Clinical Connections  –  Autumn 2023

Andy Fiske-Jackson, Deputy Head of RVC Equine and Associate Professor in Equine Surgery

Gannicus, an 11-year-old thoroughbred gelding, spent more than three months at the RVC Equine Referral Hospital earlier this year due to a degloving wound sustained by kicking through the side of a horsebox.

On presentation the left hindlimb was bandaged and he was reluctant to fully load the limb. Removal of the bandage revealed exposure of almost the entire medial aspect of the third metatarsal bone, from the distal tarsal joints to the fetlock joint.

There was skin loss, loss of the outer surface of the medial metatarsal condyle, with marked contamination, and the tendons and ligaments at the back of the leg were visible.

Diagnostic tests and procedures

Radiographic examination revealed substantial soft tissue loss but no evidence of a fracture. Due to the severity of the soft tissue damage and suspicion of infection of the fetlock joint, the team elected to take Gannicus to surgery and perform further diagnostics under general anaesthesia.

A sample of synovial fluid retrieved from both the digital flexor tendon sheath and fetlock joint confirmed infection of the fetlock joint but not the digital flexor tendon sheath. The fetlock joint was arthroscopically lavaged, but the degree of tissue loss compromised the ability to close the joint capsule completely.

The wound was meticulously debrided but, due to the substantial loss of tissue, could only be partially closed. During the procedure it became evident that the medial collateral ligament of the fetlock joint was damaged. This, alongside the significant soft tissue damage, led to the decision to place a distal limb cast.     

Recovery and complications

The wound after recovery

Gannicus remained in a cast for two weeks. This required four-hourly checks by our dedicated team of vets, veterinary nurses and students. Inevitably, due to the presence of compromised tissue, a significant volume of wound exudate was seen emanating from the top of the cast. This led to the decision to remove the cast. At this point a significant amount of granulation tissue had formed, almost completely covering the previously exposed metatarsal bone.

Continued communication between the fetlock joint and the wound could not be ruled out but, on account of his comfort, and the lack of healthy tissue to close the defect, Gannicus was maintained in a bandage and monitored.

Approximately two weeks after the cast was removed, Gannicus' level of comfort decreased and, on sampling the fetlock joint fluid, repeat infection was confirmed.

Gannicus subsequently underwent a second surgery to lavage the fetlock joint, and punch skin grafts were placed in the granulation bed. These were harvested from the pectoral region. A distal limb cast was placed, which was maintained for a period of six weeks.

Enrichment, delivered by RVC veterinary nurses, was a key aspect of recovery

Environmental enrichment by the nursing team

When horses are on box rest for long periods it is vital that they are given regular human interaction and stimulation. This can include stable-based exercises to maintain core stabilisation muscles. With Gannicus, the dedicated nursing team took time to enrich his environment with various toys, including a fruit and vegetable treat rope.
When the cast was removed, the wound showed significant contraction and granulation tissue was covering the whole wound. As the granulation tissue was slightly exuberant it was debrided to encourage epithelialisation.

During subsequent bandage changes the exuberant granulation tissue was treated with a dehydrating agent, causing it to contract, allowing continued epithelialisation. He was then able to be discharged to complete his convalescence at home.

Gannicus experienced several mild colic episodes during his stay, which resolved with medical management. On the last occasion there was suspicion of an ileal impaction, which resolved with intravenous fluid therapy overnight. These episodes appeared to be associated with sedation.

Gannicus is now being ridden out and enjoyed by his owners – something which seemed so far away at one point! His care involved the entire team at RVC Equine, from the students, technicians, nurses and vets, and his highly dedicated owners who refused to give up on him.

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