FRANK J. MILNE STATE-OF-THE-ART LECTURE


mally if it can lean its body/shoulder/pelvis against firm support (trailer wall/partition). The other major shipping error is often made with


foal fractures. Foals get tired quickly when they are stressed and balancing on three limbs. Place an intravenous catheter. Take the time to get the foal in recumbency on the trailer and, if at all pos- sible, keep an attendant armed with drugs with the foal to maintain it in recumbency during shipping. This is especially important in more proximal frac- tures that are difficult to stabilize with a splinted bandage (e.g., radius and tibia). Protect the eyes of any recumbent foal/horse during transport. If possible, ship the horse with the injured limb


closest to the rear of the trailer/van. Smooth accel- eration (loading the south end of a horse headed north) is easy. Smooth braking is not always possible.


6. Errors in Wound Management


Wound management is usually very difficult in a seriously injured horse. If you have a truly severe fracture that will require emergency surgery it will be nearly impossible to do a meaningful debride- ment in a field situation. Valuable time and re- sources will be spent attempting something that will need to be repeated. It is probably wiser in such instances to wrap the site up in an antiseptic-soaked gauze (if anatomically feasible) and ship to a referral facility as quickly as possible. Broad-spectrum an- timicrobials should be administered intravenously if a wound of any kind is evident in a horse with a suspected fracture.


7. Pain Management/Sedation


Every horse with any type of serious injury should probably be given a fully therapeutic dose of a non- steroidal anti-inflammatory drug (e.g., phenylbuta- zone/flunixin). A horse is very unlikely to have enough pain relief from such drugs that it will sig- nificantly worsen the injury. It is impossible to be purely prescriptive about sedation but the general principle should be to give enough sedation to get the job done (bandage, splint, wound care, loading, shipping) but not enough to make them unstable enough to slip or fall. BUT…the most important element in first aid is making an informed decision before taking an irre- vocable action. What does the Taijitu (“yin-yang symbol”; Fig. 1)


have to do with fractures in horses? It is to remind one that a philosophical harmony is essential for success. Mechanics and Biology. Think of the yin and yang as these two antagonistic forces compris- ing the whole when we attempt to manage a frac- ture. If you rip apart a limb in order to meticulously reconstruct a fracture with implants that you are sure will provide maximum stability/ strength, a nearly inevitable consequence is that the bad biology of that approach will result in failure (infection, incisional problems, avascularity, poor/


Fig. 1. Taijitu (“yin-yang symbol).


slow healing). If you go all out to minimize com- promise of the “normal” biology but fail to provide adequate mechanical stability, the horse will usu- ally remain painful, the anatomy is not restored, function is lost, skeletal alignment is skewed, the contralateral limb is deformed and, in the horse, there is always the lurking specter of laminitis. The bottom line in equine orthopedics is that there are many converging paths to failure. Modern orthopedic surgery must seek a harmony


of Mechanics and Biology. What are some ways we can do this?


1. Do our best to limit tissue damage caused by the surgical approach.


2. Do our best to be accurate with all internal fixation. Accurate placement of implants op- timizes the mechanics of the reconstructed fracture. Proper pre- and intra-operative im- aging is paramount.


3. Use (and develop!) better fracture fixation de- vices and techniques. Just because some- thing worked “well enough” 20 years ago does not make it state of the art.


4. Be open to change in order to achieve this harmony.


The concept of limiting the damage of a surgical approach has evolved so far in joint surgery that it is now forgotten how revolutionary arthroscopy has been in equine orthopedics. A tool that was ini- tially used as “I’ll take a look with this scope and then open it up the way we always did,” is now used as the definitive means of managing nearly any frac- ture involving a joint. The continued evolution of fracture repair will certainly involve the develop- ment of less and less invasive means of both manip- ulation and reduction of fractures as well as the internal fixation of fractures. We are only in the earliest and crudest stages of this process with lim- ited ability to apply principles of less invasive techniques.


ACCURACY Demands Guidance


When we consider any fracture involving a joint, the single most important element providing long-term success is perfect reconstruction of the joint surface.


AAEP PROCEEDINGS  Vol. 65  2019 89


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