Equine limbs Fractures: The Incidence and Management

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INTRODUCTION. Equine fractures are usually resulted in serious conditions manifested by lameness. A comprehensive fracture classification is important for the ...
Minufiya Veterinary Journal Vol. 8 (1): 247-261 Special Issue for the 8th Scientific Conference of Faculty of Vet. Med., University of Sadat City

7-10 April, 2014

Equine limbs Fractures: The Incidence and Management S., Gadallah1, M., El-Keiey2, M.S., Amer3, and A.A. Shamaa2 1 2

Depart. of Surgery, Anesthesiology and Radiology, Faculty of Veterinary Medicine, University of Sadat City. Depart. of Surgery, Anesthesiology and Radiology, Faculty of Veterinary Medicine, Cairo University.

Abstract During the period from January 2010 to September 2012, 400 equine species were admitted to surgery clinic, faculty of veterinary medicine, Cairo University as well as some private horse clinics around Giza province. These cases were suffering musculoskeletal disorders. Out of all admitted cases 55 fracture cases were diagnosed and managed in 34 fore- and 21 hind limbs. Descriptive details of all fracture cases included animal species, age, sex, weight, type of work, cause of fracture, fractured bone, clinical and radiological signs were collected and analyzed to determine the incidence of fracture among equine population. Fracture management in this study was categorized into non-surgical and surgical methods. The first method was conservative while the second was surgical and included tans-skeletal fixation and internal fixation via lag screw and double bone plating techniques. Euthanasia was the proper treatment in compound and hopeless fracture cases. All treated cases were evaluated according to the designed score system. The obtained results showed that the incidence of fore limb fracture was 60.7 % compared with those recorded in hind limb (39.3%). The right fore and hind limbs recorded the highest incidence (29.9% and 15.6 % respectively) Metacarpal and metatarsal fractures recorded the highest incidence while ulnar, carpal, proximal sesamoidal and patellar fractures recorded the lowest incidence. Conservative treatment in terms of stall rest , administration of NSAIDs and limb casting using fiberglass cast alone or augmented with polyvinylchloride pipe (PVC) gave satisfactory results in terms of adequate stability and complete weight bearing in standing posture in most of cases particularly those included metacarpal and metatarsal regions .The use of trans-skeletal and internal fixation gave promising results in treatment of most of fracture cases particularly those recorded in the radius , metacarpus and digit of foals and donkeys so this study recommended that animals weighing 80-250 kg. are good candidates for surgical reconstruction. In conclusion, the present study emphasized on the necessity of weight, age, sex, type of fractured bone, clinical and radiological signs and the cost of treatment while dealing with equine fractures. Key words: Equine limbs, Fractures, Incidence, Internal fixation, External fixation

INTRODUCTION Equine fractures are usually resulted in serious conditions manifested by lameness. A comprehensive fracture classification is important for the veterinary orthopedist who would comprehend the method of reduction and subsequent treatment and fixation in such cases (Bramlage, 1983). There was a

significant correlation between the type of bone and the fracture configuration (Fürst et al., 2008) Fractures of the scapula and femur are seldom to be occurred because of the protection afforded to these bones due to its position and the extensive surrounding soft tissues (Stashak, 1987).Incomplete humeral 247

Minufiya Vet. J. 8 (1): 247-261 fractures are most commonly recognized in race horses and are particularly difficult to be diagnosed (Nixon et al., 1996). Radial fractures are significantly orthopaedic emergencies in adult horses (Watkins, 2006). Fractures of the ulna are relatively common in foals and adult horses (Levine and Meagher, 1980). Carpal bones fracture is frequently occurred as result of heavy falls or run over by street cars (Auer et al., 1990). Distal limb fractures are the most common cause for equine euthanasia in all types of race horses. Fractures of the digit were recorded in all the phalanges with different limb prevalence (Ratzlaff et al., 1990). The basics of fracture management in the horse have the same basic guidelines established for humans and small animals. Many techniques can be derived from them, but some principles are unique in the treatment of equine long bone fractures (Auer 1999; Fackelman et al., 2000; and Johnson, Houlton et al., 2005). Principles of equine fracture treatment depend mainly on prevention of further soft tissue damage, debridement of necrotized and contaminated tissues, and stabilization of fracture fragments. Nonsurgical management techniques include stall rest and external Cooptation (Fessler and Turner, 1983) while surgical management includes; trans-skeletal fixation (Nunamaker and Richardson, 1992 McClure et al., 2000), internal fixation including pins (Nixon et al., 1996 and Fitch et al), lag screw (Perren and Buchanan, 1981), and bone plates (Auer and Stick, 2006). The aim of the present study is to determine the incidence of fore and hind limbs fractures in equine species with trials to manage some of them.

and farms around Giza province from Jan. 2010 till Sept. 2012. All presented cases were suffered musculoskeletal disorders. The fractured cases (55 cases) were selected and identified according to the affected region and fractured bone, with complete animal identification, case history and anamnesis, physical examination, complete musculoskeletal system examination and finally radiographic examination for confirmation of diagnosis and complete fracture identification. Observation of gait abnormalities was done during rest and motion positions for detection of the lameness character. The lameness degrees were determined according to the lameness grading system (AAEP). The suspected animal was prepared for examination via tranquillization using Xylazin HCl (Anased® Lloyd Lab., USA.) 1.1 mg/kg.b.wt and Acepromazine (Acepromazine® Butler Co., Dublin) 0.02 mg/kg.b.wt that were administered intravenously. The radiographic examination was performed using a mobile x-ray machine (Ficher Machine, Eureka X-ray tube/ Model EMerald-125, 1985, U.S.A). A portable x-ray tube (Toshiba/ Model D-183BS/12496/1988, Japan) was used for radiographic examination of the field cases. The used exposure factors were 60-75 kVp, 1 mAs (for mobile machine), 3 mAs (for portable tube) and 90 cm focal film distance. General intravenous anaesthetic regimen has been used, included premedication by Xylazine HCl (Anased® 10%) 1.1 mg/kg.b.wt. i.v. and Acepromazine (Aceproject®) 0.02 mg/kg.b.wt, i.v. and induction using Ketamine HCl (Ketamine®10%) bolus 2.2 mg/ kg.b.wt, i.v.. The maintenance was performed using Triple Drip Mixture “TDM” (Ketamine HCl 1gm+Xylazine HCl 0.5gm+ Glyceryl Guaiacolate “Gauiphenesin®” 25gm) that were dissolved in 500 ml. Dextrose 5% (Dextrose® 5%) solution. TDM was administered at a dose rate 3 drops/ sec. / 500 kg.b.wt, i.v along the desired time of the operation. Preoperative preparation was preformed including, preparation of the affected limb for aseptic surgery and controlling the animals in lateral recumbency with the affected limb upper most. External fracture reduction was

MATERIALS & METHODS A survey study was performed on 400 equine cases (250 horses, 2 ponies, 145 donkeys and 3 mules) of both sexes, the age of them ranged from 4 months to 15 years old with body weight range 80-500 Kg, and its type of work was sport/show or draught. They were presented at the clinic of the department of Surgery, Anesthesiology and Radiology, Faculty of Veterinary Medicine, Cairo University besides some private horse clinics 248

Minufiya Vet. J. 8 (1): 247-261 performed via either manual traction (extension and counter extension forces) or through indirect traction by a wire fixed to the hoof from two pre-drilled holes in its wall. After obtaining adequate reduction; fracture management was performed through conservative and surgical methods. The conservative methods included confinement and stall rest, external fixation (limb casting), intra-articular injection and medicinal treatment (Nixon et., al 1996). The surgical methods included; trans-skeletal fixation (TSF) and internal fixation, the later composed from lag screw and bone plate fixation methods (Fackelman et al., 2000). Euthanasia was used in hopeless cases or according to the owner requisite. It was performed under humanitarian method the animal was tranquilized using Anased® then intravenous euthanasia was done using over dose of Thiopental® (30 mg/kg.b.wt) and Potassium Chloride oversaturated solution i.v. (Doherty &Valverde, 2006). The selected method of treatment was differed according to the fractured bone (Table 1).Post-operative management including, immediate postoperative radiographs, Maxipim® i.m course for 7 days and ketofan® for 3 days and

pressure bandage at the operation site. Daily wound dressing was performed with Betadine. Dynacast was applied at one week P.O. The obtained results were analyzed according to the designed score system Good (G): Adequate alignment, rigid fixation and complete weight bearing in standing posture, Fair (F): Inadequate alignment, incomplete fixation and partial weight bearing in standing posture and Poor (P): Mal-alignment, unstable fixation and non-weight bearing (deadly lame) in standing posture. RESULTS The obtained results revealed that the incidence of equine limb fracture was differed according to the affected limb; the fore limb fractures represented 34/55 (61.8%) while this incidence was 21/55 in hind limbs (38.2%). The right fore and hind limbs recorded a higher incidence 35/55 (63.6%) than the left fore and hind limbs 20/55 (36.4%). The incidence of fractures in all recorded cases was illustrated according to the affected bone in (Table 2 ), besides descriptive details of 55 equine limb fractured cases were recorded and analyzed according to the designed score system (Table 3 & 4).

Hind limb (21 cases)

Fore-Limbs (34 cases)

Region

Table (1): The distribution of fractured cases in relation to fracture management:

Fractured Bone

No. of cases

Humerus Radius Ulna Radius & Ulna Carpus Metacarpal Bones Phalanx I Phalanx II Digit Phalanx III Proximal sesamoids Distal sesamoid Femur Patella Tibia Metatarsal Bones Phalanx I Digit Phalanx II Total

3 8 1 2 1 10 2 1 3 1 2 4 1 5 7 2 2 55

Fracture Management Conservative surgical Dyna Dyna cast + TransInternal cast Polyvinylskeletal Lag chloride pipe fixation Bone plate screw (TSF) (PVC) 0 0 0 0 0 2 1 1 1 0 1 0 0 0 0 1 0 0 0 0 1 0 0 0 0 0 5 2 1 0 0 2 0 0 0 0 1 0 0 0 0 2 0 0 1 0 0 0 0 1 1 0 0 0 0 1 0 0 0 0 1 0 0 0 0 1 0 0 0 1 3 0 0 2 0 2 0 0 0 0 2 0 0 0 0 26 3 2 3 3

249

Euthanasia

3 3 0 1 0 2 0 0 0 0 1 3 0 3 2 0 0 18

Minufiya Vet. J. 8 (1): 247-261

(Table 2): The incidence of fracture according to the fractured bone in 55 equine cases Region

Fore-Limbs (34 cases)

Hind limb (21 cases)

Left

Right

Number of cases

%

Humerus

0

3

3

5.5

Radius

2

6

8

14.5

Ulna

0

1

1

1.8

Radius & Ulna

0

2

2

3.6

Carpus

0

1

1

1.8

Metacarpal Bones

6

4

10

18.2

Phalanx I

1

1

2

3.6

Phalanx II

0

1

1

1.8

Phalanx III

1

2

3

5.5

Proximal sesamoids

0

1

1

1.8

Distal sesamoid

1

1

2

3.6

Femur

2

2

4

7.5

Patella

0

1

1

1.8

Tibia

1

4

5

9.1

Metatarsal Bones

4

3

7

12.7

Phalanx I

1

1

2

3.6

Phalanx II

1

1

2

3.6

20

35

55

100

Fractured Bone

Total

250

Minufiya Vet. J. 8 (1): 247-261 Table (3): Descriptive details of 55 fore and hind limbs fracture in equine species:Case No.

Animal

Age

Sex

Weight (Kg)*

36

Horse

2y



300

Sport

Rt. Humerus

60

Foal

6m



170

Sport

Rt. Humerus

73

Horse

6y



400

Draught

Rt. Humerus

25

Foal

2m



80

Sport

Rt. Radius

43

Horse

3y



300

Draught

Rt. Radius

44

Horse

7y



450

Draught

Rt. Radius

46

Foal

8m



200

Draught

Rt. Radius

52

Horse

4y



450

Draught

Rt. Radius

56

Horse

5y



400

Draught

Lt. Radius

61

horse

5y



400

Draught

Lt. Radius

Horse

11 y



450

Draught

Rt. Radius

17

Horse

3.5y



350

Draught

Rt. Ulna

18

Horse

3y



400

Draught

Rt. Radius & Ulna

19

Horse

2.5y



300

Draught

Rt. Radius & Ulna

64

Horse

3y



350

Draught

Rt. Carpus

4

Horse

3y



350

Draught

Lt. Metacarpus

6

Foal

8m



170

Sport

22

Foal

6m



180

Sport

Work

Fractured Bone

Fracture Description Clinical Radiological Open, complete, single midshaft oblique spiral fracture Deadly lame, shoulder Complete single, mid-shaft, swelling, dropped elbow spiral overlapped fracture. Deadly lame, shoulder and Complete, diaphyseal single elbow swelling, pain fracture Medial old open wound Open single, transverse exposing radius with necrosis diaphyseal overlapped fracture Deadly lame, fore-arm Complete metaphyseal swelling till carpus, crepitus transverse overlapped fracture Pregnant, deadly lame, pain, Multiple mid-shaft fracture abnormal movement, swelling Deadly lame, fore-arm Complete single transverse swelling, crepitus, dropped diaphyseal fracture elbow. Deadly lame, swelling, Complete long oblique crepitus, dropped elbow diaphyseal fracture Swelling, crepitus, abnormal Comminuted distal diaphyseal movement and conformation fracture. Deadly lame and dragging, physeal fracture extending to swelling, crepitus metaphysis (Salter Harris II)

Treatment

Result

Euthanasia

-

Euthanasia

-

Euthanasia

-

Direct skeletal fixation

F

External fixation by Fiber glass cast enforced with metal splint

F

Conservative

P

Surgical management by double plate fixation technique (fig .1)

G

Euthanasia

-

Euthanasia

-

External fixation using fiber glass cast.

P

Euthanasia

-

Conservative by stall rest.

P

Euthanasia

-

Conservative and stall rest

F

Old 4th carpal bone chip fracture

Conservative by intra-articular injection and bandaging(fig.2)

F

Deadly lame, manus swelling, crepitus

Complete transverse distal diaphyseal with longitudinal fr.line in the proximal end

External fixation by fiber glass cast

F

Rt. Metacarpus

Pain, swelling, crepitus, abnormal movement

Complete , transverse, distal diaphyseal fracture

Treated with external fix. by Dynacast. Then with external skeletal fixation.(fig.3)

G

Lt. metacarpus

Open old medial metacarpal wound exposing distal fr. Segment.

complete diaphyseal metacarpal fracture.

Euthanasia

66

Swelling, pain, crepitus, abnormal movement. Lameness variable (IV-V), pain, toeing, elbow swelling Deadly lame, dropped elbow, swelling and abnormal movement Lameness (IV-V), pain, slight swelling, toeing Hard swelling, abnormal conformation, difficult flexion

251

Fracture type 5 (body fracture line extending to joint) Complete, oblique, proximal diaphyseal radial and transverse ulnar body fracture Radial fissure and complete transverse ulnar body fracture

-

Minufiya Vet. J. 8 (1): 247-261 23

Horse

3y



300

Draught

Rt. Metacarpus

24

Horse



-

Draught

Lt. Metacarpus

41

Horse

3.5y 4.5 y



300

Draught

Lt. Metacarpal

42

Horse

2y



300

Sport

Rt. Metacarpals

51

Horse

3.5y



400

Draught

Lt. metacarpals

55

Horse

4y



400

Draught

Lt. metacarpals

57

Foal

7m



200

Sport

Rt. Metacarpals

69

Horse

3.5y



300kg

Draught

70

Horse

6y



350kg

Draught

26

Horse

5y



400

Draught

Rt. Fore 2nd phalanx

7

Donkey

4y



250

Draught

Rt. Fore 3rd phalanx

15

Horse

3y



350

Draught

Rt. fore 3rd Phalanx

16

Horse

4y



400

Draught

21

Donkey

4y



250

Draught

27

Horse

4y



350

Sport

53

Horse

2.5y



300

Draught

Rt. Fore 3rd phalanx Rt. Fore proximal sesamoids Rt. Fore distal sessamoid Lt. fore distal sessamoid

11

Foal

1y



270

Sport

Rt. Femur

29

Horse

2y



300

Sport

Lt. Femur

47

Foal

2m



150

Draught

Rt. Femur

75

Foal

20 d



45

Sport

Lt. Femur

54

Horse

5y



450

Sport

Rt. Patella

Lt. fore 1st Phalanx Rt. Fore 1st phalanx

Previously treated with malunion Previously treated animal Swelling, abnormal movement and posture, crepitus

Mid-diaphyseal fracture with callus formation Segmental mid-shaft fracture

Direct skeletal fixation(fig.4)

F

External fixation by casting

F

-

External fixation by Fiber glass cast

-

Swelling, abnormal conformation, crepitus, pain

Comminuted mid-shaft MTc III and distal splints fractures

External fixation using fiber glass cast augmented with PVC and metal splints(fig.5)

F

Medial bleeding metacarpal wound exposing bone shaft Medial bleeding wound exposing bone, deadly lame Deadly lame, abnormal conformation, pain Variable lameness (IV-V), pastern swelling, toeing

Open Comminuted mid-shaft fracture. Open comminuted proximal diaphyseal fracture Old Comminuted proximal diaphyseal fracture in all MCs Comminuted fracture (intraarticular pastern joint) Multiple fracture, fr.line extend to fetlock j.

Euthanasia

-

External fixation by PVC cast. Then euthanized External fixation using fiber glass cast.

F

External fixation

P

External fixation

P

Comminuted fracture

External fixation with fiber glass cast

P

Complete, abaxial fracture

Lag screw (fig.6)

G

Accidental incomplete hoof separation

Small solar fragmentation with palmar process.

Hoof trimming and fracture segments extraction with application of hoof bandage.

p

Lameness III degree increased with trotting

Old Splinter fracture of the extensor process

External Fixation with cast

F

III degree lameness with fetlock swelling.

Old complete, transverse midbody fracture

Surgical management by Lag screw fixation(fig.7)

F

Intermittent lameness III to IV degree.

Longitudinal mid-body fracture

Conservative with stall rest.

F

Complete hoof sloughing.

Para-sagittal fracture

Euthanasia

-

Deadly lame, stifle swelling , abnormal conformation Stifle swelling, deadly lame, limb extension

Complete supracondylar (Salter-Harris I) Supracondylar displaced (Salter-Harris II) Epiphyseolysis, (supracondylar fracture in situ). Salter-Harris V

Euthanasia

-

Euthanasia

-

Conservative management and stall rest.

P

Segmental shaft fracture

Euthanasia

-

Transverse articular fracture

Conservative with stall rest

F

Toeing, deadly lame, swelling IV to V degree lameness and deadly lame by trotting with swelling Accident with III-IV degree lameness increased on hard ground and trotting

Stifle swelling, lameness IV-V Thigh swelling, deadly lame limb Stifle effusion, pain lameness III-IV

252

Minufiya Vet. J. 8 (1): 247-261 Stifle hard swelling with abnormal limb conformation Lameness IV, stifle swelling and pain Thigh swelling, deadly lame abnormal conformation open wound, swelling, deadly lame, abnormal movement Stifle swelling, pain lameness IV, temporary limb extension Lameness V, swelling, abnormal movement Previously treated by cast, mal-union, tarsal swelling, lameness IV-V

Old Complete, single, oblique proximal diaphyseal, articular

Euthanasia

-

Tibial tuberosity in situ fracture.

Conservative with stall rest.

G

Complete, oblique, diaphyseal with fragments

Euthanasia

-

-

Euthanasia

-

Transverse tibial tuberosity fracture (avulsed fracture) Single, transverse, Diaphyseal fracture

Lag screw fixation with medial patellar desmotomy(fig.8) Conservative by external fixation with Plaster of Paris

Old ,complete, oblique, proximal diaphyseal fracture

Previously treated by fiber glass cast.

P

Deadly lame, swelling, severe pain

Complete oblique proximal diaphyseal in situ fracture extending to tarsal joint.

euthanasia

-

Fetlock swelling

Condylar Splinter fracture

Conservative

-

30

Donkey

4y



200

Draught

Rt. Tibia

58

Horse

3y



350

Sport

Lt. Tibia

68

Horse

3y



350

Sport

Rt. Tibia

72

Horse

5y



350

Draught

Rt. Tibia

76

Pony

2y



70

Show

Rt. Tibia

1

Donkey

5y



250

Draught

Rt. Metatarsus

5

Horse

5y



400

Sport

Lt. Metatarsus

13

Horse

4y



350

Draught

Rt. Metatarsus II, III and IV

38

Horse

4y



350

Draught

Rt. Metatarsus III

40

Pony

1y



170

Show

Rt. metatarsus

50

Foal

6m



150

Sport

Lt. Meta-tarsal

63

Donkey

4y



200

Draught

Rt. Metatarsus III

65

Horse

11 y



400

Sport

Lt. metatarsus III

14

Horse

5y



400 kg

Draught

Rt. Hind 1st Phalanx

Previously treated by Gypsona, abnormal limb movement, pain Deadly lame, Pain, swelling, abnormal movement, crepitus Swelling, deadly lame, crepitus Open wound at the dorsomedial aspect of fetlock exposing prox. Fr. segment Hard fetlock swelling, lameness IV-V, toeing

20

Horse

5y



400 kg

Draught

Lt. hind 1st Phalanx

Hard pastern region swelling, pain, Lameness IV-V

45

Horse

5y



350 kg

Draught

62

Horse

2.5y



350 kg

Draught

Rt. Hind 2nd phalanx Lt. hind 2nd phalanx

Comminuted mid-shaft fracture Complete single short oblique

Conservative by cast followed by platting technique with application of fiberglass cast(fig.9) External fixation with fiber glass cast Surgical management by Bone platting

G P

G F P

-

Euthanasia

Old Complete, oblique, single Intra-articular Old complete, single oblique with periosteal reactivity and fetlock osteoarthritis.

External fixation by cast and stall rest Induction of chemical arthrodesis by corticosteroid inta-articularly with casting

Deadly lame, pastern swelling

Multiple fracture

Conservative casting

P

Deadly lame, pastern swelling, lacerated wounds

Comminuted articular fracture

Conservative casting

P

(G) Good: Adequate alignment, rigid fixation and complete weight bearing in standing posture. (F) Fair: Inadequate alignment, incomplete fixation and partial weight bearing in standing posture. (P) Poor: Mal-alignment, unstable fixation and non-weight bearing (deadly lame) in standing posture.*: Approximate weight

253

P P

Minufiya Vet. J. 8 (1): 247-261 Fig.1: (A) An eight month old foal showing dropping and dragging of the limb and swelling of the fore-arm. (B) Pre-operative LM (a) and AP (b) radiographs showing complete, single oblique, diaphyseal radial and ulnar fractures (C) Postoperative AP (a) and LM (b) radiographs showing fixation of the fracture using double plate technique. (D) Photograph showing application of fiber glass cast on the operated limb to obtain rigid fixation.

Fig.2: A) A-3- years old draught horse with noticeable carpal swelling. (B) DP (a) LM (b) and Ob (c) carpal radiographs showing slap and chip fractures of C3(yellow arrows) with osteoarthritic changes and prominent soft tissue swelling (red arrows). (C) DP (a), Ob (b) and LM (c) radiographs showing the carpal joint 30 days after treatment with intraarticular injection (DMSO and DepoMedrol), slight fracture fusion (red arrows) and decreased joint effusion (yellow arrow).

Fig.3: (A) An eight month old foal with left metacarpal fracture fixed with bilateral uniplaner acrylic external skeletal fixator. (B) 21-days post-operative LM (a) and DP (b) radiographs showing periosteal reactivity and incomplete closure of fracture gap with new bone. (C) 60-days post-operative LM (a) and DP (b) radiographs after removal of fixation device showing complete disappearance of fracture gap and cortical union. 254

Minufiya Vet. J. 8 (1): 247-261

Fig. 4: (A) Immediate DP radiographs showing complete, oblique mid shaft metacarpal II,III& IV fractures treated by unilateral unipalner acrylic external skeletal fixator with improper reduction. LM radiographs after 45 days before (B) and after (C) removal of the fixation device showing complete fracture union with unorganized callus formation.

Fig. 5: A) LM (A) and DP (B) radiographic views showing comminuted mid shaft comminuted metacarpal fracture. B) The same case after fracture fixation using fiber glass cast with metal splint. C) 2 months post-operative DP (a) and LM (b) radiographs (left) showing fracture healing and slight callus organization (red arrow). D) DP (a’) and LM (b’) radiographs after cast removal (right) showing the fracture gap was nearly disappeared and incomplete callus remodeling (red arrow).

Fig.6: (A) Ob (a) and DP (b) radiographs showing abaxial 3rd phalanx fracture (yellow arrow). (B) Post-operative DP radiograph showing fixation of the 3rd phalanx fracture using lag screw technique with adequate reduction and alignment (yellow arrow).

255

Minufiya Vet. J. 8 (1): 247-261

Fig.7: (A) LM and DP radiographs showing midbody sessamoidan fracture. (B) The same case after fixation by two lag screws.

Fig.8: A) LM (a) and AP (b) stifle radiographs showing avulsion of the tibial tuberosity (yellow arrow). B) AP (a) and LM (b) radiographs of the same case showing the fixation of the tibial tuberosity fracture by lag screw.

Fig.9: (A) LM (a) and DP (b) radiographs showing comminuted mid shaft metatarsal fracture in a Pony (white arrow). (B) The case after fixation using DCP plate in combination with external cast. (C) 4 weeks post-operative DP (a) and LM (b) radiographs showing the fracture lines were almost disappeared with the beginning of callus remodeling (yellow arrow).

256

Minufiya Vet. J. 8 (1): 247-261 DISCUSSION Long bone fractures in horses are considered as a major problem for owners, trainers, and veterinarians for long periods. The practices of humanitarian euthanasia of horses with any long bone fracture particularly open comminuted fractures were the only acceptable management of choice for many years ago (Nunamaker, 2002). Management of equine fractures and prognosis are determined by different factors such as the affected region, the fractured bone, the age, the sex, the weight and the temperament (LeJeune et al., 2003 and Fürst et al, 2008). The present study comprises surveillance on the fractured cases presented to the surgery clinic and some private clinics at Giza Government. Descriptive details of each fractured case referring the incidence in relation to equine species, type of work, age, weight, sex, affected region and fractured bone were recorded. It was recorded that equine fractures are almost encountered in all species. They were diagnosed in 55 cases by a percentage of 13.8% out of the presented 400 cases. They were encountered in 49 horses, 1 ponies, 5 adult donkeys. These findings were nearly similar to those reported by Nunamaker (2002). Regarding the incidence of equine fractures, a higher prevalence was recorded in draught (65.5%) and sport horses (31%)than in show horses (4%). According to the animal age; adult (more than 2 years) showed an incidence up to 71%, yearling (above one up to 2 years) 9% and foals (up to one year) 20%, according to sex males were recorded by an incidence 78% while in females the incidence was 22%. In relation to the animal weight, most of the fractures were recorded in heavy weight animals (more than 250 kg.b.wt) by incidence of 74.5% and in case of light weight animals (less than 250 kg.b.wt) was 25.5%. These findings were in agreement with those reported by Fackelman et al., (2000). The obtained results revealed that the incidence of the fractures were differed according to the affected region i.e. fore-limbs fractures represented 55/77 (62%), the right

limb had the higher incidence 23/55 (76.6%) than the left one 11/55 (32.4%). The hind limbs represented 55/77 (38.2%); the right limb was 12/21 (57.1%) whereas the left one was 9/21(42.9%) (Beard, 1999 and Sarrafian et al., 2012). The mostly common recorded long bones fractures were in metacarpal bones with an incidence of 10/77 (12.9%) followed by radial fractures with an incidence of 8/77 (10.4%) then the humeral fractures with an incidence of 3/77 (3.9%), both radial and ulnar fractures 2/77 (2.6%) and finally ulnar and carpal fractures 1/77 (1.3%). While in hind limbs; the highest prevalence was recorded in metatarsal fractures by 8/77 (10.4%) followed by the tibia 5/77 (6.5%) then the femur with an incidence of 4/77 (5.2%). The patellar fracture was the lowest incidence by 1/77 (1.3%). These results are in agreement with those reviewed by Dyson, (1994); Fackelman et al., (2000); Whitton et al., (2000); Veen et al., (2005) and Smith, et al., (2009). Concerning the digital fractures, they were recorded in both fore and hind limbs by an incidence of 13/55 (23.6%). PI fractures recorded the highest incidence 4/55 (7%) and represented in all limbs with the same incidence this result is in contrary with that review by Ratzlaff et al., (1990). PII fractures were recorded in right fore-limb and both hind limbs with an equal incidence for each limb. PIII represented in both right and left fore-limbs only with higher incidence in the right one. The distal sessamoids fractures had the third rank by an incidence of 2/55 (4%) in both fore-limbs only, with an equal incidence followed by proximal sessamoids by an incidence of 1/55 (1.8%) in the right forelimb. These results are in contract with those recorded by Ramzan and Powell, (2010). The present study attributed the variance in the fractures incidence to many contributing factors such as type of work (draught more susceptible than race and pleasure horses), age (adults more subjected to traumatic affections than yearlings), sex (males were more susceptible than females as a results of differences in temperament and working nature), affected region (fore-limbs recorded 257

Minufiya Vet. J. 8 (1): 247-261 the highest prevalence as a result of the weight bearing capacity is mostly loaded on them and they are the gait start and subjected firstly to the trauma). The distal limb fractures (below the carpus and the tarsus) are most prevalent because these regions are only covered by tendons and skin i.e. without soft tissue protection unlike upper limb as in humerus or femur. Similar findings were reported by Nixon, (1996). Management of equine fracture can be divided into conservative (non-surgical), surgical methods and euthanasia. Conservative treatment included stall rest, medical treatment and external coaptation for example splints or casts. While the surgical treatment consisted of trans-skeletal fixation and internal fixation using lag screw, bone plate, pins, cerclage wire either alone or in combinations. The prognosis of all managed cases was cited according to the returning to normal function of the fractured region. Euthanasia may be required in such cases of bad prognosis, old open fractures and some complicated cases. This is in agreement with that reviewed by Auer, (2000) and Fackelman et al., (2000). External fixation of limb fractures through application of splints or casts still the most common method of treatment employed in veterinary practice either as first aid or less frequently as complete treatment (Nemeth and Black, 1991). In the present study, Conservative treatment via application of casting materials gave an encaurgeing results in 16 out of 26 cases (3 distal radial, 6 metacarpal, 2metatarsal and 5 digital fractures). The prognosis was favourable in 10 cases and unfavourable in 6 cases. Because of their bulky, unmaleable nature, they are not well adapted to be used in case of fractures of bones proximal to the carpus and the tarsus. This is in agreement with that mentioned by Derungs et al., (2001). Two different types of casting materials (plaster of Paris and fiberglass) were evaluated. External fixation by using a cast (Dynacast®) showed advantages as a better fixation than plaster of paris (Gypsona®), in terms of harder, allow the skin to breath, lighter in weight so it is more comfortable and requires shorter time of curing in management of distal limb fractures. This is in agreement

with the characters listed by Auer et al., (1996). The limb casts were applied in this study by two ways; distal limb cast which used for distal metatarsal and digit fractures fixation (7 cases) and full limb cast which was advocated for fractures of proximal metacarpus/tarsus and distal radius (11 cases) with favourable prognosis. Some complications such as cast breakdown and fragility were recorded. So that the use of full limb casts in conjunction with polyvinyl chloride (PVC) pipes or metal splints as a coaptation device gave more support to the cast materials, as well as preventing cracking and failure of the splinting procedure. The use of PVC pipes coaptation gave excellent results in terms of optimal healing with good consolidation of the callus across the fracture line particularly in severely comminuted fractures. These results are in agreement with those reported by Janicek et al., (2013). The recorded Complications with conservative management of fractures were in terms of instability of fracture segments, soft tissues adhesions, tendons laxity and cast soreness. The same observations were obtained by Bramlage, (1983). Trans-skeletal fixation (TSF) is another type of exploration for fractures fixation in the horse. This method of treatment has not been widely used in equine orthopedics (Reichel, 1956). This type of fixation is often working as emergency treatment in open or in severely comminuted fractures when anatomic reduction and internal fixation are not possible (Nixon et al., 1996). In this study, the use of Trans-skeletal fixation gave satisfactory results in terms of rigid stability and complete weight bearing in a case of distal metacarpal fracture in a foal while inadequate stability and incomplete weight bearing was recorded in anther foal with compound radial transverse diaphyseal fracture. Similar findings were reported by Nunamaker (1986) and Nixon et al., (1996). They mentioned that external fixator could aid in immediate weight bearing. The Steimann and Schanz screws that used with this fixation device create minimal additional trauma to the injured soft tissue. Internal fixation of equine fractures will always remain a huge challenge for the facts 258

Minufiya Vet. J. 8 (1): 247-261 that of the horse needing to be able to bear weight on the fractured limb immediately after surgery. Adding that the fact; many of our equine patients weigh over 300 kg. Body weight is the primary reason that fractures in foals and ponies tend to have more favourable prognosis than heavy weight horses. This study recommended that, animals weighing 80- 250 Kg.b.wt or less are good candidates for surgical reconstruction using internal fixation. The same results are issued by Auer, 1999 and Fackelman et al., 2000). Other contributing factors determine the decision for using of internal fixation; the fracture location in the same bone, whether or not the fracture extends into a joint, the number of fracture fragments involved and the condition of the skin over the fracture and the availability of implants specialized for fracture repair. Although it seems naturally that horses would need much bigger plates, the laws of physics and the amount of skin present limit the plate size that may be used (Auer, 1996 and Fackelman et al., 2000). Occasionally, the costs of surgical treatment are too expensive. The cost associated for repair of many fractures can vary tremendously depending on the duration of hospitalization, number of implants (plates and screws etc.)and the type of surgery needed (Bramlage, 1983) and Auer, 1996). The previous factors contributed the main hindrance and limitation in the working of the present study. Lag screw fixation was the simplest method for fracture fragments compression. Interfragmentary compression through lag screws is used in many equine fractures reconstruction (Perren and Buchanan, 1981). In the present study lag screw fixation was used successfully in management of 3 cases a mid-body sessamoidean fracture, abaxial fracture of PIII and avulsion fracture of tabial tuberosity. These findings are in agreement with that reported by Field, (1993) and Auer, (1996). Some complications such as screw bending, restricted digital joint movement and soft tissue swelling were recorded in using lag screw fixation which are in contract with Hubert et al., (2001). Dynamic compression plate (DCP) is the implant of choice for treatment of

equine fractures. In the present study; bone plate was used for fracture fixation in case of mid shaft radial and distal diaphyseal metatarsal fractures. The prognosis in radial fracture was favourable while that for the distal metatarsal fracture was unfavourable which attributed to the complications associated with plate fixation which were infection and inadequate fracture reduction leading to implant failure. Similar findings were reported by Auer, (1999) and Auer and Stick, (2006). In this study euthanasia was the proper treatment in management of 18 fractured cases (3 humeral, 4 radial and ulnar, 2 metacarpal, 1 distal sesamoidal, 3 femural, 3 tabial and 2 metatarsal ). The present study attributed the use of this method for management to weight, age, type of fracture, type of bone, infection, inplant failure and cost of treatment, similar finding were reported by Auer and Stick, (2006), Baxter and Turner (2002). In conclusion, the present study emphasized on the necessity of weight, age, sex, type of fractured bone, clinical and radiological signs and the cost of treatment while dealing with equine fractures. REFERENCES Auer, J.A. & Stick, J.A. (2006): Equine Surgery, (3rd ed), Elsivier, USA. Auer, J.A. (1999): Internal fixation. In Mayhew IG, Merritt AL, Colahan P, Moore JN, editors: Equine Medicine and Surgery, ed. 5, St Louis, Mosby. Auer, J.A.; Taylor, J.R.; Watkins, J.P., (1990): Partial carpal arthrodesis in the horse. Vet comp orthop Traumatology; 3:51-60. Baxter, G.M. and Turner, A.S. (2002): Diseases of Bone and related structures. pp. 401-407. In: Adams' Lameness in Horses, 5th ed. (Stashak, T.S. ed.), Lippincott Williams and Wilkins, Philadelphia. Beard, W. (1999): The skull, maxilla, and mandible. In: Equine Surgery, 2nd ed., (Eds): J. Auer and J. Stick, W.B. Saunders, Philadelphia. pp. 887-899. Bramlage, L.R. (1983): Long bone fractures. Vet Clin. North Am. Large Anim. Pract.; 5:285. Derungs, S.; Fuerst, A. and Haas, C. (2001): Fissure fractures of the radius and tibia in 23 horses: A retrospective study, Equine Vet. Educ.; 13:313. Doherty, T.J. and Valverde, A. (2006): Euthanasia in: Manual of equine anaesthesia and analgesia. P 354355, Blackwell Publishing Ltd, UK. Fackelman, G.E.; Auer, J.A. and Nunamaker, D.M.

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Minufiya Vet. J. 8 (1): 247-261 (2000): AO Principles of Equine Osteosynthesis. Stuttgart, Germany, Thieme. Fessler, J.F. And Turner, A.S. (1983): Methods of external fixations. Symposium on equine orthopaedics. Vet Clinc. North Am. Large Anim. Pract., 5:311 Field, J.R. (1993): Screw torque and interfragmentary compression in equine cadavers long bone fractures. Vet. Comp. Orthp. Trauma, 6:163. Fitch, G.L.; Galuppo, L.D. and Stover, S.M. (2001): An in vitro biomechanical investigation of an intramedullary nailing technique for repair of third metacarpal and metatarsal fractures in neonates and foals. Vet. Surg.; 30:422 Fürst, A.; Meier, D. and Michel, S. (2008): Effect of age on bone mineral density and micro architecture in the radius and tibia of horses: An Xtreme computed tomographic study. BMC Vet. Res.; 4:3 Hubert, J. D.; Latimer, F.G. and Moore, R. M. (2001): Proximal Sesamoid Bone Fractures in Horses. Compendium Equine, Vol. 23, No. 7, 678687. Janicek, J.C.; McClure, S.R.; Lescun, T.B.; Witte, S.; Schultz, L.; Whittal, C.R. and WhitfieldCargile, C. (2013): Risk factors associated with cast complications in horses: 398 cases (1997-2006). JAVMA, 1; 242(1):93-98. Johnson, A.L.; Houlton, J.E. and Vannini, R. (2005): AO Principles of Fracture Management in the Dog and Cat, Stuttgart, Thieme. LeJeune, S.S.; MacDonald, M.H. and Stover, S.M. (2003): Biomechanical investigation of the association between suspensory ligament injury and lateral condylar fracture in Thoroughbred racehorses. Vet. Surg.; 32:585-59 Levine, S.B. and Meagher, D.M. (1980): Repair of an ulnar fracture with radial luxation in a horse. J. Vet. Surg.; 9:58. McClure, S.R.; Hillberry, B.M. and Fisher, K.E. (2000): In vitro comparison of metaphyseal and diaphyseal placement of centrally threaded, positive-profile transfixation pins in the equine third metacarpal bone, Am. J. Vet. Res.; 61:1304. McKee, S.L. (1995): An update on racing fatalities in the UK. Equine Vet. Edu; 7, 202–204 Nemeth, F. and Black, W. (1991): The use of a walking cast to repair fractures in horses and ponies. Equine Vet. J.; 23:32–36. Nixon, A.J.; Watkins, J.P. and Auer, J.A. (1996):

Principles of fracture treatment. In Nixon AJ, editor: Equine Fracture Repair, Philadelphia, WB Saunders. Nunamaker, D.M. (2002): On Bone and Fracture Treatment in the Horse.” Milne Lecture. AAEP Proceedings vol. 48. Nunamaker, D.M. and Richardson, D.W. (1992): External skeletal fixation in the horse. AAEP Proceeding 37:549–555. Nunamaker, D.M.; Richardson, D.W. and Betterweck D.M. (1986): A new external skeletal fixation device that allows immediate full weight bearing; application in the horse. Vet. Surg., 15, 345–355. Perren, S.M. and Buchanan, J. (1981): Basic AO/ASIF Technique: Aims and Principles. In Texhammar R, Colton C (eds): AO/ASIF Instruments and Implants: A Technical Manual. New York: Springer-Verlag, pp. 26. Ramzan, P.H. and Powell, S.E. (2010): Clinical and imaging features of suspected prodromal fracture of the proximal phalanx in three Thoroughbred racehorses. Equine Vet J.; 42(2):164-9. Ratzlaff, M.H.; Hyde, M.L.; Grant, B.D.; Balch, O. and Wilson, P.D. (1990): Measurement of vertical forces and temporal components of the strides of horses using instrumented shoes. J. Equine Vet. Science 10, 23–35. Reichel, E. (1956): Treatment of fractures of the long bones in large animals. J.am. Vet. Med. Assoc.; 138:8–15. Smith, L. C. and Greet, T. R. (2009): A lateral approach for screw repair in lag fashion of spiral third metacarpal and metatarsal medial condylar fractures in horses. Vet. Surg., 38(6): 681-8. Smith, L. C. and Greet, T. R. (2009): A lateral approach for screw repair in lag fashion of spiral third metacarpal and metatarsal medial condylar fractures in horses. Vet. Surg., 38(6): 681-8. Stashak, T.S. (1987): Lameness and Diagnosis of lameness. In: Stashak TS,(ed) Adams’ Lameness in Horses. Philadelphia: Lea & Febiger, 103 & 678-679. Veen, L. and Greef, R.J. (2005): Conservative treatment of open incomplete radial fracture in an adult horse. Tijdschr Diergeneeskd, 15; 130(12):3757. Watkins, J.P. (2006): The radius and ulna, in Auer JA (Ed): Equine Surgery. Philadelphia, PA, Saunders, pp. 1267–1279.

260

‫‪Minufiya Vet. J. 8 (1): 247-261‬‬

‫الملخص العربي‬ ‫كسور القوائم في الفصيلة الخيلية‪ :‬الحدوث والمعاملة‬ ‫‪2‬‬

‫شعبان محمد جاد هللا‪ ، 1‬محمد طه القيعى‪ ،2‬محمد سعيد عامر‪ ، 2‬أشرف على شمعة‬ ‫‪ 1‬قسم الجراحة و التخدير و األشعة كلية الطب البيطري‪ -‬جامعة مدينة السادات‬ ‫‪ 2‬قسم الجراحة و التخدير و األشعة كلية الطب البيطري‪ -‬جامعة القاهرة‪.‬‬

‫ورد إلي مستشفى كلية الطب البيطبرج جامعبة القباورع واعبي العيباداص الاامبة االم باط‬ ‫المجاورع لمحافظة الجيزع في الفترع من يونيبو ‪ 2212‬حتبي سببتمبر ‪ 022 ، 2212‬حيبوان مبن‬ ‫الفصبيلة الايليببة نعبباني مببن مشباكز االج ببا العضببلي الحركبي كببان م ببا ‪ 55‬حالببة كسببور ‪40‬‬ ‫االقوائم األمامية و ‪ 21‬حالة االقوائم الالفية ) حيب نبم اختياروبا و نومبيف ا مبن ناحيبة العمبر ‪،‬‬ ‫الو ن ‪،‬الج س ‪ ،‬طبيعية عمز الحيوان‪ ،‬سجز التاريخ المرضي ‪ ،‬سب الكسر ‪ ،‬العظبا المكسبورع‬ ‫و األعراض السريرية و الشعاعية حي نم نجميع كز وبه ال تبائو ونحليل با لتحديبد نسببة حبدوث‬ ‫الكسور في الفصيلة الايلية ‪ .‬استادمت فبي وبه الدراسبة طبريقتين ماتلفتبين فبي العب شبملت‬ ‫التعامببز التحفظببي و الجراحببي‪ .‬أشببتمز التعامببز التحفظببي علببي الع ب الببدوائي والراحببة مببع او‬ ‫الثبيت الاارجي التجبيس) اي ما انقسم التعامز الجراحي إلي التثبيت ال يكلي الاارجي و التثبيت‬ ‫الداخلي و أشتمز ال وع األخير علي التثبيت ااسبتادا الشبرائا العظميبة و المسبامير المحلزنبة و‬ ‫استادمت طريقة القتز الرحيم إجباريا في الحاالص ضعيفة األيلولة و عديمة األمز ‪ .‬أظ رص نتبائو‬ ‫الدراسة المسحية أن حاالص الكسور نمثز نقريبا ‪ )022 55 %1431‬من إجمالي الحباالص التبي‬ ‫نم فحص ا‪ .‬نو عت حاالص الكسور اين القبوائم االماميبة و الالفيبة حيب سبجلت القبوائم األماميبة‬ ‫أعلبببي نسببببة كسبببور ‪ )%7236‬امقارنت بببا ابببالقوائم الاليبببة ‪ )%4.34‬و سبببجلت أيضبببا كسبببور‬ ‫ال احية اليم ي من القوائم األمامية و الالفية أعلي نسبة ‪ ) % 7437‬امقارنت با اكسبور الجانب‬ ‫األيسر للقائمتين ‪ % 4730‬و أظ برص الدراسبة ايضبا ان عظبا المبدفع االمبامي و الالفبي األكثبر‬ ‫نعرضا ً للكسور امقارنت ا اعظا الكعبرع و المشط و الصااونة ‪ .‬أعطي التعامز التحفظي ااستادا‬ ‫الع الدوائي و الراحة مع التجبيس فقط أو مع استادا دعاماص من اوليمراص الب سبتي نتبائو‬ ‫مرضية في كسور عظا المدفع األمامي و الالفي حي أثبتت ال تائو أن معظم الحاالص عادص إلي‬ ‫طبيعت ا في خ ل أراع ش ور دون أدني مضاعفاص‪ .‬كما أظ ر التعامز الجراحي من خ ل التثبيبت‬ ‫ال يكلي الاارجي والتثبيت الداخلي ااستادا الشبرائا العظميبة المزدوجبة و المسبامير المحلزنبة‬ ‫نتائو جيدع في رد الكسر و نثبيته و خامة كسور عظا المدفع األمامي و الالفي و اعبي حباالص‬ ‫كسور الزند و األمااع في االم بار و الحميبر التبي يتبراوو و ن با مبا ابين ‪ 252- 12‬كيلوجرامبا‬ ‫كمببا نومببي الدراسببة أيض با ً اأوميببة دراسببة الببو ن و العمببر و الج ب س و نببوع العظببا المكسببورع‬ ‫واألعراض السريرية و الشعاعية و نكلفة الع قبز التعامز مع كسور الفصيلة الايلية‪.‬‬ ‫‪261‬‬