Casting for Wound Care- Why on Earth Would You Do That? | Veterinary Videos & Podcasts

Hi everybody and welcome to this lunchtimes webinar. We're just going to give it a few seconds whilst the participants all drop into the room. It's great to see the numbers already flying up.

There's already 60 of you in the room. Obviously, a topic that, oh, there's 70, 80. It feels like I'm holding some kind of online auction for casting of wound care.

But it's fantastic to have so many of you here. We'll give it another 30 seconds or so, for people to drop into the room, and then we'll get started with some introductions. OK, so we're living and out to about 130 people joining us live.

It's great to have you here from all over the world, everybody, and hopefully you're gonna get away with some, some fantastic bits of insight for this lunchtime webinar sponsored by Aity looking at the casting for wound care. Now it's fantastic sometimes to be able to look at a webinar and go, you know, you really are. Being lectured by equine greatness.

So it's fantastic to have our two speakers with us this lunchtime. Patrick Pollock qualified from the University of Glasgow in 1998 and worked in mixed general practise in Northeast Scotland before moving to Ireland to undertake an internship and residency in large animal surgery at UC Dublin. After his residency, Patrick worked as a college lecturer in equine surgery at the same university for several years before moving off to Denmark, and has since worked in private and academic practise, and after 11 years at the Wiper Centre in Glasgow, he's now the director of Equine Hospital and practise at the Royal Dick School of Veterinary Studies in Edinburgh.

Patrick's a diplomat of the European College of Veterinary Surgeons and a European and RCVS recognised specialist in equine surgery, a fellow of the Royal College of Veterinary Surgeons and a fellow of the Higher Education Academy with an enthusiasm for teaching in the clinical setting. Patrick's involved with a number of projects around the world with Working equidae, including training vets and equid owners in resource limited settings. His clinical and research interests include equine, poor performance, the upper airway, ophthalmic surgery, trauma and wound healing, and Patrick has been instrumental in the development and validation of the technique of overground endoscopy.

He's worked closely with emergency services to develop a network for incidents involving animals and is an advocate for supporting vets in remote and rural practise. Although principally a veterinary surgeon, Patrick has a range of experience with exotic zoo animals and wildlife and has served as a trustee and veterinary director for the Irish seal for many years. He's also a trustee of the Donkey Sanctuary.

We're also joined by Professor Derek Nottenbelt, who qualified from Edinburgh in 1970 and has spent his first years as a research veterinarian in Zimbabwe. Thereafter, he spent 12 years in mixed and equine practise before turning to the academic world at Liverpool, where he specialised in equine internal medicine. He retired from his personal chair in equine Internal Medicine, Liverpool in 2010, and then acted as a consultant to the Equine centre in the University of Glasgow up until January 2019.

He's a diplomat of the European College of Equine Internal Medicine and of the American College of Veterinary Internal Medicine. He's a director of Equine Medical Solutions, and through this provides an advisory service to equine Oncology. He's the primary author of 10 recognised textbooks and over 90 refereed scientific papers.

He's been awarded honorary life memberships of the ECEIN, Beaver, VWHA and ACVIN. He's received the animal. Health Trust scientific Award in 2003, and the Beaver Blue Cross Welfare Award in 2004, and the Merck Weaver Welfare Award in 2006.

In 2005, he was appointed OBE by the Queen for his services to equine medicine. He's published widely on a range of topics and maintains an inquest, an interest in equine internal medicine and oncology in particular. Through Equine Medical Solutions, he offers a consultancy service in equine oncology and other challenging clinical conditions for vets worldwide.

His main interests are in oncology, ophthalmology, wound management, and dermatology. He's actively involved in animal and human charity work in both the UK and abroad, and is a founder member of the Vets with Horsepower team who championed the cause of working equines all over the world, as well as other welfare and humanitarian charities to raise money for charity through provision of high quality CPD to vets and horse owners. Suffice to say that they are two fairly monumental CVs that we have joining us today, and I'd like to hand you over at this moment to Patrick, and we can get going.

Thank you very much, Ben. Thanks for the introduction, and, welcome to everybody who's, joining us today from wherever, you are in the world. So, we've got two presentations and then we hope to have some discussion and hopefully answer some of your own questions about this important topic, which is, casting for wound care and, articulates.

Why on earth would you do that? And I think Before you get involved in casting, you do think the idea of covering a wound, not looking at it, not resisting the veterinary urge to poke things, which we're all very guilty of at times, and people find that very hard when they first cover wounds. But once you've done it, once you've done it once, once you've had a few successes, you will be a convert, I hope, like, both Derek and myself are.

So, Why on earth would you immobilise a wound? Well, there are lots of reasons why we try to cover wounds all the time. We want to facilitate moist wound healing.

We want to facilitate the use of special dressings and special treatments, which will help to debride and remove that magical term bio burden. That's all of the contamin. The bacteria, the necrotic tissue, the faecal material, the bedding, all of the things that horses put into their wounds.

We know that's very important in terms of wounds that aren't able to heal. So covering a wound is going to help to reduce further bi a burden and help to remove the bio burden that's already there. Immobilising a wound is going to help to facilitate delayed closure, and we now have kind of changed our entire approach to wounds.

Whenever I was a, a student, the idea that you would close a wound below the hock or the carpus was really nearly anathema. Whereas now that's an absolutely stand. Thing to do if we possibly can.

And of course, the horse doesn't have much in the way of soft tissues between the outside and the inside of important neurovascular structures and also articular structures. So protecting those underlying structures can be done very effectively. And there's lots of science behind why immobilisation makes a big difference.

It has a direct effect on the rate of contraction, helps to improve the, the, the type of collagen that's laid down and how it's laid down. So it's going to help to reduce formation of exuberant granulation tissue, which is a, obviously a major issue in equid species. And of course, help to deal with instability in limbs.

And of course, we've all heard, we've all heard owners say to us, Would it not be better just to leave the bandage off. Let's, let's let the air at it. Let's let that wound heal.

It needs to, to scab over. We've all been well indoctrinated by years as small children, with wounds on our knees, where we were told to leave the scab alone. But of course, we know that's not the case.

We know that if we can keep the wound moist, If we can keep the wound immobile, then it will epithelialize at roughly twice the rate as it would if it was allowed to scar over. Movement, of course, is, is probably the most common of the, the many impediments to healing, and I, I won't preface too much more because Derek is going to talk about, about this a little bit later on. But we know that when we have too much movement, we're gonna see.

Excessive collagen deposition, disorganised collagen deposition, and we're going to end up with exuberant granulation tissue. And of course, there is a balance. We need some movement.

We need some normal forces on the limb to encourage the collagen to line up in the way that it should. But because of the way the horse is constructed with lots of bony tuberosities, lots of movement in those distal limbs, there are lots of areas which are particularly subject to movement. And the other The issue, of course, is sometimes we'll have structures moving up and down through the wound.

That might be a tendon or a ligament, and that will stop the two sides of the granulation tissue meeting over the top. And here's an example of a wound on the, lower limb, lower distal limb of the horse. And you can see there's this great pad of granulation tissue, which is stuck onto the extensor tendon.

And my colleague is flexing and extending the distal limb, the fetlock. There and look at this great pad of granulation tissue moving up and down. There's no way that your epial cells are going to be able to nicely cover the surface of that granulation tissue, or for that granulation tissue to meet on both sides when all this movement is going on.

And if you think about the number of times that the horse will flex and extend its fetlock in the course of a day, there's going to be a huge amount of movement there, which is going to lead you to problems. So, how do you know when movement's an issue? Well, these are, are some of the impediments to, to healing, and, and Derek will talk about these in more detail.

But signs that, that movement is probably a problem are wounds that appear to be doing nothing. So, wounds that have been sitting there for a long period of time, might be weeks, might be months, that are just not really moving on. They can look relatively healthy, but they're not contracting, they're not epithelizing.

Perhaps the granulation tissue isn't present or is unhealthy looking. There's a big cleft, or a kind of a, a hole in the middle of it, or two areas of granulation tissue, which, which don't meet in the middle. Maybe the granulation tissue is pale or discoloured, or knobbly and, and not, not flat.

All of these things, may be evidence that movement, movement's a problem. And I would go as far as to say that if you have to trim the granulation tissue on more than 2 occasions, you're missing an impediment to healing, and, and it may well be movement. And you should look again at that wound to see what might be causing the problem.

There are lots of ways, of course, to deal with excessive movement, lots of mobilisation options, and, and this discussion today is really about casting, but it is worth just mentioning briefly some of the other techniques that we can use. Right back to the multi-layer bandage described by the Welsh human orthopaedic surgeon, Robert Jones. He was a surgeon who dealt with lots of injuries from people who worked in mines.

He was one of the first, human orthopaedic surgeons to, to undertake, fracture repair in children, and Much of that involved just immobilising bone, and he did that with this multi-layer bandage. So, practise your bandaging. We'll come back to that in just a second.

A splinted bandage, and Derek's going to, talk about some great ideas for using casting material to make a splint in order to make a bandage, more rigid. And then, of course, the two things that we're really gonna talk, or concentrate on here, the bandage cast and the cast, and some of the materials which are available now, have really facilitated this. And there's been an explosion in the use of this technique, for the treatment of, equine wounds.

So, first question to ask you all is, can you place a good bandage? We all believe that the answer to that question is yes. And yet, probably every day, or every week, we encounter bandages, which are, have caused problems, they've caused complications, they've caused rubs, perhaps they're too loose, perhaps they're too tight, perhaps they put undue pressure on a particular area of the horse's anatomy.

So, ask yourself some questions. How often do you place a bandage? Is it something you do daily or weekly or monthly?

Do you practise your bandages? Do you ever get, your own horse or a, a, a friendly colleague's horse and have a go at putting a bandage on? Do you have any complications?

Do you record them? Does the whole practise bandage in the same way? I find that if you compare the way the veterinary world works with the way our human colleagues work, we all have a slightly different way of doing things.

And that's sometimes a problem in human medicine, they have a protocol, evidence-driven way of approaching these types of things so that they can work out which is going to lead to the highest degree of success and what's going to avoid complications. So, my advice is that although the pony club said there was only one way to bandage, that's not really true, you should pick one that works for you, and you should stick with it, and you should try and do that. As a group of people.

So that if someone, one of your colleagues goes out the following day to, to change the bandage, they do something relatively similar. And there are lots of opportunities to practise bandaging. You can host practise events, you can attend, various, CPD events to learn how to do this effectively.

And in stark, stark contrast to the situation in small animals, bandage complications in equine medicine are usually caused by bandages which are too loose. Where there's movement. And because of the weight and the size of our patients, those, that small amount of movement and movement of the bandage leads to a rub very, very quickly.

And those rubs can be much more severe than the original wound that you're treating. So, this is how I bandage. I put my dressing on, I hold it in place with some orthopaedic, conforming, material, like this.

I then use a padded layer, which will be something like cotton wool. I prefer personally cotton wool to Gamji, but GAMG does work extremely well, and if you're used to using it, that's fine. I then compress that with a layer of open weave bandage, white open weave bandage here.

And this is the layer that I'm gonna pull very tight. Use your hand to massage the side of the limb. Make sure that you're creating a column of, of bandaged, a bandaged leg.

We don't want bananas. We shouldn't have a bandage which tapers at the top and the bottom and has a big fat bit in the middle. And if the Bandage looks really bad.

Take it off and put it on again. That's an OK thing to do. The final layer is going to be your crep elastic bandage, and it's, very well put together in such a way that you can't pull it too tight because it breaks.

And if you have it at the right tension, it loses its kind of, chequered box appearance that it has on the surface. There's lots of mythology when it comes to bandaging. Number one is that you should cut and make a little hole over bony tu, tuberosities.

There's absolutely no evidence for that whatsoever. That changes the pressure on the whole bandage massively and doesn't concentrate it over the area that you've made your cut. So don't do that.

And don't forget, a, an evenly tight bandage is much safer than a slightly loose bandage. But we're really here to talk about total immobilisation and in this case, casting. But it's important to be able to put on a good bandage under your cast, particularly if you're going to use, a bandage cast.

The cast is going to very effectively eliminate movement. It's going to compress, and it's going to protect the tissue underneath. And the options are just a straight cast, a cast over the top of a bandage, a bivalve cast, and possibly a back slab or a half cast, which is used as, as a splint.

And Derek will talk about that in, in some detail in just a moment. It is a skill to place a good cast. It can be placed either standing or under GA, sometimes a little bit more difficult to do it under a standing in the hind limb, but it certainly can be done.

And you do have to practise this. It's a skill, and like all skills, it needs practise. And occasionally you'll put on a poor cast, and you'll notice that fairly quickly in the way that the animal is moving or not moving, as the case may be, and you may need to take the cast off and, and start again.

There's lots of fantastic materials around for casting. This is the way that I have always done it. And, we've practised this a bit, and, and we spend a lot of time to make sure we get a cast really, really nicely.

You're gonna need, obviously all your standard banjing material. You're gonna need stocking nets, you're gonna need some sort of orthopaedic felt for the top of the cast. And then you're gonna need your polyurethane impregnated fabric, or casting material.

Most of that is now fiberglass-free, and there'll be some discussion at the end about the products which are available to do this. And I think in the time that I've been a veterinary surgeon, the materials available to put on a good cast have changed massively. They're much more pleasant to work with.

They are not certainly designed for use in, horses. They were obviously all designed for use in humans, but now there's companies with interest in using these materials and horses, and that's made a big difference to us and, and how they can be used. And lots of advice out there about how to use them.

They have similar constructs, they're all activated by water, and the idea of these . These casting tapes are that they laminate together to create one structure. So we don't have 5 different, you know, rolls of bandage tape that, or casting tape that, are acting independently.

They become one construct. And that's really, really important. And that means that you got to get these on in a timely manner, and you've got to make sure that they're all sticking together.

And there is a bit of sort of staff training involved in making sure you get a good result with this. They're obviously designed for use in a human hospital. The temperature there is, warmer and stays the same all the time, and they don't put as many layers generally on, as when they are, where we were doing the same thing in, veterinary species.

So, I always use cold water, and the technicians always bring out hot water, and I always tell them to go back and use cold water. It just slows the process down a little bit. It still cures very nicely, but it slows things down a bit and allows, allows everything to stick together, and it does make a big difference, because these curing times are quite, quite quick.

There are lots of ways to cast a horse, just like the bandaging, we'd encourage you to, to pick a technique and, and stick with it. This is an example, just to kind of get us started. This is an acute, wound.

It doesn't look, very nice, but, it's come in, after 24 hours. It's heavily contaminated, as you can see. This wound was, this horse was taken to surgery.

The wound was, was debrided and lavage using Using hydrosurgical lavage, and then it was partially closed, and, then placed into a, a cast. So here we are. This is us after having done our, delayed primary closure.

So we've cleaned the wound and we've partially closed it, so it looks quite nice there. But we know this wound is not going to stay looking like that if we just put, place it in a standard bandage. We've got to immobilise it.

So, here we go. Oops. There we go.

So, here we go, at, the point of removal of the cast at 2 weeks after presentation, you can see we've got a wound which has healed beautifully. We've got a couple of small granulating areas just distally and proximately, but we've been able to immobilise this, and get to a stage where in just 2 weeks after wounding, we've got a horse which He's only going to have to wear quite a light dressing, and very quickly, it's going to be able to return to normal management. So, the value of mobilisation, clear to see, but what is the technique.

So, this is how we do it in our clinic. I'll play you a series of videos here and we'll run through how the casting is, is done. So, this is a bandage cast.

We've already put a dressing onto the, this limb of this horse. It's got a wound over the dorsal aspect of its fat lock. And, we're gonna roll on our stocking net.

This is, this is really important. This is a technique used lots in human casting. You always get great ideas from our, human medical colleagues.

They've been doing these things for a long time, and they've got lots of good little, tips and tricks, which you can, you can pick up. So, roll on, your, your stocking net. Get that right up and make sure you've got a big overlapping part at the very top of the cast that you can use, to pull down over the cast, as you'll see in, in just a moment.

This horse is, as you can see, under general anaesthesia. So it's lying in lateral recumbency with the affected leg up. And, the positioning, it will be important in just a moment, and you'll see that whenever we move to the stage of actually popping on the cast.

There's also got a tourniquet on its, upper limb, which is why, it's got this, this area here that you can see. OK, so we've got on our stocking net. We're then going to use this orthopaedic felt.

This is a material which has got, adhesive, back. It's, heavily padded, and it doesn't settle to the same extent as a standard bandage would. And this is going to go on top of the stocking net at the position at the top of the car.

For this half limb cast, that's going to be at the level of the head of the splint bones, whether that be a, a hind limb cast or a forelimb cast. We usually put, a layer of it just over the coronary band as well, which is again, a, a, an area, a pressure point that we might be a little bit worried. So, over the corary band and around the heel bulbs.

We just tape it in position, otherwise, it can sometimes fall off whenever we're manipulating. The bandage. Good.

OK. So, then move on to popping on. Our bandage.

So this is a standard bandage cast, so we're using cotton wool, hopefully, over our stocking net. Remember the bandage is nice and even. Overlapping by about 1/3 to 5.

And then halfway up the orthopaedic philtre, so. Just making, adding, padding where you think you need it. And on top of that, we go with our open weave bandage.

And this is the first layer that we placed, pretty tight. So we're going to use this to really compress. Remember, this is going to be underneath our cast.

We can't have movement, we can't afford to have movement here, that's going to cause or increase the risk of a rub. So you can see my colleague here is is rubbing the The surface just to try and Make everything as even as possible, even our, our tension and deal with any lumps or bumps that are going to lead to areas where we have pressure points. OK, so that's gonna come up again to about a 1/2 to 2/3 of the way up the padding.

We may use a couple of layers of that if we think that we need to really get a good, a good bit more attention on board. So the second layer of that, I think it's worth just, I know it's a little bit slow, but it's worth just going through this because these are, this is, these are really important techniques. And getting the, the bandage underneath the bandage cast correct is absolutely critical to reducing your complications.

We're aware that we're going to be able to leave these casts on for between 2 and in some cases, 6 weeks. So we really need a dressing which is going to be comfortable, and which is going to support the wound that's healing underneath. I know some of you will be thinking the idea of covering a wound for 6 weeks is absolutely a shocking proposition, but don't worry, you can, you'll be converted once you've seen some of the results that you can get with just simple immobilisation.

On top of that layer then is going to go, the adhesive. Core bandage. Yeah.

And that's a really important layer, because the, the cast material doesn't stick to it. So when you come to take off the cast, then it just facilitates removal of the cast. The cast material will stick very effectively to the open weave bandage or to the padded bandage.

So having that crep bandage on top makes a big difference to the, amount of, the amount of trouble you have when you go tape cast off. And cast can be, can be quite Difficult to remove whenever the time comes. OK.

So, We're then ready to actually cast. So this is a two-person job, at least, you can see we've got somebody with the, with the hind limb with their hands on the stifle, and their hand on the toes. We've got this, this leg and extension.

And then we've got a third person who's preparing the casting tape to hand it over to the person who's actually putting the cast in place. We've started the cast at the top of the bandage. You can see it's been pulled tight, we are overlapping by.

A third to a half again. We're running ourselves all the way down the limb, going as quickly as possible. At this point, you would turn to the person who's opening your casting tape and say, right, I'm ready for the next one.

You don't have a big gap in between the various different layers being passed over to you, because that's gonna lead to individual layers laminating and not sticking as nicely as they would to themselves. Next rule should be ready to come. Any moments.

We don't want folds, we don't want areas folded over on themselves. There's the next one ready to go. And off we go.

We know we're gonna have inherent weak spots around joints, around areas of movement. So the person who's extending that leg really needs to be staying in position, and the caster is working around those fingers to try and, we don't want lots of micro movement, lots of micro movement at this point, it's gonna lead to, a, a cast, which is gonna be a little bit less tight than it should be. Obviously, there are areas where There's going to be extra pressure on the cast around articulations here in the back leg, that's gonna be the fit lock, and around the toe.

So on we go. We're gonna run through these relatively quickly. For a full limb cast, we're going to look for.

This 500 kg horse, kind of 5 to 6 layers, 5 to 6 rolls, essentially, which is going to be multiple layers of casting tape, and you can see there how nicely the next one is just being passed to you, just to make the job a little bit more straightforward. So we're on rule number 3. So now I need to think about how we're going to manage.

The distal part of the cast, what we're going to do with the, the toe and the heel. And there's a variety of options here to allow us to have, a little bit of heel extension to keep this animal in a nice position. The options are to use either a block of wood like this, so we use a block of hardwood, which, is, is turned so that we've got.

A heel at the back and a toe at the front, and that's just going to give the horse a more comfortable position to stand in. Some people like to use a one roll of casting tape to do the same thing, and that does work. It's a little bit more awkward to place because the horse can tend to pivot on sort of the, the kind of equine equivalent of a stiletto.

So I like these, these blocks of wood. We have a range of them that the, kind of look. The local estates and buildings guys make for us.

They have made out of hardwood. Soft wood doesn't work. They just break in two.

And you need to have, sort of different sizes for different sizes of, equine foot. So, right up to a big draught and down to a small pony. So we have, we have 4 sizes that we tend to tend to frequently use.

And, they're, that just makes the whole job a little bit easier. So next role coming, so this is rule number 4, so we're getting close now to Having enough on, and if you were beside this cast now, what you'd start to see is that there'd be some bubbles coming through the surface of it, makes a bit of a noise, bit of a hissing noise. And, that's evidence that it's all starting to laminate to itself and starting to, starting to go off.

And you'll see every now and then that my colleague here just rubs the cast. You can see those bubbles there starting to come out, and that just suggests that the laminating process is, is happening. If you've ever been casted yourself.

At this point, the, the cast heats up quite a bit. It is quite an exothermic reaction. It's quite pleasant actually, if you've got a, got an injury, if you got a fracture, and then your, your limb begins to warm up with the, it's quite analgesic.

Obviously this horse is G8, so that's not gonna make any difference. So at the top of the cast, now that we're getting to nearly the last roll of casting tape that we want to put on, we're going to, think about, pulling down our stocking net. And that's going to fold over this area of padding at the top of the cast.

So we don't have an area that's going to rub in or, or dig over. So this is a nice wee trick. Pull down your stocking net, pull it down good and hard, that folds the orthopaedic felt over the top, over the kind of lip of the, the top of the cast.

And that's just going to give us, just a, a, a, A much more comfortable top of the cast. So, we're not going to end up with a sharp area there, which is going to potentially cause a, a rub or a problem. So this is our last layer going on, I pulled down the stocking net and pulling it good and hard to make sure that we've got it as well positioned as we possibly can.

Good. OK. So.

What about the top and the bottom of the cast? Well, we've looked at the top of the cast, that's where we're gonna fold over our, layer of stock and that works very well. Bottom of the cast's really important.

The heel needs a wedge. And once you've placed your casting material, then you need to use something more hard wearing at the bottom. This material is called hexalites, which is a hard wearing casting material.

It works extremely well. You can also use polymethyl methacylate, or, or you can use a combination of the two. And that makes the cast, a little bit more, secure at the bottom, which just reduces the, the risk of the animal wearing through the foot.

If you just use casting tape at the bottom, what ends up happening is that within 24, 48 hours, there'll be a hole in the bottom of the cast. There'll be a cast that's moving, and there'll be rubs developing further up the horse's legs. So this is the bottom of the cast, you'll see now.

So we've got our cast placed, and we're just gonna pop on. Our, vet light or hex light material. It's just a, a very hard wearing cast.

It comes like a, it's like kind of like a, like a bit of a fencing material, really. The, temperature of the water in order to activate this material has to be boiling. So it can't be hot, it has to be boiling.

So, boil the kettle, cut it into sections like this, and then place it over the foot of the cast. I usually put more Multiple layers, on, and then I use one round the outside just to stick it all on. Great stuff about this material is that if you make a, a, a bit of a mess of it, you just pull it off and stick it back in the boiling water and reactivate it.

And it does a, does a good job. So it's, it's, it's very easy material to use. And, it's very, very hard wearing.

And actually, you can see, because of it's, because of the shape of it, because of the sort of, Fence-like appearance of it. It actually, it provides quite a bit of grip, which can be quite useful. So if you are worried about the horse wearing through the bottom and you want to use some polymethyl methacrylate, that's Demetec, which is the material that's used for putting, slips onto the, onto the feet of cattle, then that will, it will give you a little bit less, of a slippy, distal end to the cast.

So the next question then is, is it a good cast? Once the horse stands up again, if you've done it under GA, if you've done it with the horse standing, that's a bit more straightforward. But, you need to look and see how's the horse standing in the cast.

We assist the recoveries of, of all of our equine patients. But as soon as they're off the ropes, I immediately look into the recovery box and see them move. I get somebody to walk the horse for me.

So, observe the horse standing and walking. What are the things that make you think that maybe the cast is not that Comfortable horses that are pivoting on the cast, or moving around in a circle and keeping the casted leg in one position. Where there's a big limb length disparity, that's a, a big issue if you put too much padding on the bottom of the cast.

And where there's a big sort of gaping hole at the top of the cast, you can get your fingers and some of your hand down into the top of the cast, and there's lots of movement back and forward, you know, that suggests that your cast and your bandage is a little bit too loose. And any horse that's just kind of standing in an odd posture, so a leg. Stuck out behind it or into the front.

These are all signs that, that there might be a problem with the cast. We always put a boot on the contralateral limb. We often do that before the horse recovers, or we get the horse to, to, to put that on very quickly after it's recovered.

And we change the elastoplast that we put at the top of the cast every single day and have a feel around here, just to make sure we don't have a, an area of swelling or any problems developing at the top of the cast. These are the types of things that go wrong with casts. They split, they crack, they fold.

You can see, in cases where there's a fold in the cast, we'll end up with, an area of a big sort of ridge on the inside of the cast, and that will cause really quite a nasty rub. Casts, which are very uneven. Casts which don't go all the way down to the floor, casts which are not laminated well together.

So this is an example where we've got areas that haven't stuck properly together, and these casts often make a funny noise. This is a cast with a, with a split in it. And obviously all of this is to try and avoid a cast which causes a rub.

I have a sort of ongoing kind of battle with some colleagues who want to take the cast off very quickly. And that, you know, you have to try and resist that temptation and you have to be brave. One of the things that we always think about is how we monitor the horse in the cast, and we'll talk about that in just a second.

How do casts fail, while most bend, and, they bend and they fold, and the effect of the likelihood of that happening is related to, kind of how you put the cast on, and I guess how well the, the material has laminated to itself. So, having that third to a half overlap really important, using different sizes or different Manufacturers, mixing different tapes together, not a good thing to do, not giving the cast a nice rub at the end, and also allowing that animal to weight bear too quickly. So most casts fail during recovery if there's a GA and that usually happens within 30 minutes to an hour and a half after cast application.

So, a big issue. Sometimes the failure can be quite subtle. So having a hand on the cast every day, listening to it, having a, a feel of it, those things are really important.

So, a few examples, just to finish off with this is a horse, which we are going to bandage cast. You can see it's got this really pretty nasty wound. It's pretty heavily contaminated.

The extension tendon is, severely damaged. What we've done here is we have debrided all that tissue. We've used, a hydrosurgical lavage for that.

We've sutured the extensive tendon, back together. You can see it's looking, looking fairly nice there. And then we've closed this wound primarily.

Obviously, there's absolutely no chance this wound will Survive without some sort of support. And so this animal has gone into a cast. And, this is the horse in, in the cast, and the horse will be in this cast, every day for at least 2 weeks.

What we do with these horses is twice a day, they walk out of the stall, and they walk down the length of the barn, and they're turned at the bottom, and they come back up. And that happens every day, twice a day, absolutely critical that happens. The people that are Instrumental in this are the owners of the horse, perhaps the, the grooms, if the horse is in the clinic, who are keeping a very close eye on the horse.

And things to look out for our horses that perhaps suddenly don't eat as much as they were eating before or look a bit dull, or, or look a bit, unhappy. And those early signs are warning signs that there's a problem. We generally We don't have these animals on non-steroidal anti-inflammatory drugs while they're in a cast.

We like to see them without any analgesia on board. And if we have discharge through the cast, like we have, as is the case here, we take a permanent marker pen and we draw around where the stain is on the cast, and that can tell us whether the, stain is getting bigger or smaller. It's unlikely to get smaller, but it does sometimes tend to get a little bit bigger.

So keep a close eye on that. When you take the cast off, a couple of things to be very wary of. There will be a smell.

There will be exudate. The granulation tissue, if there's any granulation tissue, present, if the wound has, has slightly opened, will bleed, and the tissue will certainly look inflamed. I always warn owners, if I'm taking a cast off in front of them, that things look worse before they look better.

And after you've given it a hose off and a dry down, it will look a whole lot, a lot better. So, this is that wound with the eccenture tendon that I showed you just a second ago. So we've had a bit of wound breakdown, but we've got relatively healthy looking granulation tissue.

And this is that wound, just several weeks after that. So you can see how quickly we've achieved limb stability and, and limb healing. Another example.

Hear of a horse with a, a wound involving the fetlock joints. This is the horse pre-surgery. This is the horse in surgery, and this is at 16 days after cast removal.

So, we've got a wound which has stayed together, a bit of granulation tissue, but closed and a, a joint which is intact. So, remember that things often don't look all that nice when you first take the cast off. You might choose to use a cast to support, a large, Skin flap.

So this is a horse with a skin flap over the pastern region, over the, palmer aspect of the pastern region. And this was involving the digital flexor tendon sheath. You can see we've cleaned this wound out using hydrosurgical advice.

This is a versagegette, which allows you to, to do that. And then we've closed the wound, and then popped the horse into the, into the cast to stabilise that wound, again, to protect the underlying, structure and to protect the integrity of the wound itself. We might want to support very large flaps using a cast.

You can see here, we've got lots of flaps, this flap hanging down, this flap hanging laterally, a large area of bone exposed. You always know you've, had a, a good trauma whenever some of that, green moss, which grows on the fence, is actually impregnated onto the surface of the cortical bone. This has been cleaned, extensively, lavaged heavily, both surgically and using lavage.

And then the wound has been closed. And this is at the point of removal of the cast at around 2 weeks after. So, video of how that looks.

So you can see, again, just that ability to immobilise the wound, giving you a wound, which is so much smaller. So, yes, you've got some areas of granulation tissue, which are exposed around that distal flap, but these are very quickly going to epithelialize and leave you in a situation where you've got a horse that just doesn't need to be bandaged for as long as if you were trying to allow this wound to heal by second intention. We should all start our casting journeys in the foot, because you can put on a foot cast very easily and very effectively.

Here's a wound over the, heel bulbs of this, horse here, and when this horse weight bears, because of the effect of the elasticity of the digital cushion, the wound tends to gape open. You can put this horse into a, a, a foot cast. Using one or two rolls of casting tape, a minimal dressing underneath.

You can see, again, we've used some orthopaedic felt at the top of the cast, just to protect the tissue directly below that. And this horse wore that, cast for, a period of 14 days. And you see here, we did suture the wound before we put it into the cast, but look how beautiful this lovely epithelial scar is here.

This is a horse which is ready to return to, exercise, really very quickly, just because you've immobilised that tissue and allowed it to heal quickly. You can use a cast, a foot cast for wounds, very traumatic, nasty wounds of the distal limb and the foot here, as you can see, we've got a large defect, a large hoof wall defect. We pop this, into, a number of foot casts, which the horse wore for 2 or 3 weeks.

This is the first removal at, 3 weeks. You can see here now where it's 6 weeks post-injury. We've now, dispensed with the, the cast, and we've got a sheep.

On to support things. And here we are, just two months after the horse was presented. So, that ability to immobilise, allows the tissue to contract, allows the granulation tissue to be, to, to develop underneath an epithelial cells to safely migrate over the surface, and really gives you a, a result much more quickly than you'd expect to get if you were, bandaging alone.

And finally, we'll just briefly talk about sleeve casts. Conventional wisdom says that you should have a cast which runs from, the middle or the top of the leg to the distal limb, and you shouldn't begin or end in the middle of a long bone. This is, what we call a sleeve cast.

This is a sleeve bandage cast, which has been placed to immobilise the carpets, and this is placed with the horse standing and sedated. This is probably, the best example of its use. This is a, a, a, a cob, riding school pony, which was kept in a, a, a, a riding school on the banks of Loch Fyne in the west of Scotland, and, had developed this as a bandage rub after treatment for a wound on the dorsal aspect of its cannon.

So this is not even the primary problem. But this bandage rub has now been present for over 5 months, overlying the, the common calcaneian tendon. You can see we've got this very edematous, kind of purple looking granulation tissue, and there's the common calcaneian tendon in the middle, running up and down through the middle, and these two sides of granulation tissue are just never gonna meet.

We've got Movement, we've got movement of the, the whole leg. We've got movement of the tendon through the wound. We've got repeat trauma of this area, and we've got hypergrenulation.

And we popped this guy into a sleeve cast. This is a sleeve bandage cast, so a snug bandage over the hook, and then a, a, a cast over the top of that. And, we've used all the same techniques that we In the under GA except we've done this in the standing horse.

They don't like having their hawk immobilised, at first, but they get used to it, relatively quickly, obviously, they can't flex their stifles either. And we managed to keep this in place for 13 days. So I'll remind you that this horse had this wound for 5 months, and after 13 days in a cast, His wound looked like this.

So, up in the top corner here, you can see how things looked at the very beginning, and look how things look after 13 days in the cast. Now, we were worried because this wound had gone on for so long, so we did pop in a few island grafts once we took the, the bandage cast off. And this is the horse just, 4 weeks after initial presentation.

So, a really, really nice scar. So, a horse, wound for 5 months in a cast for 13 days, and a wound, which is in a whole, different place. So, just to summarise that before I hand over to Derek, movement is absolutely the most common impediment to healing.

And for some reason, we vets seem to sometimes ignore movement. I get sent a lot of pictures where people say, I, I just don't know why this wound isn't healing. And, you know, it's over an articulation, there's a structure moving through the middle of it.

Movement is clearly the problem. It's absolutely safe to cover and immobilise wounds, with a cast for 2 to 6 weeks, you've got to be brave at first, but you can do it. And think about using cast to help you with flaps and reconstructed wounds.

If you're a bit nervous about it, start with the foot. Very few complications with foot casting, a good place to start. Don't forget, monitoring of horses in the cast are very important.

We, if we ever send horses home in a cast, we give them, the owners a very clear set of instructions on an A4 sheet with a set of instructions that they should perform every single day. And I'll, leave you with a view of Upper Loch Fyne and to say before I pass on to Derek, don't be afraid to cast wounds. And if you have got examples of wounds that you'd like to share with us, please get in touch.

We always love to look at your wounds. Thanks very much. OK, so now it's my turn.

I hope that's worked satisfactorily, and it's my turn, my turn to talk about immobilisation and wound management, and Patrick has very elegantly showed you most of the important features of this. The ones I'm going to show you are a little bit Simpler, I suppose, and for the kind of circumstance that other people might find themselves in, but I would absolutely agree with Patrick that immobilisation in wound management is a really important factor in healing the wound. The important point, I suppose, is that not every site is entirely immobilizable.

So there are some wounds where clearly you can't immobilise them, in which case, you do have, definite problems with the, the movement within the wound. So these distal limb injuries that Patrick has been talking about, you know, this kind of thing that we see so often, they're very common, of course, and they're caused by a lot of different things. And so we've got to remember that the, the wound management is not just a simple matter of casting the wound.

You have to understand the basic principles of wound management right from the start, because one of the big dangers is to assume, for The example that putting a cast on is going to solve all the problems of the wound. Well, it isn't. You have to deal with the wound, and I think that's something which both Patrick and I would absolutely agree with because ultimately we have to try to find ways of closing this wound with the fastest possible return to functional status of the of the limb or whatever structure is involved.

So distal limb injuries, this is the kind of thing, you know, that we, that we're all faced with, and you know there's there's things going on in this wound that are difficult to cope with. But of course you have to understand that the wound itself has to be interpreted, has to be monitored, has to be assessed in every respect, and that means using the acronym Time, which is the one that I commonly use, and many people will know that that time stands for what tissues are involved. That's the T.

What, and we need to understand every single tissue has to be assessed in its own right. It's no good just saying there's one wound, so there's going to be one scar. It is not like that, because there may be tendon involved.

We saw how Patrick had that beautiful case with a severed extensive tendon, which was then repaired. And so the tendon was involved. So what tissues were involved?

Well, the bone was involved. Well, that's important. The muscle.

May be involved tendon, ligaments, joints, nerves, neurovascular bundles, all sorts of things can be involved. So, you know, it's important to remember that in the old days, second intention healing was worked on the one wound, one scar principle where we just say we're going to get a big wound, we've got a big scar, we're going to just seal it all up and hope that it makes a big fibrous knot, which is ugly and very often non-functional. So, the method that we, we would emphasise to everybody, of course, is the distal limb injuries without skeletal complication because this is not a, this is not a, a, a, a talk on skeletal complications, you know, where there are fractures and other things which go and the casting of a fracture is Somewhat different in because you have to immobilise them very, very much more strictly.

A little bit of movement is OK for a wound, but of course you don't want a little bit of movement inside a cast because actually that's counterproductive because you're going to get all sorts of rubs and so on. So it's the, the, there's a sort of compromise between the orthopaedic casting and the wounds, wound healing casting support for wounds. So, you know, I, I, I think it's important, so just to answer Patrick's question, is casting the answer to some of the problems.

Well, absolutely it is, because, of course, bandaging predisposes to exuberant granulation tissue, but casting inhibits it. Bandaging prolongs wound healing, particularly if you're going to investigate the wound every day. If you want to inspect a wound every day, then you're going to be disrupting the wound every day and you're going to open it to infection.

It's very easy to convert the wound. Inspection to the word infection just by scratching out the s and rubbing out a little bit of the P, then it becomes infection. So you can see that that's it.

And of course bandaging itself almost always fails to immobilise. It just acts as a cover and conceal if you will. So it's just going to cover it and hide the wound.

So there's all sorts of splinting mechanisms which we can use, including the Robert Jones bandage. It's a heavy, cumbersome, great slab of stuff that has to go on, and it's very hot, and horses don't get on very well with this, even when there is a splinting mechanism included in it. And Patrick listed this as well.

This is, this is where we are in the wound management standard because every single You know, tissue involved has to be assessed in the light of all 12 of these options. Obviously some of them aren't really relevant in every wound, but we all think of infection as being the most important thing. So you've got a huge wound like this.

Is the infection the problem? Well, no, it isn't. You know, are foreign bodies the problem?

Well, if there are foreign bodies, then they should be removed. Is t necrotic tissue a problem? Well, dead tissue is a problem because it becomes a foreign body, but The biggest single factor in my opinion is movement, and again, as Patrick said, it's one of the things that we forget, you know, we don't, we don't pay very much attention.

To movement, so the horse needs to move around a little bit. Actually, the last thing it needs, the wound just definitely does not need to move. And of course tissue deficits are where tissue's missing.

Well of course what can you do about that? And then continued trauma. And all three of those red highlighted areas there are things that Patrick has already alluded to and explained very carefully.

So spreading of the heel bulb when The horse has cut its heel bulb every time he puts his foot down, spreads and opens the wound, spreads and open. Any movement within the wound or absolute movement across the wound over joints and so on and so forth. And then of course if there's great big slabs of tissue that are missing, then it's very hard to compensate for that.

And then you have to try to find a way of protecting the wound so that the granulation tissue is encouraged to fill the wound. And compensate for the tissue deficit. So immobilisation is a basic principle of wound healing, as we've already shown you, and you know, movement is a major factor in its inhibition, but it also has sight-related problems.

So here we've got an axillary wound, for example. It's very difficult to immobilise this. It's very difficult to immobilise the horse effectively, but every time this horse Took a step, it pumped more air subcutaneously and it blew itself up like a barrage balloon.

Here we see a fat lock injury and of course, as you can see, every time the horse takes any weight on this, it's going to stretch and open the wound and of course what's, what's involved? Is there involvement of the flexor tendon, the deep flexor tendon? Is there involvement of The flexor tendon sheath is their involvement of the neurovascular bundle?

Has the animal got a blood supply to its foot anymore? So these are the kind of injuries which we are very keen to try to immobilise, but these ones here are much less capable of being immobilised effective. So the methods for General immobilisation of the wound.

Obviously you can cross tie the horse in a stable. I view that as being not immobilising the wound at all because the horse is taking weight on its leg, then it's resting the leg, then it's putting it down again, and so on and so forth. I don't believe the Robert Jones dressing bandage dressing does very much at all.

I think unless it is placed extremely well. It is not going to be an immobilisation system and of course it's very heavy. Bandage casting with Patrick's mentioned that, but I'm going to come back to that myself in a minute.

Then of course all the casting methods which we describe here, so this is a splintered. Dressing here with a with a piece of wood that's been put down the back here and then that's been strapped in to try to keep the carpets from flexing. That works reasonably well and of course he has a cast which is put halfway up the leg in exactly the same way as Patrick has told for a wound over the dorsal aspect of the hock joint.

Then, so those are splinted things. This is a splint, this is a cast, and then of course you can use the external splints, which Patrick showed as well. We don't think slings are viable, and when, when I was at university, I was told that if you have to sling a horse, you might as well shoot it.

But it's not true, of course, but its slings are very difficult to manage. So the crosstie system, you know, makes horses angry, you know, the overhead wire system, it doesn't stop the movement, but it also makes horses angry. They, they don't like being inside.

They don't like being confined, and they don't like being restricted when they're confined. So there are difficulties with this, and then of course, you know, the horse. It's difficult, then you have to monitor the wound and it becomes difficult under addressing to monitor wounds.

And as Patrick said, you know, we monitor these wounds from outside and we interpret what's going on inside the wound without taking the dressing off if we are confident that the wound is in a decent state of health. But here are some of the kinds of things that you can do. This is a set of pictures courtesy of my good friend Dylan Gorvey in Sweden.

And you can see that he's put a cast on, then he's got the horse in slings. This is how it started out and this is what happened in the end. You can see the moment you immobilise the horse by one means or another, and I don't believe it was the sling that helped this.

It would just help the horse. Cope with the cast. It was the cast that resulted in the good outcome.

You can cross tie the horses. I don't think this is a good thing to do. I, I don't like that game.

I think it's difficult for horses to cope with that. This is the kind of circumstance where that is sensible, and this is that horse I showed you earlier on. Every time this horse takes a step.

It pumps air into it, so it's literally like a barrage balloon. You could, you could, there was emphysema everywhere right up to its ears, and you could just lay your hand on it like this and you could see the imprint for all the emphysema. It's dangerous, you know, it's a dangerous circumstance.

That's a bad wound to be dealing with, and it needs immobilisation. It needs closure and immobilisation to allow it to avoid the complications of that. And there it is again.

OK, so the slings again, as we mentioned before, people do like to sling horses in some circumstances. They're very difficult to manage in my experience, they can lead to, you know, very strong difficulties. Some horses love them and just relax in the hammock and get better, but a lot of them resent them severely.

So then restricting bandages, planes. Supporting bandages, I don't think that stops this kind of bandage, a very heavy bandage, but you can see it's bending, you know, the horse is very strong, very powerful movement in its legs, and of course they're very easy to stretch these. When this front part stretches, the back part tightens.

So that has to happen and because the tension has to be taken somewhere and then you land up with this very dangerous circumstance both over bony prominences around the hock, the point of the hack, and then over the common calcanean tendon as well. So. We are trying to change people's attitudes towards this to lighten the dressings and to use the bandage casting systems.

These are restrictive. They're light, they're effective. They're economic because you use minimal casting materials, and they are incredibly, money conscious.

They, it's much better to put a cast on and leave the dressing on for 2 or 3 or 4 weeks and sometimes even longer than that, as Patrick mentioned. Rather than have to change the dressing every day and every 2nd day and every 3rd day, where you put another vast amount of money into sophisticated dressings, when maybe you can just truncate that and short, shortcut the whole issue. So, as as Patrick mentioned, he mentioned all this, you know, the wound support is a different kind of cast from the fracture support.

OK, so. In the wound you've got a little bit of flexibility about when you do it. Obviously if you've repaired the wound, then you have to do it immediately.

But if the horse can be accustomized to taking restriction before you actually do the casting, it helps enormously, and that's a little tip I learned from Anton first in Zurich. And he customises horses to the slining system for wounds. He puts the puts a system of usually gutters, you know, plastic gutters and things that he heats up and so on.

I'll come back to that later, but he puts that on and then he puts it on the horse, holds it on for 1 hour, stands with the horse, takes it off for 1 hour, then puts it back on for 2 hours and so on and so forth. And then once the horses are customised to that, He goes the whole hog and then seals the thing in and of course that works very well. So you can do that with a wound, clearly you can't do that with a fracture support.

So that's the important thing. One thing that Patrick perhaps didn't mention and just occurred to me while he was doing it, please don't put a cast on unless you've got a mechanism to remove it. It's very easy to buy the casting material and put it on and then find the cast is not comfortable.

And they think, well, I'll take it off. Well, that may be easier said than done. For a bandage cast, it's relatively easy, and, and of course, if you do have a cast saw, then you go down to where the vet wrap or the cohesive bandage is, is in place, or you can use.

Toilet paper, frankly, and rolls and rolls and rolls of toilet paper instead of the instead of the cohesive bandage. It's, it works just as well and it allows the cast to be cracked off very easily and so that makes it easier, but don't put a cast on unless you've got a mechanism to take it off. A bandage casting, the bandage and dressings, as Patrick has said, is applied normally.

You could dress and clean and treat the wound, and then you're going to use the casting material to reinforce restriction, plus or minus splints within the casting. And in the old days before I started trying to find other ways of doing it, I would just use ballpoint pens, you know, the little big ballpoint pens, just save them all. Don't throw them away when you're finished with them, just keep a stack of them and you can just Put them into the casting material and that and that maximises the strength that makes it a very powerful splint for a very small amount of casting material.

You've got to be careful because you don't want pressure, of course, it's a question of putting it in at the right level, incorporating it into the cast material. and this makes it much better and you use less casting material, of course, in the wound management anyway than an orthopaedic cast. But if you add the splinting material within it, within the casting, it makes it even less, and you can get away with a very light economic and well tolerated, dressing and cast.

So here's a typical case in point. It is the kind of thing, distal limb injuries that we might consider casting. Remember, the wound has to be managed.

You cannot use the cast as a mechanism to just overcome everything and say, Well, I've got a casting material. This is a big wound. I don't have to bother with it.

I'll just put it in the cast. That often leads to a complete disaster and it's very important that you Put the cast on at the right time, so only when you are comfortable that the horse can be left in the cast without anything because otherwise you're going to have to take it off and put it on and take it off and put it on, and that negates the whole objective of the caste system. Distal limb casts, just as, as Patrick mentioned, we, you can do it under general anaesthetic, of course, half limb cast.

You can even do whole limb cast under general anaesthetic. They just struggle to get up and in some cases it's better to put a temporary splintered system onto them until they're up and then maybe put a, put a slab which we'll be talking about in a minute or cast. Over everything at that stage.

So here's a case. This horse cut it, cut its its heel very badly. It was a hideous wound cleaned with a with a hydrosurgical unit again.

We really like that and we believe that, you know, if you can get hold of one or you can combine together with practises to get one amongst yourselves, it's a very valuable mechanism. And and then we've just put this on in the standing horse. We've reinforced the heel here to raise the heel a little bit so that the so that the foot is comfortable and this is it.

I think it was 3 weeks, I think 3.5 weeks or 4 weeks later and look at it, it just has healed from a, from an injury that was a disaster actually. It was a more or less disaster.

We spent time preparing the wound, and we'd spent time putting the cast on in the standing horse without any difficulty at all, and it went extremely well. It was just a very easy process that resulted in an astronomic, an incredibly impressive healing process. So this is a 5 month old wound that hasn't healed, and you can see the consequences of what you start off with.

This is what you end up with. You can see the advantage. Patrick showed another one of these.

We've probably all got those, any one of us who do this have got these kind of cases to show you, to prove that this is an effective method of treatment. Please remember that if synovial structures are involved, you have to get the priority right. So whenever you're doing the time acronym, and assessing the tissues and then combining the eye with the inhibitors of healing, you're going to, prioritise the wounds, prioritise the structures.

So if a synovial structure is involved, that's the priority. You get that right first before you do anything else. Of course, you're looking at the whole wound.

You're not just saying, Well, we'll get this right. You're managing the rest of the situation as well. So that's the kind of thing.

So this is the heel bulb injury which we just saw, this one here, and you can see. To fix the wound, and this is us using a hydrosurgical unit here which is just a stable side, of course, and you can see we did this here, we cleaned it all out with the hydrosurgical unit, nice red blood here because it's lots of oxygen and lots of blood going through it, and that's fine. And then of course we're putting it in the cast and you've already seen that.

So I'm going to skip past this now because we're kind of running out of time. OK, so this is the case that we showed you before. This was at the first bandage cast, removal, and then this, so that was 2 weeks, and then this, I think this was 4 weeks or 5 weeks.

I can't remember exactly the time. But again, you're addressing the wound as well as immobilising it. Here's one from Dylan which just shows a horrendous wound that was then put in a cast that healed, and that's another case which you can see, and this is the after effect.

Of course there's a scar. Don't believe that this is not going to create a scar because every wound creates a scar. Scarring is inevitable.

It's just minimising it by rapid, appropriate immobilisation and wound care that results in a satisfactory conclusion. There's a, there's a wound that hasn't healed and hasn't healed and hasn't healed, and And it's taken to surgery. We took that to surgery.

We cleaned it all up. We put it in a cast. There's the foot cast over it, and there is the consequence a few weeks later.

So you can see, I think this was 2 weeks later like this, and this was 4 weeks later like this. So it's a very impressive thing to do. You've got to remember, however, that it's not the only thing that you have to do.

So here's another case which shows a different kind of sleeve cast as Patrick showed. This horse had a very chronic wound. It smelt pseudomonacy and it looked a mess.

So we set out trying to keep the wound clean. And allow it to debride itself because we didn't want to seal all that in. That was going to be counterproductive.

So we created a circumstance where we put the leg in a bandage. It was a hot, heavy bandage in those days and and we seemed to get good granulation tissue. And of course then suddenly.

The wound cracked. That's simply because the movement now was assumed to be enough, and the wound wasn't actually healed. So every time the horse walked, it bent its carpus, then of course we got this split, and of course that was never going to heal.

So this is day 18, the split develops. So but the wound is fresh, it's reasonably clean and it looks quite healthy. There's a nice epithelial edge and some evidence of contraction.

Then of course, the next day we, after putting Robert Jones with a silver dressing, we just controlled the last of the infection and then We dressed the wound and then we put a bandage cast directly over the dressing like this. It was just a sleeve cast and inside here are ballpoint pens. There are 9 or 10 ballpoint pens throughout this front part here which we go from the from here round to the inside laying the ballpoint pens inside.

This horse couldn't move this. And he stood in the box. This was day 20 when we put the bandage cast on standing in its box, as you can see.

And then on day, day 44, which is now 4 or 5 days later, this is what it looks like. After the bandage cast been taken off, we could have left it on for longer, but we decided to stop at that point and just restrict the dressing to a restrictive dressing with a controlled exercise programme because we were confident now that this had healed, and sure enough, there it is on day 65 and then of course there it is on day 90, healed properly, very nice scar with lots of contraction. Immobilisation shortened the course of this treatment.

Dramatically, and it should, and there's the lovely owner who was very pleased with us. A customization of casting is helpful, usually, usually helpful. So if you kind of customise the horse to restriction, then that's good.

And that's why sometimes you put the bandage on if the wound is suitable for it, you can put a bandage on and just restrict it to some extent for 24, 36 hours, particularly if you go. To try to clean the wound, you want delayed 22 intention, delayed primary healing, of course, where you're going to allow it to come toward you a little bit and then close the wound and then cast it. You can, if you set out to restrict the horse to some extent at the outset, you can find that they tolerate this very much better.

One of the things that I thought of many years ago was the construction of a slab splint, splint that conforms precisely to the limb. It's reinforceable by other means, which we'll tell you about in a minute or two, but it avoids the need for huge and difficult and expensive Robert Jones bandages because they don't always conform and they don't immobilise. I don't think they immobilise unless they put on absolutely correctly, and that means building up a solid tube.

Not just putting the same thing all the way up and down, you have to build up where it's narrow a little bit more so that where it's not narrow, you incorporate those areas later on. So it becomes a solid structure, then it becomes immobilised, but the way it's put on in practise in most cases is not a mechanism to immobilise the leg. It's adaptable to all limb sites, the slabbing, and, and I use it now a lot.

People want to put sticks and broom handles, etc. But I don't think they conform. In fact, they don't conform.

How can a broomstick conform to the leg? How can you make it bend where it's supposed to? Some people use guttering, you know, plastic guttering, which you heat up with a blow lamp.

You can make that conform to some extent, at least, but actually you need a mechanism that conforms exactly. To the leg. That would be very, very comfortable and very good because you can then reuse the slab as many times as you need to, particularly if you really need to examine the wound more frequently, it does help.

So slabs are easy and sensible. They, they allow you to conform the leg. So I just made a mockup here using the Dinaar Prelude.

Comes in a roll inside a sheet like this on the bottom here where you cut off the right amount. So you measure the amount you need. Just use a piece of string or your hand if you want.

Where do you want to go from? Well, we want to go from the dorsal aspect to the hock or just proximal to the hock here, and we want to run down the front of the leg down to Foot so we cut off the right amount. We then spray it with water, cold water, iced water gives you a little bit better at a time, as Patrick mentioned before you spray this casting material inside the lint packing around it, the bandage on the outside of it, then starts to set, and then you take a bandage and you strap the bandage onto the site because the moment you do this, you're conforming the splint to the leg.

OK, so now, of course, if there's a dressing underneath, you can, it will go over the top of that, that's fine. It doesn't matter. It will conform completely to what the leg actually looks like.

And having done that, you cut off this bandage here and let it set a little bit. When it, when you're finished letting it set a little bit, I take it off the horse and let it set outside. So here we're cutting it off.

He's cut off, and we're just letting this set now on its own. And once it's set completely. Then have to make, just make sure it conforms to where you want it to be, and then you just trim off the little, the little cloth, the little fibre materials within it to just make it a bit smoother.

You can pad those ends because that's the rough end and you don't want a rough end, as Patrick said, so you pad that up. And then of course you can fasten it on. You can make them for the back, you can make them for the front.

If you're going to make them go around a sharp corner like at the fatlock, you can see that if you put that on, there's a little kink here. And you need to cut that out, so if you cut out a little oval here on either side, then it will conform very accurately. Of course you can make one for the back and one for the front.

Then you've got a bivalve cast. You can take that over the top of the hock if you like and go all the way up to. There as well.

It'll just continue to do this. This is a quite wide 10 inch slab cast that comes in this box and it really is a very effective thing to do. And of course it's not an orthopaedic cast.

You can't use this to restrain. An orthopaedic fracture to to to immobilise an orthopaedic thing, but for a wound, it's really helpful because it's very light and extremely strong, and you can reinforce it. You can put that hexite material that that material down the front of it as well.

You can put that onto it as well. It'll stick like crazy onto the top of it and reinforce. The, the bends, if you will.

So where you're worried about it bending or you think it might bend, you can just reinforce it, and then you can just use something like gaffer tape to strap the thing on, and it will keep the thing very, very tight. You can put a glossy bandage on the outside if you like. So tips to make it easier, measure the length of the cast material you need, fairly accurate.

It's important. A piece of string or a tape is a good way of doing it. Check the length of the material you've cut against the horse to make sure that it's the right length.

Mark can cut any conforming corners. Remember, it goes around the back. You're doing a fetlock, for example, or pasten, and you want to splint it from the back as well.

You've got to go round the fetlock. That's quite a sharp bend, and you need to cut out. The, the sides of it just to try to make it conform easily and smoothly round the fat lock.

Once you've done that, damp down the slab with a sprayer. OK. Remember, you can, we've got a video of this which we'll put up on our, on the equine Medical Solutions website in due course, that it's coming out, I think next week or so.

It needs to be damp, not soaking wet. Do both sides, just rub it gently rub the surface on both sides for a few minutes just to try to get the water onto the casting material. It does exactly the same as the casting material.

Make sure the horse is standing in a suitable, comfortable position that you've decided is comfortable for the horse, and then place the slab in position over a wound dressing if if that is in position, and bandage it firmly in place with a cohesive bandage or gaffa tape or whatever you want to use. Keep the horse still until the slab is set. Then remove the slab carefully and lay it aside to fully set.

Don't try and let it set on the horse because the, the constriction commonly makes them resent that just a little bit, and then you can reinforce it as much as you like on the outside. So you've cleaned up the top, you've padded the top, you've padded the bottom, you then reinforce the bits you want, place the cast, the slab onto this site. Protected, of course, from anything underneath, so you've got bandages underneath if you have to, and then just strap that on and then you can just lock it on with whatever adhesive material you like and then the horse will be very, very comfortable, extremely light and extremely strong.

Just, it's important, as I said, to just customise the horse a little bit if you're putting it on for the first time. It's important to do that. And then you can just retrieve the slab at each dressing change and reuse it again and again and again and again and again as much as you like.

Remember, finally, to deal with the wound properly. You need a light but properly padded wound dressing. There's no need for huge Robert Jones bandages anymore.

No need for broomsticks, clanks, etc. They can't conform anyway. The slab can be made as long as you like and in any direction you like, so you can splint from the outside if you have to.

You can splint from the inside. You can splint from back, and you can splint from front. And you can cut out on the bends to make them conform very nicely, pad the ends carefully, minimal thickness to protect the leg from contact with the material because it's very sympathetic.

The material is sympathetic, and then you can reinforce the slab as required with delta cast, you're just ordinary cast material if you like, or with hexalite over the force points, those areas where there's going to be damage. You can remove this and change it in 2 days' time. So for wounds that are exud, for example, wounds that for some other reason you may want to not put a permanent locked on full cast onto the leg, you can do this to start with.

It's a useful thing to start with. And then once the wound is a little bit cleaner and a little bit better, you'll find that it will tolerate the cast very much better in any case. Some wounds can't be immobilised, of course, and then you just need to find a way of doing that.

And this is a case in point. This was a wound that was sent in to me and of course this is how it started. The vets spent a lot of time doing this beautifully sutured in all the layers, everything was beautifully done, but of course it's just too much movement and it just disrupts and lands up.

With a mess. So you know this is the kind of thing we want to try to find ways of immobilising this. And if we had restricted the movement of the horse and perhaps immobilised this right from the front all the way down the leg, we could have made a slab going right from here all the way down because it will conform all the way down.

That would keep the leg very straight, very still, and I don't think it probably would have happened. Maybe it would have anyway, but you know, casting and is faster. You get faster wound healing.

It's cheaper. In the end it's much cheaper than these multiple dressings. Robert Jones costs hundreds of pounds by the time you've done 2 or 3 of them for a wound.

Easier for sure. Better tolerated than bigger dressings, safe, as Patrick has shown you already. There's little risk associated with it.

Of course you may have cast sores and so on, but slabbing is a really good thing to do, and I do think we should use this very much more often. So casting and bandage casting is not a substitute for good wound management, you know, if you can't make it better, don't make it worse. This is a good little book if someone wants to read it.

If wound management is not good, casting will make it worse, not better. So, you know, be careful, select your cases correctly. So are they useful?

Absolutely, yes, they are. That protects and stabilises wounds. It's economic.

And the risks are minimal if correctly applied, but there is a but. Be careful and always make sure absolutely that you know that the wound is managed first and individual tissues within the wound are prioritised accordingly. Don't just think the cast is the end of the world.

It isn't. It's very good, but it's not the absolute end of the world. Thanks very much indeed.

Hello everyone. My name is Charlotte Wood, and I'm veterinary key account manager for ST. ET is a leading global hygiene and health company dedicated to improving well-being through its products and solutions essential for everyday life.

SAT is best known in the veterinary market for key brands such as Softban and Tenderplast. Today I will give you a brief presentation about a small number of STT products. First we have Keyed Deri clean for fast and effective wound cleansing.

Cimer debris clean is a double-ended cleansing pad. The white looped monofilament fibres offer gentle debridement. The blue more abrasive fibres offer a stronger debridement option if required.

The inner foam layer supports absorption and rinsing during use and aids with the cleansing efficiency of the pad. The pad features a hand loop for comfortable and accurate use. Kea debris clean is packaged in a hard blister pack, which can be used for moistening the pad with your chosen wound rinsing solution and can also be used for disposal of the product after use.

The white monofilament loops on one end of the cuteed debris clean pad are designed to remove and retain slough, biofilms, and microorganisms. The more abrasive blue loop fibres at the other end of the pad are used to break up firm slough and remove it from the wound. During trials, cutamide debrile shows much higher bacterial binding to wound microorganisms than other products.

In summary, Ketamed derile offers fast and effective wound cleansing, effective bacterial binding, and greater than 99% biofilm removal. Keimed Siltec is Esser's range of foam dressings for extra date management. Keyed siltec dressings have been designed to offer dynamic X-tape management for a wide range of wound types.

The layers of the dressing integrate to provide an ideal dressing choice for chronic wounds. The dressings are designed to offer quick, easy, and a traumatic dressing changes. The wound contact layer of all cuteed siltec dressings is made of perforated silicone with either a feather tag of the cuteed siltec, as you can see here, or a soft tag of the cuteed Syltec B which we will look at next.

The middle layer of Qemed siltec is made up of a highly absorbent polyetthane foam which is capable of managing all types of extradate, even very viscous extradate. Super absorbent strips within the adhesive that binds the foam to the top film help to retain each state in the dressing, even under pressure. The highly breathable branded top film of Cimed Siltec allows for a dynamic moisture vapour transmission rate.

Qamed Siltec B is a bordered version of this product which offers gentle but reliable adhesion. The product can be cut to size and is showerproof. Ketamed siltec absorbs extradate vertically, transporting it to the super absorbent fibres above the foam core.

Transparency of the top film allows visibility of saturation to help determine the ideal time for dressing change. Ketamed siltec offers dynamic breathability as the film top layer cleverly adapts the rate of MVTR to saturation level of the dressing. The silicon wound contact layer of cutammed siltec seals around the wound margins to help minimise the risk of maceration.

The silicon wound contact layer also allows easy passage of fluid through it whilst forming an effective barrier against tissue ingrowth into the foam. The silicon wound contact layer adheres to dry skin but not a moist wound bed, offering pain-free and a traumatic dressing changes. Now we will take a look at some of ECT's under cast padding.

Softban natural made entirely from rayon fleece is an under cast padding that provides soft, comfortable cushioning and protection to the patient. This product tears easily, is highly absorbent, and conforms well for easy shaping to all body contours and joints. Softband synthetic is a comfortable, soft, and smooth orthopaedic padding.

Softband synthetic is made from viscose and features a high loft for maximum cushioning and protection, and feathers out easily, giving the padding a smooth finish. Softband synthetic is also highly conformable for easy shaping around body contours and joints. It is resistant to moisture absorbency, minimising the risk of skin maceration.

In summary, the benefits of soft ban under cast padding include easy to tear products, which feather easily and clings to itself. It blends well to give a smooth finish. Next we will take a look at Dynocast Prelude, a synthetic casting system from ST.

Dynaca Prelude is a pre-assembled synthetic splinting system which is easy to use. It is made from polyurethrane-coated fibreglass covered by polypropylene padding. This versatile splinting system is ideal for individual patient application.

It offers a clean, modern alternative to plaster of Paris slabbing. It is strong and lightweight with no plaster mess. This all in one roll is easy and quick to apply.

Now we will look at Deltacast Elite, which is one of ST's synthetic casting tapes. Deltacast Elite is a non-fiberglass synthetic casting tape, which is lightweight and rigid. It is designed for easy application and high levels of patient comfort.

The excellent conformability of Deltacast Elite helps to create well-fitting casts with wrinkle-free application. The product conforms well to body contours. Deltacast Elite has excellent pliability and a reliable, precise working time window.

That rounds up a short presentation on some of SAT's wound care and casting products. If you would like any further information, please contact myself, Charlotte Wood, using email address [email protected].

Thank you.

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