are very common in horses, especially to the distal limbs. Factors that contribute to this high incidence are the excitable nature of the species and their environment. The consequences of a wound to the horse range from trivial to permanent lameness and death. Larger wounds are not necessarily the most serious, so careful assessment is essential for determining the correct prognosis and planning treatment. The basic principles of wound healing, suture patterns and materials were covered in 3rd year and will not be repeated here. 

Always remember to take a quick history and do a quick physical exam prior to addressing the wound. Assess the degree of lameness while doing this.

• A visual assessment should be made of the extent, depth, level of contamination of the wound, the integrity of vascularity, nerve supply, and synovial fluid or suppuration. If the horse is non- weight bearing or has an obviously flail limb see later information on stabilisation of the limb which should be the first priority. If not proceed as below:

• A digital exploration (wearing sterile gloves) to investigate possible penetration of adjacent/deeper structures, deeper contamination, the presence of fracture fragments or lacerated tendons, or the presence of foreign material is then performed.

• Control of acute haemorrhage
Haemorrhage can usually be controlled by the application of clean pressure bandaging. Severe arterial haemorrhage may require the application of haemostats until the wound has been cleaned of contamination before attempting vessel ligation where appropriate. Ligatures placed in contaminated tissue will act as safe havens for pathogens

• Removal of gross contamination.
Removal of gross contamination reduces the pathogen concentration in contact with the wound, and allows a better visual inspection (can use tap water for this). 

A careful examination should be performed for concurrent injuries including: 

Fractures, ligamentous / tendon damage, synovial penetration (see below), penetration of body cavities, injuries at distant sites. Most horses with concurrent injuries should be referred to a hospital if possible.
Ancillary diagnostic techniques including radiography, ultrasonography, distension of synovial cavities, centesis of samples for cytology and microbiology may also be necessary for a thorough evaluation of the injury.

If the horse is to be transported before the wound is fully managed, careful bandaging prevents further contamination from entering the wound, binds surface debris, protects the tissues from further injury and increases the horse's comfort. 

Once the wound has been thoroughly appraised the most important aspect in preparing the wound for healing is debridement which: removes adhered bacteria; removes devitalised tissue; removes contamination; enables healing processes to commence.
Wound debridement is achieved by hydrodynamic lavage with isotonic fluid or dilute (0.05%) chlorhexidine or povidone-iodine solutions (dilute to 0.05% as concentrations >1% will damage fibroblasts) or by surgical debridement with a sharp blade. 

Wounds may be repaired by primary closure, delayed primary closure or second intention healing.
Primary closure is suitable for mildly contaminated wounds and upper limb / trunk wounds. Placement of a drain may be indicated. Delayed closure is suitable for heavily contaminated wounds, or wounds with extensive bruising / loss of vascular perfusion. Closure is performed after any infection has been controlled, ideally prior to fibroplasia. This necessitates careful management during initial (open) stage. 

Wound dressings 

Dressings are very important and should change with the stage of wound healing in horses with second intention healing or delayed closure. Primary closures can be protected by a soft semi-permeable dressing while hypertonic dressings, honey or other dressings may be used acutely in open wounds. 

Wounds that penetrate into synovial cavities should be referred for arthroscopy if possible as this is the gold standard of treatment. This can be determined by distension of any joints or tendon sheaths close to a wound after a sterile preparation and injection of saline to see if any exits by the wound- if yes then there is a synovial sepsis that must be treated. Synovial fluid aspirates and analysis can also be obtained for a diagnosis if necessary. Horses with confirmed communication should be started on systemic antimicrobials, bandaged and referred. Treatment in the field can be attempted with a needle lavage of the joint prior to wound repair if- and only if- referral is not an option. These have a good prognosis is referred early. 

Any penetrating nail to the foot should be carefully examined and if there is any doubt as to the depth and direction of the injury referral for examination should be done. These injuries can easily penetrate the navicular bursa, coffin joint or tendons sheath and prompt treatment is key to survival. If possible take a radiograph prior to removal of the penetrating object. 

Eyelids require careful reconstruction if lacerated which can be done with local anaesthetic and sedation. Dehiscence does occur and a second repair should be attempted. Referral is an option. If the eye is badly lacerated then referral to see if saving the eye itself is possible or enucleation prior to closure of the wound can be performed with local anaesthesia and sedation. Horses can return to athletic activity after enucleation and do very well. 

these can have lots of haemorrhage and may get a secondary sinusitis. Reconstruction of the bone may be necessary but in general these horses do very well. Must watch for excessive depression or quiet horses that may have cranial trauma and swelling around the brain which require intensive care. 

These do remarkably well in general with repair of the wound, antimicrobial treatment and aspiration to re-inflate the collapsed lung. Penetration is rarely into the lung due to the thickness of the ribs and muscles, commonly just into the pleural cavity causing collapse of the lung away from the penetrating object. Referral is recommended as management is easier in a hospital with suction and oxygen but prognosis is generally good. 

Must ensure has indeed penetrated the abdomen and not just tracked along fascial planes as penetrating abdominal trauma carries a less good prognosis due to contamination of the abdomen with intestinal contents. Recommend referral for ultrasound, paracentesis and exploratory surgery if required.
For abdominal and thoracic wounds if possible to leave the penetrating object in place for transport then do so, otherwise remove and immediately pack wounds with moist clean towels and bandage in place. Can also place a circumferential wrap with cling film to create a seal. Start antimicrobial therapy and analgesia at the farm and refer. 

Hypergranulation “Proud Flesh” in horses 

Compared to other species and even to ponies, horses are prone to developing large lumps of granulation tissue which protrude above the wound edges and prevent further healing. This is due to basic physiological differences in the healing of limb wounds in horses compared to ponies or trunk wounds. There is a prolonged and ineffective inflammation. Predilection sites for proud flesh are the distal limbs and over joints i.e. sites of skin movement and reduced vascularity. Proud flesh is dealt with by bandaging or casting to restrict movement and regular debridement using a scalpel blade. No anaesthesia is required as granulation tissue contains no nerves. Many topical agents are available (silver nitrate, “wound powders”, copper sulphate etc) but are not worth using as they will delay healing. 

Wounds of the hoof wall and coronary band 

Although in principle the same rules of wound healing apply, this region is specialised, these wounds heal best in a small cast up to the fetlock to immobilise the area after careful exploration, treatment and primary or delayed primary closure. If these are not immobilised they are prone to dehiscence and exuberant granulation tissue due to motion. 

Sequestrum formation 

A bone sequestrum is a dead fragment of bone associated with infection. A fragment of bone without infection is just.... a fragment of bone. The “involucrum” is the reactive bone surrounding the sequestrum. An infected fragment of bone results in constant or recurrent discharge from a tract. In the horse, sequestrae most frequently result from wounds to the metacarpal or metatarsal bones. Removal of the sequestrum is the cure. Antibiotics alone do not penetrate the avascular area.

These are common if bone has been exposed and so with degloving wounds over the dorsal aspect of the cannon bone- usually warn owners to watch for a non- healing wound in 3-4 weeks times with fistula formation and that they may require a quick surgery. Prognosis is very good but can be costly for owner. 

 lacerations are common on the dorsal aspect of the hindlimbs and do not require surgical apposition. Full transection of both extensor tendons results in knuckling forward at the fetlock. The prognosis for return to being an athlete is around 80-85%. In some horses (around 15%) with large wounds some degree of fibrosis restricts movement and can lead to a string-halt like gait. The limb must be supported in a heavy bandage or splint if the extensor function has been lost until fibrosis restores extensor function and prevents knuckling. 

are more serious. Laceration of the SDFT and suspensory will result in the fetlock dropping and laceration of the DDFT will result in the toe flipping up. Laceration of one flexor tendon gives a 50% prognosis to return to some degree of athletic activity (not any high level) and the prognosis is worse the more tendons are involved. The prognosis is also worse if the laceration is within the tendon sheath. These cases should be referred for surgery and cast support during tendon healing. 

Skin grafting 

Skin grafting in horses is used where skin loss is extensive, and can achieve improved cosmetic results. Grafting requires a healthy granulation tissue bed without infection. A non- infected wound will be ready to accept a graft two days after debridement. Infection / movement is the main cause of failure of grafts. Common graft techniques in horses include: pinch and punch grafts, mesh grafts, and line grafts. Pedicle and tunnel grafts are impractical in this species. Pinch and punch grafts are relatively simple techniques which can be performed in sedated horses with local analgesia, although the vast majority of wounds will heal without the need for grafts. 

Injuries with a probable hopeless prognosis: 

 Complete fractures of the radius or humerus with horse >300kg

- Long bone fractures with severe soft tissue injuries
- Complete fractures of the femur or tibia in adults
- Severely contaminated fractures 

Guarded prognosis (horse may be used for breeding; pasture pet, light pleasure riding) for:

Flexor tendon lacerations*
Note: lacerations of the extensor tendons are fairly common and carry a good prognosis as these tendons carry little weight. Do not destroy these cases!

Good prognosis: (for an athlete depending on bone, soft tissue damage etc...)

Joint luxations
Some fractures- particularly distal limb fractures, minimally displaced fractures, olecranon fractures
Foal fractures

Fractures can be fixed and depending on a number of factors the prognosis can vary significantly from extremely poor to very good for return to performance so always worth a call to the referral centre. 

Stabilisation of suspected fractures: 

Aims are to prevent: further soft tissue injury, (further) displacement of the fracture, conversion to a compound (open) fracture
Splints, bandages and or casts are used but a bad coaptation can make things worse so always ask a colleague or the referral centre if in doubt. Some fractures are better without a splint or bandage for example. Place a bandage over the limb to protect the soft tissues prior to placement of a cast or splint.

In lecture pictures and diagrams will be presented to demonstrate the appropriate splint for each type of fracture.

Transport of horse with suspected fracture

Ideally, travel horse facing backwards with a forelimb fracture (weight onto hindlimbs during braking) and forwards with hindlimb fracture (weight onto forelimbs when braking).