet. J. 32: 318–326.
29: 171–181. 32 Raisis, A.L., Young, L.E., Meire, H.B. et al. (2000).
19 Lindsay, W.A., McDonell, W., and Bignell, W. (1980). Measurements of hindlimb blood flow recorded using
Equine postanesthetic forelimb lameness: Doppler ultrasound during administration of
intracompartmental muscle pressure changes and vasoactive agents in halothane‐anesthetized horses.
biochemical patterns. Am. J. Vet. Res. 41: 1919–1924. Vet. Radiol. Ultrasound 41: 64–72.
20 Lindsay, W.A., Pascoe, P.J., McDonell, W.N., and 33 Raisis, A.L., Young, L.E., Meire, H.B. et al. (2000).
Burgess, M.L. (1985). Effect of protective padding on Variability of Doppler ultrasound measurements of
forelimb intracompartmental muscle pressures in hindlimb blood flow in conscious horses. Equine Vet. J.
anesthetized horses. Am. J. Vet. Res. 46: 688–691. 32: 125–132.
21 Lindsay, W.A., Robinson, G.M., Brunson, D.B., and 34 Richey, M.T., Holland, M.S., McGrath, C.J. et al. (1990).
Majors, L.J. (1989). Induction of equine postanesthetic Equine post‐anesthetic lameness. A retrospective study.
myositis after halothane‐induced hypotension. Am. J. Vet. Surg. 19: 392–397.
Vet. Res. 50: 404–410. 35 Robertson, S.A., Green, S.L., Carter, S.W. et al. (1992).
22 McCord, J.M. (1985). Oxygen‐derived free radicals in Postanesthetic recumbency associated with
postischemic tissue injury. N. Engl. J. Med. 312: hyperkalemic periodic paralysis in a Quarter Horse.
159–163. J. Am. Vet. Med. Assoc. 201: 1209–1212.
23 Muir, W.M. (1991). Complications. In: Equine Anesthesia, 36 Serteyn, D., Mottart, E., Deby, C. et al. (1990). Equine
Monitoring and Emergency Therapy (ed. W.M. Muir and postanesthetic myositis: a possible role for free radical
J.A.E. Hubbell), 419–443. St. Louis: Mosby. generation and membrane lipoperoxidation. Res. Vet.
24 Norman, W.M., Dodman, N.H., and Court, M.H. Sci. 48: 42–46.
(1988). Interstitial pH and pressure in the dependent 37 Serteyn, D., Mottart, E., and Michaux, C. (1986).
biceps femoris muscle of laterally recumbent Laser doppler flowmetry: muscular
anesthetized horses. Vet. Surg. 17: 234–239. microcirculation in anaesthetised horses. Equine
25 Norman, W.M., Williams, R., Dodman, N.H., and Vet. J. 18: 391–395.
Kraus, A.E. (1989). Postanesthetic compartmental 38 Stolk, P.W.T., van der Velden, M.A., and Binkhorst, G.J.
syndrome in a horse. J. Am. Vet. Med. Assoc. 195: (1991). Thoracolumbar myelomalacia following general
502–504. anaesthesia in horses. In: Proceedings of the
26 Odeh, M. (1991). The role of reperfusion‐induced International Conference of the Association of
injury in the pathogenesis of the crush syndrome. N. Veterinary Anaesthetists, vol. 4, 100. North Mymms,
Engl. J. Med. 324: 1417–1422. UK: AVA.
27 Owen, C.A., Mubarak, S.J., Hargens, A.R. et al. (1979). 39 Taylor, H.W., Vandevelde, M., and Firth, E.C. (1977).
Intramuscular pressures with limb compression: Ischemic myelopathy caused by fibrocartilaginous
clarification of the pathogenesis of the drug‐induced emboli in a horse. Vet. Pathol. 14: 479–481.
muscle‐compartment syndrome. N. Engl. J. Med. 300: 40 Valverde, A., Boyd, C.J., Dyson, D.H., and Pascoe, P.J.
1169–1172. (1990). Prophylactic use of dantrolene associated with
28 Pierce, G.N., Maddaford, T.G., Kroeger, E.A., and prolonged postanesthetic recumbency in a horse. J. Am.
Cragoe, E.J. (1990). Protection by benzamil against Vet. Med. Assoc. 197: 1051–1053.
www.ajlobby.com
41 Waldron‐Mease, E. (1978). Correlation of post‐ 43 White, N.A. and Suarez, M. (1986). Change in triceps
operative and exercise induced myopathy with the muscle intracompartmental pressure with
defect malignant hyperthermia. In: Proceedings of the repositioning and padding of the lowermost thoracic
American Association of Equine Practitioners, vol. 24, limb of the horse. Am. J. Vet. Res. 47: 2257–2260.
95–99. Lexington, KY: AAEP. 4 Yovich, J.V., LeCouteur, R.A., Stashak, T.S. et al. (1986).
4
2 Weaver, B.M.Q., Lunn, C.E.M., and Staddon, G.E. (1984).
4 Postanesthetic hemorrhagic myelopathy in a horse.
Muscle perfusion in the horse. Equine Vet. J. 16: 66–68. J. Am. Vet. Med. Assoc. 188: 300–301.
www.ajlobby.com
823
45
Implant Removal
Alan J. Ruggles
Indications present when the implant was in situ. If a horse is to be

kept for breeding or pasture activity only, removal
Removal of surgical implants (screws, plates, wires) is of implants used in fracture repair is generally not indi-
generally performed for one of the following reasons: cated unless sepsis is present.
1) The function of the implants is complete (fracture
healed, correction of deformity).
2) The presence of the implant may potentially cause Timing of Implant Removal
lameness.
3) The presence of the implant is not cosmetic. Screws
4) The presence of the implant prevents resolution of Intentional physeal retardation is used for correction of
sepsis. angular limb deformity. Implant removal is required
after resolution of angular deformities to prevent over-
correction of a deformity. Timing of removal is based on
Risk of Implant Removal rate of growth, degree of deformity, and age of the foal at
the time of implantation as well as removal. In some
A decision on implant removal should be balanced with circumstances, implants inadvertently remain despite
the risk/benefits of the procedure. The risk of implant correction of the angular deformity. This could lead to
removal varies with the location and function of the overcorrection of the deformity and/or difficulty in
implant, the type of original injury, and the time from removal of the implants due to bone overgrowth.
fracture repair to anticipated removal of the implant(s). As a general rule, screws spanning a physis or screws
The unequivocal indications for screw or plate removal securing a plate across a physis should be removed if the
include (i) infection around the implant; (ii) screws or a physis has considerable remaining growth potential
plate creating a growth disturbance by bridging a physis; (Figure 45.1). Some physes are sufficiently damaged by
(iii) broken or loose screws or a plate; and (iv) lysis the fracture that closure is inevitable and implant
beneath the screw head with associated lameness. removal is futile. However, where physeal growth is
Removal of implants for other reasons requires a more maintained, staged or complete removal is required. In
complex analysis of the risk/benefit ratio. other situations, where physeal bridging is required to
Removal of single or multiple screws for correction of achieve stability, radiographic monitoring of fracture
angular limb deformity or fracture repair generally car- healing is used to determine the earliest possible time for
ries little to no risk. Infection of the soft tissues is possi- implant removal (see Figure 45.1). In foals, this may be as
ble during implant removal and can occasionally become soon as four weeks, but more commonly is six to eight
serious. Conversely, a second fracture of a long bone is weeks. Removal of one or several plate screws that span
possible after implant removal, even after staged removal. a physis, while leaving the remaining plate screws until
In general, cosmetic results after removal of single screws the fracture has completely united, achieves both goals
are excellent. After plate removal, the presence of seroma of primary fracture union utilizing the epiphysis to add
and scar tissue may lead to a less cosmetic result than to plate stability, and then continued physeal growth

www.ajlobby.com
(A) (B) (C)
Figure 45.1 Removal of the plate in a foal with an olecranon fracture. (A) Radiograph on Day 7 after repair using a dynamic compression
plate with screws penetrating through the ulna to engage the radius. (B) Radiograph at the time of plate removal seven weeks later,
showing healed fracture and distal displacement of the ulna relative to the humeral condyles (arrow) as a consequence of the continued
growth in the proximal radial growth plate. (C) Radiograph obtained three years after plate removal, showing return of joint congruency
(arrow). Source: Images courtesy Dr. Alan J. Nixon.
after removing selected screws. The disadvantage is the fracture and the surgeon’s preference. Unicortical
obviously the added expense of multiple surgeries. screws placed for the treatment of dorsal cortical meta-
A complication of fractures of the radius and ulna in carpal stress fractures are typically removed eight weeks
foals includes a fracture callus–induced synostosis of the postoperatively and after fracture healing. Controversy
radius and ulna (Figure 45.2). The impact on elbow con- usually surrounds the removal of lag screws following
gruity is the same as ulna fixation in foals, where plate repair and bony union of third metacarpal/metatarsal
screws also engage the radius. The age of the foal deter- condyle fractures, proximal phalanx fractures, and third
mines the extent of the elbow dysplasia that develops as carpal bone slab fractures. Generally, screws in these
a consequence of continued growth of the proximal locations are left in place provided that there is no break-
radial physis. Continued growth of the proximal physis age, lysis has not developed beneath the heads, lameness
of the radius separates the humero‐ulna joint, resulting does not occur in cold weather, and there is no consistent
in erosion of the humeral trochlea and condyles by the lameness attributable directly to the screw rather than
anconeal process of the ulna. Dysplasia is inevitable in the adjacent joint. Screws are frequently removed unnec-
foals less than 7 months of age. Growth disparity then essarily, even though the obvious degenerative changes
declines until the foal is 12 months of age, after which it in the adjacent joint are actually causing the lameness
is generally irrelevant. Synostosis of the radius and ulna (Figure 45.3). In the author’s experience, removal of
can occur even if screws used in the plate application for implants after repair of these fractures is not generally
the radius repair do not cross into the ulna. Implant indicated.
removal is required (see Figure 45.2), and an intraopera- Evidence of lysis beneath a screw head, sometimes the
tive decision needs to be made as to whether an ulna result of reaction to the metal but more often due to
osteotomy or ostectomy should be done. Radiographs motion of the bone, is an indication for screw removal.
are generally indicative of the most appropriate site to The distal screw in condyle repairs (see Figure 45.3), and
perform an ulnar ostectomy. Separation of the proximal some third carpal slab fracture repairs, frequently devel-
aspect of the ulna from the caudal perimeter of the ops lysis beneath the head. This is due to restriction of
radial metaphysis and epiphysis is generally unnecessary. the elastic motion normally occurring in these bones.
Gradual realignment of the ulna with the proximal Spanning the bone with a screw places a restraint on this
perimeter of the radius and normalization of the articu- motion, resulting in cortical lysis beneath the head.
lation with the humerus spontaneously develop during Screws in third carpal bone fractures are most fre-
the months after ostectomy. quently involved in dorsal cortical lysis or excessive
Recommendations for removal of single or multiple bone proliferation. Some of this may be periarticular
screws for fracture management vary by the location of osteophyte formation associated with osteoarthritis as a
www.ajlobby.com
(A) (B) (C) (D)
Figure 45.2 Synostosis of the radius and ulna, resulting in elbow dysplasia. (A) Radiograph showing proximal midshaft fracture of the
radius and ulna in a three‐month‐old Quarter Horse foal. (B) Immediate postoperative radiograph showing repair using two dynamic
compression plates, with several screws in the cranial plate penetrating the shaft of the ulna to gain additional fixation in this proximal
fracture. (C) Fracture bridging is complete 12 weeks after surgery, and the plates can be removed. A distal ulna synostosis to the radius
has developed at the site of fracture, and three screws bind the radius and ulna proximal to this region, both of which contributed to the
elbow dysplasia (arrow). (D) Postoperative radiograph showing the bones after plate removal and ulna ostectomy proximal to the
synostosis, allowing the shaft of the ulna to gradually shift proximally to reestablish normal elbow congruency. Source: Images courtesy
Dr. Alan J. Nixon.
Figure 45.3 A healed condylar fracture in

a Thoroughbred racehorse presented (A) (B)
for screw removal due to lameness and
lysis underneath the screw heads.
(A) Dorsopalmar radiographs reveal a healed
fracture, lysis under the screw heads (white
arrows), osteoarthritis with periarticular
osteophytes (white arrowheads), and a
persisting palmar osteochondral disease
lesion (black arrowheads). (B) Lateral to
medial radiographic projection showing
osteoarthritis, with supracondylar lysis (black
arrowheads), osteophytes on the sesamoids
(white arrows), one of which has fractured,
and lysis surrounding the screw heads (black
arrows). The lameness was eliminated by
intraarticular anesthesia, confirming joint
disease as the source of the lameness, rather
than the lag screws. Source: Images courtesy
Dr. Alan J. Nixon.
www.ajlobby.com
consequence of the original fracture. Occasionally, lysis Broken screws in a plate result from motion at the
and periarticular fracture extending to the proximal fracture site. One or two broken screws are usually not
surface of the third carpal bone can develop due to sec- destabilizing, provided that the plate remains intact. As
ondary bone porosity. Removal of these screws does callus forms and union eventuates, motion is elimi-
little to change the joint disease, but is commonly
nated and screw breakage stops. If screw breakage con-
requested. The decision for removal must be made after tinues, fixation failure is imminent, and additional
full discussion of the broader issues with owner and external or internal support is indicated to salvage the
trainer. repair. Eventual removal of broken screws, or at least
their heads, is indicated only if they may potentially
erode through the skin or neurovascular structures, or
Plates irritate adjacent musculoskeletal structures. This is
Removal of plates after long bone fracture repair is particularly important in intraarticular or periarticular
generally required if the horse is to be used for athletic repairs.
purposes. An exception to this is for plates used for
olecranon fracture repair, since in most circumstances
no morbidity associated with the presence of the implant
Infected Implants
is recognized. That being said, these plates are com- If implants are to be removed secondary to sepsis, then
monly removed after fracture healing in horses destined a decision needs to be made about balancing the effec-
for public auction due to a perceived bias in purchase tiveness of leaving an infected implant in for stability
values in horses which have implants present. Plate and/or fracture healing, and the effect of the local sep-
removal is often utilized after long bone repair in horses sis on fracture healing, extension of infection to adja-
destined for athletic purposes. Typically, plate removal cent structures, and cosmetic outcome. Infected
is performed 12–16 weeks after fracture fixation and at implants usually result in intermittent chronic drainage
least 30 days after the beginning of pasture turnout. In with some lameness. Provided that the implants are
foals, plate removal can occasionally occur earlier, conferring some stability, they should remain in place.
sometimes as soon as 4–6 weeks after surgery, if bone Seriously infected screws in a plate rarely have residual
union has progressed normally. In general, plates and holding power and may be spontaneously backing out.
other implants are removed far more frequently in foals They provide no stabilization and are a nidus for fur-
than adults. This allows the bone to fully remodel ther sepsis. Occasionally, several screws can be removed
according to the natural strains being applied, rather from a plate fixation to control drainage, leaving the
than being compounded by stress protection and inter- remainder to provide stability until the fracture heals.
nalization of plates. Once a plate begins to drain purulent material to the
If two plates are present, staged removal of the plates is skin surface, it is unlikely that drainage will perma-
recommended (Figure 45.4). The author tends to initially nently resolve until all the implants are removed, even
remove the plate which is theoretically under more load, though the fracture may heal. In the interim, drainage is
followed by removal of the second plate after at least reduced or temporarily eliminated by long‐term antibi-
30 days of pasture activity. Intraoperative radiographic otic therapy.
examination is useful to assess the healed fracture In general, infected implants used for correction of
appearance after removal of one plate. Often significant angular limb deformities can be left in until the deform-
lucencies and even residual fracture lines are evident (see ity is corrected. However, management of the infection
Figure 45.4), obviously mandating a delay in removing with local, regional, or systemic antimicrobial therapy
the second plate. External coaptation and assistance for and drainage is usually necessary. After fracture repair or
recovery from anesthesia may also be indicated. The arthrodesis procedures, the implants are functioning to
author has left some secondary neutralization plates in maintain stability, and their early removal may cause
situ if, in theory, the presence of the implants has little lameness and failure of the repair. However, prolonged
chance of inducing a lameness. Generally, these plates use of the infected implant may lead to significant soft
have been shorter plates placed on the medial or lateral tissue infection and potentially spread of the infection to
aspect of a long bone, with screws which do not engage adjacent synovial structures or the fracture site itself.
the dorsal (cranial) and palmar (plantar or caudal) corti- Again, a decision based on the circumstance of each
ces. Screw purchase in the cortices which are placed in individual case is required to balance the risk of removal
bending when loaded during exercise may lead to lame- of the implant on destabilizing the repair compared to
ness, either by union of the cortices or because of poten- implant removal and resolution of the infection. Implant
tial differences between the modulus of elasticity of the loosening associated with infection is an indication for
bone and the implants. removal. The use of locking screw/plate systems reduces
www.ajlobby.com
(A) (B) (C) (D)
Figure 45.4 Staged plate removal after double plate fixation of a midshaft third metacarpal fracture in a foal. (A, B) Lateromedial and
dorsopalmar radiographs eight months after the primary repair indicate solid cortical bridging and smooth callus. (C) Intraoperative
dorsopalmar radiograph reveals significant bony deficit at the fracture site and a persisting fracture line in the lateral cortex (arrow).
The yearling was manually assisted to recover from anesthesia with the limb in a full‐length splint. (D) Dorsopalmar radiograph obtained
two months after the initial plate removal showed extensive bony bridging. The second plate was removed. Source: Images courtesy
Dr. Alan J. Nixon.
the amount of instability of the construct in the face of bone growth precludes access to the screw head for easy
infection, because the screws are locked at a fixed angle removal, if wound revision is necessary, or if patient or
and cannot move relative to the plate. surgeon safety concerns are present, then general anes-
thesia may be elected.
Standard chemical restraint for implant removal in our
Preoperative Preparation hospital consists of intravenous xylazine/butorphanol
combination, or detomidine. The area is then prepared
Implant removal is often performed in the conscious for local anesthesia, with sterile preparation for sur-
sedated horse, using local anesthesia. General anesthesia gery after the local anesthetic block is performed.
can be elected if the location of the plate precludes effec- Regional nerve blocks can also be used if the implanted
tive local anesthesia, such as the proximal limb, or if the region is sufficiently distal on the leg to allow local
nature of the patient prevents safe removal of the nerve blocks.
implants in the conscious horse. Most implants placed In any event, care to remove these implants under
for angular limb deformities can be removed without clean, if not sterile, conditions is paramount to improve
general anesthesia (Figure 45.5). However, if excessive the ultimate outcome. Clipping/shaving and standard
www.ajlobby.com
forceps into the screw head and rotating the forceps to

excavate the full 360° of the hex socket. The hemostat
also allows accurate identification of the screw head
position and angle of placement required to fully insert
the screwdriver into the screw head (Figure 45.6). The
surgeon should be confident that the screw head has
been identified with the hypodermic needle prior to
making the stab incision. If not, a radiograph should be
taken with the needle in place to confirm the location of
the needle in relation to the implant. Once the screw
head is identified and the incision made, the screwdriver
should be firmly seated in the screw head prior to
removal of the screw. This is especially important when
shallow‐head screws such as 3.5 mm cortical screws are
being removed, as stripping of the screw head is possible
if the screwdriver is not seated adequately, especially
if bone or soft tissue is still present in or over the screw
head. As the screw head emerges from the skin, the
incision edges can be forced over the screw head, or
the incision may need to be enlarged slightly for com-
plete screw removal. During loosening of the screw in
the conscious horse, it is important that the horse not
Figure 45.5 Removal of a single transphyseal 4.5 mm screw from
the distal lateral radius in a yearling. The yearling is restrained with make any sudden movement which could cause bend-
sedation and location anesthesia, and removal is through a stab ing or breakage of the implant. If multiple screws are to
incision. be removed, typically one or more screws are left in
place, but loosened enough to allow protrusion of their
heads external to the skin, which can then be used as
skin and surgeon preparation are used, wherever possible. reference points for the location of additional screws
An exception to this rule is when the owner’s require- based on preoperative radiographs and measurements
ments prevent clipping of the surgical field for single (see Figure 45.6). After removal of single or multiple
screw removal. In general, removal of single screws or screws, stab incisions may be left unsutured and typi-
screws/wires for transphyseal bridges without clipping cally heal cosmetically. Larger incisions may require
of the hair is not associated with a dramatic increase in primary closure or use of Steri‐Strips.
postremoval infections and in the author’s opinion is an Plate removal generally requires a 3–4 cm incision
acceptable practice. made over the proximal or distal end of the plate to allow
The use of systemic prophylactic antimicrobial use exit of the plate after all screws are removed (Figure 45.7).
for implant removal is based on surgeon’s preference. For most plate removals in the standing horse, this
For removal of a transphyseal bridge or a screw(s) for requires a proximal incision to avoid extracting the plate
fracture repair, usually a single dose of intramuscular down toward the floor. Plates applied to propagating
procaine penicillin G is given perioperatively. For larger third metacarpal/metatarsal fractures are commonly
skin approaches for plate removal, systemic intravenous removed standing. Patient preparation includes a long
penicillin and gentamicin are typically given periopera- adhesive barrier drape, and proximal and distal draping
tively for 24 hours. with hand towels secured with sterile Vetrap or use of
Vetrap alone (Figure 45.8A). A sterile glove can be placed
on the foot and the draped foot placed on a sterile drape
Surgical Technique laid on the floor for a relatively complete sterile field.
Gowning is optional for the surgeon, but is useful to
For removal of single screws or screws/wire transphy- provide forearm protection, especially during suturing.
seal bridges, the surgical technique consists of localizing Identification of screw heads is again established with
the head of the screw with a small‐gauge hypodermic hypodermic needles (see Figure 45.6). A sterile plate of
needle followed by a small stab incision with a #15 similar dimensions is helpful to identify the location of
scalpel blade over the screw head (Figure 45.5). Typically, the plate screws, and can be placed on the skin over the
some soft tissue is present in the screw head. This can plate to be removed, to act as a template. Additionally,
be removed by placing the tip of a mosquito hemostatic access to the preoperative radiograph or a print of the
www.ajlobby.com
which screwdriver (hex or star drive) is appropriate to

(A) (B)
loosen the screw isolated through each stab incision. On
occasion, it may be necessary to use an osteome to
remove bone that has overgrown the plate.
Once the screw heads are identified, stab incisions
with a #15 blade are made and the screws removed.
The screws are partially backed out until all screws are
visible and accounted for (see Figure 45.8B). Bone and
soft tissue can grow into the screw heads, and thor-
ough cleaning of the head may need a hypodermic needle
or Kirschner wire. After complete removal of the
screws, the plate typically needs to be loosened using a
wide periosteal elevator or an osteotome and mallet
(see Figure 45.8C). After loosening of the plate, the
proximal hole in the plate can be hooked with an
Ochsner hemostat, thyroid retractor, towel clamp, or
the screwdriver shaft, and the plate withdrawn through
Figure 45.6 Standing removal of two 4.5 mm screws placed for the initial incision (see Figure 45.8D). On occasion, the
lateral condylar fracture repair, in a conscious, sedated horse with plate is too deep or bone overgrowth so excessive that
a local anesthetic block. (A) The proximal screw is infected and multiple 3–4 cm incisions or one large incision is nec-
there is a draining tract present, which allows a needle to be easily essary for plate removal. The stab incisions for screw
inserted into the screw head. The distal screw has been identified
with a needle and the screw head is being cleaned of soft tissue
removal are typically left unsutured, but can be sutured
using a hemostat introduced via a stab incision. (B) Removal of if elected or excessive in length. The longer incision for
screws is done only after both are partially exteriorized. The plate removal is closed in two or three layers. Penrose
fracture had healed prior to screw removal, and the sepsis drains are occasionally placed to prevent seroma for-
resolved after implant removal. mation if a large dead space or excessive hemorrhage
has occurred. The use of drains and absorbable anti-
microbial beads is recommended after the removal of
infected implants.
Coaptation for recovery from anesthesia may be nec-
essary, depending on the individual circumstance of the
case. Manual assistance to rise during recovery from
anesthesia is frequently indicated. In most cases, band-
aging is all that is necessary in the postoperative period
after recovery from anesthesia.
Postoperative Management
Postoperative management differs with individual
cases. After removal of implants for correction of angu-
Figure 45.7 Removal of a plate applied to an olecranon fracture lar limb deformities, no special restrictions aside from
in a yearling after the fracture has healed 12 weeks
postoperatively. The yearling is under general anesthesia and a wound management are necessary. After removal of
5 cm proximal incision has been made for initial screw removal plates used in fracture repair, radiographs of the
and subsequent plate extraction. The more distal screws were affected area should be obtained before and after recov-
identified and removed through stab incisions, using the recent ery from anesthesia, to check for any injury or refrac-
radiographs as a guide, allowing the plate to then be withdrawn ture following the plate removal. After discharge from
from the proximal incision.
the clinic, a period of 10–14 days of stall rest is prudent,
followed by small paddock turnout for four weeks. If a
radiograph is important to identify the number of screws second plate is present, the author prefers staged
in the plate, and is vital if a locking compression plate removal, which occurs four to six weeks after removal
(LCP) was inserted, where the sequence and positioning of the primary plate. Cosmetic results after removal of
of cortical and locked screws are important in defining transphyseal bridge implants are generally excellent
www.ajlobby.com
Figure 45.8 Standing plate removal after

(A) (B) repair of a spiral medial condylar fracture
involving the metacarpal diaphysis.
(A) Removal of the distal‐most plate
screws though stab incisions. Note that all
screws are identified and partially
exteriorized before complete screw
removal. The limb is draped with a large
adherent plastic drape, secured with
Vetrap proximally and distally, and with a
sterile glove on the hoof, which is placed
on a sterile drape. (B) A print of the
radiograph is secured to the stocks and
indicates the sequence of locked (L) and
regular cortical screws (R) as screw
removal progresses proximally in the
broad locking compression plate.
(C) (D) (C) Extraction of the plate through the
proximal incision, using an osteotome as a
ramp to prevent binding on the soft
tissues. The plate can be gripped for
withdrawal with a large hemostat, parallel
pliers, bone hook, or the screwdriver shaft
held horizontally with both hands
(as shown). (D) The screwdriver shaft is
used to extract the plate proximally
through the incision. Source: Images
courtesy Dr. Alan J. Nixon.
unless infection or seroma has occurred. After plate bone and lessen the effects of stress protection derived
removal cosmetic results can be worse than preopera- from the implants. Removal of a second plate should be
tively, due to the presence of scar tissue and white hairs at least 30 days after the primary plate removal. Removal
after a second incision. of implants in the standing horse is preferred whenever
possible, and removes the risk of catastrophic failure
during recovery from anesthesia.
Complications of Implant On occasion, a screw head will be stripped during
Removal removal. In general, this is secondary to failure to
properly seat the screwdriver in the screw head before
Infection of the soft tissues can occur after implant attempting removal. If stripping of the head is starting,
removal, so care should be taken to reduce this risk. it is important to reassess the seating of the screw-
Closure of dead space, use of drains, and several days of driver prior to moving forward. It may be that bone or
antibiotic coverage may be required. The presence of soft tissue within the screw head is the issue and this
white hairs and scar tissue formation is more likely to should be thoroughly cleaned out. If the screw head
occur after larger incisions made for plate removal, com- is stripped, the screw can be backed out by grasping
pared to stab incisions for screw removal. Refracture of the screw head with parallel pliers or by the use of
the limb is possible after plate removal, and can occur proprietary extraction sets (see Chapter 8). The need
after single or staged removal of multiple plates. In the to remove broken or stripped screws should be con-
author’s opinion, at least 30 days of paddock turnout is sidered on a case‐by‐case basis, depending on their
recommended before initial plate removal, to stress the location and function.
www.ajlobby.com
831
46
Orthopedic Implant Failure
David M. Nunamaker
Introduction of an implant, even within the elastic range of the mate-

rial, can lead to fatigue failure. Materials with a higher
Implant failure is relatively common when equine frac- modulus are stiffer than those with a lower modulus. The
tures are treated with internal fixation. Constant rede- modulus for stainless steel is 10 times that of bone.
sign and development of implants, as well as the Therefore, stainless steel is 10 times stiffer than bone.
introduction of new techniques especially for large ani- The sectional properties (thickness and width) of the
mals, have improved the clinical course of fracture treat- bone and implant also are important in determining the
ment and reduced the complication rate. Introduction of strength of each. When comparing an equine bone such
the locking compression plate (LCP) has changed many as the third metacarpal bone with a broad stainless‐steel
of the principles of plate application in equine fracture plate used in fracture fixation, it can be seen that the
repair, and represents the most recent advance in provid- bone seems much stiffer than the plate, even though the
ing stable fixation capable of resisting the forces applied modulus of stainless steel is 10 times greater than that of
to the repair by the horse. Traditional implants are still bone. The reason for the bone’s greater stiffness is related
frequently used, however, some even performing better to its sectional properties. Moving mass away from
in selected locations. To avoid implant failure, it is its midpoint increases its resistance to bending. Steel
important to understand the materials that are used to I‐beams are an example of this technique. Increasing
manufacture these implants, as well as the implants cross‐sectional area is a good method of increasing com-
themselves, and the proper techniques for using them. pressive or tensile strength. In this way, implants can be
designed to limit bending in tension and compression.
Design of the implant to meet the demand of the situ-
Mechanical and Sectional ation is important. Even more important is the ability of
Properties the surgeon to recognize the strengths and weaknesses
of any implant to ensure that it will be used optimally.
The mechanical properties of an implant are based on the For instance, double plating a long bone fracture with the
material properties of the device as well as its sectional plates placed at 90° to each other will double the com-
properties. The material properties are related to the pressive strength (by doubling the cross‐sectional area of
modulus of the material, i.e., the relationship of load to the implanted device), but can increase the bending
deformation (stress–strain; Figure 46.1). When a material strength 5–10 times, based on the inertial properties of
is loaded, it will deform elastically in a linear fashion until the bone and the sectional properties of the plates.
it starts to plastically deform (yield point). The slope of the
straight‐line portion of the stress–strain curve represents
the material’s modulus. Following nonlinear deformation Loading of Implants
(plastic deformation), failure of the material will occur at
its ultimate stress. The implant functions properly only When implants are placed on bone, they must form a
within its elastic region. Higher loads (stresses) initiate bone–implant composite that should be strong enough to
plastic deformation and failure. Continuous cyclic loading resist the loads imposed during recovery from anesthesia

www.ajlobby.com
Ultimate stress
Yield stress Peak cyclic
stress
Stress
(load) Endurance
limit
102 104 106 108

Number of cycles (log scale)
Strain (deformation)
Figure 46.2 Stress–number of cycles curve showing the
Figure 46.1 Stress–strain curve showing the linear elastic relationship of stress to the number of cycles before failure. The
component, the area of plastic deformation (yield stress), and the solid line represents the failure point, and all loads and cycle
failure point (ultimate stress). combinations above this line represent failure of the material. The
dotted line is the endurance limit, while the dashed line shows the
and subsequent weight bearing. The weight‐bearing relationship of load to cycles for materials, such as bone, that do
loads transmitted to the implant can be diminished by a not have an endurance level.
cast or splint, but loads should never exceed the elastic
limit of the device, as bending and failure of the plate can the endurance limit is affected, so implants placed within
ensue. The locking‐head screw and locking plate change the body can show a diminished endurance limit.
the dynamic of the bone–implant interface by locking the
plate and screw into a fixed metallic unit. Maintenance of
the plated fracture stability no longer depends on friction Implant‐related Problems
between plate and bone. Rather, stable fixation depends
on the threaded screw head remaining locked in the Implant failures can occur because of design errors,
combi hole of the LCP. Under bending, the failure mode manufacturing flaws, or because of metallurgical prob-
changes from screw pullout to actual bone failure, which lems within the material itself. Current manufacturing
increases the stability and cycles to failure of the LCP and metallurgical problems probably represent a very
construct. More information on LCP design and applica- small percentage of implant failures. Few implants have
tion can be found in Chapters 9 and 10. been designed with the horse in mind, however, so most
The initial loads on an implant are not as important as implants must be viewed with suspicion when used in an
the cyclic loads that they must bear before healing equine application.
occurs. When the loads are less than the yield stress of When metals are placed into the body they are sub-
the implant, failure can still occur through cyclic load- jected to a saline environment, which may lead to corro-
ing. This occurrence is called fatigue failure and operates sion. Areas of low oxygen concentration, such as those
below yield stress. Fatigue failure can occur in all materi- around the screw head contact with the plate holes, can
als, including bone, and is represented by the stress– lead to fretting corrosion. Corrosion has a tendency to
number of cycles curve (S–N curve), as shown in weaken the material and can lead to premature failure of
Figure 46.2. The graph indicates that load to failure is the device. Corrosion can sometimes be seen on the
inversely related to the number of cycles. Failure occurs metal surfaces when plates and screws are removed fol-
on or above the line of the curve. lowing fracture healing. However, it does not seem to be
Some materials, such as steel, have an endurance limit. a significant clinical problem in horses. Some species
This means that repeated loads below the endurance limit may have allergic responses to stainless steel. This allergy
of the material will not cause failure. The endurance limit is well documented in people, but not so in the horse.1 As
for stainless steel is about 30% of its ultimate tensile the alloy undergoes dissolution in the body at a very low
strength. This feature is useful in designing implants, since rate, the metal ions bind with protein and interact with
loads below the endurance level can be sustained indefi- the immune system, causing metal sensitivity. Some
nitely by the implant. Most composite materials do not horses exhibit pain associated with their implants after
display this endurance limit, and the load to failure gradu- fracture healing has occurred. This pain is resolved by
ally decreases as the number of cycles increases. Bone implant removal, but the actual cause of the problem,
appears not to have an endurance limit and must depend allergic or mechanical, is rarely determined. Certainly,
on remodeling to remove cycled bone and prevent failure. the mismatch of modulus between bone and implant
When metal implants are used in a saline environment, could explain some of these cases.
www.ajlobby.com
46 Orthopedic Implant Failure 833
Most implant failures are the result of technical errors the tension band principle is important, so that a plate
that involve surgical technique, choice of implants, or will be placed on the bone subject to tension and not
judgment. Since large animals must be weight bearing bending. Screws are placed using interfragmentary com-
following fracture fixation to avoid the complications of pression or through plates, thereby compressing the
laminitis and gastrointestinal functional disturbances, it plate to the bone. Improperly drilled holes that do not
is important that implants for internal fixation be used in allow interfragmentary compression may lead to loading
an optimal manner. of the bone screw in shear rather than tension, with
resultant breakage.
Since most implants have not been specifically
Soft Tissue Injuries designed for use in the horse, it is important to take
advantage of every opportunity to prevent implant fail-
When fractures occur in horses, soft tissue injury is often ure. Specific techniques can be applied to internal fixa-
ignored or underestimated. The soft tissues absorb the tion with the use of plates and screws to improve the
energy released when a bone is fractured, and the energy clinical results, which in turn will decrease the incidence
absorbed can be assumed to be proportional to the com- of implant failure. Using the LCP requires a specific
minution of the fracture. Surgical intervention through the sequence of screw insertion, commencing with several
fracture area can further compromise the soft tissues and cortical screws to draw the contoured plate toward the
lead to devitalized tissue that invites infection. Infections bone, and finishing with as many locked screws as pos-
decrease the rate of fracture healing, thereby subjecting sible, within the constraints of needing to angle some
the implants to an increased number of loading cycles and screws to avoid fracture lines, other screws, an articula-
to possible failure. Infection also invades the tissues around tion, or adjacent physes.
the implant, making it difficult to eliminate this infection The use of cancellous bone graft may make the differ-
until the implants are removed. Worse still, sepsis around ence between fracture healing and implant failure. The
the implants can lead to necrosis of bone and loosening of graft material is placed where callus is desired. Bone
the implants, which in turn causes implant failure. Careful graft can be desirable even if there are no frank defects in
evaluation of soft tissues is needed prior to surgical inva- the reconstruction. It is especially helpful in young ani-
sion. When soft tissue injury precludes normal approaches mals and in areas where soft tissue viability is good. The
to the fracture, other alternatives need to be evaluated. bone graft will start to add support, decreasing the load
The recent interest and reported results using external on the implant within 10 days. As the graft is incorpo-
skeletal fixation in horses indicate that certain fractures rated into the healing bone, the implant is spared the full
and breakdown injuries are amenable to this treatment loading that could lead to cyclic failure.
modality.3 It should be remembered that loss of vascularity The use of 5.5 mm cortical screws improves plate fixa-
can negate the skin’s natural barrier to bacterial invasion, tion. However, the added expense of these implants can
and even closed injuries treated in a closed manner can unnecessarily increase the cost of the internal fixation.
develop serious complications from infection. When long plates are used, the screws at the end of the
Excessively long surgical procedures also increase plate and nearest the fracture site are predominantly
the likelihood of infection. A complete understanding stressed. Therefore, more secure internal fixation results
of the surgical approach and technique for application of from the use of 5.5 mm screws in these locations. The
the implant will minimize surgical exposure times. smaller, less expensive 4.5 mm screws can be used to fill
Preoperative planning, access to necessary instrumenta- in the holes in the remainder of the plate. Whenever
tion, and some backup plan to the proposed technique large loads are expected on the implants, 5.5 mm screws
can also help in the reconstruction of a fracture. Stripped should be used throughout.
screws can be replaced by larger screws if they are avail- The cross‐sectional area of the narrow dynamic com-
able, and broken drill bits and screws can and should be pression plate (DCP) is quite small at each screw hole.
removed with the proper instruments, so that the same The broad plate has a greater cross‐sectional area and
hole can be used to help anchor the implant. Small tech- will be stronger in all situations. In addition, the axial
nical mistakes that occur at surgery often seem to location of the screw holes in the narrow plate will help
become magnified at the time of fixation failure. promote cracks from screw hole to screw hole, especially
in the cortex directly beneath the plate. The staggered
placement of holes of the broad plate eliminates this
Biomechanical Principles problem. The undercuts of a limited‐contact dynamic
compression plate (LC‐DCP) are designed to balance the
An understanding of the biomechanical strengths and strength of the plate at the plate holes and between plate
weaknesses of any implant used for fracture fixation is holes, which eliminates the weak region of the plate hole
necessary to improve the chances of success. The use of in the DCP.
www.ajlobby.com
Once the ends of the bone are in contact, it is unneces- bone. Application of the plate will elastically straighten
sary and undesirable to use the load guide to provide fur- the plate to the bone, but will apply additional compres-
ther compression at the fracture site. The neutral drill sion to the trans cortex. Interfragmentary compression
guide still applies some compression, while use of the with the use of a screw across the fracture line is an addi-
load guide places the screw high up in the inclined hole tional step that can help stabilize the fracture, and can
of the DCP, and tightening of the screw bends the screw even be used in transverse fractures in large bones.
head at its junction with the shaft. Bending of the screw Plate luting, a technique that applies a polymeric (poly-
repeatedly occurs while the screw is turned, thus plasti- methylmethacrylate) substance between the bone and
cally deforming and weakening the screw. These screws the plate, as well as between the screw heads and the
are often closest to the fracture site, and are highly plate, has been used to improve the fatigue life of cycli-
stressed and can break. Bending of the screw head con- cally loaded implants. Reports in vitro have shown a
centrates stress in the cortical bone directly beneath the 3‐fold to 12‐fold increase in the number of cycles to fail-
plate, since the screw actually starts bending immedi- ure.4 The clinical results are similar to those in the in
ately below the cortical bone surface. vitro experiments. Plate luting alone seems to have
Overtightening 4.5 mm cortical screws may also cause greatly improved the results of fracture fixation with
plastic deformation of the head–neck junction. One plates and screws in horses. It has allowed immediate full
hand is adequate to tighten screws, and the palm of the weight bearing when plates and screws are used. The
hand should be on the top of the screwdriver so that too clinical results of tibial fracture repair in foals have
much force cannot be applied. Overtightening is not a improved markedly with the use of plate luting, and it
problem with 5.5 mm cortical screws. has had a profound effect on internal fixation of other
Drilling holes in large bones can sometimes lead to long bone fractures.
technical errors. If the surface of the trans cortex is not
parallel to the cis cortex, the drill bit can wander and drill
a malaligned hole. A crooked hole increases the risk of Conclusion
the drill bit or tap breaking in the hole or of a screw
bending during insertion. Drill wobble is a classic indica- Although implant failure is still a problem in equine
tor that a crooked hole is being drilled. If the drill begins orthopedics, many of the disasters of former years have
to wobble during entry into the trans cortex, the drill bit been overcome with the use of new techniques and a bet-
should be retracted and advanced slowly to start the new ter understanding of the implants and the weight‐bearing
hole directly opposite the hole in the cis cortex. environment in which they must exist. However, there
Application of a straight plate to a straight bone can is still room for improvement in both implants and
result in a gap in the fracture along the cortex opposite techniques. The LCP and its various specialized modifi-
the plate. This gap will be exaggerated if the bone is not cations (see Chapters 10 & 50) have been the most
straight and the plate is inadequately contoured. Small significant development in recent decades, but further
gaps are detrimental to any fixation; stress is concen- development will ultimately help equine fracture repair.
trated in the implant at that location, and the fatigue life Most of the current failures associated with fracture fixa-
of the plate is reduced. This problem can be overcome by tion in the horse can be related to the biologic problems
plate overbending.2 With this technique, the plate is con- associated with sepsis. Infection can be addressed in
toured to the bone, and then an additional bend is made many ways, but it remains the single most important reason
at the fracture site so that the plate is 1–2 mm above the for failure of fracture treatment.
References
1 Brown, S.A., Devin, S., and Merritt, K. (1983). Metal 3 Nunamaker, D.M. and Richardson, D.W. (1992). External
allergy, metal implants and fracture healing. Biomater. skeletal fixation in the horse. In: Proceedings of the
Med. Devices Artif. Organs 11: 73–81. American Association of Equine Practitioners, vol. 37,
2 Nunamaker, D.M. and Perren, S.M. (1979). A 549–555. Lexington, KY: AAEP.
radiological and histological analysis of fracture healing 4 Nunamaker, D.M., Richardson, D.W., and Butterweck,
using prebending of compression plates. Clin. Orthop. D.M. (1991). Mechanical and biological effects of plate
Rel. Res. 138: 167–174. luting. J. Orthop. Trauma 5: 138–145.
www.ajlobby.com
835
47
Delayed Union, Nonunion, and Malunion
Norm G. Ducharme1,2 and Alan J. Nixon1,2
1
2
Delayed Union and Nonunion Vascular nonunions are nonunions capable of biologic

repair. They are classified into three categories, depend-
Delayed union and nonunion are potentially devastating ing on the relative amount of callus present.39,52,60
complications of long bone fractures in all species, but are Hypertrophic nonunions have abundant hypervascular-
associated with greater morbidity and mortality in horses.52 ized callus and are usually seen in an unstable fracture.
Secondary effects of prolonged weight bearing on the sound Mildly hypertrophic nonunions have inadequate callus
limb include tendon breakdown and angular deformity in and mild sclerosis of the medullary cavity at the fracture
the foal, and laminitis (particularly “sinking”) and tendon site. They reportedly occur in association with rota-
breakdown in the adult. Furthermore, deterioration of the tional instability. Oligotrophic nonunions have no visi-
animal’s condition is often manifested as decubital sores, ble callus, with the ends of the medullary cavity sealed at
decreased appetite, and the side effects of prolonged use of the fracture site. In addition, rounding of the fragment
nonsteroidal anti‐inflammatory medication. ends is seen. However, unlike avascular nonunions, oli-
gotrophic nonunions have fibrous tissue and blood ves-
sels between the fragment edges and thus are still
Definitions capable of a biologic response. Oligotrophic nonunions
are seen with significant displacement of the fracture
Delayed Union fragments.
Avascular nonunions39,60 are classified as dystrophic,
Delayed union occurs when there has been an adequate necrotic, defect, or atrophic. Dystrophic nonunions
interval of time for healing of the fracture (average time occur when a secondary fragment has healed, but the
to union for that particular bone) but healing is not com- main fragments are still unhealed and devoid of callus.
plete. Therefore, healing is progressing, but at a slower Necrotic nonunions are seen in highly comminuted frac-
rate than expected (Figure 47.1). For practical purposes, tures in poorly vascularized areas (such as the cannon
long bone fractures in the horse should be healed by four bone). In these cases, the major fragments eventually die
months in an adult and three months in a foal. without being incorporated in callus. Defect nonunions
result from either loss of fragments at the time of injury
or resorption of a fragment. These three types of nonun-
Nonunion ions can result in atrophic nonunion, where significant
Nonunion occurs when all healing repair processes have bone resorption and osteoporosis are observed.
stopped, but bony continuity has not been restored Infected nonunions are characterized by marked lysis
(Figure 47.2). There is a “gray” zone between delayed of the major fragments with varying degrees of callus,
union and nonunion, where an exact categorization of depending on the vascularity at the fracture site
the nonhealing fracture cannot be made. There are three (Figure 47.3). Purulent discharge is generally present,
types of nonunion: vascular (viable), avascular (nonviable), although the quantity can vary and the fistula may close
and infected.60 intermittently.

www.ajlobby.com
(A) (B) (C) (D)
Figure 47.1 Delayed union following surgical repair of a spiral fracture of the third metacarpal bone in a three‐year‐old Thoroughbred
stallion. (A) Preoperative radiograph showing a longitudinal fracture plane along the dorsal cortex (black arrows), and a sharply spiraling
palmar component (white arrows). (B) Dorsopalmar radiograph two days after surgical repair using an independent cortical screw placed
in lag fashion and a spiral dynamic compression plate applied to span the entire metacarpus. The fracture planes appear to have
completely compressed. (C) Radiograph showing the return of obvious dorsal and palmar fracture lines three months after repair,
signaling delayed union. (D) Radiograph obtained 12 months following repair (8 months following plate removal), showing a persisting
fracture nonunion along the dorsal cortex and the distal subchondral bone plate within the fetlock (arrows). The horse required another
six months before returning to training.
Figure 47.2 Nonunion of a tibial fracture in

(A) (B)
a pony. (A) The preoperative craniocaudal
radiograph showing a severely comminuted,
multisegmental, displaced tibial fracture.
(B) Nonunion at 17 weeks following repair. The
initial repair using two dynamic compression
plates failed within two weeks, and the
subsequent transfixation cast with transosseous
pins in the proximal tibia and proximal third
metatarsus have not provided sufficient stability
to allow callus formation.
www.ajlobby.com
(A) (B)
the soft tissue trauma of the distracted bone ends. It is
also possible for soft tissues to become interposed
between the fragment ends and therefore interfere
with osseous union of the fracture.
3) Inadequate immobilization. The concept of mobiliza-
tion versus immobilization has changed over the last
decade. Well‐immobilized fragments allow revascu-
larization and therefore improve the rate and degree
of healing. Further, if the fracture fragments are
appropriately immobilized in relation to one another,
active weight bearing results in compression of the
bone ends, which is beneficial to fracture healing.
4) Soft tissue disruption. A large amount of soft tissue
damage associated with an injury will delay fracture
healing because of associated disruption of peripheral
blood supply. For the same reason, during surgery for
reduction and fixation of long bone fractures, limited
subperiosteal dissection is preferred, and new plate
designs such as the limited‐contact dynamic com-
pression plate (LC‐DCP) and the locking compres-
sion plate (LCP) preserve this blood supply. Disruption
and damage to soft tissues can also influence the
effect of the musculature on the bioelectric potential
of bone. As discussed later, the electric force along the
Figure 47.3 Infected nonunion in a four‐month‐old
diaphysis or physis, or around fracture sites, influ-
Thoroughbred foal following double plate fixation. (A)
Appearance of the limb 11 weeks following internal fixation. ences healing.
Drainage is apparent from a persisting open skin wound. (B) 5) Osseous distraction. Distraction of the fracture ends
Dorsopalmar radiographs 11 weeks after internal fixation with two during surgical repair or as result of improper reduction
dynamic compression plates. The cortex beneath the medial plate of the fragments will negatively influence bone healing.
has atrophied (arrows), there is no callus, and the fracture gap has
The effect on bone healing is similar to that of inade-
widened since repair. The fracture was treated by debridement
and massive cancellous bone graft. quate compression. Distraction also delays healing,
because of the need for increased callus and therefore
increased time for healing. This is not to say that “heal-
ing” is impossible if distraction occurs; healing occurs
Etiology
normally following distraction in limb‐lengthening
procedures (i.e. distraction osteogenesis).
Many factors are implicated in the production of delayed
6) Surgical management. There are fractures for which
union and nonunion of fractures.29 They are, in order of
closed reduction and external fixation are appropri-
importance:
ate and others where internal fixation is appropriate;
1) Infection from an open fracture. Either osteitis or a surgical decision is required. Factors to consider in
osteomyelitis can occur following an open fracture or internal fixation include possible damage to the vas-
intraoperative contamination. The condition is cular supply at the fracture site, and possible damage
characterized by drainage from one or more fistulae, to the periosteum. Therefore, in a highly commi-
or periosteal new bone formation and lucency, espe- nuted fracture, particularly of the proximal or middle
cially around the implants (see Figure 47.3). Sequestra phalanx,47,48 it may be preferable to use external fixa-
and implant loosening are common sequelae to such tors to avoid increased vascular damage, interference
infection. with healing, or increased risk of infection at the
2) Inadequate reduction. Properly reduced fractures fracture site.12
heal far more rapidly than do fractures that are poorly 7) Inadequate internal fixation. These errors are gener-
reduced. This is partly associated with the larger ally technical and involve the use of inappropriate
amount of callus required to immobilize and unite the implants on the fracture, e.g., pins in highly commi-
fracture ends when the fracture is not adequately nuted fractures, short plates, dynamic compression
reduced. Additionally, blood supply takes longer to plate (DCP) rather than LCP (Figure 47.4), or too short
become reestablished, which could be associated with a glide hole in a screw placed using lag technique.
www.ajlobby.com
Figure 47.4 Inadequate internal fixation of

(A) (B) a comminuted tibial fracture leading to
nonunion in a four‐month‐old foal. (A)
Preoperative craniocaudal radiograph
showing a displaced, long oblique spiral
fracture of the tibia with moderate
comminution. (B) Craniocaudal radiograph
showing fixation failure and severe
angulation of the limb. The fracture
proceeded to nonunion.
8) Sacrifice of osseous stock. Although there is a tendency 3) Progressive bowing or angular deformity at the frac-
to discard avascular cortical fragments, these frag- ture site.
ments may serve as autogenous cortical grafts, and 4) Bone atrophy.
may quite appropriately be left in place if they can be 5) Excess callus around the fracture site with radiolucent
incorporated in the fixation. lines in the callus itself.
6) Persisting instability detected on stressed radio-
graphic projections.
Diagnosis Nuclear scintigraphy can also be used in the diagnosis
of nonunions. Typically, delayed union and nonunion
Clinically, horses with delayed union or nonunion of fractures have a persistent photopenic region (“cold
fractures have persistent lameness, depending on the spot”), because of decreased or absent radiopharmaceu-
degree of instability. In cases of infected delayed union tic uptake at the fracture site.55
and nonunion, one or more draining fistulae can be seen
(see Figure 47.3). The true assessment of bone healing is
obtained by serial radiographs (three to six weeks apart)
using at least two views: dorsopalmar/plantar (cranio-
anagement of Delayed Union
M
caudal) and lateromedial. and Nonunion
The radiographic signs of delayed union include peri-
osteal and endosteal partially bridging callus formation, Surgical Treatment
with an open medullary cavity at the fracture site.39
Infected Delayed Unions and Nonunions
Thus, changes indicative of bony union are present, but
Removal of implants is key in resolving osteitis and
are progressing at a slower pace than expected.
osteomyelitis associated with infected delayed union and
The radiographic signs of nonunion (Figure 47.5)
nonunion. Obviously, removal of the implant can only be
include:
done if adequate healing has occurred, or if the implants
1) Sclerosis of bone ends at the fracture site (evidence of no longer contribute significantly to the fixation.
sealing of the medullary cavity). Following removal of implants, curettage and seques-
2) No bony progress or change over a three‐month trectomy are indicated to remove diseased tissue.58 Not
period. all implants used in internal fixation need to be removed
www.ajlobby.com
(A) (B)
(C) (D)
Figure 47.5 Nonunion of a minimally displaced, complete distal radius fracture in an adult Quarter Horse. (A) Craniocaudal radiograph on
admission, showing minimal displacement, minor medial comminution, and mild crush injury. (B) Radiograph at seven weeks, showing
lysis at the fracture line, sclerosis forming in the medullary cavity, and minimal stabilizing callus. (C) Craniocaudal radiograph two years
after injury, showing the persisting nonunion with severe angulation, collapse of the medial cortex, and proliferative callus. (D)
Lateromedial radiograph at two years showing the massive cranial and caudal fracture callus, persisting fracture line, and interference
with function of the antebrachiocarpal joint. The horse required an external prosthesis to allow weight bearing.
to correct the infectious process.28 However, if implants of debridement, as a route for drainage is required.12 If
are removed and stability is still required, external coap- primary closure is obtained, drains must be placed to
tation or fixation (standard cast, walking cast, or trans- facilitate the removal of exudate.
fixation cast) should be applied. Appropriate antibiotic
therapy is needed for a significant period of time (up to Noninfected Delayed Unions
two months). For further detail, see Chapter 48. Unless significant malalignment is present or implant
Following debridement and curettage of the fracture loosening has occurred, noninfected delayed unions are
site, massive primary autologous cancellous bone graft is best treated by restricting the horse’s activity, and on occa-
required and might need to be repeated (Figure 47.6). sion by external fixation (Figure 47.7). A decision is neces-
For the biology of bone grafting, see Chapter 11. sary in selecting the optimal route of treatment. In foals in
Complete soft tissue coverage is not essential at the time which good stability is present but marked osteoporosis is
www.ajlobby.com
(A) (B) (C) (F)
(D)
(E)
Figure 47.6 Massive autologous cancellous bone graft for the treatment of an infected nonunion. (A) Adult Quarter Horse at cast change
two weeks following surgical repair of an open midshaft third metacarpus fracture using two dynamic compression plates (DCPs). Poor
wound healing with profuse purulent discharge is evident from a skin wound that occurred at the time of fracture from a displaced
proximal bone spike. (B) The appearance of the leg at the third cast change, seven weeks after repair. The edge of the bone plate is visible
through the wound. (C) Exposure of the infected fracture site, and debridement of necrotic bone has left a segmental bone defect
(arrows). The medial bone plate has been removed, leaving the dorsal DCP. (D) Autologous cancellous bone graft obtained from the tuber
coxae is being tamped into the bone defect. (E) The defect has been completely grafted, ready for skin closure. (F) The healed leg five
weeks after bone grafting and external coaptation.
noted, increasing the activity of the horse or removing placement of a plate (see Figure 47.8). In cases of mildly
the external support, or both, may reduce osteoporosis hypertrophic or oligotrophic nonunion, the ends of the
and stimulate more callus formation. If fracture instabil- fragments at the fracture site may have become sealed by
ity is present, external fixation with enforced stall rest is endosteal callus. In these cases, opening of the medul-
recommended. lary cavity followed by autogenous bone grafting and
If a loose implant or malalignment is present, surgical rigid fixation improves the chance of progression toward
revision is required. Loose implants can be removed, union (Figure 47.9).39
replaced, or tightened, and cancellous bone graft placed Nonviable nonunions are treated by the removal of all
around the fracture site. necrotic and avascular bone, in conjunction with open-
ing of the medullary cavity and autogenous cancellous
bone grafting. Rigid fixation is then needed to improve
Noninfected Nonunions
the chance of union (Figure 47.10).
Treatment of nonunion varies depending on the location
of the fracture. Nonunion of the splint bone is usually of
no clinical significance, or at worst contributes to sus- Physical Stimulation Therapies
pensory desmitis. For the latter reason (and sometimes
for cosmetic reasons), the distal fragment of the nonun- Electrostimulation in the Treatment
ion can be removed if at least one‐third of the second or of Nonunions
fourth metacarpal or metatarsal bone remains. Electrostimulation and its effects on bone have become
Viable nonunions are treated according to the type of important in the last 50 years, following the discovery by
nonunion: cases of hypertrophic nonunion, such as Yasuda in 1953 that new bone forms around a negative
untreated fractures of the ulna diaphysis, should respond electrode (cathode), and that bone resorption occurs at
to rigid fixation (Figure 47.8).58 Usually, internal fixation the positive electrode (or anode), if this electrode is
is used and just enough callus is removed to allow proper placed directly on bone. Thereafter, many investigators,
www.ajlobby.com
(A) (B) (C)
(D) (E)
Figure 47.7 Nonunion treated by additional external coaptation. (A) Dorsopalmar radiograph of a two‐year‐old adult Quarter Horse with
severe angular deformity of the forelimb and collapsing osteoarthritis of the fetlock joint. (B, C) Radiographs obtained 22 weeks after
surgery showing nonunion (arrow) of the repair using two locking compression plates. Revision and debridement with grafting of
collagen containing 2 mg BMP‐2 was done four weeks after the initial surgery. (D, E) Improving callus formation (arrows) 9 months
following repair, after further stabilization by 2 months of cast support. The fracture went on to complete union by 18 months after repair.
www.ajlobby.com
(A) (B) (D)
(C)
Figure 47.8 Viable nonunion of the ulna diaphysis, treated by debridement of the fracture gap to allow better articular surface
reconstruction, and then bone plating supplemented with cancellous bone graft. (A) Preoperative radiograph showing displaced
comminuted fracture of the ulna. (B) Intraoperative appearance after fibrous tissue removal from the fracture gap. (C) Intraoperative
appearance after reduction, dynamic compression plate application, and cancellous bone graft of the residual gaps (arrows).
(D) Radiograph on Day 7 showing fracture compression. Two cortical screws are inserted into the cranial articular fragment using lag
principle to further stabilize the joint surface.
the convex side of the bone. This type of electric poten-

tial is independent of cell viability, since it could still be
measured in dead bone. Bioelectric potential is depend-
ent on cell viability. The diaphysis, for example, is elec-
tropositive, whereas the physis and metaphysis are
electronegative. If fractures occur, the diaphysis then
becomes electronegative.
With the knowledge of the electric potentials of
bones, as well as the fact that new bone forms around
the negative electrode (the cathode), the effect of
electrostimulation on bones was studied. The effects of
electrostimulation on the bone include the following:
1) Increased DNA synthesis

2) Increased cyclic adenosine monophosphate (AMP)
production
Figure 47.9 Osteotomy of a malunion showing endosteal callus 3) Reduced disuse osteoporosis
sealing the medullary cavity of a third metacarpal bone, prior to
opening by forage.
4) Change in growth of the epiphyseal plate
5) Increased callus stiffness
6) Realignment of collagen fibers.
including Bassett et al., Brighton et al., Lavine and
Grodinsky, and others, have further characterized the Electrostimulation was then recommended, with the
effect of electricity on bone.5,8,9,41 prime indication being treatment of nonunions. Three
First, two types of electrical potentials in bone were types of electric modalities are available: (i) direct cur-
defined: stress‐generated potential and bioelectric rent; (ii) pulsing electromagnetic field (inductive cou-
potential. Stress‐generated potential is associated with pling); and (iii) capacitive coupling. In the direct current
stress on the bone, which leads to a negative potential on modality, the cathode is placed at the fracture site, since
the concave side of the bone and a positive potential on bone forms on the negative electrode. The anode is then
www.ajlobby.com
(A) (B) (C)
(D) (E)
Figure 47.10 Transfixation cast fixation for stabilization of a nonunion comminuted midshaft tibial fracture. (A) Preoperative lateral
radiograph showing a severely displaced multisegmental comminuted fracture of the tibial diaphysis, extending into the tarsocrural joint.
(B) Craniocaudal radiograph 10 weeks after repair, showing breakdown and displacement of the fracture which had originally been
repaired using multiple lag screws, cerclage wires, and a broad locking compression plate. (C, D) Craniocaudal and lateromedial
radiographs 11 weeks after repair, following removal of the plate and nonfunctional screws, and application of a transfixation cast. Note
the minimal callus, suggesting atrophic nonunion. (E) Craniocaudal radiograph obtained 11 months after repair, showing persisting
nonunion, angulation of the tibia, and lack of stabilizing callus.
www.ajlobby.com
placed on the skin, since bone resorption occurs at the the routine use of ultrasound or shockwave therapy to
positive electrode, and the signal generator is attached to enhance the rate of healing in acute fractures.25
the skin. Alternatively, a fully implantable unit can be Furthermore, a study of variable waveform low‐intensity
used where the anode and the signal generator are pulsed ultrasound in horses, using the fourth metacarpal
implanted in the soft tissue. This latter method has the osteotomy gap model, found no significant improvement
advantage of preventing ascending infection or problems in radiographic, quantitative computed tomography
associated with percutaneous penetration of the wires. (CT), or histologic indices of fracture healing.44 Given
Inductive coupling uses external coils at the level of the these studies, ultrasound therapy would appear to add
fracture site to induce magnetic fields that vary in dura- little to fracture or nonunion management in horses.
tion and time. Precise placement of the coils is required.
Capacitive coupling devices develop electric fields rather Shockwave Therapy for Nonunion
than magnetic fields over the fracture site. Unlike mag- The use of shockwave therapy for nonunion, avascular
netic fields, far less precision is required in the place- necrosis, and delayed healing of stress fractures in
ment of the unit to develop an electric field over a humans has anecdotal support.19 However clinical studies
fracture site. In capacitive coupling, two charged metal indicate that the success in treating delayed union or
plates are placed on the skin on either side of the frac- nonunion cases is no better than standard s urgical
ture. The electric field is constant, alternating, or pulsed. treatment. The advantage of shockwave therapy seems
All three modalities have been used successfully in the to be limited to decreased morbidity and expense, and
treatment of nonunions. improved safety, compared to more invasive treatments.
In humans, it is felt that 80–87% of nonunions treated A prospective randomized trial of extracorporeal shock-
by electrostimulation successfully proceed to union. A wave therapy in human nonunions found no evidence
critical analysis of the literature describing electrical to support the use of shockwave therapy.7 While shock-
stimulation of fracture sites in humans found moderate wave therapy is used frequently in equine lameness and
support for its use in fracture repair.46 Although the pri- orthopedic disease, including the treatment of soft tissue
mary indication for the use of electrostimulation in injuries and joint diseases, there is little information in
humans has been nonunion,13,14 all of the controlled the literature to support its use for equine delayed union
studies in equine fracture healing have focused on acute or nonunion.
fracture. None of these studies supported the use of elec-
trostimulation in acute fracture healing, except for one
study that evaluated the filling of a drilled defect in the Biologics for Delayed Union
equine third metacarpal bone, where electrostimulation and Nonunion
apparently enhanced bony healing. However, there are
anecdotal reports of successful use of electrostimulation Autologous Cancellous Bone Graft
in horses for healing nonunions.15,50 Autologous cancellous bone graft remains the gold stand-
ard in the treatment of delayed union and nonunion in the
horse. Autologous bone graft provides osteogenic, osteoin-
Low‐intensity Pulsed Ultrasonography ductive, and osteoconductive components to fracture
for Nonunions repair, without increasing the risk of immune response or
Low‐intensity pulsed ultrasound is frequently used in the transmission of infectious disease. Furthermore, autol-
human medicine to enhance or to accelerate fracture ogous bone graft can be readily obtained from the tuber
healing. Pulsed ultrasonography is thought to work by coxae or sternum in the horse. In humans, the literature
creating sound waves that generate micromechanical strongly supports the use of autologous bone graft for the
stress at the fracture site. These stresses then stimulate treatment of bone defects and nonunion.2,6,10,11,34,43,52
cellular and molecular changes that promote healing.11 Autologous bone graft of infected equine nonunions and
A recent meta‐analysis of suitably rigorous randomized infected joints has been described.31,51 Application of
controlled trials in humans indicated that low‐intensity autologous cancellous bone is frequently recommended
pulsed ultrasound effectively reduced the time to radio- during acute fracture repair, particularly where there are
graphic fracture union.53 However, this did not directly cortical defects, and has been used for decades to salvage
result in a beneficial effect in reducing time to functional delayed union and nonunion fractures of equine long
recovery, or in the prevention of delayed union or non- bones. Harvest and application of autologous bone graft is
union. A similar study evaluated ultrasound and shock- more completely described in Chapter 11. Delayed union
wave therapy for acute fractures in adults.25 Most of the and nonunion fractures respond favorably to local debride-
trials in the analysis supplemented routine surgical fixa- ment of the fracture site, removal of dead and infected
tion with the physical modality. Results of these trials bone fragments, and application of autologous bone graft,
indicated that there was insufficient evidence to support gently packed into the fracture site (see Figure 47.6). If the
www.ajlobby.com
implants continue to provide stabilization, an improved and other biologics to enhance fracture healing is
rate of fracture repair can be anticipated. Unstable frac- provided in Chapter 12. BMPs mediate their effect by
tures may need supplemental external coaptation or exter- binding to osteoprogenitor cells, and increasing the tran-
nal fixation. Demineralized bone matrix has not been scription of osteoinductive genes such as RUNX2, which
found to be an effective substitute to autologous cancellous enhances osteoblast differentiation.11 BMP‐2 has been
bone graft in fracture repair models in the horse.36 used in humans to enhance acute tibial fracture repair
and nonunion, and lumbar spinal fusion in skeletally
Autologous Bone Marrow Aspirate mature patients.38 Debate continues as to the advantages
and Bone Marrow Aspirate Concentrate of BMP‐2, with one study indicating a strong impact of
Autologous bone marrow aspirate and bone marrow BMP‐2 on bony union in open tibial fractures repaired
aspirate concentrate have become popular in human with intramedullary nailing.24 However, most studies
orthopedics.43,54 Bone marrow aspirate from the tuber suggest little additional benefit to the use of BMP‐2 over
coxae or sternum contains progenitor cells that have autologous cancellous bone graft.21,27,57 Three different
both osteogenic and angiogenic properties.11 Moreover, meta‐analyses of the human literature suggested that
the cells have proliferative capabilities and are able to there was little impact of BMP‐2 on nonunion fracture
produce growth factors such as bone morphogenetic repair; however, there may have been benefit to the
protein (BMP) and vascular endothelial growth factor use of BMP‐2 in acute tibial fracture healing.20,21,27
(VEGF), both of which stimulate bone healing. In These conclusions have been recently reiterated.4 There
humans, interest in bone marrow aspirate rather than is no evidence that BMP‐2 is more or less effective than
surgically harvested cancellous bone stems from the per- bone graft in the repair of human fracture nonunion. As
sisting postoperative pain following harvest of autolo- an alternative to autologous bone graft, there is strong
gous bone graft from the iliac crest. Long‐term surgical evidence to support its use.
pain or complications from harvest of autologous can- Application of BMP‐2 in equine fracture and nonun-
cellous bone are not recognized concerns in equine bone ion repair has research and clinical anecdotal evidence
grafting. Wound dehiscence has been reduced by to support the local application of BMP‐2 combined
minimally invasive harvest approaches to the sternum with synthetic bone substitute materials.49 Grafting of
and tuber coxae. Both sites yield substantial volumes of 2 mg human BMP‐2 to delayed and nonunion of a fet-
autologous cancellous bone. Consequently, using bone lock arthrodesis and recalcitrant distal tarsal joint
marrow aspirate instead of autologous cancellous bone arthrodesis has induced radiographic improvement. A
graft offers few advantages. Limited experience with combination of BMP‐2 and calcium phosphate com-
bone marrow aspirate and immediate injection to a frac- posites can induce bone in most locations. A recent
ture site using percutaneous, minimally invasive tech- evaluation of bone graft substitutes did not support the
niques suggests that this may be helpful in certain use of calcium phosphate as a standalone bone substi-
delayed union cases. However, where surgical debride- tute.27 However, a combination of calcium phosphate
ment, sequestrectomy, and removal of infected implants and BMP‐7 resulted in enhanced fracture repair in
are anticipated, the application of autologous cancellous human clinical trials. Exuberant bone formation is a
bone would still seem to be more appropriate. risk in humans and horses (Figure 47.11). Licensing of a
The effects of bone marrow aspirate on bone union BMP‐2 product for equine use has not been secured.
can be further enhanced by centrifugation to concen- Additionally, human recombinant BMP‐2 is expensive
trate the number of cells and growth factors.11 Loading ($1500–2000 for 2 mg). Experimental use of BMP‐2
porous synthetic bone marrow substitutes with concen- gene therapy may be an alternative (see later discussion
trated bone marrow aspirate represents a less painful but of mesenchymal stem cells).56
more costly approach to bone grafting in human ortho-
pedics. In equine fracture repair, there is indication for Platelet‐rich Plasma
the injection of bone marrow aspirate concentrate for Platelet‐rich plasma (PRP) has become a major therapeu-
delayed union or nonunions only when surgical exposure tic modality in equine orthopedics and sports medicine.
is not desired or anticipated. Principal applications are in tendon and ligament disease,
but there is increasing interest in PRP use in joint disease
Bone Morphogenetic Proteins and fracture healing. Platelets are an important compo-
BMPs are members of the transforming growth factor‐β nent of the fracture hematoma, where they accumulate
(TGF‐β) superfamily, which has numerous roles in devel- and subsequently degranulate to release a number of vital
opmental biology and tissue regeneration. Of the 15 dif- growth factors, including platelet‐derived growth factor
ferent BMPs, BMP‐2 and BMP‐7 are the most relevant to (PDGF), transforming growth factor‐β, vascular endothe-
bone healing.38 An in‐depth review of growth factors lial growth factor (VEGF), and fibroblast growth factor‐β.
www.ajlobby.com
human PDGF‐BB mixed in a beta‐tricalcium phosphate

(TCP) scaffold (Augment® Bone Graft, Wright Medical,
Memphis, TN, USA). The PDGF‐TCP product is mar-
keted for ankle fusion in humans, where it is considered
comparable to autologous bone graft, resulting in similar
fusion rates, but less pain and fewer side effects.40 Equine
PDGF‐A and PDGF‐B have been cloned and recombi-
nant proteins expressed.16 However, application to equine
fracture repair and treatment of nonunion have not been
described.
Mesenchymal Stem Cells

Bone marrow or adipose tissue‐derived mesenchymal
stem cells (MSCs) represent a ready source of stem cells
that may enhance fracture healing.1,37,59 Implantation of
predifferentiated MSCs has been shown to rapidly
reconstruct massive femoral defects in rodent experi-
mental models.59 However, a recent systematic review of
clinical studies using MSCs found little individual merit
for MSC use in acute fracture in humans.37 Culturing
equine MSCs has become commonplace, with applica-
tion in numerous musculoskeletal diseases. Bone mar-
row aspirate and specific isolation of MSCs for
autogenous application would seem to be excessively
complicated, compared to the concept of autologous
cancellous bone graft or percutaneous injection of bone
Figure 47.11 Excessive bone formation (arrows) on the medial
aspect of the proximal phalanx after leakage of resorbable bone marrow aspirate concentrate. However, they may repre-
cement containing BMP‐2, used in combination with lag screws to sent a vehicle for introducing cells overexpressing growth
treat subchondral bone cysts of the distal portion of the phalanx. factors, such as BMP‐2. This may be the only economical
mechanism to introduce BMP‐2 to acute fracture sites,
or for the treatment of delayed union and nonunion. A
The advantages of PRP include autologous source, ease of
comparison of MSCs and MSCs overexpressing BMP‐2
application, and relatively low cost. Application in frac-
in experimental fracture models strongly supports the
ture healing is the least substantiated use in equine mus-
use of cells overexpressing BMP‐2.32,42 Equine BMP‐2
culoskeletal repair. Limited analysis in human fracture
has been cloned and evaluated in fracture healing mod-
repair provides little positive support for PRP use in frac-
els in the horse.33 These research trials support a broader
ture repair.23,26 One recent double‐blind study suggests
application of MSCs expressing genes such as BMP‐2,
that the addition of PRP to autologous bone graft pro-
BMP‐7, or PDGF.
vides additional stimulus to nonunion fracture healing.22
Clinical improvements included higher union rates,
shorter interval to fracture stabilization, and reduced
postoperative pain. The only negative caveat was a higher
Systemic Biologics for Nonunion
incidence of infection. Parathyroid Hormone
Parathyroid hormone (PTH) is a key regulator of mineral
Platelet‐derived Growth Factor metabolism. Intermittent injection of the active PTH
Platelet‐derived growth factors have an important role in (1‐34) metabolite has been approved by the US Food and
fracture healing, by attracting progenitor cells to the Drug Administration for the treatment of osteoporosis
damaged bone, driving mitogenesis, and stimulating the in humans. PTH has also been shown to enhance frac-
production of VEGF and interleukin‐6 at the fracture site, ture healing in animal models and clinical trials.11
both of which regulate angiogenesis and promote bone Fracture healing may be accelerated by 20 μg PTH (1‐34).
healing.17,30 Of the three subtypes of PDGF, PDGF‐BB In horses, a PTH (1‐34) gene‐activated matrix was found
has been developed for therapeutic use because it can sig- to improve healing in diaphyseal cortical defects, but not
nal through both alpha and beta receptors. PDGF can be subchondral bone defects.3 Despite this, clinical applica-
delivered to the fracture site either as a platelet gel, con- tion has been described for subchondral bone cysts
sisting of PRP mixed with thrombin, or as recombinant opening to the pastern joint.18 There are no descriptions
www.ajlobby.com
of local or systemic clinical use of PTH (1‐34) in equine be recommended. The possibility of a negative impact
fracture repair. should also be considered.
Bisphosphonates
Bisphosphonates inhibit osteoclastic bone resorption,
Future Directions in the Treatment
and are commonly used in the treatment of osteoporosis. of Nonunion
Since the remodeling phases of fracture healing involve Other agents to enhance bony union in delayed or non-
bone resorption, and bisphosphonates reduce bone union fractures are in research and clinical trial phases.
resorption, there has been interest in the possible effect These include PTH/PTHrP receptor agonists, activators
of bisphosphonates to enhance fracture healing. The of Wnt/β‐catenin signaling, and recombinant FGF‐2.38
concept relies on existing strong anabolic activity to heal These biologically active peptides can promote bone for-
the fracture, but with bisphosphonate enhanced down- mation, which is important for the stability of bridging
regulation of the osteoclastic‐driven catabolism. Case callus, and some can promote cartilage formation, which
reports in the human literature support the concept. may have a significant role in the early phases of soft cal-
Application of bisphosphonates in equine musculoskel- lus formation. Appropriately timed stimulation of chon-
etal disease has become common. Use of tiludronate drogenesis and osteogenesis in the fracture callus may
(Tildren®, Ceva Animal Health, Lenexa, KS, USA) and provide a more effective approach in preventing or treat-
clodronate (OsPhos®, Dechra, Overland Park, KS, USA) ing delayed union and even nonunion, compared to ben-
for navicular disease and other bone‐resorptive syn- efits derived from simply stimulating osteogenesis.
dromes has resulted in resolution of lameness.35 There is
no information about the clinical impact of these bispho-
sphonates in equine fracture healing, or in treatment of Malunion
nonunion. However, sequential magnetic resonance
imaging (MRI) analysis of horses with avulsion fracture Malunion is defined as the healing of bones in an abnor-
of the suspensory ligament from the palmar surface of mal position. Malunions are subdivided to functional or
the third metacarpus suggests a positive healing impact nonfunctional. Malunions are associated with either axial
of the systemic administration of 50 mg of tiludronate.45 or rotational deformities (or possibly both). If a functional
Further studies are necessary before the use of bisphos- malunion is present, no treatment is required. Complete
phonates in fracture repair or treatment of nonunion can and functional bony malunion of the humeral or femoral
(A) (B) (C)
Figure 47.12 Malunion of the third metatarsal bone in a four‐month‐old foal. (A) Clinical assessment shows the mid‐metatarsal
angulation, displaced tendons, and compensatory deformity of the proximal phalanx. (B) Radiographs show the complex curvature
preoperatively, and (C) following wedge osteotomy and plate fixation.
www.ajlobby.com
diaphysis is occasionally seen following conservative Prognosis

treatment of overridden midshaft fractures. Undiagnosed
fractures of these bones can also eventually result in func- The prognosis for delayed unions, nonunions, and non-
tional bony healing, but with a shortened limb. If a nonfunctional malunions is poor because of the serious
functional malunion is present, correction of the effect of prolonged weight bearing on the sound limb,
malunion is generally done using osteotomies. Malunion cycling and breakdown of the metallic implants, and the
of the third metacarpal or metatarsal bones results in need for repeated surgical intervention. Laminitis and
abnormal stress on the distal limb joints, and often tendon breakdown are significant factors in the sound
arthritic changes in the fetlock joint (Figure 47.12). These limb, and seriously compromise the prognosis even if the
cases generally need corrective osteotomy and bone plat- delayed union or nonunion can be treated by further
ing, to realign the axial stresses within the lower limb. stabilization.
References
1 Alwattar, B.J., Schwarzkopf, R., and Kirsch, T. (2011). 11 Buza, J.A. III and Einhorn, T. (2016). Bone healing in
Stem cells in orthopaedics and fracture healing. Bull. 2016. Clin. Cases Miner. Bone Metab. 13: 101–105.
NYU Hosp. Jt. Dis. 69: 6–10. 12 Cabanela, M.E. (1984). Open cancellous bone grafting
2 Azi, M.L., Aprato, A., Santi, I. et al. (2016). Autologous of infected bone defects. Orthop. Clin. North Am. 15:
bone graft in the treatment of post‐traumatic bone 427–440.
defects: a systematic review and meta‐analysis. BMC 13 Collier, M.A., Brighton, C.T., Norrdin, R. et al. (1985).
Musculoskelet. Disord. 17: 465. Direct current stimulation of bone production in the
3 Backstrom, K.C., Bertone, A.L., Wisner, E.R., and horse: preliminary study with a “gap healing” model.
Weisbrode, S.E. (2004). Response of induced bone Am. J. Vet. Res. 46: 610–621.
defects in horses to collagen matrix containing the 14 Collier, M.A., Kallfelz, F.A., Rendano, V.T. et al. (1985).
human parathyroid hormone gene. Am. J. Vet. Res. 65: Capacitively coupled electrical stimulation of bone
1223–1232. healing in the horse: in vivo study with a Salter type IV
4 Barcak, E.A. and Beebe, M.J. (2017). Bone osteotomy model with stainless steel surface electrodes.
morphogenetic protein: Is there still a role in orthopedic Am. J. Vet. Res. 46: 622–631.
trauma in 2017? Orthop. Clin. North Am. 48: 301–309. 15 Collier, M.A., Were, K.E., DeFreitas, C.B., and Lamar,
5 Bassett, C.A., Pilla, A.A., and Pawluk, R.J. (1977). A A.M. (1981). Electrostimulation of bone production in the
non‐operative salvage of surgically‐resistant horse. In: Proceedings of the American Association of
pseudarthroses and nonunions by pulsing Equine Practitioners, vol. 27, 71–89. Lexington, KY: AAEP.
electromagnetic fields. A preliminary report. Clin. 16 Donnelly, B.P., Nixon, A.J., Haupt, J.L., and Dahlgren,
Orthop. Relat. Res. 124: 128–143. L.A. (2006). Nucleotide structure of equine platelet‐
6 Bell, A., Templeman, D., and Weinlein, J.C. (2016). derived growth factor‐A and ‐B and expression in
Nonunion of the femur and tibia: an update. Orthop. horses with induced acute tendinitis. Am. J. Vet. Res. 67:
Clin. North Am. 47: 365–375. 1218–1225.
7 Biedermann, R., Martin, A., Handle, G. et al. (2003). 17 Friedlaender, G.E., Lin, S., Solchaga, L.A. et al. (2013).
Extracorporeal shock waves in the treatment of The role of recombinant human platelet‐derived
nonunions. J. Trauma 54: 936–942. growth factor‐BB (rhPDGF‐BB) in orthopaedic bone
8 Brighton, C.T., Hozack, W.J., Brager, M.D. et al. (1985). repair and regeneration. Curr. Pharm. Des. 19:
Fracture healing in the rabbit fibula when subjected to 3384–3390.
various capacitively coupled electrical fields. J. Orthop. 18 Fuerst, A., Derungs, S., von Rechenberg, B. et al. (2007).
Res. 3: 331–340. Use of a parathyroid hormone peptide (PTH(1‐34))‐
9 Brighton, C.T., Katz, M.J., Goll, S.R. et al. (1985). enriched fibrin hydrogel for the treatment of a
Prevention and treatment of sciatic denervation disuse subchondral cystic lesion in the proximal
osteoporosis in the rat tibia with capacitively coupled interphalangeal joint of a warmblood filly. J. Vet. Med.
electrical stimulation. Bone 6: 87–97. A Physiol. Pathol. Clin. Med. 54: 107–112.
10 Brinker, M.R. and O’Connor, D.P. (2016). Management 19 Furia, J.P., Rompe, J.D., Cacchio, A., and Maffulli, N.
of aseptic tibial and femoral diaphyseal nonunions (2010). Shock wave therapy as a treatment of
without bony defects. Orthop. Clin. North Am. nonunions, avascular necrosis, and delayed healing of
47: 67–75. stress fractures. Foot Ankle Clin. 15: 651–662.
www.ajlobby.com
20 Garrison, K.R., Donell, S., Ryder, J. et al. (2007). Clinical healing of segmental femoral defects in rats. Bone 40:
effectiveness and cost‐effectiveness of bone 931–938.
morphogenetic proteins in the non‐healing of fractures 33 Ishihara, A., Zekas, L.J., Litsky, A.S. et al. (2010).
and spinal fusion: a systematic review. Health Technol. Dermal fibroblast‐mediated BMP2 therapy to
Assess. 11 (30): 1–66. accelerate bone healing in an equine osteotomy model.
21 Garrison, K.R., Shemilt, I., Donell, S. et al. (2010). Bone J. Orthop. Res. 28: 403–411.
morphogenetic protein (BMP) for fracture healing in 34 Kadhim, M., Holmes, L. Jr., Gesheff, M.G., and Conway,
adults. Cochrane Database Syst. Rev. 6: CD006950. J.D. (2017). Treatment options for nonunion with
https://doi.org/10.1002/14651858.CD006950.pub2. segmental bone defects: systematic review and
22 Ghaffarpasand, F., Shahrezaei, M., and Dehghankhalili, quantitative evidence synthesis. J. Orthop. Trauma 31:
M. (2016). Effects of platelet rich plasma on healing 111–119.
rate of long bone nonunion fractures: a randomized 35 Kamm, L., McIlwraith, C.W., and Kawcak, C.E. (2008).
double‐blind placebo controlled clinical trial. Bull. A review of the efficacy of tiludronate in the horse.
Emerg. Trauma 4: 134–140. J. Equine Vet. Sci. 28: 209–214.
23 Gianakos, A., Ni, A., Zambrana, L. et al. (2016). Bone 36 Kawcak, C.E., Trotter, G.W., Powers, B.E. et al. (2000).
marrow aspirate concentrate in animal long bone Comparison of bone healing by demineralized bone
healing: an analysis of basic science evidence. J. Orthop. matrix and autogenous cancellous bone in horses. Vet.
Trauma 30: 1–9. Surg. 29: 218–226.
24 Govender, S., Csimma, C., Genant, H.K. et al. (2002). 37 Killington, K., Mafi, R., Mafi, P., and Khan, W. (2017). A
Recombinant human bone morphogenetic protein‐2 systematic review of clinical studies investigating
for treatment of open tibial fractures: a prospective, mesenchymal stem cells for fracture nonunion and
controlled, randomized study of four hundred and fifty bone defects. Curr. Stem Cell Res. Ther. 13: 284–291.
patients. J. Bone Joint Surg. Am. 84‐A: 2123–2134. 38 Kostenuik, P. and Mirza, F.M. (2017). Fracture
25 Griffin, X.L., Parsons, N., Costa, M.L., and Metcalfe, D. healing physiology and the quest for therapies for
(2014). Ultrasound and shockwave therapy for acute delayed healing and nonunion. J. Orthop. Res. 35:
fractures in adults. Cochrane Database Syst. Rev. 6: 213–223.
CD008579. https://doi.org/10.1002/14651858. 39 Kraus, K.H. and Bayer, B.J. (2012). Delayed unions,
CD008579.pub3. nonunions, and malunions. In: Veterinary Surgery:
26 Griffin, X.L., Wallace, D., Parsons, N., and Costa, Small Animal (ed. K.M. Tobias and S.A. Johnston),
M.L. (2012). Platelet rich therapies for long bone 647–656. St. Louis, MO: Elsevier.
healing in adults. Cochrane Database Syst. Rev. 7: 40 Krell, E.S. and DiGiovanni, C.W. (2016). The efficacy of
CD009496. https://doi.org/10.1002/ 14651858. platelet‐derived growth factor as a bone‐stimulating
CD009496.pub2. agent. Foot Ankle Clin. 21: 763–770.
27 Hagen, A., Gorenoi, V., and Schonermark, M.P. (2012). 41 Lavine, S.L.S. and Grodzinsky, A.J. (1987). Current
Bone graft substitutes for the treatment of traumatic concepts review. Electrical stimulation of repair of
fractures of the extremities. GMS Health Technol. bone. J. Bone Joint Surg. Am. 69: 626–630.
Assess. 8: 1–13. 42 Lieberman, J.R., Daluiski, A., Stevenson, S. et al. (1999).
28 Hance, S.R., Bramlage, L.R., Schneider, R.K., and The effect of regional gene therapy with bone
Embertson, R.M. (1992). Retrospective study of 38 morphogenetic protein‐2‐producing bone‐marrow
cases of femur fractures in horses less than one year of cells on the repair of segmental femoral defects in rats.
age. Equine Vet. J. 24: 357–363. J. Bone Joint Surg. Am. 81: 905–917.
29 Heppenstall, R.B. (1980). Delayed union, nonunion, and 43 Lin, S.S. and Yeranosian, M.G. (2016). The role of
pseudoarthrosis. In: Fracture Treatment and Healing, orthobiologics in fracture healing and arthrodesis. Foot
80–96. Philadelphia: W.B. Saunders. Ankle Clin. 21: 727–737.
30 Hollinger, J.O., Hart, C.E., Hirsch, S.N. et al. (2008). 44 McClure, S.R., Miles, K., Vansickle, D., and South, T.
Recombinant human platelet‐derived growth factor: (2010). The effect of variable waveform low‐intensity
biology and clinical applications. J. Bone Joint Surg. Am. pulsed ultrasound in a fourth metacarpal osteotomy
90 (Suppl. 1): 48–54. gap model in horses. Ultrasound Med. Biol. 36:
31 Honnas, C.M., Schumacher, J., and Kuesis, B.S. (1992). 1298–1305.
Ankylosis of the distal interphalangeal joint in a horse 45 Mizobe, F., Nomura, M., Kato, T. et al. (2017). Signal
after septic arthritis and septic navicular bursitis. J. Am. changes in standing magnetic resonance imaging of
Vet. Med. Assoc. 200: 964–968. osseous injury at the origin of the suspensory ligament
32 Hsu, W.K., Sugiyama, O., Park, S.H. et al. (2007). in four Thoroughbred racehorses under tiludronic acid
Lentiviral‐mediated BMP‐2 gene transfer enhances treatment. J. Equine Sci. 28: 87–97.
www.ajlobby.com
46 Mollon, B., da Silva, V., Busse, J.W. et al. (2008). and treatment recommendations. Int. Orthop. 42:
Electrical stimulation for long‐bone fracture‐healing: a 247–258.
meta‐analysis of randomized controlled trials. J. Bone 53 Rutten, S., van den Bekerom, M.P., Sierevelt, I.N., and
Joint Surg. Am. 90: 2322–2330. Nolte, P.A. (2016). Enhancement of bone‐healing by
47 Nemeth, F. and Back, W. (1991). The use of the walking low‐intensity pulsed ultrasound: a systematic review.
cast to repair fractures in horses and ponies. Equine JBJS Rev. 4: 1–11.
Vet. J. 23: 32–36. 54 Schottel, P.C. and Warner, S.J. (2017). Role of bone
48 Nunamaker, D.M., Richardson, D.W., Butterweck, D.M. marrow aspirate in orthopedic trauma. Orthop. Clin.
et al. (1986). A new external skeletal fixation device that North Am. 48: 311–321.
allows immediate full weightbearing: application in the 55 Selcer, B.A. (1983). Imaging: bone. Vet. Radiol.
horse. Vet. Surg. 15: 345–355. Ultrasound 24: 243–250.
49 Perrier, M., Lu, Y., Nemke, B. et al. (2008). Acceleration 56 Southwood, L.L., Frisbie, D.D., Kawcak, C.E., and
of second and fourth metatarsal fracture healing with McIlwraith, C.W. (2004). Delivery of growth factors
recombinant human bone morphogenetic protein‐2/ using gene therapy to enhance bone healing. Vet. Surg.
calcium phosphate cement in horses. Vet. Surg. 37: 33: 565–578.
648–655. 57 Takemoto, R., Forman, J., Taormina, D.P., and Egol,
50 Pratt, G.W. Jr., Fackelman, G.E., and Sheehan, R.J. K.A. (2014). No advantage to rhBMP‐2 in addition to
(1982). Electro‐stimulation in the treatment of autogenous graft for fracture nonunion. Orthopedics
nonunion sesamoidal fractures. In: Proceedings of the 37: e525–e530.
American Association of Equine Practitioners, vol. 28, 58 Turner, A.S. (1982). Long bone fractures in horses. Part
73–83. Lexington, KY: AAEP. III postoperative management. Compend. Contin. Educ.
51 Richardson, D.W., Nunamaker, D.M., and Sigafoos, Pract. Vet. 4: S254–S257.
R.D. (1987). Use of an external skeletal fixation device 59 Watanabe, Y., Harada, N., Sato, K. et al. (2016). Stem
and bone graft for arthrodesis of the cell therapy: is there a future for reconstruction of large
metacarpophalangeal joint in horses. J. Am. Vet. Med. bone defects? Injury 47 (Suppl. 1): S47–S51.
Assoc. 191: 316–321. 60 Weber, B.G. and C.O. (1976). Pseudoarthrosis:
52 Rupp, M., Biehl, C., Budak, M. et al. (2018). Diaphyseal Pathology, Biomechanics, Therapy, Results. Berne,
long bone nonunions – types, aetiology, economics, Switzerland: Hans Huber Medical Publisher.
www.ajlobby.com
851
48
Osteomyelitis
Laurie R. Goodrich
College of Veterinary Medicine, Colorado State University, Fort Collins, CO, USA
Introduction options have also become more sophisticated. New diag-

nostics and local treatment options have allowed some
There are few complications in orthopedic surgery more of the more complicated and/or open fractures to be
dreaded than infection.39 This is especially true when sep- successfully managed. This chapter reviews the current
sis is associated with orthopedic implants, because of the literature on the pathophysiology of osteomyelitis, as well
degree of difficulty of the original surgery, the destabilizing as current diagnostic and treatment modalities. Some of
effect of the bone lysis, and the monetary investment asso- these techniques are still being refined and long‐term
ciated with the original implants, as well as the subsequent outcome data may not be readily available at this time, but
surgical and pharmaceutic costs required to resolve the emerging techniques should be considered in the manage-
problem. In the horse, these concerns are especially magni- ment of osteomyelitis and their advantages are discussed
fied because of the significant costs of intensive antibiotic here. Traditional treatments are only briefly reviewed.
treatment. Furthermore, because of the ongoing weight‐
bearing activity following fracture repair in the horse, early
implant removal because of loosening associated with lysis Definition and Causes
and infection may result in a catastrophic outcome. A
study reviewing the overall infection rate in equine muscu- Osteomyelitis is an inflammatory process accompanied
loskeletal surgery reports an overall postoperative infec- by bone destruction and caused by infecting microor-
tion rate of approximately 10%.56 Of those cases considered ganisms.54,55 The infection can be limited to a single por-
clean‐contaminated in the same study, a 53% infection rate tion of bone or can involve several regions, such as the
was found. This rate is much higher than those experi- marrow, cortex, periosteum, and surrounding soft tis-
enced by orthopedic surgeons operating on human sues, in addition to the synovial structures at the ends of
patients,55 and this fact alone highlights the need for equine the bone.6,103 If only the cortical bone is infected, it is
orthopedic surgeons to understand the pathophysiology of classified as osteitis, and if bone marrow is also involved,
osteomyelitis and the current armamentarium of diagnos- it is more appropriately termed osteomyelitis.
tic and therapeutic options. A recent retrospective study of In general, the sources of infection can be divided into
postoperative infections in horses undergoing long bone hematogenous, traumatic, and iatrogenic.6 Hematogenous
fracture repair or arthrodesis confirmed an infection rate infections are almost exclusively seen in foals as a result of
of 28% and, as expected, these cases had a significantly bacteremia from a septic focus such as the respiratory,
reduced probability of discharge from the hospital.2 Clearly, gastrointestinal, or umbilical systems. The secondary
prevention of infection has to be foremost in any surgical musculoskeletal involvement often develops in a joint,
planning, since the consequences of contamination and epiphysis, or physis, and can be more debilitating than the
osteomyelitis are so dire.116 primary focus. Traumatic infections are usually secondary
Within the past decade, research in the area of orthope- to a laceration or puncture wound, and can infect the
dic infection has revealed compelling data regarding the bone, joint, tendon sheath, or bursa. Finally, iatrogenic
nature of bacterial growth on bone and implants. Because infections are generally secondary to surgical procedures
of an improved understanding of the pathophysiology with or without implants. Osteomyelitis associated with
of osteomyelitis, diagnostic techniques and treatment implants presents the greatest treatment challenge.

www.ajlobby.com
Pathophysiology and the ability to use horizontal gene transfer to protect

against environmental challenges.22,98 It is this biofilm
Bacterial colonization requires the adherence of bacte- substance that makes the treatment of osteomyelitis so
ria to bone or substrata and subsequent permanent challenging. The promotion of additional bacterial
attachment.42 In most tissues, host defense systems adherence is probable and likely to result in syntropic
naturally eliminate transient bacterial colonization interactions. Unfortunately, the surface colonization in
unless (i) the inoculum exceeds threshold levels; (ii) biofilm is a survival strategy that is often successful
host defense is impaired; (iii) tissue surfaces are trau- because of its impenetrability, and thus resistance to
matized; (iv) a foreign body is present; or (v) the surface antimicrobials.10,35,58 Studies suggest that biofilm also
or tissue has low cellularity.41,42 Bone or cartilage in a prevents inflammatory molecules and phagocytic cells
traumatized state is an example in which many of these from effectively penetrating the biofilm matrix, and the
apply. The smooth articular surface of joints and the inflammatory response is often more damaging to the
surfaces of bone are unique in that they have low cellu- host tissue than the biofilm.98 In fact, the release of
larity. Furthermore, these surfaces do not have a proinflammatory proteases may be beneficial to biofilm
tective layer. Traumatized tissue and normal bone and bacteria by promoting host cell lysis and the subsequent
cartilage have surfaces that resemble natural surfaces release of cellular contents as a nutrient source for the
that have evolved an affinity for bacteria. The presence bacteria.
of a biomaterial enhances infectivity, decreases the Surface colonization in biofilms is a survival strategy
effectiveness of host defense mechanisms, and alters that is often successful, because bacteria can logarithmi-
bacteria phenotypic behavior and susceptibility to cally multiply and the infection can become a “multispe-
antimicrobials.39 cied consortia of bacteria” within the adhesive biofilm
Bacteria colonize on the surface of bone, cartilage, or layer.21 Furthermore, biofilms as organisms have antibi-
implants by way of direct contamination, spread of local otic resistance levels that are three levels of magnitude
wound infection, or hematogenous seeding. A condi- greater than those displayed by planktonic or free‐living
tioning film of glycoproteinaceous material spontane- bacteria of a similar strain.29 This results in a formidable
ously forms when exposed to a biologic environment.41,42 challenge to the clinician to medicate and cure the infec-
Bacteria anchor to the nutrient‐rich substratum, prolif- tion before the devastating effects of osteomyelitis lead
eration occurs within the polysaccharide slime, and a to the patient’s demise.
biofilm layer forms. The “biofilm slime” layer is formed
by bacterial extracapsular exopolysaccharides that bind
to surfaces or participate in cell‐to‐cell aggregation, and Organisms Commonly
promote tissue adhesion and microcolony formation Associated with Osteomyelitis
within the infected tissue.90 Biofilm formation follows a
developmental progression consisting of four main It is important to be familiar with the organisms that are
stages: reversible attachment, irreversible attachment, most commonly cultured from osteomyelitis foci, so that
growth and differentiation, and dissemination (or patients can be placed on the appropriate antimicrobial
detachment). The extracellular polymeric slime that drug for prophylaxis or treatment before the results of
forms the matrix of biofilm within which the individual culture and sensitivity testing become available. In cases
cells live is the hallmark feature of biofilms. In the dis- of hematogenous osteomyelitis in foals, enteric gram‐
semination phase, cells within the biofilm are released to negative organisms are most commonly isolated.103
colonize new surfaces through a number of different However, this is not the most common bacterial isolate
processes. Motile bacteria, such as Pseudomonas aerugi- in adult osteomyelitis.
nosa, swim out of specialized “fruiting body‐like” micro- In a study by Moore et al., analyzing bacterial culture
colonies into the surrounding fluid, or move along and susceptibility results from 233 horses with osteo-
surfaces by gliding or twitching motility.98 Nonmotile myelitis, septic arthritis, or septic tenosynovitis, 91%
species, such as Staphylococcus aureus, seem to use of the bacteria were aerobic or facultatively anaerobic
fluid‐borne dispersal and detach as large multicellular and 9% were anaerobic.66 The most common bacterial
aggregates encased in slime, or roll along surfaces using group isolated was Enterobacteriaceae (29%), followed
viscoelastic tethers.98 by non‐ß‐hemolytic streptococci (13%), coagulase‐
Being attached to a surface and encased within a positive staphylococci (12%), ß‐hemolytic streptococci
matrix allows bacteria obvious advantages with regard (9.4%), and coagulase‐negative staphylococci (7.3%).66
to maintaining homeostasis and a defense. Other The rest of the organisms were other gram‐negative
advantages include undertaking cooperative metabo- (15.8%), other gram‐positive (2.3%), and miscellaneous
lism based on complex intercellular signaling systems, (2.6%) bacteria.66 These findings were similar to an
www.ajlobby.com
earlier study, where 147 bacterial isolates were cul- Clinical Findings
tured from 60 equine orthopedic patients.95 Multiple and Diagnosis
bacteria were often identified in osteomyelitis cases
that developed subsequent to surgical fracture repair. Clinical findings can vary according to the severity or
Therefore, broad‐spectrum antimicrobial coverage is duration of infection. The horse may begin with a slight
indicated as prophylaxis in any procedure that requires increase in lameness compared with that observed previ-
surgical implants.39 A more recent study by Ahern ously, and the lameness may worsen rapidly. Local swell-
et al., summarizing infection rates in 192 cases of ing often appears in the area of a wound or surgical
orthopedic infection in equine long bone fractures and incision. Furthermore, a painful response to digital palpa-
arthrodeses, found gram‐positive infections to be 32% tion can usually be elicited. The incision line may produce
of all infections and gram‐negative 28%.2 The most local drainage, and granulation tissue may appear along
common gram‐negative bacteria was Enterobacter the drainage site. Few systemic signs are associated with
cloacae (25%), and the most common gram‐positive osteomyelitis, except for a febrile response. Leukocytosis
organism was Staphylococcus (21%). A mix of gram‐ may be present, but this symptom is never diagnostic for a
positive and gram‐negative organisms was found in bone infection. One recent paper reviewed plasma fibrin-
40% of all postoperative infections. ogen concentrations in foals with confirmed osteomyelitis
Antibacterial sensitivity patterns can vary according of the physis or epiphysis and found a strong correlation of
to geographic location. Therefore, patterns should fibrinogen levels above 900 mg dl−1.68 Although this has
be established for every laboratory. Although empiric not been analyzed in adult horses with osteomyelitis, a
antibacterial selection should be used only until cul- common clinical impression is that fibrinogen levels may
ture and sensitivity results are available, knowledge of be one of the most useful of the available laboratory assays.
sensitivity patterns can be crucial in the early treat- Serum amyloid A is now generally considered a more sen-
ment of osteomyelitis.39,103 The data in Table 48.1 sum- sitive and earlier indicator of septic conditions than fibrin-
marize the most recent studies analyzing bacterial ogen, and is a vital predictor of both the development and
isolates from various cases of osteomyelitis with differ- resolution of osteomyelitis and other septic conditions.
ent etiologies. They include the most common organ- Osteomyelitis and/or septic arthritis are almost always
isms found, together with the corresponding sensitivity associated with moderate to severe lameness and/or
patterns and references that list them. This should be joint effusion, except in the case of an open draining
considered a rough guide to the commonly cultured joint. A good physical examination should be performed,
organisms and their sensitivity patterns. Each labora- paying special attention to the area of concern to deter-
tory should establish its own sensitivity patterns for mine whether heat, pain, or swelling accompanies the
bacteria. lameness. Thorough digital palpation that carefully
Table 48.1 A summary of recent studies reporting common sensitivity patterns of organisms found in various types of bone infections.
Population
of horses Problem Most common organism(s) cultured Antibiotics most likely to be effectivea
Foals Hematogenous osteomyelitis/physitis Enterobacteriaceae Amikacin, cefotaxime, moxalactam

Adults Septic arthritis secondary to injection or surgery Staphylococci Amikacin
Adults Septic arthritis attributable to a wound Often mixed Enterobacteriaceae, Amikacin
β‐hemolytic Streptococcus Cephalothin
Staphylococcus haemolyticus Amikacin
Other Staphylococcus spp
Adults Osteomyelitis attributable to a wound Enterobacteriaceae Amikacin
Adults Osteomyelitis attributable to an implant Often mixed Enterobacteriaceae Amikacin
infection/fracture repair non‐β‐hemolytic Streptococcus Chloramphenicol,
trimethoprim‐sulfonamides
Coagulase‐positive Staphylococcus Amikacin
β‐hemolytic Streptococcus Cephalothin
a
Data from Moore et al. 1992.66
www.ajlobby.com
attempts to localize the pain and swelling can be helpful Scintigraphy using technetium (99mTc) is an emerging
in localizing the site of infection and determining the technology used to aid in the diagnosis of osteomyelitis
most appropriate site for aspiration, radiography, or (Figure 48.2).92 It can be used to detect osteomyelitis sev-
ultrasonography. eral weeks or even months before radiography.17 Although
Many imaging techniques are available to assist in the scintigraphy is a sensitive indicator of bone turnover, it
diagnosis of osteomyelitis. Several modalities, such as does not distinguish between bone turnover attributable
magnetic resonance imaging (MRI), computed tomogra- to infection, recent trauma, or fracture development.
phy (CT), and biomarker analysis, have been used more Given this, it is not helpful in cases in which recent
recently and have become useful tools in the sometimes implantation or trauma has occurred. Furthermore, false‐
difficult task of establishing a diagnosis of osteomyelitis. positive results can also occur in young foals, in which
The overall diagnostic accuracy using various imaging physeal development is still taking place. White blood cell
modalities is approximately 80–90%.108 Radiographic labeling is an emerging technology in veterinary medi-
diagnosis remains the most commonly used modality to cine. Indium‐111 is used to label and reinject a patient’s
determine whether osteomyelitis is present, but is insen- white blood cells to observe whether “pooling” (an indi-
sitive to bony changes that occur early in the disease cation of infection) is present. This is available at a few
process. The infection must cause 50–70% bone demin- referral institutions, and can be of great benefit in younger
eralization to observe bone lysis on plain radiographs. animals and when implants are present or recent trauma
Furthermore, this amount of bone loss may take up to 21 has taken place.92 A more recent scintigraphic approach
days to detect.108 As infection progresses, radiographic to diagnosing osteomyelitis consists of using 99mTc‐
lucencies associated with areas of demineralization and labeled ciprofloxacin (99mTc‐CIPRO). This method can
bone lysis become more evident. These areas can form be used to distinguish infection from other causes of
sequestra, and an envelope of demineralized bone and inflammation.73,86 Ciprofloxacin binds to bacterial DNA
periosteal proliferation called an involucrum can form gyrase. Advantages of 99mTc‐CIPRO scintigraphy for
around the sequestra. If implants are present, radiolu- detecting infection include high specificity and no blood
cencies are often seen along the margins (Figure 48.1). handling, as well as the fact that minimal time, technical
(A) (B) (C) (D)
Figure 48.1 Radiographic and gross examples of the progression of osteomyelitis. (A) Mid‐diaphyseal oblique fracture; (B) repair with two
dynamic compression plates; (C) subsequent drainage associated with osteomyelitis; and (D) radiolucencies around plates and screws
associated with severe bacterial infection and osteolysis. Source: Images courtesy Dr. Alan J. Nixon.
www.ajlobby.com
Figure 48.2 Nuclear scintigraphy of

osteomyelitis of the distal radius in a four‐
year‐old horse. (A) Craniocaudal view and
(B) lateral view.
(A) (B)
skills, and laboratory equipment are needed for

radionucleotide preparation and scanning.97 A recent

study in rabbits revealed that 99mTc‐hydroxydiphospho-
nate (HDP) and 99mTc‐CIPRO had higher uptake ratios in
infected fractures compared to noninfected fractures.97
Although 99mTc‐CIPRO was better than 99mTc‐HDP for
diagnosing infections, it was also associated with a
higher rate of false‐positive results.97
CT scanning can be used to determine the extent of
bony involvement in osteomyelitis.15 CT can reveal puru-
lent material within the medullary cavity, adjacent soft
tissue abscesses, intraosseous gas, decreased density of
bone, or the presence of soft tissue masses, abscesses, or
foreign bodies. CT is an excellent imaging modality to
diagnose osteomyelitis in areas in which radiographic
interpretation is difficult, such as the head (Figure 48.3).
CT can also be used to identify sequestra in cases of
chronic osteomyelitis. Contrast material can be used to
delineate abscesses in necrotic tissue that are not deline-
ated from the surrounding tissue.15
MRI has also been used for evaluating bone and joint
infections.15 It is particularly helpful for diagnosing lytic
areas within the medullary cavity, because of the distinct
changes that it can reveal within soft tissues and fat. In a
study of human patients, MRI was superior in sensitivity
Figure 48.3 A computed tomography scan of a head, very clearly
(97%) and specificity (92%) to 99mTc‐HDP bone scanning
demonstrating severe osteomyelitis of the left
for the detection of osteomyelitis. MRI can be used to temporomandibular joint.
detect changes, such as lytic areas, much earlier in the
course of disease than other imaging modalities, because
it provides greater definition of the medullary cavity. The more accurate than radiography for diagnosing infection,
signal changes seen on MRI, however, may be nonspe- because small accumulations of fluid around implants are
cific, and anything that causes edema or hyperemia, such easier to detect. In one study, ultrasonography was used
as fractures, tumors, and inflammatory processes, causes to diagnose osteomyelitis correctly in 30 of 32 cases,
signal changes similar to those seen with osteomyelitis. while radiography was accurate in only 10 of the 32
Furthermore, because of the strong magnetic field, MRI cases.82 Imaging fluid pockets in perpendicular planes
should not be used with metallic implants.15 Although coincides with irregular bony echoes; this allows location
MRI is good for detailing medullary involvement, it does and aspiration of the infected fluid, so that the organisms
not reveal cortical bone involvement like CT does. associated with the infection can be determined.
Ultrasonography can be an extremely helpful addition Deep aspiration of fluid accumulations should follow
to other imaging modalities.82 Ultrasonography may be ultrasonographic determination of location. A white
www.ajlobby.com
blood cell count of the aspirated fluid can be used to into the blood. In a study evaluating these biochemical
determine the serous or purulent nature of the aspirate. markers in rabbits with and without osteomyelitis, meas-
A diagnostic culture of the aspirated fluid should be per- urement of OC, BS‐ALP, and DPYR serum concentra-
formed for aerobic and anaerobic bacteria.103 The litera- tions could predict the presence of osteomyelitis with
ture suggests that fluid should be inoculated directly into 96% accuracy at four weeks.96 The use of these biomark-
broth, particularly commercial culture vials, to enhance ers for determining the presence of infection in the horse
bacterial growth and decrease culture turnaround may be extremely useful, economical, and accurate.
time.23,30,69 Alternatively, aspirated fluid can be placed Certainly, further studies in the horse are indicated to
on a swab and put into transport medium, which stabi- determine if their accuracy in the diagnosis of osteomy-
lizes the local pH and minimizes the growth of contami- elitis is similar to that in the rabbit.
nate bacteria, such as anaerobes, but does not possess An emerging trend in the study of orthopedic implant
the growth‐enhancement characteristics of broth. In the infection is the use of molecular assays, such as confocal
absence of fluid accumulations on ultrasonography microscopy and real‐time polymerase chain reaction
examination, an existing draining tract should be pre- (PCR)–based techniques, to examine the bacterial charac-
pared aseptically and a swab inserted for culture. The teristics of biofilm.98 Authors of some reports claim that
swab should be processed as described previously. In PCR‐based analyses for 378 bacteria can be used to
cases of septic arthritis with adjacent osteomyelitis, the identify microorganisms in samples in which standard
synovial fluid should be aspirated and a white blood cell microbiologic culture techniques have failed.59,101 Some
count, cytology, and total protein content measured. If criticism exists, however, that PCR may be too sensitive an
the synovial fluid white blood cell count is greater than assay, and may yield false‐positive results when no active
30 000 cells ul−1 and the total protein concentration is infection persists but DNA from nonviable bacteria may
more than 3.5–4.0 g dl−1, infection is present.6,7,65 still be present.98 Real‐time PCR tests are currently being
Cytology consistent with sepsis usually reveals mostly developed to detect bacterial RNA that only exists in live
neutrophils; occasionally, bacteria are observed on direct bacteria, thus eliminating false‐positive results.98
smears. Synovial fluid should also be cultured in an
attempt to determine the bacterial cause accurately.
In cases in which a diagnosis of infection is still sus- Traditional Treatments
pected but is not confirmed after these diagnostic proce- for Osteomyelitis
dures, a biopsy instrument such as a Michele trephine
can be used to obtain a sample of bone for histopatho-
logic examination as well as culture and sensitivity test-
Systemic Antimicrobial Therapy
ing. This may result in an accurate diagnosis and a The traditional systemic therapy for osteomyelitis
definitive bacterial culture, thereby aiding the clinician in involves appropriate intravenous antimicrobial drugs,
determining appropriate local and systemic antimicrobial together with improving the wound environment.24
treatment. In the case of osteomyelitis with involvement Before the advent of local and more innovative depot
of adjacent orthopedic implants, resolution often requires therapies, systemic antimicrobials were the cornerstone
removal of the implant as well as the tissue (inflammatory of treatment for osteomyelitis. Local therapy may even-
tissue, fibrin, and/or fluid) surrounding it, all of which tually supplant systemic therapy. Systemic antimicrobi-
should be cultured, as these materials and tissues often als alone are often ineffective for treating horses with
consistently have an associated bacterial glycocalyx layer severe or chronic osteomyelitis or synovial infections.6
which harbors the bacteria responsible for infection. Broad‐spectrum antimicrobials should be used as proph-
Currently, serum biomarkers are being evaluated for ylaxis before orthopedic surgery or to treat osteomyelitis
their use in the diagnosis of osteomyelitis. Various bio- until the results of culture and sensitivity patterns are
chemical markers of bone metabolism, including osteoc- known. Two studies analyzing the sensitivity patterns of
alcin (OC), bone‐specific alkaline phosphatase (BS‐ALP), common bacteria cultured from horses with osteomyeli-
and deoxypyridinoline (DPYR), have been evaluated.96 tis revealed that the combination of cephalosporin and
OC is a specific product of osteoblasts and is associated amikacin provides the broadest coverage.66,95 Adequate
with bone mineralization.47,70 A fraction of an OC mol- coverage of both gram‐positive and gram‐negative bac-
ecule is released into the blood during the incorporation teria is paramount, as a recent study of postoperative
of OC into bone in bone formation. BS‐ALP is an osteo- infections in horses undergoing long bone fracture repair
blast enzyme that is thought to play a role in the forma- revealed that 40% of infections were due to mixed bacte-
tion and mineralization of bone matrix.81,105 DPYR is a rial populations.2
molecule associated with bone resorption.70 When bone Penicillin (or cefazolin) and gentamicin in combina-
is resorbed, collagen is degraded and DPYR is released tion are commonly used to treat osteomyelitis until
www.ajlobby.com
definitive culture and sensitivity results are known. detachment from periosteum and surrounding soft tis-
Benefits of the combination are that it provides a broad sues.103 At the time of debridement, grossly affected tis-
spectrum of activity, is not cost prohibitive, and has sue should be obtained for culture and sensitivity testing
minimal side effects. Furthermore, the increased bacte- to assist the clinician in choosing the most appropriate
rial kill and reduced renal toxicity of once‐daily dosing of antimicrobial drug.
gentamicin make it more efficacious than administering
doses two or three times a day.37 Amikacin is often simi-
Bone Graft
larly administered at this frequency. Oral antimicrobials
are commonly used as follow‐up therapy after the infec- Bone grafts have been used in bone surgery for several dec-
tion has been controlled with parenteral antimicrobials. ades to augment bone repair, speed healing of complicated
In general, parenteral antimicrobials are recommended fractures, and promote healing of nonunions and infected
for a minimum of 7–10 days or until the osteomyelitis is fractures. Autogenous bone grafts can serve two major
controlled. To prevent relapses, oral antimicrobials are functions in treating osteomyelitis: they have osteogenic
frequently instituted after that time because of their ease potential, and they can provide mechanical support.5,9,38,40
of administration, modest cost, and relative efficacy after Bone grafts assist healing in cases with osteomyelitis by
the infection has abated. Oral antimicrobials are usually three different mechanisms: osteogenesis, osteoinduction,
continued for approximately one month or longer, and osteoconduction. Cancellous bone has osteogenic
depending on the response to therapy, specific drainage potential, because it has a much greater volume of viable
techniques, and severity of infection.83 More studies are cells compared with cortical bone. These cells begin form-
needed to determine the proper timing for discontinua- ing new bone when implanted into debrided defects. The
tion of antibiotics after resolution of infection. osteoinduction capabilities of cancellous bone are attribut-
The duration of prophylactic antimicrobial admin- able to the mesenchymal precursor cells, which differenti-
istration remains controversial.8,51 For routine ortho- ate into preosteoblasts and then into osteoblasts. Proteins,
pedic procedures, prophylactic antimicrobials should such as bone morphogenetic protein (BMP) and trans-
only be given 1 hour before surgery and up to 24 hours forming growth factor‐β (TGFβ), are secreted from the
after surgery.26 No difference has been noted if antimi- graft and induce the migration of additional cells as well as
crobials are continued for 3 days or stopped 24 hours the differentiation of mesenchymal cells within the graft.
after surgery.26 Nevertheless, antimicrobial therapy is This osteoinduction occurs within the first weeks of bone
extended if implants are used or the surgery is consid- grafting. The osteoconductive capabilities of cancellous
ered clean‐contaminated. bone include ingrowth of capillaries, perivascular tissue
formation, and osteoprogenitor cell migration.38,104
Cancellous bone provides a scaffold that mechanically
supports the tissue. In contrast to osteoinduction, osteo-
Curettage and Implant Removal conduction lasts for several months with cancellous grafts,
Osteomyelitis is often considered a surgical disease. and may last for many months to years with cortical bone
Thorough debridement of bone and soft tissue to remove grafts, depending on their size.60 The benefits of cancellous
necrotic debris, purulent material, and avascular bone is bone grafts in treating osteomyelitis are numerous, and
imperative for successful treatment.24 Necrotic bone acts in the horse there are abundant sources of autogenous
as a chronic focus of inflammation and encourages puru- bone in the ilium, sternum, and proximal tibia.60
lent drainage until removed. When a biofilm is present The fourth coccygeal vertebra has been reported as an
(which is almost always the case with osteomyelitis), alternative site of bone graft collection in the horse.64
even a 5‐ or 6‐log kill of bacteria with antibiotics will still The authors of this study also quantified the number of
result in a repopulation of bacteria, and although these osteogenic cells and the percentage of osteoprogenitor
mostly are phenotypically similar, they are often resistant cells within the osteogenic population of the fourth coc-
to the antibiotic in the presence of a nidus.29 Granulation cygeal vertebra, tibial periosteum, sternum, and tuber
tissue frequently forms around necrotic bone, which coxae.64 The tuber coxae, coccygeal vertebra, and perios-
prevents resorption and impedes healing by isolating the teum were the best sites for osteogenic harvest, and the
bone from a healthy vascular supply.49 Wound debride- tuber coxae and periosteum yielded the greatest popula-
ment should be combined with appropriate stabilization tion of osteoprogenitor cells.64 Another report described
of unstable fractures or removal of metallic implants. the technique of harvesting cancellous bone from the
Stable fractures can heal in the face of infection. proximal humerus in horses; however, one of eight
Determining whether bone is viable may be challenging. horses sustained a catastrophic fracture on recovery,
The decision to retain or discard a bone fragment should which suggests that this site may be unsatisfactory for
be based on its size, importance to stability, and extent of cancellous bone collection.43
www.ajlobby.com
Recently, culture‐expanded bone marrow–derived volume of fluid surrounding the cement, antimicrobial
mesenchymal stem cells (MSCs) have been studied, both concentration placed in the PMMA, and diffusion
for augmenting fracture repair and for decreasing osteo- properties of each antimicrobial.14,44,100 Antimicrobial
myelitis in the horse.63 No significant effects have been elution rates of AI‐PMMA are directly proportional to sur-
observed in preliminary studies, but further research face area. Therefore, placing small rough beads in wounds
will determine the efficacy of this approach. Genetically is preferred over smooth beads, because small rough
modified bone marrow–derived MSCs overproducing beads have a large surface area per volume, and a sphere
BMPs may be the key to driving these cells to signifi- has the greatest surface area per volume. AI‐PMMA is most
cantly contribute to fracture healing.115 effective when formed into spheres before implantation.
The amount of antimicrobial eluted from bone cement
is directly proportional to the amount loaded into the
Innovative Treatments bead. Therefore, the maximal concentration of antimi-
for Osteomyelitis in the Horse crobial should be used in the implants to achieve the
highest local antimicrobial concentrations. However, if
Antibiotic-laden Polymethylmethacrylate the “undefined” maximum concentration of an antimi-
(PMMA) Beads crobial is exceeded during AI‐PMMA preparation, it
The use of antimicrobial‐impregnated polymethylmeth- seems to prolong, or inhibit, the “setup” time and lower
acrylate (AI‐PMMA) implants for the prevention and treat- the quality of the bone cement. Therefore, concentra-
ment of osteomyelitis in horses has drastically improved tions previously reported to elute successfully are best to
the success rate of treating osteomyelitis. Several case stud- use. A rule of thumb that the author currently uses is 5%
ies in horses testify to the strides that have been made in of the weight of the PMMA (i.e., 0.5 g amikacin for 10 g
managing osteomyelitis.45,94,99,100 In the 1980s, many studies PMMA). In general, a ratio of 1:10 antimicrobial:PMMA
reported the successful prevention and treatment of osteo- powder should not be exceeded.48
myelitis using AI‐PMMA.71,102 Since then, a steady increase The combination of antimicrobials in PMMA may also
in the use of AI‐PMMA in human and animal patients has enhance or inhibit elution of the antimicrobial. For
occurred.100 Implantation of AI‐PMMA results in high local example, in a study in which tobramycin and oxacillin
concentrations of antimicrobials for prolonged periods.12,14 were combined in PMMA, the elution of oxacillin was
The slow local elution of antimicrobials can result in con- increased, but that of tobramycin was decreased com-
centrations in wound fluid of up to 200 times that obtainable pared with when they were used separately.102 Recently,
with systemic administration of the same antimicrobial. Watts et al. reported that the combination of ticarcillin
Antimicrobial concentrations above the minimum inhibi- and amikacin reduced the antibiotic elution of both anti-
tory concentration (MIC) can last for up to 80 days after biotics from resorbable bone cement when combined,
implantation.28,51,106 The distinct advantage of this form of and that these antibiotics should not be used together in
antibiotic prophylaxis and treatment is that serum concen- this medium.107 This is not the case for all antimicrobial
trations do not reach toxic levels, despite high wound con- combinations. Therefore, the clinician beginning to use
centrations of antimicrobials after bead implantation.14,28,51 AI‐PMMA should be familiar with the antimicrobial
Furthermore, this method of treatment reduces, and some- combinations documented to elute successfully.
times eliminates, the need for systemic therapy. The result- Culture results are sometimes used to determine anti-
ing decrease in the risk of drug toxicity and the drastic microbial selection, but organisms have often not yet
decrease in costs incurred in treating osteomyelitis in the been cultured, or AI‐PMMA is being used prophylacti-
horse are noteworthy. Although variable, up to 80% of horses cally. In these situations, a broad‐spectrum antimicrobial
have had successful resolution of osteomyelitis after local (alone or in combination) that has high water solubility,
depot antimicrobial therapy, which is a substantial improve- low tissue toxicity, and is stable at temperatures up to
ment compared with systemic treatment responses.14,45 100 °C should be chosen.1,33,79
Prophylactic depot antibiotic use in humans has resulted in Gentamicin‐impregnated PMMA has been the focus
as much as a 34% decrease in infection rates.14,114 of much of the literature because of gentamicin’s broad‐
Antimicrobials are eluted from PMMA in a bimodal spectrum bactericidal activity, as well as its water‐soluble
pattern.100 Rapid elution of the antimicrobial usually takes and heat‐stable characteristics. Although this remains a
place within the first 24 hours.14,44 The subsequent elution good antimicrobial choice, there are now many different
rate is slower and, depending on the antimicrobial and antimicrobials that reportedly have good elution rates
bone cement used, detectable amounts of the drug may be from PMMA.11,25,114 Table 48.2 lists some antimicrobials
released weeks to months after implantation. that are reportedly viable options to use in PMMA.
There are many factors that affect the elution rate of Amikacin’s broader coverage and greater efficacy in treat-
antimicrobials from PMMA. Those factors include the ing equine orthopedic infections compared with gen-
type and porosity of PMMA, surface area of the bead, tamicin have made it a popular antimicrobial choice.66
www.ajlobby.com
Table 48.2 Antibiotics and their combinations that may be appropriate for use with polymethylmethacrylate.
Antibiotics that elute well Antibiotics that have minimal Antibiotic combinations that Antibiotic combinations that have a
from PMMA elution from PMMA elute well from PMMA negative effect on elution
Amikacin Ceftiofur (<MIC for 10 days) Vancomycin/amikacin Tobramycin/oxacillin

Gentamicin Polymyxin Ba Cefazolin/amikacin Amikacin/ticarcillin
Tobramycin Tetracyclinea Cefazolin/metronidazole
Amoxicillin Chloramphenicola Metronidazole/gentamicin
Ciprofloxacin
Imipenem
Amoxicillin
Ticarcillin
Cefazolin
Clindamycin
Vancomycin
Erythromycin
Metronidazole
Fluoroquinolones
MIC, minimum inhibitory concentration; PMMA, polymethylmethacrylate.

a
Not sufficiently heat stable to retain activity during the exothermic hardening process.
It should be noted that liquid antimicrobial prepara-

tions are efficacious in PMMA. Powdered formulations
of antimicrobials were previously reported to be supe-
rior to liquid formulations.100 Elution was optimized,
however, when a crystalline formulation rather than a
fine powder was used.27
Preparation of AI‐PMMA is easy and can be per-
formed at or before surgery, and implanted or sterilized
for later use. PMMA is a high‐density acrylic formed by
combining a fluid monomer and powdered polymer
(Figure 48.4). When an antimicrobial is added, the anti-
microbial becomes suspended in the cement as it hard-
ens.14 Elution rates vary according to the various brands
of PMMA. Common brands used with reportedly good
elution rates are Surgical Simplex P (Howmedica,
Rutherford, NJ, USA) and Palacos® R (Richards Medical, Figure 48.4 Polymethylmethacrylate bone cement. The powder
Philadelphia, PA, USA; or Zimmer Biomet, Warsaw, IN, (polymer) usually comes in 40 g packets. The fluid (monomer) is
USA). Palacos R can be obtained already containing gen- most often packaged in a glass vial in appropriate volume to
catalyze reaction of the entire pack of powder. Source: Image from
tocin (Palacos R+G). Typically, polymer (10 g) is placed
Goodrich and Nixon 2004.39
into a plastic mixing bowl, and liquid monomer is added
according to the manufacturer’s directions, along with
the crystalline form of antimicrobial. The components Implants not used immediately can be ethylene oxide
are thoroughly mixed until the mixture becomes paste- gas‐sterilized for storage. A potential loss in antimicro-
like (Figure 48.5). The mixture is placed into a bead mold bial potency from steam autoclaving makes ethylene
(Instrumentation and Model Facility, University of oxide gas the preferred sterilization method.34,113 Gas‐
Vermont, Burlington, VT, USA) with a suture in the sterilized beads should be aerated for approximately
center (Figures 48.6 and 48.7), or the cement is mixed 24 hours at room temperature before use.
into beads or molded into cylinders by hand (Figure 48.8). It is important to note that the addition of amounts
The approximate time to hardening is 5–10 minutes. greater than 10% of the PMMA (i.e., any antimicrobial at a
www.ajlobby.com
Figure 48.5 The polymer, monomer, and antibiotic are mixed

until they have a paste‐like consistency. Source: Image from
Figure 48.8 Antibiotic‐impregnated polymethylmethacrylate can
be molded into cylinders or spheres by hand. Source: Image from
rate of 4.5 g or more to 40 g PMMA) weakens the biome-

chanical properties of the PMMA. The compressive and
tensile strengths are inferior when large amounts of the
antimicrobial are used, which is important to remember
when the PMMA is used to lute a plate or metal implant.34,113
Some controversy exists regarding the removal of
AI‐PMMA implants. Some surgeons prefer to remove
the implants, whereas others suggest that beads only be
removed if they become infected. Figures 48.9 and 48.10
are radiographs of implants placed at the time of fracture
repair and two years later, respectively. No complications
Figure 48.6 The paste‐like antibiotic‐impregnated
polymethylmethacrylate is smeared with a spatula into the bead were associated with the beads, the mare was sound, and
mold that has a suture placed in it. Source: Image from Goodrich removal of the implants was not necessary. The author
and Nixon 2004.39 only anticipates removal of beads if they are placed in an
infected wound that is healing by second intention
(Figure 48.11). If removal is anticipated at the time of
bead placement, the surgeon should be aware that many
small beads attached to a suture may be easier to remove
compared with beads placed randomly into a wound.
Few complications have been associated with the use
of AI‐PMMA. Allergic reactions have not been reported.
The most significant complications have been soft tissue
damage during removal and the formation of fibrous
connective tissue complicating removal. Furthermore,
AI‐PMMA should not be placed in joints because of its
abrasive nature.32 The widespread use of AI‐PMMA by
orthopedic surgeons represents the general belief that
the benefits from high local levels of antimicrobials and
minimal systemic side effects outweigh the minimal risk
of complications associated with these implants.
Figure 48.7 Once the antibiotic‐impregnated
polymethylmethacrylate hardens, the mold can be unscrewed In conclusion, AI‐PMMA is invaluable in treating and
and the string of multiple beads can be placed into a wound or preventing bone infections. Infection rates in humans with
along a plate. Source: Image from Goodrich and Nixon 2004.39 grade III open fractures decreased from 42.9% to 8.7% with
www.ajlobby.com
Figure 48.10 Two years later with the fracture healed, the beads
can still be visualized. The filly is sound, and the beads appear to
be quiescent. Removal is not necessary.
Figure 48.9 An open fracture in a five‐month‐old filly repaired

with two dynamic compression plates and multiple strands of
sulfate hemihydrate was first weighed into aliquots and
amikacin‐impregnated polymethylmethacrylate beads. dried by baking for four hours at 200 °C.89 Dried calcium
sulfate hemihydrate (20 g) was then combined with
the addition of AI‐PMMA.14 AI‐PMMA implants should gentamicin sulfate (5 ml) and phosphate‐buffered saline
never be used as the sole treatment of bone infection, but (PBS; 3 ml) in a mixing bowl. The POP–gentamicin
should always be used in addition to adequate surgical slurry was then poured into a 20 ml syringe and injected
debridement. Proper use of AI‐PMMA can mean greater into a bead mold with a #2 PDS® suture (Ethicon,
surgical success in preventing and managing osteomyelitis, Somerville, NJ, USA) in place.89 The bead mold, mixing
decreased cost, and fewer episodes of systemic toxicosis. vessel, stirrer, gentamicin, and PBS were all chilled in a
Furthermore, the use of AI‐PMMA facilitates management freezer before making the beads. The beads were left at
of dead space and is more convenient than long‐term par- room temperature overnight and then gas‐sterilized with
enteral administration of antimicrobials. ethylene oxide and stored at room temperature for five
months before use.89 Neither gas sterilization nor stor-
Antibiotic-laden Plaster of Paris age negatively affected the elution of antimicrobials,89
Plaster of Paris (POP), consisting of calcium sulfate which was consistent with other reports.11,16,20
hemihydrate, has been used for decades for local delivery The major technical disadvantage of using these beads
of antimicrobials in cases of orthopedic infection. Its is the necessity of preparing, sterilizing, and aerating them
advantages are numerous and include bioabsorbability, before surgery. However, the high antimicrobial elution
biocompatibility, availability, and affordability.19,20,57,89 rate from POP in the first 48 hours and the complete
Studies assessing the elution of antimicrobials from POP absorption of the beads, combined with their purported
reveal that antimicrobial release actually surpasses that osteoconductive and osteoinductive capabilities, make
of PMMA in the first 24–48 hours of implantation.11,89 these beads an attractive alternative to AI‐PMMA.89
Elution is so rapid, however, that antibiotic concentration
rapidly drops below the MIC after 48 hours.57 Therefore, Other Biodegradable Antibiotic Delivery
POP’s greatest efficacy in preventing and treating osteo- Compounds
myelitis is within the first two days. If long‐term elution Intense research to find other biodegradable materials
is desired, PMMA remains a more viable option, or a that effectively deliver antimicrobials to bone is being
combination of POP and PMMA could be considered. conducted, and various materials have shown promise in
In a publication by Santschi and McGarvey,89 the animal models of osteomyelitis.4,18,31,46,80,87 Some of
process of preparing POP beads was described. Calcium these materials include carbonated calcium phosphate
www.ajlobby.com
Figure 48.11 Osteomyelitis of the distal

(A) (B) radius. (A) Preoperative radiograph showing
metaphyseal lysis and soft tissue swelling. (B)
After debridement and antibiotic‐
impregnated polymethylmethacrylate bead
insertion.
(Norian™, DePuy Synthes, West Chester, PA, USA),

hydroxyapatite (HAP), b‐tricalcium phosphate (b‐
TCP), poly‐lactic acid (PLA), polyglycolic acid (PGA),
and polylactide‐co‐glycolide (PLGA). The advantages
that these materials bring include prolonged systemic
antimicrobial therapy for four to six weeks, bioresorba-
bility, biocompatibility, excellent mechanical properties,
and positive effects on new bone formation.87 Although
promising for the future treatment of osteomyelitis,
these materials presently remain unavailable or cost pro-
hibitive for use in the equine patient.
Intravenous and Intraosseous
Regional Limb Perfusion Figure 48.12 A bone cannula for intraosseous perfusion that was
The use of regional limb perfusion to treat osteomyelitis originally manufactured to administer fluids to pediatric patients
is available from Cook (Bloomington, IN, USA).
in the limbs of horses has proven to be an effective,
affordable, and convenient route of antimicrobial drug
delivery.74,110–112 This procedure has increasingly been given systemically.93 Extrapolating that principle to treat
used by equine orthopedic surgeons to treat and prevent orthopedic infections has resulted in tissue antimicro-
bone and synovial infections. The technique uses an bial concentrations well above the MIC.72,91,109–111 This is
extracorporeal circuit, such as an isolated artery or vein, imperative when treating infected tissues, such as bone,
which supplies an area of tissue to which the antimicro- where the inflammatory process causes vascular throm-
bial is administered. Alternatively, the medullary space bosis, necrosis, and a biofilm layer that inhibits the deliv-
in the bone can be utilized by inserting a cannulated ery of systemically administered antimicrobials.3,62
bone screw6 or a commercial device specially manufac- An Esmarch or pneumatic tourniquet is applied to the
tured to deliver fluids to human neonates (Figure 48.12). affected limb proximal to the infection site to occlude the
Intravenous or intraosseous antimicrobials are delivered superficial vascular system. The antimicrobial solution is
under pressure distal to a tourniquet.67,88 As perfusate then injected through a catheter or butterfly needle
enters the venous system, it distends the vasculature, under pressure. The antimicrobial should be diluted in
which promotes perfusate diffusion into local tissues.91 saline (30–60 ml) to facilitate an increase in pressure via
Regional limb perfusion was first used to deliver anti- a volume effect and to minimize local tissue toxicity.
neoplastic drugs that resulted in toxic side effects when Injection under pressure distends the venous vascula-
www.ajlobby.com
ture, allowing diffusion into the tissue distal to the tour- the distal radius region and measurement of antibiotic
niquet. A subtraction radiography study by Whitehair levels in the metacarpophalangeal joints.52 The pneumatic
and et al.110 showed that perfusate injected into the med- tourniquet resulted in the highest antibiotic concentration
ullary cavity of the metacarpus exited through the epi- in the synovial fluid, followed by wide rubber and then nar-
physeal vein and entered the adjoining synovial venous row tourniquets, which were least effective (antibiotic levels
system. Figures 48.13–48.16 illustrate the technique and not achieving efficacious levels). Examples of each are pro-
the tissue perfusion that occurs when radio‐opaque dye vided in Figure 48.17. Additionally, when tourniquets are
is injected under pressure. The tourniquet should be applied, a gauze roll or folded gauze squares should be
maintained for a minimum of 30 minutes to allow com- placed under the tourniquets in areas between boney pro-
plete diffusion of the antimicrobial solution. trusions and tendons/or ligaments (Figure 48.17).
Mattson et al.62 used 99mTc pertechnetate and scinti- Because veins are more accessible and an intravenous
graphic imaging to show that horses regionally perfused catheter is easier to maintain and less invasive than an
using a vein or an intramedullary cavity had no differ- intramedullary device, intravenous regional perfusion is
ence in limb perfusion. Butt et al.13 confirmed these find- used more commonly. Intramedullary regional perfusion
ings by comparing antimicrobial concentrations in joints is a logical alternative, however, when vessel morbidity
of limbs perfused via an intravenous or an intramedul- associated with limb swelling and infected tissues is a con-
lary route. In another study, however, amikacin concen- cern. A recent case report revealed osteomyelitis and oste-
tration in the tibiotarsal joint was compared after onecrosis in a horse after intraosseous perfusion into the
amikacin (1 g) was diluted in lactated Ringer’s solution proximal phalanx (for treatment of navicular osteomyeli-
(56 ml) and administered by intravenous or intraosseous tis) with gentamicin at a dose of 3 g given twice, 24 hours
regional perfusion (distal portion of the tibia).93 In this apart.75 Catastrophic breakdown and subsequent eutha-
study, intravenous perfusion resulted in an amikacin nasia resulted, indicating the potential for gentamicin tox-
concentration up to three times higher in the synovial icity when given by this route and dosage.75
fluid compared with intraosseous perfusion.93 Higher concentrations of antimicrobials in the horse
Tourniquet type also appears to be of major importance. are reached using regional perfusion rather than systemic
In a study by Levine et al., narrow rubber, wide rubber, and dosing, including antibiotics such as cefazolin, ampicillin,
pneumatic tourniquets were compared by application to amikacin, and potassium penicillin.76,111 No local toxic
Figure 48.13 An Esmarch bandage is used as a tourniquet to Figure 48.14 A xeroradiograph taken 10 seconds following
restrict blood flow. A 20‐gauge catheter in the palmar digital vein injection with a 40 ml solution of radiopaque dye under pressure.
infuses antibiotic solution. Source: Image from Palmer and Hogan Excellent perfusion of the venous and arterial vessels is occurring.
1999,74 with permission. Source: Image from Palmer and Hogan 1999,74 with permission.
www.ajlobby.com
Figure 48.15 A xeroradiograph taken 1 minute after injection Figure 48.16 A xeroradiograph taken 15 minutes later
with a radiopaque dye. The dye is beginning to exit the vascular demonstrating diffusion of the dye throughout the soft tissues
space and diffuse into the perivascular tissue. Source: Image from distal to the tourniquet. Most of the dye has completely diffused
Palmer and Hogan 1999,74 with permission. out of the vessels. Source: Image from Palmer and Hogan P. 1999,74
with permission.
effects were reported.76,111 To date, the only reported subchondral bone were compared after the administration
local toxic effect associated with regional perfusion of gentamicin (1 g) by intraarticular injection or regional
involved enrofloxacin.77 In that study, three of seven limb perfusion (1 g in 20 ml). No difference was noted
horses developed vasculitis with the administration of in subchondral bone antimicrobial concentrations.109
1.5 mg kg−1 of enrofloxacin. It is theorized that concen- Furthermore, concentration of gentamicin in subchondral
trated doses of the vehicle in this antimicrobial can be bone remained above the MIC for up to eight hours
detrimental to tissues. A study reporting on the local when administered by regional intravenous perfusion.
concentrations of regionally administered enrofloxacin Alternatively, in the study by Mattson and coworkers, gen-
did not report an associated toxicity, however.76 tamicin (2.2 mg kg−1) was administered in sterile saline
Appropriate dose rates for most of the common locally (0.9% NaCl) at a rate of 1 ml kg−1 and injected, under pres-
administered antimicrobials have not been established. sure, into the midmetacarpal bone with a tourniquet
This remains one of the unknowns associated with this applied at the proximal metacarpus.61 Using this technique,
technique. Some authors use one‐third of a systemic daily gentamicin concentrations attained in the bone reached
dose of gentamicin and amikacin, whereas others use a full 2–6 times the MIC for up to 36 hours for some locations of
single systemic dose for ampicillin sodium and potassium the metacarpal bone. The authors recommended using this
penicillin.74,111 A dose of cefazolin based on the approxi- dose once every 36 hours to allow the antimicrobial con-
mate weight of the perfused limb was used in another centrations to drop below the level at which adaptive resist-
study.36 Still other clinicians recommend diluting one sys- ance of bacteria can take place. Table 48.3 lists the current
temic dose with saline to a volume of 30 or 60 ml before recommendations of dosages of antibiotics administered
administration.6 Many of the uncertainties regarding dos- via regional limb perfusion based on measured concentra-
age come from the unknown pharmacokinetics of regional tions of antibiotics from either synovial fluid and/or tissues.
drug delivery, and more clinical trials are necessary. The Table 48.4 lists reported antibiotic doses administered
most conclusive equine studies on this subject to date are regionally with apparent efficacy, but with no supporting
those by Mattson et al.61 and Werner et al.109 In the latter pharmacokinetic data of levels within the joint or surround-
study,109 antimicrobial concentrations in joint fluid and ing tissues.
www.ajlobby.com
(A) (B) (C)
Figure 48.17 Various tourniquets that have been described for regional perfusion. (A) Pneumatic tourniquet that has been placed just
above the carpus. These tourniquets are the most effective method of delivering high concentrations of antibiotics locally. (B) An Esmarch
tourniquet applied to just above the carpus is also an effective method; however, it is not as effective as a pneumatic tourniquet. (C) A
narrow red rubber tubing tourniquet. This method should not be utilized, as resulting local concentrations of antibiotics in tissues are low
(often this technique does not result in the minimum inhibitory concentration of antibiotics).
Table 48.3 Recommended antibiotics for regional limb perfusion Table 48.4 Antibiotics and dosages administered via regional
or intraosseous regional perfusion from studies revealing efficacy limb perfusion with apparent efficacy, but with no supporting
(levels above minimum inhibitory concentration for >24 hours) pharmacokinetic data of levels within the joint or surrounding
in tissues or synovial fluids. tissues.
Drug Dose Studies Complications Drug Dose Study
61,110,114 111
Gentacin 1 g 3 g intraosseous resulted K‐Pen 10 million units
in osteonecrosis of the 111
Ampicillin 9 g
proximal phalanx75
84
13,52,93 Timentin 1 g
Amikacin 500 mg/1 g
50
25 g Erythromycin 1 g
78
Ceftiofur 2 g
85
Vancomycin 300 mg
Enrofloxacin 600 mg 77
3 of 7 horses sustained administration of intravenous and intraosseous regional
vasculitis perfusion in standing horses and sedated foals with mini-
mal objection from the patients (Figures 48.18 and 48.19).
In patients with chronic osteomyelitis (and most
In both regional limb perfusion techniques, clinicians implant‐related osteomyelitis cases are chronic), the
need to attain adequate and constant tourniquet pressures, preservation of the vessels of the limb is crucial. Methods
preferably using a pneumatic tourniquet, because inappro- that can be utilized are (i) the use of small‐gauge needles;
priate tourniquet application can lead to inadequate con- (ii) the use of indwelling catheters in vessels; and (iii) the
centrations of antimicrobials in the target tissues (see application of 1% diclofenac sodium liposomal cream at
previous information on tourniquet variability). This tech- the site of vessel puncture following regional limb perfu-
nique can be performed in an anesthetized or standing sion.50,53 When repeated puncture of the vessel occurs
horse. Earlier reports claimed that general anesthesia was using butterfly catheters, often loss of that vessel results.
necessary;110 however, the author has performed repeated Butterfly catheters of 27 gauge and smaller reduce vessel
www.ajlobby.com
(A)
(B) (C)
Figure 48.18 A standing and minimally sedated patient receiving

regional limb perfusion through a catheter in the cephalic vein.
inflammation and increase the potential for multiple

regional limb perfusions. Indwelling catheters have also
been evaluated in 18 horses,50 and reported to be main-
tained for seven days. In some of the cases, however,
complications occurred including local inflammation,
lameness, thrombophlebitis, and one severe tissue reac-
tion to erythromycin, although most of these complica-
tions resolved within seven days. The use of 1% diclofenac
sodium liposomal cream was also reported following
regional limb perfusion of 2.5 g of amikacin.53 Figure 48.19 (A) Hindlimb of a moderately sedated foal receiving
Ultrasonography revealed significantly decreased tissue regional limb perfusion through the saphenous vein distal to an
Esmarch tourniquet. (B) Dorsoplantar and (C) lateral radiographs
swelling and vasculitis following diclofenac application.
of the limb receiving the local perfusion. The distal physis has
moderate focally septic physitis.
Managing Osteomyelitis by Implant
Removal and Local Therapies and surrounding tissue. A comprehensive examination
When implants or the bone surface that implants are and application of local therapies should proceed without
applied to become infected, there must be a clinical deci- wasting time deliberating whether infection is present
sion regarding the need to: or not. The sooner the correct antibiotics are instituted
locally, the more probable it is that the infection can be
1) attempt to treat using aggressive local therapies;
overcome without implant removal. If resolution of
2) debride the osteomyelitic bone and reapply an implant; or
the infection does not occur with local aggressive
3) debride the bone and remove the implant completely.
therapies, then the clinician may be faced with aggres-
Often the decision is not immediately obvious and sive debridement and implant replacement, or implant
the clinician must balance the risk of destabilizing the removal and other forms of bone stabilization such
bone by removing the implant too early with the risk of as transfixation cast application or other types of coap-
ongoing infection that will ultimately destroy the bone tation (Figure 48.20).
www.ajlobby.com
(A) (B) (C) (D) (E)
(F) (G) (H) (I)
Figure 48.20 An adult with an effectively repaired fetlock breakdown injury that has developed infected implants. The implant infection
necessitated removal of hardware, wound debridement, coaptation, antibiotic‐impregnated bead placement, and finally transfixation cast
application. These measures resulted in a positive outcome and preservation of the horse. (A, B) Initial implant placement for arthrodesis.
(C, D) The implants became infected; the wound was debrided and the hardware replaced. (E, F) Removal of the hardware and antibiotic‐
impregnated polymethylmethacrylate placed within the wound. (G) The appearance of the distal limb following ongoing infection and
debridement. (H, I) A transfixation pin cast and more antibiotic‐impregnated beads are placed to provide greater stabilization and higher
local antibiotic concentrations. (J, K) Radiographic appearance of the limb following removal of the transfixation pin cast. The
osteomyelitis is resolving and there is stability of the fetlock joint. (L) Appearance of the limb at resolution of infection. (M) Final outcome.
Source: Images courtesy Dr. Dean Richardson.
www.ajlobby.com
(J) (K) (L) (M)
Short‐ and Long‐term Results review by Ahern et al., surgical times greater than 180 min-
of Ongoing Osteomyelitis utes resulted in a significantly greater postoperative infec-
tion rate and significantly reduced rate of discharge from
It has been stated that “the best treatment for disease is pre- the hospital, when compared to surgical times less than 90
vention,” and this rule applies completely to osteomyelitis, minutes, and 90 minutes to 180 minutes, respectively.2
especially implant‐associated osteomyelitis. The complica-
tions of osteomyelitis include considerable increase in Conclusion
expense, decreased athletic performance, angular limb
deformity of the contralateral limb (in young horses), Antimicrobial delivery systems, such as AI‐PMMA, anti-
reduced cosmesis, support limb laminitis, and, commonly, microbial‐impregnated POP, and intravenous or intraos-
euthanasia. A review of postoperative infections in equine seous regional limb perfusion, have revolutionized the
long bone fractures and arthrodeses reported that repairs prevention and treatment of osteomyelitis. It is impera-
without postoperative infections were 7.25 times more tive for the equine orthopedic surgeon to use these more
likely to be discharged from the hospital.2 There is nothing aggressive treatments and preventative strategies to
more disheartening to the equine orthopedic surgeon than inhibit infection. New implants such as locking com-
to have the most elegant fracture repair or arthrodesis pro- pression plates provide greater stability to equine bones
gress to osteomyelitis and implant infection. This author and may decrease the incidence of osteomyelitis, or at
routinely uses regional limb perfusion with broad‐ least the mortality rate associated with osteomyelitis,
spectrum antibiotics before beginning the procedure to since bone can heal in the presence of infection, pro-
maximize the level of antibiotics present prior to making an vided that the fracture is stable. Furthermore, reports
incision. Although no studies exist to determine if this of closed, noninvasive fracture repair also suggest a
reduces postoperative infection rates, clinical impression decreased incidence of postoperative infection, and this
suggests that this may be an effective approach. Copious technique for fracture repair may allow sufficient stabil-
lavage with antibiotic solutions intraoperatively may also ity to be achieved under conditions that lessen the risk of
help to minimize bacterial contamination. wound contamination.2 New reports emerge frequently
An important goal for the equine orthopedic surgeon is to describe antimicrobial compatibility with delivery sys-
to strive for the shortest possible surgical time. Many equine tems and use of proper doses, which requires clinicians
fracture repairs can be complicated, and the need for a per- to stay current on the literature. Advances in the last
fect repair to maximize weight‐bearing capacity is para- decade have contributed a great deal to our ability to
mount. However, the surgeon must keep in mind that treat osteomyelitis and implant infection, which previ-
“more time equals more tissue trauma,” and longer surgical ously commonly ended in failure of the repair or loss of
times result in a higher incidence of infection. In the case the horse from the complications of osteomyelitis.
www.ajlobby.com
References
1 Adams, K., Couch, L., Cierny, G. et al. (1992). In vitro 16 Cook, V.L., Bertone, A.L., Kowalski, J.J. et al. (1999).
and in vivo evaluation of antibiotic diffusion from Biodegradable drug delivery systems for gentamicin
antibiotic‐impregnated polymethylmethacrylate beads. release and treatment of synovial membrane infection.
Clin. Orthop. Relat. Res. 278: 244–252. Vet. Surg. 28: 233–241.
2 Ahern, B.J., Richardson, D.W., Boston, R.C., and Schaer, 17 Creutzig, H. (1976). Bone imaging after total
T.P. (2010). Orthopedic infections in equine long bone replacement arthroplasty of the hip joint. A follow‐up
fractures and arthrodeses treated by internal fixation: with different radiopharmaceuticals. Eur. J. Nucl. Med.
192 cases (1990–2006). Vet. Surg. 39: 588–593. 1: 177–180.
3 Anwar, H., Strap, J.L., and Costerton, J.W. (1992). 18 Da Costa Gomez, T.M. and Taga, E.M. (2001). Rabbit
Kinetic interaction of biofilm cells of Staphylococcus bone marrow response to bovine osteoinductive
aureus with cephalexin and tobramycin in a chemostat protein and anorganic bovine bone. Int. J. Oral Myol.
system. Antimicrob. Agents Chemother. 36: 890–893. 16: 799–808.
4 Artzi, Z., Givol, N., Rohrer, M.D. et al. (2003). 19 Dacquet, V., Varlet, A., Tandogan, R.N. et al. (1992).
Qualitative and quantitative expression of bovine bone Antibiotic‐impregnated plaster of Paris beads. Trials
mineral in experimental bone defects. Part 2: with teicoplanin. Clin. Orthop. Relat. Res. 282:
morphometric analysis. J. Periodontol. 74: 1153–1160. 241–249.
5 Bassett, C.A. (1972). Clinical implications of cell function 20 Dahners, L.E. and Funderburk, C.H. (1987).
in bone grafting. Clin. Orthop. Relat. Res. 87: 49–59. Gentamicin‐loaded plaster of Paris as a treatment of
6 Baxter, G.M. (1996). Instrumentation and techniques experimental osteomyelitis in rabbits. Clin. Orthop.
for treating orthopedic infections in horses. Vet. Clin. Relat. Res. 219: 278–282.
North Am. Equine Pract. 12: 303–335. 21 Dankert, J., Hogt, A., and Feijen, J. (1986). Biomedical
7 Bertone, A.L. (1999). Update on infectious arthritis in polymers: bacterial adhesion, colonization, and
horses. Equine Vet. Educ. 11: 143–152. infection. CRC Crit. Rev. Biochem. 2: 219–301.
8 Bertone, A.L., Davis, D.M., Cox, H.U. et al. (1992). 22 Davies, D.G., Parsek, M.R., Pearson, J.P. et al. (1998).
Arthrotomy versus arthroscopy and partial The involvement of cell‐to‐cell signals in the
synovectomy for treatment of experimentally induced development of a bacterial biofilm. Science 280:
infectious arthritis in horses. Am. J. Vet. Res. 53: 295–298.
585–591.
23 del Rio, M.L., Gutierrez, B., Gutierrez, C.B. et al. (2003).
9 Bonfiglio, M. and Jeter, W.S. (1972). Immunological
Evaluation of survival of Actinobacillus
responses to bone. Clin. Orthop. Relat. Res. 87: 19–27.
pleuropneumoniae and Haemophilus parasuis in four
10 Borriello, G., Werner, E., Roe, F. et al. (2004). Oxygen
liquid media and two swab specimen transport
limitation contributes to antibiotic tolerance of systems. Am. J. Vet. Res. 64: 1176–1180.
Pseudomonas aeruginosa in biofilms. Antimicrob.
24 Dernell, W.S. (1999). Treatment of severe orthopedic
Agents Chemother. 48: 2659–2664.
infections. Vet. Clin. North Am. Small Anim. Pract. 29:
11 Bowyer, G.W. and Cumberland, N. (1994). Antibiotic
1261–1274.
release from impregnated pellets and beads. J. Trauma
25 DiMaio, F.R., O’Halloran, J.J., and Quale, J.M. (1994). In
36: 331–335.
vitro elution of ciprofloxacin from
12 Buchholz, H.W., Elson, R.A., and Heinert, K. (1984).
polymethylmethacrylate cement beads. J. Orthop. Res.
Antibiotic‐loaded acrylic cement: current concepts.
12: 79–82.
Clin. Orthop. Relat. Res. 190: 96–108.
26 Dipiro, J.T., Bivins, B.A., Record, K.E. et al. (1983). The
13 Butt, T.D., Bailey, J.V., Dowling, P.M., and Fretz, P.B.
prophylactic use of antimicrobials in surgery. Curr.
(2001). Comparison of 2 techniques for regional
Probl. Surg. 20: 69–132.
antibiotic delivery to the equine forelimb: intraosseous
27 Downes, S. (1991). Methods for improving drug release
perfusion vs. intravenous perfusion. Can. Vet. J. 42:
from poly(methyl)methacrylate bone cement. Clin.
617–622.
Mater. 7: 227–231.
14 Calhoun, J.H. and Mader, J.T. (1989). Antibiotic beads
28 Eckman, J.B. Jr., Henry, S.L., Mangino, P.D., and
in the management of surgical infections. Am. J. Surg.
Seligson, D. (1988). Wound and serum levels of
157: 443–449.
tobramycin with the prophylactic use of tobramycin‐
15 Cleveland, K.B. (2005). General principles of infection.
impregnated polymethylmethacrylate beads in
In: Campbell’s Operative Orthopaedics (ed. S.T. Canale
compound fractures. Clin. Orthop. Relat. Res. 237:
and J.H. Beaty), 643–659. Philadelphia, PA: Elsevier.
213–215.
www.ajlobby.com
29 Ehrlich, G.D., Stoodley, P., Kathju, S. et al. (2005). 43 Harriss, F.K., Galuppo, L.D., Decock, H.E. et al. (2004).
Engineering approaches for the detection and control Evaluation of a technique for collection of cancellous
of orthopaedic biofilm infections. Clin. Orthop. Relat. bone graft from the proximal humerus in horses. Vet.
Res. 437: 59–66. Surg. 33: 293–300.
30 Elsayed, S., Gregson, D.B., and Church, D.L. (2003). 44 Henry, S.L., Seligson, D., Mangino, P., and Popham, G.J.
Comparison of direct selective versus nonselective agar (1991). Antibiotic‐impregnated beads. Part I: bead
media plus LIM broth enrichment for determination of implantation versus systemic therapy. Orthop. Rev. 20:
group B streptococcus colonization status in pregnant 242–247.
women. Arch. Pathol. Lab. Med. 127: 718–720. 45 Holcombe, S.J., Schneider, R.K., Bramlage, L.R. et al.
31 Ethell, M.T., Bennett, R.A., Brown, M.P. et al. (2000). In (1995). Lag screw fixation of noncomminuted sagittal
vitro elution of gentamicin, amikacin, and ceftiofur fractures of the proximal phalanx in racehorses: 59
from polymethylmethacrylate and hydroxyapatite cases (1973–1991). J. Am. Vet. Med. Assoc. 206:
cement. Vet. Surg. 29: 375–382. 1195–1199.
32 Farnsworth, K.D., White, N.A. 2nd, and Robertson, J. 46 Houser, B.E., Mellonig, J.T., Brunsvold, M.A. et al.
(2001). The effect of implanting gentamicin‐ (2001). Clinical evaluation of anorganic bovine bone
impregnated polymethylmethacrylate beads in the xenograft with a bioabsorbable collagen barrier in the
tarsocrural joint of the horse. Vet. Surg. 30: 126–131. treatment of molar furcation defects. Int. J. Periodontics
33 Fish, D.N., Hoffman, H.M., and Danziger, L.H. (1992). Restorative Dent. 21: 161–169.
Antibiotic‐impregnated cement use in U.S. hospitals. 47 Ingle, B.M., Hay, S.M., Bottjer, H.M., and Eastell, R.
Am. J. Hosp. Pharm. 49: 2469–2474. (1999). Changes in bone mass and bone turnover
34 Flick, A.B., Herbert, J.C., Goodell, J., and Kristiansen, T. following distal forearm fracture. Osteoporos. Int. 10:
(1987). Noncommercial fabrication of antibiotic‐ 399–407.
impregnated polymethylmethacrylate beads. Technical 48 Ivester, K.M. and Adams, S.B. (2007). Orthopedic
note. Clin. Orthop. Relat. Res. 223: 282–286. infection: the use of local antimicrobial therapy.
35 Fux, C.A., Wilson, S., and Stoodley, P. (2004). Compend. Equine Ed.82–89.
Detachment characteristics and oxacillin resistance of 49 Kahn, D.S. and Pritzker, K.P. (1973). The
Staphyloccocus aureus biofilm emboli in an in vitro pathophysiology of bone infections. Clin. Orthop. 96:
catheter infection model. J. Bacteriol. 186: 4486–4491. 12–19.
36 Gagnon, H., Ferguson, J.G., Papich, M.G., and Bailey, 50 Kelmer, G., Catasus, C.T., Saxton, A.M., and Elliot, S.B.
J.V. (1994). Single‐dose pharmacokinetics of cefazolin (2009). Evaluation of indwelling intravenous catheters
in bovine synovial fluid after intravenous regional for the regional perfusion of the limbs of horses. Vet.
injection. J. Vet. Pharmacol. Ther. 17: 31–37. Rec. 165: 496–501.
37 Godber, L.M., Walker, R.D., Stein, G.E. et al. (1995). 51 Klemm, K.W. (1993). Antiobiotic bead chains. Clin.
Pharmacokinetics, nephrotoxicosis, and in vitro Orthop. 295: 63–76.
antibacterial activity associated with single versus 52 Levine, D.G., Epstein, K.L., Ahern, B.J., and Richardson,
multiple (three times) daily gentamicin treatments in D.W. (2010). Efficacy of three tourniquet types for
horses. Am. J. Vet. Res. 56: 613–618. intravenous antimicrobial regional limb perfusion in
38 Goldberg, V.M. and Stevenson, S. (1989). Bone standing horses. Vet. Surg. 39: 1021–1024.
transplantation. In: Surgery of the Musculoskeletal 53 Levine, D.G., Epstein, K.L., Neelis, D.A., and Ross,
System, 2e (ed. C. McCollister Evarts), 54–81. London: M.W. (2009). Effect of topical application of 1%
Churchill Livingstone. diclofenac sodium liposomal cream on inflammation in
39 Goodrich, L.R. and Nixon, A.J. (2004). Treatment healthy horses undergoing intravenous regional limb
options for osteomyelitis. Equine Vet. Educ. 16: perfusion with amikacin sulfate. Am. J. Vet. Res. 70:
267–280. 1323–1325.
40 Gray, J.C. and Elves, M.W. (1979). Early osteogenesis in 54 Lew, D.P. and Waldvogel, F.A. (1997). Osteomyelitis. N.
compact bone isografts: a quantitative study of Engl. J. Med. 336: 999–1007.
contributions of the different graft cells. Calcif. Tissue 55 Lew, D.P. and Waldyogel, F.A. (2004). Osteomyelitis.
Int. 29: 225–237. Lancet 364: 369–749.
41 Gristina, A.G., Naylor, P.T., and Myrvik, Q.N. (1991). 56 MacDonald, D.G., Morley, P.S., Bailey, J.V. et al. (1994).
Mechanisms of musculoskeletal sepsis. Orthop. Clin. An examination of the occurrence of surgical wound
North Am. 22: 363–371. infection following equine orthopaedic surgery
42 Gristina, A.G., Oga, M., Webb, L.X., and Hobgood, (1981–1990). Equine Vet. J. 26: 323–326.
C.D. (1985). Adherent bacterial colonization in the 57 Mackey, D., Varlet, A., and Debeaumont, D. (1982).
pathogenesis of osteomyelitis. Science 228: 990–993. Antibiotic loaded plaster of Paris pellets: an in vitro
www.ajlobby.com
study of a possible method of local antibiotic therapy in 71 Olmstead, M.L., Hohn, R.B., and Turner, T.M. (1983). A
bone infection. Clin. Orthop. Relat. Res. 167: 263–268. five‐year study of 221 total hip replacements in the dog.
58 Mah, T.F., Pitts, B., Pellock, B. et al. (2003). A genetic J. Am. Vet. Med. Assoc. 183: 191–194.
basis for Pseudomonas aeruginosa biofilm antibiotic 72 Olson, M.E., Ceri, H., Morck, D.W. et al. (2002). Biofilm
resistance. Nature 426: 306–310. bacteria: formation and comparative susceptibility to
59 Mariani, B.D., Martin, D.S., and Levine, M.J. (1996). antibiotics. Can. J. Vet. Res. 66: 86–92.
Polymerase chain reaction detection of bacterial 73 Oyen, W.J. and Corstens, F.H. (1995). Scintigraphic
infection in total knee arthroplasty. Clin. Orthop. 331: techniques for delineation of infection and
11–22. inflammation. Br. J. Hosp. Med. 54: 75–80.
60 Markel, M.D. (1996). Bone grafts and bone substitutes. 74 Palmer, S.E. and Hogan, P.M. (1999). How to perform
In: Equine Fracture Repair (ed. A.J. Nixon), 87–92. regional limb perfusion in the standing horse. In:
Philadelphia: W.B. Saunders. Proceedings of the American Association of Equine
61 Mattson, S., Boure, L., Pearce, S. et al. (2004). Practitioners, vol. 45, 124–127. Lexington, KY: AAEP.
Intraosseous gentamicin perfusion of the distal 75 Parker, R.A., Bladon, B.M., McGovern, K., and Smith,
metacarpus in standing horses. Vet. Surg. 33: 180–186. K.C. (2010). Osteomyelitis and osteonecrosis after
62 Mattson, S.E., Pearce, S.G., Boure, L.P. et al. (2005). intraosseous perfusion with gentamicin. Vet. Surg. 39:
Comparison of intraosseous and intravenous infusion 644–648.
of technetium Tc 99m pertechnate in the distal portion 76 Parra, A., Lugo, J., and Boothe, D.M. (2005).
of forelimbs in standing horses by use of scintigraphic Pharmacokinetics of enrfloxacin and amikacin after
imaging. Am. J. Vet. Res. 66: 1267–1272. intravenous regional perfusion of the distal limb. In:
63 McDuffee, L.A. (2010). Osteoprogenitor cell therapy in Proceedings of the American College of Veterinary
an equine fracture model. In: North American Surgeons. Germantown, MD: ACVS.
Veterinary Regenerative Medicine Conference, vol. 1, 1. 77 Parra‐Sanchez, A., Lugo, J., Boothe, D.M. et al. (2006).
NAVRMA. Pharmacokinetics and pharmacodynamics of
64 McDuffee, L.A. and Anderson, G.I. (2003). In vitro enrofloxacin and a low dose of amikacin administered
comparison of equine cancellous bone graft donor sites via regional intravenous limb perfusion in standing
and tibial periosteum as sources of viable horses. Am. J. Vet. Res. 67: 1687–1695.
osteoprogenitors. Vet. Surg. 32: 455–463. 78 Pille, F., De Baere, S., Ceelen, L. et al. (2005). Synovial
65 Meijer, M.C., van Weeren, P.R., and Rijkenhuizen, A.B. fluid and plasma concentrations of ceftiofur after
(2000). Clinical experiences of treating septic arthritis regional intravenous perfusion in the horse. Vet. Surg.
in the equine by repeated joint lavage: a series of 39 34: 610–617.
cases. J. Vet. Med. A Physiol. Pathol. Clin. Med. 47: 79 Popham, G.J., Mangino, P., Seligson, D., and Henry, S.L.
351–365. (1991). Antibiotic‐impregnated beads. Part II: factors in
66 Moore, R.M., Schneider, R.K., Kowalski, J. et al. (1992). antibiotic selection. Orthop. Rev. 20: 331–337.
Antimicrobial susceptibility of bacterial isolates from 80 Poynton, A.R., Zheng, F., Tomin, E. et al. (2002).
233 horses with musculoskeletal infection during Resorbable posterolateral graft containment in a rabbit
1979–1989. Equine Vet. J. 24: 450–456. spinal fusion model. J. Neurosurg. 97: 460–463.
67 Murphey, E.D., Santschi, E.M., and Papich, M.G. 81 Raekallio, J. and Makinen, P.L. (1969). Alkaline and acid
(1999). Regional intravenous perfusion of the distal phosphatase activity in the initial phase of fracture
limb of horses with amikacin sulfate. J. Vet. Pharmacol. healing. Acta Pathol. Microbiol. Scand. 75: 415–422.
Ther. 22: 68–71. 82 Reef, V.B., Reimers, T.J., and Reid, C.F. (1991).
6 8 Newquist, J.M. and Baxter, G.M. (2009). Evaluation Ultrasonographic findings in horses with
of plasma fibrinogen concentration as an indicator osteomyelitis. In: Proceedings of the American
of physeal or epiphyseal osteomyelitis in foals: 17 Association of Equine Practitioners, vol. 37, 381–391.
cases (2002–2007). J. Am. Vet. Med. Assoc. 235: Lexington, KY: AAEP.
415–419. 83 Ross, M.W., Orsini, J.A., Richardson, D.W., and Martin,
69 Nguyen, T.M., Gauthier, D.W., Myles, T.D. et al. (1998). B.B. (1991). Closed suction drainage in the treatment of
Detection of group B streptococcus: comparison of an infectious arthritis of the equine tarsocrural joint. Vet.
optical immunoassay with direct plating and broth‐ Surg. 20: 21–29.
enhanced culture methods. J. Matern. Fetal Med. 7: 84 Rubio‐Martinez, L.M. and Cruz, A.M. (2006).
172–176. Antimicrobial regional limb perfusion in horses. J. Am.
70 Ohishi, T., Takahashi, M., Kushida, K. et al. (1998). Vet. Med. Assoc. 228: 706–712.
Changes of biochemical markers during fracture 85 Rubio‐Martinez, L.M., Lopez‐Sanroman, J., Cruz, A.M.
healing. Arch. Orthop. Trauma Surg. 118: 126–130. et al. (2005). Evaluation of safety and pharmacokinetics
www.ajlobby.com
of vancomycin after intravenous regional limb 99 Swinebroad, E.L., Dabareiner, R.M., Swor, T.M. et al.
perfusion in horses. Am. J. Vet. Res. 66: 2107–2113. (2003). Osteomyelitis secondary to trauma involving
86 Ruther, W., Hotze, A., Moller, F. et al. (1990). Diagnosis the proximal end of the radius in horses: five cases
of bone and joint infection by leucocyte scintigraphy. A (1987–2001). J. Am. Vet. Med. Assoc. 223: 486–491.
comparative study with 99mTc‐HMPAO‐labelled 100 Tobias, K.M., Schneider, R.K., and Besser, T.E. (1996).
leucocytes, 99mTc‐labelled antigranulocyte antibodies Use of antimicrobial‐impregnated polymethyl
and 99mTc‐labelled nanocolloid. Arch. Orthop. Trauma methacrylate. J. Am. Vet. Med. Assoc. 208: 841–845.
Surg. 110: 26–32. 101 Trampuz, A., Osmon, D.R., Hanssen, A.D. et al.
87 Sanchez, E., Baro, M., Soriano, I. et al. (2001). In vivo‐in (2003). Molecular and antibiofilm approaches to
vitro study of biodegradable and osteointegrable prosthetic joint infection. Clin. Orthop. Relat. Res.
gentamicin bone implants. Eur. J. Pharm. Biopharm. 52: 414: 69–88.
151–158. 102 Trippel, S.B. (1986). Antibiotic‐impregnated cement
88 Santschi, E.M., Adams, S.B., and Murphey, E.D. (1998). in total joint arthroplasty. J. Bone Joint Surg. Am. 68:
How to perform equine intravenous digital perfusion. 1297–1302.
In: Proceedings of the American Association of Equine 103 Trotter, G.T. (1996). Osteomyelitis. In: Equine Fracture
Practitioners, vol. 44, 198–201. Lexington, KY: AAEP. Repair (ed. A.J. Nixon), 359–366. Philadelphia: W.B.
89 Santschi, E.M. and McGarvey, L. (2003). In vitro Saunders.
elution of gentamicin from Plaster of Paris beads. Vet. 104 Urist, M.R. (1965). Bone: formation by autoinduction.
Surg. 32: 128–133. Science 150: 893–899.
90 Savage, D. and Fletcher, M. (1985). Bacterial Adhesions: 105 Volpin, G., Rees, J.A., Ali, S.Y., and Bentley, G. (1986).
Mechanisms and Physiological Significance. New York: Distribution of alkaline phosphatase activity in
Plenum Press. experimentally produced callus in rats. J. Bone Joint
91 Schaadt, J., Crowley, R., Miller, D., and Kavanah, M. Surg. Br. 68: 629–634.
(2002). Isolated limb perfusion: a literature review. J. 106 Wahlig, H., Dingeldein, E., Bergmann, R., and Reuss,
Extra Corpor. Technol. 34: 130–143. K. (1978). The release of gentamicin from
92 Schauwecker, D.S., Braunstein, E.M., and Wheat, L.J. polymethylmethacrylate beads. An experimental and
(1990). Diagnostic imaging of osteomyelitis. Infect. Dis. pharmacokinetic study. J. Bone Joint Surg. Br. 60‐B:
Clin. North Am. 4: 441–463. 270–275.
93 Scheuch, B.C., Van Hoogmoed, L.M., Wilson, W.D. 107 Watts, A.E., Nixon, A.J., Papich, M.G. et al. (2011). In
et al. (2002). Comparison of intraosseous or vitro elution of amikacin and ticarcillin from a
intravenous infusion for delivery of amikacin sulfate to resorbable, self‐setting, fiber reinforced calcium
the tibiotarsal joint of horses. Am. J. Vet. Res. 63: phosphate cement. Vet. Surg. 40: 563–570.
374–380. 108 Wegener, W.A. and Alavi, A. (1991). Diagnostic
94 Schneider, R.K., Andrea, R., and Barnes, H.G. (1995). imaging of musculoskeletal infection.
Use of antibiotic‐impregnated polymethyl methacrylate Roentgenography; gallium, indium‐labeled white
for treatment of an open radial fracture in a horse. J. blood cell, gammaglobulin, bone scintigraphy; and
Am. Vet. Med. Assoc. 207: 1454–1457. MRI. Orthop. Clin. North Am. 22: 401–418.
95 Snyder, J.R., Pascoe, J.R., and Hirsh, D.C. (1987). 109 Werner, L.A., Hardy, J., and Bertone, A.L. (2003).
Antimicrobial susceptibility of microorganisms isolated Bone gentamicin concentration after intra‐articular
from equine orthopedic patients. Vet. Surg. 16: injection or regional intravenous perfusion in the
197–201. horse. Vet. Surg. 32: 559–565.
96 Southwood, L.L., Frisbie, D.D., Kawcak, C.E., and 110 Whitehair, K.J., Adams, S.B., Parker, J.E. et al. (1992).
McIlwraith, C.W. (2003). Evaluation of serum Regional limb perfusion with antibiotics in three
biochemical markers of bone metabolism for early horses. Vet. Surg. 21: 286–292.
diagnosis of nonunion and infected nonunion fractures 111 Whitehair, K.J., Blevins, W.E., Fessler, J.F. et al. (1992).
in rabbits. Am. J. Vet. Res. 64: 727–735. Regional perfusion of the equine carpus for antibiotic
97 Southwood, L.L., Kawcak, C.E., McIlwraith, C.W. et al. delivery. Vet. Surg. 21: 279–285.
(2003). Use of scintigraphy for assessment of fracture 112 Whitehair, K.J., Bowersock, T.L., Blevins, W.E. et al.
healing and early diagnosis of osteomyelitis following (1992). Regional limb perfusion for antibiotic
fracture repair in rabbits. Am. J. Vet. Res. 64: 736–745. treatment of experimentally induced septic arthritis.
98 Stoodley, P., Kathju, S., Hu, F.Z. et al. (2005). Molecular Vet. Surg. 21: 367–373.
and imaging techniques for bacterial biofilms in joint 113 Wilson, K.J., Cierny, G., Adams, K.R., and Mader, J.T.
arthroplasty infections. Clin. Orthop. Relat. Res. 437: (1988). Comparative evaluation of the diffusion of
31–40. tobramycin and cefotaxime out of antibiotic‐
www.ajlobby.com
impregnated polymethylmethacrylate beads. 115 Zachos, T.A., Shields, K.M., and Bertone, A.L. (2006).
J. Orthop. Res. 6: 279–286. Gene‐mediated osteogenic differentiation of stem
14 Wininger, D.A. and Fass, R.J. (1996). Antibiotic‐
1 cells by bone morphogenetic proteins‐2 or ‐6.
impregnated cement and beads for orthopedic J. Orthop. Res. 24: 1279–1291.
infections. Antimicrob. Agents Chemother. 40: 116 Zalavras, C.G. (2017). Prevention of infection in open
2675–2679. fractures. Infect. Dis. Clin. North Am. 31: 339–352.
www.ajlobby.com
874
49
Stress‐induced Laminitis
Scott Morrison
Introduction at risk is necessary to detect subtle signs of structural

failure. Weekly radiographs, and daily palpation of the
Supporting limb laminitis is the most devastating com- coronary band and digital pulses, are recommended.
plication of prolonged unilateral weight bearing. Radiographs of the foot at risk should be part of the
Laminitis in the supporting limb is believed to be caused initial examination to serve as a baseline to compare
by mechanical overload, decreased perfusion, and subse- future radiographs. Radiographs should be taken in a
quent failure at the lamellar interface. The risk of lamini- consistent, replicable manner. The hoof should be touch-
tis in these cases appears to be related to the duration ing the plate and the beam centered on the middle of the
and severity of the lameness in the opposite limb. The hoof wall. Bandages or boots should be removed to
incidence is unknown, but is thought to be greater than improve detail and prevent magnification. Soft tissue
10%,15 and the mortality rate is estimated to be around thickness between the hoof wall and the parietal surface
50%.13 Foot conformation and type are also believed to of the distal phalanx (horn lamellar zone) should be
influence risk and severity. Strong, robust feet with thick measured on baseline radiographs and compared to fol-
sole depth seem to be more resilient and do not succumb low‐up films. In most normal horses the distance should
to the supporting limb laminitis as easily as a weak, thin‐ be about 16–17 mm; however, this will vary with breed,
soled foot. age, and size of horse. In a study by Peloso et al., the horn
lamellar zone for a normal horse was determined to be
less than 29% of the palmar cortical length of the distal
Clinical Signs phalanx.13 Often an increase in the horn lamellar zone
distance occurs before any radiographic signs of distal
Support limb laminitis is often secondary to complete frac- phalanx displacement.13
tures, sepsis of synovial structures, catastrophic break- Palpation of the coronary band can be a more reliable
down, and other conditions such as neurologic deficits indicator of structural failure compared to radiographs.13
which may cause significant lameness or non‐weight bear- As the hoof capsule is overloaded and the suspensory
ing. Clinical signs may develop at any time, but generally apparatus of the distal phalanx begins to fail, the proxi-
occur after three to six weeks of unilateral weight bearing. mal hoof wall will begin to feel prominent. As the soft
The complicating factor is the insidious nature of the tissue structures sink within the rigid hoof capsule, a pal-
disease. Often, signs of a problem do not become evident pable ledge or cavitation can be appreciated. Frequently
until there already is significant damage and structural the hairs on the coronary band in the affected area will
failure. Unlike other forms of laminitis, support limb no longer lie flat and will begin to raise (Figure 49.1).
laminitis cases frequently do not become acutely painful, The first clinical signs are usually an increased digital
or the degree of pain is masked by the pain of the original pulse, followed by a tendency to unweight the limb. An
injury. For this reason, frequent examination of the foot altered stance such as pointing may also be observed.

www.ajlobby.com
49 Stress-induced Laminitis 875
(A) (C)
(B) (D)
Figure 49.1 The coronary band in the affected region will suffer varying degrees of damage. (A) Sinking in this quarter creating distal
displacement of the coronary corium. The coronary band is still intact, but the wall growth is slowed and the hairs of the coronet stick up.
(B) If the displacement continues, a palpable ledge or cavitation will be evident; separation of the external hoof wall layer can be
appreciated. (C) Complete separation with a coronary band shear lesion along the affected area. The separation is full thickness.
(D) Subsequent swelling and inflammation as the detached wall impinges the coronary corium.
As the degree of pain increases, lameness may become to the prevention of backflow by venous valves and the
more apparent and the horse may spend more time recovery of previously compressed tissue. Blood there-
recumbent. fore fills the low‐pressure vasculature of the foot with the
To develop an understanding of how to prevent sup- aid of gravity, normal arterial blood flow, and the cen-
porting limb laminitis, it is necessary to first discuss foot tripetal force generated during the swing phase. At
perfusion and loading patterns of the foot. ground contact the vasculature and soft tissues are com-
pressed, rapidly increasing digital venous pressure and
forcing blood out of the foot through low‐resistance
Perfusion of the Foot pathways such as vessels in the collateral cartilages and
the porous parietal surface of the digital phalanx.3
The equine foot is designed for constant movement, and Movement of blood into and out of the foot is believed to
is capable of accommodating large loads and shock help support the architecture of the foot by turgor pres-
vibrations generated during the stance and impact sure and also aid in shock absorption with the movement
phases of the stride. Fluid volume or blood flow to and of fluid (blood) within closed spaces, essentially func-
from the foot are thought to play an integral role in these tioning as a hydraulic shock‐absorbing mechanism and
processes. pump to aid circulation.2 High pressures generated dur-
In the moving horse, as the foot is unloaded, venous ing the loading phase require a mechanism to ensure
pressures are lower than resting pressures.14 This is due low‐resistance, unidirectional blood flow. Valveless veins
www.ajlobby.com
in most of the foot and arterial occlusion during the 2) unweighting the limb
loading phase are important components aiding in 3) recruitment of axial components of the foot into
the effectiveness of this pumping mechanism. Van weight bearing (frog, bar, and sole).
Kraayenburg et al. showed that during the loading phase
the palmer digital arteries were occluded at the level of
the navicular bone; this prevented blood flow to the ter- Redistributing Load
minal arch and dorsal lamellae.19 This arterial occlusion Perfusion deficits and overload are believed to cause tis-
may be a mechanism preventing arterial backflow during sue fatigue and failure at the lamellar interface. The
the high‐pressure loading phase. The degree of occlusion entire foot can succumb to these factors, or one region of
was proportionate to the amount of load; however, lifting the foot can be affected more than others. Therefore,
even one forelimb was enough load to compress or knowledge of the normal quasi‐static digital loading pat-
occlude the arteries in the other. The mechanism of tern can be helpful in formulating a foot support plan to
occlusion is unknown, but believed to be mechanical minimize the risk and severity of damage. Determining
compression by flexion of the distal interphalangeal which regions of the foot to load or unload is a somewhat
(DIP) joint, compression of the soft tissue structures subjective decision based on the physical examination
beneath the hoof wall, and tension on the deep digital and baseline radiographs of the foot.
flexor tendon (DDFT) and digital annular ligaments.18 Pressure mat studies show that the normal horse at
Perfusion to the foot was previously thought to be stance loads the dorsal medial regions of the forefoot.7,10
dependent on cyclic loading of the frog and digital cush- The center of pressure (COP) is located just behind the
ion to help pump blood out of the foot. However, studies apex of the trimmed frog and slightly medially. The
have shown negative pressures in the digital cushion action of the DDFT pulling on the distal phalanx is
during loading.3,5 Therefore, direct loading of the frog responsible for the COP being positioned in the dorsal
and digital cushion may not act as the pumping mecha- regions or dorsal to the center of the DIP joint. In the
nism previously believed to aid perfusion. fully loaded limb, the fetlock is displaced downward and
The circulation and venous pressure changes in the the DDFT is engaged or under tension, pulling on its
moving horse and during stance support the notion of insertion site on the distal phalanx. This creates slight
continuous movement as a requirement for healthy circu- rotation of the distal phalanx around the DIP joint. This
lation to the foot. The aforementioned blood flow pattern action stretches the submural tissue and compresses the
is recognized as an important aid in tissue support and sole corium in the toe regions. Perfusion deficits caused
shock absorption in the moving horse, but poses a signifi- by tension and compression of soft tissue can be appre-
cant risk in the constantly loaded foot. The horse’s foot at ciated in these regions in venograms performed in the
rest is also dependent on constant movement. The nor- loaded limb (Figure 49.2). Pressure mat measurements
mal resting horse is never completely static; rather, it is made before and after surgery showed that transection
quasi‐static. The standing horse is constantly shifting of the DDFT in laminitis cases shifted the COP from
weight from one foot to the other as many as 125 ± 55 just behind the frog apex to directly beneath the center
times per hour.7 This constant cyclic loading and unload- of the DIP joint in all three cases studied.11 Force plate
ing allow blood to perfuse all regions of the foot, provid- studies showed that normal horses with lower hoof
ing nutrients, hydration, and waste removal. It is currently angles had more force in the heel region compared to
unknown how often cyclic unloading is required to pre- normal feet. Feet with higher angles had increased force
vent laminitis, but it probably varies with foot type. in the toe region.1 So the toe is under more load in an
Maintaining normal perfusion in the constantly loaded upright foot and the heel is under more load in the low‐
foot remains a challenge. There currently are no foot angled hoof. The COP can also be altered by limb posi-
support devices that can substitute for the cyclic loading tion and limb conformation. For instance, a limb with a
and unloading of the foot. base narrow stance will have a COP positioned more to
In the author’s opinion, foot conformation and type the lateral region of the foot. This may be clinically
should be taken into account when selecting a foot sup- important in a hindlimb which stands base narrow in an
port system to help prevent a supporting limb laminitis. effort to unload the opposite limb. These cases typically
present with lateral sinking and rotation. Since most
forelimbs with normal conformation load the medial toe
Treatment and Prevention region, these cases often present with medial sinking
and rotation (Figure 49.3).8
Specific goals to help prevent or limit damage include:
Chronic laminitis can manifest as phalangeal rota-
1) redistributing load from most stressed or weakened tion, medial sinking, lateral sinking, or vertical sinking.
regions to least stressed regions of the hoof The type of displacement is dependent on the severity
www.ajlobby.com
(A) (B)
(C) (D)
Figure 49.2 (A) Venogram of a normal foot, during full weight bearing (with opposite foot held up). Notice the compression of
vasculature to the sole corium and parietal vascular plexus. (B) Same foot, fully weight bearing with 10° of heel elevation; note the change
in venogram. (C) Arteriogram of same foot standing square. (D) Arteriogram of same foot, fully weight bearing; note the decreased filling
of the arteries with contrast.
(A) (B)
Figure 49.3 (A) Supporting limb laminitis in the right hindlimb, with lateral sinking and rotation. (B) Right front foot affected with medial
sinking and rotation.
www.ajlobby.com
(A) (B)
Figure 49.4 (A) A 10° heel wedge cuffed shoe (Nanric, Lawrenceburg, KY, USA). The ground surface of the toe is beveled, creating a rolled
toe (right side of image). (B) With the foot’s normal digital loading pattern the foot will rock forward on the beveled toe (finger pressure is
simulating rocking forward), further increasing the hoof angle.
A 10° wedge with a rolled toe placed beneath the dorsal

region of the coronary band is applied. This allows the
foot to rock forward slightly, increasing the angle fur-
ther than the 10° (Figure 49.4). For upright or normally
angled feet, this is a reasonable place to start. However,
in the low‐heeled foot, prolonged wedging can cause
overload of the quarters and heel region. Heel elevation
shifts the COP caudally and increases strain in the
quarters, especially the medial quarter.17 In the author’s
experience, prolonged periods of heel elevation can
create overload or laminitis in the quarters, demon-
strated by either medial or lateral sinking (Figure 49.5),
especially in the low‐heeled foot conformation. In the
author’s opinion, this foot type generally does better
with leaving the foot flat and providing axial support
such as a boot and soft pad.
Knowledge of foot conformation gives us an e stimate
of where and how the load is distributed throughout the
foot. An evaluation of the foot can help determine the
integrity, strength, or weakness of different regions of the
Figure 49.5 Example of a foot experiencing overloading of the
medial quarter secondary to prolonged heel elevation. Note the
foot. For instance, a club foot probably has strong, robust
hoof wall separation and shearing of the coronary band. heel structures and weak, compromised toe regions,
which is evident with dishing or flaring of the dorsal hoof
wall, thin sole depth in the toe region, and often a preex-
isting stretched white line, all indicating compromised or
and location of the lamellar damage. The area under the overloaded toe structures. This foot type generally
most load will most likely be the first to succumb to responds favorably to heel elevation.
lamellar failure. The normal foot at stance loads the Managing the supporting limb requires frequent
dorsal regions of the foot, and the laminae at the toe examination to detect compromised or overloaded areas
region will be under the most tensile strain. Since most and adjusting the foot support accordingly. For example,
lamellar damage and failure usually occur in the toe a normal foot that has been wedged for a period of time
region, and tension of the DDFT is thought to aid in and then shows slowed wall growth in the medial q uarter,
occluding the digital arteries during limb load, attempts or a palpable cavitation or ledge in the medial proximal
to decrease tension on the DDFT and shift the COP coronary band, may need the height of the wedge
toward the heels are usually warranted. Wedging the reduced or eliminated. Likewise, a low‐heeled foot that
hoof up by 23° significantly decreased tension on the was originally placed in a flat pad/boot that begins
DDFT.17 Redden reports that maintaining a palmar to show some rotation may require the application of a
angle of 20° preserves perfusion in the loaded limb.15 heel wedge.
www.ajlobby.com
(A) (B)
(C)
Figure 49.6 (A) Beveled toe to decrease resistance and ease dorsopalmar/plantar breakover. (B) Beveled quarters to decrease resistance
when turning and ease medial‐lateral breakover. (C) Wooden clog (which is beveled in toe and quarters) can be adhered to the foot
with epoxy.
Most cases requiring preventative measures for groove should extend the full length of the compromised
support limb laminitis are confined to stall rest. region. Elastomer sole support material is molded to the
Their movement is predominantly turning or twisting sole surface and taped in place with Vetrap. The foot is
about the stall and they rarely ambulate in a straight line. cast using a stockinette, cast padding, and fiberglass
The constant torque creates shear on the lamellar inter- casting tape (see Figure 49.7). The cast extends up to the
face. The lamellar suspensory apparatus is very effective mid‐pastern region. The foot is set down on a firm, flat
at resisting tensile strain and is less effective at resisting surface until the cast has set up. Five ounces of acrylic are
shear forces.4 To address this, attempts should be made used to create a dome‐like contour on the ground surface
to reduce the moment arm around the DIP joint of the cast. The apex of the dome should be located near
(Figure 49.6). Easing breakover in all directions is aimed the center of the DIP joint (or at the widest part of the
at decreasing the shear forces generated during move- sole). The foot casting technique is not believed to
ment around the stall. unweight the foot to any significant degree; rather, it is
Once a case begins to show signs of sinking, it is impor- thought to decrease the independent movement of the
tant to aggressively address the shear forces on the lamel- hoof wall and bone column; that is, hoof shear when
lar interface. Areas of lamellar separation can quickly moving. The foot cast is left in place and changed every
propagate to adjacent areas of the foot. An effective foot 30 days. Two or three casts are usually required. Signs of
casting technique can help salvage cases that begin to new wall growth seen at the first cast change would indi-
sink (Figure 49.7).12 The procedure involves trimming cate a good prognosis. Detailed foot management for the
the foot flat and heavily rolling or beveling the distal bor- unstable chronic laminitic foot is described elsewhere in
der of the hoof wall. Subcoronary band grooving is per- the literature.11,12
formed in areas that show signs of sinking, or slowed or
ceased wall growth. Coronary band grooving is per-
formed by making a horizontal groove in the proximal
Unweighting the Limb
hoof wall (about ½ in. distal to the hairline; Figure 49.8). Unweighting the limb periodically is probably the
The groove should extend through the stratum medium, most effective method to intermittently perfuse the
so that the pliable stratum internum is exposed. The foot. If the injured limb is stable enough, frequent
www.ajlobby.com
(A) (B)
(C) (D)
Figure 49.7 Foot casting technique for treatment of sinking in the quarters. (A) Stockinette and ring of cast felt applied. (B) Cast
padding applied up to level of fetlock. (C) Fiberglass casting tape applied. (D) Sole is domed with acrylic to minimize shear and ease
breakover in all directions.
hand walking would be indicated. Although the fre-

quency and duration required to prevent laminitis are
unknown, it is believed that frequent short walking
may help prevent or limit complications of unilateral
weight bearing.
Unweighting the limb may also be accomplished by
encouraging the patient to lie down. Often cases in
splints, casts, or other support may not lie down, for fear
of not being able to get up or because of too much activity
in the barn. Keeping cases in a quiet area with less traffic
may be helpful. Bedding the stall with high banks on the
walls may help encourage sternal recumbency, and may
facilitate the patient rolling up and rising easily. Straw can
be used to bank up onto the walls of the stall and shavings
or straw can be used on the ground (Figure 49.9). For
cases which are unable to bend or flex the carpus/tarsus,
Figure 49.8 Subcoronary band grooving technique. Groove is shavings make it easier to move around the stall.
made parallel to the coronary band in the compromised region(s) Slings can be used to lift or partially lift the patient,
and about ½ to ¾ in. distal to the hairline. decreasing weight on the limb. Slings can be static/built
www.ajlobby.com
Figure 49.9 Stalls should be bedded with

straw banked up onto the walls to
encourage lying down. This will also
encourage the horse to lie in sternal
recumbency. The banked walls will facilitate
the process of getting up and down.
into a stall or mobile, in which the patient can ambulate

in a sling on wheels (Figure 49.10). The benefit of mobile
slings is that they can be transported to the patient if
needed (Figure 49.11). Use of slings can be labor inten-
sive and not all cases will tolerate them. The sling can
also create pressure sores, especially in hot, humid times
of the year.
Matching limb length may encourage even weight dis-
tribution.6 For cases immobilized in casts, splints, or
bracing, attempts should be made to match limb length.
Looking at both limbs, the carpi or point of hocks should
be at the same height when standing square. Pads or
wooden clogs16 can be used to elevate the height of the
supporting limb to match the limb length of the injured
limb. Even limb length promotes even weight bearing,
and also helps facilitate ambulation or allow the patient
to swing and advance the immobilized limb more easily.
Axial Support
Recruiting the frog, bars, and sole into weight bearing
with the use of axial support may help unload the perim-
eter hoof wall and lamellar interface.9 There are many
products available on the market that function as sole
or arch support. Polyurethanes, silicones, elastomers,
closed‐cell foams, StyrofoamTM (Dow Chemical Company,
Midland, MI, USA), and rubber can all be used to recruit
the sole, frog, and bars into weight bearing (Figure 49.12). Figure 49.10 Slings can be used to decrease the weight on the
There are a variety of different densities and hardness limb (Liftex, Ivyland, PA, USA).
www.ajlobby.com
(A)
(B)
Figure 49.11 (A, B) Mobile slings can be transported to the patient or used to get the horse outside for a period of time (Enduro Nest,
Enduro Medical Technology, South Windsor, CT, USA).
available in commercial products. Harder products hardness of a healthy trimmed frog (around 40–45 Shore)
offer more support, but are less forgiving and can create are usually suitable.
pressure and soreness. Softer products are more forgiv- Sole support materials can be mixed and bandaged to
ing, but offer less support. It is generally thought that the the foot, or placed beneath a pad or into the shoe. Boots
hardest materials a patient will tolerate are best; this will with sole support pads are also available. The benefits of
vary among cases. However, materials which match the boots are the ease of application.
www.ajlobby.com
(A) (B)
(C) (D)
Figure 49.12 Various forms of axial support can be used. (A) Polyurethane poured into and adhered to the sole (Vettec, Oxnard, CA, USA).
(B) Elastomer placed beneath a heel plate (Advance Cushion Support, Nanric, Lawrenceburg, KY, USA). (C) Silicone placed beneath a pad.
(D) Cushioned pads (Horse Trax, Impact Gel Equine, Ettrick, WI, USA).
Preventing and managing support limb laminitis detailed evaluations of the foot. Detecting subtle hoof
requires close monitoring and a proactive, ever‐changing capsule changes early can dictate the necessary changes
foot support strategy. Foot support should be altered to prevent further damage.
based on clinical response and findings from frequent,
References
1 Barrey, E. (1990). Investigation of the vertical hoof force Organization of the Foot of the Horse, Comprising the
distribution in the equine forelimb with an instrumented Study of the Structure, Functions and Diseases of That
horseboot. Equine Vet. J. 22 (Suppl. 9): 35–38. Organ]. Paris: Labé.
2 Bouley, M.H. (1851). Traité de l’organisation du pied du 3 Bowker, R.M. (1998). The anatomy of the ungula
cheval, comprenant l’étude de la structure, des fonctions cartilage and digital cushion. In: Annual Bluegrass
et des maladies de cet organe [Treatise on the Laminitis Symposium, vol. 12, 75–88.
www.ajlobby.com
4 Collins, S. (2009). Hoof loading and biomechanics. 12 Morrison, S.E. (2010). Foot management. Vet. Clin.
In: International Equine Conference on Laminitis and North Am. Equine Pract. 62: 425–446.
Diseases of the Foot, vol. 5, 72–79. 13 Peloso, J.G., Cohen, N.D., Walker, M.A. et al. (1996).
5 Dyhre‐Poulsen, P., Smedegaard, H.H., Roed, J., and Case‐control study of risk factors for the development
Korsgaard, E. (1994). Equine hoof function investigated of laminitis in the contralateral limb in Equidae with
by pressure transducers inside the hoof and unilateral lameness. J. Am. Vet. Med. Assoc. 209:
accelerometers mounted on the first phalanx. Equine 1746–1749.
Vet. J. 26: 362–366. 14 Ratzlaff, M.H., Shindell, R.M., and DeBowes, R.M.
6 Hendrickson, D.A., Stokes, M., and Witten, C. (1997). (1985). Changes in digital venous pressures of horses
Use of an elevated boot to reduce contralateral support moving at the walk and trot. Am. J. Vet. Res. 46:
limb complications secondary to cast application. 1545–1549.
In: Proceedings of the American Association of Equine 15 Redden, R.F. (2004). Preventing laminitis in the
Practitioners, vol. 43, 149–150. Lexington, KY: AAEP. contralateral limb of horses with non‐weightbearing
7 Hood, D.M. (1998). Center of digital load during lameness. Clin. Tech. Equine Pract. 3: 57–63.
quai‐static loading. In: Annual Bluegrass Laminitis 16 Steward, M.L. (2003). How to construct and apply
Symposium, vol. 12, 47–62. atraumatic therapeutic shoes to treat acute or chronic
8 Hood, D.M. (1999). The mechanisms and consequences laminitis in the horse. In: Proceedings of the American
of structural failure of the foot. Vet. Clinic. North Am. Association of Equine Practitioners, vol. 49, 337–1346.
Equine Pract. 15: 437–461. Lexington, KY: AAEP.
9 Hood, D.M., Taylor, D., and Wagner, I.P. (2001). Effects 17 Thompson, K.N., Cheung, T.K., and Silverman, M.
of ground surface deformability, trimming and shoeing (1993). The effect of toe angle on tendon, ligament and
on quasistatic hoof loading patterns in horses. Am. J. hoof wall strains in vitro. J. Equine Vet. Sci. 13:
Vet. Res. 62: 895–900. 651–653.
10 Judy, E.D., Galuppo, L.D., Snyder, J.R., and Willits, N.H. 18 Van Eps, A.W., Collins, S.N., and Pollitt, C.C. (2010).
(2001). Evaluation of an in‐shoe pressure measurement Support limb laminitis. Vet. Clin. North Am. Equine
system in horses. Am. J. Vet. Res. 62: 23–28. Pract. 62: 287–302.
11 Morrison, S.E. (2009). Deep digital flexor tenotomy and 19 Van Kraayenburg, F.J., Fairall, N., and Littlejohn, A.
realignment shoeing for chronic laminitis. In: (1982). The effect of vertical force on blood flow in the
International Equine Conference on Laminitis and palmar arteries of the horse. In: International Congress
Diseases of the Foot, vol. 5, 50–51. on Equine Exercise Physiology, vol. 1, 144–154.
www.ajlobby.com
885
50
New Implant Systems
Joerg A. Auer
Introduction proximal to the second plate. By squeezing the main clamp

handles together, the proximal plate is pressed firmly
In this chapter, new implant systems that have been down onto the bone surface (Figure 50.3). Once the
recently developed will be briefly described. Most of desired clamping force is reached, an additional handle is
them have not yet been applied in horses, or only in a squeezed to cut the tube flush with the upper plate, leav-
few cases. Additionally, it is not guaranteed that these ing an oval crush site in the tube so that the upper plate
implants will become available for equine use. cannot slip off (Figures 50.4–50.6).
These implants are manufactured from titanium and
are therefore tissue friendly. Minimal adverse reaction is
FlapFix encountered. The limited applications in horses thus far
have all been successful and none of the implants have
The FlapFix™ system (DePuy Synthes, West Chester, PA, needed to be removed.
USA) has been developed for fast, easy, and stable fixation The FlapFix represents an alternative to wire loops. Its
of bone flaps following an osteotomy, craniotomy, or the advantages include rapid application, the increased sta-
treatment of craniomaxillofacial fractures in humans. The bility of the fixation, the increased contact area of the
system has been applied in a few horses (see Figure 41.13 implant with the bone, the inertness of the implant mate-
in Chapter 41).2,5 The implant consists of a round, smooth, rial, and the greater resistance to failure.1 The major dis-
or teethed titanium plate that is centrally connected to a advantage is the cost of the implant, which far exceeds
thin, orthogonally oriented titanium tube (Figure 50.1). the cost of a simple cerclage wire loop.
The plate is slightly cupped to ensure that only the outer
rim makes initial contact with the underside of the bone.
A smooth, also slightly cupped, cloverleaf‐shaped plate is Special Locking Plates
inserted over the titanium tube to provide compression
(see Figure 50.1). The implants are available in three dif- Locking technology has gained rapid acceptance in
ferent sizes, depending on the shape and type of fracture human10 and veterinary traumatology,2,7 and has been
or bone flap needing to be repaired or reaffixed. described in detail in Chapters 8 and 10. In most equine
In a clinical case, the round plate with the perpendicular orthopedic centers, these implants are now routinely
tube is inserted underneath the fractured bone and the applied and represent the technology of choice, espe-
tube exits through the fracture line or the osteotomy cut cially in adult equine fractures.2 It has been shown that
(Figure 50.2). The cloverleaf plate is subsequently lowered the use of two locking‐head screws on either side of the
over the vertical tube and slid down to the bone. An alter- fracture results in a significant increase in construct
native is to slide the cloverleaf plate over the tube, hold it stiffness.3 A study comparing 4.5 mm locking compres-
with the FlapFix clamp, and maneuver the round lower sion plates (LCPs) with 4.5 mm limited‐contact dynamic
plate through the osteotomy cut/fracture line underneath compression plates (LC‐DCPs) confirmed the superior
the bones to be united again (see Figure 50.2) The FlapFix strength and stiffness of the LCP.8 The LCP is presently
clamp is then slid over the tube and applied immediately considered the universal equine plate.

www.ajlobby.com
Figure 50.3 The right FlapFix is applied and tightened, whereas

the left one is presently being tightened with the special clamp.
By squeezing the clamp handles, tension is applied to the tube,
while the clamp pushes the cloverleaf plate down, which results in
solid fixation of the two bone portions trapped between the
FlapFix plates.
Figure 50.1 The assembled FlapFix consists of a toothed round

footplate to which a vertical tube is attached; the cloverleaf‐
shaped top plate is fed over the vertical tube (left). On the right,
the identical implant with a smooth foot plate is shown. Both
implants are manufactured in titanium. Source: © by DePuy
Synthes Inc., West Chester, PA, USA.
Figure 50.4 The FlapFix has now been tightened, and by

squeezing the additional bottom handle of the clamp (arrow),
the tube is deformed and cut, preventing slipout of the
cloverleaf plate.
5.5 mm Locking Compression Plate

Because of the loads exerted on bone plates in equine
patients and the fact that horses need to bear weight on
a repaired fracture immediately postoperatively, a
5.5 mm LCP has been developed. The plate has the
same width as the standard 4.5/5.0 mm LCP and a
thickness of 6.0 mm (0.8 mm thicker than the standard
4.5/5.0 mm LCP; Figure 50.7). Again, this plate was
tested in an in vitro study against the 4.5 mm LCP.9 The
Figure 50.2 One FlapFix is in place (right) and a second one is 5.5 mm LCP was superior in resisting static overload in
being applied to a sinus bone flap in a horse. palmarodorsal four‐point bending and cyclic fatigue
www.ajlobby.com
Figure 50.5 Two FlapFix implants of different diameters are in

place and solidly tightened.
testing. These results were superior to those achieved

with the 5.5 mm LC‐DCP (no longer available). Taken
together, these findings have established the 5.5 mm
LCP as the premier equine plate for long bone fracture Figure 50.6 Ventrodorsal radiographic projection of an equine
fixation and arthrodesis of the metacarpophalangeal or skull, four months following curettage of a sinus infection through
metatarsophalangeal joint. Contouring of this plate is a flap sinusotomy. The sinus flap was secured with two FlapFix
implants (arrows). There is no osseous reaction visible. The
more difficult and requires additional force on the osteotomy is healed.
bending press.
aspect of the equine radius perfectly. The ideal combi-

Human Femoral Locking nation is a 5.5 mm equine LCP applied cranially and a
Compression Plate human femoral LCP applied laterally (Figure 50.8). The
The human femoral LCP represents a standard LCP implants are available in stainless steel and titanium in
with an added slight, continuous, craniocaudal curva- all sizes.
ture when viewed from the side, which makes it ideal
for application to the lateral aspect of the equine radius. Human Distal Femoral Locking
The equine radius has a similar curvature when viewed
from the side. It is therefore not possible to apply a
Compression Plate
straight plate to its lateral aspect and span the entire The human distal femoral LCP represents a forged
bone. Either the middle holes are caudal to the bone or expanded‐head, preshaped, very strong plate that
the proximal holes are cranial to the bone. The shape of contains seven stacked combi holes in the head of the
the human femoral LCP therefore matches the lateral plate and a shaft that contains standard combi holes
Figure 50.7 A standard 13‐hole human 4.5/5.0 mm locking compression plate (LCP; bottom) and a 5.5/5.0 mm 14‐hole veterinary LCP
(top) are shown. Note that both plates are of approximately the same length. The reason for this is that the human LCPs have a beveled tip
on either end, whereas the veterinary plate has a rounded edge at one end, and a stacked combi hole, both of which shorten the plate.
The benefit of the veterinary plate is that it is possible to insert a locking‐head screw near an articular surface, without having the beveled
tip protruding over the articular component. Note the difference in plate thickness.
www.ajlobby.com
Figure 50.9 The top view of a right 5‐hole human distal femoral
locking compression plate. Note that there are three indentations
near the stacked combi hole in the center of the head of the plate
Figure 50.8 A polyurethane model of an equine radius and ulna for fixation to the plate application device. Two 2.5 mm Kirschner
with a long oblique radial fracture repaired by means of a wires can be inserted to stabilize the expanded end of the plate
standard 16‐hole (not veterinary) locking compression plate (note and adjacent bone fragments through the holes at the periphery
the beveled tips at both ends of the plate) applied cranially, and a (gray arrows) and a third hole in one of the indentations (white
16‐hole human femoral plate applied laterally. Note that because arrow). This plate allows the insertion of seven slightly
of the curvature of the plate, it spans the entire radius at its lateral predetermined, diverging locking‐head screws in the head of
aspect without twisting it in the more cranial position proximally. the plate.
4.5 mm Locking Compression Plate

(Figure 50.9). Additionally, there are three dedicated
holes to accommodate 2.5 mm Kirschner wires for tem-
T‐Plate
porary fixation, all arranged around the center stacked T‐plates have been available for many years. The head of
combi hole in the expanded head of the plate. Two spe- T‐plates is arranged at a right angle relative to the long
cific configurations of plate are available, one which con- axis and contains three screw holes, which is a benefit
forms to the medial and the other to the lateral aspect of in situations where a small or short metaphyseal
the distal femur (see Figure 50.9). These can then be fracture needs to be repaired, because the plate allows
interchanged to fit the left or right curvature of equine three screws to be inserted into the small fragment.
bones such as the distal femur. The plate is 5.5 mm thick, Previous versions of these plates were relatively thin,
the shaft has a width of 16 mm, and the shaft length var- and they could only be applied in areas with minimal
ies from 156 (4‐hole) to 179 mm (13‐hole). axial load. Clearly, there has been a need in equine
The benefit is that multiple locking‐head screws in orthopedic surgery for a stronger T‐plate. Lately, DePuy
predetermined, diverging angles can be inserted into the Synthes introduced the 4.5 mm LCP T‐plate, which
smaller fragment. This is especially important when a fulfills the needs of a thicker, more robust T‐plate with
relatively small fragment must be repaired to the main LCP combi holes (Figure 50.11). A precursor of this
portion of a long bone, such as the supraglenoid tubercle plate, with a 7‐hole stem and 3‐hole horizontal bar, a
(Figure 50.10).4 narrow 4.5/5.0 mm T‐shaped LCP, was successfully
www.ajlobby.com
Figure 50.11 A 6‐hole 4.5 mm locking compression T‐plate. Note

that there are two 2.5 mm holes in the horizontal bar to allow the
Figure 50.10 A human distal femoral plate applied to a
insertion of 2.5 mm Kirschner wires to temporarily attach the plate
supraglenoid tubercle fracture of a horse. Four of the screws
to the desired location. The bottom hole of the vertical bar is a
inserted into the head of the plate are visible in the incision, and
stacked combi hole.
the shaft of the plate can be seen at one place further proximally
(arrow). Source: Image courtesy A. Fürst, University of Zurich,
Switzerland.
Variable‐axis Locking‐head Screw

6
applied to a tarsometatarsal subluxation. While the It has been shown that the use of two locking‐head
three stacked combi holes in the T‐portion of the human screws on either side of the fracture results in a signifi-
plate are directed in a distal direction, the respective cant increase in construct stiffness.3 The drawback
holes in the veterinary plate are directed at a 95° angle, of locking‐head screws is the need to insert them
allowing the use of either 4.5 or 5.5 mm cortex screws, perpendicular to the plate holes. This is a disadvantage if
or 4.0 or 5.0 mm locking‐head screws (Figure 50.12).8 plates are applied at axial right angles relative to each
The horizontal bar of the plate is 36 mm long and other, especially if a combination of locking‐head and
13.5 mm wide. The vertical part varies in length between cortex screws is used in both plates.2,7 Since the locking‐
91 mm (4‐hole plate) and 199 mm (10‐hole plate); 6‐ and head and cortex screws are inserted at different ends
8‐hole plates are also available. The vertical bar contains within the combi hole, it becomes increasingly difficult
regular combi holes. The plate thickness measures
to avoid screws in the second plate, because of the
4.2 mm and the width 13.5 mm. complexity of the added variable of screw position in
The plate is usually applied in conjunction with either a each combi hole. As a result of these shortcomings,
broad or narrow 4.5/5.0 mm LCP. The first clinical appli- attempts were made to develop a locking mechanism
cations of these plates included a partial carpal arthrode- that allows the insertion of locking‐head screws at vari-
sis and a step osteotomy in the third metatarsal bone, ous angles. Thus, the variable‐angle locking compression
both of which were successful (Dr. Fabrice Rossignol, plate (VA‐LCP) was created. Screws can be angled
Clinique du Gros Bois, Paris, France). This plate ideally anywhere within a 30° cone around the central axis of
complements either standard, 5.5/5.0 mm LCPs, or the each plate hole (Figure 50.13A). The plate hole has a
human distal femoral LCP (described earlier). cloverleaf shape (Figure 50.13B) containing four threaded
www.ajlobby.com
Figure 50.14 Double drill guide: left for fixed‐angle drilling, right
for off‐axis drilling. Source: © by DePuy Synthes Inc., West Chester,
PA, USA.
regions, where the specially constructed screw head can

interlock with the plate. The head of the variable‐axis
locking‐head screw has a rounded shape to facilitate use
of various angles within the locking hole (Figure 50.13C).
A special double drill guide has been developed that
facilitates drilling of the variable‐axis screw holes on
one end and fixed‐angle drilling on the other end
(Figure 50.14). The nozzle of the drill guide inserts coaxi-
ally into the central hole. The principal difference to the
standard drill guide, which supports the drill bit along its
entire length, is the funnel shape, where the drill bit can
be angled to glide along the wall of the cone at up to a 15°
angle to the central axis, and enter the bone at any posi-
Figure 50.12 Intraoperative view of a 6‐hole preliminary 4.5 mm tion around the perimeter of the 30° cone (Figure 50.15).
locking compression T‐plate applied to the medial aspect of the The first application of these variable‐axis locking‐
tibia in a cadaveric limb. In this plate, the two stacked combi holes head screws was the 2.4 mm VA‐LCP distal Radius
are located at the distal end of the vertical bar, compared to just
the most distal hole in the approved plate. Source: Image courtesy System (DePuy Synthes, West Chester, PA, USA). The
A. Fürst, University of Zurich, Switzerland. plate is anatomically contoured to the volar aspect of the
human distal radius, and is designed to address both
(A) (B) (C)
Figure 50.13 (A) The top of a variable‐axis locking compression plate demonstrating the angles at which a screw can be inserted through
the holes. (B) Bird’s‐eye view of the plate hole design. The four ridges in each of the four holes contain threads, where the screw‐head
threads interdigitate with the plate. (C) Close‐up side view of the screw head, depicting its threads on the rounded head and the star‐drive
design for the screwdriver. Source: © by DePuy Synthes Inc., West Chester, PA, USA.
www.ajlobby.com
2 Auer, J.A. (2012). Principles of fracture treatment.

In: Equine Surgery, 4e (ed. J.A. Auer and J.A. Stick),
1000–1029. St. Louis, MO: Saunders, Elsevier.
3 Florin, M., Arzdorf, M., Linke, B., and Auer, J.A. (2005).
Assessment of stiffness and strength of four different
implants available for equine fracture treatment: a
study on a 20 degree oblique long bone fracture model
using a bone substitute. Vet. Surg. 34: 231–238.
4 Fürst AE. Scapula. AOVET Surgery Reference. http://
www.aovet.org/education/surgeryreference/equine/
scapula (accessed 9 November 2018).
5 Fürst, A.E. and Auer, J.A. (2019). Fractures of the head.
In: Equine Fracture Repair, 2e (ed. A.J. Nixon). 770–799,
Wiley Blackwell.
6 Keller, S.A., Fürst, A.E., Kircher, P. et al. (2015).
Locking compression plate fixation of equine tarsal
subluxations. Vet. Surg. 44: 1–8.
7 Levine, D.G. and Richardson, D.W. (2007). Clinical use
of the locking compression plate (LCP) in horses: a
retrospective study of 31 cases (2004–2006). Equine
Figure 50.15 The off‐axis drill guide is coaxially inserted into a Vet. J. 39: 401–406.
plate hole. With the drill bit leaning at 15° onto the side wall of the
drill guide, total divergent angles of 30° can be achieved through 8 Sod, G.A., Mitchell, C.F., Hubert, J.D. et al. (2008).
the same plate hole in all directions. Source: © by DePuy Synthes In vitro biomechanical comparison of locking
Inc., West Chester, PA, USA. compression plate fixation and limited‐contact
dynamic compression plate fixation of osteotomized
simple and complicated fractures. Subsequently, this equine third metacarpal bones. Vet. Surg.
plate hole design has been applied to other locking plates. 37: 283–288.
For details on the availability of plates allowing the use 9 Sod, G.A., Riggs, L.M., Mitchell, C.F. et al. (2010).
of variable‐axis locking‐head screws, consult DePuy An in vitro biomechanical comparison of 5.5 mm
Synthes VET (www.synthes.vet).4 locking compression plate fixation with a 4.5 mm
locking compression plate fixation of osteotomized
equine third metacarpal bones. Vet. Surg.
References 39: 581–587.
10 Wagner, M. and Frigg, R. (2006). AO Manual of
1 Auer, J.A. (2006). Craniomaxillofacial disorders. Fracture Management: Internal Fixators; Concepts
In: Equine Surgery, 3e (ed. J.A. Auer and J.A. Stick), and Cases Using LCP and LISS. Stuttgart: Thieme
1341–1362. St. Louis, MO: Saunders, Elsevier. Verlag.
www.ajlobby.com
892
Index
Note: Page numbers in italics refer to figures and those in bold to tables.
a regional limb perfusion 862–866, Arthrodesis, proximal

Acepromazine, for laminitis 875 865, 862–866 interphalangeal
in pentafusion 95 resistance to 852 anatomy 283
for postanesthetic myopathy 819 AO instruments 107–117, 108–117 chemical fusion 282
Adaptive remodeling 8, 9 Apophyseal fractures, of ulna complications 289, 289, 290
Adductor myopathy 814–815, 817 545–547, 549 diagnosis 280–282, 281
Adults, criteria for fx repair in 39 Area moment of inertia 18 implant selection 285
Alkaline phosphatase, in fracture Arthrodesis, carpus indications for 277–280, 278–280
healing 27–28, 27 complications 525 laser‐assisted 282
Allografts 166–167, 104 implants for 520–521, 520, 521 minimally invasive 283
Alpha chains, collagen 5–6, 6 indications for 515–519, 516–518 postoperative management
Amikacin 50, 50 postoperative management of 288–289
for osteomyelitis 856, 853 of 524 results of 291–292
preoperative 91, 93, 92 results of 525, 525 surgical technique of 282–288,
Aminoglycosides 93, 92 surgical preparation 519, 519 285, 286, 288–290
for osteomyelitis 856, 853 surgical technique 521–524, 519, Arthrodesis, shoulder
Analgesia 93–95, 96, 97 522–524 for luxation 599–600, 598,
Ancef (cefazolin) 92 Arthrodesis, distal interphalangeal 589, 590
Anesthesia 95–99, 97, 98 anatomy 257 postoperative management
myopathy after 814–820, 815, indications for 257, 258 of 601
816, 819 postoperative management results of 601
perineural 95–96 of 261 surgical technique of 599–600, 598
recovery from 807–813, 809, results and prognosis 262–263, Arthroscopic surgery, of
811, 812 263 carpus 484–488, 484–488
Anesthetic recovery 807–813 surgical technique of 257–261, of distal interphalangeal
Anderson sling for 809–810, 809 259–261 236–237, 237, 238
head and tail rope for 808, 809 Arthrodesis, fetlock of metacarpophalangeal or
medication for 810 complications of 434, 433 metatarsophalangeal joint,
pool for 810–813, 811, 812 diagnosis 426–427 proximal dorsal 321–325,
recovery room design 807–808 indications for 425–426, 426–428 321–325
tilt table for 809 palmar tension band 431–432, 432 proximal palmar or plantar
Angiogenesis 26 pastern tension band 432, 433 330–333, 331–333
Anisocoria, with cranial trauma 775 preoperative support 427–428 Aspiration, in diagnosis of
Anisotropy 14 postoperative management osteomyelitis 855
Antibiotics 91–93, 92 of 433–434 Atlantoaxial fusion 745–748, 747
for osteomyelitis 856–861, 859, results of 434 Atlantoaxial luxation 742–745,
859–862 surgical technique of 429–433, 743–745
local 858–861, 859, 859–862 430–432 Atlantoaxial subluxation 737–742,
prophylactic 91, 92 treatment 428–429 737–742

www.ajlobby.com
Index 893
Atlas, fractures and luxations Bone grafts Calvaria, dorsolateral, fractures

of 736–737, 736, 737 allograft 166–167 of 773, 773
Atracurium 98, 104 autologous 164–166, 165 Callus formation 25–26, 25
Axis, fractures and luxations biology of 163–164 Canaliculi 6, 7, 7
of 745–750, 747–751 cancellous 164–166, 165 Cancellous bone 3
cortical 166 Cancellous bone grafts 164–166, 165
b demineralized 167–168 for implant failure 349
Bandage, after cast removal 206 functions of 163 for osteomyelitis 365, 366
Bandage cast, application 199–201, harvesting sites for 164–166, 165 for sesamoid fracture 365
201–203 integration of 163–164 Cancellous screws 118, 118
Bar shoe, for distal phalanx surgical technique, 164 Cannulated screws 118, 119
fracture 222–224, 224 types of 164–166, 164 set of 113
Basilar skull fractures 775, 775 vascularized 166 technique for 118–119, 119
Baytril (enrofloxacin) 50, 92 Bone graft substitutes 167–168 Capacitive coupling 842, 844
for osteomyelitis 864, 865 collagen 168 y‐carboxyglutamate protein, in
Bending 15–16 demineralized bone 167 fracture healing 27, 28
four‐point 16, 16 Bone growth factors 29, 29, 30, 169, Carpal fractures
three‐point 15, 16 174, 174, 177 accessory 510–512, 510–511
Bending resistance 18 Bone morphogenic proteins (BMPs) avulsion fracture, palmar
Bending stiffness 18 173–177, 174, 174–176 intercarpal ligaments
Bioelectric potential 837, 842 clinical considerations 490–491, 490–491
Biomechanical behavior, of with, 176–177 osteochondral chip 480–490
bone 12–17, 13–16 cloning of human 176 cartilage grading scheme 487
Biomechanical family of 175, 176 categories 485
terminology 11–13, 13 future developments with 176 clinical signs of 482
Blood pressure monitoring, during gene therapy 178–180 incidence and location of 480,
anesthesia 99, 817, 818 osteoinductive potency of 481, 481–482
BMPs See Bone morphogenic 174–177, 174 lag screw, reattachment 488
proteins (BMPs) purification of bovine 173 pathogenesis of 483–486, 483
Bone(s), biomechanical behavior Bone y‐carboxyglutamate protein, in postoperative care for 488, 488
of 14–18, 14–17 fracture healing 27, 28 results with 489–490
cancellous 3 BMP‐2 173–174 surgery for 484, 484
cellular components of 4–5, 4, 5 BMP‐7 173–174 treatment of 484
cortical 3 Bone plates, strengths and palmar 491
geometry of 18 weaknesses of 20, 20 diagnosis 492
inorganic component of 6 Bone substitutes 167–168 incidence 491, 491–492
lamellar 6–7 Bridge, acrylic 788–790, 789 treatment 492–493, 493–494
mechanical properties of 14 Broken screw, set 114–115, 114 results 493–494,
organic matrix of 5–6, 6 technique 115, 115 slab, other carpal bones 503–506,
osteon of 6–7, 7, 8 Bucked shins complex 452–456, 459 504–507
proteoglycans 5 Bupivacaine hydrochloride 94–95, 96 slab, third 494
rate dependency of 17, 17 Butorphanol 47–49, 49 combination, frontal and
response to stress of 8–9 Buttress plate 137 sagittal 499–502, 499, 503
structure of 3–7, 4–8 comminuted collapsing
trabecular 3 c 506–507, 508–509
woven 6 Cable 124 diagnosis of 495
Bone cement 64 Calbindin D9k, in fracture emergency splinting 65–68, 68
with antibiotics 93, 858, 859 healing 27, 28 frontal 496–497, 496–500, 508
for oral fractures 788 Calcaneus, fractures of 622–625, incidence of 495
as plate luting 128, 129, 134, 442 623–625 postoperative care and results
for vertebral fusion 761, 762 Calcium sulfate, as bone for 507–508
Bone differentiation factors 29, 29, substitute 168 sagittal 497, 502
30, 173, 174, 174 as antibiotic carrier surgery for 496–497, 496–498
Bone fatigue 17 bead 861–862, 862 treatment of 495–496
www.ajlobby.com
894 Index
Carpal fractures (Cont’d ) Cerclage wire 124 Compressive loading 13–14, 13

types of 494–495 applications of 133, 363 Compressive stress 13–14, 13
Cast(s), adaptations of 201 Chip fracture(s), carpal 480–490, Computed tomography
bandage cast 199–201, 201–203 481, 481–482 to assess carpal fractures 492, 494,
bivalved 199, 200, 201–202, 206 of proximal phalanx 320–334 504, 506, 519
care of 205–206 palmar or plantar 330–334, to assess condylar fractures 405,
complications of 201–205, 204 332–334 406
equipment required for 192 proximal dorsal 320–327, to assess fracture healing 176
foot 199, 200 321–324, 326 to assess hip fracture and
full‐limb 196–199, 197–198 Chlorhexidine gluconate scrub 101 luxation 706, 708, 709, 717
half limb 192–196, 195 Chondroitin 4‐sulfate, in fracture to assess hock fractures 614,
indications for 188 healing 28, 27 621, 624, 628, 633, 637, 638
materials for 189–193, 190, Ciprofloxacin, for osteomyelitis 854, to assess metacarpal stress
193, 197 859 fractures 457, 462
methods of application of Circulatory failure, from to assess navicular fractures 243
191–199, 192, 195, 197 postanesthetic to assess pelvic fractures 725, 726
for middle phalanx fracture myopathy 819 to assess phalangeal
139–140, 140 Circumferential wiring, for sesamoid fractures 221, 268, 269,
padding for 189, 190, 191 bone fracture 363–365, 364 300, 336
principles of 189 Clipping 99–101 to assess shoulder luxation 591,
removal of 199, 206, 204, 206, 207 Closed fractures 36, 127–128 594, 611, 611
sleeve 199 management of 127–128 to assess skull fractures 771,
tube 199 Cobrahead plate 122, 137, 123 773–775, 784, 795, 797
types of 188 Collagen 5, 6 to assess vertebral fractures 735,
uses of 188 with bone morphogenic 735, 740, 741, 749, 758, 759
Cast, transfixation 206–215 proteins 168 Concussion 800
care and monitoring 213 in fracture healing 27, 27 Condylar fractures, third metacarpal/
complications 214, 214–215 Comminuted fractures metatarsal 738–420
indications 207, 207, 208, 211 of calcaneus 622–625, 623–625 anatomy 378–379
methods for application 210–212, of carpal bones 506–507, biaxial 416, 419
212 508–509 complications 413–414
of proximal phalanx 211, of middle phalanx 267–273, displaced lateral 395–401, 397–398
314–316, 315 267–273 treatment 397–400, 398–399
of middle phalanx 207, 207, casting of 272 etiology 379–381
273–274 complications of 275 incomplete bicortical 385–393,
of radius 529–532 diagnosis of 267–268, 268 386, 389, 390
of third metacarpus and plating of 268–273, 269–270, treatment 387, 389, 390
metatarsus 443–445, 272–273 incidence 381–382
444–445 prognosis for 274–275 lateral, spiral 414–415, 416–418
of tibia 207, 208 transfixation casting medial, spiral 401–413, 402–406
pins for 208–210, 209 of 273–274 lag screws 407–408
principles 208–210 treatment of 268–274, plating 408–411, 409, 410, 412
prognosis 215 269–273 standing screw repair 411
removal 213 of proximal phalanx, nondisplaced, complete
Cast saw 206, 206 moderate 308–311, 305, 308, 393–395, 394–396
Cefazolin (Ancef ) 50, 91, 92, 856, 310, 311 treatment 393–395, 394–395
859, 864 severe 312–316, 313, 315, 316 palmar/plantar cortex
Ceftiofur (Naxcel) 50, 50, 91, 92, of sesamoid bones 371–372, 372 382–385, 383–384
859, 865 of talus 622, 623 postoperative care 411–413
Cellular components, of bone 4–5, Compartment syndrome 817 standing repair 411
4, 5 Competence factors, in fracture types 382
Cephalosporins 91, 92, 93 healing 29 Contact healing 31, 31
for osteomyelitis 856, 859 Complete fractures 35–38 Contracture deformity, with ulna
Cerclage wire set 115 Compressive fracture 15 fracture 550
www.ajlobby.com
Index 895
Coronoid process, fracture of 771, for radial fracture 536–539 Diaphysis 3, 4
771, 797, 798 for third metacarpal or metatarsal Differentiation factors 29, 29, 30,
Cortical bone 3 fracture 441 173, 174, 174
Cortical bone grafts 163–164, DCU (dynamic compression Digital neurectomy, for distal phalanx
164, 166 unit) 121, 137, 156 fracture 222, 223, 224–225
Cortical screws 118, 119 Debridement, and infection 226, for navicular fracture 245, 248,
Corticosteroids, for vertebral 236, 837, 839, 840, 857, 866 249, 254
fracture 746, 748, Decubital sores 205, 857 Dimethyl sulfoxide (DMSO)
for brain injury 771, 800 Delayed union for cranium fracture 771, 776, 802
for post anesthetic myopathy 819 defined 835, 836 for postanesthetic myopathy 818
Countersink 111 diagnosis of 838, 836 for vertebral fracture 746, 748,
Coxofemoral luxation 706–721 etiology of 837 756, 760, 765
computed tomography for 708, infected 838 Distal phalanx fracture(s) See Phalanx
708–709, 717 management of 838–847 fracture(s), distal
closed reduction 708–709 noninfected 839 Distopalmar metacarpal disease
diagnosis 706–708, 706–710 prognosis for 848358 (fragmentation) 334–336, 335
femoral head resection for 711 Deltoid tuberosity fractures, of DMSO See Dimethyl sulfoxide (DMSO)
incidence 706 humerus 549, 574 Dorsal laminectomy, cervical 736,
open reduction 709–715, Demineralized bone graft 167–168 738, 739, 756, 757
711–715 Demineralized bone matrix lumbar 760–761, 761–765
postoperative care 719–720 (DBM) 167–168 Dorsal metacarpal disease
prognosis 720–721 Dens, fracture of 745–748, 745, 747 452–456, 459
Coxofemoral subluxation 715–720 Depth gauge 111 Double drill guide 109, 109
arthroscopy for 715–719, Dermatan sulfate, in fracture Double plate fixation, of middle
717–719 healing 28, 27 phalanx 268–273, 269–273
MRI for 720 Detomidine hydrochloride 48, 48, Drains 37, 128–129, 442, 471, 581,
Cranium fractures, 93–95 691, 693, 693, 756, 765
calvarium 773–776 for postanesthetic Draping, surgical 101–102–103, 103
classification of 770 myopathy 818–819 Drill 108, 108
clinical signs of 771, 774, 775, 775 for standing condylar fracture Drill bits 108–109
causes 773 repair 411 Drill guide 109–111
diagnosis of 774–775, 774, 775, 801 for standing implant removal 827 Durotomy 746, 762, 762
perioperative considerations Dexamethasone sodium phosphate Dynamic compression
with 775 for cranium fracture 776 plate (DCP) 120, 121
postoperative care for 776 for postanesthetic myopathy 819 application of 131–136, 135–136
prognosis for 776 for vertebral fracture 746, 756, 760 for diaphyseal fractures of
treatment, conservative 775–776, DHS (dynamic hip screw) plate 117, humerus 576–582, 577–582
800–802 120, 123, 124 for mandibular fracture
treatment, surgical 776 application of 140, 141, 445 787–788, 788, 789
Culture(s), bacterial intraoperative for femoral fractures 690, 701, 702 for middle phalanx
852–856, 853, 856 Diaphyseal fractures fracture 268–273, 269–273
Cultured cell therapy 179,‐182 of femur 688–694, 689–693 for proximal humerus
Cutting cone 7, 8 of humerus 574–584, 575–576 fracture 569–674, 69, 73
Cytokines, in fracture healing 29, 29 of radius 527–535, 528–537 for radius fracture 533–537,
of third metacarpus and 534–537
d metatarsus 436–446, 437 for scapula fracture 609–610,
DBM (demineralized bone complications and prognosis 610, 611
matrix) 167–168 with 446 for third metacarpus or
DCP See Dynamic compression diagnosis of 436 metatarsus fracture
plate (DCP) dynamic compression plates 436–446, 437
DCS (dynamic condylar screw) for 437–443, 437–441 for ulna fracture 546–562,
plate 117, 123 treatment methods for 552–562
application of 140, 141 437–446, 437–445 limited‐contact (LC‐DCP)
for carpal arthrodesis 520, 521, 525 of tibia 656–660, 649–650, 657–659 120, 121
www.ajlobby.com
896 Index
Dynamic compression unit External skeletal fixation (ESF), Fetlock fractures, proximal phalanx
(DCU) 121, 137, 156 classification of devices dorsal frontal type 328–330, 329
Dynamic condylar screw (DCS) for 146–152, 147, 148 proximal dorsal osteochondral
plate 117, 123 equine device for 125–126, chip type 320–327,
application of 140, 141 150–152, 151, 152 321–324, 326
for carpal arthrodesis 520, instruments for 125 proximal palmar or plantar
521, 525 mechanical characteristics fragmentation type
for femur fracture, 696 of 147–149, 147, 148 296–298, 297, 303, 330–334,
for radial fracture 536–539 of middle phalanx 273–274 332–334
for third metacarpal or metatarsal pin insertion for 149–150, 150 standing arthroscopic chip
fracture 441 of proximal phalanx 316, 316 removal 327
Dynamic hip screw (DHS) of radius 529–532 Fetlock joint, luxation of 336–338,
plate 117, 120, 123, 124 strengths and weaknesses 336
application of 140, 141, 445 of 21–22, 21, 147–149, Fetlock osteochondrosis 327–328
for femoral fractures 690, 147, 148 Fetlock palmar osteochondral
701, 702 surgical technique for 150 fragmentation disease
transfixation casting in 206–215 334–336, 335
e FGF (fibroblast growth
Edrophonium chloride 98 f factor) 30, 30
EGF (epidermal growth factor) 30, 30 Fatigue fracture 18 Fiberglass casts See Cast Materials
Elastic energy 13 Fatigue loading 18 Fibroblast growth factor
Elastic region 13, 13 Fatigue studies, of metacarpal stress (FGF) 30, 30, 177
Elbow joint, splinting of fractures fractures 453–455 First aid
proximal to 70, 86–87 Femoral fractures for fractures of distal
Electrostimulation, for diaphyseal 688–694 hindlimb 87, 87
nonunions 840–844 conservative for fractures of femur 88
Emergency treatment See First aid treatment 694, 694 for fractures of middle and
Eminence fractures, of middle complications of 695–696, 697 proximal metatarsus 87
phalanx 265, 266–267, diagnosis of 688–689, 689 for fractures of middle and
277, 279 surgical repair 689–693, proximal radius 86, 86
biaxial 266–267, 266 690–693 for fractures of
uniaxial 265, 266, 279–280, distal physeal 672–675, 674–675, midforelimb 86, 86
279–280 688, 689, 693–696 for fractures of phalanges
Endochondral ossification 3 prognosis for 695 and distal metacarpus
Enrofloxacin (Baytril) 50, 92 surgical repair of 672–675, 85–86, 85
for osteomyelitis 864, 865 693–695, 694–696 for fractures of tibia and
Enzymes, structural, in fracture greater trochanter 703, 703 tarsus 87, 88
healing 27–28, 27 proximal physeal 696–700 for fractures proximal to elbow
Epicondylar fractures, of complications of 702 joint 86–87
humerus 569, 584–585, 585 diagnosis of 696–697, 698 moving fracture patient in 75–77,
Epidermal growth factor prognosis 702, 703 76, 77, 83, 88–89
(EGF) 30, 30 surgical repair of 698–700, objectives of 83–84
Epiphyseal fractures, of ulna 699, 700 splinting in 84, 84
546–551, 548, 549 splinting of 73–74 systemic medication in 89
Epiphysis 3 subtrochanteric Fixateur externe 125
Equine External Skeletal fractures 698–702 Fixation See Fracture fixation
Fixator 125–126, 150–152, diagnosis 697, 700 Flagyl (metronidazole) 92, 93,
151, 152 surgical repair 701–702, 129, 859
Equipment See Surgical equipment 700, 702 Flexural modulus 18
and implants third trochanter 704 Flunixin meglumine,
ESF See External skeletal fixation (ESF) Femoral head ostectomy 711, for postanesthetic myopathy 819
Exostosis, from proximal 716, 717 for vertebral fracture 748
interphalangeal Fetlock arthrodesis See Arthrodesis, Forceps, reduction 105, 113, 133,
arthrodesis 291 fetlock 134, 785, 786
www.ajlobby.com
Index 897
Fracture(s) See also under specific growth factors, cytokines, and h

anatomy, e.g., Radial prostaglandins in 29–30, Half‐pin splints 147–148, 148
fractures 29, 30 Haversian canal 5, 6, 7
in adults 39–41 mechanisms of 24, 25, 31 Haversian remodeling 9, 26–28, 26,
chip See Chip fractures phases of 24–26, 31 31, 31
classification of 36–37 primary (direct) 31 Haversian system 6–8, 7, 8
closed 36 principles of 24, 25 Head tilt 735, 748, 749, 750, 775, 802
complete 36–38 progenitor stem cells for 180–182 Healing, fracture See Fracture
comminuted. See Comminuted secondary (indirect, healing
fractures spontaneous) 25, 31 Heart‐bar shoe 275, 585
compressive 15, 15 structural proteins and enzymes Hematoma, from cranial
configuration of 37 in 27–28, 27 trauma 775–776, 802
delayed union of. See Delayed Fracture reduction devices Hematopoietic marrow 3, 8
union 104–105, 104 Hemorrhage, from cranial
fatigue 17 Fracture reduction set 113 trauma 775
in foals 39–40 Fracture repair, general Heterotopic bone 167
high energy 17 considerations in selecting Hindlimb, splinting of distal 87
incomplete 37–38 cases for 35–39, 36 Hock, fractures
low energy 17 Fracture table 102, 103 diagnosis of 613–614, 614, 615
malunion of 847–848, 842, 847 Fracture union, delayed See also incidence of 613
nonunion of See Nonunion(s) Delayed union of calcaneus 622–625, 623–625
open 36–37, 37 mechanisms of 31 of central and third tarsal
slab See Slab fractures Fragment distractor set 115–117, bone 635–640, 636–641
splint bone See Splint bone 116 of distal tibia 632–635, 632–635
fractures Fragmentation, distopalmar of fourth and second‐first tarsal
stable 36 metacarpal 334–336, 335 bone 641
stress See Stress fractures proximal palmar or plantar, of of talus, comminuted
tensile 14, 14 proximal phalanx 330–334, fracture 622, 623
unstable 37 332–334 of talus, sagittal fracture
very high energy 37 Frontal bones, fracture of 776–781, 618, 622
Fracture fixation, cerclage wire 776–782 of talus, trochlear ridges
application in 133 Full‐pin splint 147–148, 148 614–617, 616–621
dynamic condylar screw and of tibial malleoli,626–632,
dynamic hip screw application g 626–632
in 140, 141 Gap healing 25, 26 Hock, luxations of, 614, 641–645,
external See External Skeletal Gentamicin (Gentocin) 50, 50, 91, 642–645
Fixation 92, 93 Hoof acrylic 196
implant removal in 823–830 for osteomyelitis 856–858, 859, Huckstep nail 125
intramedullary 19–20, 19, 864 Humeral fractures
142–146, 143, 145 Gloves 104 deltoid tuberosity 574
management of soft‐tissue injuries Glycosaminoglycans 5–6 diagnosis of 567–569, 68
in 127–129, 128 GM‐CSF (granulocyte macrophage‐ distal condylar and
plating in 133–141, 135–136, colony stimulating epicondylar 584–585,
139, 141 factor) 29, 29 584, 585
relative strengths and weaknesses Gowns, surgical 104 emergency splinting 70
of methods of 19–22, 19–21 Grafts See Bone grafts greater tubercle 569–573,
screw application techniques Granulocyte macrophage‐colony 570, 571, 573
in 129–133, 130 stimulating factor incidence of 567
transfixation casting in 206–215 (GM‐CSF) 29, 29 management of 569
Fracture healing Greater tubercle fractures, of middle and distal diaphyseal
cellular therapy in 180 humerus 569–573, 570, 574–582, 575–582
contact 25 571, 573 open reduction and
gap 25, 31 Growth factors 30, 30, 173–178, intramedullary interlocking
gene therapy in 178–180 174, 174–176, 181 nail 581–584, 583
www.ajlobby.com
898 Index
Humeral fractures (Cont’d) Inorganic component, of bone 6 for distal phalanx fractures
open reduction and plating Instruments, AO 107–117 226–236, 227, 229–236
576–582, 577–582 Insulin‐like growth factors for greater tubercle fractures 572,
postoperative care 585 (IGFs) 29, 30, 117 573
prognosis for 586 Interdental space, fractures of 781, for nondisplaced condylar
proximal 569–573, 569, 573 784, 787, 787, 792, 792–794 fractures 393–395, 394–396
types of 569–570 Interleukin‐1 (IL‐1) 29, 29 for sagittal fractures of proximal
Hydroxyapatite, as bone Interleukin‐6 (IL‐6) 29, 29 phalanx 303–307, 302, 303
substitute 168–169 Interlocking nails 128, 144–146, for sesamoid bone fractures
Hypertrophic nonunion 835 145–146 358–363, 360–362
applications of 581–584, 583, 693 for tarsal bone 618, 622,
i development of 144–145 635–640, 636–641
IGFs (insulin‐like growth for femoral fracture 693 for uniaxial eminence
factors) 29, 30 for humeral fractures 581–584, fractures 265, 266, 279–280,
IIN fixation See lntramedullary 583, 586 279–280
interlocking nail (IIN) fixation material properties of 144–145 Lamellae 6, 7, 8
IL‐1 (interleukin‐1) 29, 29 technique in equine 145–146, Lamellar bone 6
IL‐6 (interleukin‐6) 29, 29 145, 146 Laminectomy, dorsal, cervical 736,
Immobilization, inadequate 837 Intertarsal joint, luxation of 738, 739, 756, 757
Implant(s), AO 107 proximal 641–643, 642 lumbar 760–761, 761–765
biomechanical principles Intramedullary fixation 19–20, 19, Laminitis 874–883
of 833–834 142–146, 143, 145 center of pressure in 876
corrosion 832 Intramedullary implants 19–20, 19, clinical signs 874–875, 875
failure of 831 142–146, 143, 145 deep flexor tenotomy for 876
intramedullary 19–20, 19, Intramedullary interlocking nail (IIN) foot cast for 879, 880
142–146, 143, 145 fixation 128, 144–146, frog and sole support 881–883, 883
loading of 831–832, 832 145–146 incidence 874
loosening of 37, 147, 837, 839 applications of 581–584, 583, 693 load redistribution
mechanical and sectional development of 144–145 in 876–877, 879
properties of 831, 831 for humeral fractures 581–584, radiography for 874
osteomyelitis from 857, 866, 867 583, 586 sinking in 876, 879, 877
removal of 823–830 material properties of 144–145 treatment and prevention
soft‐tissue injuries due to 832 technique for 145–146, 145, 146 876–878, 877, 878
technical problems with 833–834 Intramedullary pins 19–20, 19, unweighting the limb 880–881,
Implant removal 823–830 142–144, 143 880–882
complications 830 Intramedullary rods, strengths and vascular perfusion in 875–876, 877
indications 823 weaknesses of 19–20, 19 LC‐DCP (limited‐contact dynamic
preoperative Involucrum 470, 624, 854 compression plate) 120, 121,
preparation 827–828 Irrigation, and infection 91, 478, 137
postoperative 623, 773, 857 “Leg Saver” splint 56, 58, 59, 59
management 829–830 Isoflurane 98–99 Lengthening plates 123
risks 823 Isotropy 9, 14 Linear strain 13
surgical technique 828–829, Load(s) defined 12
828–830 k Load‐deformation curve 12–13, 13
timing 823, 824, 825, 827 Ketamine 94, 95, 97 Loading, combined 14, 17, 14
Incisive bone, fractures of 776, 781, Kirschner–Ehmer frame 21, 21, 790 compressive 15–16, 15
780, 790, 792, 792, 793 fatigue 18
Incomplete fractures 37–38 l tensile 14, 14, 16
Inductive coupling 842, 844 Lacunae 6, 7, 8 Loading mode 14, 14, 15, 21
Infection, from open Lag‐screw technique 129–131, Limited‐contact dynamic
fracture 36–37, 837 See also 130, 131 compression plate (LC‐
Osteomyelitis for deltoid tuberosity 574 DCP) 120, 121, 137
Inflammatory phase, of fracture for displaced lateral condylar Locking compression plate
repair 24–25 fractures 395–401, 397–398 (LCP) 138–140, 139
www.ajlobby.com
Index 899
application of 156–161 Matrix y‐carboxyglutamate protein, in proximal metatarsus 447–448

design 156, 157 fracture healing 29, 29 prognosis 446
equine 5.5mm LCP 886–887, 887 Matrixins, in fracture healing 27, 28 transfixation casts for 443–444,
human distal femoral LCP Maxillary fractures 776–784 444, 445
887–888, 888, 889 incidence 776, 776, 777 Metacarpus and metatarsus, third,
human femoral LCP 887, 888 orbital 781, 783, 784 fracture of the condyles See
surgical technique 158–161, treatment 777–781, 778–782 Condylar fractures
159, 160 M‐CSF (macrophage‐colony Metacarpus, stress fractures of
T‐plate LCP 888–889, 889, 890 stimulating factor) 29, 29 diagnosis of 452–453, 453, 454
Locking head screws, 112, 119, 157, 158 Mechanical properties, of bone 14 pathogenesis of 453–455, 454
variable axis locking head Mesenchymal stem cells 29, 174, treatment of 455–463, 458–462
screw 889, 890, 891 846, 858 Metacarpus, third
Luxation(s) Metacarpal and metatarsal bones, small, osteochondritis dissecans
atlantoaxial 742–745, 743–745 (splint) fractures of 465–478 of 327–328
coxofemoral 706–717, 706–717 complications of 471 splinting of 63–64, 63–67
of fetlock joint 336–338, 336 distal portion strain surfaces 22
of hock 641–645, 642–645 clinical signs 465–466, 466, 467 Metalloendopeptidases, in fracture
of shoulder 588–601, 589, treatment 466–468, 468 healing 27–28, 27
590, 591–599 excision, lateral splint 478 Metalloproteinases, in fracture
middle third, body, healing 27–28, 27
m clinical signs 468–469, 469 Metaphyseal fractures, of
Macrophage‐colony stimulating treatment 470–471, 470 radius 536, 540
factor (M‐CSF) 29, 29 postoperative care for 478 Metaphyseal fractures, third
Malleoli, fractures of 626–633, prognosis for 478–479 metacarpus and
626–632 proximal, body, metatarsus 449, 449
Malunion 847–848, 842, 847 clinical signs 470–471, 471–472 Metaphysis 3–4
Mandibular fractures 781–798 plating 472, 478, 473–478 Metatarsal bones, small, fractures of
See also “Skull fractures, treatment 475–478, 475–478 See Metacarpal and
mandible and incisive bone suspensory adhesions metatarsal bones, small,
clinical signs of 781 with 470, 474 fractures of
etiology 781–782 hyaluronate membranes Metatarsophalangeal joint, luxation
external fixator for 790 for 470, 474, 473–477 of See also Fetlock joint,
horizontal body 794–795, suspensory desmitis luxation of
794–796 with 465, 468, 467 proximal palmar or plantar
incidence of 781 Metacarpal disease, dorsal fragmentation of 330–334,
interdental space, incisive and 452–456, 459 332–334
maxilla 792, 793 Metacarpophalangeal joint, luxation Metatarsus, third
interdental space, mandible 792, of 336–338, 336 condylar fractures See Condylar
793, 794 proximal dorsal osteochondral chip fractures
pinless fixator for 790, 791 fractures diaphyseal and metaphyseal See
surgical technique for 783–790 of 320–327, 321–326 Metacarpus and metatarsus,
incisor wiring 785–792, 786, proximal palmar or plantar diaphyseal and metaphyseal
787, 791, 792 fragmentation of 330–334, fracture
intraoral wires 783–785, 787 332–334 middle and proximal fractures,
polymethylmethacrylate and Metacarpus and metatarsus, splinting of 71, 72, 87
wire 788–789 diaphyseal and metaphyseal proximal 447–448
screws and plates 787–789, fracture strain surfaces of 22
788, 789 diagnosis 436 Metronidazole (Flagyl) 92, 93,
treatment overview 782–783, 785 diaphyseal 436–446, 437 129, 859
temporomandibular joint distal metaphyseal 449–450, 449 MIC (minimal inhibitory
797–798, 797 internal fixation of 437–443, concentration), of
vertical ramus 794–798, 795 437–441, 443 antibiotics 856, 858, 859
Mannitol, for cranial proximal metacarpus 446–447, Middle phalanx fractures See Phalanx
fracture 800, 802 446–448 fractures, middle
www.ajlobby.com
900 Index
Midforelimb fractures, splinting prognosis 248–254 Osseous distraction 837

of 86 treatment, rest and Osteitis 727, 727, 773, 837, 838, 851
Mineral portion, of bone 6 shoeing 248–249 Osteoblasts 4, 4
Minimal inhibitory concentration types 242–245, 243, 244 Osteocalcin, in fracture healing 27,
(MIC), of antibiotics 856, Neurologic deficits, with cranium 28, 856
858, 959 fracture 773–774, 801 Osteochondral chip fractures,
Mitogenic factors, in fracture Neuromuscular blocking agents 98, of carpus 480–490,
healing 29, 30 99, 592 481–485, 481
Morphine 49, 49, 93–95, 746, 810 Neutralization plate 137 of proximal phalanx, palmar or
Muscle crush syndrome 816 Nonsteroidal anti‐inflammatory plantar 330–334, 332–334
Myoglobinemia 815 agent 49, 93, 95, 456 of proximal phalanx, dorsal
Myoglobinuria 815 Nonunion(s), atrophic 835 320–327, 321–326
Myopathy, postanesthetic 814–820 avascular 835 Osteochondritis dissecans, of
blood pressure and 817–818 bisphosphonates for 847 metacarpus 327–328
clinical presentation of 814–815 bone graft for 840, 844 Osteoclasts 4–5, 5
compartment syndrome and 817 bone marrow aspirate for 845 Osteoconduction 163–164
etiology of 816–817 bone morphogenetic proteins Osteocytes 4, 5
incidence 814 for 845, 846 Osteogenesis 163, 164, 167, 167
pathologic appearance of 815, defined 835 inducers of 30, 30
815, 816 diagnosis of 835, 836, 838, 839 Osteogenic growth peptide 174,
prevention of 817–818 dystrophic 835 174, 176, 178
reperfusion injury in 816–817 electrostimulation for 840–844 Osteoinduction 163–164
triceps 814, 817, 819 etiology of 837 by bone morphogenetic proteins
treatment of 818–820, 819 hypertrophic 835 173–177, 174, 174–176
infected 835–838, 837, 840 Osteomyelitis
n management of 835–847, 840–843 antibacterials for 856–857
Nails, intramedullary 19, 144–146, mesenchymal stem cells for 846 antibiotic‐laden beads for
145, 146 mildly hypertrophic 835 858–861, 859–862, 859
applications of 145–146 necrotic 835 antibiotic‐laden plaster of paris
development of equine nail 144–145 noninfected 840 for 861
for humeral fractures 247–250, 251 nonviable 835 bone graft for 857
material properties of 145 oligotrophic 835 causes of 851
reaming and placement of 144–146 parathyroid hormone for 846 clinical signs of 853–856
Nasal bones, fracture of 770, 771, platelet derived growth factor curettage for 857
777, 777–779 (PDGF) for 846 definitions of 851
Naxcel (ceftiofur) 50, 50, 91, 92, platelet rich plasma (PRP) delayed union or nonunion due
859, 865 for 845–846 to 835–838
Navicular bone fractures 242–255 prognosis for 848 diagnosis of 853–856, 854, 855
anatomy 242 pulsed ultrasound for 844 general considerations with 851
chip fractures 254 shockwave for 844 implant removal for 866–867,
clinical signs 245–246 vascular 835 867, 868
complications 250 viable 835, 842 innovative treatment for 858–860
diagnosis 246–247, 246, 247 intravenous and intraosseus
etiology 245 o regional perfusion for
incidence 242 Olecranon body, fractures 862–866, 862–866, 865
internal fixation, c‐clamp 251, 251 of 531–562, 52 minimizing risk of 868
internal fixation for 249–259, Open fractures 36–37, 37 organisms in 852–853, 853
250, 251 management of 28–129 pathophysiology of 852
internal fixation, jig 250–251, 250 type I, 36 results of treatment for 868
multipartite 254–255 type II 36 surgical debridement for
palmar digital neurectomy type III 37 866–867, 867, 868
for 249, 254 Organic matrix, of bone 5–6, 6 treatment of 856–858
pathology 248 Orthotopic bone 167 Osteon(s) 5, 6–7, 7, 8
treatment, coaptation 249 Oscillating bone saw 117 primary 6–7
www.ajlobby.com
Index 901
remodeling of 8–9 incidence of 723 palmar osteochondral 265–266

secondary 7, 8, 31, 31 prognosis after 732 plating of 268–273, 269, 270,
Osteonectin, in fracture healing 27, scintigraphy for 726, 726, 728 272, 273
27–28 treatment by internal prognosis for 274–275
Osteopontin, in fracture healing 27, fixation 728–731, 730, 731 simple 265
27–28 tuber coxae 725, 727 transfixation casting of 207, 207,
Osteoprogenitor cell 163, 168, 173, tuber ischia 726, 729 273–274
174, 174, 178–179 Penicillins 50, 50, 91–93, 92, 129 treatment of 268–274
for osteomyelitis 856, 863 types of 265–268, 266–270
p Pentoxifylline, for laminitis 876 Phalanx fractures, proximal
Padding, and postanesthetic Perineural anesthesia 94–95, 96, 97 chip type of 320–327, 321–324,
myopathy 100, 817, 820 Perioperative period 326, 330–334, 332–334
Padding for cast 188–200, 190, 191, analgesics in 93–95, 96, 97 diagnosis of 296–300
193, 192 anesthesia in 95–99, 97, 98 displaced sagittal and sagittal‐
Padding for recovery room 807 antibiotics in 91–93, 92 oblique 307–308, 307, 308
Pain control 48–49, 49, 93–95, fracture reduction devices dorsal frontal 297, 301, 328–330,
96, 97 in 104–105, 104 299, 306, 329, 330
Palmar chip fractures, of carpal positioning in 99, 100–102 emergency care 61–62, 63
bones 491–494 preparation of surgical team external skeletal fixator
diagnosis 492 in 103–104, 103 for 316, 316
incidence 491, 491–492 skin preparation in 99–101 in foals 316–317, 317
results 493–494 surgical draping in 102–103, 103 major 295, 303–316
treatment 492–493, 493–494 Periorbital rim fractures 781, 783, 784 medial collateral avlusion
Palmar chip fractures, of proximal Periosteal callus cells 17, 26, 26 296–297, 298, 301, 336, 337
phalanx 330–334, 332–334 Periosteum 4 moderately comminuted
Palmar eminence fractures, of middle Phalanx fracture(s), distal 308–311, 305, 308, 310, 311
phalanx 265, 266–267, complications 234 nondisplaced sagittal 303–307,
277, 279 diagnosis and treatment of 302, 303
biaxial 266–267, 266 221–226, 222 pin‐cast combinations for
uniaxial 265, 266, 279–280, extensor process fracture 314–316, 315
279–280 treatment 236–238, 237–239 postoperative considerations
Palmar osteochondral fracture, of incidence of 221 with 311
middle phalanx 265–266 internal fixation 238, 239 proximal dorsal osteochondral
Palmar wing fracture, of proximal lag screw repair, single 229, 230, chip type 320–327,
phalanx 296–298, 297, 303, 231, 233, 234 321–324, 326
332, 330, 333–334 lag screw repair, double 229–236, proximal palmar or plantar (wing)
Pancarpal arthrodesis 507, 232, 235, 236 fragmentation type
515–525, 521, 522, 525 neurectomy for 224 296–298, 297, 303, 330–334,
Parallel screw method, for proximal postoperative care 234 332–334
inter‐phalangeal surgical repair of, internal severely comminuted 312–316,
arthrodesis 282–288, 285, fixation 226–238, 227, 228 313, 315, 316
286, 288–290 types of 222–226, 223–226 short sagittal 297–298, 300, 301
Pastern joint, subluxation of 264, Phalanx fractures, middle smaller 296–299, 296, 297
265, 277, 278, 279–282 anatomy of 264 surgical preparation for 300
Patellar fractures 678–682, 680–682 comminuted 267–273, 267–273 surgical technique for 301–311,
See also Stifle fracture, casting of 272 310, 311
involving the patella complications of 275 types of 296–299
Patellectomy, partial 680–682, 681 diagnosis of 267–268, 268 splinting of 85–86, 85
PDGF (platelet‐derived growth etiology of 265 Phenylbutazone 48–49, 93, 95
factor) 30, 30, 177, 846 of palmar and plantar eminences for postanesthetic myopathy 819
Pelvic fracture 723–732 265, 266–267, 277, 279 Physeal fractures, types 40, 41
computed tomography biaxial 266–267, 266 of femur, distal 672–675,
for 725, 726 uniaxial 265, 266, 279–280, 674–675, 688, 689, 693–696
diagnosis of 723–727, 724–727 279–280 prognosis for 695
www.ajlobby.com
902 Index
Physeal fractures, types (Cont’d) removal of 823, 824, 825, Proximal interphalangeal arthrodesis
surgical repair of 672–675, 826–829 See Arthrodesis, proximal
693–695, 694–696 standard 20, 20, 107, 120, interphalangeal
of femur, proximal 696–700 120, 121 Proximal phalanx fractures See
complications of 702 T‐plate LCP 888–889, 889, 890 Phalanx fractures, proximal
diagnosis of 696–697, 698 third tubular 122
prognosis 702, 703 Platelet‐derived growth factor r
surgical repair of 698–700, (PDGF) 30, 30, 177, 846 Racetrack fracture management,
699, 700 Plate luting 20, 128, 134 first aid
of tibia, proximal 651–655, and implant failure 834 analgesics 48–49, 49
652–655 for radial fracture 538 antibiotics 50, 50
Physical examination 35, 95, 205 for third metacarpal or metatarsal bandaging 51–53, 51–53
Physis 3, 41 fracture 442 bandage cast 53, 54
Pin(s) 125, 142 Plate overbending 535, 608, 834 casts for 53–54
transfixation 206–210, 209 Plate set 108, 110, 114 clinical assessment 47
Pin‐cast combinations, for severely Plate‐screw technique 132 compression boots 54–56, 55, 56
comminuted fracture Plating 20, 113, 133–137, 135, 136 dorsal splints 56–58
of proximal phalanx of middle phalanx 268–273, 269, horse ambulances 74–77, 76–77
314–316, 315 270, 272, 273 initial 45
Pin insertion, for external fixation Polar moment of inertia 18 insurance compliance 46
device 150–152, 151, 152 Polymers, with bone morphogenic pathogenesis of fractures 44
Pin stiffness, in external fixation proteins 167, 168, 169, regulatory considerations 45–47
device 149 175–176, 175 sedation 48, 48
Plantar eminence fractures, of middle Polymethylmethacrylate beads, splints, fetlock and phalanges
phalanx 265, 266–267, 277, 279 antibiotic‐impregnated 93, 57–60, 57–60, 62–67, 63–67
biaxial 266–267, 266 858–861, 859, 859–861 splints, hindlimb fracture 71–74,
uniaxial 265, 266, 279–280, Pool recovery 810–813, 811, 812 72, 73
279–280 Positioning, and postanesthetic splints, upper forelimb
Plantar or palmar fragmentation myopathy 817–818 fracture 68–74, 68–71
(wing), of proximal perioperative 99–101, 100, 101 specific fracture, emergency
phalanx 296–298, 297, 303, Position‐screw technique 6–7, 132 care 60–74
330–334, 332–334 Povidone‐iodine scrub 101, 192, temporary immobilization 50–60
Plaster of Paris 207, 251 Radius fractures
as antibiotic delivery 861 Power drill 108, 108 complications 541–543, 542
as bone substitute 168 Premaxilla (incisive), fractures concurrent with ulnar
casts of 54, 189 of 781–787, 786, 787 fracture 535–536, 539
Plastic energy 12 Pressure‐stretch myopathy 816 diagnosis of 527–528, 528, 529
Plastic region 13, 13 Progenitor (stem) cell emergency splinting 69, 69, 70
Plate(s) 120–124, 120 therapy 181–182 external coaptation and
additional miscellaneous genetically modified 182 transfixation pinning
types 123 homing 181 of 529–532
buttress 133, 137, 438, 438, 520 targeting 181 external fixators for 533
dynamic compression 20, 120, transplantation 181 in foals 540–541, 540
121, 133–134, 135, 136 Prognosis, factors that determine 36 incomplete 529–531, 528, 531
for fetlock arthrodesis 429–433, Progression factors, in fracture internal fixation of 533–537,
430–432 healing 28, 29, 29 534–537
lengthening 123 Prophylaxis, antibiotics for metaphyseal 536, 540
limited‐contact dynamic 91–93, 92 preoperative assessment
compression 120, 121, Prostaglandins, in fracture 527–529, 530
123, 137 healing 24, 29, 29, 30, 163, postoperative management of 541
locking compression (LCP) Proteins, structural, in fracture prognosis for 543
138–140, 139 healing 24–27, 27 splinting of 530
modified cobrahead 122, 137, 123 Proteoglycans 5–6 treatment of 529–537, 534–537
neutralization 137 in fracture healing 27, 27 Radius. strain surfaces of 22
www.ajlobby.com
Index 903
Ramus, vertical, mandible fractures stress fracture in 605, 605 prognosis for 352–353, 357,
of 794–798, 795 treatment by, supraglenoid internal 366, 370
Rate dependency, of bone 17, 17 fixation 607–608, 608 sagittal 370–371, 371
Reaming, for interlocking treatment by, supraglenoid surgical techniques for 348, 353,
intramedullary resection 605–606, 607 356, 358
nails 143–145 treatment for, neck and surgery, midbody, bone
Recovery pool 810–813, 811, 812 body 609–610, 610, 611 graft 365–366
Recovery room 807–808 treatment for, scapular surgery, midbody,
Reduction devices 104, 104, 115, 116 spine 610, 611 conservative 358
Reduction forceps 113, 134, 135 Screw(s) 117, 118 surgery, midbody,
Remodeling, of osteons 8–9 application techniques for 129–132 hemicircumferential
Remodeling phase, of fracture broken 114 wiring 363–365, 364
repair 26 cancellous 118, 118, 118 surgery, midbody, screw
Renal failure, from postanesthetic cannulated 118, 119 fixation 358–363, 360–362
myopathy 819–820, 819 cortical 117, 118 types of 348–372
Reparative phase, of fracture dynamic condylar and dynamic Sesamoid fracture, distal See
repair 25 hip 117, 123, 140 Navicular fracture
rhBMP‐2, 173–174, 174, 174 headless 119 Sesamoid clamps 358–359
Ring sequestrum, at transfixation pin locking head 119, 112 Shaft fracture, of third metacarpus
site 149–151, 150, removal of 132 or metatarsus
213–214, 214 self‐tapping 117 diagnosis 436
Ruffled border, 5 sizes of 118, 132 diaphyseal 436–446, 437
Rush pins 125, 144 Screwdriver 112 internal fixation of 437–443,
Screw head, lysis of 393, 401, 437–441, 443
s 823–824, 825 Shear modulus 14
Sacrum, fractures of 763–765, 765 Screw rack 108, 109, 110 Shear strain 14
Sagittal fractures, of distal phalanx, Screw set 113 Shear stress 14, 14, 16, 16, 17
222, 225, 225, 231 cannulated 113, 118 Shock 47, 83, 89, 800
of carpal bones 497–500, 502, 503 cortical, 3.5 mm 114 Shoe covers 102, 103
of proximal phalanx 297–308, cortical, other 117, 118 Shoulder luxation 588–601
300, 302, 304, 307 lag 118 anatomy of 588
of sesamoid bones 370–371, 371 locking head 119 clinical signs with 591, 592, 593
of talus 618–622, 622 Scrub, surgical 101 computed tomography for 594
Salter–Harris fractures, types 40, 41 Sedation 48, 48, 89, 95 etiology of 588–591
type I, of ulna 546–549, 547, 548 Self‐tapping screws 117 postoperative care 601
type II, of femur 672–675, 674, Seroma, from femur fracture 693, prognosis 601
688, 689 695–6, 697 prevalence 588, 589, 590
of tibia 648–649, 651–655 Sesamoid bone fractures, radiography 591–594, 591,
of ulna 548 proximal 341–373 594–596
type III, of femur 675 abaxial 353–358, 354, 355 reduction of 592–593
type IV, of femur 674, 689 anatomy of 341–342 reduction, and arthrodesis
Saucer fractures, metacarpal apical 348–352, 349, 350, 351 for 599, 599, 600
452–462, 458–461 apical‐abaxial 352–353, 354, 355 reduction, and internal fixation
Saw, oscillating 108, 117 basilar 367–370, 368, 369 for 593–595, 597
Scapular fractures classification 344 reduction, and tension band
clinical signs and diagnosis of, neck comminuted or stabilization 576–598,
and body 604–605, 604, 605 biaxial 371–372, 372 597, 598
clinical signs of, supraglenoid emergency care 64, 67 Skin, preparation of 99–101
tubercle 603–604, 604 etiology of 342–343 protection of 83
emergency care of 70–71 external trauma 372–373 Skull fracture 770–773
etiology of 603 in foals 344–347, 345, 346 anatomy 770
incidence of 603 incidence 343–344 diagnosis 771
prognosis for, supraglenoid midbody 358–365 incidence 770–771
tubercle 609 postoperative care for 351, 356, 366 treatment overview 772–773, 772
www.ajlobby.com
904 Index
Skull fractures, calvarium 773–776 Sling, for laminitis 880, 881, 882 tibia and tarsus 72–73, 73, 87, 88
basilar 773–775, 775 Sling, for postanesthetic proximal to elbow joint 70–71,
diagnosis 774–775, 801, 774, 775 myopathy 815, 819 70, 86
etiology 773–774 Sling, for radius fracture 527–529, temporary immobilization 50–60
prognosis 776 528 upper forelimb fracture 68–74,
treatment, conservative 775–776, Soft‐tissue injuries, delayed union and 68–71,
800–802 from implants 832 Stable fractures 36
treatment, surgical 776 management of 127–129, 128 Stacked pin fixation 142–144, 143
Skull fractures, facial nonunion due to 833, 837 of humerus 143, 143, 575, 581
bones 776–784 Somatomedin C (IGF‐I) 29, 30–31, Steinmann pins 125, 142–144
incidence 776–707, 776, 777 175, 177 Stem cells See Progenitor stem
nasal bone 770, 771, 777, 777, Sores, cast 201–205, 201 cell therapy
778, 779 Splintage, Sternebrae, bone graft from
orbital fracture 781, 783, 784 full‐pin 146–153, 148, 151, 152 164–166, 165
treatment 777–781, 778–782 half‐pin 146–151, 148 Stiffness 13–14, 13, 19
Skull fractures, mandible and incisive Splint(s), fiberglass 52, 56, 63, 85, 87 Stifle fracture, involving the,
bone 781–798 Splint bone fractures 465–478 cruciate attachments 668, 678,
clinical signs of 781 complications of 471 670, 671, 679
etiology of 781–782 distal portion, diagnosis 664–665, 665
incidence of 781 clinical signs 465–466, incidence 664
horizontal body, mandible 466, 467 femoral condyles 668–672,
794–795, 794–796 treatment 466–468, 468 669–673
interdental space, incisive and excision, lateral splint 478 femoral epiphysis 672–676,
maxilla 798, 793 middle third, body, 674, 675
interdental space, mandible 792, clinical signs 468–469, 469 femoral trochlear ridges
793, 794 treatment 470–471, 470 666–668, 667, 668
surgical repair 783–798 postoperative care for 478 patella 678–681, 680, 681
external fixator 790 prognosis for 478–479 apex fragmentation 682, 682
incisor wiring 785–787, 786, proximal, body, chip 680–682, 681
787, 791, 792 clinical signs 470–471, complete 682–686, 683–686
intraoral wires 783–785, 787 471–472 tibia, intercondylar
pinless fixator 790, 791 plating 472, 478, 473–478 eminence 676–677, 676, 677
polymethylmethacrylate and treatment 475–478, 475–478 tibial crest 677–678, 678
wire 788–789, 789 suspensory adhesions Stockinette 102, 103, 189, 192, 193,
screws and plates 787–789, with 470, 474 194, 195, 199, 200, 212
788, 789 hyaluronate membranes Strain(s) 12
temporomandibular joint for 470, 474, 473–477 defined 13
797–798, 797 suspensory desmitis with 465, linear 13
treatment overview 782–783, 785 468, 467 measurement of 13, 13
vertical ramus 794–798, 795 Splinting, emergency care, shear 13
Slab fractures, carpal, third 494 distal hindlimb 71, 72, 87, 87 Strain surfaces, of specific bones 22
comminuted collapsing 506–507, femur 73–74, 88 Strength 11–12
508–509 fetlock and phalanges 57–60, Stress(es), compressive 12, 13–14
diagnosis of 495 57–60, 62–67, 63–67 defined 13
emergency splinting 65–68, 68 hindlimb fracture 71–74, 72, 73 measurement of 13–14
frontal 496–497, 496–500, 508 intraoral 330–331, 331 normal 13
incidence of 495 middle and proximal response of bone to 9–11
postoperative care and results metatarsus 71, 72, 86, 86 shear 13
for 507–508 middle and proximal tensile 13, 14
sagittal 497, 502 radius 69, 69, 70 units of 13
surgery for 496–497, 496–498 midforelimb 69, 86, 86 Stress concentration factor 19
treatment of 495–496 phalanges and distal metacarpus Stress fractures, metacarpal,
types of 494–495 61–63, 63, 85, 85, diagnosis of 452–453, 453, 454
Sling, for anesthetic recovery third metacarpus or pathogenesis of 453–455, 454
809–810, 809 metatarsus 63–64, 63–67 treatment of 455–463, 458–462
www.ajlobby.com
Index 905
Stress fractures, tibial 650, 650, broken 114 Third metacarpus See Metacarpus,
651. 660 cancellous 118, 118, 118 third
Stress‐generated potential 842 cannulated 118, 119 Third metatarsus See Metatarsus, third
Stress ratio 17–18 cortical 117, 118 Third tubular plates 114, 120,
Stress risers 18–19 dynamic condylar and dynamic 122, 474
Stress–strain curve 13–14, 13 hip 117, 123, 140 Three‐dimensional tent
Stress–strain ratio 13 headless 119 fixation 147, 148
Structural proteins and enzymes, in locking head 119, 112 Tibia, proximal, bone graft
fracture healing 27–28, 27 removal of 132 from 164–166, 165
Subluxation, atlantoaxial 737–742, self‐tapping 117 Tibia, strain surfaces of 22
737–742 sizes of 118, 132 Tibial fractures,
of pastern joint 264, 265, 277, Surgical gowns 103–104 diagnosis of 648, 649
278, 279–282 Surgical scrub 99–101 diaphyseal 656–660, 649, 650,
Sulfonamides 92, 853 Surgical team, preparation of 657–659
Supraglenoid tubercle fractures, 103–104, 103 incidence of 648
clinical signs of 603–604, 604 Suspensory desmitis, with splint bone incomplete 650–651, 660,
prognosis for 609 fractures 465, 468, 467 660, 650
treatment by, internal Synthetic bone substitutes 168–169 management of 651–659
fixation 607–608, 608 bioactive glass 169 minimally invasive plating
treatment by, resection biologic/synthetic 659–660, 659
605–606, 607 composites 169 postoperative care for 660–661
Surgical draping 102–103, 103 ceramics 168–169 prognosis for 661–662, 662
Surgical equipment and glass ionomers 169 proximal physeal 651–655,
implants, AO 107–125 652–655
cerclage wire in 124 t splinting of 72–73
for external fixation 125 Talus, fractures of, stress 650–651, 660, 650, 651
intramedullary implants comminuted 622, 623 of tuberosity 655–656, 649, 655,
as 125, 142 sagittal 618, 622 656, 662
new developments in 885–891 Tap 111–112 types of 648–650, 649, 650, 651,
plates 120–124, 120 Tarsal bone fractures, central and 655, 656, 660
additional miscellaneous third 635–640, 636–641 Tibial malleoli, fractures of
types 123 fourth and second‐first 641 626–632, 626–632
buttress 133, 137, 438, 438, 520 splinting of 72, 73, 73 Tibial tuberosity, fractures of
dynamic compression 20, 120, Tarsocrural joint luxations 655–656, 649, 655, 656, 662
121, 133–134, 135, 136 641–642, 642, 645 Ticarcillin 91, 92, 92, 858, 859
for fetlock arthrodesis Tarsometatarsal joint, luxations of, Titanium implants 107, 119,
429–433, 430–432 614, 641–645, 642–645 125, 715,
lengthening 123 emergency splinting 73 for interlocking intramedullary
limited‐contact dynamic Teeth, injuries to 781–787 nails 125
compression 120, 121, Temporohyoid osteopathy 798, 800 Toe elevation, from proximal
123, 137 Temporomandibular joint, fracture or interphalangeal
locking compression luxation of 797–798, 797 arthrodesis 291
(LCP) 138–140, 139 Tensile fractures 14, 14, 15 Toggling 104
modified cobrahead 122, Tensile loading 14 of femoral fracture 690
137, 123 Tensile stress 13, 14, 16 of radial fracture 534
neutralization 137 Tension 14, 14 Torque 19
removal of 823, 824, 825, Tension‐band wires, in fetlock Torque limiting device 112
826–829 arthrodesis 431–432, 432 Torsion 16, 16
standard 20, 20, 107, 120, Tension device 112, 112 Torsional resistance 19
120, 121, Tent fixation, three‐ Torsional stiffness 19
third tubular 122 dimensional 147, 148 Toughness 12, 13
T‐plate LCP 888–889, 889, 890 TGF‐B (transforming growth T‐plate LCP 654–655, 655, 888,
screws 117, 118 factor‐B) 29, 30, 173, 174, 889, 890
application techniques 177, 845 Trabecular bone 3
for 129–132 T‐handle 111 Traction 99, 104, 104, 105
www.ajlobby.com
906 Index
Transfixation casting 206–215 with proximal radius sacral and caudal (coccygeal)
of middle phalanx 207, 207, fracture 558, 560 763–767, 765, 768
273–274 surgical technique 552–562, incidence 763
pins for 207–209, 209 553–562 diagnosis 763–765, 765, 766
of radial fractures 529–532 Union, bone, delayed See Delayed treatment 765–767, 765
of third metacarpal and metatarsal union thoracolumbar 759–763,
fractures 443–445, 444–445 mechanisms of 25–26, 25 diagnosis 759–760, 760
Transfixation wiring, for sesamoid Unstable fractures 36, 48 dorsal spinous process 759, 759
bone fractures 363–365, 364 and splinting 84 incidence 759
Transforming growth factors 29, pathologic 760, 760
30, 173, 174, 177, 845 v treatment 760–763, 761–764
Transportation, ambulance 75–77, Vascular endothelial growth Vision, with cranial trauma 774,
76, 77 factors 177 775, 781
Tricalcium phosphate, as bone Vascularized bone grafts 166 Vitamin D‐dependent protein, in
substitute 167, 168–169, 846 Ventral plating, of cervical fracture healing 27, 28
Triceps myopathy 814, 817, 819 vertebrae 748, 750, 750, Vitamin K‐dependent protein, in
Trimethoprim‐sulfamethoxazole 755–756, 755 fracture healing 27, 28
(Tribressin) 92, 776, 853 Vertebral fractures 734–767
for osteomyelitis 776, 853 cervical, atlas and axis, w
Trochlear ridges, fracture of fractures 734–752 Walking bar cast 210
614–617, 616–621 atlantoccipital 734–735, 735 Winches, fracture reduction 99,
Tropocollagen 5, 6 atlas 736–737, 736, 737 101, 104, 104, 105, 535,
Tuber coxae, bone graft from atlantoaxial luxation 742–745, 539, 576, 711
164–166, 165 743–745 in rope recovery 808, 809
fracture of 725, 727 atlantoaxial subluxation Wing fracture, of proximal
737–742, 737–742 phalanx 296–298, 297, 303,
u axis body 750–751, 750, 751 330–334, 332–334
Ulnar fractures 545–564 axis dens 745–748, 747 Wolff ’s law 9
anconeal process 550, 550, 551 axis, cranial articulation Woven bone 7–9, 25, 26
apophyseal and epiphyseal 748–750, 748, 749
546–551, 548, 549 cervical C2–C3 kyphosis x
complications 563, 564 751–752, 751 Xylazine 48, 48, 49, 89, 93
classification of 546–547, 547 cervical, middle and caudal combination for anesthetic
diagnosis of 545 752–756, 752–754 induction 97
incidence of 545 dorsal laminectomy 756, 757 for implant removal 821
management of 546–562, pedicle or facet 756–758, for postanesthetic
552–562 757, 758 myopathy 818–819
monteggia fracture 558 pathologic 758–759, 759
of olecranon body 531–562, 552 ventral plating 748, 750, 750, y
postoperative care of 562–563 755–756, 755 Yield 12, 13
prognosis for 564–565 incidence 734 Young’s modulus 13, 13
www.ajlobby.com

Equine Fracture Repair 2nd Edition

Uploaded by

Copyright:

Available Formats

You might also like

Equine Fracture Repair 2nd Edition

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Equine Fracture Repair 2nd Edition

Uploaded by

Copyright:

Available Formats

Equine Fracture Repair

Alan J. Nixon, BVSc, MS, Diplomate ACVS

Limit of Liability/Disclaimer of Warranty

Library of Congress Cataloging‐in‐Publication Data

Set in 10/12pt Warnock by SPi Global, Pondicherry, India

1 Bone Structure and the Response of Bone to Stress 3

4 General Considerations for Fracture Repair 35

5 Racetrack Fracture Management and Emergency Care 44

6 First Aid and Transportation of Equine Fracture Patients 83

8 Surgical Equipment and Implants for Fracture Repair 107

9 Principles of Fracture Fixation 127

10 Application of the Locking Compression Plate (LCP) 156

11 Bone Grafts and Bone Substitutes 163

12 Biologic Agents to Enhance Fracture Healing 173

13 Casting and Transfixation Casting Techniques 188

Part II Specific Fractures 219

14 Fractures of the Distal Phalanx 221

15 Fractures of the Navicular Bone 242

16 Arthrodesis of the Distal Interphalangeal Joint 257

17 Fractures of the Middle Phalanx 264

18 Arthrodesis of the Proximal Interphalangeal Joint 277

19 Fractures of the Proximal Phalanx 295

20 Fractures and Luxations of the Fetlock 320

21 Fractures of the Proximal Sesamoid Bones 341

22 Fractures of the Condyles of the Third Metacarpal and Metatarsal Bones 378

23 Arthrodesis of the Metacarpo/Metatarsophalangeal Joint 425

24 Fractures of the Third Metacarpal/Metatarsal Diaphysis and Metaphysis 436

25 Third Metacarpal Dorsal Stress Fractures 452

26 Fractures of the Small Metacarpal and Metatarsal (Splint) Bones 465

27 Fractures of the Carpus 480

28 Arthrodesis of the Carpus 515

29 Fractures of the Radius 527

30 Fractures of the Ulna 545

31 Fractures of the Humerus 567

32 Luxation of the Shoulder 588

33 Fractures of the Scapula 603

34 Fractures and Luxations of the Hock 613

35 Fractures of the Tibia 648

36 Fractures of the Stifle 664

37 Fractures of the Femur 688

38 Luxation and Subluxation of the Coxofemoral Joint 706

39 Fractures of the Pelvis 723

40 Fractures of the Vertebrae 734

41 Fractures of the Head 770

42 Medical Aspects of Traumatic Brain Injury in Horses 800

Part III Postoperative Aspects of Fracture Repair 805

43 Systems for Recovery from Anesthesia 807

44 Postanesthetic Myopathy 814

45 Implant Removal 823

46 Orthopedic Implant Failure 831

47 Delayed Union, Nonunion, and Malunion 835

49 Stress‐induced Laminitis 874

50 New Implant Systems 885

Stephen B. Adams, DVM, MS, Diplomate ACVS Cornell University

Preface to the Second Edition

­Preface to the First Edition

­Introduction tions, called trabeculae, enclosing the cavities within the

Equine Fracture Repair, Second Edition. Edited by Alan J. Nixon.

Medullary cavity Figure 1.2 Light microscopic image of a 5 μm undecalcified

Preface to the First Edition

Introduction tions, called trabeculae, enclosing the cavities within the

Response of Bone to Stress

Introduction called loads.19 Loading a structure such as bone causes

shear strain, which causes a change in the angular relation

Mechanisms of Fracture Union

Introduction system (CNS) must also be evaluated, particularly in the

Introduction Racehorses have a commodity value either for contin

ecessarily will be less effective as a form of immobiliza

difficult to be confident whether this is a result of disarm