So in this talk over the next 45 minutes to an hour, I'm going to discuss really the clinical approach, the first opinion approach to managing orthopaedic emergencies, which in this instance, really we're talking about acute severe lameness. Now that's a big topic. There's lots of things that can cause that, but really I'm just gonna aim to have an overview of the most important of those conditions, but also really think about the practicalities of managing these types of cases because they can be quite challenging and quite stressful for you as a vet.

Now I'm Obviously, all different types of vets may be listening to this. I'm going to, present this really to, mixed practise equine vets, perhaps fairly recently qualified equine vets. We're not going to have the scope to go into a huge amount of detail.

But I guess if, if there's anything you want to know in more detail that that potentially could be talks for another time. So we're gonna discuss the clinical assessment and initial management of these types of lameness cases. He think a bit about decision making and the importance of communication in these cases.

And the conditions that I'm going to focus on are managing fractures, some soft tissue injuries such as tendon lacerations and tendon injuries. Investigating and assessing cases which may have synovial sepsis, a joint or 10 yeast infections, solar penetrations. And, street owl cases, another important differential.

And also what to do in some frustrating cases where you have a horse that's severely lame and really has no localising signs and, and it can be a real frustration and a real challenge, to know what to do next with these horses. So as I mentioned, these can be really challenging cases. They can be cases where you're asked to work and make difficult decisions and situations of high stress.

Emotions can be running high in the people associated with the horse, the owner, sometimes children, and all sorts can be going on. The horse can be challenging in itself if the horse is particularly anxious or distressed in a lot of pain, adds to a level of risk for you and those around you. The environment can be a challenge.

Sometimes you are sent to examine a horse that's immobile in the middle of a field, for example, and you have to manage the best you can in that type of scenario. And also they're challenging from a personal perspective, stressful for you. They can be physically challenging sometimes and as I mentioned, a little bit dangerous too, so you do have to look after yourself as well.

So this is by no means an exhaustive differential diagnosis list, but these are the sorts of things that you might be considering as causes of acute onset severe lameness in horses. Trauma would be fairly high up on that list. Which could culminate in a fracture, not that common, but certainly severe.

This picture is of a horse that was kicked in the field and was found, with this swinging leg, very sadly. Trauma can cause injury to tendons and ligaments. Again, by kicks or, or overstrained situations.

Wounds can culminate in infection of synovial structures. I've put wounds in a subheading here because wounds themselves rarely cause severe lameness just because of the skin defect. There's usually something more sinister going on if a wound is associated with severe lameness.

Athletic injuries such as superficial digital flexor tendon overstrain injuries. Or vulsions or, injuries that you might associate with performance animals such as racehorses on the racetrack. Solar puncture, solar penetration clearly is an important cause of lameness.

Pass on the foot, probably the most common and the most satisfying of all of these cases, and it really highlights the difficulty with these cases, you know, you may be called out to see a horse with a leg like this, you've got a very stressful and and. Well, fairly clear cut situation there. Or, or you may simply, have a horse that, that you need to dig some pus out of its foot.

I say simply, they're not always as simple as that. That pus might be in the back leg of a shire horse or the front foot of an unhandled, yearling, but usually it's more a logistical challenge than, a diagnostic challenge. Cellulitis can cause severe lameness, particularly peritarsal cellulitis can cause quite a lot of pain and discomfort in horses.

You need to be careful that you're not overlooking a synovial sepsis or a wound in the midst of that cellulitis, but, cellulitis on its own can, can cause, . Fracture level lameness. Usually though the horse will walk out of the lameness if they're moved around, and they should respond fairly well to to medical management in quite a short space of time.

Laminitis clearly is a differential that hopefully would be obvious on examination, as with exertional rhabdomyolysis or tying up, there should be some history and clinical signs that will put you in that direction. And they are less commonly neurologic causes of lameness. Which is probably beyond the scope of today's talk.

So first of all, I would say be prepared for these cases when I was out and about on the road, I would always be anxious if I felt like I didn't have the things that I might need safely stowed away in the back of my car. So have the kit that you need. By and large it's nothing complicated.

You will really struggle if you don't have some hoof knives and hoof testers, in your car, for example, pain relief and sedation, drugs. Plenty of bandaging material you may or may not carry splints or cast tape. In your car, I think some lengths of wood and a hacksaw or PVC pipe and a hacksaw are, are very handy if you are able to take them with you.

Other times, if it came to it, where there's a will, there's a way on a yard, you can rustle something up with, what's around you or somebody, will be able to find something for you. Cast tape will come on to it, it can be very handy. Antimicrobial drugs, clearly, tetanus and toxin, for wound cases, and then less sort of absolute essentials, but you will need them, means of cleaning wounds, lavaging, sterile gloves for palpation.

Increasingly now, and I'd say that that really you shouldn't be out and about without a hard hat, for, for certain situations. A head collar and no rope is useful. You don't always know that you're gonna have the means to restrain a horse in some of these situations.

The ability to euthanize a horse is absolutely essential. Some of these cases will need immediate euthanasia on welfare fair grounds. So you have to be prepared for that scenario.

Now that's in the vast majority of cases now is with soullose . Injectable. But, occasionally, I guess the bullet is still used.

Phone numbers you need to make sure that you are able to contact your local referral centre. This may simply be for advice or to organise a referral for those cases which require it. Also, .

Your local Nakaman as well to arrange for a collection or, or to manage euthanasia cases. Now if you have an X-ray machine that you're able to take out to a suspected fracture situation, then that's great if you, if you have one in your car and you're able to use it. But at the very least, if you're suspecting you might be involved with examining a potential fracture, making some sort of plans to be able to.

Radiograph that horse, even if it's not in the initial instant, but, to have someone come to bring it to you or that you're able to collect it, is certainly important as well. So you're all set with the kit that you might need, and, I always find that driving out to these cases, all different possible scenarios are running through my mind. You know, you've been called out by a panicky owner.

My horses, can't walk, can't get him out of the field. I think he must have broken his leg, and, you know, any possibility, could be running through your mind if you don't have a lot of information. That horse might have passing the foot or it might have something a lot more, severe.

So it adds a little bit of excitement to your, your journey. And I think if you have a little bit of information or you're mulling over what you might be expected to, to encounter, there's certainly typical, histories that might point you in certain directions. Obviously, anything can happen to any animal, but there are definite trends.

For example. A young thoroughbred pulling up on the gallops might have a just a limb fracture, or a fracture of of some sort, from overuse injuries. An older horse lay in a stable might have hopefully something less serious like a cellulitis, or.

Tendon injury that happened the night before and they've stiffened up overnight in the stable. A horse that's had a fall, may, have a soft tissue injury or? Fracture of some sort.

Clearly something like this, you might be thinking about neck injuries or something of that, something similar. Well, I'm yelling in a field, . Again, anything could have happened, but pass the foot would be quite high up my possible list in that situation.

And once you get there, unfortunately sometimes you do have this sort of situation. There's nothing wrong with this individual horse, but a severely lame horse might be rooted to the spot wherever the injury occurred. And wherever possible, it is really helpful if you can.

Get your vehicle as close to the horse as possible. Trying to guess what you might need and carry it across the field, you can almost guarantee that the thing you really need will be back in your car. So, within what's possible, try and, get, the animal.

If not, you have to hike out there and Do, do your best, . And ultimately, depending on what you find, you will need to be able to examine the horse safely, so you may find that you do have to move this animal and depending on what's going on, to allow you to make the appropriate investigation. Do you need to remember that you are responsible for the situation that you're in.

So, as unreasonable as it may seem, you, you are responsible for the safety of that horse and the people around you. So you do need to be prepared to be quite assertive, in a polite and kind way into managing the people around you. I think it's imperative that you Establish who's who once you arrive.

So who is the owner of the horse? Are they present? If they're not present, are you able to talk to them?

It's sod's law that that owner will be on holiday in the Seychelles or, or something. So, failing that, you need to know who has been given the responsibility of the animal, who perhaps owns the yard or looks after the horse, who knows the history of the animal, if it's not the owner. The recent history that's led up to the, the injury.

You may need a few extra pairs of hands depending on what's going on. So you might want a bit of help, but otherwise I'd encourage you to politely make sure everyone else keeps a safe distance and doesn't add to the stress of the situation by by crowding you. It's important to get a, a history from, whoever knows that history.

Now, clearly if you've got a horse with its legs swinging in the breeze, then, then, detailed history isn't appropriate. You want to get on and look after that animal. But otherwise you can learn an awful lot from, from a history.

So, . When the horse was last seen normal, if a trauma or accident was observed, the age and use of the horse, whether they have any concurrent issues, whether they're prone to any conditions, and, you know, if a horse is rooted to the spot and it has laminitis every spring, and it's this time of year, then, you know, that's gonna lead you down, down one, obvious, thought process. Also the, the progression of lameness, sometimes the horse will be found very lame in a stable in the morning and it'll have been brought in in the dark the night before, perhaps won't have noticed a wound or something, so it's had the whole night to develop into a painful situation.

Other medications, things like that, just, a thorough history, . Pertinent to, to what's, in front of you. We're looking at the horse, I've already mentioned access to the animal, handling the animal safely and making sure that it's appropriately restrained.

We'll talk about sedation in in a minute. Analgesia, . We'll also come on to in a moment.

So assessing this lame horse, as I said, it might be very clear what's actually wrong with the animal. But if not, you're presented with a horse like this that's clearly very lame on its right forelimb, but with no obvious external signs, it's perhaps a little bit sweated up. Maybe it's distressed and it doesn't want to go anywhere, sort of flaring its nostrils, it's not, not particularly happy, .

If you can, oh sorry. Make your, the first part of your assessment before sedating the animal, that is really helpful. So, if appropriate, try to walk the animal first of all, because, a horse that's reported as being non-weight bearing can, present in a very wide range of lameness levels, and you might find that actually, once you, are the person with a bit more confidence to ask it to walk, you realise that it's really not as lame as, was initially suspected, .

Or might walk out of the lameness, but a really truly non-weight bearing horse, a horse that literally can't put the, the limbs to the ground, is quite rare and you're certainly not gonna be wanting to walk that, any real distance. So you'll get a judgement pretty quickly of how severe the lameness is. TPR, if you can, it's useful, before sedating the horse.

And then with regards to sedation, I think you have to judge your sedation doses quite carefully. If the horse is very distressed with the loss of adrenaline, you may need a lot, a bit more domidine to sedate the horse, if that's what you're using, or. Than than you might normally use, if they are .

Dehydrated in a lot of pain, sweating, wobbly on three legs, you might want to use a lower dose. The last thing you want to do is make them ataxic on sedation and mean that they won't bear more weight through an injury than than they should be. I would always usepitorphanol in, combination with my alpha 2 sedation, and would usually use, you know, a mL, a reasonable dose, to provide a, a little bit of analgesic, component to that, .

To that sedation. At the same time, you might also want to give them, I probably, recommend getting some additional analgesia on board. So, phenolbutazone or flunexin would be my preference.

Phoenix in 1.1 MB per kg, be 4.4 MBs per kg, .

for me, I don't think, other non-steroidals are as effective as those two, so I would personally, prefer not to use loxicam or. Or others, but use what you have. And then you can concentrate on your clinical assessments of the animal.

Now, Most lame horses with a good careful clinical exam. We'll give you some clues if not a complete diagnosis, then a provisional diagnosis or partial diagnosis of what you are dealing with. Yes, radiography, ultrasound, other additional tests may become useful, but really the mainstay is simply a good examination.

So you don't really need more than than your own hands, maybe a pair of gloves. Some hoof testers and a hoof knife, to, to hopefully really make some inroads into what's going on. So palpation is really important.

You might want to look first about how the horse is standing, how they're choosing to bear weight. The swellings, fusions, heat in certain areas of the limbs, cellulitis, edoema, pitting, and palpation. wounds, .

And then if you lift the limb or palpate it more closely looking for Areas of pain on palpation, changes in pain on manipulation of the limb, . Flexion and extension of, of joints. Palpating for, for puncture wounds.

Really any clues of, traumatic injuries that you might be able to find? Foot examination, clearly who testers, who's nice, clean up the foot, have a look, for that nail that might have caused a solar penetration or a track to follow for passing the foot. Assessment we'll discuss in a moment.

And general exam, again, I've mentioned, you know, chronic sepsis might be pyrexic, for example, and knowing the heart rates or other concurrent issues, just thinking I had a horse come in not that long ago with a pretty significant wound, but it also had, atrial fibrillation and that affected our our prognostics and and plan ultimately, . So knowing a bit more about the horse is also useful. Now, limb fractures.

These are the big events, I suppose, that you might be called out to see. I guess they're divided into two broadly speaking into two categories, athletic factors, which by and large will happen on a racetrack, so a very different sort of set of scenarios, not really what we're here to talk about today. Or traumatic events are typically a horse like this poor horse here, that was kicked in the field by another horse and found in the morning, in the wrong field.

It was in a starvation paddock and chose to jump out into its neighbor's lush green paddock, and the neighbouring horse didn't think too much of, sharing that field, sadly. So, the common kick fractures that we see, clearly anything can happen, but the common kick fractures that can cause severe lameness would be, long growing fractures such as . This, a third metacarpal cannon bone fracture, here, these are high impact, clearly high force fractures, and this was committed and open, .

And, the animal was in, in severe pain and completely non-weight bearing. Other factors that are more amenable to, to, to, and have good treatment options. Would be fractures of the electronon.

So a non-weight bearing ulnar fracture of the ulnar bone, gives us good treatment options and potentially a good prognosis for those fractures. And also non-displaced radial fractures, so kicks usually to the medial aspect of the radius that cause a spiral hairline fracture line, but non-displaced, so they can be very lame, . But have the potential to recover, as long as it doesn't displace.

Now, Thinking about what fractures, you know, clearly if you find a horse with a a complete long bone fracture, there is only one. Next step, and that is going to be euthanasia of that animal on welfare grounds. But we should also bear in mind that that sometimes in these highly charged situations, sometimes actually we're we're sort of leaned on to euthanize animals, when there are options for treatment.

Now, of course, those treatment options are not always practical or viable or fair or humane, potentially, but, certainly with regards to . The beaver guidelines for immediate destruction on welfare grounds. This is the list of bone related injuries that can that immediate destruction is not questioned in any scenario and .

And so, in theory, the non-treatable fractures, those would be a communitated fracture of the pastum, of the, proximal phalanx. So no in intact struts of bone spanning from the pastan joint to the metacarpal phalangeal joint, that's that that joint. So it would require radiography to know that's the case really, unless it just palpates as a as a bag of marbles.

Compound long bone fractures, so as we've seen in a couple of the pictures that I've showed, cannon bone fracture, as we've just seen, would certainly qualify. Multiple tarsal or carpal bone fractures or displaced, radial tibial femoral, humeral fractures in an adult, and a pelvic fracture that results in a recumbent horse. So in theory, all other fractures have the potential to .

To be saved, but clearly that is not always the case. So really, I'm just putting this up to highlight the fact that, yes, in these situations, there's really no further work up or treatment required, that euthanasia is the only option and should be performed, you know, with consent and sooner rather than later for the welfare of the animal. But in other scenarios, it's worth if you can just pausing and making sure that.

You know, you are making the right decision at the right time. So an example of fractures that we might want to manage out in the field. The first here is an electronon fracture here through into the elbow joint on this radiograph.

Now these horses can be no well will often be non-weight bearing and will be quite distressed, but the reason that they are is more mechanical rather than pain related, simply because this fracture, . Disarms the, triceps apparatus attaching to the back of the electron here. So with no functioning triceps muscle, the horse is unable to maintain extension of its carpus.

So it can't lock its limb out and it can't weight bear through the limb. But simply if you are able to bandage . Put a full limb bandage on and splint the carpus with either a dorsal or a cordal splint.

Then you can maintain the horse can then maintain its limb, it's carpus in extension and will immediately be weight bearing and, and far more relaxed and, less anxious. And once you've done that, then, it's panic over really. The horses, .

In a much better state and then you can do further investigation or move the horse, get organised radiography without so much . Urgency. So, that's something that can really easily be done quite, quite quickly to get control of that situation.

The second example here, this is a a radial spiral radial fracture, . Non-displaced, this I don't think is an acutely acute radiograph. I think this has probably taken a week or two down the line.

They often don't look, unfortunately this obvious on on radiography. But typically you will see a horse that has a history that will fit with it being kicked, . The medial aspect of the radius here, has no real soft tissue cover.

You can palpate the skin and under that directly, you're onto the radius. You may have a small wound in that region that points you in the direction of a kick. There may be pain on percussion of that region.

But otherwise you might have a limb with no real signs of what's been going on. And these horses, you need to, to treat very cautiously. Clearly if it's in a field, you'll need to get it out of the field, to allow you to, to get, get radiographs.

You might want to be to box them out or just walk them very carefully, but it is a slightly . Nerve-wracking, situation. Often the horse though will have already been led into the stable, and, you're, you're evaluating it there.

But really, the priority is getting some radiographs and taking things from there. We'll look at bandaging and splinting options a little bit later. I'm not gonna talk too much about this, but athletic fractures, so those in you know, racehorses or or polar ponies, evenventors, even hunters sometimes can have these fractures, .

Because they're overstrains of stress related cumulative injuries that finally fracture, they have quite a predictable, sort of pathogenesis or location of the fractures. And certainly the most common fractures that we would see would be . P1, sagittal or parasagittal fractures, condylar fractures, so parasagittal, fractures of the distal, the metacarpus or metatarsis that may be complete or incomplete, displaced or non-displaced, and sometimes, the proximal sesamoid bones as well.

We usually have clues in the history, and, clues on palpation. So, all of these fractures will have haemorrhage into the joint, which should be palpable as an effusion, the pain on direct pressure, swelling. There may be a wound associated potentially but not usually in these sorts of cases, and ultimately they're diagnosed on radiography.

If you can get your diagnosis with an X-ray first, then that will help guide you the best way to coact and stabilise the limb, otherwise you may need to bandage and stabilise the limb to allow you to then transport the horse to somewhere it can be x-rayed or or to a referral establishment. Just depends on the situation. So limb fractures, clearly some catastrophic fractures, euthanasia is, is really your only option.

But otherwise, these horses, as I've discussed, will require analgesia. But really stabilising the limb can be as effective or probably more effective than . Drugs in reducing pain and anxiety in these animals.

And the aim of your stabilisation really is to reduce that pain and anxiety, allow you to transport the horse to the most appropriate place, whether that's back to a stable or to a referral centre. If necessary, but then crucially, you want to stop these injuries from getting worse, a non-displaced. Patern fracture, for example, if that displaces, you may go from a fixable injury to a non, fixable injury, in a short space of time, and that can be the end of that.

So your aim is to resist the distracting forces of the fracture. So really you just need to think about what, what forces on that fracture and what you need to overcome with your stabilisation method. Preserving soft tissues, so preventing fractures from becoming open, preventing preventing trauma to the neurovascular bundles, preserving blood supply to the lower limb.

And looking after the fracture line as well, the better it can those fracture gap can be closed and opposed, the better the prognosis from a, from a surgical perspective, I'm thinking that. Radiography, along the way, at whichever stage is appropriate is obviously key. May not be part of your initial first aid stabilisation kind of assessment, but will need to occur at some, some point to allow you to progress with managing the case.

And there's never a wrong time or it's. It's never a bad idea to speak to a referral centre at any stage, whether that's to WhatsApp some, X-ray pictures from your, that you've taken on your phone, of your, of your, X-ray screen, or just to speak to them about the best way to, bandage a limb, to discuss whether treatment is feasible or possible. I would say that assessing radiographs from a a photo on a on a phone, is clearly not ideal, but it's something that we do regularly, in the first instance, just to get a bit of an idea of what may be going on, but you have to appreciate that we may not be able to give you an absolute definitive .

A plan based on those types of images. If you are able to send, you know, DICO images, then that's clearly the, the best situation, but out in the field, that's almost an impossibility, really. So yeah, always feel that you can pick up the phone, speak to your local referral centre and help get advice on the best way to manage these cases, after that initial.

Kind of triage process. So just a quick word on stabilising limb fractures, actually we'll go on to . To this slide.

Firstly, just something to note that these condylar fractures, putting these fractures into something like a Kinsey splint, or any captation method that aligns the dorsal cortices of these bones is contraindicated. This fracture line disarms the lateral collateral ligaments of the fatlock joint and really produces instability in a medial to lateral direction. And the best way of maintaining that stability is keeping the foot flat to the floor.

So these sorts of cases, and actually most plast and fractures as well, are best bandaged or splinted or cast, with a foot flat to the ground. So do not put these into a sy splint. Eleronon, as I discussed, simply splinting the carpus is all you need to do, if that's your suspicion of, of what's going on.

Now a radial fracture, in all honesty, it's rarely appropriate to, bandage or stabilise these cases because the only effective thing that you can do is a full Robert Jones bandage as shown in this picture, of a pony I diligently bandaged a long time ago, . A full Robert Jones up to the point of the elbow with a lateral and a caudal splint, and the important bit here is the lateral splint. And you need to prevent this horse from moving their limb laterally, so that splint should go to the floor.

It's a little bit short, up to the withers, and there should be sufficient padding on the top of this splint, that there's no gap between the forearm muscles and the splint. Keep doing that, sorry. Oh.

There we go. . Now you can only use this splint really this setup for.

Transporting a horse to a referral centre if they're very, very lame and they need that . To allow them to travel safely and minimise the risk of a catastrophic . Displacement of the fracture during transport, or if the horse is very lame and you're managing it on the yard, and it's going to be cross tied.

And really the benefit that you gain from, bandaging a horse in this way on a yard is rarely outweighs the risks associated with it. There's lots of problems that you can encounter. Firstly, with the fact that the horse must be cross tied, you run the risk of, a life threatening plural pneumonia if they're not mad.

Adequately on cross ties. Also, there's the potential that the horse tries to lie down in the middle of the night, the splints move, things sag, and they can end up doing more harm than good. So it's something to very carefully consider and, perhaps take further advice on if it's something that you're considering doing.

Just a little note on bandaging, really for more information on this, I'd refer you to a really good, series of three articles written in EVE by Ian Wright. This, . Refers to part two of that, trilogy, techniques for, temporary immobilisation of limbs.

It's focused on racecourse, fracture management, but it really shows some excellent, images and descriptions of appropriate bandaging and, stabilisation techniques. This image is taken from, this paper that shows a distal limb, Robert Jones bandage. Anything less than this, really isn't gonna provide sufficient support for a suspected fracture.

So they are quite, You know, serious bandages to to perform. And really a bandage like this, I guess the, the, the message I'm trying to say is make sure that you have plenty of bandage material in your car or have the means for an alternative method of supporting a limb. So this bandage typically would have 3 rolls of cotton wool, 6 or 8, knit firm conforming.

Layers, rolls of, of conforming layer, . Of conforming bandage, maybe 3 or 4 rolls of elasa plaster over the top, . If you've got unstable or concerned of a serious fracture, you probably want to back this up with, a medial and later splint.

And, and the aim is to have a parallel sided, firm bandage that's about twice the diameter of the limb. And the last final layers of this bandage you were applying the it from as tight as you possibly can. It's kind of knuckle bleeding, tight, by the time you've put this bandage on.

So it's rarely, necessary to use a bandage of that type. Usually a modified Robert Jones, if you're not looking to, bandage a fracture, but, a wound or, tendon injury, for example, you might be using a slightly lesser, size of bandage. But, something.

To also consider is having some cast material in your car, the, . 3 or 4 rolls of cast material that can be used simply by immersing it in warm water, 20 to 25 degrees. It's not for you don't need hot water, can turn a modified Robert Jones, so a smaller bandage than this, .

In a bandage cast and provide stabilisation and resist forces in all planes. So it's a really useful thing to consider. So simply, you place a 2 or 3 layer bandage on the limb and then apply perhaps 3 rolls of cast tape over the top of that under the foot and around the entire limb, and then that leg, .

It's pretty well immobilised for transport. It's not a sort of cars that's going to be left on for very long. The risk of complications are very low.

The only thing to bear in mind is that the car does have an expiry date on it, so it's not the sort of thing you can have in the back of your car for 10 years and pull out in a, you know, once in a blue moon, but it is a good option to consider. So leaving fractures behind, well, limb fractures, we're just gonna speak briefly on pelvic fractures. These can be difficult to diagnose in some cases, but there will usually be a feature of the history, so a full .

Perhaps a cross country, fence fall or, a young horse falling on rearing up and going over backwards on concrete, those sorts of things are instances where I can think of, where I've seen pelvic fractures. They're also a stress injury and racehorses as well. The severity of a pelvic fracture depends on the location of the fracture line, and the displacement, if any.

Of the fracture, it's worth bearing in mind that these can progressively displace, so of course, So, what may not seem so bad in the first instance can become, a severe or life threatening scenario, . And really, I guess, fractures that turn out to, span, the ileum, the wing of the ileum, so sort of through here or here, are, are life threatening and serious injuries. Those fractures that, affect the proximal part of the ileum or the tuberscrala or the lateral part of the ileum and the tubercocca, or certainly the tuber, which are not non-weight bearing, they are, .

Less of a concern, but clearly, you're not gonna know what's going on, until you've done a bit more investigation. So pelvic fractures, as I said, they can be difficult to diagnose in the first instance and really part of your clinical examination and assessing for a pelvic fracture is careful assessment of symmetry or asymmetry, and . Careful assessment of the bony landmarks of the pelvis, to, to try and assess that asymmetry.

That can be easier said than done because you can have changes in posture, they might be not standing fully on one leg, which makes it hard to. Assess, there can be muscle spasm and unlikely muscle ay in the first instance. There can be swelling.

So it can be easier said than done to assess for this asymmetry. This is a horse that fell across country schooling, and was immediately very, very lame, couldn't really walk, . And this was the horse in the first day or so after the injury.

And you can see, some asymmetry to the, to the shape of the pelvis. It got more severe as time went on and there was more muscle atrophy. So the features that you're looking for, would be ventral displacement of the.

Tubercoxa on the affected side, or a reduction in the gap between the tubercoxa and the last rib, so sort of lumbar region, . can signify fractures. If you've got ventral displacement of the tuba sealli and the tuber coxa on the same side, then that signifies that you've got an allele fracture of of really some significance and displacement and and potentially communion.

And those, those are life threatening, . Fractures because they do have the potential, if there's displaced fracture fragments of lacerating internal vessels and and these horses can be at risk of, of internal haemorrhage that is, of a life threatening or fatal, severity. And clearly if, if one of those vessels is ruptured, or lacerated, then that horse will exsanguinate and, you will not really be, be needed, unfortunately, but.

There are very few and far between. Certainly I've not come across them, but I guess I haven't done a huge amount of racecourse work. And perhaps that's where we might see those sorts of fractures more more frequently.

More often it's more peripheral fractures, and ultimately the diagnosis may be made on. Ultrasound examination, percutaneously or perectum, or by nuclear centigraphy in a referral hospital. So, these horses may need moving or referring to, to get an accurate diagnosis.

Now that can be a bit difficult because you know, you don't know what severity of fracture you may have in there and it can be a difficult decision to know whether what the risks of travelling that animal are going to be, but ultimately sometimes you know you're not able to take things any further without travelling the animal, so, you know, careful decisions have to be made there. And again, you know, cross tying is appropriate if you suspect a pelvic fracture, with the . Pros and cons, that I mentioned earlier.

So moving on now, away from bones, a brief look at some causes of tendon, some tendon and ligament injuries that cause, acute severe lameness. Now these horses, with these sorts of injuries usually, well, the most common scenarios will be, a tendon or ligament laceration associated with a, with a wound. Sometimes the injury can be related to a blunt trauma, or you can have athletic animals with a, superficial flexor tendinopathy, less likely to be non-weight bearing or acute, .

But possible, and also sometimes geriatric horses, you get STF tendinopathy in older horses, and they can be found in the field, severely lame, reluctant to move, and, your clinical exam though will give you . a lot of information as to, as to the likely diagnosis because there will be, significant swelling of the tendons. So in this instance, it'll be mid or proximal palma metacarpus, usually, enlarged STF on palpation, painful on palpation, heat, there, .

And so you'll know that that that's what what you're dealing with in all of these cases you'd expect some some palpable abnormalities. Postural changes are interesting. This video clip here, I'll just play now.

Now this was a horse that was referred with a wound in the Palmer Paston region. It had an open tendon sheath but was also severely lame. And quite simply, without any further investigation, the fact that this horse, We were able to lift its toe off the floor without any other movement in its leg, and meant that it, by definition, it must have had a ruptured deep disal flexor tendon.

There's no other scenario in which that would be possible. So that told us a lot of important information about, about this injury. So, yeah, usually you've got palpable clinical findings associated with the injured soft tissue structure, and they may be associated most likely with a wound or a trauma of some sort in most cases.

This is just another example, this is a show, show jumping pony that just got tangled up in a schooling show jump. They weren't jumping high, they just got their legs caught around the poles, must have had some . Trauma to this region of the, of the fallen.

Went immediately non-weight bearing lane and then had a small wound, but was far more lame than than the small skin wound would have been consistent with, but quickly developed swelling on the palm of metacarpus. This is a few days down the line. And ultimately an ultrasound, this horse had, almost rupture its entire, cross section of its superficial digital flexor tendon.

There should be tendon in that black hole. It had maybe. A quarter or less of its tendon intact.

This horse, to enable it to be referred, was put in a Robert Jones bandage and received analgesia prior to travel, and was ultimately managed in a cast. And and did very well, for it in the end. So further diagnosis, may require further imaging, most likely, but in the initial, stages of, of management, really you need to, practically address the presenting complaints.

So appropriate bandaging, appropriate management of any wound, and clearly analgesia. And Boxfest, of course, as well. Now, Just moving briefly through the last couple of topics that can cause acute severe lameness because these are big topics on on their own, just a few things to think about really assessing wounds on horses that are severely lame.

I think I keep coming back to this really, that that a wound itself is rarely the primary cause of a severe lameness, and so you really need to be looking for what else might be going on. That might be a tendon injury, it might be a fracture, but probably more commonly, or at least as, yeah, more commonly I would say, that wound might be affecting a, a synovial structure. And the key to assessing, whether a synovial structure is involved really is having a good knowledge of the anatomy of the horse's limbs.

You'll struggle to diagnose a, a synovial sepsis, unless you know where exactly those synovial structures are, particularly with regards to the hock, so remember that we've got the calcaneal bursa, the task sheath, extensive tendon sheaths, as well as the, the joints themselves. So really, the key here is a careful exam and knowing the anatomy of the structures that you're you're looking at. So in order to perform these exams, you, you need to get the horse into an environment that you can examine it safely and properly and you.

Need to, examine the wound, and I would normally clean the wound and then, just using a sterile glove, palpates the wound. Some people like to use a probe. I find my finger, tells me, more information really of, of being able to follow wounds, to, to the structures that are affected.

And you know, appropriate restraint sedation is required is important. Now, a horse with an infected joint or tendon sheath would usually be very lame, perhaps not as lame as . As a fracture but not far off.

There'll usually be a wound associated with the structure involved, although not necessarily if you've got a a a small puncture wound, for example, you might not find an obvious wound on your first exam. Situations where they may not be as lame as you expect would be as if they're leaking high volumes of the synovial fluid, so you don't have a joint distention causing so much pain. Or if it's a very acute injury, it might take 46, maybe more hours before the horse develops the signs that cause the lameness, the synoitis, so you might, really have caught synovial sepsis in the very early stages.

Typical signs clearly are a wound over a synovial structure and a fusion of the affected joint or tendon sheath, pain or palpation of that region, particularly tendencies, if they're distended and infected, they're often painful to palpate, painful to flex the affected area. Localised heat, more long standing cases might be pyrexic. And really, probably the most common synovial structures that we see would be wounds to the Paston region, the Palmer, planter fat lot region, causing sepsis of the digital flexor tendencies, as in this case, I keep doing that.

Or, joints of the distal limb, but also, wounds to the dorsal tarsus, that have gone into the tarsicroal joints. And this is the front of the tarsus, front of a hot cover also got tangled up in, electrical fence tape, and, . Sometimes they can have quite extensive wounds and not, go into the joints, and then other times they can.

So you, you'll make your initial assessment, you might . Then want to go further with sampling a joint or distending a joint with saline or further imaging, those would be examples of your next steps. If you suspect or have confirmed a synovial sepsis, then then really a surgical lavage is the gold standard treatment for this arthroscopic lavage under general anaesthesia, .

And so in which case you will be speaking to a referral centre about referral. Typically, You'll be providing analgesia for these animals because they'll need to be comfortable to travel humanely. And that's fine.

You may want to discuss that with whoever's receiving the case, providing broad spectrum antimicrobial therapy such as procaine penicillin and gentamicin. Sulphate would be an example of a good combination. Providing support or at least covering the wound with a bandage and considering tetanus cover if the horse isn't vaccinated.

The next, cause of acute lameness would be solar penetrations. Now these can clearly be obvious if you have a horse with an L in its foot, and the owner might, you know, will hopefully report that to you as they, they call you out. And these are, serious injuries that need to be taken, taken seriously.

There needs to be appropriate work up to, to decide whether that, solar penetration, that nail has affected, important deeper structures. If you can, keep the nail in place to allow you to take radiographs before it's removed, and that's ideal. Of, .

The reflex action of the person with the horses to to pull the ail out but it's always nice to know where it's gone, if at all possible. And really the key structures or the key areas that we're most concerned about are in the central third of the horse's foot and in the middle third of the horse's foot. So if you have a nail that's penetrating into this portion of the foot, often they do, .

Find themselves in the sula on either side of the frog. Those need to be taken seriously and often need to come into a clinic or referral establishment for radiography, navicular bursa, synovicentesis, those sorts of things. There's actually quite not a huge amount that can be done out and about.

You know, if you have the means and the facilities and enough pairs of hands, you, you might be able to tap the navicular bursa on the road, but it isn't always that easier, a thing to be tackling. Because the structures that we're worried about ultimately are the deep flexor tendon, the navicular bursa. In, as well as the, the coffin joints and occasionally the tendon sheath as well.

And these are, if any of these structures are involved, they have a serious, implications for the, . Outcome, whether it's for athletic use or even survival of the animal. Now finally, There are times when you might just not have any idea why your horse is lame.

There can be all sorts of scenarios where there really are, no real clear, obvious localising signs. It can be hugely frustrating because you have a very lame horse and you can't tell your owner, why that horse is as painful as it is. .

So, but it does happen from time to time. And, certainly, after you've provided analgesia, blocking the foot, so diagnostic analgesia, palm digital nerve block of the foot can help you differentiate whether you've got a foot issue because sometimes a subsolar abscess or a solar penetration or even a fracture of the distal phalanx can be very difficult to. To localise, if a horse improves to a block of the foot, then you at least know, you know, you've made a good start.

Other times you, you literally just have to, to strictly box rest the horse, provide analgesia, and pause, reassess the horse in 12 to 24 hours and see what comes of it. Survey radiographs can be helpful, and if you suspect a fracture that you can't see, many, . Radial fractures, for example, aren't evident on radiographs initially.

You might want to repeat radiographs in 7 to 14 days, or if you're happy to transport the horse, nucleus and graph you can provide an answer. But again, you need to wait a few days, ideally before imaging those animals. Transport, I think you just need to use common sense, transporting a horse.

If you know what your diagnosis is, providing appropriate immobilisation or bandaging is really important. Getting the transport as close to the horse as you can so you don't have to move it. It's the loading and unloading that is the critical point really.

So anything you can do to have a minimal slope on the loading ramp, . It's helpful and once the horse is moving, having supported partitions so it can support itself. Travelling backwards has been reported as helpful for for limb injuries, but I think realistically it's not hugely practical, and having the horse in the way it's most accustomed to is probably probably just as effective.

I'm running out of time here, I think, but, the final thing, I'd just like to say is that . Decision making about euthanizing a horse can be a very difficult . Situations sometimes, because you need to balance the, welfare of the animal against the wishes of the owner, and, sometimes the communication that is involved, .

It's difficult to have because everyone just wants you to get on and put the animal out of its distress. But really taking a few moments to make sure that you've had the right level of communication or even have the right paperwork signed is hugely important to avoid quite serious administrative or worse headaches later down the line. If a horse is insured for all risks mortality, .

Then, You may want to defer to the beaver guidelines on humane destruction. They exist to help with decision making, but they really only apply for horses insured for mortality. So, these lists I've just shown you earlier the orthopaedic.

Bho lists, but these lists, tell you which horses you can, without any hesitation, euthanize on the spot, and will, be able to make a claim for all risk mortality. Every other scenario than those circled on these two lists, are feasibly, can feasibly survive. And so if you're euthanizing animals that aren't in these circles, don't apply, then.

Then you need to make the owner aware that they may not have a mortality claim from their insurance company. Now that may not matter in the heat of the moment, but it can often matter hugely two weeks later when the owner has no horse and no money to buy a new horse. So, it really is important to, to make sure that, you've, sort of at least ask, is the horse insured for mortality?

If it is, then you need to discuss whether that horse, may or may not, be eligible for, for a claim, . If it's important to the owner that they're able to make a mortality claim, then you should not euthanize the horse on the spot unless it satisfies these scenarios and seek a second opinion or further diagnostics, contact the insurance company, and those sorts of steps. And I think some, issues sometimes arise because in our minds, a horse might, qualify for immediate euthanasia on humane grounds whereby, strictly speaking, according to the paperwork, they may not, so there can be a grey area there, hence, the potential for, for complication.

So I think no matter how highly charged the situation is when you're faced with a horse that requires immediate euthanasia, it's really important that you have identified the owner, you have communicated with that owner, gained their consent, ideally written but if not verbal. If you're not able to speak to the owner that you've established who is the nominated person who is responsible for decision making on that horse and have received the appropriate consent from them, that you've identified the horse, that you are euthanizing the the horse that you that you believe you are. And if in doubt, don't euthanize straight away, pause and make sure you've got, the right diagnosis, the right information, .

And, know where you stand. With the proviso that welfare must always take priority of the animal. So yeah, a racer.

I think I tried to cover quite a lot of information there. I think these cases are challenging, they are stressful, but they can be very rewarding, and can really increase the bond that you have, with the client, bond, if you do the right thing at the right time and really are able to help that animal, whatever the ultimate outcome may be. Clinical exam is the crucial thing, .

Taking the time to carefully make your assessments, when necessary. Don't let yourself be rushed and make sure that you can pause and think about what's the appropriate thing. Ask for help if necessary, whether that's down the phone or getting a second opinion, a colleague to come and assist you, .

Be careful, you know, euthanasia is a a one way situation. Don't be rushed into euthanasia if you have any, any doubts about the overall situation. and yeah, we're there.

Thank you very much.