12 Fracture Repair Take-Homes From a Top Equine Surgeon
Many millennial veterinarians aren’t old enough to remember Gary Larson and his “The Far Side” comic, quipped Dean Richardson, DVM, Dipl. ACVS, as he opened the 2019 Frank J. Milne State of the Art Lecture on equine bone fracture repair. Richardson was happy to introduce the younger audience members to Larson, whom he described as one of the great comic artists of the late 20th century. But there’s one Larson comic Richardson can’t stand. “I absolutely detest it,” he deadpanned.

Let us paint the picture for you with our words (be sure to take a moment to Google “Gary Larson Horse Hospital”): The single-panel comic shows what appears to be a military hospital ward. The patients are horses, each reclining in a hospital bed with a casted leg in traction. The doctors ominously carry shotguns through the aisle. “BLAM!” exclaims a speech bubble from behind a curtain. Below, the text simply reads “Horse hospitals.”

“Too many people believe this cartoon,” Richardson said. “We have to change that.”

During his lecture, Richardson, who serves as chief of surgery at the University of Pennsylvania’s New Bolton Center School of Veterinary Medicine, took the opportunity to change preconceived notions that equine fractures equal euthanasia. While he originally named his presentation, “From Larson to Laotzu,” he settled on “The Tao of Equine Fracture Management” and continually returned to the theme of balance. Here are 12 of his takeaways.

1. Successful Fracture Repairs Are All About Balance

As Richardson transitioned from Larson’s cartoon to Laotzu’s Daoism, he shared an image of the taijitu (the symbol of yin yang fundamental to Daoism). In his analogy, the image represented biology as it relates to horses and the mechanics of surgery and orthopedic repair. His approach, in all aspects of surgery and recovery, comes back to balancing the two and creating harmony that leads to successful surgical outcomes.

2. Recovery Is Achievable if Balanced With Expectations

“Horses are not somehow inept at healing,” said Richardson. “They are not some biological misfit in the big scheme of natural selection. The reality is that quite a few horses with orthopedic problems could adequately heal their injuries if we didn’t have demands for their performance or wildly disparate opinions about their suffering.

3. Three ‘I’s’ Lead to Fracture Surgery Failure

Richardson outlined them:

  • Infection: Surgical wounds are more susceptible to infection and biofilms (challenging-to-treat bacterial communities) than traumatic wounds;
  • Inaccuracy: Tools such as CT, arthroscopy, and radiography can improve accuracy and reduce surgery-related tissue trauma; and
  • Instability: It takes more screws and other hardware to surgically stabilize injuries in horses than in humans and other species.

“Those are the keys,” he said. “Those are what we screw up when we screw up surgery.”

4. A Horse’s Size Matters

“Size is a big deal,” he said about horses and fracture repair. “It makes it hard.”

Miniature Horses are easier to fix, he said, showing photo and radiograph examples of complex breaks and surgical solutions in Minis, followed by videos of one of the patients sashaying around his paddock with a friend. “You put (Minis) back together and, presto, they’re fixed—it’s as easy as that,” he said. “If I had a 1,200-pound Warmblood turn out like that, I’d be really happy,” he said.

5. Horses Are Not Humans

Equine orthopedic surgeons rely on human medical devices, such as plates and other hardware, to repair horses, even though horses are much larger than humans and can’t understand rehab instructions for rest. Richardson summed up the fine print on the hardware:

“You aren’t supposed to fix fractures with these devices in an overweight patient … who is going to be walking or running … who is senile or mentally ill. This is the absolute, quintessential definition of my patient: a morbidly obese, hyperkinetic nut job.”

6. A Horse Must Walk After Surgery

Additionally, Richardson noted equine orthopedic surgeons must use more metal than their human surgeon counterparts because, unlike humans, horses must stand after surgery. That’s because supporting-limb laminitis is all too common in horses post-surgery, and the best preventive is getting the horse to move, he said.

When dealing with limb fractures, “We fail almost every time we don’t get the horse comfortable and walking after surgery,” he said. “We have to fix it in a way that the animal can bear weight. If we don’t get them comfortable, they’ll often be euthanized for laminitis, and that’s the just the reality.”

7. Poor Soft Tissue Coverage Complicates Healing

Most fractures in horses occur in the limbs, which have very little soft tissue and muscle coverage; in fact, there’s no muscle below the knee and hock. “Muscle is the most valuable tissue to have over a fracture,” Richardson said. It provides the major blood supply to healing bones and offers protective covering.

8. Splinting Is Critical

Proper emergency splinting of a leg injury can be a life-saving procedure, Richardson said, adding that “having appropriate splinting materials immediately available can make all the difference.”

Six-inch diameter PVC pipes halved lengthwise are versatile and create a stable splint, he said, when applied correctly. The key is to ensure the splint itself is sturdy and placed close to the limb. He showed examples of failed splints and pointed out errors, such as supporting the wrong side of the injury (the splint should be applied to the injury’s “open” side) or using elastic bandaging, too much padding, or too short of a splint (it’s crucial to splint beyond the fracture above and below the joint). He also noted that too heavy of a splint, such as those made of lumber, can also cause more harm than good.

9. Ship Carefully

“Clients often make serious errors when shipping an injured horse,” Richardson said, adding that the most serious error—giving the horse extra room in the trailer—is done with the best of intentions. “Make sure adult horses are shipped in as tight a condition as possible” to allow them to balance against the wall or partition.

Foals with fractured limbs, in contrast, should be shipped sedated, recumbent (lying down—make sure to protect the foal’s eyes to avoid ocular injuries), and with an attendant if possible.

10. Angled Stable Fixation Plates Aid Stability

With a traditional bone plate, screws tighten the plate against the bone much like screws affix decking into joists. In contrast, stable fixation plates have threaded screw holes, and the screws have threaded heads that lock into the plate. The result is more stability between plate and bone and less leverage that could otherwise pull the screws out of the bone. “This technology has allowed us to use more biologically friendly techniques,” Richardson said.

11. Even Small Fractures Can Create Long-Term Performance Problems

Many small fractures are easy to repair, said Richardson, and the horses will heal. “We are seeking perfection,” he said, and most owners approve surgery with the expectation their horse will return to its previous performance level. However, it’s important to note these horses are more likely to have osteoarthritis or lameness without a perfect repair, he said.

12. Practice for Surgeons Is Hard to Get and Progress Slow

Progress in equine surgery is slow due to the relatively low case numbers equine surgeons see because of clients’ financial resources and motivation. “Only a small fraction of horses with repairable orthopedic injuries end up being treated, and then equine surgeons are understandably inexperienced and often inadequately equipped,” Richardson said. But, he concluded he is nevertheless optimistic that equine fracture management will continue to evolve to a point where the concept portrayed in Gary Larson’s “horse hospital” will be completely unfamiliar, a thing of the past.